Every finding on record at Port Arthur Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of 1 of 1 facility reviewed for governing body.The facility failed to ensure the Director of Operations, who was acting as the facility Administrator, had an active Texas Administrator license. The facility had not had a licensed administrator since 07/08/2026. This deficient practice could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care. The findings included:Record review of the facility employee list printed on 08/16/2026 by the facility indicated the Director of Operations first and last name, department listed Administrator and position listed Administrator. The Regional Director of Operations was not listed on the form.Record review of the former Administrator's employee record form titled Facility Termination Form dated 07/08/2026 indicated he was positioned as the Interim Administrator in the department of Administrator full-time with last day worked as 07/08/2026. During an interview on 08/16/2026 at 9:00 a.m., an entrance conference was conducted with the Director of Operations who said he was hired on in July 2026 and was licensed in the state of Colorado as a nursing home administrator but did not have a Texas administrator license. He said the previous administrator was at the facility until sometime in July 2026. The Director of Operations said he was responsible for the Administrator duties and could call the RDO for guidance anytime he needed advice. He said the RDO (Regional Director of Operations) had a current Texas administrator license and was not currently in the building every day but was available by phone. The Director of Operations said the RDO was in the building 2-3 times a week to check on things. The Director of Operations said the RDO had not worked 40 hours per week consistently in the facility since he started at the facility on July 8, 2026. He said he talked with the RDO on the phone for his input. He said he was not aware that a Texas license administrator had to be in the building for 40 hours 5 days a week. The Director of Operations said that his title would change to the position of Administrator as soon as he was approved for a Texas reciprocity license. The Director of Operations said there was no actual risk to the residents because he was a licensed Administrator in another state.During an interview on 08/18/26 at 1:30 p.m., the DON said the facility did not have a full-time administrator because the Director of Operations was not licensed in the state of Texas. The DON said the RDO had not been in the facility consistently for 40 hours per week since the Director of Operations has been here 07/08/26. She said the RDO checks in by phone with the Director of Operations. The DON said that she could not think of a negative outcome for not having a licensed Administrator because the situation was working and there had been no negative impacts.During an interview on 08/18/26 at 2:00 p.m., the IP said she had not seen the RDO physically present in the facility for 40 hours weekly. She said she was not aware that a license Administrator had to be in the building that many hours and days. She stated the negative outcome could be no monitoring of regulations being followed.During an interview on 08/18/26 at 2:30 p.m., the Director of Operations said, his first day was 07/08/26. He said he had already created a TULIP account and uploaded his application and supporting documentation on 8/7/26. The Director of Operations said he checked on the status of his application every other day and when he called the TULIP helpdesk he was told that every time he called it would start the review process timer all over again. The Director of Operations said the facility was in their 30-day window to obtain an Administrator.During interview on 08/18/26 at 2:45pm the RDO stated the facility has been without a full-time Texas licensed Administrator for about a month. He said he was a licensed Administrator in Texas. He said he had not been actively seeking a licensed administrator because the job had been offered to the Director of Operations. The RDO said the Director of Operations was hired to move into the position of licensed administrator over the facility when he obtained his Texas reciprocity license. He said he had visited the facility about 2-3 times a week since the last licensed administrator's employment ended, and he was always available by phone for the Director of Operations if he was needed. He said he thought the Assistant Administrator was doing an excellent job of managing the facility. He said that he did not know of any negative outcome for residents as a result of the facility not having a licensed administrator. Record review of facility's Active Employee Report provided by the facility, dated 08/16/26 at 10:15 a.m. indicated the Director of Operations in the position of Administrator and hired on 7/8/26.Record review of the facility's Administrator job description, 2001 MED-PASS, Inc., revised July 2024 indicated. Must possess a current unencumbered nursing home administrator's license or meet the licensure requirements of the state. Record review of the facility's policy titled Administrator revised March 2026 indicated The governing board of this facility has appointed a licensed nursing home administrator (LNHA) in accordance with current federal and state requirements.

Based on observation, interview, and record review, the facility failed to properly store, prepare, distribute, and serve food in accordance with the professional standards for food service safety 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were sealed and/or labeled properly in the cooler.2. The facility failed to ensure food items in the kitchen cooking space were labeled, dated, sealed, and not expired.3. The facility failed to ensure dented cans in the dry pantry were not stored and co-mingled with non-dented food cans ready for use. These failures could place residents, who received food and beverages from the kitchen, at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: During initial observation and interview in the kitchen on 08/16/26 at 9:20 a.m. of the cooler with the DM indicated there was: - an open, undated, original labeled, cut open, 1/2 block of cream cheese that was cut open, not properly sealed and exposed to the elements at the cut end. The DM said it was 1/2 block of cream cheese. the DM removed the cream cheese from the cooler threw it in the trash and said it should have been dated as to when it was opened or due to be expired and also in a sealed container. During an observation and interview on 08/16/26 at 9:35 a.m. with the DM the commercial storage can rack indicated the following canned food items were stored and co-mingled with non-dented food cans: - One #10 can of diced red peppers with a large dent in the middle of the can the top seam was lifted upward approximately 1-inch. The DM said the cans of diced red peppers contained dents and should have been stored separate from non-dented cans. During an observation and interview on 08/16/26 at 9:50 a.m. of the dry good stored in the kitchen for cooking with the DM indicated there were: - One, Quaker Grits 5-minute 5lb bag 1/2 used ripped open from the top and folded down upon itself. The bag was opened and used not dated when opened, not properly sealed and exposed to the elements at the ripped end. - One, Imperial brown gravy mix 1/2 used 15oz bag used ripped open from the top and folded down upon itself. The bag was opened and used not dated when opened, not properly sealed and exposed to the elements at the ripped end. - One, 5.3lbs container of mashed potato complete, 1/2 used and covered with plastic wrap not properly sealed and exposed to the elements. The container was opened and used not dated when opened or when to discard. The DM said she did not know when or who opened the grits, gravy or potato complete mix and would discard it, can cause decreased quality and taste. During an interview on 08/16/26 at 10:00 a.m., the DM said the #10 can contained dents and should have been stored separate from non-dented cans. The DM said she was not sure who put up the can goods. The DM said she was to check Monday for dented cans but had not had a chance to check for dented cans because surveyors walked in before she could check. The DM said she kept the dented cans in an area in the pantry so she could return them. The DM said risk of using dented cans could contaminate food. The DM said she expected all products in the kitchen to be stored correctly. She said packages of food items should be sealed so as not to expose food to the elements. The DM said it was the responsibility of all the dietary staff to ensure products were labeled and stored correctly. The DM said she could not explain why the improperly sealed or undated foods had not been removed from the dry storage or cooler. The DM said all kitchen staff completed the required food preparation and food storage trainings. The DM said the potential harm to residents would be food poisoning, diarrhea, sickness, and bacteria on food. The DM said the failure occurred due to staff not paying attention. During an interview on 08/18/26 at 2:00 p.m., the Director of Operations said his expectation was for kitchen staff to follow policies on food storage, preparation, and that everything was dated. He said the DM monitored that kitchen staff were following the facility's policy. The Director of Operations said not storing and preparing food appropriately could cause residents to be given food beyond the expiration date and not the correct time frame. The Director of Operations said it could also affect the freshness and quality of resident's food. The Director of Operations said the facility did not have a policy on storing dented cans of food. Record review of facility policy revised 11/2022 titled, Food Receiving and Storage read,: .Foods shall be received and stored in a manner that complies with safe food handling practices. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Review of the Food and Drug Administration Food Code, dated 2022, reflected, . 3-201.11 Safe, Unadulterated, and Honestly Presented. Compliance with Food Law. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely and clean bed and bath linens that are in good condition for 3 of 12 (Resident #40, Resident #57, and Resident #61) residents reviewed for a homelike environment. The facility failed to ensure Resident #40 and Resident # 57, was provided with clean and sanitary pillows on 08/16/2026. The facility failed to ensure Resident #40, Resident #57, and Resident #61 were provided with clean, non-ripped, and non-sinking mattresses on 08/16/2026.The facility failed to ensure an adequate amount of linen was available for use and was not discolored. These failures could place residents at risk of exposure to infectious diseases, unsanitary environment and a decline in quality of life. Findings included: During an observation and interview on 08/16/2026 at 9:35 a.m., Resident #40's pillow was completely flattened and stained with multiple brown spots all over it. Resident #40's mattress had a large sunken area in the center. Resident #40 said she had not been offered a new pillow or new mattress. Resident #40 said she had informed a staff member about wanting a pillowcase but did not recall which staff member or how long it was since she informed the staff member. During an observation and interview on 08/16/2026 at 10:04 a.m., Resident #57's pillow on his bed had a foul odor and dry rotted cracks on it. The pillow was stained with multiple brown and black spots all over it. Resident #57's mattress had a large rip longer than two 12-inch rulers with the inside mattress contents (dark brown in color with a foul odor present) exposed. Resident #57 said he had not been offered a new pillow nor a new mattress. Resident #57 said he had informed a staff member about wanting a pillow and mattress but did not recall which staff member or how long it was since he informed the staff member. During an observation and interview on 08/16/2026 at 10:45 a.m., Resident #61 was in her bed and was leaning towards her left hip. The mattress was compressed almost flat on the left side. Resident #61 said she had told them about the mattress being wore out and it had an open area on the right side of the mattress. She said the facility had a meeting with her in her room and the maintenance supervisor knew about it. The right side of the mattress had a split 3/4 of the length of the mattress with frayed material hanging approximately 4-6 inches out of the mattress. During an observation and interview on 08/16/26 at 11:00 a.m., the Housekeeping/ Laundry supervisor said 7 of the fitted sheets were not white as they should be. She said the new company had ordered new linen, and she would take those fitted sheets and replace them with new sheets. She said the linen should have been homelike for the residents to provide homelike environment. The Housekeeping/ Laundry supervisor said Resident # 40 and Resident #57's pillows should had been discarded because they were visibly flattened and soiled. She said Resident #40 and Resident #57's pillow could not be sanitized due to the pillows condition. She said the potential risk was residents could develop a skin infection. During interview on 08/16/2026 at 11:15 a.m., the Operations Manager (he has the same duties as an Administrator) said the sheets left in the linen closet were not dingy. He said they had ordered new linen, and the supervisor will be putting out new linen as needed. The Operations Manager said his expectations were for all residents to have clean pillows and non-damaged mattresses. He said the potential risk to the residents was not having a homelike environment. He said all staff were responsible for observing potential needs for residents. During an interview on 08/16/2026 at 3:00 p.m., the Maintenance Supervisor denied knowing about Resident #40, Resident #57, and Resident #61's mattress was in bad shape. He said his expectation was for residents who needed new mattresses to receive them. He said the potential risk would have been residents not being comfortable. Record review of a computerized notification from 05/04/2026 to 08/14/2026 to the maintenance supervisor indicated no mention of need of new pillows, new linen, or new mattresses. Record review of an undated facility's policy titled Laundry and Bedding, Soiled indicated: Policy StatementSoiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control.Policy Interpretation and Implementation Storage1. Clean linen is stored separately, away from soiled linens, at all times.Covers are not needed on contaminated textile hampers in resident care areas (unless state licensing rules require them).Clean linen is kept separate from contaminated linen. The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination. Mattresses, Pillows and Overlays1. Moisture-resistant mattress covers are cleaned and disinfected using EPA registered disinfectants between uses by different residents.Fabric mattress covers are laundered between uses by different residents.Mattresses that are torn, stained with bodily fluids, or have been wet for prolonged periods are discarded and replaced.Air fluidized beds and pressure-reducing overlays are maintained, cleaned, and replaced in accordance with manufacturers' instructions.Washable pillows and pillow covers are laundered in hot water when soiled with bodily substances and before exchange between residents. Pillows that are torn, damaged, or permanently stained are discarded and replaced.

Based on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls for 1 (Hall 500 medication cart) of 5 medication carts reviewed for pharmacy services. The facility failed to ensure medications were not stored on top of the 500 Hall medication cart on 08/17/2026 at 8:05 a.m. This failure could place residents at risk of misappropriation of medications, adverse reactions by ingesting medication that did not belong to them, and not receiving therapeutic effects of medication. Findings included:During an observation on 08/17/2026 at 8:05 a.m., LVN B was preparing to give medications to Resident #6, LVN B placed the oxybutynin 5 mg in a small medication cup. LVN B's blood pressure machine would not work so she left Resident #6 at the locked medication cart and on the top of the medication cart was the oxybutynin in a small medication cup. LVN B walked down the hall out of sight.During an observation on 08/17/2026 at 8:09 a.m., LVN B returned to the medication cart and placed the other medications for Resident #6 in the medicine cup with the oxybutynin and administered.During an interview on 08/17/2026 at 9:00 a.m., LVN B said she had been trained to secure all medications in her locked medication cart. She said she just forgot and would never do that again.During an interview on 08/17/2026 at 10:00 a.m., requested drug storage policy from the DON and she said she wanted medications to be stored properly and secured in the medication cart for safety.Record review of the . Medication Labeling and Storage policy dated February 2023 indicated Policy heading The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially.

Based on observation and interview the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 5 halls (Hall 400) reviewed for accidents and hazards: The facility failed to ensure a pepper spray canister was not left on top of a bedside table unattended and unsupervised on Hall 400. This failure could place residents at risk for injury to themselves and other residents.Findings included: During an observation and interview on 08/16/2026, at 10:11 a.m., there was a keychain that had keys and a teal-colored canister of pepper spray with a spray button push on top of a bedside table against the wall on Hall 400, unsupervised. The Weekend RN Supervisor said the keychain belonged to CNA A who is assigned to the 400 hall. She said it should not have been stored in an area where residents could get ahold of it. She said it was the CNAs responsibility to ensure her belongings were stored in an area that residents could not get ahold of. The weekend supervisor said CNA A could have stored her belongings in the cabinet at the nurses station since the facility did not have staff lockers. She said she had not noticed the canister when she walked down the hall. During an interview and observation on 08/16/2026 at 10:22 a.m., CNA A said the teal-colored canister was pepper spray. She said she placed her belongings on the bedside table because she did not know where to store her personal belongings. She said the canister of pepper spray should not had been there. CNA A said it was her responsibility to put her personal items up so residents could not get to it. She said the residents could potentially get ahold of the pepper spray and harm themselves or others. During observation CNA A showed the label on the canister it stated [NAME] Red per spray WARNING: SEVERE SKIN, EYE AND RESPIRATORY IRRITANT. Active ingredients oleoresin capsicum (red pepper) Keep out of reach.). During an interview on 08/16/2026 at 1:10 p.m., the DON said CNA A was responsible for ensuring the pepper spray canister was not left unattended on a bedside table on hall 400 and unsupervised. She said staff are expected to store their items in cabinets at the nurses station. She said items such as pepper spray were expected to be left in employees vehicles. The DON said it would be a safety issue if it were left unattended because anyone could grab it. She said the facility did not have an accident and hazards policy that addressed residents because they have a corporation. During an interview with the Administrator on 08/17/2026 at 2:35 p.m., he said it was his expectation for resident halls to be free from employee's personal belongings and for there not to be pepper spray anywhere in the building and not be unattended. He said CNA A was responsible for ensuring there was no pepper spray in the building. He said a resident could potentially get ahold of the pepper spray and harm themselves or others. The Administrator said he could only find an accident and hazards policy for employees. He said he would have to look for a residents accidents and hazard policy. Record review for the facility's policy addressing accidents and hazards was attempted on 08/16/2026- 08/18/2026. The facility did not provide an accidents and hazard policy upon exit.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #27) reviewed for infection control.The facility failed to ensure CNA A changed her gloves or sanitized her hands after performing incontinent care for Resident #27. She touched Resident #27's clean brief and sheet with her dirty gloves after providing incontinent care.These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.Findings included:Record review of Resident #27's face sheet dated 5/6/25 indicated Resident #27 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #27 had diagnoses including cerebral infarction (blood vessel that carries oxygen-rich blood to the brain gets blocked), anxiety disorder, and major depressive disorder.Record review of Resident #27's quarterly MDS assessment dated [DATE] indicated Resident #27's BIMS score was 02 which indicated severe cognitive impairment. Resident #27 was dependent on staff for toileting hygiene. Resident #27 had frequent urinary incontinence (lack of control over urination).Record review of Resident #27's care plan, no date, indicated Resident #27 .Resident #27 is at risk for bladder incontinence and requires assistance with toileting cares r/t Obstructive Uropathy (structural or functional blockage of normal urine flow anywhere in the urinary tract). Date Initiated: 03/20/2023 Revision on: 05/24/2023.During an observation and interview on 8/16/26 at 11:25 a.m., CNA A did hand hygiene after entering the room. CNA A completed incontinence care on Resident #27. CNA A grabbed the clean brief and sheet with the same dirty gloves, without doing hand hygiene, and placed them next to Resident #27 to replace the dirty items. This surveyor asked CNA A when hand hygiene should be completed. CNA A stated before patient care and after patient care. CNA A stated, I should have washed my hands after cleaning her (Resident #27) and placed new gloves. CNA A stopped providing care, removed her gloves, and proceeded to wash her hands. She placed new gloves and finished putting the clean brief on the resident and the clean sheet under the resident. Immediately after, CNA A stated she had been trained regarding hand hygiene and the incontinent care process. She stated she was trained to remove gloves and do hand hygiene when going from dirty to clean. She stated not removing dirty gloves and completing hand hygiene could be a risk for infection.During an interview on 8/17/26 at 1:10 p.m., the ADON stated staff were expected to complete hand hygiene before and after patient care as well as going from dirty to clean. Hand hygiene should be completed before touching the clean brief and linens. He stated all staff have received training on infection control and the risk of not following this protocol was it could cause cross contamination.During an interview on 8/18/26 at 10:16 a.m., the IP (infection preventionist) stated hand hygiene was to be completed before and after patient care and when going from dirty to clean after incontinence care. The IP stated she was responsible for training staff. She stated she observed incontinence care and would stop staff during the observation to ensure proper hand hygiene when going from dirty to clean. She stated the risk of not completing hand hygiene when going from dirty to clean was infection.Record review of a facility's Perineal (on women the area of tissue and skin situated between the vaginal opening and the anus) Care, dated 8/18/26, indicated, .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.1. Wash and dry your hands thoroughly.15. Discard disposable items into designated containers. 16. Remove gloves and discard into designated container. 17. Wash and dry your hands thoroughly. 18. Reposition the bed covers. Make the resident comfortable.22. Wash and dry your hands thoroughly.Record review of Perineal (Peri) Care Competency Check-off With Education, dated 6/8/26, .Employee name: CNA A Date: 6/8/26 Observer: IP.Step.1. Performs hand hygiene before beginning care.remove gloves and performs hand hygiene. (did not specify hand hygiene after perineal care or from dirty to clean).

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #2) reviewed for infection prevention. 1. The facility failed to ensure CNA D used PPE when she provided care to Resident #2 who was on Enhanced Barrier Precautions (EBP) for his suprapubic catheter. 2. The facility failed to ensure CNA D did not place and leave Resident #2's suprapubic catheter bag on the floor. 3. The facility failed to ensure CNA D performed hand hygiene before starting care, between glove changes and after completed care. These deficient practices could place residents at risk for infection.Findings include:Record review of Resident #2's face sheet, dated 02/23/2026, indicated a [AGE] year-old male, with an initial admission date of 01/01/2021 and a readmission date of 09/11/2025. Resident #2 had diagnoses which included: hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage) and hemiparesis (one-sided muscle weakness) affecting left non- dominant side, chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), urinary tract infection (an infection in the kidneys, ureters, bladder, or urethra), unspecified bulbous urethral stricture (is a narrowing of the bulbar urethra, often caused by trauma or injury, leading to urinary flow obstruction).Record review of Resident #2's Quarterly MDS assessment, dated 12/17/2025, indicated he had a BIMS score of 15, which indicated normal, intact cognition. Resident #2 had an indwelling catheter. Record review of Resident #2's Active Orders, dated 02/23/2026, indicated orders which included: Enhanced Barrier Precautions- providers and staff must: Put on gown & gloves before room entry and providing high-contact care activities such as: Bathing/showering, transferring residents, providing hygiene, changing bed linens, changing briefs or assisting with toileting, caring for or using an indwelling medical device (for example, central venous catheter, urinary catheter, feeding tube care, tracheostomy/ventilator care), Performing wound care, two times a day listed under Special Instructions in the Orders tab.Record review of Resident #2's Care Plan, dated last reviewed 02/23/2026, indicated he was on enhanced barrier precautions related to his suprapubic catheter. The care plan listed enhanced barrier precautions interventions as Staff will wear gloves and gown (per protocol) to provide high-contact care activity to include: Dressing, Bathing/Showering, Transferring, Hygiene, Changing Linens, Changing Briefs, Assisting with Toileting, Device Care or Use (PICC/Central Line, Catheter, Feeding Tube, Trach-(- a surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised), Vent (refers to ventilator, a medical device used to provide mechanical ventilation by moving breathable air into and out of the lungs.), wound care.) initiated 02/18/2025. The care plan listed Resident #2 had an indwelling catheter related to obstructive uropathy (is a condition in which urine flow is blocked, causing urine to back up and potentially damage the kidneys) with an intervention of Enhanced Barrier Precautions (per protocol): Use gloves and gown to provide high contact care. Use face mask if there is a risk of splash or spray.During an observation on 02/21/2026 at 11:11 a.m. indicated CNA D entered Resident #2's room without gown or gloves. Resident #2's suprapubic catheter was on the floor near his bed. CNA D put on gloves without hand hygiene. CNA D picked Resident #2's catheter bag off the floor and emptied it (580 ml of urine) into a urinal. CNA D placed the catheter bag back onto the floor. CNA D discarded used gloves and applied a new pair without using hand hygiene. CNA D used the same gloves for Resident #2's incontinent care and to dress him. CNA D had picked Resident #2's catheter bag off the floor and placed it in on his bed to dress him without sanitizing or changing his catheter bag (did not changed bed sheets.) CNA D did not perform hand hygiene after she completed Resident #2's care.During an interview with CNA D on 02/21/2026 at 11:20 p.m., she said she should have worn a gown while she attended to the needs of Resident #2. She said she did not put a gown on because she was nervous and rushing. She said she noticed his catheter bag on the floor but didn't think to put it on the bedframe. She said she knew the catheter bag should have been on a fixed structure below the bladder. CNA D said she should have used hand hygiene between gloves changes and should have sanitized his catheter bag before putting in into his bed to prevent the potential for cross contamination. During an interview with LVN E on 02/21/2026 at 11:29 a.m., she said she was the charge nurse for CNA D. LVN E said her expectations were for CNAs to wash or sanitize their hands before, between, and after glove changes. LVN E said CNA D should have sanitized Resident #2's catheter bag then made her aware so she could have gotten him a clean catheter bag. She said CNA D should have worn a gown while she was caring for Resident #2 to prevent the potential for cross contamination. During an interview with the DON on 02/21/2026 at 11:45 a.m., she said her expectations were for all staff to wash or sanitize their hands before, between, and after glove changes. She said the catheter bags should never be left on the floor but be placed on a fixed structure to prevent any pulling or potential trauma. The DON said all staff should wear gowns and gloves when carrying out tasks for residents on enhanced barrier precautions to ensure there was no cross contamination. She said hand hygiene should be done before and after resident care and gloves should be changed after incontinent care. She said she educated staff on enhanced barrier precautions, hand hygiene, and catheter care.An interview with the Administrator was not obtained. The Administrator was out of town, the DON was the designee at the time. Record review of the facility's policy, revised August 2022, titled, Catheter Care, Urinary, indicated: Purpose-The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.Infection Control1. Use aseptic technique when handling or manipulating the drainage system.2. Be sure the catheter tubing and drainage bag are kept off the floor.Changing Catheters2. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.Cleaning and Disinfecting Drainage Bags1. Disconnect the drainage bag from the catheter; replace with a clean bag. Record review of the facility's policy, dated December 2023, titled Infection Prevention and Control Program, indicated: Policy StatementAn infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.7. Prevention of Infectiona. Important facets of infection prevention include:(1) identifying possible infections or potential complications of existing infections;(2) instituting measures to avoid complications or dissemination;(3) educating staff and ensuring that they adhere to proper techniques and procedures;(4) communicating the importance of standard precautions and respiratory hygiene to visitors and family members;(5) screening for possible significant pathogens;(6) immunizing residents and staff to try to prevent illness;(7) implementing appropriate enhanced barrier and transmission-based precautions when necessary; and(8) following established general and disease-specific guidelines such as those of the Centers forDisease Control (CDC).

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 2 residents (Resident #1) reviewed for treatment and services related to indwelling suprapubic catheters. 1. The facility failed to ensure Resident #1's indwelling suprapubic catheter was secured on [DATE]. 2. The facility failed to ensure Resident #1's indwelling suprapubic catheter was a 16 FR (catheter with size of 5.3 mm) instead of an 18 FR (catheter with size of 6 mm diameter). These failures could place residents at risk for urinary tract infections, dislodgment, potential complications and a decreased quality of life. Findings include: Record review of Resident #1's face sheet, dated [DATE], indicated a [AGE] year-old female who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #1 had diagnoses which included: neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination), aphasia (a disorder that affects how someone communicates), quadriplegia (paralyzed in both arms and both legs),tracheostomy (a surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised), injuries of the head, sequela (closed head injury). Record review of Resident #1's care plan, dated [DATE], with a target date of [DATE], indicated she had an indwelling 18 FR suprapubic catheter with a goal that she will be/remain free from catheter-related trauma through the next 90 days. The care plan listed an intervention Ensure statlock is in place to secure foley tubing to prevent injury. Record review of Resident #1's quarterly MDS, dated [DATE], indicated she had a BIMS score of 0, which indicated she had severe cognitive impairment. Resident #2 had an indwelling catheter. Record review of Resident #1's order summary, dated [DATE], indicated: to exchange the suprapubic catheter 16 FR/ 30ml every 4 weeks and as needed if clogged and unable to flush. Please secure SPT (suprapubic catheter with statlock. After surveyor's intervention, ADON C obtained an order for the 18 FR suprapubic catheter on [DATE]. Record review of Resident #1's MAR, dated February 2025, indicated on [DATE] at 2:20 a.m. Resident #1's suprapubic catheter was changed by LVN B. The MAR indicated the suprapubic catheter size was 16 FR/30 ml. During an observation on [DATE] at 10:15 a.m. indicated Resident #1 was lying in his bed with the head of his bed elevated. Resident #1's suprapubic catheter was unsecured, there was no statlock (leg securement device) in place on her leg securing her suprapubic catheter. Resident #1's suprapubic catheter had 18 FR/30 ml on it. During an observation on [DATE] at 5:10 p.m. the facility had 16 FR and 18 FR catheters in stock at the facility inside the supply room. During an attempted interview with Resident #1 on [DATE] at 10:20 a.m. indicated the resident was unable to respond verbally or physically to surveyors questions. During an interview with LVN A on [DATE] at 10:20 a.m., she said Resident #1 had an order for a 16 FR suprapubic catheter since [DATE]. She said Resident #1 currently had an 18 FR suprapubic catheter. LVN A said she was unaware Resident #1 had no securement device in place and did not know for how long Resident #1 had not had a statlock (leg securement device). LVN A said nurses were responsible for ensuring and verifying indwelling catheters were secured and had the correct catheter size in place. LVN A said she should have verified the indwelling suprapubic catheter size and compare it to the order at the beginning of her shift. She said it was important to ensure all catheters were secured to prevent the catheter being dislodged out of the bladder, causing trauma or injuries. During an interview with ADON C on [DATE] at 12:20 p.m., he said the nurses were responsible for making sure the statlock/ leg securement device was in place securing the suprapubic catheter. ADON C said it was important for the catheter to be secured so it did not become dislodged or cause urinary tract infection. The ADON C said Resident #1 had an order for a 16 FR suprapubic catheter since [DATE]. He said Resident #1 had an 18 FR suprapubic catheter placed in by LVN B since [DATE] according to the MAR. He said he was not aware Resident #1 had the wrong catheter size in place. He said the facility had 16 FR suprapubic catheters in stock at the facility. He said the suprapubic catheter that should have been used was 16 FR/30 ml. He said the associated potential risk related to the wrong size catheter used would be a deceased quality in care. During an interview with the DON on [DATE] at 12:30 p.m., she said she was not aware Resident #1's suprapubic catheter was unsecured nor that she had not had a statlock (leg securement device) in place. She said she educated staff on making sure residents had statlocks (leg securement device) if they had a catheter. The DON said she was not aware Resident #1 had an 18 FR catheter instead of the ordered 16 FR catheter. She said Resident #1 should have had the 16 FR placed. The DON said the nurses were responsible for verifying physician orders and implanting the orders correctly. She said it was her expectation for the nurses to insert the correct size catheter and then secure the catheter to prevent the potential of dislodgement. The DON said it was important for the catheters to be secured because if they were not, it could potentially pull out and hurt the residents. The DON said she expected the nurses to follow policy and procedures regarding catheter securement. An interview with the Administrator was not obtained. The Administrator was out of town, the DON was the designee at the time. Record review of the facility's policy, revised [DATE], titled, Catheter Care, Urinary, indicated: Purpose-The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.General Guidelines:4. Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site.

Based on interviews and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment to reflect the current condition for 1 of 18 (Resident #1) residents reviewed for comprehensive care plans. The facility failed to ensure Resident #1's care plan was updated to indicate Resident #1 had a resident-to-resident incident on 07/18/2025 and 08/16/2025. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.The findings included: Resident #1Record review of Resident #1's admission Record dated 01/06/2026 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), aphasia (a disorder that results from damage (usually from a stroke or traumatic brain injury) to areas of the brain that are responsible for language) and dysphagia (difficulty swallowing) following cerebral infarction, anxiety disorder (persistent and excessive worry that interferes with daily activities), and seizures.Record review of Resident #1's quarterly MDS assessment, dated 06/22/2025, indicated she had a BIMS score of 00 which indicated she had severely impaired cognition, and was sometimes able to make herself understood and usually understood others. She had no behaviors indicated during the 7-day look back period prior to completing the MDS assessment. The functional abilities self-care indicated she required maximum assistance with oral care, toileting hygiene, personal hygiene, lower body dressing, putting on/taking of footwear, and required moderate assistance with shower/bathing and upper body dressing. Her functional abilities mobility indicated she required moderate assistance with all tasks except rolling left to right, sitting to lying, and lying to sitting on side of bed which required supervision or touching assistance. She uses a manual wheelchair with supervision or touching assistance at times.Record review of Resident #1's care plan, revision dated 11/03/2025, indicated she had history of being physically aggressive with staff and other residents. Interventions included administering medications as needed, assessment and anticipating resident's needs: food, thirst, toileting needs, comfort level, body positioning, and/or pain, communication techniques, effective strategies, behavior monitoring, labs, psychiatric/psychogeriatric consult as indicated, and proper authorities notified (Abuse Coordinator, Ombudsmen, DON, ADON, police dept, and RP). The care plan did not indicate Resident #1 had an updated or revised care plan for resident-to-resident incident on 07/18/2025 and 08/16/2025. Further review of care plan indicated no interventions added since 06/17/2024.Record review of Resident #1's progress notes/incident report, authored by LVN A, indicated on 07/18/2025 at 3:55 p.m., [Resident #1] was in wheelchair in the hallway. While walking out the shower room, [CNA B] witnessed resident grabbed another resident by the hands and slapped her on the left side of face. [CNA B] immediately separated the residents. Nurse notified. [Resident #1] was nonverbal and unable to provide a statement. Monitoring initiated. Head to toe assessment completed. No skin issues noted. Pain assessment completed. No pain or discomfort indicated at the time of the incident. Vitals taken. Will continue to monitor. Administrator, DON, Ombudsman, local police department, NP with Psych, NP with MD, and RP notified of incident.Record review of the provider investigation report dated 07/22/2025 for the Resident-to-Resident incident revealed Resident #1 hit another resident on the left side of face/neck on 07/18/2025. An assessment of both residents revealed no injuries. Resident #1 was placed on behavioral monitoring for 72 hours with no adverse events.Record review of Resident #1's progress notes/incident report, authored by LVN C, indicated on 08/16/2025 at 9:45 am, [CNA B] reported to [LVN C], [Resident #1] hit her roommate twice in the chest. Roommates immediately separated for safety. Assessed for injuries and pain. No injuries noted to hands. Shakes head no to pain. Administrator, DON, Ombudsman, local police department, NP with Psych, NP with MD, and RP notified of incident. Orders for labs and urine to be collected on Monday 8-18-25. Behavior monitoring started. Local police department interviewed involved residents.Record review of the provider investigation report dated 08/16/2025 for the Resident-to-Resident incident revealed Resident #1 hit another resident on the chest on 08/16/2025. An assessment of both residents with no injuries. Resident #1 was placed on behavioral monitoring for 72 hours with no adverse events.Unsuccessful attempts to interview CNA B on 01/06/2026 at 11:40 a.m., 01/07/2026 at 11:35 a.m., and 01/08/2026 at 11:41 a.m. were made, with no returned call to voice mail or text message.During an interview on 01/08/2026 at 1:03 p.m., LVN A said she was the nurse on duty 7/18/2025 when CNA B reported she witnessed Resident #1 hit another resident. She said that Resident #1 was non-verbal and tended to hit other residents to get their attention because she did not speak. She said that facility staff had been trained to report all physical contact to charge nurses and administrator for alleged physical abuse. She said that she assessed both residents after the incident, and no injuries were identified. She said she followed the facility's protocol separated involved residents for residents' safety, initiated monitoring for 72 hours, assessments, notified administrator/AC, DON, MD/NP, RP, local police, ombudsman, and followed any new orders received. She said Resident #1 did make physical contact to get staff or other residents' attention, but not to cause harm or injury. She said during the assessment, following the incident, Resident #1 did not show any aggressive behavior. She said Resident #1 may have patted face or hit arm or chest to get attention or direct eye contact. She said that Resident #1 had been provided with a communication board to attempt to communicate and staff monitor her and redirect if anticipated incidents. She said she worked until 6:00 p.m. the day of the incident and continued to monitor both residents with no further incidents or negative effects identified and reported the incident to the oncoming staff. She said when residents had incidents or changes in condition, the care plans were revised or updated by the MDS Coordinator or DON.During an interview on 01/08/2025 at 11:58 a.m., LVN C said she was the nurse on duty on 08/16/2025 when CNA B reported she witnessed Resident #1 hit another resident. LVN C said that Resident #1 was non-verbal and patted/hit to get others attention because she did not speak. LVN C said that facility staff have been trained to report all physical contact to the nurse and administrator for alleged physical abuse. LVN C said CNA B reported while she was changing linens and making the roommate's bed, Resident #1 was touching and putting her feet on the bed. LVN C said the roommate and CNA instructed Resident #1 to stop and she did. LVN C said the roommate exited the room and Resident #1 remained in the room, then the roommate returned to the room and Resident #1 went up to her roommate and hit/patted her on the chest. LVN C said she assessed both residents after the incident and no injuries were identified. LVN C said she followed the facility' protocol after the incident was reported, separate or verified separation for residents' safety, initiated monitoring for 72 hours, head-to-toe assessments, notified proper authorities, followed any new orders received. LVN C said Resident #1 was found to have a UTI and received treatment. LVN C said since the residents involved were roommates, Resident #1 was moved to another room to prevent further interactions. LVN C said Resident #1 is non-verbal and did pat/hit to get staff or other residents' attention, but not to cause harm or injury. LVN C said that she did not feel that Resident #1 hit her roommate in the chest to causes harm or injury. LVN C said that she worked until 6:00 pm the day of the incident and monitored Resident #1 with no further incidents. LVN C said when residents have incidents or changes in condition that the care plans or revised or updated by the MDS Coordinator.During an interview on 01/08/2025 at 3:00 p.m., MDS Coordinator said she participated in morning meetings and incident reports, and allegations were discussed during the morning meeting, if residents' care plans require updating and/or the IDT care plan meeting scheduling required it to be completed, if applicable. She said she recalls discussing the incidents with Resident #1 on 07/18/2025 and 8/16/2025 and thought the care plan was updated to reflect the incidents and the interventions updated. She said the care plan should have been updated to reflect the current residents' needs and interventions. She said that monitoring interventions for 72 hours was completed, authority notification and communication techniques were discussed, and the care plan should have reflected those interventions. She said she had forgotten to update the care plans with the revised interventions. She said she was responsible for updating or revising care plans and the DON reviews the care plans for completion. She said that the facility did not have a policy for care plan updating or revision, they followed the Resident Assessment Instrument (RAI) Manual. During an interview on 01/08/2026 at 3:30 p.m., the DON said that all incidents and allegations were discussed during morning meetings (including herself, Assistant DONs, administrator, department heads, MDS Coordinator, and Regional Nurse per phone if needed) and the MDS Coordinator is notified of any incidents requiring care plan revisions, and she was responsible for updating the care plans. She stated new interventions should be added to the care plan regarding recurrent resident-to-resident altercations. She stated she did not know why the care plans and interventions for Residents #1 had not been updated and/or revised after the alleged incidents. She said the MDS Coordinator is responsible for updating and revising the care plan as indicated. She said she was responsible for monitoring and ensuring that the care plans were completed and updated by the MDS Coordinator. She said if care plans were not updated or revised, the care plan would not reflect the current residents' needs. She said that the facility did not have a policy for care plan updating or revision, they followed the Resident Assessment Instrument (RAI) Manual. During an interview on 01/08/2026 at 4:00 p.m., the Administrator said the MDS Coordinator, and the DON were responsible for ensuring all care plans were updated/revised as needed. He said the possible negative outcome of care plans not being revised or updated could be residents not receiving the care they needed.Requested a policy for care plan updating and revision, the DON and MDS Coordinator said they did not have a care plan policy for updating or revising care plans. They followed the Resident Assessment Instrument (RAI) Manual. Record review of the mds-3.0-rai-manual-v1.20.1_October_2025 indicated A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #1) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #1's Foley catheter (an indwelling catheter) was secured on 11/04/2025. This failure could place residents at risk for urinary tract infections, dislodgment, potential complications and a decreased quality of life. Findings included: Record review of face sheet dated 11/04/2025 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination). Record review of Resident #1's care plan dated 11/03/2025 with a target date of 08/17/2025 indicated he had an indwelling catheter with a goal that he will be/remain free from catheter-related trauma through the next 90 days. Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was able to make himself understood and was usually understood by others. The MDS assessment indicated Resident #1 had a BIMS score of an 1, which indicated Resident #1 was severely cognitively impaired. The MDS assessment indicated Resident #1 required touching assistance from staff for all ADLs. The MDS assessment indicated Resident #1 had an indwelling catheter. Record review of Resident #1's Order Summary Report dated 10/01/2025 indicated: Monitor to ensure leg strap placement to secure Foley catheter drainage tubing. two times a day related to neuromuscular dysfunction of bladder, unspecified., with a start of 10/31/2022. During an observation on 11/04/2025 at 9:05 a.m. indicated Resident #1 was lying in his bed with the head of his bed elevated. Resident #1's Foley catheter was not secured to his leg. There was no securement device observed. During an interview on 11/04/2025 at 2:00 p.m. LVN B said nurses were responsible for ensuring Foley catheters were secured. LVN B said she should have checked it at the beginning of her shift. LVN B said she was unaware Resident #1 had no securement device in place. LVN B said she was nervous and had forgotten to check to see if Resident #1's Foley catheter was secured. LVN B said it was important to ensure Foley catheters were secured to prevent the catheter being dislodged out of the bladder, causing trauma or injuries. During an interview on 11/05/2025 at 10:35 a.m., ADON C said the nurse was responsible for making sure the catheter device was in place to secure the catheter. ADON C said it was important for the catheter to be secured so it doesn't become dislodged or cause urinary tract infection. During an interview on 11/05/2025 at 11:05 a.m., the DON said the nurses were supposed to make sure the Foley catheters are secured. The DON said it was important for the catheters to be secured because if they were not, it could potentially pull out and hurt the residents. The DON said she expected the nurses to follow policy and procedures regarding Foley catheter securement. During an interview on 11/05/2025 at 12:00 a.m., the Administrator said he expected the Foley catheter to be secured and maintained correctly by facility policy and acceptable standards CDC guidelines. He said a urine infection can be introduced to the residents if the Foley catheter is not secured and physician orders not followed. Record review of the facility's policy revised August 2022, titled, Catheter Care, Urinary, indicated: Purpose-The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.General Guidelines:4. Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site.

Based on observation, interview, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to medication carts for 1 of 4 Nurse medication carts (Hall 300 Nurse Cart) reviewed for medication storage. LVN A failed to ensure the Hall 300 Nurse medication cart was kept locked and under direct observation where residents and unauthorized staff could not access it when left at the main nurse's station for five minutes on 11/04/2025 at 9:23 a.m. This failure could place residents at risk of unauthorized persons, as well as residents, at risk of gaining access to unlocked medications that were not prescribed to them.Findings included: During an observation on 11/04/2025 from 9:23 a.m. to 9:28 a.m., indicated the Hall 300 Nurse medication cart was noted to be unsecured and unsupervised on hall 300. The Hall 300 Nurse medication cart was front facing with the drawers facing the hallway with the lock mechanism out (indicating it was unlocked). At 9:28 a.m. the state surveyor notified LVN A, who was coming out of a residents room that was two rooms down, approximately 100 feet away from the unlocked 100 hall nurse medication cart. Further observation of 300 hall nurse cart with LVN A, indicated inside the medication cart Drawer #1 were glucometers, OTC (over the counter) aspirin, vitamins, minerals and eye drops. Drawer #2 had a locked compartment with several controlled substances, and multiple resident's individual medication bubble-blister packets. During an interview and observation on 11/04/2025 at 9:28 a.m. LVN A said she was in charge of the cart. LVN A walked to the cart and locked it and said I know I should have locked my cart, I have been trained on locking my cart and she was the person responsible for administering medications on the 300 hall and used the cart. LVN A said she was two rooms down talking with a resident with the medication cart was out of her site. LVN A said she forgot to lock the cart before she stepped away from it. LVN A said the cart should not be unlocked and unattended because anyone walking by could get into the medications and risk medication theft or diversion. LVN A said she was in-serviced this year to keep the medication cart locked when not in use. During an interview on 11/04/2025 at 12:15 p.m., the DON said she expected the nurses to follow the facility policy and procedure related to locking the medication cart. She said the medication carts should always be locked if staff walked away from it or turned their back to it. The DON stated she was responsible for making sure the nurses locked the carts because of risk for misappropriation of property. She said she and both ADON's had in-serviced nursing staff to keep the medication cart locked when not in use. During an interview on 11/05/2025 at 2:45 p.m., the Administrator said his expectation was for nurses to have their medication carts in their line of site and keep the medication cart locked if it's not in use. He said all nursing staff were responsible for securing medications when not in use. He said the potential risk of unsecured medication cart was medication safety. Record review of the facility's Security of Medication Cart policy and procedure, dated April 2007, indicated: Policy Statement: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation:1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.2. The medication cart should be parked in the doorway of the resident's room during the medication pass.The cart doors and drawers should be facing the resident's room.3. When it is not possible to park the medication cart in the doorway, the cart should be parked in thehallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurseenters the resident's room.4. Medication carts must be securely locked at all times when out of the nurse's view.5. When the medication cart is not being used, it must be locked and parked at the nurses' station or insidethe medication room.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for residents, staff, and the public, for 2 of 4 shower rooms (Hall 300 and Hall 400) reviewed for physical environment. Hall 300's shower room had two shower chairs soiled with brownish/black substance under seats and on frames. Hall 400's shower room had a shower bed and under the cushion with a thick black substance. This failure could lead to residents experiencing a diminished quality of life. Findings included: 1. During an observation and interview on 06/23/2025 at 10:45 a.m., two shower chairs were soiled with brown and black substances on the seat, under the seats and on frame. The wall in shower on the right side has area (approximately four 12 x 12 tile squares and approximately 4 x 6 baseboard) were soiled with black substance. LVN C said shower chairs should be cleaned before and after each use. She said the staff who provide the showers were responsible for cleaning between uses. During an observation and interview on 06/23/2025 at 11:00 a.m., the housekeeping supervisor and two housekeepers were in the shower room scrubbing soiled areas. The housekeeping supervisor said they clean the shower chairs when they are soiled, and the aides are to clean daily and before and after each use. During an interview on 06/23/2025 at 12:45 p.m., CNA D said the shower chairs were to be cleaned before and after each use. She said facility has cleaning disinfectant provided to use for cleaning. The chairs are to be cleaned top and bottom of seat as well as the frame. She said the cleaning solution was kept secured in locked storage in shower room and out of reach of residents. During an interview on 06/24/2025 at 2:20 p.m., the DON said her expectations were to clean shower chairs before and after each use. She said the aides were responsible for task. Management was responsible for following behind to ensure cleanliness of equipment. Housekeeping was responsible for cleaning shower stalls. During an interview on 06/25/2025 at 1:30 p.m., the administrator said the aides were expected to clean shower room and shower chairs after each resident was bathed. She said they are supplied with a cleaner as well as a disinfectant to use when scrubbing the shower chairs. The administrator said each shower room on the halls contained their own cleaning supplies which were stored under lock and key. 2. During an observation on 06/23/2025 at 1:40 p.m., Hall 400's shower room had a shower bed that had a cushion, and underneath was a thick black substance coated the full length of the white plastic stretcher part of the shower bed. During an observation and interview on 06/23/2025 at 1:50 p.m., LVN F looked at the shower bed in the shower on Hall 400 and looked under the cushion and said that needs to be cleaned. During an interview on 06/23/2025 at 2:00 p.m., CNA K said she might have used the shower bed last and said that was a couple of weeks ago. She said she cleaned the shower bed with soap and water, however, did not remove the cushion and did not clean the plastic under the cushion. Record review of the Cleaning and Disinfection of Resident-Care Items and Equipment Policy Statement dated September 2022 indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). a. Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g., bedpans, urinals). 6. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions. 9. Durable medical equipment (DME) is cleaned and disinfected before reuse by another resident.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal and physical abuse for 4 of 7 residents reviewed for abuse. (Residents #3, #9, #37, and #55) 1. The facility failed to ensure Resident #3 was free from physical abuse when Resident #61 rolled up in her wheelchair and slapped Resident #3 on the face on 05/28/25. 2. The facility failed to ensure Resident #9 was free from verbal abuse when Resident #46 cursed her and told her it was her fault her daughter died on [DATE]. 3. The facility failed to ensure Resident #37 was free from physical abuse when Resident #46 walked up to her, grabbed her by the wrists, and shook her on 06/11/25. 4. The facility failed to ensure Resident #55 was free from physical abuse when Resident #45 hit her on the arm when she backed into him with her wheelchair on 06/14/25. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: Resident #3 Record review of a face sheet dated 06/25/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), intellectual disabilities (a condition that affects a person's ability to learn and function at an expected level), visual loss (partial or complete loss of the ability to see), and cognitive communication deficit (problem with communication that results from impaired cognition, as opposed to a problem affecting language and/or speech). Record review of the MDS dated [DATE] indicated Resident #3 had severely impaired cognition with a BIMS of 3 out of 15 and had no behaviors. Record review of the care plan reviewed on 06/23/25 indicated Resident #3 had impaired thought processes related to cognitive impairment AEB by her history or perceived physical aggression. The goal was she will remain free from actual harm of injury and verbalize feeling safe in her environment daily. Interventions included assess and document the resident's specific claims of physical aggression, conduct a head-to-toe assessment after each claim to rule out actual injury, consult psych services, and separate resident from other resident to ensure safety. Resident #61 Record review of a face sheet dated 06/25/25 indicated Resident #61 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included schizophrenia (a mental disorder characterized variously by hallucinations (typically, hearing voices), delusions, disorganized thinking and behavior, and flat or inappropriate affect), cocaine abuse, hypertension (a condition in which the force of the blood against the artery walls is too high), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), and vascular dementia (a type of loss of cognitive functioning caused by conditions that damage blood vessels and block blood flow to your brain). Record review of the MDS dated [DATE] indicated Resident #61 had severely impaired cognition with a BIMS of 2 out of 15 and had no behaviors. Record review of the care plan last reviewed on 05/05/25 indicated Resident #61 had a behavior problem related schizophrenia. The goal was she would have no evidence of behavior related to schizophrenia through the next 90 days. Interventions included administer medications as ordered, intervene as necessary to protect the rights and safety of others, remove from situation and take to alternate location as needed, monitor behavior episodes and attempt to determine underlying cause, and refer to psychiatric services for evaluation and treatment. 1. Record review of a Provider Investigation Report dated 06/04/25 indicated an incident categorized as Abuse occurred on 05/28/25. The incident involved Resident #3 and Resident #61. Resident #61 was ambulating around the nurse station in her wheelchair, rolled up to Resident #3, and slapped her in the face. An assessment was conducted on Resident #3 indicated she had no pain and there was no bruising or injuries to her face. Resident #61 was placed on 15-minute checks for 72 hours and was seen by the psychiatric services. Record review of Nurse Notes for Resident #3 indicated the following: * on 5/28/2025 at 08:52 p.m. at Resident #3 was sitting up in wheelchair. She had no signs or symptoms of acute distress. She had no signs or symptoms of facial discoloration, edema, warmth or open areas. * on 05/29/2025 at 11:33 a.m. Resident #3 was up in her wheelchair. She had no signs or symptoms of pain or discomfort, and no injuries were noted to her face. * on 05/30/2025 at 05:00 p.m. Resident #3 was up propelling herself around facility throughout shift. She had no signs or symptoms of distress. She denied pain or discomfort to face with no redness or swelling noted to her face. She was in a friendly mood. * on 05/31/2025 at10:20 a.m. Resident #3 was up in her wheelchair rolling around facility. She was cheerful and voiced no discomfort. * on 05/31/2025 at 04:36 p.m. Resident #3 was up propelling herself around facility throughout shift. She had no signs or symptoms of distress. She had a calm friendly mood. There was no redness or swelling noted to right cheek and she denied pain or discomfort. During an observation and interview on 06/23/25 at 09:45 a.m., Resident #3 was in bed. She indicated she was doing good. She indicated she had no issues. She was confused when asked about the incident involving Resident #61. She had no redness or bruising on her face. During an observation and interview on 06/23/25 at 10:25 a.m. Resident #61 was in bed. She was calm. She indicated she was doing fine. She indicated she could not recall the incident. During an interview on 06/23/25 at 01:15 p.m. LVN G said Resident #61 was fairly new and was adjusting. She said she had no issues of Resident #61 hitting anyone before or after the incident with Resident #3. She said residents were put on 15-minute checks and referred to psychiatric services if they had behaviors towards other residents. During an interview on 06/23/25 at 01:20 p.m. LVN C said Resident #3 would roam around the facility. She said she had not had any issues with the resident provoking any other resident. Resident #46 Record review of a face sheet dated 06/11/25 indicated Resident #46 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (an injury to the brain caused by an outside force), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (persistent and excessive worry that interferes with daily activities), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and behavioral syndromes (consistent pattern of behaviors that are correlated and often observed across different situations). Record review of the MDS dated [DATE] indicated Resident #46 had intact cognition with a BIMS of 15 out of 15 and had verbal behavioral symptoms directed toward others occurred 1 to 3 days. Record review of the care plan last reviewed 03/26/25 indicated Resident #46 had potential to be verbally and physically aggressive to staff and other residents. The goal was he would demonstrate effective coping skills and not harm himself or another resident. Interventions included monitor/document/report as needed any signs or symptoms of resident posing danger to self and others, separate resident from other residents due to behaviors, and refer to behavior hospital for admission due to escalating behaviors. Resident #9 Record review of a face sheet dated 06/25/25 indicated Resident #9 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities), depression (mental illness that negatively affects how you feel, the way you think and how you act), and diastolic congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly). Record review of physician orders for June 2025 indicated Resident #9 had no new orders for any medications. Record review of the MDS dated [DATE] indicated Resident #9 had intact cognition with a BIMS of 14 out of 15 and had no behaviors. Record review of the care plan last reviewed 05/28/25 indicated Resident #9 had no behaviors. 2. Record review of a Provider Investigation Report dated 06/23/25 indicated an incident categorized as Abuse occurred on 06/16/25. The incident involved Resident #9 and Resident #46. Resident #46 stood in front of Resident #9's walker in the smoke area and cursed her out. Resident #46 was placed on 15-minute checks for 72 hours and was sent to a psychiatric hospital for treatment of his escalation in behaviors. Record review of Nurse Notes for Resident #9 indicated an entry on 06/16/25 at 04:55 p.m. Resident #9 stated that she feels safe now, that she was just afraid when it happened. Record review of Social Services Notes for Resident #9 indicated an entry on 06/17/25 at 03:48 p.m. Resident #9 stated she was okay, and that the other resident did apologize to her the after the incident and they shook hands. She stated the incident did scare her, but she was okay and felt safe. During an observation and interview on 06/23/25 at 09:35 a.m. Resident #9 was sitting in bed working a word find puzzle. She said she was doing fine at this time. She said she did have an incident involving Resident #46. She said she was giving out candy and offered him a piece. She said she told him if he had a top denture, he would have to take it out because the candy would stick. She said he got up quickly and came to where she was sitting and started cursing at her. She said he also made the comment that the reason her daughter died was because of her. She started crying and said she had not seen him in a few days, but she was afraid of him at the time. She said she was sad about her daughter's death but was okay about the incident because he did apologize to her. Resident #37 Record review of a face sheet dated 06/25/25 indicated Resident #37 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of the MDS dated [DATE] indicated Resident #37 had moderately impaired cognition with a BIMS of 10 out of 15. She had behaviors of verbal behavioral symptoms occur 1 to 3 days and wandering occurred 1 to 3 days. Record review of the care plan last reviewed 05/05/25 indicated Resident #37 had behavior problem related to bipolar disorder. The goal was she would have no evidence of behavior problems through the next 90 days. Interventions included administer medications as ordered, explain/reinforce why behavior is inappropriate and/or unacceptable to the resident, and monitor behavior episodes and attempt to determine underlying cause. Record review of a face sheet dated 06/11/25 indicated Resident #46 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (an injury to the brain caused by an outside force), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (persistent and excessive worry that interferes with daily activities), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and behavioral syndromes (consistent pattern of behaviors that are correlated and often observed across different situations). Record review of the MDS dated [DATE] indicated Resident #46 had intact cognition with a BIMS of 15 out of 15 and had verbal behavioral symptoms directed toward others occurred 1 to 3 days. Record review of the care plan last reviewed 03/26/25 indicated Resident #46 had potential to be verbally and physically aggressive to staff and other residents. The goal was he would demonstrate effective coping skills and not harm himself or another resident. Interventions included monitor/document/report as needed any signs or symptoms of resident posing danger to self and others, separate resident from other residents due to behaviors, and refer to behavior hospital for admission due to escalating behaviors. 3. Record review of a Provider Investigation Report dated 06/18/25 indicated an incident categorized as Abuse occurred on 06/11/25. The incident involved Resident #37 and Resident #46. Security camera footage showed Resident #46 was walking down the hall and saw Resident #37 standing in his doorway. He was hollering and using inappropriate language as he approached her. Staff were positioned between the residents but Resident #46 bypassed staff and forcefully grabbled Resident #37 by the wrists and appeared to shake her. Resident #37 was assessed, and she had no scratches or bruising noted and she had no pain. Resident #46 was placed on 15-minute checks for 72 hours and was seen by the psychiatric services. Record review of Nurse Notes for Resident #37 indicated: * on 06/12/25 at 05:40 p.m. Resident #37 was ambulating in hallway with no complaints of pain or discomfort. * on 06/13/25 at 01:42 p.m. Resident #37 was in her room watching TV. She had no distress and no complaints of pain. During an observation and interview on 06/23/25 at 10:30 a.m. Resident #37 was ambulating independently in the facility. She had no bruising to her wrists. She said she was fine and had an issue with one resident, but she had no further issues with him. During an observation and interview on 06/25/25 at 10:22 a.m. Resident #46 was sitting in his room in his recliner. He was calm. He said he was doing fine. He said he had a problem with his attitude and went to the hospital for a little while but was doing better now. He said he did not want to talk about the incidents. During an interview on 06/23/25 at 01:15 p.m. LVN G said Resident #37 was known for wandering into other resident rooms and Resident #46 kept groceries in his room that were visibly seen from the open door. She said he was always accusing others of trying to take his food he had in his room. Resident #55 Record review of a face sheet dated 06/25/25 indicated Resident #55 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hypertension (a condition in which the force of the blood against the artery walls is too high) and cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). Record review of the MDS dated [DATE] indicated Resident #55 had intact cognition with a BIMS of 15 out of 15 and she had verbal behavioral symptoms directed toward others 1 to 3 days. Record review of the care plan last reviewed 03/26/25 indicated Resident #55 rolled backward in her wheelchair and had a history of running into another resident accidentally. The goal was she would not roll into another resident while wheeling through the hall. The interventions included consult with DOR related to therapy/restorative evaluation to assist resident with moving forward in wheelchair for safety and educated resident that rolling backward in hallway can be a safety hazard and potentially injure self and/or other residents. Resident #45 Record review of a face sheet dated 06/25/25 indicated Resident #45 was a [AGE] year-old male admitted on [DATE]. His diagnoses included hypertension (a condition in which the force of the blood against the artery walls is too high) and cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). Record review of the MDS dated [DATE] indicated Resident #45 had intact cognition with a BIMS of 15 out of 15 and he had no behaviors. Record review of the care plan last reviewed 05/05/25 indicated Resident #45 had no behaviors. 4. Record review of a Provider Investigation Report dated 06/20/25 indicated an incident categorized as Abuse occurred on 06/14/25. The incident involved Resident #45 and Resident #55. Resident #55 while rolling backwards in her wheelchair down the hallway accidentally made contact with the right arm of Resident #45 that was hanging on the side of his wheelchair. Resident #45 struck Resident #55 on the back of her arm. Resident #55 denied any pain or injury. There was no bruising or visible injury noted upon assessment. Resident #45 was placed on 15-minute checks for 72 hours and was seen by the psychiatric services. Record review of Nurse Notes for Resident #55 indicated on 06/15/25 at 05:57 p.m. Resident #55 had no signs of redness, warmth, or swelling. She denied pain or discomfort. During an observation and interview on 06/23/25 at 09:55 a.m. Resident #45 propelling self in hallway. Interactions with other residents were appropriate at this time. He said he had an incident with Resident #55. He said she back into him and did not even try to apologize to him so he hit her. He said it was the second time she backed into him with the wheelchair so he hit her, punched her right in the arm. During an observation and interview on 06/23/25 at 09:58 a.m. Resident #55 said she was able to propel herself backwards better than forwards. She had no bruising to her right upper arm. She said she accidently bumped into Resident #45 and before she even had the chance to apologize to him he hauled off and punched her in the arm. She said she knows they had a talk with him and she thought her husband spoke with him too. She said her husband was not happy about him hitting her. During an interview on 06/23/25 at 01:10 p.m. LVN F said Resident #45 was seen by psychiatric services shortly after the incident. She said she had had no other issue with Resident #45 before or after the incident. During an interview on 06/23/25 at 01:22 p.m. LVN C said Resident #55 always rolled herself backwards with the wheelchair. She said she knew therapy was trying to work with her on propelling forward. She said the resident was not known for deliberately rolling into other residents. During an interview on 06/25/25 at 02:15 p.m. the DON said she expected staff to prevent residents from being abused. She said they could not control a resident's unexpected behaviors or reactions to other residents' actions. She said the resident with behaviors would be placed on 15-minute checks and a psychiatric review would be done. She said if it was needed the resident would be sent to the psychiatric hospital for treatment. During an interview on 06/25/25 at 02:20 p.m. the Administrator said they tried to do everything to prevent residents from being abused but they could not determine when a resident would have a behavior or reaction to another resident. She said the resident with behaviors would be placed on 15-minute checks and a psychiatric review would be done. She said if it was needed the resident would be sent to the psychiatric hospital for treatment. Record review of the Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy revised April 2021 indicated the following: Policy Statement Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members; g. legal representatives; h. friends; i. visitors; and/or j. any other individual

Based on interview and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality for 2 of 7 residents reviewed for following physician orders. (Residents #46 and #317) 1. The facility did not administer a new medication Depakote prescribed to Resident #46 for behaviors as ordered. 2. The facility did not obtain a urine specimen on Resident #317 for a UTI Panel prior to ABT administration as ordered. These failures could place the residents at risk of not having their individual needs met and of not receiving adequate care and medical interventions to maintain their health and prevent worsening health conditions. Findings included: 1. Record review of a face sheet dated 06/11/25 indicated Resident #46 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (an injury to the brain caused by an outside force), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (persistent and excessive worry that interferes with daily activities), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and behavioral syndromes (consistent pattern of behaviors that are correlated and often observed across different situations). Record review of the Psychiatric Hospital discharge orders dated 06/24/25 indicated Resident #46 had a new order for Depakote 250mg twice daily for mood. Record review of the physician orders for June 2025 indicated Resident #46 had an order dated 06/24/25 with start date of 06/25/25 for Depakote Oral Tablet Delayed Release 250 mg (Divalproex Sodium) Give 250 mg by mouth two times a day for mood with Pending Confirmation. Record review of the Progress Notes with an entry dated 06/24/25 at 05:13 p.m. indicated LVN G documented Resident #46's provider was notified of return to facility and new order for Depakote. Record review of the June 2025 MAR indicated Resident #46 did not receive the evening dose of Depakote on 06/24/25 or the morning dose of Depakote on 06/25/25. During an interview on 06/25/25 at 11:14 a.m. LVN H said she did not give Resident #46 the morning dose of Depakote since there was no area to document the medication on the MAR. During an interview on 06/25/25 at 11:18 a.m. the ADON reviewed Resident #46's June 2025 Orders since readmitted from the psychiatric hospital and he said he had an order for Depakote twice daily with Pending Confirmation on it. He said he did not understand why a start date of 06/25/25 when the resident would have been at the facility to receive his evening dose. He said the resident should have received an evening dose on 06/24/25. He said the Depakote was available in the emergency medication supply. During a phone interview on 06/25/25 at 11:21 a.m. LVN G indicated she had notified the physician's NP and conducted the medication reconciliation. She said she did not give the evening dose Depakote on 06/24/25 and did not notify the physician of the missed dose. During an interview on 06/25/25 at 11:36 a.m. LVN H said Resident #46 did not have any Depakote on the cart this morning, so she ordered it from the pharmacy. She said the pharmacy said they had not received a request to fill the medication previously. During an interview on 06/25/25 at 02:15 p.m. the DON said she expected staff to follow the physician orders. She said the negative outcome could be a delay in receiving care. She said she expected staff to notify the physician if they were unable to carry out an order. She said the negative outcome could be a delay in receiving care. 2. Record review of a face sheet dated indicated Resident #317 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included pyelonephritis (a type of urinary tract infection that usually moves from your bladder to your kidneys), injuries of the head, and quadriplegia (a loss of motor function in all four limbs). Record review of the physician orders for May 2025 indicated Resident #317 dated 05/05/25 and start date of 05/29/25 for UTI Panel one time only. Record review of the Progress Notes for Resident #317 with an entry dated 05/05/2025 at 07:38 p.m. indicated the physician made rounds with new orders for Ambien (hypnotic) 10mg at bedtime, Macrodantin (antibiotic) 100mg four times a day for 10 days before kidney surgery, and obtain urine culture before the start of antibiotic. Record review of the May MAR indicated Resident #317 had a UTI Panel to be obtained dated 05/29/25. There was no documentation of the sample being collected on 05/29/25 or 05/30/25. She also had Macrodantin 100 mg four times a day for 10 days with a start date of 05/30/25. The medication was initiated on 05/30/25. Record review of the Progress Notes for Resident #317 indicated there was no documentation on 05/29/25 or 05/30/25 of the UTI specimen being obtained. Record review of the EMR from 05/29/25 through 05/30/25 indicated there was no UTI Panel results under the Results tab and none scanned in under the Miscellaneous tab. During an interview on 06/24/25 at 02:00 p.m. LVN [NAME] said she initiated Resident #317's ABT. She said she did not notice if the UTI specimen was obtained prior to initiating the ABT. During an interview on 06/25/25 09:37 a.m. ADON L said the UTI Panel was not done prior to the initiation of the ABT and the physician was notified. Record review of a laboratory report dated 06/06/25 provided by ADON L indicated a UTI Panel specimen was obtained and processed on 06/06/25. During an interview on 06/25/25 at 12:45 p.m. the DON said the CN should have obtained the specimen as ordered by the physician on Resident #317. Record review of a Medication and Treatment Orders policy revised July 2016 and provided was not pertinent to the information needed.

Based on observation, interview, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 5 medication carts(400 Hall cart) and 1 of 1 treatment carts (Station 2 Nurse Cart) reviewed for medication storage. - The facility failed to ensure the medication treatment cart was locked when left unsecured and unsupervised at the main nurse station. - The facility failed to ensure Hall 400 Nurse Cart did not contain loose pills. - The facility failed to ensure an insulin pen of basaglar insulin (long acting insulin used to lower blood sugar) had a date as to when it was opened. These failures could place residents at risk of adverse reactions to medications, misappropriation of medications and not receiving therapeutic effects of medication. Findings include: During an observation and interview on 06/23/2025 at 09:00 a.m., the medication treatment cart was noted to be unsecured and unsupervised at the main nurse station. Located inside the unlocked medication treatment cart was the following items labeled as keep out of reach of children: -Mupirocin 2% ointment - treats bacterial skin infections. -Iodosorb Cadexomer Iodine Gel 10gm/0.35 oz - a gel applied to the skin to treat wet ulcers and wounds. This medication can kill bacteria, absorb exudate (pus), and clean out your wound so it can heal faster. Can be bought over-the-counter. -Zinc Oxide Ointment - used to treat and prevent diaper rash. Also used to protect skin from being irritated and wet. Iodine 10% swabs - used as a first aid antiseptic to prevent infection in minor cuts, scrapes and burns. -Hydrophilic Wound dressing pansement hydrophile - for the local management of pressure and venous stasis ulcers, superficial wounds, scrapes, burns, and partial-and-full thickness wounds. -16 oz bottle hydrogen peroxide - used as an oxidizer, bleaching agent, and antiseptic. -bottle of Dakin solution full strength - a dilute antiseptic solution containing bleach and other ingredients, traditionally used for cleaning wounds and preventing infection. - 8 oz bottle povidine-iodine 10% solution - an over-the-counter antiseptic solution used to treat and prevent skin infections. Antifungal powder - treats fungal or yeast infections in your skin. ADON B approached the medication treatment cart and reviewed the unsecured items with surveyor. She said the treatment cart should never be unlocked and unsupervised. She said anyone could pass by and take anything out at any time. ADON B said all the nursing staff were responsible for providing treatments to their assigned residents and whomever was last to use the cart should always lock when finished. She said the key to unlock treatment cart was kept in medication room. During an interview on 06/24/2025 at 2:00 p.m., the DON said licensed nursing staff perform the treatments to the residents they oversee. She said the keys to the treatment cart was kept in the medication room behind locked door. She said medication and treatment cart should be kept locked and always secured when not in use for safety purposes. She said the treatment carts should be always kept clean. The DON said the risk of treatment cart being left unlocked and unsupervised would be that any resident, staff, or visitors could open the drawers while passing by and retrieve harmful items including scissors or any treatment medications. During an observation and interview on 06/25/2025 at 7:45 a.m., the medication treatment cart was noted to be unsecured and unsupervised at the main nurse station and containing the same items as previously noted. ADON B approached surveyor as before and said the medication treatment cart was left unsupervised and unsecured and should not have been. She said she did not know who had used the treatment cart last, and whomever should have secured after use. During an observation and interview on 06/25/25 at 2:00 p.m., indicated inventory of the Hall 400 Nurse Cart with LVN F indicated had 4 loose pills and one basaglar insulin pin was used, did not have a date as to when it was opened. LVN F said nursing staff were expected to check their carts daily for inappropriately labeled medication or lose pills. She said all medications are were expected to be packaged in the original pharmacy packaging containing all the required pharmacy labels or in the OTC stock bottles to ensure patient safety. She said if mistakenly administered, unlabeled insulin usage or loose pills could place residents at risk of disastrous side effects since their identification was unknown; so they must be crushed and discarded in the sharp's container and the insulin had to be reordered. LVN F said she was educated on medication storage and keeping the medication cart clean of loose pills. During an interview on 06/25/25 at 3:44 p.m., the DON said the nurses were responsible for keeping medication carts clean, free of loose pills and label medication with date of when first opened. She said the pharmacy consultant checked random carts monthly for loose pills and medication labeling. She said the nurses were educated on keeping the medication carts clean and labeling insulins with first opened. The DON said having loose pills and usig insulin that was not labeled can lead to adverse reactions, infection from contamination or uncontrolled health conditions. Record review of a facility policy titled, Medication Labeling and Storage revised February 2023 indicated, 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others .

Based on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 1 of 23 residents reviewed for accuracy of assessments. (Resident #s 14) The facility did not accurately complete the MDS assessment to indicate Resident #14 did not have a restraint/ side rail. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of a face sheet dated 06/23/25 indicated Resident #14 was a [AGE] year-old female readmitted on [DATE]. Her diagnoses included dementia (group of thinking and social symptoms that interfere with daily function) and bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #14 was severely impaired of cognition and needed supervision for sit to lying, lying to sitting on the side of bed, sit to stand, and chair/ bed-to chair transfer. The assessment indicated Resident #14 had restraints and alarms of bed rails used less than daily during the last 7 days marked. Record review of Resident #14's care plans with a target date of 08/26/25 did not include a care plan for side rails. Record review of the physician's orders dated 06/23/25 indicated Resident #14 was not prescribed side rails or restraints. Record review of Resident #14's June 2025 MAR printed 06/23/25 indicated no side rails prescribed or received in June 2025. During an observation and interview on 06/24/25 at 10:47 a.m., Resident #14 was lying on her bed with no restraints and no side rails on her bed. She was confused but said yes to was she was treated well. During an interview on 06/24/25 at 2:16 p.m., LVN E said she was providing care for Resident #14 today. She said Resident #14 was not restrained and did not have side rails on her bed. LVN E said Resident #14 never had side rails on her bed. She said Resident #14 was on the secure unit of the facility and monitored 24 hours a day 7 days a week. During an interview on 06/25/25 at 9:34 a.m., the MDS Nurse said she was responsible for all MDSs completed in the facility. She said her back up was the Senior Director of Clinical Reimbursement. The MDS Nurse said she was educated on completion of MDS and accuracy. She said Resident #14 did not have a restraint or side rails on her bed. The MDS Nurse said it was an error on her part, she checked the box on the MDS by accident for side rails. The MDS nurse said there was no resident risk of Resident #14's MDS marked for side rails less than weekly, just an inaccurate MDS and not following regulations. During an interview on 06/25/25 10:48 a.m., the DON said the MDS Nurse was responsible for all MDSs completed in the facility, and she was educated on completion of MDSs. The DON said the backup was the Senior Director of Clinical Reimbursement. She said Resident #14 did not have side rails on her bed nor a restraint. The DON said the MDS should not have been marked for side rails. She said it was an oversight. The DON said there was no resident risk, it was just an inaccurate assessment. The DON said her expectation was all MDSs completed accurately and timely. During an interview on 06/25/25 at 10:57 a.m., the Administrator said the MDS nurse was responsible for all MDSs completed in the facility and she was educated on completion of MDSs. She said the Senior Director of Clinical Reimbursement was the back up. The Administrator said Resident #14's MDS marked for side rails was a typo and no risk to the resident. The Administrator said her expectation was for all MDSs completed accurately and timely. During an interview on 06/25/25 at 12:30 p.m., the DON said the facility did not have an MDS policy they followed the RAI. During an interview on 06/25/25 at 12:54 p.m., the Senior Director of Clinical Reimbursement said the MDS Nurse was responsible for all MDSs completed in the facility. She said she completed OIG audits (a systematic examination of government programs, operations or financial record to assess for compliance with laws and regulations) and completed quarterly audits of a randomly selected group of resident's MDSs to review and audit the MDS coding. She said she educated MDS nurses weekly about rotating MDS coding topics along with any trends identified in the audits. She said there was no resident risk since it was only the MDS that was incorrect, not the care plan or Kardex (a nursing documentation system that organized and summarizes key patient information to guide nursing care plans), and therefore did not impact the care provided to the resident. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 indicated, . P0100: Physical Restraints Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restrict freedom of movement or normal access to one's body Coding: 1. Not used 2. Used less than daily 2. Used daily . Used in Bed . A. Bed rails . Bed rails include any combination of partial or full rails.

Based on interview and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 2 of 5 residents reviewed for physician notification. (Residents #46 and #317) 1. The facility failed to notify the physician of Resident #317 when an ordered UTI Panel specimen was not obtained. 2. The facility failed to notify the physician of Resident #46 when he missed 2 doses of Depakote a new medication prescribed for behaviors. These failures could place residents at risk of not receiving appropriate medical treatments, which could result in a decline in health. Findings included: 1. Record review of a face sheet dated indicated Resident #317 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included pyelonephritis (a type of urinary tract infection that usually moves from your bladder to your kidneys), injuries of the head, and quadriplegia (a loss of motor function in all four limbs). Record review of physician order for May 2025 indicated Resident #317 dated 05/05/25 and start date of 05/29/25 for UTI Panel one time only. Record review of the Progress Notes for Resident #317 with an entry dated 5/5/2025 at 07:38 p.m. indicated the physician made rounds with new orders for Ambien (hypnotic) 10mg at bedtime, Macrodantin (antibiotic) 100mg four times a day for 10 days before kidney surgery, and obtain urine culture before the start of antibiotic. Record review of the May MAR indicated Resident #317 had a urine sample for a UTI Panel to be obtained dated 05/29/25. There was no documentation of the sample being collected on 05/29/25 or 05/30/25. She also had Macrodantin 100mg four times a day for 10 days with a start date of 05/30/25. The medication was initiated on 05/30/25. Record review of the Progress Notes for Resident #317 indicated there was no documentation on 05/29/25 or 05/30/25 of the urine specimen being obtained or the physician being notified it was not obtained. During an interview on 06/24/25 at 02:00 p.m. LVN F said she initiated Resident #317's ABT. She said she did not notice if the UTI specimen was obtained prior to initiating the ABT. She said the physician should have been notified if the specimen was not obtained. During an interview on 06/25/25 09:37 a.m. ADON L said the UTI Panel was not done prior to the initiation of the ABT. He said the physician was not notified until after the initiation of the medication. 06/25/25 12:45 PM the DON said the CN should have obtained the specimen as ordered on Resident #317 or the physician should have been notified at the time. 2. Record review of a face sheet dated 06/11/25 indicated Resident #46 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (an injury to the brain caused by an outside force), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (persistent and excessive worry that interferes with daily activities), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and behavioral syndromes (consistent pattern of behaviors that are correlated and often observed across different situations). Record review of the Psychiatric Hospital discharge orders dated 06/24/25 indicated Resident #46 had a new order for Depakote 250mg twice daily for mood. Record review of the physician orders for June 2025 indicated Resident #46 had an order dated 06/24/25 with start date of 06/25/24 for Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 250 mg by mouth two times a day for mood with Pending Confirmation. Record review of the Progress Notes with an entry dated 06/24/25 at 05:13 p.m. indicated LVN G documented Resident #46's provider was notified of return to facility and new order for Depakote. During an interview on 06/25/25 at 11:14 a.m. LVN H said she did not give the morning dose of Depakote since there was no area to document the medication on the MAR and she had not notified the physician of the missed dose. During an interview on 06/25/25 at 11:18 a.m. ADON L reviewed Resident #46's June 2025 Orders and Progress Notes since readmitted from the psychiatric hospital. He said the resident had an order for Depakote twice daily with Pending Confirmation on it. He said he did not understand why a start date of 06/25/25 when the resident would have been at the facility to receive his evening dose. He said there was no documentation of the physician being notified of the missed doses. During a phone interview on 06/25/25 at 11:21 a.m. LVN G indicated she had notified the physician's NP and conducted the medication reconciliation. She said she did not give the evening dose Depakote and did not notify the physician of the missed dose. During an interview on 06/25/25 at 02:15 p.m. the DON said she expected staff to notify the physician if they were unable to carry out an order. She said the negative outcome could be a delay in receiving care.

Based on interviews and record reviews, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #117) of seven residents and one of five medication carts(Hall 400 cart) reviewed for pharmacy services. The facility failed to ensure all of Resident #117's medications was administered as ordered by the physician resulting in the incorrect dose of Vitamin C administration. The facility failed to ensure three insulin pens of aspart insulin were removed from use. Aspart insulin (rapid acting insulin used to lower blood sugar), with open date of 04/25/25, had been expired for 31 days, open date of 05/19/25, had been expired for 9 days, and open date of 05/23/25, had been expired for 5 days. This failure could place residents at risk of not receiving medications as ordered by their physicians and exacerbations of their medical conditions. Findings included: Record review of Resident #117's face sheet dated 06/25/25 indicated a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included protein-calorie malnutrition (insufficient intake of protein and caloric-energy), abnormal findings in urine, allergic rhinitis (watery eyes sneezing associated with immune reaction to irritants), diabetes and cerebrovascular disease (decreased blood flow to brain). Record review of Resident #117's quarterly MDS dated [DATE] indicated he had a BIMS of 9 out of 15 indicating he had moderately impaired cognitive skills for daily decision making. Record review of Resident #117's active orders as of 05/08/25 included a physician order for asorbic acid tablet 500 mg give 2 tablet equal 1 gram by mouth one time a day for UTI. Date started was 06/28/24. Record review of Resident #117's June 2025 MAR/TAR revealed LVN C documented administration of asorbic acid tablet 500 mg tablet, 2 tablets on 06/24/25 in the morning at 9:00 a.m. Record review of Resident #117's undated care plan included: Focus - Resident #117 was at risk for iron deficiency anemia and Interventions - encourage intake of food high in iron, vitamin c and to give medications as ordered. Focus- Resident #117 has multiple complications and at risk for vitamin deficiency and Interventions - administer my vitamins per MD orders and monitor for effectiveness. In an interview on 06/23/25 at 2:00 PM, the DON stated Resident #117 received the vitamin c 500mg for preventative reasons for UTI. She said a pharmacy consultant comes in monthly and reviews medication administration, reports any errors and also provides training to the staff. The DON said she expects the staff to follow the orders as written and the order for Resident #117's vitamin c should have been 2 tablets to equal the full dose of 1 gram. The DON said Resident #117 was given the wrong dosage of medication. The DON said she expected her nurses to pass medications and do basic medication functions like following the 5 Rights of Medication Administration and notify the Physician for anything out of the ordinary. The DON said the risk to residents would be not receiving the correct therapeutic dosages of medications. During an observation on 06/24/25 at 8:45 a.m., LVN G prepared medications for Resident #117. LVN G sanitized her hands and placed the following medications into a medication cup: Amlodipine 10mg one tablet, buspirone 15 mg one tablet, metformin one tablet, sotalol 80mg one tablet, alfuzosin 10mg one tablet, vitamin c 500mg one tablet, cranberry 450mg 1 tablet, iron 324mg 1 tablet sertraline 50mg one tablet and hydrocodone 10/325mg two tablets. LVN G administered the medications to Resident #117 and he swallowed them without incident. During a phone interview on 06/25/25 at 1:43 p.m., LVN G said Resident #117 received vitamin c 500mg one tablet for supplementation. LVN G said the order was for vitamin c 500mg x 2 tablets. LVN G said she gave one tablet instead of two and stated it was her mistake, and just missed it. She said she checks the medication cart drawers for each medication to ensure she has everything needed. She said then she takes each medication container and dispenses the drug into cups while checking the order again before finally administering. LVN G did not see there would be any severe risk to Resident #117 when he did not receive the full dose and she thought she was following the orders at the time. She said it was a medication error and would report it to the DON right away and next time she will slow down and re-check what she is doing. During an observation and interview on 06/25/25 at 2:00 p.m., inventory of the Hall 400 Nurse Cart with LVN F indicated in the top draw, 3 insulin pens in use beyond the recommended time frame of use after opened. Observation on the medication cart insulin pens included: - one with open date of 04/25/25, had been expired for 31 days, - one open date of 05/19/25, had been expired for 9 days, - one open date of 05/23/25, had been expired for 5 days LVN F said nursing staff were expected to check their medication carts daily for expired medication and inappropriately labeled medication. LVN F said the insulin pens should have been removed from the medication cart 28 days from the opening date, but they were overlooked. She said she was providing care for residents on the 400 hall today, and had not given any insulin. LVN F said she was educated on medication storage and removal of insulin in use beyond the recommended time frame of use after opened. LVN F said the resident risk of insulin, in use beyond the recommended time frame of use after opened, was the medication may not be as effective. During an interview on 06/25/25 at 3:44 p.m., the DON said the nurses were responsible for the removal of insulin on the nurses' medication cart, 28 days after the open date. She said the pharmacy consultant checked random carts monthly for expired medication. She said the nurses were educated on removing expired medication off the nurse's medication cart during orientation, annually and on an as needed basis. The DON said insulin pens on 400 hall, in use beyond the recommended time frame of use after opened, were overlooked and should have been removed. She said the resident risk of insulin in use beyond the recommended time frame of use after opened was the medication may not be as potent as it should be. The DON said her expectation was all insulin removed, at the beyond use date, off the nurse's medication cart. Record Review of facility policy titled, Administering Medication revised dated April 2019 read in part: . Policy Statement: Medications are administered in a safe and timely manner, and as prescribed . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Record review of a facility policy titled, Medication Labeling and Storage revised February 2023 indicated, 3. If the facility has discontinued, outdated, or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .

Based on interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident reviewed for tracheostomy care. (Resident #317) LVN A did not change Resident #317's outer tracheostomy cannula on 05/11/25 as listed on the May 2025 MAR. This failure could place residents with a tracheostomy at risk for infections to the tracheostomy site. Findings included: Record review of a face sheet dated indicated Resident #317 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included injuries of the head, quadriplegia (a loss of motor function in all four limbs), and tracheostomy status (an opening in the neck in order to place a tube into a person's windpipe so they can breath). Record review of physician orders for May 2025 indicated Resident #317 had an order dated 04/11/2025 to change tracheostomy outer cannula every month one time a day the 11th every month. Record review of the May 2025 MAR indicated Resident #317 did not receive her tracheostomy outer cannula change on the day ordered or anytime during the month. During an interview on 06/24/25 02:10 p.m. ADON L said Resident #317's May 2025 MAR was blank on the day the tracheostomy outer cannula was to be changed and it was not documented on any other day of the month. He said he did not see where it was changed out on another day of the month. He said if it was not documented as being done then it was not done. During an interview on 06/25/25 at 12:45 p.m. the DON reviewed Resident #317's May 2025 MAR and said the tracheostomy outer cannula was blank on the 11th when it was to be changed. She said if it was not documented then it was not done. During an interview on 06/25/25 at 12:50 p.m. LVN A reviewed Resident #317's May 2025 MAR and said she was on duty on 05/11/25. She said she had been trained on tracheostomy care. She said she just may have forgotten to document on the MAR. She said if it was not documented as being done then it was not done. Record review of a Tracheostomy Care Policy and Procedure revised August 2013 indicated Purpose: The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas General Guidelines: 4. Tracheostomy tubes should be changed as ordered and as needed (at least monthly) . During an interview on 06/25/25 at 02:15 p.m. the DON said she expected staff to provide the required tracheostomy care. She said the negative outcome could be infection. She said all nurses were trained on tracheostomy care upon hire and reviewed annually.

Based on interview and record review , the facility failed to accurately submit a PL1 (PASRR Level 1 Screening) screening when a resident admitted with a diagnosis of Mental Illness, Intellectual Disability or Developmental Disability for 1 of 5 residents reviewed for PASRR screenings. (Resident # 29) The facility failed to submit a new PL1 screening when Resident #29 was readmitted from mental health hospital on [DATE] . This failure could place residents at risk of not receiving specialized services. Findings included: Record review of Resident #29's face sheet dated 06/25/25 was a [AGE] year-old-female admitted on [DATE] and readmitted on [DATE] . She had diagnoses of convulsions (uncontrolled jerking, loss of consciousness and other symptoms caused by abnormal electrical activity in the brain), and stroke. Record review of Resident #29's annual MDS dated [DATE] indicated she was not PASRR positive and had a BIMS score of 00 indicated severely impaired with cognition. The assessment indicated she had diagnoses of anxiety (feelings of worry and nervousness), schizophrenia (disorder that affects the thinking ability) and depression (persistent feelings of sadness). The assessment indicated Resident #29 received an antianxiety during last 7 days. Record review of Resident #29's quarterly MDS dated [DATE] indicated she had a BIMS score of 00; indicatinged severely impaired with cognition. Record review of Resident #29's care plan created on 05/28/24 indicated Resident #29 had a history of seizures and psychotropic medication for depression and anxiety with a goal to monitor for effectiveness of psychotropic medication. Record review of Resident #29's PL1 form dated 05/28/24, indicated she was positive for mental illness. There was no PASRR Level II Screening or Form 1012 (Mental Illness/Dementia Resident Review) found in the clinical record from the resident's readmission on [DATE] to 06/25/25. Record review of Resident #29's annual MDS dated [DATE] indicated she was not PASRR positive and had a BIMS score of 00 indicated severely impaired with cognition. The assessment indicated she had diagnoses of anxiety (feelings of worry and nervousness), schizophrenia (disorder that affects the thinking ability) and depression (persistent feelings of sadness). The assessment indicated Resident #29 received an antianxiety during last 7 days. During an interview on 06/25/25 at 11:15 a.m., the MDS nurse said she was responsible for all PASRR forms in the facility. She said Resident #29's PL1 was positive for mental illness, and she overlooked transmitting the PL 1 to the local mental health authority. The MDS nurse said Resident #29 would need a PASRR evaluation to be completed by the local mental health authority. The MDS nurse said the risk of a PL1 form being missed the resident could miss out on needed services. She said she had been trained and it was an oversight when Resident #29 was readmitted from the mental health hospital. During an interview on 06/25/25 at 11:25 a.m., the DON said the MDS nurse was responsible for all PASRR forms in the facility and was educated on completing PASRR forms correctly and timely. She said Resident #29 's PL1 form was overlooked. The DON said the risk of PASRR forms completed incorrectly or not transmitted was a resident could miss out on services if deemed PASRR positive. The DON said her expectation was all PASRR forms completed correctly and timely. She said the facility followed the RAI for their PASRR policy. Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision for Resident #1 with two staff members for bed mobility during incontinent care to prevent a fall with injury on 9/19/2024 which resulted in Resident #1 having complaint of pain to the right knee. An x-ray was conducted on 09/19/2024 with the results of evidence of acute fracture of the right distal femur (bone in the upper leg) requiring hospitalization for surgical intervention. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 09/19/2024 and ended on 09/24/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and harm due to the lack of supervision provided by the facility. Findings included: Record review of the face sheet for Resident #1 indicated she was initially admitted on [DATE], was [AGE] years old female with diagnoses of high blood pressure, Chronic Obstructive Pulmonary Disease, muscle weakness, muscle wasting, cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), dementia (loss of cognitive functioning), and morbid obesity. Record review of the MDS state optional assessment dated [DATE] indicated Resident #1 required 2 staff members for bed mobility. Her BIMS indicated she was cognitively intact with a score of 14. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #1 was able to understand and make her needs known. She required substantial/maximal assistance with the helper doing more than half the effort. Her BIMS indicated she was cognitively intact with a score of 14. Record review of the care plan dated 12/28/2024 indicated Resident #1 had an ADL self-care performance deficit. Resident #1 required 2 staff for assistance with bed mobility, with start date of 08/16/2024. Record review of the physician's orders September 2024 for Resident #1 indicated she had an order for Acetaminophen Tablet 650 mg, give 1 tablet by mouth every 4 hours as needed for general discomfort related to right knee pain with start date of 08/24/2024. Record review of the Kardex (electronic care task utilized by care staff) dated 09/19/2024 indicated Resident #1 required 2 staff for bed mobility. Record review of the nurse progress notes for Resident #1 authored by LVN D indicated on 09/19/2024 at 07:45 a.m., CNA A had reported to LVN D that while getting things ready to change the resident and while waiting on help to change the resident, Resident #1 slid off the bed feet first, so she guided the resident to floor and informed nurse of the incident. The CN performed a head-to-toe assessment and the resident denied pain or hitting her head. Resident #1 was able to move all extremities. The CN provided care to a skin tear to the left toe and Resident #1 was assisted back to bed using a mechanical lift and 3 staff members. Record review of the MAR for September 2024 indicated Resident #1 received 3 doses of Tylenol 650 mg 1 tablets on 09/19/2024 at 8:14 a.m., 4:24 p.m., and 8:29 p.m. for pain and it was effective. Record review of the nurse progress note authored by LVN H for Resident #1 indicated on 09/19/2024 at 4:40 p.m. the resident had an x-ray of her right hip for pain. Record review of the nurse progress note authored by LVN X for Resident #1 indicated on 09/20/2024 at 11:19 a.m. the resident was admitted to local hospital for a closed distal right femur fracture (lower leg bone fracture that occurs without leaving any open wound in the skin) and surgery was scheduled for later that evening. Record review of an x-ray report dated 09/19/2024 indicated Resident #1 had evidence of an acute fracture of the right distal femur (bone in the upper leg) and diffuse osteopenia (a condition of lower-than-normal bone mineral density that may lead to a condition in which bones become weak and brittle) is present. Record review of the nurse progress note authored by LVN D for Resident #1 indicated on 09/20/2024 at 12:02 a.m. the facility received x-ray report which reflected an acute fracture (a break in a bone that occurs due to sudden, one-time injury, typically from direct impact or fall) of the distal femur (bone in the upper leg). Notified the on-call physician of the x-ray report and was ordered to send Resident #1 to the local ER for evaluation. Resident #1 transferred to local hospital via ambulance. Record review of the hospital records dated 09/20/2024 indicated Resident #1 had a distal femur fracture that required surgical intervention. On 09/24/2024 a right femur fluoroscopic (is a medical imaging procedure that uses several pulses (brief bursts) of an X-ray beam to show internal organs and tissues moving in real time on a computer screen) indicated a previous exam showed a fracture of the distal right femur extending into the right knee joint. There had been placement of a plate along the medial aspect (toward the middle or center) with multiple screws and alignment was normal. Impression revealed: Open reduction internal fixature (a surgical procedure used to repair severe bone fractures by realigning and stabilizing the broken bones with hardware such as plates and screws) of right femur fracture. Record review of the facility's investigation report dated 09/26/2024 indicated on 09/19/2024 Resident #1 had a fall from bed requiring head to toe assessment. Resident #1 assisted back to bed using Hoyer lift and 3 staff members. Resident #1 began to complain of hip and knee pain and mobile x-ray ordered. Resident #1's x-ray results showed an acute fracture of the distal femur (upper bone of leg). Resident #1 was transported via ambulance via stretcher to the local hospital related to acute fracture of the distal femur with surgical intervention scheduled for 09/20/2024. The investigation interviews led to CNA A admitting on 09/19/2024 she provided incontinent care alone to a Resident #1 which required 2 persons assistance for incontinent care resulting in Resident #1 falling and having a significant injury. CNA A was suspended and terminated related to this incident. Facility staff in-serviced on following Kardex for required assistance with each resident and on identifying abuse and neglect. Record review of the nurse progress notes authored by LVN X for Resident #1 indicated on 10/01/2024 at 1:19 p.m., the resident was back in facility after she was hospitalized at the local hospital for a right femur fracture with surgical intervention. Resident #1 had a surgical incision to right knee with 14 staples intact. Assist x 2 staff with all ADL's and transfers. Record review of the physician's orders October 2024 for Resident #1 indicated she had an order for Acetaminophen Tablet 650 mg, give 1 tablet by mouth every 4 hours as needed for general discomfort related to pain with start date of 08/24/2024 and Tramadol 50 mg, give 1 tablet every 8 hours as needed for pain with start date of 10/04/2024. Record review of the MAR for October 2024 indicated Resident #1 received 1 dose of Tylenol 650 mg 1 tablet on 10/01/2024, 10/02/2024, 10/03/2024, 10/04/2024, 10/05/2024, 10/06/2024, 10/10/2024, 10/15/2024, 10/18/2024, and 10/20/2024 for pain and it was effective, and she received 1 dose of Tramadol 50mg 1 tablet on 10/05/2024, 10/06/2024, 10/07/2024, 10/11/2024, 10/14/2024, 10/16/2024, 10/22/2024 and 10/27/2024 for pain and it was effective. Record review of the Kardex dated 10/01/2024 indicated Resident #1 required 2 staff for bed mobility. Record review of CNA A's personnel file indicated that she was terminated on 09/19/2024 for failing to follow safety protocols and notation showed the employee did not follow the facility's safety protocol with a two-person assistance to turn and reposition a resident in bed and the failure resulted in the resident having a significant injury. Record review of an in-service dated 09/20/2024 indicated nursing staff were retrained on the use of the Kardex system and the Kardex must be followed at all times. If the Kardex indicated that a resident required 2 people for transfer, bed mobility, etc., then staff must have 2 people assisting. Mechanical transfers must always be completed with 2 staff members, no exceptions. During an interview on 06/03/2025 at 9:30 a.m., Resident #1 said she did not remember much about the day she fell. She said she recalled having to go to the hospital and have surgery from a broken leg after the fall. During an interview on 06/03/2025 at 1:05 p.m., LVN H said Resident #1 had always been 2 staff with turning her and for her care. She said Resident #1 required a mechanical lift with 2 staff for transfers. LVN H said the Kardex, and care plan identified care needs and assistance required. During an interview on 06/03/2025 at 1:15 p.m., LVN C said when staff reposition Resident #1 they must use 2 staff. LVN C said the Kardex, and care plan identified care needs and assistance required. During an interview on 06/03/2025 at 1:30 p.m., CNA G said she knew to use 2 staff with Resident #1. She said when giving incontinent care or bed mobility and use a mechanical lift with 2 staff members for transfer out of bed. CNA G was able to correctly identify residents requiring 2 persons assist on her assigned hall and Kardex system to identify if resident required 1 or 2 persons assist. CNA G said if a resident requires a 2 persons assistance always find another staff member to help with care. During an interview on 06/03/2025 at 1:40 p.m., CNA F said she knew to use 2 staff with Resident #1. She said when giving incontinent care or bed mobility and use a mechanical lift with 2 staff members for transfer out of bed. CNA F was able to correctly identify residents requiring 2 persons assist on her assigned hall. CNA F said the Kardex identified care required and assistance needed. CNA F said if a resident requires a 2 persons assistance always find another staff member to help with care. During an observation on 06/03/2025 at 2:00 p.m., revealed CNA G and CNA F provided incontinent care to Resident #1 on her back and pulled her up in the bed and repositioned. Both staff were present the entire time care was provided, and supplies required were obtained prior to the start of care, and adequate assistance/supervision was provided from start to finish. During an interview on 06/03/2025 at 2:45 p.m., CNA A said she had been oriented about the Kardex system. CNA A said on 09/19/2024 she was making her last rounds around 4:30 - 5:00 a.m. alone and was going to provide incontinent care. She said while she was changing Resident #1's brief, she turned her over towards her and the resident rolled off the bed, landed on her feet but her knees buckled because she can't walk/hold her weight and she guided/assisted Resident #1 to the floor. She said Resident #1 was a 2 person assist with task but because the facility was always short staffed, she had to provide the care by herself. She said Resident #1 was a large lady and she should have had someone assist her while providing care. She said that the Kardex provided if the resident required 1 or 2 persons to assist with care and Resident #1 was a 2 person assist and she should have requested help or waited on help. She said, If care would not have been provided would have got in trouble and now got terminated for the incident. Record review of staffing schedule for nursing on 09/18/2024 indicated the 6:00 p.m. to 6:00 a.m. shift had 3 LVNs and 6 CNAs scheduled. An attempted telephone interview on 06/03/2025 at 3:45 p.m. with LVN D, was unsuccessful. During an interview on 06/03/2025 at 6:10 p.m., CNA Q said Resident #1 required 2 staff members for bed mobility and mechanical lift with 2 staff members for transfers. He said he looked at the Kardex and provided care as directed on the Kardex. During an interview on 06/03/2025 at 6:10 p.m., CNA R said Resident #1 required 2 staff members for bed mobility and mechanical lift with 2 staff members for transfers. She said she looked at the Kardex and provide care as directed on Kardex. CNA R was able to correctly identify residents requiring 2 persons assist on her assigned hall. During an interview on 06/03/2025 at 6:35 p.m., the ADON/LVN B said CNA A was terminated on 09/20/2024 due to failing to follow facility safety protocol. The ADON said all the nursing staff were retrained on the Kardex system to ensure all staff knew about the residents who needed 2 staff for bed mobility. The ADON said his expectation was for the staff to get help in turning the residents who required 2 staff members per Kardex or care plan. During interviews on 06/03/2025 at 8:00 a.m. to 7:00 p.m. and 06/04/2025 at 7:00 a.m. to 3:00 p.m., 14 CNAs (CNA F, CNA G, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA U, CNA V and CNA Y), and 8 LVNs (ADON/LVN B, LVN C, LVN D, LVN E, LVN H, LVN J, LVN T and LVN W) revealed all the staff were retrained on the Kardex system and said the program indicated how many staff was required for eating, transfer, bed mobility and ambulation. During an interview on 06/04/2025 at 9:00 a.m., the Administrator said she expected the staff to use the Kardex system and get help when help was needed or required. The facility policy revised July 2017 titled Safe Lifting and movement of Residents indicated the Policy Statement In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.1. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include Resident's preferences for assistance; Resident's mobility (degree of dependency); Resident's size; Weight-bearing ability; Cognitive status; Whether the resident is usually cooperative with staff; and the resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting, and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. 8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged . On 06/04/2025 at 10:28 a.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 09/19/2024 and ended on 09/24/2024. The facility had corrected the noncompliance before survey began.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 4 of 14 residents (Resident #2, #3, #4 and #5) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2, #3, #4, and #5 were free of abuse from Resident #1. -On 07/10/24 Res #1 hit Res #3's head. -On 07/21/24 Res #1 hit Res #2 in the TV room. -On 07/22/24 Res #1 pushed Res #2 in the TV room. Res #2 sustained a head injury and was sent out to the ER for treatment. -On 09/02/24 Res #4 alleged Res #1 hit her. -On 11/24/24 Res #1 punched Res #3 in the forehead and chest. -On 12/28/24, Res #1 hit Res #5 in the face in the dining room The facility did not review, update, or implement interventions to include adequate supervision and continued to leave Resident #1 alone and unsupervised with other residents. An Immediate Jeopardy (IJ) was identified on 02/26/25 at 2:00 p.m. The IJ template was provided to the facility on [DATE] at 2:15 p.m. While the IJ was removed on 02/27/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of physical abuse from other residents. Findings included: 1. Record review of Resident #1's face sheet dated 02/20/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included schizophrenia (chronic mental disorder), diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin), convulsions (sudden, violent, irregular movement of a limb or of the body), latent syphilis (a stage of syphilis infection where the bacteria (Treponema pallidum) remains in the body without causing any noticeable symptoms), and OCD (unwanted thoughts and fears, or obsessions). Record review of Resident #1's annual MDS assessment dated [DATE] indicated she was admitted to the facility with a serious mental illness, she was able to make herself understood and understood others, and she had mild cognitive impairment (BIMS-9). Record review of Resident #1's care plan dated 04/09/24 indicated she sometimes displayed verbally aggressive behavior. Interventions included social services to evaluate and visit with me, activity staff to visit with me, provide diversional activities, and remove me from public area when behavior is disruptive and unacceptable. Interventions included discuss behavior, monitor behavior episodes, and attempt to determine underlying causes. The interventions did not include resident specific interventions or supervision to prevent resident physical aggression towards others. Record review of Resident #1's care plan dated 06/12/23 indicated Resident #1 had potential to be physically aggressive by resident to resident altercations related to history of harm to others. Interventions included administer medications as ordered, labs as ordered by physician, monitor, document, and report PRN any sign or symptom of resident posing danger to self and others, and nursing staff to notify abuse coordinator, police, Ombudsman, MD, RP and psych, and psychiatric/psychogeriatric consult as indicated. Interventions included discuss behavior, monitor behavior episodes, and attempt to determine underlying causes. The interventions did not include resident specific interventions or supervision to prevent resident physical aggression towards others. Record review of Resident #1's care plan dated 04/20/24 indicated Resident #1 had a behavior problem related to schizophrenia and OCD. Interventions included discuss behavior, monitor behavior episodes, and attempt to determine underlying causes. The interventions did not include resident specific interventions or supervision to prevent resident physical aggression towards others. Record review of progress note dated 07/10/24 at 10:00 a.m., completed by LVN B indicated she was sitting at the desk charting and heard a loud noise. LVN B heard HSK Z say Resident #1 hit Resident #3 in the back. Resident #1 and Resident #3 were standing at the double doors of the secure unit. Resident #3 was crying and there was some redness to her upper back. MD A, Administrator, Ombudsman, NP K, (named police department), and DON notified. LVN B did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of IDT progress note dated 07/16/24 completed by the DON for Physical Aggression that occurred on 07/10/24 indicated Resident #1 was still showing signs of aggression and was sent out to behavior hospital on 07/12/24. The IDT note did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of facility investigation dated 07/17/24 indicated Resident #1 was discharged to behavioral hospital on 07/12/24. The facility confirmed Resident #1 hit Resident #3. Psych notification ordered 15 minute monitoring and labs. Resident #1 remained on 15 minute monitoring and continued to show signs of aggression until discharged to behavior hospital. Staff were trained on abuse/neglect/exploitation on 07/10/24. Monitoring sheets dated 07/10/24-through 07/12/24 indicated Resident #1 was on 15 minute monitoring. The investigation did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of Resident #1's progress note dated 07/18/24 at 1:45 p.m., completed by LVN A indicated Resident #1 returned to the facility from the behavior hospital. LVN A did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of Resident #1's progress note date 07/19/24 at 12:48 p.m., completed by LVN B indicated Resident #1 refused to let her roommate use the bathroom in their shared room. Resident #1 told the CNA to fuck off when she told Resident #1 her food was in the room. Record review of Resident #1's progress note dated 07/21/24 at 9:12 a.m., completed by LVN B indicated at 6:15 a.m. LVN B was at the medication cart. Resident #1's roommate stated Resident #1 hit another resident in the chest. There was no redness or complaint of pain from the other resident. Resident #1 was separated from the other resident. Critical monitoring started. Message left for NP/MD. Administrator and DON notified. (named police department) notified. NP K and RP notified. LVN B did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of Resident #1's progress note dated 07/22/24 at 08:32 a.m., completed by LVN A indicated Resident #1 pushed another resident down in the TV room. Administrator, DON, (named police department), and Ombudsman notified. Resident #1 on 1-1 at this time. (named police department) arrived at 7:20 to talk to Resident #1. Resident refused to tell (named police department) what happened or why it happened. RP notified. Record review of Resident #1's IDT Behavior Health Review dated 07/23/24 indicated Resident #1 was sent to behavioral hospital on 7/10/24 and returned back to the facility on [DATE]. Resident #1 came back with no new orders. Labs drawn and received critical ammonia level. New orders for Lactulose 15 ml tid x 5 days. Educated staff on recognizing agitation and de-escalate behaviors. Interventions care planned for all events. Emergency care plan set up with family related to behaviors and possible discharge from the generation unit. Psych NP involved and received no medication change. 07/21/24 Resident #1 was placed on q 15 min behavioral monitoring due to behavioral and MD and psych notified. Psych stated they would see the resident on visit. 07/22/24- Resident #1 placed one to one and sent out to the behavioral related to physical aggression. There was no resident specific intervention implemented to prevent and protect other residents from Resident #1's aggression towards others. The note did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors upon her return to the facility. Record review of the facility investigation dated 07/24/24 indicated Resident #1's roommate came to LVN B and said Resident #1 hit another resident in the chest. There was no redness or open areas noted to the other resident's chest and no complaint of pain. Residents were separated immediately. Psych was notified and Resident #1 was place on q 15 minute behavioral monitoring. Staff was inserviced on abuse and neglect and improving resident behavior. Behavior monitoring to continue for 72 hours post allegation with Q 15 min for first 24 hours. There were no specific interventions noted to prevent Resident #1's aggression toward others. The investigation did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of facility investigation dated 07/29/24 indicated Resident #1 was noted sitting in the television room on 07/22/24 when another resident reported to LVN A that Resident #1 had pushed Resident #2 to the floor. Residents were separated immediately. Resident #2 sustained a 1 inch laceration to the back of her head. Psych stated to do an q 15 min behavioral monitoring. Resident #1 placed on one on one and sent to behavioral hospital. Resident #2 sent out to medical center for evaluation and treatment Upon Resident #2 returned with 6 staples noted to the back of her head. In-services provided on abuse and neglect and notifying abuse coordinator/administrator with any allegation of abuse, neglect or misappropriation. In-service completed on behavior monitoring and interventions to use to dissuade physical altercation behaviors. Emergency care plan held with family. Behavior monitoring to continue for 72 hours post allegation with Q 15 min for the first 24 hours. There were no specific interventions noted to prevent Resident #1's aggression toward others. Record review of IDT Event Review dated 09/03/24 for Physical Aggression initiated on 09/02/24 indicated Resident #4 reported to the nurse that Resident #1 hit her on the back of the head while she was coming out of their shared room. There was no injury. Residents were immediately separated and place on behavior monitoring q-15 minute monitoring for 72 hours. Orders received to send Resident #1 to hospital for psych evaluation. Resident #1 transferred to another room. Psych NP visited on 09/03/24 and received order to send Resident #1 out to behavioral hospital. Resident returned from hospital and was transferred to behavior hospital. The note did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of Resident #1's progress note dated 11/24/24 at 11:25 a.m., completed by LVN B indicated LVN B was standing at the medication cart with her back turned away from the residents and heard a CNA shout no. CNA reported Resident #1 hit Resident #3 forehead and chest. The residents were separated. There were no injuries. Administrator, psych NP, family, RP, ombudsman, named police department and physician notified. Record review of facility investigation dated 11/29/24 indicated psych ordered 15 minute behavioral monitoring for 72 hours. The facility confirmed Resident #1 abused Resident #3. Record review of Resident #1's progress note dated 12/28/24 at 8:00 a.m., completed by LVN A indicated CNA was standing in the doorway monitoring residents in the dining room when she witnessed Resident #1 getting up from a table and went to another table and struck Resident #5 in the face. Staff separated residents. Resident #1 was on 1-1 monitoring. Administrator, DON, ADON, were notified immediately. (named police department) was called. Ombudsman was notified. On call was notified and gave new orders to send Resident #1 out for evaluation. Psych was called. Resident was transported to ER for evaluation. Record review of Resident #1's progress note dated 12/29/24 at 2:55 a.m., completed by LVN AA indicated Resident #1 returned to the facility. Resident RP and MD notified of Resident #1's return. Will continue to monitor resident for behaviors and all other concerns. LVN AA did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors. Record review of IDT Event Review dated 01/03/25 for physical aggression initiated on 12/28/24 indicated Resident #1 was unable to say what happened or why. Resident #1 was sent to ER for evaluation. She returned with no new orders. Psych indicated discontinue 1-1 and begin 15-minute monitoring for 72 hours. Psych would see resident next facility visit. The note did not indicate Resident #1's level of supervision implemented to protect other residents from further aggressive and physical behaviors upon her return to the facility. Record review of the facility investigation dated 01/03/25 indicated Resident #1 and Resident #5 were in the dining room on 12/28/24 at 7:57 a.m. Resident #1 walked over to Resident #5 and struck him in the face. Residents were separated. Residents were assessed. There were no injuries. Resident #5 asked why Resident #1 hit him. Resident #1 was place on 15 minute monitoring and transferred to the ER for evaluation and treatment. Resident #5 did not provoke Resident #1. Staff were in-serviced on abuse and neglect. Staff were in-serviced on improving resident behaviors (resident-to resident altercations)-redirect any resident that is causing agitation towards another resident. Separate residents immediately before/after an altercation and monitor each resident. 2. Record review of Resident #2's face sheet dated 02/25/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnosis included IDD (intellectual or developmental disorder), anxiety (a feeling of fear, dread, and uneasiness), diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin), depression (mental health condition), and delirium due to known physiological condition (state of acute mental confusion and disorientation caused by an underlying medical condition). Record review of Resident #2's annual MDS dated [DATE] indicated was usually able to make herself understood and understood others, had severe cognitive impairment (BIMS-5), had verbal behavioral symptoms directed at others that put her at risk for physical illness or injury and significantly interfered with the resident's participation in activities or social interactions. She had wandering behaviors that significantly intruded on privacy or activities of others. Record review of Resident #2's care plan dated 12/14/23 indicated she was an elopement risk/wanderer related to a history of wandering. Interventions included admit to secure unit, identify pattern of wandering, and intervene as appropriate. Record review of an incident report dated 07/22/24 completed by LVN A indicated an un-named resident notified LVN A Resident #2 was pushed down by another resident. Resident #2 was crying and lying on the floor of the activity room. Resident #2 had bleeding and a 1 inch laceration to the back of her head. Resident #2 was sent to the ER for evaluation and treatment. Record review of Resident #2's hospital records dated 07/22/24 indicated she was admitted due to a fall caused by being pushed by another resident. She had a laceration to the back of her head. It was repaired with 6 staples. 3. Record review of Resident #3's face sheet dated 02/26/25 indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included schizoaffective disorder-bipolar type (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), anxiety (a feeling of fear, dread, and uneasiness), cognitive communication deficit (problems with communication), and dementia (loss of cognitive functioning). Record review of Resident #3's annual MDS assessment dated [DATE] indicated she was sometimes able to make herself understood and usually understood others, and she had severe cognitive impairment (BIMS-00). Record review of Resident #3's care plan dated 07/30/21 indicated Resident #3 had cognitive impairment and required cues and redirecting. Interventions included repeating information, allowing time for response, and assist as needed with tasks. Record review of Resident #3's care plan indicated she had a history of inappropriate/disruptive behavior. Interventions included activities, administer medications, and monitor and document behavior. Record review of Resident #3's care plan dated 04/28/22 indicated she wandered aimlessly and significantly intruded on privacy and activities. Interventions included offering diversions, activities, food, conversation, television or books. Record review of progress note dated 07/10/24 at 4:15 p.m., completed by LVN B indicated she was charting at the desk in the hall and heard a loud noise. LVN B heard HSK Z say Resident #1 hit Resident #3 in the back. Both residents were standing at the secure unit double doors. There was some redness noted to Resident #3's upper back. Residents were separated for safety. 4. Record review of Resident #4's face sheet dated 02/26/24 indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included schizophrenia (mental health disorder), major depressive disorder (mood disorder), mild cognitive impairment (stage between normal aging and dementia), anxiety (a feeling of fear, dread, and uneasiness), and dementia (loss of cognitive functioning). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others, and she had severe cognitive impairment (BIMS 6). Record review of Resident #4's care plan dated 09/20/24 indicated she had the potential for physical aggression. Interventions included critical behavior monitoring, separate resident from other resident, and intervene before agitation escalates. Record review of IDT Event Review dated 09/03/24-Physical Aggression Received on 09/02/24 indicated Resident #4 reported Resident #1 hit her on the back of the head. Residents were separated and assessed with no injuries or pain. Resident #4 stated she was o.k. and no distress was noted. Resident #4 was transferred to another room. 5. Record review of Resident #5's face sheet dated 02/26/25 indicated he was an [AGE] year old male, admitted on [DATE], and his diagnoses included dementia (loss of cognitive functioning and cognitive communication deficit (problems with communication). Record review of Resident #5's quarterly MDS assessment indicated he was able to make himself understood and understood others and had severe cognitive impairment (BIMS-3). Record review of Resident #5's care plan dated 07/19/23 indicated he had impaired cognition related to dementia. Interventions included cue, reorient and supervise as needed. During an observation on the secure unit on 02/20/25 at 11:00 a.m., Resident #1 was asleep in her room with the door closed. There were other residents observed walking in the hall, in their rooms, or in the TV room and dining room. There was no staff observed near Resident #1 or her room. During an interview on 02/20/24 at 11:30 a.m., CNA G said on 12/28/24, Resident #1 was leaving the dining room and then she turned around and hit Resident #5 in the face. She said she redirected Resident #1 to her room and called for the nurse. She said there was nothing happening at the time of the incident. She said there was no warning before Resident #1 hit Resident #5. She said there was no specific interventions to prevent Resident #1's aggression towards others. She said staff could only watch and intervene and separate before and after the aggression. During an interview on 02/20/25 at 1:12 p.m., CNA G said she was working on 07/22/24 when Resident #1 pushed Resident #2 to the floor in the TV room. She said she was not working the day before when Resident #1 hit Resident #2 and was not aware of the incident. She said she was not aware Resident #1 was being monitored. She said Resident #1 was no on 1-1 monitoring for behavior. She said she was busy with other resident care and LVN A was at the medication cart in the hallway. During an interview on 02/20/25 at 1:20 p.m., CNA H said she was assisting other residents in the shower and did not observe Resident #1 push or hit Resident #2 on 07/22/24. She said she was not aware Resident #1 was on 15 minute monitoring. She said after Resident #1 pushed Resident #2 the residents were separated. She said Resident #1 was in her own room after the incident. During an interview on 02/20/25 at 1:23 p.m., LVN A said the aides were taking care of the residents and as they got each resident ready for the day, each resident was brought to the TV room. She said Resident #1 was already in the TV room. She said she was busy passing medications and heard a bump and then Resident #4 said Resident #1 pushed Resident #2 to the floor. She said she went to the TV room and and separated the residents. She said Resident #1 refused to say what happened and refused to leave the TV room. She said one aide stayed with Resident #1 while they moved the other residents. She said Resident #2 had a 1 inch laceration to the back of her head and was sent out to the hospital. She said Resident #1 was on 15 minute monitoring that started from 07/21/24. She said Resident #1 eventually went to her room and and stayed in in her room until a referral and transfer to to a behavioral hospital on 07/22/24. During an interview on 02/21/25 at 9:30 a.m., the DON said the facility had attempted to discharge Resident #1 to another facility but no facility would accept her due to her aggressive behaviors. She said Resident #1 resided on the secure unit. She said there was 1 nurse on shift (6a-6p and 6p-6a 7 days/week), 2 aides (6a-2p,2p-10p, and 10p-6a 7 days/week) and 1 activity staff/CNA (8a-5p Monday through Friday). She said said staff was increased to protect the residents from aggressive behavior. She said Resident #1 was assessed for any medical issues, removed and separated from other residents, and had psychiatric interventions after each behavior. She said Resident #1 was sent to the ER and then, if necessary, referrals were obtained to send her to a behavioral hospital. She said Resident #1 may have been on 1-1 prior to being sent out to the behavior hospital. She said if there was no additional signs of aggression or behaviors the monitoring was reduced. During an interview on 02/21/25 at 12:22 p.m., SW J said she was employed with the facility since December 2024 and had not attempted to find alternative placement for Resident #1. She said she was aware the previous SW had attempted to find alternative placement for Resident #1 but was not successful due to her behaviors. During an interview on 02/24/25 at 12:30 p.m., LVN C said the IDT discussed interventions for the incident that occurred on 07/22/24 when Resident #1 pushed Resident #2. She said there were no new specific interventions to protect other residents from Resident #1's aggression added to the care plan. She said she did not know why interventions were not added. She said she was responsible for adding the interventions to the care plan. She said the monitoring intervention was already in place. During an interview on 02/25/25 at 1:34 p.m., LVN B said there were no residents who were said they were afraid or acted as if they were afraid of Resident #1. She said staff have to watch and be on the look out for Resident #1 was she is walking past or by other residents because her aggression and behaviors were unpredictable. During an interview on 02/25/25 at 1:40 p.m., Activity Staff C said she was not aware of any residents or staff who were afraid of Resident #1. She said staff would attempt to keep Resident #1 separate from other residents to avoid aggressions. During an interview on 02/25/25 at 1:45 p.m., Resident #5 said he was not afraid of anyone. He said he did not get hit by anyone or remember anyone hitting him. During an interview on 02/25/24 at 3:48 p.m., NP F said it was her first psych visit with Resident #1 was on 12/23/24. And she was in the process of reviewing her medications for possible adjustments. She said it would be her expectations the facility would implement 1-1 after resident to resident aggression until the resident was calm then go to 15 minute monitoring. She said moods were not predicable and behaviors would happen. She said she did not know what interventions were available to prevent the behaviors. She said the resident may need a referral to a behavior hospital if the behavior was not caused by a medical issue. During an interview on 02/25/25 at 4:30 p.m. LVN B said staff knew to be aware of Resident #2 wandering around Resident #1 and to keep them separate. She said she was usually in the hall monitoring to keep residents away from resident #1. During an interview on 02/25/25 at 4:34 p.m., CNA I said Resident #1's behaviors were unpredictable. She said staff were aware of her behaviors and monitored other residents to keep them away from Resident #1. She said she was not aware of any specific interventions to prevent Resident #1's behaviors. She said she was standing in the hall on 11/24/24 and she saw Resident #1 used her right hand/fist and hit Resident #3 on her forehead and her chest. She said she told the charge nurse and the residents were separated. During an interview on 02/25/25 at 5:40 p.m., the DON said Resident #1 was not monitored every 15 minutes for behaviors upon her return from the behavior hospital. She said Resident #1 was monitored for 72 hours just as every new admission was monitored. She said there was no policy related to resident behavior monitoring. During an interview on 02/26/25 at 8:30 a.m., Resident #4 said she saw Resident #1 push Resident #2 in the TV room. She said Resident #2 fell and hit her head. She said Resident #2's head was bleeding. She said Resident #2 was not doing anything to Resident #1. She said there was no staff in the TV room. She said LVN A was in the hall with the medication cart. She said she told LVN A that Resident #1 pushed Resident #2 and the staff came running fast to take care of Resident #2. She said she did not know if any other residents were afraid of Resident #1 except Resident #2. She said Resident #2 would come and sit by her (Resident #4) if Resident #1 would be in the same room. During an observation on the secure unit on 02/26/25 at 9:00 a.m., Resident #1 was in her room, dressed and sitting on her bed. She said she was fine and had no complaints. There was no signs of distress or agitation. There were other residents observed walking in the hall, in their rooms, or in the TV room and dining room. There was no staff observed near Resident #1 or her room. During an interview on 02/26/25 at 9:10 a.m., LVN A said Resident #1 was in the TV room. She said Resident #2 walked into the TV room. She said she heard a loud noise from the TV room and then Resident #4 came and told her (LVN A) that Resident #1 had pushed Resident #2 to the floor. She said Resident #1's behaviors were unpredictable. She said at the time of the incident on 07/22/24, Resident #1 was on 15 minute monitoring from 07/21/24. During an interview on 02/26/25 at 10:00 a.m., the Administrator said Resident #1 was constantly redirected due to her behaviors. She said staff were aware they had to be attentive to Resident #1 due to her history of aggressive behaviors and her risk of aggressive behavior. She said the facility was doing everything possible to prevent behaviors including activities and medications changes. She said she was not aware Resident #1 was left alone in the TV room on 07/22/24. She said she was not going to say whether or not Resident #1 should have been left alone with other residents. During an interview on 02/26/25 at 10:15 a.m., LVN C said behavior interventions should be on Resident #1's care plan. She said the interventions should have included educating staff, redirection, and activities. She said resident specific interventions should be on the Kardex and available for all staff. During an interview on 02/26/25 at 10:20 p.m., the DON said Resident #1's was compulsive and her behaviors could not be anticipated. She said the facility had previously attempted to find alternate placement but was not successful due to her aggressive behavior. During an interview on 02/26/25 at 11:00 a.m., CNA G said she was not aware Resident #1 was being monitored for behaviors or that anyone should have been watching her on 07/22/24. She said other residents were at risk of Resident #1's aggressive behaviors because the behaviors were unpredictable. She said staff had to watch Resident #1 and keep her separate from other residents or keep other residents away from being too close to Resident #1. During an interview on 02/26/25 at 11:00 a.m. CNA H said she was not aware Resident #1 was being monitored for behaviors or that anyone should have been watching her on 07/22/24. She said Resident #1 had unpredictable aggressive behaviors. She said all residents had to be keep away from Resident #1 for their protection. During an interview on 02/26/25 at 11:00 a.m., LVN A said she was aware of Resident #1 being on 15 minute monitoring but was not aware of the reason for the monitoring. She said she would look to see where Resident #1 was and what she was doing and document on the sheet. She said on 07/22/24 after the incident, Resident #1 refused to say anything. She said Resident #2 said Sorry mama help. She said Resident #1's behaviors were unpredictable and all other residents on the secure unit were at risk from her aggressive behaviors. During an interview on 02/26/25 at 2:47 p.m., NP K (previous psychiatric provider) said Resident #1's behaviors were unpredictable and she was a danger to others. She said it was her opinion Resident #1 was not appropriately placed in the facility. She said she was aware the facility had attempted to find alternate facility placement and was not successful. She said Resident #1 really needed placement in a state facility. She said Resident #1's medications never really worked and were always being adjusted but nothing ever worked to prevent the unpredictable behaviors. Review of the facility's Abuse and Neglect Policy dated 04/2021 indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; . 2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. 10. Protect residents from any fur [TRUNCATED]

Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 14 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA D had assistance from another staff member during incontinent care on 01/13/24 which resulted in Resident #1 rolling off the bed and being transferred to the hospital where she was diagnosed with a small left anterior frontal scalp hematoma. The noncompliance was identified as PNC. The Immediate Jeopardy began on 01/13/24 and ended on 01/15/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for falls resulting in injury, pain, and hospitalization . Findings included: Record review of Resident #1's face sheet dated 03/11/24 indicated she was a [AGE] year-old female admitted [DATE], and her diagnoses included quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food status, tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) status, and aphasia (loss of ability to understand or express speech, caused by brain damage). Record review of Resident #1's MDS assessment dated [DATE] indicated she was rarely/never understood, had severely impaired cognitive skills, and was totally dependent with two+ persons physical assist for bed mobility, transfers, and toilet use. Record review of Resident #1's care plan dated 05/23/22 (revised 05/09/23) indicated she was totally dependent on two staff for bed mobility, toilet-use, bathing/showering, dressing, and transfers. Record review of Resident #1's Kardex (electronic care task utilized by care staff) dated 03/11/24 indicated she was totally dependent on two staff for bed mobility, toilet-use, bathing/showering, dressing, and transfers. Record review of Resident #1's progress note dated 01/13/24 at 10:30 p.m., completed by LVN C, indicated CNA D approached the nurse station and requested assistance with Resident #1. CNA D stated Resident #1 had fallen on the floor. Resident #1 was lying face up, awake and alert, and responded to stimuli. There was a hematoma on the left side of her forehead. The physician, family member, DON, and Administrator (abuse coordinator) were notified. Resident #1 was transported to the hospital for evaluation and treatment. Record review of Resident #1's progress note dated 01/14/24 at 3:04 a.m., completed by RN E indicated hospital reported Resident #1 was stable. CT results were pending. Record review of Resident #1's progress note dated 01/14/24 at 4:33 a.m., completed by RN E indicated the hospital reported Resident #1's CT showed no irregularities and would be transported back to the facility. Record review of Resident #1's progress note dated 01/14/24 at 5:40 a.m., completed by RN E indicated Resident #1 returned to the facility. She had a slightly raised area to the middle left side of her forehead. Record review of Resident #'s hospital CT record dated 01/14/24 indicated a small left anterior frontal scalp hematoma. Record review of the facility's investigation report dated 01/16/24 indicated on 01/13/24 at 10:30 p.m., CNA D provided incontinent care to Resident #1 by herself. CNA D attempted to reposition Resident #1 in her bed. Resident #1 rolled off the bed and fell on to the floor. Resident #1 sustained a small hematoma to the left side of her forehead. Resident #1 was transferred to the hospital for treatment. Resident #1 returned to the facility on [DATE]. At 5:40 a.m. Resident #1's CT dated 01/14/24 indicated no irregularities. During an interview on 03/11/24 at 10:30 a.m., the Administrator said CNA D was providing incontinent care to Resident #1 without a second staff on 01/13/24. She said Resident #1 fell off the bed and sustained a small hematoma to the left side of her forehead. She said there was no reason for CNA D to provide Resident #1's incontinent care without a second staff. She said the facility was not short staffed. She said CNA D did not request assist for any of the other CNA on shift or any of the nurses on shift. She said it was her expectation CNA D and all staff would follow the care guide on Resident #1's Kardex. She said Resident #1 could have sustained a more serious injury. She said CNA D was suspended pending the facility's investigation. She said CNA D was trained during her orientation to provide care per Resident #1's Kardex care guide. She said CNA D and all staff were retrained on following resident care guide on 01/14/24 and 01/15/24. During an interview on 03/11/24 at 12:18 p.m., CNA D said she provided incontinent care to Resident #1 without a second staff to assist on 01/13/24. She said she did not see any available CNA to ask for assistance. She said she did not ask any of the nurses for assistance. She said she went to reposition Resident #1 in the bed and Resident #1 rolled off the bed on to the floor. She said she went to the nurse station to report the fall and get assistance to put Resident #1 in bed. She said LVN C assessed Resident #1 and checked for injuries. She said Resident #1 had a small bump and bruise on her left forehead area. She said Resident #1 was crying. She said EMS arrived at the facility and transported Resident #1 to the hospital. She said she was trained on the Kardex and resident care guide. She said she thought Resident #1 was a 1-person or a two-person assist. She said she was told by CNA E during her orientation that if she felt comfortable, she could do Resident #1's care by herself. She said she did not check the Kardex to verify Resident #1's level of care or assistance required for ADLS. During an interview on 03/11/24 at 2:03 p.m., CNA F said she was retrained to follow the Kardex resident care guide after Resident #1 fell off her bed on 01/13/24. She said she had performed Resident #1's incontinent care by herself and without staff second staff on previous occasions but Resident #1 had not fallen off the bed. She said CNA D did not ask other staff for assistance on 01/13/24. She said she did not know why CNA D had performed Resident #1's care without a second staff. She said CNA D said she was a new staff and did not feel comfortable without a second staff. She said there was other staff available to assist with Resident #1's care but CNA D had not asked anyone for assistance. During an interview on 03/13/24 at 10:30 a.m., the Administrator said all staff were trained on the Kardex during orientation. She said the Kardex was not specifically listed on the check-off list. She said it was added as a separate check off and skills packet to the orientation packet after Resident #1 fell from her bed on 01/13/24. During an interview on 03/13/24 at 10:30 a.m., the RNC said the facility started retraining staff on 01/14/24 and 01/15/24 to use the Kardex to ensure they provide the required level of care for each resident. She said all staff were retrained and passed a test and were able to access the Kardex and provide the required level of care. The surveyor attempted to contact LVN C for an interview on 03/11/24 1:29 p.m. She did not respond. The surveyor attempted to contact RN E for an interview on 03/11/24 at 1:31 p.m. She did not respond. Record review of the facility's Safety and Supervision of Residents policy dated 2001 (revised July 2017) indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Systems Approach to Safety 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. On 03/13/24, the surveyor confirmed the facility implemented appropriate measures to ensure the safety of residents after the incident on 01/14/24-01/15/24 involving Resident #1 by: Observations of staff on 03/11/24 and 03/13/24 providing care indicated no observed concerns. During interviews on 03/11/24 from 9:30 a.m. through 4:00 p.m., and 03/13/24 from 9:30 a.m. through 2:20 p.m., 5 LVN's (on all shifts) 10 CNA's (on all shifts) and the ADON said they received training prior to the incident and after the incident on 01/13/24 from the DON and the RNC regarding resident abuse, neglect, rights and resident Kardex care levels. The nursing staff verbalized understanding of the trainings and were able to give examples of resident Kardex care levels, they would ask for assistance if required, they would report any non-compliance of care level to the Administrator, DON, or charge nurse. Interviews conducted on 03/11/24 and 03/13/24 with 3 residents who required 2 person assist with ADLS indicated they had no complaints or concerns with their care and always had two staff as required. They would report to the Administrator or the DON if staff attempted to provide care without a second staff. Record review of staff re-training dated 01/14/24 and 01/15/24 indicated all facility nursing staff were retrained on the residents' Kardex and level of care and continued to 3/07/24 with new hires. The facility tested and competency assessed all nursing staff for Kardex and level of care on 01/15/24. All nursing staff passed the test and check off skills for the Kardex and resident care system. Record review of the auditing and monitoring of three random residents and staff conducted by the Administrator and DON weekly from 01/14/24 through 03/13/24 indicated no additional issues or concerns related to resident care were identified. The facility retrained CNA D on 01/18/24, related to the Kardex, level of care and 2-person required for bed mobility for the Kardex system and to check for proper assist level. As of 03/13/24, the facility continued to randomly monitor 3 staff per week to ensure staff provide the required level of care. Record review of QAPI notes dated 01/2024 showed a meeting was held to discuss the incident with Resident #1 on 01/13/24. Members present included the Administrator, DON, Medical Director, MDS Coordinator, and ADON A and ADON B. The interventions and plan for correction included: retraining all CNAs and LVNs and new hires on 2-person assist and how to check the Kardex. Record review of the staff in-services dated 01/14/24 through 01/15/24 included: 2-person assist and how to check the Kardex. The noncompliance was identified as PNC. The Immediate Jeopardy began on 01/13/24 and ended on 01/15/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 11 of 27 residents (Resident #s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11) reviewed for abuse. The facility failed to ensure the abuse coordinator and/or designee implemented the facility policy to report immediately to HHSC withing two hours of an allegation or incident of alleged abuse: 1. The facility failed to report immediately to the abuse coordinator and failed to report to HHS on 6/12/23, after LVN A was hit by Resident #5, LVN A assaulted Resident #5. She pushed Resident #5 hard against a wall, elbowed her in the face, and scratched her face. LVN A continued to work in the facility from the time of the incident (approximately 5:16 p.m.) until 9:11 p.m. on 06/12/23 and from 6 a.m. until 9:30 a.m. on 06/13/23. 2. The facility failed to report immediately to the abuse coordinator and failed to report to HHS on 7/24/23, after CNA B restrained Resident #10 by the wrists, put her hands around Resident 10's neck, and was rough with her during care. CNA B worked from the time of the incident (approximately 5:16 p.m.) until 10:03 p.m. 3. The facility failed to report 7 incidents of resident-to-resident abuse between 06/21/23 and 10/22/23. On 6/21/23 Resident #5 hit Resident #4. On 7/15/23 Resident #8 hit Resident #4. On 8/12/23 Resident #9 was holding Resident #4's wrist in bed while standing over her, telling her to shut up. On 8/23/23 Resident #1 hit Resident #3. On 9/1/23, 9/13/23 Resident #1 hit Resident #2. On 10/22/23 Resident #6 hit Resident #7. 4. The facility failed to report injury of unknown origin on 09/22/23. Resident #11 was found with bruises on his neck. An Immediate Jeopardy (IJ) situation was identified on 10/31/23. The IJ template was provided to the facility on [DATE] at 2:32 p.m. While the IJ was removed on 11/02/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 (revised April 2021) indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat resident's symptoms.1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not limited to: a. facility staff; b. other residents; .9. Investigate and report any allegations within the timeframes required by federal requirements. 10. Protect residents from any further harm during investigations. Record review of the facility's policy Abuse, neglect, Exploitation, or Misappropriation-reporting and Investigating dated 2001 (revised September 2022) indicated All reports of resident abuse (including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicions must be reported immediately to the administrator and other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for survey/licensing the facility; b. The local/state ombudsman, c. The resident's representative; . e. law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or serious bodily injury. 1. Record review of Resident #5's face sheet dated 10/27/23 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and latent syphilis a period when there are no visible signs or symptoms of syphilis; a multisystem chronic infection caused by treponema pallidum. It can cause psychiatric disorders including depression, mania, psychosis, personality changes, delirium and dementia). Record review of Resident #5's MDS dated [DATE] indicated she was able to make herself understood, sometimes understood others, had moderate impaired cognition (BIMS score 7). She had hallucinations and delusions. She had physical and verbal behavioral symptoms directed at others every 1-3 days. She had had other behavioral symptoms not directed at others every 1-3 days. She required supervision for all ADLS. Record review of Resident #5's care plan dated 06/12/23 (revised 07/06/23) indicated she had the potential to be physically aggressive related to a history of harm to others. Interventions included assess and anticipate resident's needs and monitor/document, report PRN any signs or symptoms of Resident #5 posing danger to self and others. Record review of Resident #5's care plan dated 12/27/21 (revised 03/27/23) indicated Resident #5 sometimes displayed verbally aggressive behavior. Interventions included do not argue, discuss my options, praise for demonstrating desired behavior, and talk with Resident #5 when her behavior was disruptive. Record review of incident report dated 06/12/23 at 6:05 p.m., completed by LVN A, indicated Resident #5 went in the shower room and began taking other residents' clothing and snacks. LVN A asked for the clothing and Resident #5 got upset and began to use foul language. LVN A offered snacks provided by the facility and Resident #5 did not want the snacks. Resident #5 took several sodas from other resident's supply and went to her (Resident #5's) room. LVN A entered Resident #5's room, retrieved the soda and exited the room. During the narcotic count on 6/12/23 at 5:19 p.m. with LVN E, Resident #5 swung and hit LVN A and pulled her hair. CNA F and CNA G pulled Resident #5 off LVN A and lowered her (Resident #5) to the floor. Resident #5 noted to have scratches near left eye. No other injuries noted. Physician, ADON C, and Administrator H were notified. Record review of Resident #5's progress noted dated 06/13/23 at 10:53 a.m., completed by RNC I indicated Resident #5 was assessed with noted scratches/abrasions below right eye and 3 scratches to left eyelid. A police officer was at the facility to speak to Resident #5. Resident #5 indicated she was in a fight but was not able to give a reason. Record review of the facility's investigation dated 06/19/23 indicated On 06/12/23 at approximately 5:14 p.m., Resident #5 went into the shower room where extra snacks and clothes were stored and got several snacks, sodas, and clothes, which did not belong to her. LVN A attempted to retrieve the snacks from Resident #5 by offering alternates. Resident #5 declined the offer and went to her room. LVN A followed Resident #5 to her room. Resident #5 threw a trashcan at LVN A. LVN A entered Resident #5's room and retrieved the snacks. LVN A went to the nurse's desk and began med count with LVN E. Resident #5 walked past LVN A, went to the nurse's desk, picked up the phone, and acted as if she was talking to someone. After a few minutes, Resident #5 walked back to her bedroom. As she passed LVN A she swung and hit LVN A. LVN A then grabbed Resident #5's wrists and pushed Resident #5 up against the wall. Resident #5 began struggling and grabbed LVN A's hair. LVN E, CNA F and CNA G attempted to get Resident #5 to release LVN A's hair. Resident #5 went limp and CNA F, CNA G and LVN E lowered Resident #5 to the floor. During the struggle it does appear LVN A's elbow came into contact with Resident #5's face. The staff were finally able to separate LVN A and Resident #5. The facility finds this incident as confirmed due to the video. Video review documentation completed by Administrator H indicated 06/12/23 Camera is three hours off-everything occurred in the 1700 (5:00 p.m.) hour, but camera time shows 1500 (3:00 p.m.) 15:16:08 (actual real time 5:16 p.m.) LVN A walked from nurse station on Hall 100 to Resident #5's room. 15:16:17 (actual real time 5:16 p.m.) LVN A goes into Resident #5's room. 15:16:20 (actual real time 5:16 p.m.) LVN A backs out of Resident #5's room. 15:16:22 (actual real time 5:16 p.m.) Resident #5 grabs her trashcan and throws it at LVN A. 15:16:24 (actual real time 5:16 p.m.) LVN A goes back into Resident #5's room. 15:16:29 (actual real time 5:16 p.m.)LVN A come out of room, closes Resident #5's door and walks toward nurse station. Several staff and residents can be seen walking the hall and interacting. 15:17:30 (actual real time 5:17 p.m.) Resident #5 comes out of her room, carrying a dress, and walking toward the nurse's station. 15:17:42 (actual real time 5:17 p.m.)Resident #5 continues to walk out to the nurse's station. 15:17:54 (actual real time 5:17 p.m.) Resident #5 walks past LVN A, turns around, says something, and then walks to phone at the nurse's station. LVN A and LVN E continue counting meds. 15:18:06 (actual real time 5:18 p.m.) Resident #5 gets on the phone. 15:19:37 (actual real time 5:19 p.m.) Resident #5 hangs up the phone and begins walking back towards her room. 15:19:40 (actual real time 5:19 p.m.) Resident #5 walks past LVN A, swings at LVN A and hits LVN A. 15:19:42 (actual real time 5:19 p.m.) LVN A grabs Resident #5's hands, charges her, backs Resident #5 to the wall. 15:19:43 (actual real time 5:19 p.m.) Resident #5 crosses LVN A's arms in the struggle. 15:19:45 (actual real time 5:19 p.m.) Resident #5 and LVN A continue to struggle. Resident #5 has moved from the wall-her back is now to the camera. LVN E, CNA F, and CNA G attempt to separate Resident #5 and LVN A. 15:19:47 (actual real time 5:19 p.m.) Struggle continues, Resident #5 begins to go to the floor as the struggle continues. 15:19:48 (actual real time 5:19 p.m.) It appears as Resident #5 lands on the ground, LVN A's elbow made contact with Resident #5's face, LVN A's hand can be seen coming off Resident #5's face. 15:19:49 (actual real time 5:19 p.m.) It appears LVN A and Resident #5 are physically separate except for Resident #5's right hand, which is extended to LVN A. 15:19:51 (actual real time 5:19 p.m.) CNA in maroon scrubs picks LVN A up and separates her from Resident #5 who is on the floor on her back. The surveyor was unable to review the video during the investigation as it was not available. The facility requested a copy of the video from the police however it was not available prior to exit. During an interview on 10/26/23 at 3:35 p.m., Resident #5 did not recall an altercation with any staff. During an interview on 10/26/23 at 1:45 p.m. the Administrator indicated she was the Abuse Coordinator. She said all allegations of abuse were reportable as soon as possible to any supervisor such as the charge nurse, the DON, or ADON and herself (the administrator). She said all allegations of abuse were reportable to the state within two hours. She said the reporting time was clarified by the quality monitors who were in the facility at the time of the surveyor's entrance. During an interview on 10/27/23 at 10:27 a.m., Administrator H said she was the previous administrator of the facility and was the abuse coordinator. She said all staff were trained on abuse and neglect and reporting. She said the incident between LVN A and Resident #5 was not reported to the state on 06/12/23 because she was not aware of the abuse until she reviewed the video of the incident on 06/13/23. She said neither LVN A nor LVN E reported the incident as abuse. She said LVN E, CNA F, and CNA G did not report the incident between Resident #5 and LVN A as abuse. She said the video was reviewed with CNA F and CNA G and their recollection of the event and statements did not match the video. She said LVN A escalated the situation and should not have reacted the way she did with Resident #5. She said LVN A should have de-escalated the situation. She said LVN E, CNA F, and CNA G should have reported the incident immediately to the DON and (Administrator H). She said all abuse allegations were reportable to the state within two hours. She said staff was retrained after the incident regarding residents with dementia. During an interview on 10/27/23 at 10:37 a.m., RNC I said the initial report on 6/12/23, by LVN A, was she was attacked by Resident #5. The incident was reported to the State Agency after she and Administrator H reviewed the video. She said the written statements from the staff did not match what was seen on the video. She said LVN A was interviewed but got upset and said she was only trying to defend herself. She said all staff were trained to work with residents with dementia on the unit. She said staff were retrained after the incident. She said all allegations of abuse were reportable to the state within two hours. During an interview on 10/27/23 at 11:38 a.m., CNA F said on 6/12/23 at approximately 5:15 p.m., Resident #5 went into the bathroom and took another resident's snacks and drinks. She said Resident #5 gave the snacks back when she was told the CNA would get her snacks from the machine, but she took the drinks to her room. She said LVN A went into Resident #5's room and retrieved the drinks. She said Resident #5 came out of her room, got on the phone and said I am going to fuck up that bitch. She said she was helping another resident and then heard a loud noise and saw Resident #5 had LVN A's hair in her hand. She denied seeing LVN A hit Resident #5. During an interview on 10/27/23 at 12:25 p.m., LVN E said on 06/12/23 Resident #5 went into the shower room and took snacks and drinks that belonged to other residents. She said LVN A came on to start her shift at 6:00 p.m. She said LVN A went into Resident #5's room and retrieved the drinks. She said they began counting medications and she heard a noise and LVN A had Resident #5 pushed up and retrained against the wall and then she brought Resident #5 to the ground and was on top of her. She said she and CNA F and CNA G removed LVN A from the situation. She said Resident #5 had scratches and discoloration on her face. She said LVN A called and reported the incident. She said she was trained on behaviors and working with residents with dementia before and after the incident. She said all allegations or incidents of abuse were supposed to be reported to the Administrator immediately. She said she did not report the incident as abuse to the Administrator. She said she did not think of the incident as abuse when it happened. She said when she reviewed the video, the incident looked like LVN A assaulted Resident #5. She said all staff to resident and resident to resident abuse was reportable to the Administrator and DON immediately. During an interview on 10/27/23 at 12:56 p.m., the DON said all allegations of abuse were reportable to the Administrator immediately. She said all allegations or incidents of abuse were reportable to the state within 2 hours. During an interview on 10/27/23 at 1:39 p.m., the Administrator said up until 10/26/23, allegations or incidents of abuse were reported to the state when it was malicious, willful, or had injury. The surveyor attempted to contact LVN A on 10/30/23 at 12:00 p.m. The cell number provided was not in service. During an interview on 11/06/23 at 12:45 p.m., CNA G said she saw LVN A walk out of Resident #5's room on 06/12/23. She said Resident #5 went to the phone and said she was going to call the law next time you (LVN A) put your hands on me. She said Resident #5 walked past LVN A and hit her face. She said LVN A pushed Resident #5 up against the wall and said you got the wrong one. She said LVN A hit Resident #5 and then Resident #5 pulled LVN A's hair. She said their hands were hitting at each other. She said she and CNA F pulled LVN A and Resident #5 apart. She said Resident #5 went to her room. She said all allegations or incident of abuse were reportable to the charge nurse, DON, or Administrator immediately. She said she did not report the incident as abuse. She said she did not think of the incident as abuse. She said she was trained prior to the incident and after the incident on dementia and behaviors. She said LVN A agitated Resident #5 instead of dealing with her in a calm manner. Record review of LVN A's personnel file included the following: Disciplinary Form dated 06/13/23- On 06/12/23, resident (Resident #5) walked past (LVN A), swung and hit (LVN A). (LVN A) pushes (Resident #5) back against the wall. A struggle ensued with (Resident #5) having hold of employee's (LVN A's) hair. Resident sustained scratches at the eye area. LVN A was suspended. Disciplinary Form dated 06/20/23- On 06/12/23, resident (Resident #5) walked past (LVN A) , swung and hit (LVN A). (LVN A) pushes (Resident #5) back against the wall. A struggle ensued with (Resident #5) having hold of employee's (LVN A's) hair. Resident sustained scratches at the eye area. Employee handbook, page 12 states abuse and/or neglect of residents is prohibited. LVN A was terminated on 06/20/23. LVN A was notified by phone. Record review of the police Offence Report dated 06/13/23 indicated that on 06/12/23 at 5:19 p.m. LVN A intentionally caused a disabled individual (Resident #5) bodily injury. 2. Record review of Resident #10's face sheet dated 11/01/23 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar type (episodes of mania and sometimes depression), homicidal ideations (thinking about, considering, or planning. a homicide), suicidal ideations (suicidal thoughts or ideas), cerebral infarction (stroke), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #10's MDS dated [DATE] indicated she was sometimes able to make herself understood, was usually able to understand others, was able to recall the location of her room and that she was in a nursing home, had severely impaired cognitive skills for daily decision making, had no behaviors, required supervision and limited assist for most ADLS, and used a walker for mobility. Record review of Resident #10's care plan dated 03/27/23 indicated Resident #10 had a history of physical aggression of pulling a staff member's hair related to poor impulse control. Interventions included assess and anticipate resident's needs. Record review of an incident report dated 07/25/23 completed by LVN L indicated a CNA (unknown who) asked Resident #10 why did you scratch that girl last night? Resident #10 grabbed her own throat. The CNA asked, that girl grabbed you by the throat? Resident #10's roommate came out of the bathroom and stated the staff was kind of abusive with her last night, like rough. The CNA asked, who the girl (Resident #10) scratched? Yeah, I could hear them from over here, the roommate stated. Resident #10 unable to explain verbally but grabbed her throat as if choking. Resident #10 was assessed with no injuries noted. Family and physician notified. Record review of the facility's investigation dated 07/28/23 indicated CNA B was suspended and terminated on 07/25/23. CNA B denied any wrongdoing but did state Resident #10 was agitated and scratched her face and she placed a firm grip on Resident #10's wrists to prevent from being hit. CNA B was terminated for placing a firm grip on Resident #10's wrists. During an interview on 10/30/23 at 12:11 p.m., CNA Z said she was passing by Resident #10's room on 07/24/23 sometime after the evening meal. She said Resident #10 motioned for her (CNA Z) to go into the room. CNA B was rough handling Resident #10 and she told CNA B not to do that and that she would go and get someone. She said she told RN L something was going on and they walked back to Resident #10's room. She said CNA B was walking toward them and said Resident #10 had scratched her face. She said CNA B told ADON D Resident #10 scratched her face. She said ADON B said she would have to report the incident to the abuse coordinator. She said the incident occurred on 07/24/23 after the supper meal. She said LVN L should have reported the abuse to the administrator immediately. She said she was called to the facility on [DATE] to write a statement. The surveyor attempted to contact CNA B on 10/30/23 at 12:33 p.m. There was no answer and a message was left with surveyor contact information. During an interview on 10/30/23 at 1:15 p.m., the DON said she became aware in morning report on 07/25/23 that Resident #10 was pointing and grabbing at her neck. She said the facility investigated and reported to the state when they were made aware of the incident. She said LVN L did not report the incident of CNA B rough handling Resident #10 on 07/24/23. She said the Administrator terminated CNA B on 07/25/23 due to grabbing Resident #10's wrists. During an interview on 10/30/23 at 1:15 p.m., ADON D said she was in the facility on 07/24/23 when she was made aware of Resident #1 scratching CNA B. She said she was not working when CNA B reported she was scratched. She said she was not aware of any abuse, so she did not report the incident to the DON or the Administrator immediately. During an interview on 10/30/23 at 1:20 p.m., the administrator said she terminated CNA B for grabbing Resident #5's wrists during care on 07/24/23. During an interview on 10/31/23 at 10:22 a.m., the surveyor asked Resident #10 if any staff had been mean or hurt her. Resident #10 placed her hands around her neck as if choking. When asked if she was o.k. and to give a thumbs up for yes or a thumbs down for no she indicated thumbs up. When asked if someone put their hands around her neck and to give thumbs up for yes or thumbs up for no, Resident #10 indicated thumbs up. When asked if she was afraid of any of the staff Resident #10 shook her head no. During an interview on 10/31/23 at 11:46 a.m., the COO indicated he trained the Administrator on 10/27/23 regarding reporting abuse to the state as required. He said the prior training was after the most recent provider training when there was a team discussion and the CNO reviewed the provider meeting information. He said there was a lot of confusion because each state has different reporting requirements. He said as company, abuse was an area of focus and there has been a lot of training. He said all newly hired employees were provided information on abuse, abuse prevention and abuse reporting. He said it was the company's expectations the facility would follow the guidelines and resident to resident abuse was reported within two hours to the state as required. During an interview on 10/31/23 at 12:40 p.m., Resident #10's roommate said CNA B was rough with Resident #10. She said CNA B said oh, you trying to hit me? Better not hit me. She said she could hear Resident #10 and CNA B struggling and fighting. She said the privacy curtain was pulled and she could not see but she could hear what was going on. She said she heard CNA B leave the room and shut the door. She said CNA B was abusive to Resident #10. During an interview on 11/01/23 at 4:55 p.m., LVN L said she did not write up an incident report, call the DON, or the Administrator on 07/24/23 after CNA Z made her aware of CNA B being rough with Resident #10. She said CNA B came out of Resident #10's room and said Resident #10 scratched her. She said CNA B had a scratch under her left eye. She said she should have documented and reported immediately. She said she was trained to report abuse immediately to the administrator. 3. Record review of the incident report dated 06/21/23, completed by LVN J indicated during medication count Resident #4 was standing behind the nurses when Resident #5 became agitated and hit Resident #4 in the chest. Resident #4 was assessed with no injuries. Record review of incident report dated 07/15/23 and completed by LVN K indicated Resident #4 was standing at the TV trying to change the TV channels and Resident #8 slapped her arm and left an imprint. Resident #4 was assessed with no additional injuries. Resident #8 was removed from the area. Record review of incident report dated 08/12/23, completed by LVN O, indicated Resident #9 was standing over her roommate's bed (Resident #4) and holding her by the wrist and yelling I told you to shut up. Resident #9 was unable to explain what happened. Resident #9 has issues with communications and her words come out wrong. She was showing aggression through actions and cursing but her words did not make sense. Residents were immediately separated. Resident #9 was sent to ER for evaluation. Resident #4 had no injuries. Record review of incident report dated 08/23/23, completed by LVN P indicated Resident #1 hit Resident #3 on top of his head with his fist. Resident #3 was redirected and educated to not assault others. Resident #3 had redness on top of his head. Resident #3 received pain medication. Record review of an incident report dated 09/01/23, completed by LVN P, indicated Resident #1 hit Resident #2 on the forehead. There was no swelling and Resident #2 did not complain of pain. Record review of an incident report dated 09/13/22 completed by LVN Q indicated Resident #1 hit Resident #2 on the back of his head. Resident #2 was assessed and had no injuries. Resident #1 was removed from the area. Record review of incident report dated 10/22/23, completed by LVN, indicated Resident #6 was standing over Resident #7 (who was attempting to sleep. Resident #6 was turning Resident #7's light on and off. Resident #7 asked Resident #6 to stop turning his light on and off. Resident #7 hit Resident #6 in the chest. Resident #7 was moved to another room for his safety. The police and ambulance were called. Resident #6 was transferred to the hospital for a psychological evaluation. Resident #7 indicated he was hit. There were no observed injuries. Record review of Resident #1's face sheet dated 10/30/23 indicated Resident #1 was a [AGE] year old male, admitted on [DATE], and his diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #1's MDS dated [DATE] indicated he was able to make himself understood and understood others. He had severe cognitive impairment (BIMS score 3), no behaviors, and required varying levels of assistance for ADLS. Record review of Resident #1's care plan dated 09/14/23 indicated Resident #1 had the potential to be physically aggressive related to dementia. Interventions included behavior monitoring and separating residents. Record review of Resident #2's face sheet dated 10/30/23 indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #2's MDS dated [DATE] indicated he was usually able to make himself understood and usually understood others. He had severe cognitive impairment (BIMS score of 5). He had no behaviors. He required various levels of assistance for all ADLS. Record review of Resident #2's care plan dated 03/02/22 indicated Resident #2 utilized psychotropic medications for behavioral management. Interventions included monitor for effectiveness. Record review of Resident #3's face sheet dated 11/9/23 indicated he was an [AGE] year old male, admitted on [DATE], and his diagnoses included metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Alzheimer's (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), cognitive communication deficit (difficulty with thinking and how someone uses language), and schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). Record review of Resident #3's MDS dated [DATE] indicated he was able to make himself understood and understood others. He had severe cognitive impairment (BIMS score of 6). He had no behaviors and required various levels of assist for all ADLS. Record review of Resident #3's care plan dated 02/10/22 indicated Resident #3 used antipsychotic medications related to paranoid personality disorder. Interventions included administer medications and monitor for effectiveness. Record review of Resident #4's face sheet indicated she was a [AGE] year-old female admitted on [DATE] and her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), psychotic disorder with hallucinations, and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #4's MDS dated [DATE] indicated Resident #4 was sometimes able to make herself understood and understand others. She had a BIMS score of 00 (severe cognitive impairment). There were no behaviors noted. Record review of Resident #4's care plan dated 11/05/21 indicated Resident #4 had a history of displaying socially inappropriate/disruptive behavior. Interventions included monitor and document behaviors and remove from public area. Record review of Resident #6's face sheet indicated he was a [AGE] year old male, admitted on [DATE], and his diagnoses included frontal temporal neurocognitive disorder (the result of damage to neurons in the frontal and temporal lobes of the brain), alcohol induced persisting amnestic disorder (a mental disorder associated with chronic ethanol abuse and nutritional deficiencies characterized by short term

Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 2 of 27 residents (Resident #s 5 and 10) reviewed for abuse in that: 1. On 6/12/23, after LVN A was hit by Resident #5, LVN A assaulted Resident #5. She pushed Resident #5 hard against a wall, elbowed her in the face, and scratched her face. LVN A continued to work in the facility from the time of the incident (approximately 5:16 p.m.) until 9:11 p.m. on 06/12/23 and from 6 a.m. until 9:30 a.m. on 06/13/23. 2. On 7/24/23 CNA B restrained Resident #10 by the wrists, put her hands around Resident 10's neck, and was rough with her during care. CNA B worked from the time of the incident (approximately 5:16 p.m.) until 10:03 p.m. An Immediate Jeopardy (IJ) situation was identified on 10/31/23. The IJ template was provided to the facility on [DATE] at 2:32 p.m. While the IJ was removed on 11/02/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #5's face sheet dated 10/27/23 indicated she was a [AGE] year-old female, admitted on [DATE], and her diagnoses included schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and latent syphilis a period when there are no visible signs or symptoms of syphilis; a multisystem chronic infection caused by treponema pallidum. It can cause psychiatric disorders including depression, mania, psychosis, personality changes, delirium and dementia). Record review of Resident #5's MDS dated [DATE] indicated she was able to make herself understood, sometimes understood others, and had moderate impaired cognition (BIMS score 7). She had hallucinations and delusions. She had physical and verbal behavioral symptoms directed at others every 1-3 days. She had other behavioral symptoms not directed at others every 1-3 days. She required supervision for all ADLS. Record review of Resident #5's care plan dated 06/12/23 (revised 07/06/23) indicated she had the potential to be physically aggressive related to a history of harm to others. Interventions included, assess and anticipate resident's needs and monitor/document, report PRN any signs or symptoms of Resident #5 posing danger to self and others. Record review of Resident #5's care plan dated 12/27/21 (revised 03/27/23) indicated Resident #5 sometimes displayed verbally aggressive behavior. Interventions included, do not argue, discuss options for appropriate channeling of anger, praise for demonstrating desired behavior, and talk with Resident #5 when her behavior was disruptive. Record review of the incident report dated 06/12/23 at 6:05 p.m., completed by LVN A, indicated Resident #5 went in the shower room and began taking other residents' clothing and snacks. LVN A asked for the clothing and Resident #5 got upset and began to use foul language. LVN A offered snacks provided by the facility and Resident #5 did not want the snacks. Resident #5 took several sodas from other resident's supply and went to her (Resident #5's) room. LVN A entered Resident #5's room, retrieved the soda and exited the room. During the narcotic count on 6/12/23 at 5:19 p.m. with LVN E, Resident #5 swung and hit LVN A and pulled her hair. CNA F and CNA G pulled Resident #5 off LVN A and lowered her (Resident #5) to the floor. Resident #5 noted to have scratches near left eye. No other injuries noted. Physician, ADON C, and Administrator H were notified. Record review of Resident #5's progress noted dated 06/13/23 at 10:53 a.m., completed by RNC I indicated Resident #5 was assessed with noted scratches/abrasions below right eye and 3 scratches to left eyelid. A police officer was at the facility to speak to Resident #5. Resident #5 indicated she was in a fight but was not able to give a reason. Record review of the facility's investigation dated 06/19/23, completed by Administrator H indicated On 06/12/23 at approximately 5:14 p.m., Resident #5 went into the shower room where extra snacks and clothes were stored and got several snacks, sodas, and clothes, which did not belong to her. LVN A attempted to retrieve the snacks from Resident #5 by offering alternates. Resident #5 declined the offer and went to her room. LVN A followed Resident #5 to her room. Resident #5 threw a trashcan at LVN A. LVN A entered Resident #5's room and retrieved the snacks. LVN A went to the nurse's desk and began med count with LVN E. Resident #5 walked past LVN A, went to the nurse's desk, picked up the phone, and acted as if she was talking to someone. After a few minutes, Resident #5 walked back to her bedroom. As she passed LVN A she swung and hit LVN A. LVN A then grabbed Resident #5's wrists and pushed Resident #5 up against the wall. Resident #5 began struggling and grabbed LVN A's hair. LVN E, CNA F and CNA G attempted to get Resident #5 to release LVN A's hair. Resident #5 went limp and CNA F, CNA G and LVN E lowered Resident #5 to the floor. During the struggle it does appear LVN A's elbow came into contact with Resident #5's face. The staff were finally able to separate LVN A and Resident #5. The facility finds this incident as confirmed due to the video. Video review documentation completed by Administrator H indicated 06/12/23 Camera is three hours off-everything occurred in the 1700 (5:00 p.m.) hour, but camera time shows 1500 (3:00 p.m.) 15:16:08 (actual real time 5:16 p.m.) LVN A walked from nurse station on Hall 100 to Resident #5's room. 15:16:17 (actual real time 5:16 p.m.) LVN A goes into Resident #5's room. 15:16:20 (actual real time 5:16 p.m.) LVN A backs out of Resident #5's room. 15:16:22 (actual real time 5:16 p.m.) Resident #5 grabs her trashcan and throws it at LVN A. 15:16:24 (actual real time 5:16 p.m.) LVN A goes back into Resident #5's room. 15:16:29 (actual real time 5:16 p.m.)LVN A come out of room, closes Resident #5's door and walks toward nurse station. Several staff and residents can be seen walking the hall and interacting. 15:17:30 (actual real time 5:17 p.m.) Resident #5 comes out of her room, carrying a dress, and walking toward the nurse's station. 15:17:42 (actual real time 5:17 p.m.)Resident #5 continues to walk out to the nurse's station. 15:17:54 (actual real time 5:17 p.m.) Resident #5 walks past LVN A, turns around, says something, and then walks to phone at the nurse's station. LVN A and LVN E continue counting meds. 15:18:06 (actual real time 5:18 p.m.) Resident #5 gets on the phone. 15:19:37 (actual real time 5:19 p.m.) Resident #5 hangs up the phone and begins walking back towards her room. 15:19:40 (actual real time 5:19 p.m.) Resident #5 walks past LVN A, swings at LVN A and hits LVN A. 15:19:42 (actual real time 5:19 p.m.) LVN A grabs Resident #5's hands, charges her, backs Resident #5 to the wall. 15:19:43 (actual real time 5:19 p.m.) Resident #5 crosses LVN A's arms in the struggle. 15:19:45 (actual real time 5:19 p.m.) Resident #5 and LVN A continue to struggle. Resident #5 has moved from the wall-her back is now to the camera. LVN E, CNA F, and CNA G attempt to separate Resident #5 and LVN A. 15:19:47 (actual real time 5:19 p.m.) Struggle continues, Resident #5 begins to go to the floor as the struggle continues. 15:19:48 (actual real time 5:19 p.m.) It appears as Resident #5 lands on the ground, LVN A's elbow made contact with Resident #5's face, LVN A's hand can be seen coming off Resident #5's face. 15:19:49 (actual real time 5:19 p.m.) It appears LVN A and Resident #5 are physically separate except for Resident #5's right hand, which is extended to LVN A. 15:19:51 (actual real time 5:19 p.m.) CNA in maroon scrubs picks LVN A up and separates her from Resident #5 who is on the floor on her back. The surveyor was unable to review the video during the investigation as it was not available. The facility requested a copy of the video from the police however it was not available prior to exit. During an interview on 10/26/23 at 3:35 p.m., Resident #5 did not recall an altercation with any staff. During an interview on 10/26/23 at 1:45 p.m. the Administrator indicated she was the Abuse Coordinator. She said all allegations of abuse were reportable as soon as possible to any supervisor such as the charge nurse, the DON, or ADON and herself (the administrator). During an interview on 10/27/23 at 10:27 a.m., Administrator H said she was the previous administrator of the facility and was the abuse coordinator. She said all staff were trained on abuse and neglect and reporting. She said the incident between LVN A and Resident #5 was not reported to the state on 06/12/23 because she was not aware of the abuse until she reviewed the video of the incident on 06/13/23. She said neither LVN A nor LVN E reported the incident as abuse. She said LVN E, CNA F, and CNA G did not report the incident between Resident #5 and LVN A as abuse. She said the video was reviewed with CNA F and CNA G and their recollection of the event and statements did not match the video. She said LVN A escalated the situation and should not have reacted the way she did with Resident #5. She said LVN A should have de-escalated the situation. She said LVN E, CNA F, and CNA G should have reported the incident immediately to the DON and (Administrator H). She said staff was retrained after the incident regarding residents with dementia. During an interview on 10/27/23 at 10:37 a.m., RNC I said the initial report on 06/12/23, by LVN A, was she was attacked by Resident #5. The incident was reported to the State Agency after she and Administrator H reviewed the video. She said the written statements from the staff did not match what was seen on the video. She said LVN A was interviewed but got upset and said she was only trying to defend herself. She said all staff were trained to work with residents with dementia on the unit. She said staff were retrained after the incident. During an interview on 10/27/23 at 11:38 a.m., CNA F said on 6/12/23 at approximately 5:15 p.m., Resident #5 went into the bathroom and took another resident's snacks and drinks. She said Resident #5 gave the snacks back when she was told the CNA would get her snacks from the machine, but she took the drinks to her room. She said LVN A went into Resident #5's room and retrieved the drinks. She said Resident #5 came out of her room, got on the phone and said, I am going to fuck up that bitch. She said she was helping another resident and then heard a loud noise and saw Resident #5 had LVN A's hair in her hand. She denied seeing LVN A hit Resident #5 on 06/12/23. During an interview on 10/27/23 at 12:25 p.m., LVN E said on 06/12/23 Resident #5 went into the shower room and took snacks and drinks that belonged to other residents. She said LVN A came on to start her shift at 6:00 p.m. She said LVN A went into Resident #5's room and retrieved the drinks. She said they began counting medications and she heard a noise and LVN A had Resident #5 pushed up and retrained against the wall and then she brought Resident #5 to the ground and was on top of her. She said she and CNA F and CNA G removed LVN A from the situation. She said Resident #5 had scratches and discoloration on her face. She said LVN A called and reported the incident. She said she was trained on behaviors and working with residents with dementia before and after the incident. She said all allegations or incidents of abuse were supposed to be reported to the Administrator immediately. She said she did not report the incident as abuse to the Administrator. She said she did not think of the incident as abuse when it happened. She said when she reviewed the video, the incident looked like LVN A assaulted Resident #5. She said all staff to resident and resident-to-resident abuse was reportable to the Administrator and DON immediately. The surveyor attempted to contact LVN A on 10/30/23 at 12:00 p.m. The cell number provided was not in service. During an interview on 11/06/23 at 12:45 p.m., CNA G said she saw LVN A walk out of Resident #5's room on 06/12/23. She said Resident #5 went to the phone and said she was going to call the law next time you (LVN A) put your hands on me. She said Resident #5 walked past LVN A and hit her face. She said LVN A pushed Resident #5 up against the wall and said, you got the wrong one. She said LVN A hit Resident #5 and then Resident #5 pulled LVN A's hair. She said their hands were hitting at each other. She said she and CNA F pulled LVN A and Resident #5 apart. She said Resident #5 went to her room. She said all allegations or incident of abuse were reportable to the charge nurse, DON, or Administrator immediately. She said she did not report the incident as abuse. She said she was trained prior to the incident and after the incident on dementia and behaviors. She said LVN A agitated Resident #5 instead of dealing with her in a calm manner. Record review of LVN A's personnel file included the following: Disciplinary Form dated 06/13/23- On 06/12/23, resident (Resident #5) walked past (LVN A), swung and hit (LVN A). (LVN A) pushes (Resident #5) back against the wall. A struggle ensued with (Resident #5) having hold of employee's (LVN A's) hair. Resident sustained scratches at the eye area. LVN A was suspended. Disciplinary Form dated 06/20/23- On 06/12/23, resident (Resident #5) walked past (LVN A) , swung and hit (LVN A). (LVN A) pushes (Resident #5) back against the wall. A struggle ensued with (Resident #5) having hold of employee's (LVN A's) hair. Resident sustained scratches at the eye area. Employee handbook, page 12 states abuse and/or neglect of residents is prohibited. LVN A was terminated on 06/20/23. LVN A was notified by phone. Record review of the police Offence Report dated 06/13/23 indicated that on 06/12/23 at 5:19 p.m. LVN A intentionally caused a disabled individual (Resident #5) bodily injury. 2. Record review of Resident #10's face sheet dated 11/01/23 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar type (episodes of mania and sometimes depression), homicidal ideations (thinking about, considering, or planning a homicide), suicidal ideations (suicidal thoughts or ideas), cerebral infarction (stroke), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #10's MDS dated [DATE] indicated she was sometimes able to make herself understood, was usually able to understand others, was able to recall the location of her room and that she was in a nursing home, had severely impaired cognitive skills for daily decision making, had no behaviors, required supervision and limited assist for most ADLS, and used a walker for mobility. Record review of Resident #10's care plan dated 03/27/23 indicated Resident #10 had a history of physical aggression of pulling a staff member's hair related to poor impulse control. Interventions included assess and anticipate resident's needs. Record review of an incident report dated 07/25/23 completed by LVN L indicated a CNA (unknown who) asked Resident #10 why did you scratch that girl last night? Resident #10 grabbed her own throat. The CNA asked, that girl grabbed you by the throat? Resident #10's roommate came out of the bathroom and stated, the staff was kind of abusive with her last night, like rough. The CNA asked, who the girl (Resident #10) scratched? Yeah, I could hear them from over here, the roommate stated. Resident #10 unable to explain verbally but grabbed her throat as if choking. Resident #10 was assessed with no injuries noted. Family and physician notified. Record review of the facility's investigation dated 07/28/23 indicated CNA B was suspended and terminated on 07/25/23. CNA B denied any wrongdoing but did state Resident #10 was agitated and scratched her face and she placed a firm grip on Resident #10's wrists to prevent from being hit. CNA B was terminated for placing a firm grip on Resident #10's wrist. During an interview on 10/30/23 at 12:11 p.m., CNA Z said she was passing by Resident #10's room on 07/24/23 sometime after the evening meal. She said Resident #10 motioned for her (CNA Z) to go into the room. CNA B was rough handling Resident #10 and she (CNA Z) told CNA B not to do that and that she would go and get someone. She said she told RN L something was going on and they walked back to Resident #10's room. She said CNA B was walking toward them and said Resident #10 had scratched her face. She said CNA B told ADON D Resident #10 scratched her face. She said ADON B said she would have to report the incident to the abuse coordinator. She said the incident occurred on 07/24/23 after the supper meal. She said LVN L should have reported the abuse to the administrator immediately. She said she was called to the facility on [DATE] to write a statement. The surveyor attempted to contact CNA B on 10/30/23 at 12:33 p.m. There was no answer, and a message was left with surveyor contact information. During an interview on 10/30/23 at 1:15 p.m., the DON said she became aware in morning report on 07/25/23 that Resident #10 was pointing and grabbing at her neck. She said the facility investigated and reported to the state when they were made aware of the incident. She said LVN L did not report the incident of CNA B rough handling Resident #10 on 07/24/23. She said the Administrator terminated CNA B on 07/25/23 due to grabbing Resident #10's wrists. During an interview on 10/30/23 at 1:15 p.m., ADON D said she was in the facility on 07/24/23 when she was made aware of Resident #10 scratching CNA B. She said she was not working when CNA B reported she was scratched. She said she was not aware of any abuse, so she did not report the incident to the DON or the Administrator immediately. During an interview on 10/30/23 at 1:20 p.m., the administrator said she terminated CNA B for grabbing Resident #10's wrists during care on 07/24/23. During an interview on 10/31/23 at 10:22 a.m., the surveyor asked Resident #10 if any staff had been mean or hurt her. Resident #10 placed her hands around her neck as if choking. When asked if she was o.k. and to give a thumbs up for yes or a thumbs down for no she indicated thumbs up. When asked if someone put their hands around her neck and to give thumbs up for yes or thumbs up for no, Resident #10 indicated thumbs up. When asked if she was afraid of any of the staff Resident #10 shook her head no. During an interview on 10/31/23 at 12:40 p.m., Resident #10's roommate said CNA B was rough with Resident #10 on 07/24/23. She said CNA B said oh, you trying to hit me? Better not hit me. She said she could hear Resident #10 and CNA B struggling and fighting. She said the privacy curtain was pulled and she could not see but she could hear what was going on. She said she heard CNA B leave the room and shut the door. She said CNA B was abusive to Resident #10. During an interview on 11/01/23 at 4:55 p.m., LVN L said she did not write up an incident report, call the DON, or the Administrator on 07/24/23 after CNA Z made her aware of CNA B being rough with Resident #10. She said CNA B came out of Resident #10's room and said Resident #10 scratched her. She said CNA B had a scratch under her left eye. She said she should have documented and reported immediately. She said she was trained to report abuse immediately to the administrator. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 (revised April 2021) indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat resident's symptoms.1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not limited to: a. facility staff; b. other residents; .9. Investigate and report any allegations within the timeframes required by federal requirements. 10. Protect residents from any further harm during investigations. This was determined to be an Immediate Jeopardy (IJ) on 10/31/23 at 2:32 p.m. The Administrator was notified. The Administrator was provided the IJ template on 10/312/23 at 2:50 p.m. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 11/02/23 at 6:30 a.m. and reflected the following: Immediate action: . A facility audit was completed by the DON/Designee on 11/1/223 of all incident reports and progress notes from 10/26/2023 to 10/31/2023 to determine if any other incidents occurred that required HHSC reporting. Other incidents prior to 10/26/23 had already been presented to state surveyor. One incident was identified to have occurred 10/31/23 that met guidelines for resident-to-resident abuse. Procedure for resident safety was followed, investigation initiated, and incident reported to HHSC within 2-hour reporting window. The facility reviewed the system for abuse identification and reporting. The facility created a plan of improvement to assure residents are free from abuse to address changes including education, daily chart reviews and IDT discussions. DON and/or Designee will review incident reports and progress notes 5 days weekly to assure that there are no incidents that could meet the qualifications of abuse and discuss any concerns with abuse coordinator immediately. In-services completed with Administrator by Regional Nurse Consultant on 11/1/23 at 2 pm related to recognizing possible abuse and neglect, abuse prevention and the administrator's responsibilities related to investigating and reporting to all required entities. Ad Hoc QAPI meeting completed with IDT, Regional Nurse Consultant and Medical Director on 10/29/2023. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: * In-services completed with Administrator by Regional Nurse Consultant on 11/1/23 at 2PM related to recognizing possible abuse and neglect, abuse prevention and the administrator's responsibilities related to investigating and reporting to all required entities. *In-services to include all staff initiated by DON/Designee on 10/31/23 related to abuse recognition, abuse reporting, employee responsibilities in reporting abuse and resident safety and working with residents with escalating behaviors. This training will be validated by completion of a post-training test, dated and signed by each employee. *Interviews initiated by DON/Designee 11/1/23 to include a sample of residents and staff to determine if any cases of unreported abuse or suspected abuse are identified. Education to be completed with all staff working 10/31/2023 by Regional Nurse Consultant. Staff who did not receive the training will receive this training by the DON and/or designee prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. On 11/02/23 at 3:02 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 11/02/23 from 8:00 a.m. though 2:45 p.m. and included 6 LVNs, 12 CNAs, 4 housekeeping/laundry staff, 4 dietary staff, and 2 ADONs who worked all shifts. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse and were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. Record review of the facility monitoring system (implemented on 10/28/23) indicated the facility audited progress notes and incident reports daily. During an interview on 11/02/23 at 2:11. p.m., the Administrator and DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegations or instances of abuse and/ or neglect. The weekend manager on duty and weekend RN Supervisor would report any incidents or allegations to the DON and administrator immediately. During observations of staff and resident interactions on 11/02/23 from 8:00 a.m. though 2:45 p.m. indicated no evidence of abuse and residents did not appear afraid of staff. Record review of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 11/2/23 at 3:02 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to immediately consult the physician with a significant change in resident physical status (that is a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 17 residents (Resident #1) reviewed for change of condition. The facility failed to notify the MD or NP of Resident #1's abnormal lab and x-ray results that indicated dehydration, kidney failure, and possible pneumonia to obtain treatment interventions after a change of condition in a timely manner. The facility failed to notify the MD or NP of Resident #1 (who had a history of weight loss) refusing to eat. Resident #1 was admitted to hospital on [DATE] with diagnoses of altered mental status and pneumonia, placed on hospice services on [DATE], and expired on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 12:29 p.m. While the IJ was removed on [DATE] at 11:45 a.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for delay of appropriate medical treatment and a worsening of a resident's condition, including death. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old male resident admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behaviors and agitation, diverticulitis (condition that affects the large intestine), depression (constant feeling of sadness and loss of interest), insomnia (a common sleep disorder that can make it hard to fall asleep), dysphagia (swallowing difficulties), cognitive communication deficit (difficulty with thinking and how someone uses language), severe protein-calorie malnutrition, and anemia (the body does not have enough healthy red blood cells). Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and understand others, had BIMS score of 3 (severe cognitive impairment), required extensive/total physical assist of one staff for all ADLS, utilized a wheelchair for mobility, and was incontinent of bowel and bladder. Record review of a care plan dated [DATE] (revised [DATE]), indicated Resident #1 had dehydration or potential fluid deficit related to dementia. Interventions included obtain and monitor lab/diagnostics work as ordered. Report results to MD and follow up as indicated. Monitor/document and report as needed any signs and symptoms of dehydration including fatigue and weight loss. Record review of a care plan dated [DATE] (revised [DATE]), indicated Resident #1 had an alteration in gastrointestinal status related to diverticulitis in his intestine. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of a care plan dated [DATE] (revised [DATE]), indicated Resident #1 had a diagnoses of anemia. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of a NP progress note dated [DATE], completed by NP D, indicated Resident #1 was positive for fatigue (staff reports resident has been very weak for one week and history of a fall) and unintentional weight loss. The NP progress note indicated Resident #1 was positive for not eating for a week. The NP progress note indicated Resident #1 had a normal respiratory rate and pattern with no distress and normal breath sounds with no rales, rhonchi, wheezes, or rubs. The NP progress note indicated Resident #1's vital signs were blood pressure ,d+[DATE], pulse 68 beats per minute, and respirations 20 breaths per minute. The NP progress note indicated Resident #1 was ordered CBC (complete blood count), BMP (basic metabolic panel, LFT (liver function test), TSH (thyroid stimulating hormone), Lipid panel (complete cholesterol test), and chest x-ray 2-views. Record review of Resident #1's physician orders dated [DATE] indicated CBC(complete blood count), BMP(basic metabolic panel, LFT(liver function test), TSH (thyroid stimulating hormone), Lipid panel (complete cholesterol test), and chest x-ray 2-views was ordered. Record review of progress note dated [DATE] at 2:35 p.m., completed by ADON B, indicated new orders per NP D included CBC, BMP, LFT, Lipid panel today, and chest x-ray 2 views. Diagnoses included HLD (hyperlipidemia-an imbalance of the cholesterol levels in the blood that can lead to serious heart conditions), weight loss, anorexia (decrease in appetite and/or food intake in old age). Record review of lab results dated [DATE] indicated the collection as [DATE] at 4:55 p.m. and reported on [DATE] at 10:21 p.m. -TSH-10.80 (high)-Reference range 0XXX,d+[DATE].50 -HCT (red blood cells)-45.3-Reference range 34XXX,d+[DATE].9-high -PLT (platelet)-80-Reference range ,d+[DATE]-low -RDW (red cell distribution width)-17.2-Reference range 11XXX,d+[DATE].4 -high -Sodium-151-Reference range ,d+[DATE]-high -Chloride-112-Reference range ,d+[DATE]-high -BUN (blood urea nitrogen test reveals important information about how well kidneys are working)-71-Reference range ,d+[DATE]-high -Creatinine-2.20-Reference range 0XXX,d+[DATE].20-high -Cholesterol-221.0-Reference range 0XXX,d+[DATE].0-high -Triglycerides-162-Reference range ,d+[DATE]-high The report had no signature or date to indicate the report was reviewed. Record review of an x-ray report dated [DATE] for Resident #1 indicated diffuse opacity is seen in bilateral upper lungs. This is likely secondary to pulmonary edema (excessive fluid in the lungs), atelectasis (complete or partial collapse of a lung) and/or pneumonia (infection in the lungs). The report had no signature or date to indicate the report was reviewed. Record review of Resident #1's meal intake dated [DATE] indicated his intake was ,d+[DATE]% for breakfast., refused lunch and ,d+[DATE]% for supper. His meal intake on [DATE] was ,d+[DATE]% for breakfast., ,d+[DATE] % for lunch and refused for supper. Record review of Resident #1's fluid intake dated [DATE] his fluid intake was 120 ml for breakfast, refused for lunch, and 120 ml for supper. His fluid intake for [DATE] was 120 ml for breakfast, 120 ml for lunch, and 0 ml for supper. Record review of a 24-hour shift report dated [DATE] indicated to increase fluids and protein QD for Resident #1. There was no information related to labs or the results for Resident #1. Record review of a 24-hour shift report dated [DATE] indicated continue to increase fluids and protein QD for Resident #1. There was no information related to labs or the results for Resident #1. Record review of a 24-hour shift report dated [DATE] indicated no information related to Resident #1. There was no information related to labs or the results for Resident #1. Record review of the fax confirmation page dated [DATE] at 4:04 p.m. indicated the fax for Resident #1's abnormal lab results and chest x-ray were not successfully sent to the specified recipient (was the wrong fax number). Record review of a progress note dated [DATE] at 10:30 a.m., completed by LVN E indicated she called the on-call number to report Resident #1's abnormal labs and x-ray. Record review of a progress note dated [DATE] (three days after the lab results had been reported to the facility) at 11:53 a.m., completed by LVN E indicated on-call NP Q ordered Resident #1 to be sent out for IV ABT and fluids. Record review of a progress note dated [DATE] at 6:27 p.m., completed by LVN E indicated Resident #1 was admitted to the hospital for hyperkalemia (high potassium), AMS, dehydration and pneumonia. Record review of hospital records dated [DATE] indicated Resident #1 was admitted for hyperkalemia, AMS, dehydration and pneumonia. During an observation and interview at the hospital on [DATE] at 3:11 p.m., Resident #1 was asleep and unresponsive in the hospital. LVN F said Resident #1 had been admitted to hospice services and was on comfort care. She said Resident #1's prognoses was poor. During an interview on [DATE] at 1:30 p.m., LVN E said on [DATE] ADON A asked her to follow up on the labs that were drawn on [DATE]. She said she called the hospital to get the on-call number and called on-call NP Q. She said she told NP Q about Resident #1's lab results and the chest x-ray showing possible pneumonia. She said NP Q ordered Resident #1 to be sent to the hospital. LVN E said if abnormal lab results or x-rays were not addressed immediately there could be a delay of medical care. She said she was not aware of the percentage of food intake or lab results in the residents' dashboard of the electronic chart. During an interview on [DATE] at 12:57 p.m., LVN E said she was not aware of a dashboard for lab results. She said if lab results were critical the lab would call directly to the facility. She said if she did not check for results then she would not know lab results or x-ray results were available. She said the hospital said the on-call physician was NP Q. She said the labs and x-ray were done on a holiday weekend. She said Resident #1's family tried to feed him fast food and asked why the facility was sedating him. She said she told them he had not been sedated. She said they wanted her to force feed him. She said he drank ensure and liked it. During an interview on [DATE] at 3:00 p.m., ADON A said on [DATE] he found Resident #1's lab results had not been reviewed or addressed as they should have been on [DATE], when the results were sent to the facility. He said he asked LVN E on [DATE] to follow-up on the results. He said nursing staff should have notified the MD or on-call NP immediately of Resident #1's abnormal lab results and chest x-ray on [DATE]. He said the nursing staff should have notified the MD or on-call NP of Resident #1 not eating or drinking adequate amounts. He said Resident #1 had delay of medical treatment and care due to the failure to notify the physician or NP. During an interview on [DATE] at 3:19 p.m., RN C said the MD should be notified if a resident has not eaten for two days. She said missed meals were documented in the kiosk (where CNAs document the residents' meal intake) and would trigger in the dashboard (in the electronic record). The nurses should have checked the dashboard for any alerts and notify the MD as needed. She said labs and lab results were supposed to be checked daily in the dashboard. She said the nurses were supposed to review, notify the MD, then check off the results as reviewed. During an interview on [DATE] at 2:14 p.m., Resident #1's roommate said Resident #1 would eat when LVN E fed him. He said he would mostly eat his breakfast then the tray would sit on the bedside table for a while until staff picked the tray up and take it from the room. During an interview on [DATE] at 2:17 p.m. LVN E said none of the aides had reported to her Resident #1 was not eating or drinking. During an interview on [DATE] at 2:34 p.m., CNA K said she assisted Resident #1 to eat his meals. She said she told LVN G Resident #1 would not open his mouth to eat and was drinking very little water or juice. She said he would sometimes eat oatmeal for breakfast with a lot of sugar. She said she tried to feed Resident #1 all meals and snacks on [DATE] and [DATE] but he would not eat. CNA K said she told the family Resident #1 would not eat. She said the family went to talk to the nurse. During an interview on [DATE] at 10:03 a.m., LVN R said she was not aware of the dashboard or Resident #1's abnormal lab results or chest x-ray. She said she was not told Resident #1 was not eating or drinking as he should. She said she was not aware of the alerts on Resident #1's dashboard. She said she did not notify the physician or NP of the abnormal results or that Resident #1 was not eating because she was not aware of the issues. During an interview on [DATE] at 10:30 a.m., RN C said the nurses should have been checking the dashboard and monitoring the labs and the results. She said management was not monitoring and there was no system in place when management was not in the facility on weekends. She said a delay of physician notification of abnormal lab results and chest x-rays could result in delay of medical care. She said the nurses should have notified the MD or the on-call NP about Resident #1 not eating. During an interview on [DATE] at 8:18 a.m., Resident #1's family member indicated he expired on [DATE]. During an interview on [DATE] at 11:31 a.m., LVN G said NP D ordered labs and chest x-ray for Resident #1 on [DATE]. She said she told NP D on Friday ([DATE]) that Resident #1 was not doing well and NP D went to see Resident #1 and ordered labs. LVN G said NP D asked her how many days Resident #1 had been like this and LVN G told NP D she could not say. She said she did not know to check the dashboard to see if the lab results were available for review. She said ADON B gave her the lab results and chest x-ray to report to MD H on Sunday [DATE]. She said she called the hospital for the on-call number and was given a fax number. She said the hospital indicated they would notify the on-call NP to call the facility. She said the on-call NP never called the facility. She said she did not follow-up to call the on-call NP again. LVN G said she texted NP D, who was Resident #1's physician's NP and was not on-call. NP D told her did not see the text from LVN G until [DATE]. She said she did not call the medical director. She said not reporting/communicating abnormal results could result in a further decline in resident health and delay medical care. She said she did not call the MD or the NP to report Resident #1 was not eating or drinking as he should. She said she should have reported Resident #1 not eating or drinking for two days as a change of condition to the MD or NP. During an interview on [DATE] at 1:50 p.m., ADON B said on [DATE] she found Resident #1's abnormal lab results and chest x-ray had not been reviewed. She said she asked LVN G to call the on-call NP and fax the results. She said she was not aware the on-call NP did not call back to the facility. She said she was not aware the fax was not sent successfully. She said there was a delay of medical intervention due to the abnormal labs and chest x-ray not being addressed timely. She said the staff should have followed up and communicated the results of the abnormal results with the physician or NP. During an interview on [DATE] at 1:55 p.m., NP D said the on-call physician or NP should have been informed of Resident #1's abnormal labs immediately. She said the facility nursing staff should have followed up with the on-call physician or NP if they did not receive a call back. She said she most likely would have ordered Resident #1 be sent to the hospital for fluids and ordered a second set of labs. During an interview on [DATE] at 1:09 p.m., the Medical Director said the facility nursing staff should have called the on-call number and followed up when the on-call NP did not call regarding Resident #1's abnormal results. He said the delay could result in further decline of health and delay of medical services. He said the facility staff should have called him (the medical Director) if they had not received a call back from the on-call NP. He said the delay of notification of abnormal results could result in a decline in health and even death. An attempted interview was made to contact MD H on [DATE] at 12:24 p.m. and on [DATE] at 12:52 p.m. MD H did not respond. Record review of the facility policy Change in Resident's Condition or Status dated 2001 (revised ,d+[DATE]) indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).3. Prior to notifying the physician or healthcare provide, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Record review of the facility's Interact SBAR form dated 2014 indicated Laboratory Tests/Diagnostic Procedures (*report why the test or procedure was done) . Report immediately . Blood/urea/nitrogen (BUN) >60 mg/dl . X-ray new or suspected finding (e.g., fracture, pneumonia, CHF) . Appetite, Diminished -no oral intake 2 consecutive meals. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 12:29 p.m. The Administrator, Regional Nurse Consultant, and CNO were notified of the IJ and a plan of removal was requested. The Administrator was provided an Immediate Jeopardy template on [DATE] at 12:29 p.m. The following Plan of Removal was submitted and accepted on [DATE] at 7:02 p.m.: Action Taken to Address Immediate Jeopardy Condition: On [DATE], regional nurse consultant (RNC) and ADON conducted a 100% lab result audit from [DATE] to current to ensure all labs ordered had been verified and carried out. The facility identified 12 labs, which were not sent to the physician and 4 labs waiting for physician response. Physicians were notified of any issues identified. All results were reviewed in an emergency/as needed (ad hoc) QAPI with IDT Team [DATE], which identified diagnostic testing results not reported to physician in timely manner and MD was not notified of change of condition, timely. Facility Plan to ensure compliance quickly. 1. Diagnostic testing policy & procedure and physician notification policy was reviewed by Regional Nurse Consultant (RNC) and ADONs on [DATE] prior to initiating training for licensed nursing staff. All licensed nurses currently on shift, were in-service by Regional Nurse Consultant/designee [DATE] on: -Nurses are to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results. -If any unreviewed results are present nursing will address them with the resident's primary PCP. -Nurses are to document in the nurse's notes as well as any interventions that are ordered by the PCP.- RNC/ADON/designee in-serviced nurses on the policy regarding change of condition notification to the physician/responsible party by [DATE] at 6:15pm*. For example, if a resident is refusing to eat or drink on more than two consecutive occurrences. - RNC/ADON/designee in-serviced CNAs on documenting residents' intake in the POC by [DATE] at 6:15pm*. - RNC/ADON/designee in-serviced nurses by [DATE] at 6:15pm* to contact medical director if primary MD does not respond: -routine - within 24 hours -abnormal - within 24 hours -critical - within 2 hours - The Regional Nurse Consultant (RNC)/ADON/designee performed training to other licensed nurses prior to their shift on all the above items. This will be completed by [DATE] at 6:15pm*. - ADON/DON/designee was trained by the Regional Nurse Consultant on [DATE] on following up with nurses notifying the PCP of abnormal labs. A monitoring tool was developed where the ADON/DON/designee will track the abnormal labs 5 days a week in the clinical meeting and review for missing/late notifications to clinician/Responsible Party. -DON/designee will monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results will be reviewed by the IDT team to determine if monitoring can be decreased. 2. Emergency/as needed (ad hoc) QAPI completed on [DATE] at 1:50pm. MDS Coordinator, Regional Nurse Consultant, Administrator, Medical Director, Human Resource, ADON, Activity Director, Rehab Director, and Dietary Manager attended emergency/as needed (ad hoc) QAPI. 3. Licensed nurses present completed 4 question communication test on [DATE] to ensure comprehension of education provided. All licensed nurses will complete the test prior to returning to work. This will be completed by [DATE]* at 6:15pm. 4. DON/ADON/designee will be monitoring all labs/x-rays, daily, to ensure they have been reviewed and PCP has been notified, effective [DATE]. This process will be completed on weekends by the weekend supervisor/designee. -DON/designee will monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results will be reviewed by the IDT team to determine if monitoring can be decreased. 5. Staff will not be able to work until they have been trained on reviewing the lab results process by completing the following in-services: -Nurses are to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results. -If any unreviewed results are present nursing will address them per facility protocol with the resident's primary PCP. -Nurses are to document in the nurse's notes and any interventions ordered by the PCP. -When there is a dashboard alert that a resident has eaten or drank less than usual, the nurse must assess the resident for change of condition and notify physician if warranted based on assessment. -Physician Notification of lab results, follow-up, or concerns. Nurses must notify MD/NP within 2 hours if lab order was unable to be carried out for any reason. In addition to notification of the MD, nurses must notify the Administrator and the DON/designee. -Nurses/staff who do not work after the [DATE] will be trained prior to their next shift. 6. All Processes will be in place by [DATE] at 6:15pm. On [DATE] at 11:45 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility's ad-hoc QAPI meeting minutes dated [DATE] (included the Medical Director) indicated the IJ failures were identified and discussed. Action plans for improvement were developed with monitoring and evaluating systems in place. Record review of the facility's chart audit dated [DATE], indicated the facility had completed 100% chart audit and notified the physicians of any changes or lab results as required. Record review of facility audit indicated 12 abnormal lab results with no physician notification. They were sent to physician for review and response. All results were reviewed by Ad HOC QAPI that included the medical director on [DATE]. Record review of the facility's lab monitoring dated [DATE] through [DATE] indicated all lab results had been addressed. Record review indicated all nursing staff were in-serviced on the facility's policy for diagnostic testing and procedure and physician notification. Record review indicated the RNC/ADON/designee in-serviced nurses on the policy regarding change of condition notification. RNC/ADON/designee in-serviced CNAs on documenting residents' meal intake in the electronic record and reporting missed or refused meals immediately to the charge nurse. Record review of communication test results dated [DATE] and [DATE] indicated all nurses tested passed with a score of 100%. Interviews conducted on [DATE] from 9:00 a.m. through 11:40 a.m. with the interim DON, two ADONs, 2 RNs, and 10 LVNS, who worked all shifts, indicated they were trained and able to correctly state the protocols for physician notification when there was a change of condition or a need to alter treatment for a resident, report abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change of condition, and ensuring the physician received the lab results. They were knowledgeable and were aware to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results, any unreviewed results to address them with the resident's primary PCP, document in the progress notes and interventions that are ordered by the PCP. They were to contact medical director if primary MD does not respond for routine labs- within 24 hours, abnormal labs- within 24 hours, and critical labs- within 2 hours. They were aware if a dashboard alerted a resident had eaten or drank less than usual, the nurse must assess the resident for change of condition and notify physician as warranted based on assessment. They were aware they must notify MD/NP within 2 hours of lab orders not completed for any reason. They were aware they must also notify the Administrator and the DON/designee. They were aware the DON/designee would monitor for compliance. Interviews conducted with 7 CNAs from all shifts indicated they were aware to document correct intake in the electronic record and to notify the charge nurse after each meal if a resident is not eating or drinking. Record review of an in-service dated [DATE] indicated the interim DON and two ADONs were trained to follow up on lab results and physician notification with a new monitoring tool. Interviews conducted with the interim DON and two ADONs indicated they were responsible for ensuring all lab results were reviewed and followed up per the new monitoring tool. They would review the monitoring tool at clinical meeting Monday through Friday for missing/late notifications to clinician/Responsible Party. The interim DON/designee was aware to monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results would be reviewed by the IDT team to determine if monitoring could be decreased. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 12:29 p.m. While the IJ was removed on [DATE] at 11:45 a.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 17 residents (Resident #1) reviewed for quality of care. The facility failed to notify the MD or NP of Resident #1's abnormal lab and x-ray results that indicated dehydration, kidney failure, and possible pneumonia to obtain treatment interventions after a change of condition in a timely manner. The facility failed to notify the MD or NP of Resident #1 (who had a history of weight loss) refusing to eat. Resident #1 was admitted to hospital on [DATE] with diagnoses of altered mental status and pneumonia, placed on hospice services on [DATE], and expired on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 12:29 p.m. While the IJ was removed on [DATE] at 11:45 a.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for delay of appropriate medical treatment and a worsening of a resident's condition, including death. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old male resident admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behaviors and agitation, diverticulitis (condition that affects the large intestine), depression (constant feeling of sadness and loss of interest), insomnia (a common sleep disorder that can make it hard to fall asleep), dysphagia (swallowing difficulties), cognitive communication deficit (difficulty with thinking and how someone uses language), severe protein-calorie malnutrition, and anemia (the body does not have enough healthy red blood cells). Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make himself understood and understand others, had BIMS score of 3 (severe cognitive impairment), required extensive/total physical assist of one staff for all ADLS, utilized a wheelchair for mobility, and was incontinent of bowel and bladder. Record review of a care plan dated [DATE] (revised [DATE]), indicated Resident #1 had dehydration or potential fluid deficit related to dementia. Interventions included obtain and monitor lab/diagnostics work as ordered. Report results to MD and follow up as indicated. Monitor/document and report as needed any signs and symptoms of dehydration including fatigue and weight loss. Record review of a care plan dated [DATE] (revised [DATE]), indicated Resident #1 had an alteration in gastrointestinal status related to diverticulitis in his intestine. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of a care plan dated [DATE] (revised [DATE]), indicated Resident #1 had a diagnoses of anemia. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of a NP progress note dated [DATE], completed by NP D, indicated Resident #1 was positive for fatigue (staff reports resident has been very weak for one week and history of a fall) and unintentional weight loss. The NP progress note indicated Resident #1 was positive for not eating for a week. The NP progress note indicated Resident #1 had a normal respiratory rate and pattern with no distress and normal breath sounds with no rales, rhonchi, wheezes, or rubs. The NP progress note indicated Resident #1's vital signs were blood pressure ,d+[DATE], pulse 68 beats per minute, and respirations 20 breaths per minute. The NP progress note indicated Resident #1 was ordered CBC (complete blood count), BMP (basic metabolic panel, LFT (liver function test), TSH (thyroid stimulating hormone), Lipid panel (complete cholesterol test), and chest x-ray 2-views. Record review of Resident #1's physician orders dated [DATE] indicated CBC(complete blood count), BMP(basic metabolic panel, LFT(liver function test), TSH (thyroid stimulating hormone), Lipid panel (complete cholesterol test), and chest x-ray 2-views was ordered. Record review of progress note dated [DATE] at 2:35 p.m., completed by ADON B, indicated new orders per NP D included CBC, BMP, LFT, Lipid panel today, and chest x-ray 2 views. Diagnoses included HLD (hyperlipidemia-an imbalance of the cholesterol levels in the blood that can lead to serious heart conditions), weight loss, anorexia (decrease in appetite and/or food intake in old age). Record review of lab results dated [DATE] indicated the collection as [DATE] at 4:55 p.m. and reported on [DATE] at 10:21 p.m. -TSH-10.80 (high)-Reference range 0XXX,d+[DATE].50 -HCT (red blood cells)-45.3-Reference range 34XXX,d+[DATE].9-high -PLT (platelet)-80-Reference range ,d+[DATE]-low -RDW (red cell distribution width)-17.2-Reference range 11XXX,d+[DATE].4 -high -Sodium-151-Reference range ,d+[DATE]-high -Chloride-112-Reference range ,d+[DATE]-high -BUN (blood urea nitrogen test reveals important information about how well kidneys are working)-71-Reference range ,d+[DATE]-high -Creatinine-2.20-Reference range 0XXX,d+[DATE].20-high -Cholesterol-221.0-Reference range 0XXX,d+[DATE].0-high -Triglycerides-162-Reference range ,d+[DATE]-high The report had no signature or date to indicate the report was reviewed. Record review of an x-ray report dated [DATE] for Resident #1 indicated diffuse opacity is seen in bilateral upper lungs. This is likely secondary to pulmonary edema (excessive fluid in the lungs), atelectasis (complete or partial collapse of a lung) and/or pneumonia (infection in the lungs). The report had no signature or date to indicate the report was reviewed. Record review of Resident #1's meal intake dated [DATE] indicated his intake was ,d+[DATE]% for breakfast., refused lunch and ,d+[DATE]% for supper. His meal intake on [DATE] was ,d+[DATE]% for breakfast., ,d+[DATE] % for lunch and refused for supper. Record review of Resident #1's fluid intake dated [DATE] his fluid intake was 120 ml for breakfast, refused for lunch, and 120 ml for supper. His fluid intake for [DATE] was 120 ml for breakfast, 120 ml for lunch, and 0 ml for supper. Record review of a 24-hour shift report dated [DATE] indicated to increase fluids and protein QD for Resident #1. There was no information related to labs or the results for Resident #1. Record review of a 24-hour shift report dated [DATE] indicated continue to increase fluids and protein QD for Resident #1. There was no information related to labs or the results for Resident #1. Record review of a 24-hour shift report dated [DATE] indicated no information related to Resident #1. There was no information related to labs or the results for Resident #1. Record review of the fax confirmation page dated [DATE] at 4:04 p.m. indicated the fax for Resident #1's abnormal lab results and chest x-ray were not successfully sent to the specified recipient (was the wrong fax number). Record review of a progress note dated [DATE] at 10:30 a.m., completed by LVN E indicated she called the on-call number to report Resident #1's abnormal labs and x-ray. Record review of a progress note dated [DATE] (three days after the lab results had been reported to the facility) at 11:53 a.m., completed by LVN E indicated on-call NP Q ordered Resident #1 to be sent out for IV ABT and fluids. Record review of a progress note dated [DATE] at 6:27 p.m., completed by LVN E indicated Resident #1 was admitted to the hospital for hyperkalemia (high potassium), AMS, dehydration and pneumonia. Record review of hospital records dated [DATE] indicated Resident #1 was admitted for hyperkalemia, AMS, dehydration and pneumonia. During an observation and interview at the hospital on [DATE] at 3:11 p.m., Resident #1 was asleep and unresponsive in the hospital. LVN F said Resident #1 had been admitted to hospice services and was on comfort care. She said Resident #1's prognoses was poor. During an interview on [DATE] at 1:30 p.m., LVN E said on [DATE] ADON A asked her to follow up on the labs that were drawn on [DATE]. She said she called the hospital to get the on-call number and called on-call NP Q. She said she told NP Q about Resident #1's lab results and the chest x-ray showing possible pneumonia. She said NP Q ordered Resident #1 to be sent to the hospital. LVN E said if abnormal lab results or x-rays were not addressed immediately there could be a delay of medical care. She said she was not aware of the percentage of food intake or lab results in the residents' dashboard of the electronic chart. During an interview on [DATE] at 12:57 p.m., LVN E said she was not aware of a dashboard for lab results. She said if lab results were critical the lab would call directly to the facility. She said if she did not check for results then she would not know lab results or x-ray results were available. She said the hospital said the on-call physician was NP Q. She said the labs and x-ray were done on a holiday weekend. She said Resident #1's family tried to feed him fast food and asked why the facility was sedating him. She said she told them he had not been sedated. She said they wanted her to force feed him. She said he drank ensure and liked it. During an interview on [DATE] at 3:00 p.m., ADON A said on [DATE] he found Resident #1's lab results had not been reviewed or addressed as they should have been on [DATE], when the results were sent to the facility. He said he asked LVN E on [DATE] to follow-up on the results. He said nursing staff should have notified the MD or on-call NP immediately of Resident #1's abnormal lab results and chest x-ray on [DATE]. He said the nursing staff should have notified the MD or on-call NP of Resident #1 not eating or drinking adequate amounts. He said Resident #1 had delay of medical treatment and care due to the failure to notify the physician or NP. During an interview on [DATE] at 3:19 p.m., RN C said the MD should be notified if a resident has not eaten for two days. She said missed meals were documented in the kiosk (where CNAs document the residents' meal intake) and would trigger in the dashboard (in the electronic record). The nurses should have checked the dashboard for any alerts and notify the MD as needed. She said labs and lab results were supposed to be checked daily in the dashboard. She said the nurses were supposed to review, notify the MD, then check off the results as reviewed. During an interview on [DATE] at 2:14 p.m., Resident #1's roommate said Resident #1 would eat when LVN E fed him. He said he would mostly eat his breakfast then the tray would sit on the bedside table for a while until staff picked the tray up and take it from the room. During an interview on [DATE] at 2:17 p.m. LVN E said none of the aides had reported to her Resident #1 was not eating or drinking. During an interview on [DATE] at 2:34 p.m., CNA K said she assisted Resident #1 to eat his meals. She said she told LVN G Resident #1 would not open his mouth to eat and was drinking very little water or juice. She said he would sometimes eat oatmeal for breakfast with a lot of sugar. She said she tried to feed Resident #1 all meals and snacks on [DATE] and [DATE] but he would not eat. CNA K said she told the family Resident #1 would not eat. She said the family went to talk to the nurse. During an interview on [DATE] at 10:03 a.m., LVN R said she was not aware of the dashboard or Resident #1's abnormal lab results or chest x-ray. She said she was not told Resident #1 was not eating or drinking as he should. She said she was not aware of the alerts on Resident #1's dashboard. She said she did not notify the physician or NP of the abnormal results or that Resident #1 was not eating because she was not aware of the issues. During an interview on [DATE] at 10:30 a.m., RN C said the nurses should have been checking the dashboard and monitoring the labs and the results. She said management was not monitoring and there was no system in place when management was not in the facility on weekends. She said a delay of physician notification of abnormal lab results and chest x-rays could result in delay of medical care. She said the nurses should have notified the MD or the on-call NP about Resident #1 not eating. During an interview on [DATE] at 8:18 a.m., Resident #1's family member indicated he expired on [DATE]. During an interview on [DATE] at 11:31 a.m., LVN G said NP D ordered labs and chest x-ray for Resident #1 on [DATE]. She said she told NP D on Friday ([DATE]) that Resident #1 was not doing well and NP D went to see Resident #1 and ordered labs. LVN G said NP D asked her how many days Resident #1 had been like this and LVN G told NP D she could not say. She said she did not know to check the dashboard to see if the lab results were available for review. She said ADON B gave her the lab results and chest x-ray to report to MD H on Sunday [DATE]. She said she called the hospital for the on-call number and was given a fax number. She said the hospital indicated they would notify the on-call NP to call the facility. She said the on-call NP never called the facility. She said she did not follow-up to call the on-call NP again. LVN G said she texted NP D, who was Resident #1's physician's NP and was not on-call. NP D told her did not see the text from LVN G until [DATE]. She said she did not call the medical director. She said not reporting/communicating abnormal results could result in a further decline in resident health and delay medical care. She said she did not call the MD or the NP to report Resident #1 was not eating or drinking as he should. She said she should have reported Resident #1 not eating or drinking for two days as a change of condition to the MD or NP. During an interview on [DATE] at 1:50 p.m., ADON B said on [DATE] she found Resident #1's abnormal lab results and chest x-ray had not been reviewed. She said she asked LVN G to call the on-call NP and fax the results. She said she was not aware the on-call NP did not call back to the facility. She said she was not aware the fax was not sent successfully. She said there was a delay of medical intervention due to the abnormal labs and chest x-ray not being addressed timely. She said the staff should have followed up and communicated the results of the abnormal results with the physician or NP. During an interview on [DATE] at 1:55 p.m., NP D said the on-call physician or NP should have been informed of Resident #1's abnormal labs immediately. She said the facility nursing staff should have followed up with the on-call physician or NP if they did not receive a call back. She said she most likely would have ordered Resident #1 be sent to the hospital for fluids and ordered a second set of labs. During an interview on [DATE] at 1:09 p.m., the Medical Director said the facility nursing staff should have called the on-call number and followed up when the on-call NP did not call regarding Resident #1's abnormal results. He said the delay could result in further decline of health and delay of medical services. He said the facility staff should have called him (the medical Director) if they had not received a call back from the on-call NP. He said the delay of notification of abnormal results could result in a decline in health and even death. An attempted interview was made to contact MD H on [DATE] at 12:24 p.m. and on [DATE] at 12:52 p.m. MD H did not respond. Record review of the facility policy Change in Resident's Condition or Status dated 2001 (revised ,d+[DATE]) indicated Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).3. Prior to notifying the physician or healthcare provide, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Record review of the facility's Interact SBAR form dated 2014 indicated Laboratory Tests/Diagnostic Procedures (*report why the test or procedure was done) . Report immediately . Blood/urea/nitrogen (BUN) >60 mg/dl . X-ray new or suspected finding (e.g., fracture, pneumonia, CHF) . Appetite, Diminished -no oral intake 2 consecutive meals. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 12:29 p.m. The Administrator, Regional Nurse Consultant, and CNO were notified of the IJ and a plan of removal was requested. The Administrator was provided an Immediate Jeopardy template on [DATE] at 12:29 p.m. The following Plan of Removal was submitted and accepted on [DATE] at 7:02 p.m.: Action Taken to Address Immediate Jeopardy Condition: On [DATE], regional nurse consultant (RNC) and ADON conducted a 100% lab result audit from [DATE] to current to ensure all labs ordered had been verified and carried out. The facility identified 12 labs, which were not sent to the physician and 4 labs waiting for physician response. Physicians were notified of any issues identified. All results were reviewed in an emergency/as needed (ad hoc) QAPI with IDT Team [DATE], which identified diagnostic testing results not reported to physician in timely manner and MD was not notified of change of condition, timely. Facility Plan to ensure compliance quickly. 1. Diagnostic testing policy & procedure and physician notification policy was reviewed by Regional Nurse Consultant (RNC) and ADONs on [DATE] prior to initiating training for licensed nursing staff. All licensed nurses currently on shift, were in-service by Regional Nurse Consultant/designee [DATE] on: -Nurses are to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results. -If any unreviewed results are present nursing will address them with the resident's primary PCP. -Nurses are to document in the nurse's notes as well as any interventions that are ordered by the PCP.- RNC/ADON/designee in-serviced nurses on the policy regarding change of condition notification to the physician/responsible party by [DATE] at 6:15pm*. For example, if a resident is refusing to eat or drink on more than two consecutive occurrences. - RNC/ADON/designee in-serviced CNAs on documenting residents' intake in the POC by [DATE] at 6:15pm*. - RNC/ADON/designee in-serviced nurses by [DATE] at 6:15pm* to contact medical director if primary MD does not respond: -routine - within 24 hours -abnormal - within 24 hours -critical - within 2 hours - The Regional Nurse Consultant (RNC)/ADON/designee performed training to other licensed nurses prior to their shift on all the above items. This will be completed by [DATE] at 6:15pm*. - ADON/DON/designee was trained by the Regional Nurse Consultant on [DATE] on following up with nurses notifying the PCP of abnormal labs. A monitoring tool was developed where the ADON/DON/designee will track the abnormal labs 5 days a week in the clinical meeting and review for missing/late notifications to clinician/Responsible Party. -DON/designee will monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results will be reviewed by the IDT team to determine if monitoring can be decreased. 2. Emergency/as needed (ad hoc) QAPI completed on [DATE] at 1:50pm. MDS Coordinator, Regional Nurse Consultant, Administrator, Medical Director, Human Resource, ADON, Activity Director, Rehab Director, and Dietary Manager attended emergency/as needed (ad hoc) QAPI. 3. Licensed nurses present completed 4 question communication test on [DATE] to ensure comprehension of education provided. All licensed nurses will complete the test prior to returning to work. This will be completed by [DATE]* at 6:15pm. 4. DON/ADON/designee will be monitoring all labs/x-rays, daily, to ensure they have been reviewed and PCP has been notified, effective [DATE]. This process will be completed on weekends by the weekend supervisor/designee. -DON/designee will monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results will be reviewed by the IDT team to determine if monitoring can be decreased. 5. Staff will not be able to work until they have been trained on reviewing the lab results process by completing the following in-services: -Nurses are to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results. -If any unreviewed results are present nursing will address them per facility protocol with the resident's primary PCP. -Nurses are to document in the nurse's notes and any interventions ordered by the PCP. -When there is a dashboard alert that a resident has eaten or drank less than usual, the nurse must assess the resident for change of condition and notify physician if warranted based on assessment. -Physician Notification of lab results, follow-up, or concerns. Nurses must notify MD/NP within 2 hours if lab order was unable to be carried out for any reason. In addition to notification of the MD, nurses must notify the Administrator and the DON/designee. -Nurses/staff who do not work after the [DATE] will be trained prior to their next shift. 6. All Processes will be in place by [DATE] at 6:15pm. On [DATE] at 11:45 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility's ad-hoc QAPI meeting minutes dated [DATE] (included the Medical Director) indicated the IJ failures were identified and discussed. Action plans for improvement were developed with monitoring and evaluating systems in place. Record review of the facility's chart audit dated [DATE], indicated the facility had completed 100% chart audit and notified the physicians of any changes or lab results as required. Record review of facility audit indicated 12 abnormal lab results with no physician notification. They were sent to physician for review and response. All results were reviewed by Ad HOC QAPI that included the medical director on [DATE]. Record review of the facility's lab monitoring dated [DATE] through [DATE] indicated all lab results had been addressed. Record review indicated all nursing staff were in-serviced on the facility's policy for diagnostic testing and procedure and physician notification. Record review indicated the RNC/ADON/designee in-serviced nurses on the policy regarding change of condition notification. RNC/ADON/designee in-serviced CNAs on documenting residents' meal intake in the electronic record and reporting missed or refused meals immediately to the charge nurse. Record review of communication test results dated [DATE] and [DATE] indicated all nurses tested passed with a score of 100%. Interviews conducted on [DATE] from 9:00 a.m. through 11:40 a.m. with the interim DON, two ADONs, 2 RNs, and 10 LVNS, who worked all shifts, indicated they were trained and able to correctly state the protocols for physician notification when there was a change of condition or a need to alter treatment for a resident, report abnormal labs, clarification of verbal orders, ensuring the physician was made aware of the change of condition, and ensuring the physician received the lab results. They were knowledgeable and were aware to monitor the dashboard throughout their shift for notifications of unreviewed lab and x-ray results, any unreviewed results to address them with the resident's primary PCP, document in the progress notes and interventions that are ordered by the PCP. They were to contact medical director if primary MD does not respond for routine labs- within 24 hours, abnormal labs- within 24 hours, and critical labs- within 2 hours. They were aware if a dashboard alerted a resident had eaten or drank less than usual, the nurse must assess the resident for change of condition and notify physician as warranted based on assessment. They were aware they must notify MD/NP within 2 hours of lab orders not completed for any reason. They were aware they must also notify the Administrator and the DON/designee. They were aware the DON/designee would monitor for compliance. Interviews conducted with 7 CNAs from all shifts indicated they were aware to document correct intake in the electronic record and to notify the charge nurse after each meal if a resident is not eating or drinking. Record review of an in-service dated [DATE] indicated the interim DON and two ADONs were trained to follow up on lab results and physician notification with a new monitoring tool. Interviews conducted with the interim DON and two ADONs indicated they were responsible for ensuring all lab results were reviewed and followed up per the new monitoring tool. They would review the monitoring tool at clinical meeting Monday through Friday for missing/late notifications to clinician/Responsible Party. The interim DON/designee was aware to monitor all lab and x-ray results to assure PCP notification in timely manner 7 days a week for four weeks and results would be reviewed by the IDT team to determine if monitoring could be decreased. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 12:29 p.m. While the IJ was removed on [DATE] at 11:45 a.m., the facility remained out of compliance at a scope of isolated and actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for 1 of 17 residents (Resident #2) reviewed for care plans. LVN G failed to follow the care plan and utilized untrained DS I and DS J who did not use a mechanical lift for repositioning Resident #2 in his wheelchair. DS I and DS J lifted and repositioned Resident #2 under his arms. Resident #2 sustained a broken right shoulder. This failure could place residents at risk of inadequate care and injury. Findings included: Record review of a face sheet dated 06/21/23 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (stroke), morbid obesity (weight is more than 80 to 100 pounds above ideal body weight), contracture of muscle, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following unspecified cerebral infarction affecting right dominant side, and age-related osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). Record review of an MDS dated [DATE] indicated Resident #2 was able to make himself understood and understood others, had a BIMS of 15 (cognitively intact), required extensive and total physical assist of 2 or more staff for transfers. He had impaired ROM of one side upper extremities and both sides of lower extremities. He utilized a wheelchair for mobility. Record review of a care plan dated 02/10/22 (revised 04/28/23) indicated Resident #2 had ADL self-care performance deficit related to hemiplegia. Interventions included a mechanical lift and two staff for transfers. Record review of a care plan dated 05/04/23 indicated Resident #2 had a pathological fracture of the right humerus that was diagnosed after an assist with repositioning by 2 staff members in an event to prevent his sliding from his wheelchair. He has the potential for this type of injury related to his diagnoses of osteoporosis. Interventions included: staff in-service/demonstration of proper transfer and assist with repositioning technique for direct care staff and support injured area with pillows and immobilize part as appropriate. Record review of an x-ray report for Resident #2 dated 05/04/23 indicated an acute humeral (upper arm bone) neck fracture. Record review of an accident report dated 05/04/23 completed by LVN G indicated Resident #2 was sliding out of his wheelchair and needed assistance with being pulled up. Resident #2 was not able to move his right limbs. Staff tried several times and then grabbed him under the arm and pulled him up. An x-ray indicated a fracture to the right shoulder. Physician ordered transport to ER. Resident #2 stated to go on and pull him up. He did not care about how, just pull him up because he was sliding down to the floor. Progress note dated 05/04/23 at 3:31 p.m., completed by LVN G indicated Resident #2 complained of right shoulder pain. The physician was notified and ordered an x-ray. X-ray result indicated fractured right shoulder. Resident #2 was transported to the hospital for evaluation and treatment. Record review of hospital admission records dated 05/04/23 indicated Resident #2 presented to the emergency department after facility staff members pulled him up in his wheelchair. He felt a pop and a pain in his right shoulder. He was assessed and diagnosed with mildly impacted and minimally comminuted fracture of the proximal right humerus. He was placed in a right-side immobilizer and given pain control. During observation and interview on 06/02/23 at 8:59 a.m. Resident #2 was in his bed with a sling on his right arm and shoulder. Resident #2 said he was sliding out of his wheelchair (on 05/03/23) and LVN G asked two male dietary staff to reposition him in his wheelchair. He said the dietary staff tried to pull him up by the sling but they were not successful. He said they put their arms under each of his arms and pulled him up. He said he heard and felt his right shoulder pop. He said he did not say anything and asked for a Tylenol. He said he was in a lot of pain the day after (on 05/04/23) the staff pulled him up by his arms in his wheelchair. He said he was in more pain currently than he was before the incident. He said he heard the staff were not trained to pull him up in the wheelchair. He said it usually required 2 or 3 staff and the electronic lift to transfer and reposition him. During an interview on 06/02/23 at 11:00 a.m., RN C said LVN G should have directed trained staff to get the mechanical lift to reposition Resident #2 in his chair as per the care plan. During an interview on 06/02/23 at 3:29 p.m., LVN G said she observed Resident #2 was sliding out of his wheelchair on 05/03/23. She said she did not see any male nurses or aides so she asked two male dietary staff to pull Resident #2 up and reposition him in his wheelchair. She said he did not complain of pain and had no change in ROM. She said on 05/04/23 Resident #2 complained of shoulder pain. She said she notified the physician. She said the physician ordered an x-ray. The x-ray results indicated a right shoulder fracture. She said Resident #2 was sent to the hospital for evaluation and treatment. She said he returned to the facility with a sling and orders to follow-up with an orthopedic. She said she did not think of the dietary staff not being trained. She said she did not think of using the mechanical lift as she wanted to prevent Resident #2 from sliding out of the wheelchair. She said she should have asked trained care staff to reposition Resident #2 in his wheelchair. She said Resident #2's injury was caused due to untrained staff lifting him inappropriately. She said they did not follow the care plan and use the mechanical lift to transfer him. During an interview on 06/05/23 at 11:40 a.m. DS I said he was asked by LVN G to pull Resident #2 up in his chair. He said he tried to assist DS J and pulled on the sling but it did not work. He said Resident #2 said to pull him up by his arms. He said he grabbed under his arm on one side and DS J grabbed under the other. He said he could not recall what side he was on. He said Resident #2 did not complain of any pain. He said he did not know he was not supposed to assist to pull Resident #2 up in his chair. During an interview on 06/05/23 at 1:45 p.m. DS J said he was asked by LVN G to assist and pull Resident #2 up in his wheelchair. He said he was not able to pull him up with the pad. He said he got under Resident #2's arm and pulled him up. He could not recall what side he was on. He said Resident #2 did not complain of pain. He said he did not know he was not supposed to assist to pull Resident #2 up in his chair. Record review of the facility's Care plans, Comprehensive Person-Centered policy dated 2001 (revised March 2022) indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

Based on interview and record review, the facility failed to ensure each resident received adequate assistive devices to prevent accidents for 1 of 17 residents reviewed for accidents. (Resident #1) LVN G had untrained DS I and DS J to pull Resident #2 up and reposition him in his wheelchair. Staff did not use a mechanical lift as required to lift and reposition Resident #1, resulting in a fracture to his right shoulder. This failure could place residents at risk of injuries. Findings included: Record review of a face sheet dated 06/21/23 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (stroke), morbid obesity (weight is more than 80 to 100 pounds above ideal body weight), contracture of muscle, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following unspecified cerebral infarction affecting right dominant side, and age-related osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). Record review of an MDS dated [DATE] indicated Resident #2 was able to make himself understood and understood others, had a BIMS of 15 (cognitively intact), required extensive and total physical assist of 2 or more staff for transfers. He had impaired ROM of one side upper extremities and both sides of lower extremities. He utilized a wheelchair for mobility. Record review of a care plan dated 02/10/22 (revised 04/28/23) indicated Resident #2 had ADL self-care performance deficit related to hemiplegia. Interventions included a mechanical lift and two staff for transfers. Record review of a care plan dated 05/04/23 indicated Resident #2 had a pathological fracture of the right humerus that was diagnosed after an assist with repositioning by 2 staff members in an event to prevent his sliding from his wheelchair. He has the potential for this type of injury related to his diagnoses of osteoporosis. Interventions included: staff in-service/demonstration of proper transfer and assist with repositioning technique for direct care staff and support injured area with pillows and immobilize part as appropriate. Record review of an x-ray report for Resident #2 dated 05/04/23 indicated an acute humeral (upper arm bone) neck fracture. Record review of an accident report dated 05/04/23 completed by LVN G indicated Resident #2 was sliding out of his wheelchair and needed assistance with being pulled up. Resident #2 was not able to move his right limbs. Staff tried several times and then grabbed him under the arm and pulled him up. An x-ray indicated a fracture to the right shoulder. Physician ordered transport to ER. Resident #2 stated to go on and pull him up. He did not care about how, just pull him up because he was sliding down to the floor. Record review of a progress note dated 05/04/23 at 3:31 p.m., completed by LVN G indicated Resident #2 complained of right shoulder pain. The physician was notified and ordered an x-ray. X-ray result indicated fractured right shoulder. Resident #2 was transported to the hospital for evaluation and treatment. Record review of hospital admission records dated 05/04/23 indicated Resident #2 presented to the emergency department after facility staff members pulled him up in his wheelchair. He felt a pop and a pain in his right shoulder. He was assessed and diagnosed with mildly impacted and minimally comminuted fracture of the proximal right humerus. He was placed in a right-side immobilizer and given pain control. During an interview on 06/02/23 at 8:59 a.m. Resident #2 said he was sliding out of his wheelchair and LVN G asked the dietary staff to reposition him in his wheelchair. He said they tried to pull him up by the sling but they were not successful. He said they put their arms under each of his arms and pulled him up. He said he heard and felt his right shoulder pop. He said he was in a lot of pain after the staff pulled him up by his arms in his wheelchair. He said he was in more pain currently than he was before the incident. He said he heard the staff were not trained to pull him up in the wheelchair. He said it usually required 2 or 3 staff and the mechanical lift to transfer and reposition him. He said it was the first time the dietary staff tried to reposition him. During an interview on 06/02/23 at 11:00 a.m., RN C said the staff should have utilized the mechanical lift and properly trained nurses and aides to reposition Resident #2 in his chair. RN C said there were nurse staff and aides who were trained and available to safely reposition Resident #2 with an electronic lift per the care plan. During an interview on 06/02/23 at 3:29 p.m., LVN G said she observed Resident #2 was sliding out of his wheelchair on 05/03/23. She said she did not see any male nurses or aides so she asked two male dietary staff to pull Resident #2 up and reposition him in his wheelchair. She said he did not complain of pain and had no change in ROM. She said on 05/04/23 Resident #2 complained of shoulder pain. She said she notified the physician. She said the physician ordered an x-ray. The x-ray results indicated a right shoulder fracture. She said Resident #2 was sent to the hospital for evaluation and treatment. She said he returned to the facility with a sling and orders to follow-up with an orthopedic. She said she did not think of the dietary staff not being trained. She said she did not think of using the mechanical lift as she wanted to prevent Resident #2 from sliding out of the wheelchair. She said she should have asked trained care staff to reposition Resident #2 in his wheelchair. She said Resident #2's injury was caused due to untrained staff lifting him inappropriately. During an interview on 06/05/23 at 11:40 a.m. DS I said he was asked by LVN G to pull Resident #2 up in his chair. He said he tried to assist DS J and pulled on the sling but it did not work. He said Resident #2 said to pull him up by his arms. He said he grabbed under his arm on one side and DS J grabbed under the other. He said he could not recall what side he was on. He said Resident #2 did not complain of any pain. He said he did not know he was not supposed to assist to pull Resident #2 up in his chair. During an interview on 06/05/23 at 1:45 p.m. DS J said he was asked by LVN G to assist and pull Resident #2 up in his wheelchair. He said he was not able to pull him up with the pad. He said he got under Resident #2's arm and pulled him up. He could not recall what side he was on. He said Resident #2 did not complain of pain. He said he did not know he was not supposed to assist to pull Resident #2 up in his chair. Record review of the facility's Safety and Supervision of Residents policy dated 2001 (revised July 2017) indicated Our facility strives to make environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 1. Due to their complexity and scope, certain resident risk factors and environment hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: .b. Safe Lifting and Movement of Residents; .

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. The facility did not prevent Resident #1 who had a history of breaking windows from leaving the facility unsupervised. Resident #1 was found 0.2 miles from facility at a restaurant. The facility was not aware the resident was missing until an unidentified neighbor alerted the staff. An Immediate Jeopardy (IJ) situation was determined to have existed on 10/3/22 to 10/4/22. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of accidents, injury, or death. Findings include: Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia, anxiety disorder, and diabetes. Upon admission the resident was noted to have bruising to the left elbow and old scabs to right hand. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 5 out of 15, which indicated his cognition was severely impaired. He required supervision with most ADLs. Record review of Resident #1's care plan, initiated on admission 08/30/22, indicated Resident #1 was an elopement risk/wanderer. Interventions included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book. Resident #1's care planned also addressed the resident is physically aggressive by punching the closed doors of secure unit and breaking windows in room. Interventions included administer medications, assess, and anticipate needs, monitor resident 1:1 and redirect if becomes agitated or attempts to elope. Record review of Resident #1's progress notes dated 10/03/22 at 5:25 p.m. through 10/04/22 at 1:10 p.m. p.m. was as follows: *10/03/22 at 5:25 p.m., LVN A documented Resident #1 was agitated, combative, and attempting to open back door forcefully. He went to his room for short period and came back out cursed at staff. *10/03/22 at 7:35 p.m., LVN B documented an unknown male came and knocked on front entrance door to tell staff that a man had climbed out of a window. All staff were alerted to account for the residents. Window in Resident #1's room noted to be broken out. Three staff members started looking for resident on foot and others were looking per vehicles. Administration notified and began arriving. The DON and police arrived at 7:45 p.m. and reviewed facility cameras. At 8:15 p.m., facility was notified Resident #1 had been located at a restaurant by police. At 8:25 p.m. Resident #1 returned to facility by police. Resident was assessed. Family and physician notified. Facility began 1:1 for resident's safety; *10/04/22 at 4:52 a.m., Resident #1 had ambulated in hallway throughout the night and remained on 1:1 at bedside. He does not recall leaving facility. *10/04/22 at 1:10 p.m., Resident #1 transported to behavioral center via ambulance service. Interview on 10/11/22 at 11:25 a.m., the administrator said Resident #1 believed his car had been stolen. She said she had reviewed the facility cameras on the evening of the elopement. Around 7:15 p.m., a CNA had gone in to check on residents. At 7:37 p.m., you could see a man running up to the door and speaking to LVN F and then see her alerting the staff and then a lot of activity happening. The department heads were also notified as well as police. The facility was notified by police that Resident #1 was found standing outside a restaurant unharmed and was transported to the facility. The neighbor could be seen approaching the front entrance in the video. He had seen Resident #1 crawling out of the window and tried to stop him and unsuccessfully redirect him to come back. Interview on 10/13/22 at 9:15 a.m., the SW said before the incident of the elopement with Resident #1, he had been busting out windows, but he never attempted to leave. She said that she had been working before the elopement incident with the family to try to find another placement for him. They had sent packets out to other facilities since the incident. She has also continued to work with the family member, and they were looking into a facility that has an all-male unit. SW indicated Resident #1 remained at the behavior unit. If Resident #1 returns from behavioral center before other placement can be found, he will be put on 1:1 monitoring until alternate placement obtained. During observations of the secure unit on 10/13/22 at 10:45 a.m., there was 1 LVN and 2 CNAs working. Resident#2 was sitting on side of his bed. Call light in reach. He said staff help him shower. He was oriented at that time to person and place. Resident #3 was ambulating in the hallway and came toward syrveyors and wanted a hug. She was non-interviewable. Resident #4 was sitting in the TV room watching an old movie. She was non-interviewable. The unit had 15 residents, with 2 being hospitalized . Interview on 10/13/22 at 11:00 a.m., CNA E said Resident #1 would break windows, but never went through them to leave. On the night of Resident #1's elopement, she was on duty on the secure unit. The facility was notified by a neighbor of the elopement on Monday. He told the front desk that there was a resident that had just went through a window and was seen running down the road, and saying he'd been kidnapped. CNA E said the secure unit was always staffed with 2 CNAs. She said she had been trained and also refresher in-services on elopements, wandering resident, dementia, abuse and neglect. Also trained on re-directing residents who wander. Interview on 10/13/22 at 12:00 p.m. with LVN F. She said she was on duty on the evening of Resident #1's elopement. She said an unknown man came to front entrance and informed her a resident had just climbed out a window and was walking down the road. She said she notified staff on duty to check for all the residents to see if anyone was missing. She said the nurse from the secure unit then realized Resident #1 was unaccounted for. She said staff then began the facility protocol for elopements. LVN F said herself and facility staff had been trained on dementia, abuse and neglect, elopement, and resident rights. She said most of the residents on the secure unit were wandering and elopement risk. Interview on 10/13/22 at 12:30 p.m. with DON. She said all staff had been retrained on abuse/neglect, resident rights and elopement. She added the evening of Resident #1s elopement, she arrived at facility within ten minutes and began reviewing the facility cameras. She said the elopement protocol was activated. She said the protocol included to initiate elopement emergenct procedures including to initaite a search of the building and premises and if not located, notify administration, resident's family, physician, and local law enforcement. The administrator was notified on 10/11/22 at 3:50 p.m. a past non-compliance situation had been identified due to the above failures. It was determined these failures placed residents in an IJ situation on 10/03/22 to 10/04/22. The facility implemented the following interventions: *Assessment of Resident #1 *Arrangements made to admit to a behavioral center *Initiated a Critical Behavior Monitoring Log with checks every 15 minutes *Resident #1 placed on 1:1 monitoring until transport to behavior center *Completion of in-services regarding elopement investigation. *Staff re-educated on Abuse, Neglect, wandering, and elopement. *Environmental rounds made to ensure integrity of windows. These interventions were completed based on 5 staff (Administrator, DON, ADON, 3 LVNs, 3 CNA, and social worker) interviews to ensure these interventions had been completed. Staff were able to appropriately define neglect, identify the abuse coordinator, and said they would immediately notify the administrator or DON of any neglect allegations or elopements. Reviewed employee in-service records with topics of routine rounding to help maintain resident safety and well-being including rounding every 2 hours and bedside hand-off report; documentation and follow-up of wandering/elopement resident incident; abuse and neglect; and wandering and elopements policy. Observational rounds conducted by maintenance supervisor and surveyor to assess all windows from the outside. Record review of the facility's Wandering and Elopements policy revised March 2019 indicated The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for resident.

Based on interview and record review the facility failed to permit each resident to remain in the facility and not transfer or discharge the resident from the facility for 1 of 4 residents (Resident 1) reviewed for transfer and discharged rights. The facility failed to safely discharge Resident #1 after Resident #1 took narcotic medication from a medication cart on 09/08/22. Resident #1 was immediately discharged on [DATE] without appropriate discharge orders or transfer orders and continuation of care. The facility failed to have a completed discharge summary. An Immediate Jeopardy (IJ) situation was identified on 09/21/22 at 2:00 p.m. The facility administrator was provided with the IJ template on 09/21/22 at 3:12 p.m. While the IJ was removed on 09/23/22 at 11:46 a.m., the facility remained out of compliance at severity level of actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for not receiving care and services to meet their needs upon discharge and could place residents at risk for a decline in heath, hospitalization , and death. Findings included: A face sheet dated 09/20/22 indicated Resident #1 was admitted [DATE], was [AGE] years old, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an MDS dated [DATE] indicated Resident #1 was able to make himself understood, was able to understand others, had a BIMS score of 11 (moderate cognitive impairment), he required supervision and limited assist for all ADLS, was physically impaired on both lower extremities, utilized a wheelchair for mobility, was occasionally incontinent of both bladder and bowel, and received scheduled pain medications. There were no plans for discharge. Record review of the comprehensive care plans dated 07/08/22 indicated he required long term care services related to acute [CONDITION(S)] exacerbation. There was no care plan related to discharge from the facility. A progress note dated 09/09/22 at 9:51 a.m., by LVN D indicated the hospital was called to pick up Resident #1 due to possible OD. A progress note dated 09/09/22 at 6:30 p.m., by LVN D indicated per the Administrator, Resident #1 no longer qualified to be housed in the facility and was discharged from MD M's services. A progress note dated 09/09/22 at 6:43 p.m., by LVN D indicated Resident #1 was transported from the ED to the facility. Resident #1 was advised he no longer had privileges of taking up residence at the facility due to his previous actions of taking narcotics off the nurse's cart. He was given his medications and offered his belongings. APS was called by SW K and advised of the situation. During an interview on 09/13/22 at 4:20 p.m., an interview on 09/13/22 at 4:20 p.m., the Administrator said Resident #1 was sent to the ER to make sure he did not OD because Resident #1 would not divulge if he ingested the narcotics. She said from there, she heard that he went to friend's house from the ER. She said physician did not want to keep him on services, so the hospital sent him to a friend's house. She said Resident #1 was in the NF for [CONDITION(S)] and was able to be discharged . She said he would sign himself out most days and hang out with people. She said the hospital tried to send him back without giving report. The administrator said she did not have the hard copy of the discharge order from the physician but had a verbal order. During She said she had a verbal conversation with Resident #1 saying he was being given an immediate discharge. She said she did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was not observed or interviewed during the survey/investigation. The number listed on the face sheet dated 09/20/22 did not accept calls. The surveyor sent a text message on 09/21/22 at 8:21 a.m. requesting a call back with contact information. There was no response to the text message prior to exit. Review of hospital records dated 09/09/22 indicated Resident #1 arrived at the emergency department via EMS from the facility with no complaints. The facility reported Resident #1 took 14 [MEDICATION(S)] from their locked narcotics cart, witnessed on video. EMS stated Resident #1 consented to coming to the ED due to the facility threatening to call the police. Resident #1 denied taking the medications. Urine Opiates Screen Positive for Benzodiazepines (depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures), Salicylates (a type of drug found in many over-the-counter and prescription medicines. Aspirin is the most common type of [MEDICATION(S)]) <1.7, and acetaminophen (a pain reliever and a fever reducer; Taking too much acetaminophen can cause liver damage, sometimes serious enough to require liver transplantation or cause death) 7. The hospital planned on repeat Tylenol level but Resident #1 requested to leave AMA. Clinical Impression was listed as pneumonia. Discharge instructions included follow-up with primary MD tomorrow. Emergency Department notes indicated the following: -09/09/22 11:14 a.m. Poison was control called and notified that the nursing facility stated Resident #1 took 14 [MEDICATION(S)] 10/ 325. Cardiac monitor, EKG, draw Tylenol Level 3 hours from now. Start antidote for Tylenol and monitor for 6 to 8 hours. Benzos as needed for [CONDITION(S)] and [CONDITION(S)]. -09/09/22 12:24 p.m. Resident #1 wheezing and notified doctor for breathing treatment. Orders received and acknowledged. -09/09/22 1:45 p.m. This RN spoke to ADON A at the nursing facility to call report for Resident #1 being discharged back to the facility. DON refused to take resident stating He has been dropped by his PCP, he has no doctor. This RN notified our social services. Gave DON phone number and stated will call back with resolution. -09/09/22 5:39 p.m. Resident #1 returned to ED transport van due to NF denying Resident #1. -09/09/22 5:40 p.m. Police called and notified of situation with NF not accepting Resident #1 back to place of residence. Police said to send Resident #1 back via transport and officer will meet transport and Resident #1 at residence. 5:51 p.m. transport wheelchair van called for Resident #1 transport home. Resident #1 currently in ER waiting room and ETA 1.5 hours. -09/09/22 7:56 p.m. Transport van arrived to transport Resident #1 to the NF at approximately 7:40 p.m. Unable to locate Resident #1. -09/10/22 1:23 a.m. Resident #1 has not presented back to ED. -09/12/22 1:06 a.m. Social Work Note SW L was called to ED to speak with Resident #1 and charge nurse regarding the NF refusing to take Resident #1 back. The nursing facility nurse called the ED and stated that the resident was being sent to the hospital because he stole 14 [MEDICATION(S)] pills out of the locked narcotic tray the facility advised Resident #1 he could go to the ER or they would call the police. He opted for the hospital. SW L met with Resident #1 for an extended amount of time. He was alert, fully dressed, with tennis shoes on, lying in the bed. He had clear speech and adamantly denied stealing and/or taking 14 pills. Nursing stated his vital signs were good and he was denying any shortness of breath, pain or discomfort. Resident #1 was not deemed to be in a medical crisis, per ED staff. SW L spoke with Resident #1 and he stated, I really want to go back there (NH). That's where I live. If I can't, I will call a friend of mine, but please, if I can, I want to go back to the NH. SW L made eight different attempts to contact any staff at the NH and no one would answer her call. A nurse at the station left her on hold for over 30 minutes. The administrator never called SW L back. SW L also contacted the facilities corporate office and spoke with a representative. SW L requested someone from the facility call the hospital for an update regarding Resident #1. At 6:00 PM, SW K from the NH called and stated, he doesn't live here anymore. SW K offered no assistance with locating safe placement for Resident #1. SW L updated staff. SW L will report to APS on 9/12/22. During an interview on 09/15/22 at 9:55 a.m., the Administrator said Resident #1 refused any care or help on his discharge and said he would return to the hospital. She said SW K gave Resident #1 brochures for home health and asked where he was going. During an interview on 09/15/22 at 11:30 a.m., SW K said she gave Resident #1 home health business cards and told him about the salvation army. She said she did not have a discharge plan of care prepared and did not have a discharge summary completed. Record review of hospital records dated 09/11/22 at 4:22 a.m. indicated Resident #1 was a [AGE] year-old male with a history of [CONDITION(S)], CAD, CHF, drug abuse, [CONDITION(S)] and [CONDITION(S)] who was recently discharged from a hospital, where he was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 said he went to the gas station where he began to experience non- radiating chest pain that he described as sharp in nature. Resident #1 was intubated on 09/10/22 and extubated on 09/11/22. He was assessed for acute hypercapnic hypoxic [CONDITION(S)] (Hypoxemic [CONDITION(S)] means that you don't have enough oxygen in your blood, but your levels of carbon [MEDICATION(S)] are close to normal. Hypercapnic [CONDITION(S)] means that there's too much carbon [MEDICATION(S)] in your blood, and near normal or not enough oxygen in your blood), pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, fungi, or chemical irritants), [CONDITION(S)] exacerbation (a worsening or flare up), and CHF exacerbation (an increase in or worsening of heart failure symptoms). His final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was discharged to an NF on 09/14/22. Record review of the Nursing Home Transfer and Discharge Notice dated 09/09/22 indicated This form is required for those transfers and dischargers initiated by the nursing home facility, and not by the resident or by the resident's physician or legal guardian or representative. Location to which resident is transferred or discharged (required): Medical Center (due to resident refusing to tell me the name and address of the son's house he stated he wanted to be discharged to) . The following reasons require either this form be signed by a physician or a physician's written order for discharge or transfer be attached. The signing physician may be the resident's attending or treating physician, the facility medical director, or nurse practitioner or physician's assistant as a physician designee. There was an X placed in the boxes that indicated Your needs cannot be met by this facility. The health of other individuals in this facility is endangered., and The safety of other individuals in this facility is endangered. Resident #1 broke into a medication cart and took 13, 10/325 Norcos. It is unknown if Resident #1 took the medication or sold it to other residents. Resident #1 refused to tell me what he did with the medicine. This action endangered Resident #1 and other residents. The facility can no longer meet his needs because his PCP, the medical director, dropped him from services. As outlined in the Department of Human Services' Fair Hearing, Fraud, and Civil Rights Handbook, you have a right to appeal the Facility's decision to discharge you. If you think you should not be transferred or discharged , you may request a hearing through the Medicaid Eligibility worker at the local Department of Health Services office within 10 days of receipt of this notice of discharge. Record review of the facility investigation dated 09/16/22 included a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/20/22 at 9:43 a.m., the Administrator said Resident #1 took 14 Norcos from the medication cart at 7:40 p.m. on 09/08/22 (as seen on video). She said Resident #1 would not say whether he took the medications or gave or sold them to other residents. She said he was sent out to the ER for evaluation on 09/09/22 and the ER sent him back a few hours later. She said before he left to the ER Resident #1 said he wanted to leave. She said she told him she would need to issue an immediate discharge and would take him back and find him another place. She said MD M (who is also the facility medical director) called and said he would not care for Resident #1. She said she did not attempt to find a new doctor for Resident #1. She said the hospital was notified the facility would not take Resident #1 back but would help find placement. She said the hospital SW (SW L) called SW K but SW K was busy. She said SW K tried calling the ER a few times and there was no response. She said Resident #1 arrived at the facility without report from the hospital. She said she believed he was on the phone with someone trying to arrange pick-up at the ER while he was in the facility parking lot. She said she did notify the ombudsman of the discharge. During an interview on 09/20/22 at 1:28 p.m., LVN D said she documented in the progress notes for Resident #1's transfer to the hospital for evaluation for possible drug overdose. She said she documented additional notes related to Resident #1's discharge from MD M's services and then from the facility per information received from the Administrator and the DON. During an interview on 09/20/22 at 2:29 p.m., SW K said Resident #1 was discharged from the facility on 09/09/22 with home health referrals. She said SW L was told the facility discharged Resident #1 due to MD M dropping him from services. She said the facility could not meet his needs without a physician. She said Resident #1 asked for referrals and she gave him home health business cards and information to local Salvation Army. She said she knew Resident #1 was homeless. She said there was no plan to discharge Resident #1 from the facility prior to him taking narcotic medication from the medication cart. During an interview on 09/22/22 at 11:30 a.m., ADON A said he arrived to work on 09/09/22, the DON said LVN D reported medications were missing. He said he reviewed the video and Resident #1 opened the cart's main medication drawer, then opened the narcotics drawer and got the narcotics from the narcotics drawer. During the time Resident #1 was at the hospital, MD M discharged him from services. He said he was not sure of the discharge process. He said he knew the SW was involved with the discharge to ensure a safe discharge. He said the hospital called the facility and he spoke to an unknown staff and advised them Resident #1 did not have a physician for re-admit to the facility. He said he told the hospital staff SW K would call and speak with the hospital SW to discuss Resident #1's case. He said he provided the hospital staff with SW K's name and number. He said someone indicated Resident #1 was in the facility parking lot and he saw Resident #1 had arrived via the wheelchair transport van. He said he went out and advised EMS F Resident #1 did not have a physician and was not able to re-admit to the facility. ADON A said Resident #1 asked why he could not return to the facility and he told him he was not sure. He said he asked him where he wanted to go but Resident #1 ignored him. He said Resident #1 entered the EMS transport van and left the facility's property. He said Resident #1 did not say he wanted to discharge from the facility prior to the incident with the narcotics being taken from the medication cart. He said as far as he was aware, Resident #1 was a long-term care resident with no discharge plans. During an interview on 09/22/22 at 4:32 p.m. MD M indicated he was the facility medical director. He said he was not aware of the discharge process in detail. He said he trusted the facility administrator and staff to follow the proper procedures and policies. He was aware Resident #1 was sent to the hospital for evaluation due to possible ingestion of narcotics. He said he gave a verbal order for immediate discharge from the facility due to Resident #1 stealing medication and based on the information he received from the facility. He said he agreed with the discharge of Resident #1 because he believed the facility was following the rules and was conducting a safe discharge of Resident #1. He said there was always a risk when discharging a resident from the facility and some of the risks are unforeseen. He said improper discharge could place residents at risk of decline of health and hospitalization . A facility's Transfer or Discharge Notice policy dated 2001 (revised (12/16) indicated 1. A resident and/or the resident's representative (sponsor) with a Thirty (30)-day written notice of impending transfer or discharge. 2. Under the following circumstances, the notice will be given as soon as it is practicable, but before the transfer or discharge: a. The Transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The Transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered; d. The health of individuals in the facility would otherwise be endangered; . Record review of the facility's Transfer or Discharge, Emergency policy dated 2001 (revised 12/2016) indicated Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). 1. Residents will not be transferred unless: a. The transfer or discharge is necessary for the resident's, welfare and the resident's needs cannot be met in the facility; . c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. The health of individuals in the facility would otherwise be endangered; . 4. should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary. A facility Social Services policy dated 08/16 indicated Social services staff, members of the interdisciplinary team, will participate in the development of a discharge plan for residents with a potential for discharge to a private residence, to another nursing facility or skilled nursing facility, or to another type of residential facility such as an assisted living center. Considerations: 1. When the interdisciplinary team determines that a resident has a potential for discharge in the next quarter or sooner, social service staff will address the following: a. Necessary, supportive relationships in the community to meet his/her emotional needs; b. The cost of needed services and financial resources necessary to pay for the services; c. Education needed by resident/family about available community resources and how to access those services; and d. Needs for emotional support to assist in adjustment to the new living environment. 2. The need for a discharge plan will be assessed upon admission. The discharge plan will be incorporated into the resident's care plan. The administrator was notified on 09/21/22 at 3:12 p.m., an IJ situation was identified due to the above failures and the IJ template was provided. On 09/22/22 at 4:15 p.m., the facility plan of removal was accepted and included: The Business Office Manager of the facility verified resident is in another facility. No desire was express by the resident to return to this facility. The facility and the resident are making arrangements to get the resident his belongings. 1. Administrator, DON, ADON, Marketer, Admissions Coordinator, Business Office Manager, MDS nurse, Rehab Director, and Social Worker has been in-serviced on the facilities discharge planning process, transfer and discharge, and permitting resident to return to the facility by Vice President of Operations. Completed on 09/21/22 2. The DON initiated a discharge checklist for every discharge. The Social Worker has been in-serviced by the DON on the discharge checklist. Completed by 09/22/22 3. The DON educated Medical Director on discharge process. Completed by 09/22/22 4. The administrator and DON performed an audit of all immediate discharges in the last 30 days to ensure appropriate discharge. Completed by 09/22/22 5. Ad Hoc QAPI attended by Medical Director, DON, ADON, Business Office Manager, and Admissions Coordinator to address failure to follow discharge planning process, failure to appropriately discharge, and failure to permit resident to return. Completed by 09/22/22 6. The administrator, DON, ADON, Social Worker, Business Office Manager, Admissions, Marketing, MDS nurse, and Rehab Director were in-serviced on the facilities discharge planning process, transfer and discharge, and permitting resident to return to the facility by Vice President of Operations and will follow the following procedures, immediately, during all discharges. Completed on 09/21/22. a. Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). 1. Residents will not be transferred unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. The health of individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies: (1) If the resident does not submit the necessary paperwork for third party payment; or (2) After the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay; or f. The facility ceases to operate. 2. If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. 3. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented. 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary. 5. Should it become necessary to transfer residents during emergency or disaster situations, transfer procedures outlined in our disaster plan will be implemented. 6. The resident's medical record must be forwarded to the Medical Records office within twenty-four (24) hours of the transfer or discharge. 7. Administrator, DON, ADON, Marketer, Admissions Coordinator, Business Office Manager, MDS nurse, Rehab Director, and Social Worker has been in-serviced on resident returning from the hospital, will not evaluate the resident based on the resident's condition when originally transferred to the hospital. The evaluation will be based upon the return of the resident. Discharges will then be determined, with the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary. 8. All items to be completed by 09/22/22 at 4:00 pm. On 09/23/22 at 11:46 a.m. the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by: Record review of in-service training dated 09/21/21 presented to all department heads included the discharge process policy and procedures, what was an appropriate discharge versus inappropriate discharge, and allowing residents tore turn to the facility. Staff must coordinate services and document discharge planning for all residents who are discharging from the facility. Record review of in-service training dated 09/22/22 presented to the medical director/MD indicated he was advised of the discharge process policy and procedures, what was an appropriate discharge versus inappropriate discharge, and allowing residents tore turn to the facility. Record review of an audit of all immediate discharges dated 09/22/22 in the last 30 days indicated no immediate discharges were issued. Record review of Ad Hoc QAPI dated 09/22/22 and attended by Medical Director, DON, ADON, Business Office Manager, and Admissions Coordinator addressed failure to follow discharge planning process, failure to appropriately discharge, and failure to permit resident to return. Record review of ins-service dated 09/22/22 indicated the Administrator, DON, ADON, Marketer, Admissions Coordinator, Business Office Manager, MDS nurse, Rehab Director, and Social Worker were in-serviced on resident returning from the hospital, will not evaluate the resident based on the resident's condition when originally transferred to the hospital. The evaluation would be based upon the return of the resident. During interviews on 09/23/22 from 8:00 a.m. through 11:40 a.m., the Administrator, the DON, ADON/LVN, SW, MDS Coordinator/LVN, admissions Director/LVN, Director of Rehabilitation, the marketer, and the BOM/AIT were knowledgeable of the requirements for discharge planning and stated they had received training regarding discharge planning and documentation. They were aware of the facility's systemic approach to discharge, the equipment and forms required, the procedure and the documentation required, the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . They indicated there were no current residents with planned or emergency discharges in process. During interviews on 09/23/22 at 11:30 a.m., the administrator and corporate RN, confirmed all department heads currently working at the facility had been trained on discharge planning and documentation of resident's discharge plans. On 09/23/22 at 11:46 a.m., the administrator was notified the IJ was removed. However, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure the written policy for returning to the facility after a hospitalization was followed 1 of 4 (Resident #1) residents reviewed for transfer and discharged . The facility did not allow Resident #1 to return to the facility. The resident was sent to the hospital for evaluation due to a possible overdose. The facility refused to take him back after the hospital cleared him for re-admission to the facility on [DATE]. Resident #1 went to a gas station where he began to experience non- radiating chest pain; Resident #1 was intubated on 09/10/22 and extubated on 09/11/22. An Immediate Jeopardy (IJ) situation was identified on 09/21/22 at 2:00 p.m. The facility administrator was provided with the IJ template on 09/21/22 at 3:12 p.m. While the IJ was removed on 09/23/22 at 11:46 a.m., the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge and could result in decline in heath, hospitalization and death. Findings included: A face sheet dated 09/20/22 indicated Resident #1 was admitted [DATE], was [AGE] years old, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an MDS dated [DATE] indicated Resident #1 was able to make himself understood, was able to understand others, had a BIMS score of 11 (moderate cognitive impairment), he required supervision and limited assist for all ADLS, was physically impaired on both lower extremities, utilized a wheelchair for mobility, was occasionally incontinent of both bladder and bowel, and received scheduled pain medications. There were no plans for discharge. Record review of the comprehensive care plans dated 07/08/22 indicated he required long term care services related to acute [CONDITION(S)] exacerbation. There was no care plan related to discharge from the facility. Record review of the facility video recording dated 09/08/22 from 7:36 p.m. through 7:44 p.m. (with the Administrator and BOM present on 9/22/22 at 8:45 a.m.) indicated Resident #1 rolled up to the medication cart on hall 500, opened the main drawer and then he proceeded to open the narcotics drawer and took a pack of narcotics. Resident #1 rolled down the hall toward his room. There was no staff observed in the hall or near the medication cart. A progress note dated 09/09/22 at 9:51 a.m., by LVN D indicated the hospital was called to pick up Resident #1 due to possible OD. A progress note dated 09/09/22 at 6:30 p.m., by LVN D indicated per the Administrator, Resident #1 no longer qualified to be housed in the facility and was discharged from MD M's services. A progress note dated 09/09/22 at 6:43 p.m., by LVN D indicated Resident #1 was transported from the ED to the facility. Resident #1 was advised he no longer had privileges of taking up residence at the facility due to his previous actions of taking narcotics off the nurse's cart. He was given his medications and offered his belongings. APS was called by SW K and advised of the situation. During an interview on 09/13/22 at 4:20 p.m., an interview on 09/13/22 at 4:20 p.m., the Administrator said Resident #1 was sent to the ER to make sure he did not OD because Resident #1 would not divulge if he ingested the narcotics. She said from there, she heard that he went to friend's house from the ER. She said physician did not want to keep him on services, so the hospital sent him to a friend's house. She said Resident #1 was in the NF for [CONDITION(S)] and was able to be discharged . She said he would sign himself out most days and hang out with people. She said the hospital tried to send him back without giving report. The administrator said she did not have the hard copy of the discharge order from the physician but had a verbal order. During She said she had a verbal conversation with Resident #1 saying he was being given an immediate discharge. She said she did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 09/15/22 at 9:55 a.m., the Administrator said there were no plan for Resident #1's discharge. She said he was not being allowed to return to the facility because he was a threat to himself and others. She said Resident #1 refused any care or help on his discharge and said he would return to the hospital. She said SW K gave Resident #1 brochures for home health and asked where he was going. During an interview on 09/15/22 at 11:30 a.m., SW K said she gave Resident #1 home health business cards and told him about the salvation army. She said she called APS on 09/09/22. She said she did a written report to APS online on 09/09/22. She said she heard back from APS on 09/12/22 and gave the caseworker details of Resident #1's discharge from the facility on 09/09/22. She said she did not have a discharge plan of care prepared. Review of hospital records dated 09/09/22 indicated Resident #1 arrived at the emergency department via EMS from the facility with no complaints. The facility reported Resident #1 took 14 [MEDICATION(S)] from their locked narcotics cart, witnessed on video. EMS stated Resident #1 consented to coming to the ED due to the facility threatening to call the police. Resident #1 denied taking the medications. Urine Opiates Screen Positive for Benzodiazepines (depressants that produce sedation and hypnosis, relieve anxiety and muscle spasms, and reduce seizures), Salicylates (a type of drug found in many over-the-counter and prescription medicines. Aspirin is the most common type of [MEDICATION(S)]) <1.7, and acetaminophen (a pain reliever and a fever reducer; Taking too much acetaminophen can cause liver damage, sometimes serious enough to require liver transplantation or cause death) 7. The hospital planned on repeat Tylenol level but Resident #1 requested to leave AMA. Clinical Impression was listed as pneumonia. Discharge instructions included follow-up with primary MD tomorrow. Emergency Department notes indicated the following: -09/09/22 11:14 a.m. Poison was control called and notified that the nursing facility stated Resident #1 took 14 [MEDICATION(S)] 10/ 325. Cardiac monitor, EKG, draw Tylenol Level 3 hours from now. Start antidote for Tylenol and monitor for 6 to 8 hours. Benzos as needed for [CONDITION(S)] and [CONDITION(S)]. -09/09/22 12:24 p.m. Resident #1 wheezing and notified doctor for breathing treatment. Orders received and acknowledged. -09/09/22 1:45 p.m. This RN spoke to ADON A at the nursing facility to call report for Resident #1 being discharged back to the facility. DON refused to take resident stating He has been dropped by his PCP, he has no doctor. This RN notified our social services. Gave DON phone number and stated will call back with resolution. -09/09/22 5:39 p.m. Resident #1 returned to ED transport van due to NF denying Resident #1. -09/09/22 5:40 p.m. Police called and notified of situation with NF not accepting Resident #1 back to place of residence. Police said to send Resident #1 back via transport and officer will meet transport and Resident #1 at residence. 5:51 p.m. transport wheelchair van called for Resident #1 transport home. Resident #1 currently in ER waiting room and ETA 1.5 hours. -09/09/22 7:56 p.m. Transport van arrived to transport Resident #1 to the NF at approximately 7:40 p.m. Unable to locate Resident #1. -09/10/22 1:23 a.m. Resident #1 has not presented back to ED. -09/12/22 1:06 a.m. Social Work Note SW L was called to ED to speak with Resident #1 and charge nurse regarding the NF refusing to take Resident #1 back. The nursing facility nurse called the ED and stated that the resident was being sent to the hospital because he stole 14 [MEDICATION(S)] pills out of the locked narcotic tray the facility advised Resident #1 he could go to the ER or they would call the police. He opted for the hospital. SW L met with Resident #1 for an extended amount of time. He was alert, fully dressed, with tennis shoes on, lying in the bed. He had clear speech and adamantly denied stealing and/or taking 14 pills. Nursing stated his vital signs were good and he was denying any shortness of breath, pain or discomfort. Resident #1 was not deemed to be in a medical crisis, per ED staff. SW L spoke with Resident #1 and he stated, I really want to go back there (NH). That's where I live. If I can't, I will call a friend of mine, but please, if I can, I want to go back to the NH. SW L made eight different attempts to contact any staff at the NH and no one would answer her call. A nurse at the station left her on hold for over 30 minutes. The administrator never called SW L back. SW L also contacted the facilities corporate office and spoke with a representative. SW L requested someone from the facility call the hospital for an update regarding Resident #1. At 6:00 PM, SW K from the NH called and stated, he doesn't live here anymore. SW K offered no assistance with locating safe placement for Resident #1. SW L updated staff. SW L will report to APS on 9/12/22. Record review of hospital records dated 09/11/22 at 4:22 a.m. indicated Resident #1 was a [AGE] year-old male with a history of [CONDITION(S)], CAD, CHF, drug abuse, [CONDITION(S)] and [CONDITION(S)] who was recently discharged from a hospital, where he was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 said he went to the gas station where he began to experience non- radiating chest pain that he described as sharp in nature. Resident #1 was intubated on 09/10/22 and extubated on 09/11/22. He was assessed for acute hypercapnic hypoxic (Hypoxemic respiratory failure means that you don't have enough oxygen in your blood, but your levels of carbon [MEDICATION(S)] are close to normal. Hypercapnic respiratory failure means that there's too much carbon [MEDICATION(S)] in your blood, and near normal or not enough oxygen in your blood), pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, fungi, or chemical irritants), [CONDITION(S)] exacerbation (a worsening or flare up), and CHF exacerbation (an increase in or worsening of heart failure symptoms). His final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was discharged to an NF on 09/14/22. Resident #1 was not observed or interviewed during the survey/investigation. The number listed on the face sheet dated 09/20/22 did not accept calls. The surveyor sent a text message on 09/21/22 at 8:21 a.m. requesting a call back with contact information. There was no response to the text message prior to exit. Record review of the Nursing Home Transfer and Discharge Notice dated 09/09/22 indicated This form is required for those transfers and dischargers initiated by the nursing home facility, and not by the resident or by the resident's physician or legal guardian or representative. Location to which resident is transferred or discharged (required): Medical Center (due to resident refusing to tell me the name and address of the son's house he stated he wanted to be discharged to) . The following reasons require either this form be signed by a physician or a physician's written order for discharge or transfer be attached. The signing physician may be the resident's attending or treating physician, the facility medical director, or nurse practitioner or physician's assistant as a physician designee. There was an X placed in the boxes that indicated Your needs cannot be met by this facility. The health of other individuals in this facility is endangered., and The safety of other individuals in this facility is endangered. Resident #1 broke into a medication cart and took 13, 10/325 Norcos. It is unknown if Resident #1 took the medication or sold it to other residents. Resident #1 refused to tell me what he did with the medicine. This action endangered Resident #1 and other residents. The facility can no longer meet his needs because his PCP, the medical director, dropped him from services. As outlined in the Department of Human Services' Fair Hearing, Fraud, and Civil Rights Handbook, you have a right to appeal the Facility's decision to discharge you. If you think you should not be transferred or discharged , you may request a hearing through the Medicaid Eligibility worker at the local Department of Health Services office within 10 days of receipt of this notice of discharge. Record review of the facility investigation dated 09/16/22 included a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility investigation dated 09/16/22 included an undated typed note signed by the Administrator, indicated On 09/09/22 at 6:42 a.m. it was reported to me that a possible drug diversion had occurred. When I got to the building, BOM G had the video pulled up. The DON, BOM G and I watched the video. It was seen that Resident #1 opened the medication cart. We brought Resident #1 in to interview. We showed Resident #1 the video footage. Resident #1 denied taking the medication even after seeing the video footage. I asked Resident #1 if he took the medication or if he gave or sold it to any of the other residents. Resident #1 refused to tell me and kept stating he wanted to be discharged due to being accused of stealing the medication. I did inform Resident #1 that I would have to issue him an immediate discharge if he did not tell me where the medication was in case another resident ingested it and had an adverse effect from it. He refused to tell me, so I verbally informed him I was issuing an immediate discharge. I then instructed the DON to contact the doctor to see if he wanted to send him to the ER for evaluation and treatment. We then interviewed LVN C who stated that she had left the keys on the cart because that was what she was told to do. I educated her on proper medication card security. EMS transport came to pick up Resident #1. Shortly after Resident #1 going to the ER. MD M's office contacted the building stated they would no longer be willing to follow him, effective immediately. At this point I instructed DON to notify the hospital to inform them and tell them to have their social worker contact my social worker to help with the discharge. The receptionist did take a phone call from their social worker. SW K attempted to call SW L back with no answer later. EMS brought Resident #1 without the hospital calling report. I went outside where Resident #1 was on the phone talking or attempting to talk to his son or nephew. He stated he was going to go stay with him. I asked him what the address was where he was going. He refused to tell me. I informed him that we wanted to get home health set up for him, but he continued to refuse to tell me. ADON A and the transport driver was also present. SW K came out and attempted to assist the resident with discharge. She gave him some home health information because he refused, so that we could get it set up. EMS transport checking back to the ER, where his son or nephew was going to pick him up. During an interview on 09/20/22 at 9:43 a.m., the Administrator said Resident #1 took 14 Norcos from the medication cart at 7:40 p.m. on 09/08/22 (as seen on video). She said Resident #1 would not say whether he took the medications or gave or sold them to other residents. She said he was sent out to the ER for evaluation on 09/09/22 and the ER sent him back a few hours later. She said before he left to the ER Resident #1 said he wanted to leave. She said she told him she would need to issue and immediate discharge and would take him back and find him another place. She said MD M (who is also the facility medical director) called and said he would not care for Resident #1. She said she did not attempt to find a new doctor for Resident #1. She said the hospital was notified the facility would not take Resident #1 back but would help find placement. She said the hospital SW (SW L) called SW K but she was busy. She said SW K tried calling the ER a few times and there was no response. She said Resident #1 arrived at the facility without report from the hospital. She said she believed he was on the phone with someone trying to arrange pick-up at the ER. She said she did notify the ombudsman of the discharge. During an interview on 09/20/22 at 1:28 p.m., LVN D said she documented in the progress notes for Resident #1's transfer to the hospital for evaluation for possible drug overdose. She said she documented additional notes related to Resident #1's discharge from MD M's services and then from the facility per information received from the Administrator and the DON. During an interview on 09/20/22 at 2:29 p.m., SW K said Resident #1 was discharged from the facility on 09/09/22 with home health referrals. She said she called APS and completed an online report on 09/09/22. She said APS returned her call on Monday 09/12/22 and asked her questions related to Resident #1's discharge from the facility. She said SW L was told the facility discharged Resident #1 due to MD M dropping him from services. She said the facility could not meet his needs without a physician. She said Resident #1 asked for referrals and she gave him home health business cards and also the information to local Salvation Army. She said she knew Resident #1 was homeless. She said Resident #1 would leave the facility on weekends and take all of his medications and return with no medication. She said there was no plan to discharge Resident #1 from the facility prior to when he took narcotics from the unlocked medication cart. During an interview on 09/22/22 at 11:30 a.m., ADON A said he arrived to work on 09/09/22 and the DON said LVN D reported medications were missing. He said he reviewed the video and Resident #1 opened the cart and got the narcotics from the narcotics drawer. He said he called the lab about drug tests and the lab indicated a urine test would determine the level of narcotics not just the presence of narcotics. He said MD M said to send Resident #1 to the hospital for evaluation. During the time Resident #1 was at the hospital, MD M discharged him from services. He said he was not sure of the discharge process. He said he knew the SW was involved with the discharge proves to ensure a safe discharge. He said the hospital called the facility and he spoke to an unknown staff and advised them Resident #1 did not have a physician for re-admit to the facility. He said he told the hospital staff SW K would call and speak with the hospital SW to discuss Resident #1's case. He said he provided the hospital staff with SW K's name and number. He said someone indicated Resident #1 was in the facility parking lot and I saw he had arrived via the wheelchair transport van. He said he went out and advised the EMS F Resident #1 did not have a physician and was not able to re-admit to the facility. ADON A said Resident #1 asked why he could not return to the facility, and I told him I was not sure. He said he asked him where he wanted to go but Resident #1 ignored him. He said Resident #1 entered the EMS transport van and left the facility's property. He said Resident #1 did not say he wanted to a discharge from the facility prior to the incident with the medications being taken from the medication cart. He said as far as he was aware, Resident #1 was a long-term care resident with no discharge plans. During an interview on 09/22/22 at 4:32 p.m. MD M indicated he was the facility medical director. He said he was not aware of the discharge process in detail. He said he trusted the facility administrator and staff to follow the proper procedures and policies. He was aware Resident #1 was sent to the hospital for evaluation due to possible ingestion of narcotics. He said he gave a verbal order for immediate discharge from the facility due to Resident #1 stealing medication and based on the information he received from the facility. He said he agreed with the discharge of Resident #1 because he believed the facility was following the rules and was conducting a safe discharge of Resident #1. He said there was always a risk when discharging a resident from the facility and some of the risks are unforeseen. He said improper discharge could place residents at risk of decline of health and hospitalization . A facility's Transfer or Discharge Notice policy dated 2001 (revised (12/16) indicated 1. A resident and/or the resident's representative (sponsor) with a Thirty (30)-day written notice of impending transfer or discharge. 2. Under the following circumstances, the notice will be given as soon as it is practicable, but before the transfer or discharge: a. The Transfer is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The Transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered; d. The health of individuals in the facility would otherwise be endangered; . Record review of the facility's Transfer or Discharge, Emergency policy dated 2001 (revised 12/2016) indicated Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). 1. Residents will not be transferred unless: a. The transfer or discharge is necessary for the resident's, welfare and the resident's needs cannot be met in the facility; . c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. The health of individuals in the facility would otherwise be endangered; . 4. should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary. A facility Social Services policy dated 08/16 indicated Social services staff, members of the interdisciplinary team, will participate in the development of a discharge plan for residents with a potential for discharge to a private residence, to another nursing facility or skilled nursing facility, or to another type of residential facility such as an assisted living center. Considerations: 1. When the interdisciplinary team determines that a resident has a potential for discharge in the next quarter or sooner, social service staff will address the following: a. Necessary, supportive relationships in the community to meet his/her emotional needs; b. The cost of needed services and financial resources necessary to pay for the services; c. Education needed by resident/family about available community resources and how to access those services; and d. Needs for emotional support to assist in adjustment to the new living environment. 2. The need for a discharge plan will be assessed upon admission. The discharge plan will be incorporated into the resident's care plan. The administrator was notified on 09/21/22 at 3:12 p.m., an IJ situation was identified due to the above failures and the IJ template was provided. On 09/22/22 at 4:15 p.m., the facility plan of removal was accepted and included: Cascades at Senior rehab will enact the following actions in order to remove the IJ. The Business Office Manager of the facility verified resident is in another facility. No desire was express by the resident to return to this facility. The facility and the resident are making arrangements to get the resident his belongings. 1. Administrator, DON, ADON, Marketer, Admissions Coordinator, Business Office Manager, MDS nurse, Rehab Director, and Social Worker has been in-serviced on the facilities discharge planning process, transfer and discharge, and permitting resident to return to the facility by Vice President of Operations. Completed on 09/21/22 2. The DON initiated a discharge checklist for every discharge. The Social Worker has been in-serviced by the DON on the discharge checklist. Completed by 09/22/22 3. The DON educated Medical Director on discharge process. Completed by 09/22/22 4. The administrator and DON performed an audit of all immediate discharges in the last 30 days to ensure appropriate discharge. Completed by 09/22/22 5. Ad Hoc QAPI attended by Medical Director, DON, ADON, Business Office Manager, and Admissions Coordinator to address failure to follow discharge planning process, failure to appropriately discharge, and failure to permit resident to return. Completed by 09/22/22 6. The administrator, DON, ADON, Social Worker, Business Office Manager, Admissions, Marketing, MDS nurse, and Rehab Director were in-serviced on the facilities discharge planning process, transfer and discharge, and permitting resident to return to the facility by Vice President of Operations and will follow the following procedures, immediately, during all discharges. Completed on 09/21/22. a. Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). 1. Residents will not be transferred unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; d. The health of individuals in the facility would otherwise be endangered; e. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies: (1) If the resident does not submit the necessary paperwork for third party payment; or (2) After the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay; or f. The facility ceases to operate. 2. If a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. 3. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented. 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary. 5. Should it become necessary to transfer residents during emergency or disaster situations, transfer procedures outlined in our disaster plan will be implemented. 6. The resident's medical record must be forwarded to the Medical Records office within twenty-four (24) hours of the transfer or discharge. 7. Administrator, DON, ADON, Marketer, Admissions Coordinator, Business Office Manager, MDS nurse, Rehab Director, and Social Worker has been in-serviced on resident returning from the hospital, will not evaluate the resident based on the resident's condition when originally transferred to the hospital. The evaluation will be based upon the return of the resident. Discharges will then be determined, with the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary. 8. All items to be completed by 09/22/22 at 4:00 pm. On 09/23/22 at 11:46 a.m. the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by: Record review of in-service training dated 09/21/22 presented to all department heads included the discharge process policy and procedures, what was an appropriate discharge versus inappropriate discharge, and allowing residents to return to the facility. Staff must coordinate services and document discharge planning for all residents who are discharging from the facility. Record review of in-service training dated 09/22/22 presented to the medical director/MD indicated he was advised of the discharge process policy and procedures, what was an appropriate discharge versus inappropriate discharge, and allowing residents tore turn to the facility. Record review of an audit of all immediate discharges dated 09/22/22 in the last 30 days indicated no immediate discharges were issued. Record review of Ad Hoc QAPI dated 09/22/22 and attended by Medical Director, DON, ADON, Business Office Manager, and Admissions Coordinator addressed failure to follow discharge planning process, failure to appropriately discharge, and failure to permit resident to return. Record review of in-service dated 09/22/22 indicated the Administrator, DON, ADON, Marketer, Admissions Coordinator, Business Office Manager, MDS nurse, Rehab Director, and Social Worker were in-serviced on resident returning from the hospital, will not evaluate the resident based on the resident's condition when originally transferred to the hospital. The evaluation would be based upon the return of the resident. During interviews on 09/23/22 from 8:00 a.m. through 11:40 a.m., the Administrator, the DON, ADON/LVN, SW, MDS Coordinator/LVN, admissions Director/LVN, Director of Rehabilitation, the marketer, and the BOM/AIT were knowledgeable of the requirements for discharge planning and stated they had received training regarding discharge planning and documentation. They were aware of the facility's systemic approach to discharge, the equipment and forms required, the procedure and the documentation required, the physician order [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 23 residents reviewed for accidents. (Resident #1) The facility did not prevent Resident #1, a resident who was cognitively impaired with exit seeking behaviors, from eloping from the facility. Resident #1 was found on a high traffic street, in a parking lot deceased . This failure could place the residents with exit seeking behaviors at risk for injury or death. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Record review of physician orders dated [DATE] indicated Resident #1 was admitted on [DATE], was [AGE] years old and had diagnoses of seizures, stroke and high blood pressure. Resident #1 MDS had not been completed due to Resident #1 was a new admission. Record review of Resident #1's care plan indicated Resident #1 was at risk for impaired safety related to wandering. The goal was Resident #1 will be free of injuries through next review date. Record review of an incident note dated on [DATE] at 2:09 p.m. written by LVN D indicated Resident #1 was found to be missing when she went to make her first round to give a.m. medications. She searched Hall 200 and outside grounds. Then she called DON and continued to search for Resident #1. The incident note indicated predisposing physiological factors included confused, impaired memory and wandering. The family members of Resident #1 were unable to interview. During an interview on [DATE] at 2:45 p.m., the Administrator said she had received the elopement notification from the DON at [DATE] at 7:05 a.m. The facility, neighborhood had been searched by staff, and the police had been notified during the morning of [DATE] and did not indicate by whom. The Administrator said Resident #1 had opened his window and exited the building. He had attempted to put screen back on window which was left open. During the interview the DON said the bed was left neat in appearance, like it had not been slept in. The administrator said the Resident #1 resided on Hall 200 (warm zone) and was in the last room on the right. The Administrator said the police came to facility at approximately 9:00 a.m. and informed the facility the resident was found deceased in a parking lot. She said the police told her they had received a call from a concerned citizen [DATE] at 6:35 a.m. regarding someone sleeping in a parking lot, and they did a welfare check and came upon deceased male later identified as missing Resident #1. The Administrator said LVN A had worked the night shift and had reported to DON that she had last walked Resident #1 to his room at 3:30 a.m. The Administrator said she was unable to verify that from facility security video footage, which was motion sensitive. The administrator said Resident #1 was wearing white tee-shirt and dark pajama pants when he was last visualized by staff during previous night. The Administrator said after reviewing the facility video footage, she reported incident to state office. The administrator said the last image of Resident #1 was seen on [DATE] at 9:40 p.m. on Hall 200. The video was reviewed through to 6:00 a.m. The Administrator said all windows had been checked and they have ordered window locks. They have accounted for all other residents. She said she arrived at facility at 8:00 a.m. this morning, repeated head count of residents and search was continued until receiving information from police. During an interview on [DATE] at 3:20 p.m., the Administrator and DON said since they had arrived at the facility this morning, they had made rounds to ensure all residents were accounted for. The DON said they were updating risk assessments for all the residents. He said Resident #1 ambulated freely and was admitted [DATE] from hospital. His family had visited the night before ([DATE]). During this interview the regional nurse said the facility was aware the resident would be placed on the secure unit. The DON said the resident was placed on warm unit do to new admission and unknown Covid status. The DON said facility should have had resident on 1:1 with CNAs to watch him and said the facility does not have wander guard system in place. The DON said LVN A and 2 agency CNAs were assigned to Hall 200 the previous night. During a phone interview on [DATE] at 4:10 p.m., the local police department Police Sergeant E said the location where resident found was approximately 5.,d+[DATE] miles from facility. Police Sergeant said the temperature during the night hours was approximately 36 degrees. Resident had on tee-shirt and socks, but pajama pants were not on resident. The resident had taken them off. The police had reviewed video from surrounding businesses. Police Sergeant E said Resident #1 fell in a community business parking lot around 11:30 p.m. on [DATE] and was found in the same location around 6:30 a.m. He said a [NAME]-by person called police and said it looked like someone was sleeping in parking lot on the ground. He said the area was a known area for homeless people. He said when the police arrived on scene the male was on the ground and deceased . Record review retrieved on [DATE], https://www.accuweather.com/en/us/port-[NAME]/ /january-weather/ 2, indicated Port [NAME] Texas weather on [DATE] the high was 78 degrees with a low of 60 degrees, on [DATE] the high was 64 degrees with a low of 39 degrees. During an interview on [DATE] at 4:12 p.m., LVN A said she worked the night shift for [DATE] from [DATE] at 6:00 p.m. to [DATE] at 6:00 a.m. She was responsible for 16 residents on Hall 100, 4 residents on Hall 200, and 12 residents on Hall 500 as charge nurse. She said she had worked with Resident #1 four times in the past and he had not attempted to leave. She said She had walked him to his room after his family left around 9:40 p.m. She said Resident #1 got in bed and she didn't see him again during the night. LVN A said she worked ,d+[DATE] A. She said the nurses don't do walking rounds between shifts, nurses check on residents as needed or when treatments or medications or treatment are required. She said no one told her Resident #1 may wander and if so, she asked why they would place him on regular unit and at the end of the Hall by the exit door. She said there were 3 agency CNAs on the night shift for [DATE]. One was on Hall 500, and two worked together on Halls ,d+[DATE]. There was one CNA for Hall 400 and one for secure unit (Hall 100). LVN A was unsure if facility had used agency staff in the past. She said she had no knowledge Resident #1 was a wanderer. She did not see any care plans, MDS., but then added she had glanced at care plan. She said he ambulated well and used restroom on his own. She said CNAs were to round every 2 hours, even if residents could go to the bathroom on their own. LVN A said Resident #2 had broken a window in the past and tried to get out but did not indicate when. He had been to behavior center after his admission to this facility. She said Resident #2 would bust open a door and jump the fence. She said Resident #2 kept getting out of the secure unit. She had not heard door alarms sound off. During an interview on [DATE] at 5:00 p.m., LVN D said she had not seen Resident #1 that morning and had not done walking rounds with LVN A. She said on her first round down Hall 200 at 6:45 a.m., she noticed Resident #1 was not in his room and began the search. She said she called DON around 7:00 a.m. and reported a missing resident. She said she had been trained on missing resident and nurse aides make every 2-hour rounds on all residents. Attempted to call CNA B and CNA C on [DATE] at 6:00 p.m. and no answer. Surveyor left messages for return phone calls. During a phone interview on [DATE] at 9:07 a.m., with agency CNA B, said she was employed with online Staffing Agency. She said the applications were taken online and not received training from her agency or the facility. She said a drug screen was performed, background checks were done, and she took a short quiz. She became a CNA in 2015 and had been with the agency ,d+[DATE] weeks. When asked if she received any training from the facility, she said no, and it had been her first night in the facility. Agency CNA B said they had Halls 200 and 300. She was paired with another agency CNA C and it was her first night as well. She said she just met CNA B that night. Agency CNA B said they did not get any information on the residents from the nursing staff. She said was not told anything except which halls they were assigned. Agency CNA B said they just started making rounds to do incontinent care by going room to room to see if the rooms were occupied. She said she did not see Resident #1 to see who he was or what he looked like. Agency CNA B said they did not know which rooms were occupied or not. First round started about 10:,d+[DATE]:45 p.m. on Hall 200. She said first she had to go outside and get linen barrels and gather supplies. Agency CNA B denied receiving a room roster or resident list. She said she was pointed in direction of her halls. Agency CNA B said she had seen 3 females on Hall 200, no males. Agency CNA B asked what time Resident #1 had went missing. Agency CNA B said CNA C had worked 6:00 p.m. - 10:00 p.m. on a different hall and then joined her on these 2 halls for remainder of shift. Agency CNA B stated they had opened doors to the rooms to see if occupied. She said she had a good relationship with CNA C. Agency CNA B said no other staff came to see if they needed anything or were okay. Agency CNA B said none of the regular staff had introduced themselves. She denied being showed around and had to find things on their own. Agency CNA B said she arrived at facility at 9:55 p.m. for her shift and was unaware if CNA C had received any orientation. During an interview on [DATE] at 9:15 a.m., the Administrator was asked if staffing agency staff had received training prior to working, and she was unaware of the agency proceedings. When asked what training/orientation the facility provided to agency staff, she replied they should be trained and orientated but did not know if they had been. During an interview on [DATE] at 5:00 p.m., the administrator said they had no training or orientation policy for the agency staff. The Administrator and DON was notified of the IJ on [DATE] at 7:29 p.m., the IJ template for Neglect and Accident/Hazard and Supervision was given to the Administrator and DON. The findings were read to them and explained the process and a POR was requested. The POR was accepted on [DATE] at 3:20 p.m. and reflected the following: The facility will enact the following actions in order to remove the IJ for Neglect and Accident/ Hazard/ Supervision. 1. All residents accounted for on [DATE]. 2. Involved staff was suspended pending investigation. [DATE] 3. Facility completed an elopement risk assessment on all residents in the facility to identify those residents that are a high risk for elopement. 6 residents identified that were at risk that were outside of the secure unit. [DATE] 4. Residents identified as high risk were assessed to determine if they need to be moved to the secured unit. One resident was moved to secure unit and the other 2 that were identified are on the COVID unit with 1 on 1 staffing. Window alarm placed on remaining residents that were identified. [DATE] Facility initiated 1 on 1 training to staff. [DATE] 5. Safety checks every hour were put in place for CNA's and nurses to check on each resident that was identified as a high risk for eloping. Safety checks was added to the residents Kardex that were identified as high risk for elopement. [DATE] 6. Resident #2 was placed 1 on 1. [DATE] 7. Door alarms were placed on the door leading outside on hall 100 and hall 500. Window alarms were also placed on windows of the residents that were identified as high risk for elopement. All doors have been checked to ensure alarm sounds. [DATE] 8. In-services have been started [DATE] by the Administrator/designee for staff members regarding: resident elopement abuse and neglect elopement procedure charge nurse walking rounds screening for wandering risk upon admission and care plan being updated 2-hour rounding agency staff orientation to building prior to their shift completing incident reports with each elopement identifying high elopement risk residents media communication. 9. Elopement binder implemented. [DATE] 10. Window screens were checked and properly secured. [DATE] 11. Care plans update. [DATE] Staff was in-serviced on checking the updated information on resident care plans in PCC [electronic medical record] on their Kardex [record system]. [DATE] 12. Nurse alert in PCC [electronic medical record] High Risk added. [DATE] Nurses were trained on checking who the identified High-Risk residents are in PCC. [DATE] 13. Environmental rounds have been implemented to include Maintenance Director and/or designee making rounds to ensure: Checking to make sure doors are secured and sound is working Checking alarms on identified high risk resident windows Round outside to make sure screens are secured properly. Making sure staff that is one on one with a resident is monitoring resident within eyesight. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to lift the immediacy by: Record review of the in services dated [DATE] related to one to one, missing resident, safety checks, shift change with report, identifying high risk for wandering and elopement, the elopement binder and the updated Kardex system. New documentation initiated for one on one monitoring and also, maintenance will be performing checks on the window screen and alarms for door and windows to ensure are working properly. During interviews of the administrator, DON and 5 LVNs and 10 CNAs the retraining related to elopement and missing resident, safety check, one to one monitoring, shift change with report, identifying high risk for wandering and elopement, the elopement binder and updated Kardex system was confirmed. During numerous observations on [DATE] at 6:00 pm and 7:00 p.m. and [DATE] at 10:00 a.m. and 2:00 p.m. indicated one on one for high risk elopement resident, door alarms in place and window alarms being installed. No policy on the use of agency staff related to orientation or training was provided. Record review of General orientation policy dated ,d+[DATE] indicated General Orientation Policy All newly hired employees are required to attend general orientation. Record review of the staffing policy dated [DATE] indicated Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with residents care plans and the facility assessment. Record review of Wandering Resident Policy dated ,d+[DATE] indicated Purpose: To establish protocols to assist the facility in ensuring the safety of facility resident. Procedure: All potential admissions to the facility will be screened per review of history and physical and interview with family/ responsible party for history of wandering. Identified residents will be placed in rooms that allow for increased supervision by the facility staff. With consents of the responsible party, at risk residents will be photograph upon admission. On admission the facility will develop plan of care for at risk residents. Record review of Emergency Procedure- Missing Resident dated [DATE] indicated . 1. Residents at risk for wandering and /or elopement will be monitored and staff will take necessary precautions to ensure their safety. The Administrator was informed the IJ was lifted on [DATE] at 4:00 p.m., However, the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an exit conference on [DATE] at 4:37 p.m. the Administrator was asked for any additional information related to neglect. No additional information was provided.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 11 (Resident #2, #3, #4, #5, #6, #7, #8, #9, #13, #14, and #15) of 15 residents reviewed for infection control. The facility failed to isolate Residents #2, #3, #4, and #5 for at least 10 days after they tested positive for COVID 19 The facility failed to quarantine unvaccinated Residents #7, #8, and #9 after they were exposed to their roommates who tested positive for COVID-19. The facility failed to immediately sanitize Residents #13, #14, and #15's rooms on the secure unit after they tested positive and were moved to the COVID unit. An Immediate Jeopardy (IJ) was identified on 01/12/22 at 3:42 p.m. While the IJ was removed on 01/13/22, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy and a scope of wide spread because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk of exposure to infectious diseases which could result in serious illness, hospitalization , and/or death. Findings included: 1. Record review for the four residents moved from isolation on the COVID unit to their previous rooms on cold units prior to 10 days reflected the following: Review of Resident #2's MDS assessment, dated 12/8/21, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His BIMS score was a 9 indicating he had moderate cognitive impairment. Review of Resident #3's most recent, MDS assessment revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes dated 1/9/22 at 12:05 a.m. indicated Resident #3 had an occasional dry cough with diminished lung sounds. Review of Resident #4's MDS assessment, dated 11/25/21, revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of progress notes dated 1/8/22 at 4:4 a.m., indicated Resident #4 had coughed up a moderate amount of thick yellow phlegm. Review of Resident #5's MDS assessment, dated 10/25/21, revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had severe cognitive impairment. Review of an email, provided by the DON, dated 12/28/21 from the CNO indicated The CDC now recommends that individuals who test positive for COVID-19 isolate for five days, if asymptomatic or if symptoms are resolving, followed by five days of wearing a mask. This has been shortened from ten days. During an interview on 1/12/22 at 9:30 a.m., the DON said he had moved four residents (#2, #3, #4, and #5) off the COVID unit on 1/11/22 because they had isolated for at least five days, but less than 10 days, and did not think any of the four residents had symptoms. He said he received a memo from corporate on 12/28/21 indicating CDC said residents only had to isolate for 5 days. He said they were not tested prior to being moved back to their previous rooms on the cold units. He said they were originally moved to the COVID unit on 1/3/22. During an interview on 1/12/22 at 10:15 a.m., the DON said COVID positive residents had been isolated for 10 days until 1/11/22. He said he had six new positive residents and needed the beds. He said they had not been placing roommates of positive residents in quarantine including those unvaccinated. He was not aware they needed to be quarantined. During an interview on 1/12/22 at 10:52 a.m., the Administrator said the four residents were going to be moved back to the COVID unit. She said she had just been educated by corporate their policy was to isolate residents for at least 10 days. During an interview on 1/12/22 at 11:56 a.m., the IP said she had been at the facility as the IP since August 2021. She said they had received an email on 12/28/21 from corporate regarding: the shortened isolation time. She said she was not up to date on the facility response plan because it changed so much. She said she was responsible for training staff related to infection control. During an interview on 1/12/22 at 12:23 p.m. LVN A said she questioned administration about the residents being placed back in their rooms prior to the 10-day isolation period. She said she was told it was ok. During an interview on 1/12/22 at 12:35 p.m., LVN B said she heard LVN A ask administration on 1/11/22 about residents being moved back to their rooms so soon after testing positive for COVID-19. During an interview on 1/12/22 at 3:42 p.m., the DON clarified his statement and said he had so many positive residents on 1/11/22 he decided to take the four residents off the COVID unit because they had not shown any symptoms and he had six new positives. When surveyor told him Resident #4 had yellow phlegm on 1/8/22 his reply was oh. He said the residents were monitored for signs and symptoms by charge nurses every shift on the COVID unit. During an interview on 1/12/22 at 3:52 p.m., the CNO for the company said she did send out the email on 12/28/21 to all their facilities indicating isolation had been cut down to five days. She said she also sent another email a few minutes later clarifying the shortened isolation/quarantine period was for employees only, not residents. She said the positive residents were to be isolated for at least 10 days. Review of the facility's infection control policy, provided by the administrator, for Infection Prevention and Control, Subject: Novel Coronavirus Control Plan reviewed 12/2021 indicated Discontinuation of transmission-based precautions for residents with confirmed COVID-19: . Symptomatic Residents: Residents with mild to moderate illness who are not severely immunocompromised may come off transmission-based precautions when: at least ten days have passed since the date symptoms first appeared . Asymptomatic Residents: Residents who were asymptomatic throughout their infection may come off precautions when at least ten days have passed since the date of their first positive [CONDITION(S)] diagnostic test. 2. Record review for the three residents who were unvaccinated and were not quarantined after exposure reflected the following: Review of Resident #7's MDS assessment, dated 12/22/21, revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's immunizations indicated the resident had not been vaccinated for COVID-19. During an observation and interview on 1/12/22 at 2:59 p.m., Resident #7 was sitting in her wheel chair in the hallway outside of her room on a cold unit. She did not have a mask covering her nose and mouth. She said she was not feeling well and had a cough. Review of Resident #8's MDS assessment, dated 11/16/21, revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her BIMS was a 15 indicating she was cognitively intact. Review of Resident #8's immunizations indicated the resident had not been vaccinated for COVID-19. During an observation and interview on 1/12/22 at 3:07 p.m., Resident #8 was in her wheel chair rolling around the facility. She said she had not been told to stay in her room to quarantine after her roommate (#6) tested positive for COVID-19. Review of Resident #9's MDS assessment, dated 1/3/22, revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's immunizations indicated the resident had not been vaccinated for COVID-19. During an interview on 1/12/22 at 10:15 a.m., the DON said the roommates of positive residents had not been placed in quarantine. He said they remained on the cold units. He was not aware they needed to be quarantined. He said Residents #7, #8, and #9 had not been vaccinated and their roommates tested positive for COVID-19. He said they had been tested and were negative at the time of the investigation. During an interview on 1/12/22 at 10:52 a.m., the administrator said the roommates of positive residents were not currently being placed in quarantine. She was not aware unvaccinated residents should have been placed in quarantine. She said her warm hall, for residents with unknown COVID status, was almost full and she did not have enough room to move them to a warm hall. CDC website accessed on 1/20/22 re: managing resident who had close contact with someone with COVID-19 infection. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_ 599 Unvaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). 3. Record review for the three residents whose rooms on the secure unit were not immediately sanitized after testing positive for COVID-19 and moved to the COVID unit reflected the following: Review of Resident #13's MDS assessment, dated 12/4/21, revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her BIMS was 99 indicating severe cognitive impairment. Resident #13 tested positive for COVID-19 on 1/11/22 and was moved to the COVID unit the same day. Review of Resident #14's MDS assessment, dated 10/16/21, revealed he was an [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His BIMS was not completed indicating he was severely cognitively impaired. Resident #14 tested positive on 1/11/22 and was moved to the COVID unit the same day. Review of Resident #15's MDS assessment, dated 11/21/21, revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15 tested positive on 1/11/22 and was moved to the COVID unit the same day During an interview on 1/12/22 at 12:23 p.m., LVN A said housekeeping had not been on the secure unit since 1/11/22. She said the rooms of the residents who tested positive on 1/11/22 had not yet been sanitized by housekeeping. She said there were residents still in the rooms of those who tested positive who were COVID-19 negative. She said there were also residents who would wander in and out of other resident rooms. She said she had taken her personal bleach to the facility because they did not have any supplies available on the secure unit to sanitize the rooms. During an interview on 1/12/22 at 12:39 p.m., the housekeeping supervisor said the housekeepers usually got off around 3:00 p.m. She said they would clean the COVID unit last. She said the rooms where COVID residents were removed should have their rooms sanitized immediately. She said she would leave supplies for the nurse to use if positive residents were moved after her staff left for the day. An Immediate Jeopardy (IJ) was identified on 1/12/22 at 3:42 p.m. due to the above listed failures. The IJ template was given to the Administrator and requested the facility to send POR to program manager. The POR was accepted 1/13/22 at 11:09 a.m. [Facility] will enact the following actions in order to remove the IJ. 1. The 4 residents that were moved from the COVID unit early will be returned to the COVID unit to finish out their quarantine days. This has been completed as of 1/12/2022 before noon. 2. All residents will be retested today 1/12/2022. Hall 100 - all negative @ 4:50pm Hall 200 - all negative @ 5:00pm Hall 300 - 1 positive, moved to COVID unit Hall 400 - all negative @ 5:00pm Hall 500 - 1 positive, moved to COVID unit 3. Resident from hall 300 that was exposed was retested today 1/12/2022 @ 10am and results were negative. Resident was placed in quarantine to her room and educated on why she is being quarantined. All residents are being educated on quarantining and reasoning behind it 1/13/2022. 4. All residents are being monitored every shift for signs and symptoms of COVID as of 1/12/2022. Any resident that exhibits signs or symptoms of COVID will be isolated, immediately tested , if positive immediately moved to the COVID unit. 5. An in-service has been started 1/12/2022 by the Administrator and/or designee for all staff members regarding the proper monitoring of residents with COVID symptoms and sanitizing rooms of COVID positive residents, as well as wiping down high surface areas every 2 hours according to policy. Staff will also be in-serviced quarantining unvaccinated roommates of COVID positive residents. All staff will be educated on residents quarantining vaccinated and unvaccinated residents. Staff not present will be called into the facility and in-servicing will take place at screening point of entrance before they start their shift. - Staff will be educated and in-serviced by 1/13/2022, staff will not be able to work until in-service has been completed? Administrator and DON will be educated and in-serviced by the Regional Vice President and Regional Nurse. 6. An in-service has been started by the Administrator and/or designee for all housekeeping staff members regarding proper sanitizing of all potentially affected areas, deep clean infected resident(s) rooms with appropriate [CONDITION(S)] disinfectant, routine cleaning, and other measures, as well as wiping down high surface areas every 2 hours according to policy. Staff will also be in-serviced quarantining unvaccinated roommates of COVID positive residents. All staff will be educated on residents quarantining vaccinated and unvaccinated residents. Staff not present will be called into the facility and in-servicing will take place at screening point of entrance before they start their shift. - Staff will be educated and in-serviced by 1/13/2022, staff will not be able to work until in-service has been completed? Administrator created a log for Environmental Supervisor to sign off on daily for the cleaning of the COVID unit. Housekeeping Supervisor will turn sign-in sheet into Administrator daily. 7. Closer monitoring and tracking of COVID positive resident days along with their signs and symptoms will take place by the Administrator/designee to prevent from happening again. Monitoring will be completed by a COVID tracking sheet by the Administrator/DON. This will be monitored anytime the facility has a COVID unit. 8. Roommates of residents who have tested positive for COVID will be quarantined in their room if unvaccinated. COVID test will be administered on day 2 and 3 if negative on day 5-7. If negative after 7th day, resident may discontinue quarantine in their room. If resident is vaccinated with recommended booster, resident does not have to quarantine to their room but will be monitored closely for 14 days. Even if the resident is boosted, they must wear a mask when outside of their room if they are being monitored for exposure. On 1/13/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of the facility's in-service and training records, dated 01/12/22, indicated staff were educated on isolating residents for at least ten days, placing unvaccinated residents in quarantine after exposure to COVID, residents were not to be moved off the COVID unit without notification to the administrator, and COVID policies and procedures. Reviewed the facility's cleaning log and COVID tracking log put in place. Interviews were conducted with staff across multiple shifts on 01/13/22 from 1:35 p.m. to 6:00 p.m., including: housekeeping supervisor, 1 housekeeper, IP, ADON, 5 LVNs, and 6 CNAs. They were able to verbalize the appropriate understanding of quarantine, isolation, and sanitization of rooms, and the plan of removal. During an interview on 1/13/22 at 2:18 p.m., the DON said he was educated on isolation procedures for COVID positive residents, quarantine for unvaccinated residents exposed to COVID, and room sanitization. On 1/13/22 at 4:42 p.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at widespread of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective system.

Based on observation, interview, and record review, the facility failed to ensure an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections related to COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older) was established and maintained for the facility. The facility did not follow infection control policy and procedures regarding COVID-19 and did not quarantine Resident #1 for 14 days when she readmitted from the hospital. The facility staff did not wear masks covering their nose and mouth at all times while in the facility. Staff did not use N-95 masks, gowns, or face shields while providing care for residents in quarantine. An Immediate Jeopardy situation was identified on 07/29/20. The Immediate Jeopardy was removed on 07/30/20. The facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: The MDS dated [DATE] indicated Resident #1 was admitted [DATE] and readmitted on [DATE]. Resident #1 was [AGE] years old and had a [DIAGNOSES REDACTED]. Cumulative physician orders [REDACTED].#1 to the secure unit due to elopement risk. There were no medications ordered to treat COVID-19. A departmental (a nurse progress note) note dated 7/22/20 at 4:14 p.m. indicated Resident #1 returned to the facility and ambulated to the secure unit (hall 100) using her walker with assistance from staff. A departmental note dated 7/26/20 at 10:05 a.m. indicated the nurse received a phone call from the behavioral hospital informing her Resident #1's COVID-19 test collected on 7/21/20 during her stay at the behavioral center was positive. The nurse notified the DON and Resident #1 was moved to the quarantine hall (hall 200). A departmental note dated 7/26/20 at 8:27 p.m. indicated Resident #1 made several attempts to ambulate the hallway with her walker. The staff redirected her to her room. During an interview on 7/29/20 at 10:50 a.m., the administrator and DON said Resident #1 was readmitted to the facility from a behavior hospital on [DATE] and was placed on the secure unit because she was at risk for elopement. They said Resident #1 was tested for COVID-19 upon readmission into the facility. They said they received her positive results on 7/28/20 and she was moved to the COVID hall. The DON said she thought the resident was weak due to being overmedicated at the behavior hospital not due to COVID-19 and was moved to the quarantine hall on 7/26/20 because she was no longer an elopement risk. The DON said the resident had been tested for COVID-19 while at the behavior hospital and the facility received those results on 7/26/20. She said the resident was moved to hall 200 (the quarantine hall) on 7/26/20 but was not moved to the COVID unit until 7/28/20 when the COVID-19 test results the facility collected were received. The administrator said he wanted to wait to move her to the COVID unit until they received their own results to verify the behavior hospital's results were correct. The administrator and DON said residents who were readmitted or out of the facility overnight were supposed to be placed on the quarantine hall (200 hall) when they returned. During an observation and interview on 7/29/20 at 12:23 p.m. LVN A's surgical mask did not cover her nose and mouth. The mask was below her nose when she talked She said every time she talked the mask would fall below her nose. LVN A said she was the treatment nurse and worked all halls except the COVID unit. During an interview on 7/29/20 at 12:25 p.m., LVN B, who worked on the secure unit, said Resident #1 was readmitted to the facility on [DATE]. She said Resident #1 was not placed in quarantine. She was placed in the same room with the same two roommates she had before the behavior hospital admission. She said the only PPE they when she returned were surgical masks and gloves. She said the resident did not get out of bed when she was readmitted . However, she had been ambulatory prior to going to the behavioral hospital. During an observation and interview on 7/29/20 at 12:27 p.m., CNA C's mask was on her chin. The mask did not cover her mouth or her nose. CNA C said she worked on the secure unit and worked with Resident #1 when she was readmitted from the behavior hospital. The CNA said the way she provided care for the resident was the same as before she went to the hospital. The CNA said she only had surgical masks and gloves when she provided care for Resident #1 when she was readmitted . During an interview on 7/29/20 at 12:45 p.m. the DON and ADON D said Resident #1 was not quarantined upon readmission from the behavioral hospital. They said she was placed on the secure unit with no gowns or face shields for staff to use and she shared a room with two other residents. They said one of her roommates was ambulatory. Her two roommates were not quarantined. During an interview on 7/29/20 at 1:15 p.m., the administrator said he thought Resident #1 was an elopement risk and he made the decision to place her back on the secure unit. During an interview on 7/29/20 at 2:14 p.m., after surveyor intervention, the administrator said he was going to move Resident #1's roommates to the quarantine hall and have 1:1 supervision due to elopement risk. He verified they were not quarantined after Resident #1 was confirmed to be positive for COVID-19. During observations on 7/29/20 from 3:25 p.m. to 3:55 p.m., LVN A and administrative staff E wore their masks below their noses. They both said the mask would not stay in place. During an interview on 7/29/20 at 4:26 p.m., CNA F said Resident #1 was able to walk when she was first readmitted but over the next few days while on the secure unit she stayed in bed. She said the room was never set up for quarantine. She said they were not told to wear N-95 masks or wear gowns when providing care for Resident #1. During an interview on 7/29/20 at 4:29 p.m., LVN G had a surgical mask on and said she was the nurse who readmitted Resident #1 to the secure unit. She said she walked in with her walker on the evening of 7/22/20. She said the resident spent the next three days in bed. She said the resident was moved to the quarantine hall on 7/26/20 when they received the results of the positive COVID test from the behavior hospital. During an observation and interview on 7/29/20 at 4:31 p.m., CNA H wore a surgical mask under her N-95 mask. She said she was wearing it that way because the N-95 mask hurt her nose. She said they were given the N-95 masks on 7/29/20. Prior to 7/29/20 they only used surgical masks. She said she had just been educated on wearing the N-95 but did not know she could not wear the surgical mask underneath. During an interview on 7/30/20 at 11:45 a.m., CNA J said she worked on the quarantine hall. They had not been using N-95 masks, gowns or face shields until Resident #1 was moved to the quarantine hall. She said prior to Resident #1 being moved to the hall they only wore surgical masks. She said they did not wear gowns or face shields. During a virtual observation and interview on 7/30/20 at 12:43 p.m., Resident #1 was in her bed with a mask on. She was weak and did not want to talk. She was only able to nod her head yes or no. She said she did not feel good and did not want to talk. LVN K said Resident #1 was getting weaker. She said the resident ate and drank very little. LVN K said the nurse practitioner ordered IV fluids for the resident. The LVN said the resident had been able to go to the bathroom with maximum assistance when she was placed on the COVID hall 7/28/20 but she was not able to get out of bed anymore. During an interview on 7/31/20 at 1:32 p.m., the marketer from the behavior hospital said it was their protocol to test all residents prior to discharge. She said Resident #1 did not have any symptoms of COVID-19. She said Resident #1's roommate, while at the hospital, tested negative for COVID-19. The facility's COVID-19, Prevention and Control policy revised 7/27/20 indicated Cohorting/Isolation .2. Isolation (Full PPE including N-95 or higher, face shield/goggles, gloves, & gown) a. All new admissions, b. All re-admissions, and c. Residents who have spent one or more nights away from the facility. Admissions/Readmissions . 5. c. All new admissions will be placed in observation with transmission-based precautions for 14 days. Staff will wear an N-95 or higher mask, gown, & gloves during care of the resident . 6. Readmission or Residents who have spent more than one night away from the facility are all considered residents with an unknown COVID-19 status. A new, 14-day, quarantine period will begin upon readmission to the facility. The Personal Protective Equipment - Using Face Masks policy revised September 2010 indicated 2. Be sure that face mask covers the nose and mouth . The website https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html updated 6/25/20 and accessed 8/05/20 indicated: .create a plan for managing new admissions and readmissions whose COVID-19 status is unknown .this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19 .residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission . The website https://www.hhs.gov/answers/public-health-and-safety/what-is-the-difference-between-isolation-and-quarantine/index.html accessed 8/05/20 indicated: .Isolation separates sick people with a contagious disease from people who are not sick .quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. These people may have been exposed to a disease and do not know it, or they may have the disease buy do not show symptoms . The administrator, DON, and ADON D were notified on 07/29/2020 at 2:44 p.m., an Immediate Jeopardy (IJ) situation was identified due to the above failures and the IJ template was provided. On 07/30/20 at 10:16 a.m., the facility plan of removal was accepted and included: Senior Rehabilitation and Skilled Nursing Facility will enact the following actions in order to remove the IJ: 1. Quarantine 2 roommates of Covid positive resident for 14 days. These residents will be on 1 on 1. This has been completed as of 7/29/20 2:45 PM. 2. Test all staff and residents on 100 Hall, where infected resident was temporarily placed, and on 200 hall, quarantine hall. This has been completed as of 7/29/20 3 PM. 3. The Covid positive resident was moved to a Covid positive wing and is on 1 on 1 monitoring. She is the only resident on that wing which is 800 hall. 4. All residents are being monitored Q4 hrs. for temp, respiratory function, pulse ox and other signs and symptoms as of 7/26/20. 5. An in-service has been started by the administrator and or designee for all staff members concerning proper wearing of mask and type of mask to be worn in appropriate areas. This will be monitored at the screening station at the only entrance by the screener and randomly throughout each shift by administrative staff and or designees. Staff not present at current time will be in-serviced by Administrator and or designee via phone or in-person prior to working their next shift. In person in-services will occur at screening point of entry. Administrative staff and or designees will continue to monitor proper wearing of mask by making random rounds throughout each shift, on each hallway and in public areas. If an employee is not wearing their mask correctly, they will be immediately educated on proper mask wearing again and will not be allowed to continue to work unless they are compliant. 6. An in-service has been started by the administrator and or designee for all admissions staff members concerning new admission and readmission quarantine. All new admits and readmits that have been out of the building for a period of 24 hrs. or greater must be placed on the quarantine hall 200. This will be monitored by the administrator or DON on each admit for a period of 3-6 months or until the CDC and HHSC directs otherwise. 7. Proper sanitation of all potentially infected areas continues including but not excluded to wiping down high touch areas every 2 hours, deep clean of infected resident's rooms with appropriate [MEDICAL CONDITION] disinfectant, routine cleaning and other measures. 8. If any other residents begin to show signs or symptoms of Covid 19, they will then be moved to the quarantined hall, tested again for Covid-19, and moved to the Covid positive hall if test results show they are positive. On 07/30/20 the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by: In-service training reports dated 07/29/20 and 07/30/20 presented to all staff indicated facemask must be worn over nose and mouth at all times inside the facility. N-95 mask must be worn while on COVID-19 unit or quarantine hall 200. Cloth masks are not permissible unless other alternatives are not present. During observations on 07/30/20 from 9:45 a.m. to 11:30 a.m. surveyor observed staff wearing N-95 masks appropriately that covered their nose and mouth, including on the secure unit and the quarantine hall. During interviews, with staff from all three shifts, on 7/30/20, 2 ADONs, 3 LVNs, 5 CNAs, the floor tech, a dietary helper, and a PTA had been trained on quarantining residents and proper mask usage. They said they were supposed to make sure the mask covered both their nose and mouth. They were told to wear N-95 masks due to positive COVID in the building. During interviews on 07/30/20, the administrator confirmed all staff currently working at the facility had been trained on quarantine and wearing masks over the nose and mouth. The administrator said other staff will receive training before starting their next shift. On 07/30/20 at 11:41 a.m., the administrator was notified the IJ was removed. However, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to effectively and efficiently administer in a manner that enabled it to use its resources to maintain the highest practicable physical, mental, and psychosocial well-being for residents. The administrator did not follow the facility policy (adopted from CDC guidelines and recommendations) and implement interventions to prevent the potential spread of COVID 19. The administrator directed RN A, who was tested for COVID 19, to work 3 shifts on the secure unit (20 residents) prior to receiving her test results which were positive. RN A had a physician's orders [REDACTED]. The administrator did not require RN A to wear a mask and gloves while providing care when she returned to work prior to receiving the results of the COVID-19 test. ADON D did not provide training to RN A regarding the appropriate PPE to wear to prevent the spread of COVID-19. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/2/20. While the IJ was removed on 4/3/20, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of contracting COVID-19 resulting in possible serious illness or death. Findings included: During a phone interview on 3/31/20 at 9:28 a.m., the administrator said RN A was tested for COVID-19 on 3/17/20. The administrator said he requested a letter from RN A's physician on 3/18/20. He said the letter indicated RN A could return to work after 7 days if she was asymptomatic. He said RN A worked 3/24/20, 3/25/20, and 3/26/20 on the secure unit. The administrator said he received RN A's test results on 3/30/20 and she was positive for COVID-19. He said RN A had a history of [REDACTED]. During an interview on 3/31/20 at 10:47 a.m., RN A said she went to the doctor on 3/17/20 because she woke up with aches. She said she was tested for the Coronavirus on 3/17/20 and was told to go home by her physician until she got the results. She said she went back to work on 3/24/20 and also worked 3/25/20 and 3/26/20 on the secure unit. She said the facility told her she would be terminated if she did not work. She said she was not told to wear a mask or any other PPE when she returned on 3/24/20. She said she did not wear a mask when she returned and only used gloves when checking blood sugars. She said she got the positive result of the COVID-19 on 3/30/20. RN A said she was told by the health department she had to stay off work for 21 days and have 2 negative tests before she could return to work. RN A said she had not had any training on COVID-19 from the facility. During an interview on 4/1/20 at 3:33 p.m., ADON D, the infection preventionist, said she took COVID-19 training material from the CDC in December 2019. She said she educated staff on the material on 3/11/20 and 3/13/20. She said she provided staff with the highlights of the facility policy on COVID-19, gave them a packet to read about COVID-19 and gave them an in-service sheet to sign. She said she did not recall providing the highlights on the policy or giving RN A a packet regarding COVID-19. An in-service dated 3/11/20 titled What you need to know about Coronavirus disease 2019 (COVID-19), did not have RN A's signature indicating she received the training. An in-service dated 3/13/20 titled Hand washing and hand hygiene did not have RN A's signature indicating she received the training. RN A's personnel file and training record indicated no training on COVID-19. Her last training on infection control was 7/17/19. During an interview on 4/1/20 9:45 a.m., the administrator said RN A was not required to wear a mask and gloves while providing care to residents after her return to work on 3/24/20, 3/25/20 and 3/26/20. He said in-services regarding COVID-19 were left at the nursing station for staff to read and sign. During an interview on 4/1/20 at 3:37 p.m., the administrator said RN A had not received training on COVID-19. During a phone interview on 3/31/20 at 10:37 a.m., the MA at RN A's physician office said RN A was seen on 3/17/20. The MA said the physician notes indicated RN A had complained of fever and symptoms off and on for 3 days. She said the physician notes indicated RN A complained of a cough and a sore throat. The MA said RN A was tested for the flu and strep throat, and both test results were negative. She said RN A was then tested for COVID-19. She said RN A was told the physician to go home and stay at home until the results were in. The MA said RN A was afraid she was going to be fired if she did not go to work. The MA said she typed a letter from the physician indicating RN A was to remain home and off of work for 7 days or until further notice. She said the results usually took 5-7 days and the until further notice was just in case the results took longer. The physician's letter dated 3/18/20 indicated This is a note to confirm that RN A was seen in my office on 3/17/20 for flu like symptoms. Screening for Flu A and Flu B as well as strep were done with negative results. Due to CDC recommendations as a precaution RN A was swabbed for Coronavirus. Patient is to remain home and off of work for 7 days or until further notice. Any questions or concerns please contact our office at . During an interview on 4/3/20 at 11:50 a.m., RN A's physician said she tested RN A for Coronavirus on 3/17/20 because she was negative for strep and flu. She said RN A told her (the physician) she (RN A) had symptoms for several days. She said she told RN A she was not to return to work until the results of the test were in. The physician said RN A was afraid she was going to lose her job if she did not return to work. During an interview on 4/1/20 at 5:05 p.m., ADON B who was the staffing coordinator, said she called RN A's physician office on 3/23/20, the day before RN A was scheduled to work, and was told by the physician's MA the results from the COVID-19 test were not back and RN A was to remain off work until the results were received. ADON B said she told the administrator what RN A's physician office said and he picked up the phone and called RN A and told her she needed to show up for work. She said she thought the administrator made the call to RN A on 3/23/20, the day before she was scheduled to work on 3/24/20. During an interview on 4/2/20 at 11:15 a.m., the administrator said the staffing coordinator brought the phone to him on either 3/23/20 or 3/24/20 and asked him to talk to RN A about returning to work. He said he asked RN A if she had any symptoms or had to take anything to relieve a fever in the last seven days. He said RN A told him she had not had any symptoms and he told her to return to work. He said he thought if she was asymptomatic for seven days she was able to work. He said he got the information from the CDC guidelines. He said he knows now that was a mistake and he was using the information for an employee who had not been tested . He said he was not told RN A's physician said she could not return to work until her COVID-19 test result was back. During an interview on 4/1/20 at 5:15 p.m., the DON said RN A usually worked on the secure unit but worked 1 shift on hall 400 prior to being tested for the coronavirus. During an observation on 4/1/20 at 12:43 p.m., the residents in the secure unit were noted in the hallway, dining area, near the medication cart and in the smoking area with no PPE and without social distancing. A COVID-19, Prevention and Control policy revised 3/14/20 indicated Policy Statement - This facility follows current CDC guidelines and recommendations for the prevention and control of COVID-19. The COVID-19, Prevention and Control policy revised 3/20/20 referenced Provider Letter 20-11, dated 3/20/20, indicating a nursing facility should do the following: 1. Follow guidance issued by: a. the Centers for Disease Control . The website https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/hcp-return-work.html, accessed on 03/31/20 indicated the following: .Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19, Return to Work Practices and Work Restrictions: Return to Work Criteria for HCP with Confirmed or Suspected COVID-19 - Use one of the below strategies to determine when HCP may return to work in healthcare settings 1.Test-based strategy. Exclude from work until *Resolution of fever without the use of fever-reducing medications and *Improvement in respiratory symptoms (e.g., cough, shortness of breath), and *Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected 24 hours apart (total of two negative specimens) 2. Non-test-based strategy. Exclude from work until *At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and, *At least 7 days have passed since symptoms first appeared If HCP were never tested for COVID-19 but have an alternate diagnosis (e.g., tested positive for influenza), criteria for return to work should be based on that diagnosis. After returning to work, HCP should: * Wear a facemask at all times while in the healthcare facility until all symptoms are completely resolved or until 14 days after illness onset, whichever is longer * Be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) until 14 days after illness onset * Adhere to hand hygiene, respiratory hygiene, and cough etiquette in CDC's interim infection control guidance (e.g., cover nose and mouth when coughing or sneezing, dispose of tissues in waste receptacles) * Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen . The administrator and VP of Clinical Services was notified on 4/2/20 at 11:22 a.m. an IJ situation was identified due to the above failures. The facility's Plan of Removal was accepted on 4/2/20 at 5:21 p.m. and included: Tag F-880 Plan of Removal for Senior Rehabilitation 4-2-20 There is evidence that it is possible that the residents and staff in the facility could possibly contract COVID-19. An infection of COVID-19 could lead to health complications in high risk residents and/or possibly death. The facility initiated immediate action to correct the noncompliance. Step 1. 16 staff members that had direct contact with the RN whom tested positive for COVID-19 have been quarantined to their place of residence as of 3/30/20 per the local health department. The staff were given the COVID-19 hotline number and urged to self-screen for signs and symptoms and get tested for COVID-19. The testing is being directed by the local health department. Step 2. All residents are being monitored for signs and symptoms Q4 hours via respiratory function/pulse ox and temperature. Any residents showing any signs will be quarantined to the 200 hall which is set up for isolation. This is a designated isolation wing. Any suspected cases will be reported to HHSC via TULIP and the local health department. Step 3. Education for all staff had been initiated as of 3/31/20 and will be completed by the VP of Clinical Services for Southwest and/or designee in a face to face setting. The Administrator was reeducated by the VP of clinical services for Southwest LTC on COVID-19 on 4/2/20 at 10 A.M in a face to face setting regarding signs and symptoms as put forth by the CDC of when an employee may return to work. Training will be completed for all non-quarantined staff ASAP as they come on to shift in a face to face setting by VP of Clinical Services for Southwest and/or designee. The goal is to have all staff trained by 4/3/20 at 2 PM. Step 4. Training for quarantined staff will have face to face training prior to returning to work. Training will be completed on 4/13/20 at the beginning of their shift when all quarantined employees are allowed to return to work per local health department. Training will be completed by VP of Clinical Services for Southwest and/or designee. Step 5. Anyone who has been tested for COVID-19 will not be allowed to return to work unless cleared by local health department. Step 6. The plan for continued screening of staff includes an assigned designee per shift will screen oncoming staff which includes questionnaire and temperature log. Staff are not able to screen themselves. Residents will be screened for respiratory symptoms and temperature each shift by a nurse. The local health department will dictate to the facility when those employees will be allowed to return to work. Currently the allowances for returning to work are after 14 days of quarantine from time of last exposure and they are asymptomatic, which would be April 10th. On 4/3/20 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: * An in-service dated 4/2/20 and continued on 4/3/20 indicated staff were trained on the facility policy related to COVID-19. Quarantined staff received training via facetime and would receive training when they returned to work. * All residents were being monitored for elevated temperature, oxygen saturation and respirations every four hours. * 16 staff members who had direct contact with RN A were self-quarantined for 14 days. * During an interview on 4/3/20 at 8:15 a.m., the administrator said he was educated as to when employees were allowed back to work after exposure or being tested for COVID-19. He was aware staff were to wear a mask when returning to work. *During an interview on 4/2/20 at 10:55 a.m., the VP of Clinical Services said the facility had 1 resident who was moved to hall 200 on 4/2/20 due to a temperature of 101.2. She said the resident was tested for flu and strep that morning but the results were not back. * During an interview on 4/3/20 at 8:40 a.m., The administrator and VP of Clinical Services said a resident had spiked a temperature and had a cough and the resident was moved to hall 200 and tested for strep and the flu. *During interviews on 4/3/20 from 12:29 p.m. thorough 3:10 p.m., the administrator, BOM, SW, activity director, housekeeping personnel, ST, marketer, cook, 3 charge nurses (all 3 shifts), 8 CNAs (all 3 shifts), and housekeeping supervisor said they had been in-serviced on the facility's policy for COVID-19. They were aware of signs and symptoms including fever, cough, and runny nose and to report to the on-call person or administrator if they feel sick or have a fever. On 4/3/20 at 4:00 p.m., the administrator, VP of Clinical Services and ADON C were informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure an effective infection control program to prevent the transmission of communicable diseases was provided for the facility regarding COVID 19. The facility did not implement interventions to prevent the potential spread of COVID 19. The facility allowed a Registered Nurse who was tested for COVID 19 to work 3 shifts on the secure unit (20 residents) prior to receiving her test results which were positive. The facility did not follow RN A's physician order [REDACTED]. The facility did not follow the CDC guidelines and recommendations for COVID-19 and require RN A to wear a mask when she returned to work, prior to the results of the COVID-19 test. The facility did not provide training to RN A regarding the appropriate PPE to wear to prevent the spread of COVID-19. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/2/20. While the IJ was removed on 4/3/20, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of contracting COVID-19 resulting in possible serious illness or death. Findings included: During a phone interview on 3/31/20 at 9:28 a.m., the administrator said RN A was tested for COVID-19 on 3/17/20. The administrator said he requested a letter from RN A's physician on 3/18/20. He said the letter indicated RN A could return to work after 7 days if she was asymptomatic. He said RN A worked 3/24/20, 3/25/20, and 3/26/20 on the secure unit. The administrator said he received RN A's test results on 3/30/20 and she was positive for COVID-19. He said 16 staff had direct contact with RN A. During an interview on 3/31/20 at 10:47 a.m., RN A said she went to the doctor on 3/17/20 because she woke up with aches. She said she was tested for the Coronavirus on 3/17/20 and was told to go home by her physician until she got the results. She said she went back to work on 3/24/20 and also worked 3/25/20 and 3/26/20 on the secure unit. She said the facility told her she would be terminated if she did not work. She said she was not told to wear a mask or any other PPE when she returned on 3/24/20. She said she did not wear a mask when she returned to work and only used gloves when checking blood sugars. She said she got the positive result of the COVID-19 on 3/30/20. RN A said she was told by the health department she had to stay off work for 21 days and have 2 negative tests before she could return to work. RN A said she had not had any training on COVID-19 from the facility. During an interview on 4/1/20 at 3:33 p.m., ADON D, the infection preventionist, said she took COVID-19 training material from the CDC in December 2019. She said she educated staff on the material on 3/11/20 and 3/13/20. She said she provided staff with the highlights of the facility policy on COVID-19, gave them a packet to read about COVID-19 and gave them an in-service sheet to sign. She said she did not recall providing the highlights on the policy or giving RN A a packet regarding COVID-19. An in-service dated 3/11/20 titled What you need to know about Coronavirus disease 2019 (COVID-19), did not have RN A's signature indicating she received the training. An in-service dated 3/13/20 titled Hand washing and hand hygiene did not have RN A's signature indicating she received the training. RN A's personnel file and training record indicated no training was provided on COVID-19. Her last training on infection control was 7/17/19. During an interview on 4/1/20 9:45 a.m., the administrator said RN A was not required to wear a mask and gloves while providing care to residents after her return to work on 3/24/20, 3/25/20 and 3/26/20. He said in-services regarding COVID-19 were left at the nursing station for staff to read and sign. During an interview on 4/1/20 at 3:37 p.m., the administrator said RN A had not received training on COVID-19. During a phone interview on 3/31/20 at 10:37 a.m., the MA at RN A's physician office said RN A was seen on 3/17/20. The MA said the physician notes indicated RN A had complained of fever and symptoms off and on for 3 days. She said the physician notes indicated RN A complained of a cough and a sore throat. She said RN A was tested for the flu and strep throat, and both test results were negative. She said RN A was tested for COVID-19 and was told by the physician to go home and stay at home until the results were in. The MA said RN A was afraid she was going to be fired if she did not go to work. The MA said she typed a letter from the physician indicating RN A was to remain home and off of work for 7 days or until further notice. She said the results usually took 5-7 days and until further notice was just in case the results took longer. The physician's letter dated 3/18/20 indicated This is a note to confirm that RN A was seen in my office on 3/17/20 for flu like symptoms. Screening for Flu A and Flu B as well as strep were done with negative results. Due to CDC recommendations as a precaution RN A was swabbed for Coronavirus. Patient is to remain home and off of work for 7 days or until further notice. Any questions or concerns please contact our office at . During an interview on 4/3/20 at 11:50 a.m., RN A's physician said she tested RN A for Coronavirus on 3/17/20 because she was negative for strep and flu. She said RN A told her (the physician) she (RN A) had symptoms for several days. She said she told RN A she was not to return to work until the results of the test were in. The physician said RN A was afraid she was going to lose her job if she did not return to work. During an interview on 4/1/20 at 5:05 p.m., ADON B who was the staffing coordinator, said she called RN A's physician office on 3/23/20, the day before RN A was scheduled to work, and was told by the physician's MA the results from the COVID-19 test were not back and RN A was to remain off work until the results were received. ADON B said she told the administrator what RN A's physician office said and he picked up the phone and called RN A and told her she needed to show up for work. She said she thought the administrator made the call to RN A on 3/23/20, the day before she was scheduled to work on 3/24/20. During an interview on 4/2/20 at 11:15 a.m., the administrator said the staffing coordinator brought the phone to him on either 3/23/20 or 3/24/20 and asked him to talk to RN A about returning to work. He said he asked RN A if she had any symptoms or had to take anything to relieve a fever in the last seven days. He said RN A told him she had not had any symptoms and he told her to return to work. He said he thought if she was asymptomatic for seven days she was able to work. He said he knows now that was a mistake. He said he was not told RN A's physician said she could not return to work until her COVID-19 test result was back. During an interview on 4/1/20 at 5:15 p.m., the DON said RN A usually worked on the secure unit but worked 1 shift on hall 400 prior to being tested for the coronavirus. During an observation on 4/1/20 at 12:43 p.m., the residents in the secure unit were noted in the hallway, dining area, near the medication cart and in the smoking area with no PPE and without social distancing. The facility's COVID-19, Prevention and Control policy revised 3/14/20 indicated Policy Statement - This facility follows current CDC guidelines and recommendations for the prevention and control of COVID-19. The website https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/hcp-return-work.html, accessed on 03/31/20 indicated the following: .Return to Work Criteria for HCP with Confirmed or Suspected COVID-19 .Use one of the below strategies to determine when HCP may return to work in healthcare settings 1. Test-based strategy. Exclude from work until * Resolution of fever without the use of fever-reducing medications and * Improvement in respiratory symptoms (e.g., cough, shortness of breath), and * Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive nasopharyngeal swab specimens collected 24 hours apart (total of two negative specimens) . After returning to work, HCP should: * Wear a facemask at all times while in the healthcare facility until all symptoms are completely resolved or until 14 days after illness onset, whichever is longer * Be restricted from contact with severely immunocompromised patients (e.g., transplant, hematology-oncology) until 14 days after illness onset * Adhere to hand hygiene, respiratory hygiene, and cough etiquette in CDC's interim infection control guidance (e.g., cover nose and mouth when coughing or sneezing, dispose of tissues in waste receptacles) * Self-monitor for symptoms, and seek re-evaluation from occupational health if respiratory symptoms recur or worsen . The administrator and VP of Clinical Services was notified on 4/2/20 at 11:22 a.m. an IJ situation was identified due to the above failures and the IJ template was provided. The facility's Plan of Removal was accepted on 4/2/20 at 5:21 p.m. and included: Tag F-880 Plan of Removal for Senior Rehabilitation 4-2-20 There is evidence that it is possible that the residents and staff in the facility could possibly contract COVID-19. An infection of COVID-19 could lead to health complications in high risk residents and/or possibly death. The facility initiated immediate action to correct the noncompliance. Step 1. 16 staff members that had direct contact with the RN whom tested positive for COVID-19 have been quarantined to their place of residence as of 3/30/20 per the local health department. The staff were given the COVID-19 hotline number and urged to self-screen for signs and symptoms and get tested for COVID-19. The testing is being directed by the local health department. Step 2. All residents are being monitored for signs and symptoms Q4 hours via respiratory function/pulse ox and temperature. Any residents showing any signs will be quarantined to the 200 hall which is set up for isolation. This is a designated isolation wing. Any suspected cases will be reported to HHSC via TULIP and the local health department. Step 3. Education for all staff had been initiated as of 3/31/20 and will be completed by the VP of Clinical Services for Southwest and/or designee in a face to face setting. The Administrator was reeducated by the VP of clinical services for Southwest LTC on COVID-19 on 4/2/20 at 10 A.M in a face to face setting regarding signs and symptoms as put forth by the CDC of when an employee may return to work. Training will be completed for all non-quarantined staff ASAP as they come on to shift in a face to face setting by VP of Clinical Services for Southwest and/or designee. The goal is to have all staff trained by 4/3/20 at 2 PM. Step 4. Training for quarantined staff will have face to face training prior to returning to work. Training will be completed on 4/13/20 at the beginning of their shift when all quarantined employees are allowed to return to work per local health department. Training will be completed by VP of Clinical Services for Southwest and/or designee. Step 5. Anyone who has been tested for COVID-19 will not be allowed to return to work unless cleared by local health department. Step 6. The plan for continued screening of staff includes an assigned designee per shift will screen oncoming staff which includes questionnaire and temperature log. Staff are not able to screen themselves. Residents will be screened for respiratory symptoms and temperature each shift by a nurse. The local health department will dictate to the facility when those employees will be allowed to return to work. Currently the allowances for returning to work are after 14 days of quarantine from time of last exposure and they are asymptomatic, which would be April 10th. On 4/3/20 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: * An in-service dated 4/2/20 and continued on 4/3/20 indicated staff were trained on the facility policy related to COVID-19. Quarantined staff received training via facetime and would receive training when they returned to work. * All residents were being monitored for elevated temperature, oxygen saturation and respirations every four hours. * 16 staff members who had direct contact with RN A were self-quarantined for 14 days. * During an interview on 4/3/20 at 8:15 a.m., the administrator said he was educated as to when employees were allowed back to work after exposure or being tested for COVID-19. He was aware staff were to wear a mask when returning to work. *During an interview on 4/2/20 at 10:55 a.m., the VP of Clinical Services said the facility had 1 resident who was moved to hall 200 on 4/2/20 due to a temperature of 101.2. She said the resident was tested for flu and strep that morning but the results were not back. * During an interview on 4/3/20 at 8:40 a.m., The administrator and VP of Clinical Services said a resident had spiked a temperature and had a cough and the resident was moved to hall 200 and tested for strep and the flu. *During interviews on 4/3/20 from 12:29 p.m. thorough 3:10 p.m., the administrator, BOM, SW, activity director, housekeeping personnel, ST, marketer, cook, 3 charge nurses (all 3 shifts), 8 CNAs (all 3 shifts), and housekeeping supervisor said they had been in-serviced on the facility's policy for COVID-19. They were aware of signs and symptoms including fever, cough, and runny nose and to report to the on-call person or administrator if they feel sick or have a fever. On 4/3/20 at 4:00 p.m., the administrator, VP of Clinical Services and ADON C were informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread due the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care. (Resident #1) LVN A did not conduct conducted an assessment on Resident #1 after she was found on the floor, was transferred from the floor to her bed and complained of arm pain. Resident #1 was later diagnosed with [REDACTED]. This failure could place residents at risk of not receiving treatment and care in accordance with their needs. Findings included: A face sheet, dated 07/01/19 indicated Resident #1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had moderate cognitive impairment, required limited to extensive assistance of 1 person for ADLs including transfers and toilet use, required staff assistance to stabilize and balance the resident when walking, noted she utilized a wheelchair for mobility, and had a history of [REDACTED]. A care plan dated 07/08/19 indicated Resident #1 was at risk for falls and interventions included monitoring the resident for changes in condition that may warrant increased supervision/assistance and notify the physician. Physician orders [REDACTED]. There were no orders for pain medications. The MAR for Resident #1 dated 06/19/19 through 07/31/19 indicated no pain medications were ordered or administered. During an interview on 08/13/19 at 11:38 a.m., CNA A said on 07/31/19 at 1:00 a.m. she was at the nurse station and heard a resident yelling. She said she found Resident #1 on the floor and Resident #1 reported she had fallen. She said she told Resident #1 to stay where she was, and she would get the nurse. She said she (CNA A) and LVN A attempted to transfer Resident #1 from the floor to her bed. She said they were not able to transfer Resident #1 into her bed and called for CNA B to assist. She said LVN A was on Resident #1's left side, she (CNA A) was on Resident #1's right side, and CNA B lifted Resident #1's legs and feet. She said Resident #1 complained her left arm was hurting when she was transferred. During an interview on 08/13/19 at 12:07 p.m., LVN A said on 07/31/19 at 1:00 a.m. CNA A called her to Resident #1's room. She said Resident #1 was half out of the bed. She said she (LVN A) and CNA A attempted to transfer Resident #1 back to the bed. She said she was on Resident #1's left side. She said they were not able to complete the transfer until they called for CNA B to assist. She said Resident #1 was transferred back to bed with the assistance of 3 staff. LVN A said she did not assess the resident for injury or call her physician regarding the fall. She educated the resident on using the call light. She said Resident #1 did not complain of pain. LVN A said when she administered Resident #1's 5:00 a.m., medication, Resident #1 complained of pain to her left arm. LVN A said she did not assess the resident for injury or call her physician, but she administered Resident #1 her [MEDICAL CONDITION] medication and gave her Tylenol. She said Resident #1 wanted to sit on the side of the bed. She said she did not check Resident #1's physician order [REDACTED].#1 had PRN orders for Tylenol. She said she did not document Resident #1's fall in the nursing note and she did not complete an incident report. She said she was busy and then she forgot to complete the required documentation. She said she did not know of Resident #1's arm fracture until she received report prior to her shift on the evening of 07/31/19. She said she believed she may have caused the fracture when transferring Resident #1 into the bed and did not consider Resident #1 had fallen because when she saw her she was half on the bed. During an interview on 08/13/19 at 8:40 a.m., the DON said Resident #1 had fallen twice on 07/29/19. She said Resident #1 had sustained no injury in the first fall 0n 07/29/19. She said Resident #1 sustained a hematoma in the second fall and was sent to the hospital for evaluation and treatment 0n 07/29/19. She said Resident #1 returned to the facility with no new orders. She said the hospital records indicated no fractures 0n 07/29/19. She said on 07/31/19 at 8:30 a.m. she assessed Resident #1 to follow up on the falls from 07/29/19 and noticed she had bruises on the left arm. She advised the nurse to call the physician for new orders for an x-ray. The DON said the facility received the x-ray results at approximately 4:00 p.m. on 07/31/19 and indicated Resident #1's left arm was fractured. She said Resident #1 was sent to the hospital for evaluation and treatment. The DON said when LVN A reported to work on 07/31/19 at 10:00 p.m., she reported Resident #1 was found on the floor at 1:00 a.m., that same morning, and said LVN A did not assess the resident, document the fall, complete an incident / accident report, or notify the resident's physician. The DON said Resident #1 reutnred to the facility on [DATE] at 5:00 a.m. She said LVN A did not follow facility policy. The facility Falls-Clinical Protocol revised 08/19 indicated 2. In addition, the nurse shall assess and document/report the following: f. Pain. G. Frequency and number of falls since last physician visit . 5. staff will evaluate, and document falls that occur while the individual is in the facility . 6. Falls should be categorized as . b. those that occur while upright and attempting to ambulate; and c. other circumstances such as sliding out of a chair or rolling from a low bed to the floor. 7.also identified as witnessed or unwitnessed events, etc.

Based on interview and record review, the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 16 residents reviewed for accidents. (Resident #11) The facility did not provide required assistance of two staff during a transfer of Resident #11 from her wheelchair to her bed. Resident #11 sustained a broken right leg when she fell during the transfer. This failure could place 74 residents who required assistance with transfers at risk of neglect or injury. Findings included: Physician orders [REDACTED].#11, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #11 had a Brief Interview of Mental Status (BIMS) of 12, indicating moderate cognitive impairment, she required 2+person physical assist for transfers, and utilized a wheelchair for mobility. The Care Plan dated 02/07/17 indicated Resident #11 required extensive assistance with transfers using a Hoyer lift and assistance of at least 2 staff. A new order, dated 03/09/17 indicated the Hoyer lift would be used only as needed due to Resident #11's refusal of the Hoyer lift. Observation on 07/21/17 at 9:30 a.m. of the electronic kiosk information indicated Resident #11 required 2 staff for transfers. An incident report dated 07/06/17 indicated Resident #11 fell during a transfer. The fall was witnessed by CNA A. The resident hit her knee when CNA A attempted to lower her to the floor, when Resident slid down. Resident #11 was assessed for pain and injuries, and noted pain to the resident's right knee was reported as 10 on a scale of 1-10. Resident #11's right knee appeared swollen and red, with an area above the knee that appeared to be disfigured. The physician was notified, and sent orders to send Resident #11 to the hospital for x-rays. The incident report indicated an in-service was recommended to educate staff on proper transfer techniques. An x-ray dated 07/06/17 for Resident #11 indicated a displaced right hip fracture. During an interview on 07/20/17 at 1:40 p.m., Resident #11 said CNA A was assisting her to transfer from the wheelchair to the bed, and was not supporting her during the transfer, so the resident fell on her knee and broke her leg. Resident #11 said the CNA told her there were supposed to be two staff assisting with the transfer, but CNA A was the only one staff assisting Resident #11 during the incident. During an interview on 07/20/17 at 3:47 p.m., CNA A said she was trained on using the kiosk (electronic resident care information center) but was not specifically trained on transferring Resident #11. She said she did not check the kiosk for Resident #11's transfer instructions prior to transferring Resident #11. She said she did not ask for assistance when transferring Resident #11. She said she transferred Resident #11 without a second staff. During an interview on 07/20/2017 at 8:40 a.m., the DON said CNA A was terminated after her unsafe transfer of Resident #11 resulted in the resident's broken right leg. She said CNA A should have checked the kiosk prior to transferring Resident #11. She said CNA A transferred Resident #11 on her wrong side. She said Resident #11 was paralyzed on her right side. She said Resident #11's leg weakened and she began to slide down during the transfer. She said Resident #11's right leg was became weak and fractured as a result of the improper transfer. CMS Form 672 dated 07/19/2017 indicated 74 residents required assistance during transfers.

Based on observation, interview and record review, the facility failed to ensure the licensed nurses had the specific competencies and skill sets to provide [MEDICAL CONDITION] (an airway surgically created for breathing) care for oxygen administration for 1 of 1 resident reviewed for respiratory care. (Resident #64) The facility did not have oxygen administration available for Resident #64 who had a [MEDICAL CONDITION]. Neither the charge nurse caring for Resident #64, the nurse who was considered the resource for oxygen set-up, or the DON knew how to connect the oxygen for administration to Resident #64 in the event her oxygen saturation (O2 sat) dropped below 92%. An Immediate Jeopardy situation was identified on 3/21/17 at 11:48 a.m. The Immediate Jeopardy was removed on 3/22/17 at 9:00 a.m. The facility remained out of compliance at pattern potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place1 resident with a [MEDICAL CONDITION] who required oxygen at risk for ineffective airway management. Findings included: Physician orders [REDACTED].#64, re-admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders specified the resident was to receive oxygen at 3 liters per minute (lpm) with FI O2 (measurement of amount of oxygen inhaled) 28% per [MEDICAL CONDITION] to be provided as needed for an oxygen saturation of less than 92%. The most recent MDS dated [DATE] indicated Resident #64 had severe cognitive impairment and was totally dependent on staff for all ADLs. [DIAGNOSES REDACTED]. Treatments included [MEDICAL CONDITION] care, suctioning and oxygen therapy. The care plans dated 3/20/17 indicated Resident #64 required oxygen at 3 lpm with FI O2 via [MEDICAL CONDITION] collar as needed to relieve [MEDICAL CONDITION] if oxygen less than 92 %. The approaches included oxygen, suctioning and management of the [MEDICAL CONDITION]. During an observation and interview on 3/21/17 at 8:00 a.m., Resident #64 was lying in bed with a [MEDICAL CONDITION] (trach) mask on her [MEDICAL CONDITION]. A hose from [MEDICAL CONDITION] was connected to an EZ Air (an air compressor) at the bedside, but no oxygen was connected into the line. The compressor was not turned on. Resident #64's nurse, LVN D said if the resident needed oxygen, she would turn it on and pointed at the air compressor. LVN D said the air compressor would deliver oxygen to the resident when needed. LVN D said Resident #64 used [MEDICAL CONDITION] for protection of the [MEDICAL CONDITION] and did not require oxygen. LVN D then turned on Resident #64's air compressor. An oxygen concentrator was behind the bedside table which held the air compressor. The oxygen concentrator was covered with the privacy curtain and was not turned on or connected to the compressor or tubing leading to Resident #64'[MEDICAL CONDITION]. The attachment required to connect the oxygen to Resident #64's [MEDICAL CONDITION] mask tubing was not at the bedside. During an interview on 3/21/17 at 8:15 a.m., the DON said she was unfamiliar with the oxygen set up for Resident #64. She did not know how to connect the oxygen concentrator to the compressor to supply oxygen to the resident. She said she did not go into that room because she did not get along with the family. She said LVN E was familiar with the oxygen set up and could answer questions. During an interview on 3/21/17 at 8:20 a.m., LVN E walked into Resident #64's room and said she was not familiar with that type of oxygen set up. She did not know how to connect the oxygen concentrator to the compressor to supply oxygen to the resident. During an interview on 3/21/17 at 9:00 a.m., the DON said there was an RRT on staff who worked in marketing and she could answer any questions with the [MEDICAL CONDITION] oxygen setup for Resident #64. During an interview on 3/21/17 at 9:10 a. m., the RRT explained the air compressor and the oxygen concentrator were different types of machines. She said if Resident #64 needed oxygen it had to come from the concentrator, not the compressor. She said the compressor would just provide the needed airflow to dispense the oxygen. During an observation and interview on 3/21/17 at 10:15 a.m., LVNs D and E provided care to Resident #64. LVN D checked the oxygen saturation on Resident #64 and the reading was 75% with pulse rate of 116. She re-positioned the oxygen measuring device to re-check Resident #64's oxygen saturation. The reading was 81% and pulse 92. LVN D said Resident #64 might need to be suctioned. LVN E said if Resident #64's oxygen saturation was below 92% she would apply O2. LVNs D and E searched Resident #64's room for the attachment required to connect the oxygen to the tubing of the compressor. They said there was no attachment setup found to supply oxygen to the [MEDICAL CONDITION] mask in the room. LVNs D and E said the oxygen concentrator was not ready for use as the connector was not available. The administrator and DON were notified on 3/21/17 at 11:48 a.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 3/21/17 at 3:38 p.m., and included: . (4). Education: A. Respiratory in-service: (5). Education of all nurses will be initiated on 3/21/17. This respiratory in-service was conducted by a certified respiratory therapist. The in-service included assessing the resident's airway, procedures for applying O2 for [MEDICAL CONDITION]/nasal cannula for PRN O2 below 92%. All nurses on all shifts will be educated with return demonstration and understand the attachments needed for the respiratory equipment including humidifier, concentrator, nebulizer etc . All new nurses will be trained before beginning on floor. All nurses will demonstrate competency with all new respiratory equipment. DON/ and or designee will train any and all nursing staff on any new equipment before equipment is used for patient care. (6). Compliance to be monitored daily through direct observation of the staff by DON/ and or designee at least q day x 2 wks. then q wk. thereafter x 2 months then 1 x a month x 90 days. DON/ and or designee will round daily hereafter to ensure all equipment is in residents room when needed. On 3/22/17, the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: In-service documentation indicated 20 staff members were in-serviced regarding respiratory, [MEDICAL CONDITION], and humidifier equipment and orders relating to oxygen settings. Eighteen LVNs and 2 RNs were interviewed and said they received in-service training on 3/21/17 and were able to answer questions regarding oxygen delivery and [MEDICAL CONDITION] care. Twenty staff did return demonstrations on oxygen set-up for tracheostomies. On 3/22/17 at 9:00 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated potential for more than minimal harm due to the facility's need to ensure all in-service training was completed and evaluate the effectiveness of the corrective systems. The CMS 672 dated 3/20/17 indicated 1 resident required [MEDICAL CONDITION] care and services. A list dated 3/21/17 titled Physician order [REDACTED].

Based on observation, interview and record review, the facility failed to provide [MEDICAL CONDITION] (an airway surgically created for breathing) care, consistent with professional standards of practice and the comprehensive care plan for 1 of 1 residents reviewed for respiratory care. (Resident # 64) The facility did not have oxygen administration available for Resident #64 who had a [MEDICAL CONDITION]. Neither the charge nurse caring for Resident #64, the nurse who was considered the resource for oxygen set-up, or the DON knew how to connect the oxygen for administration to Resident #64 in the event her oxygen saturation (O2 sat) dropped below 92%. An Immediate Jeopardy situation was identified on 3/21/17 at 11:48 a.m. The Immediate Jeopardy was removed on 3/22/17 at 9:00 a.m. The facility remained out of compliance at pattern potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place1 resident with a [MEDICAL CONDITION] who required oxygen at risk for ineffective airway management. Findings included: Physician orders [REDACTED].#64, re-admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders specified the resident was to receive oxygen at 3 liters per minute (lpm) with FI O2 (measurement of amount of oxygen inhaled) 28% per [MEDICAL CONDITION] to be provided as needed for an oxygen saturation of less than 92%. The most recent MDS dated [DATE] indicated Resident #64 had severe cognitive impairment and was totally dependent on staff for all ADLs. [DIAGNOSES REDACTED]. Treatments included [MEDICAL CONDITION] care, suctioning and oxygen therapy. The care plans dated 3/20/17 indicated Resident #64 required oxygen at 3 lpm with FI O2 via [MEDICAL CONDITION] collar as needed to relieve [MEDICAL CONDITION] if oxygen less than 92 %. The approaches included oxygen, suctioning and management of the [MEDICAL CONDITION]. During an observation and interview on 3/21/17 at 8:00 a.m., Resident #64 was lying in bed with a [MEDICAL CONDITION] (trach) mask on her [MEDICAL CONDITION]. A hose from [MEDICAL CONDITION] was connected to an Easy Air (an air compressor) at the bedside, but no oxygen was connected into the line. The compressor was not turned on. Resident #64's nurse, LVN D said if the resident needed oxygen, she would turn it on and pointed at the air compressor. LVN D said the air compressor would deliver oxygen to the resident when needed. LVN D said Resident #64 used [MEDICAL CONDITION] for protection of the [MEDICAL CONDITION] and did not require oxygen. LVN D then turned on Resident #64's air compressor. An oxygen concentrator was behind the bedside table which held the air compressor. The oxygen concentrator was covered with the privacy curtain and was not turned on or connected to the compressor or tubing leading to Resident #64'[MEDICAL CONDITION]. The attachment required to connect the oxygen to Resident #64's [MEDICAL CONDITION] mask tubing was not at the bedside. During an interview on 3/21/17 at 8:15 a.m., the DON said she did not know how to connect the oxygen concentrator to the compressor to supply the oxygen for Resident #64. She said she did not go into that room because she did not get along with the family. She said LVN E was familiar with the oxygen set up and could answer questions. During an interview on 3/21/17 at 8:20 a.m., LVN E walked into Resident #64's room and said she was not familiar with that type of oxygen set up. She did not know how to connect the oxygen concentrator to supply oxygen to the resident. During an interview on 3/21/17 at 9:00 a.m., the DON said there was an RRT on staff who worked in marketing and she could answer any questions with the [MEDICAL CONDITION] oxygen setup for Resident #64. During an interview on 3/21/17 at 9:10 a. m., the RRT explained the air compressor and the oxygen concentrator were different types of machines. She said if Resident #64 needed oxygen it had to come from the concentrator, not the compressor. She said the compressor would just provide the needed airflow to dispense the oxygen. During an observation and interview on 3/21/17 at 10:15 a.m., LVNs D and E provided care to Resident #64. LVN D checked the oxygen saturation on Resident #64 and the reading was 75% with pulse rate of 116. She re-positioned the oxygen measuring device to re-check Resident #64's oxygen saturation. The reading was 81% and pulse 92. LVN D said Resident #64 might need to be suctioned. LVN E said if Resident #64's oxygen saturation was below 92% she would apply O2. LVNs D and E searched Resident #64's room for the attachment required to connect the oxygen to the tubing of the compressor. They said there was no attachment setup found to supply oxygen to the [MEDICAL CONDITION] mask in the room. LVNs D and E said the oxygen concentrator was not ready for use as the connector was not available. The administrator and DON were notified on 3/21/17 at 11:48 a.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 3/21/17 at 3:38 p.m., and included: . (4). Education: A. Respiratory in-service: (5). Education of all nurses will be initiated on 3/21/17. This respiratory in-service was conducted by a certified respiratory therapist. The in-service included assessing the resident's airway, procedures for applying O2 for [MEDICAL CONDITION]/nasal cannula for PRN O2 below 92%. All nurses on all shifts will be educated with return demonstration and understand the attachments needed for the respiratory equipment including humidifier, concentrator, nebulizer etc . All new nurses will be trained before beginning on floor. All nurses will demonstrate competency with all new respiratory equipment. DON/ and or designee will train any and all nursing staff on any new equipment before equipment is used for patient care. (6). Compliance to be monitored daily through direct observation of the staff by DON/ and or designee at least q day x 2 wks. then q wk. thereafter x 2 months then 1 x a month x 90 days. DON/ and or designee will round daily hereafter to ensure all equipment is in residents room when needed. On 3/22/17, the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: In-service documentation indicated 20 staff members were in-serviced regarding respiratory, [MEDICAL CONDITION], and humidifier equipment and orders relating to oxygen settings. Eighteen LVNs and 2 RNs were interviewed and said they received in-service training on 3/21/17 and were able to answer questions regarding oxygen delivery and [MEDICAL CONDITION] care. Twenty staff did return demonstrations on oxygen set-up for tracheostomies. On 3/22/17 at 9:00 a.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at isolated potential for more than minimal harm due to the facility's need to ensure all in-service training was completed and evaluate the effectiveness of the corrective systems. The CMS 672 dated 3/20/17 indicated 1 resident required [MEDICAL CONDITION] care and services.

Based on observation, interview and record review, the facility failed to implement an effective infection control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for 8 of 21 residents reviewed for infection control. (Resident #s 66, 25, 24, 105, 104, 8, 101 and 59) *The ICP (Infection control preventionist) had no formal training for infection prevention, control, tracking and trending or educating and monitoring staff for infection control practices. *LVN E had no formal training in tracheostomy (surgical opening in throat to enable breathing) care and was unable to perform tracheostomy care using aseptic (sterile) technique for Resident #66. *Hand hygiene was not maintained during catheter care for Resident #66. *Hand hygiene was not maintained during wound care for Resident #s 101, 25, 59, *Hand hygiene was not maintained during incontinent care for Resident #s 8 and 104; *Hand hygiene was not maintained during incontinent care and skin assessment for Resident #105; *A biohazard bag containing soiled bandages was taken in and out of multiple resident rooms; *A bottle of hand sanitizer was placed on a Resident #24's bed, then placed in staff's pocket and the resident's catheter drainage bag was not kept below the level of the bladder; *A glucometer (a device used to assess blood sugar level) was not sanitized after resident use. *Medications were placed on a resident's bed prior to administration and placed back into the medication cart; *Resident rooms contained uncovered, undated respiratory tubing and supplies, O2 tubing was on the floor, and clothing and blankets were on floors in numerous rooms. An Immediate Jeopardy situation was identified on 5/19/16 at 5:25 p.m. The Immediate Jeopardy was removed on 5/20/16. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the census of 108 a risk of spread of infection and cross contamination. Findings included: The following observations of cross-contamination were observed during the survey from 5/17/16 to 5/20/16: Tracheostomy Care: 1. Physician orders [REDACTED].#66, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED].#6 Shiley (size of the cannula). The most recent MDS dated [DATE] indicated Resident #66 had severe cognitive impairment and was totally dependent on staff for all ADLs. [DIAGNOSES REDACTED]. Treatments included tracheostomy care, suctioning and oxygen therapy. Care plans dated 4/27/16 indicated Resident #66 required tracheostomy care. There were no specific interventions for management of the tracheostomy. During observation on 5/18/16 at 8:30 a.m. of Resident #66's tracheostomy care, LVN E did not wash or sanitize her hands after entering the resident's room and placed tracheostomy care supplies on the bed without a sterile field. The sterile towel fell on the floor. LVN E picked up the sterile towel off the floor and put it on the bed. LVN E said, It only hit the bottom, and continued to use the contaminated towel. She placed 4 x 4 gauze, a split 4 x 4, 2 containers for the hydrogen peroxide and normal saline on the contaminated towel. LVN E did not place a sterile field under the resident's tracheostomy site. She proceeded to wet the contaminated 4 x 4 gauze with hydrogen peroxide and normal saline in two separate stacks. She changed gloves and picked up the wet gauze and began to clean the tracheostomy site which contained a thick mucous secretions by wiping under the tubing collecting secretions on the gauze pads. She then separated the wet gauze and used the next layer of 4 x 4's from the first pass around the resident's tracheostomy and removed the inner cannula. LVN E donned sterile gloves, opened the inner cannula package with sterile gloves, thus contaminating the gloves then handled the inner cannula. She then placed the cannula in the tracheostomy opening and placed the split 4 x 4 gauze under the outer neck plate. During an interview on 5/18/16 at 8:30 a.m., LVN E acknowledged she did not maintain sterile technique or perform hand hygiene during tracheostomy care for Resident #66. LVN E stated, What did I make, a zero? When asked about her training in tracheostomy care, LVN E said she did not have any formal training in tracheostomy care only instructions with the ICP nurse. The policy and procedure dated February 2014 for Tracheostomy Care indicated: . Aseptic technique must be used: . c. During tracheostomy tube changes, either reusable or disposable. Sterile gloves must be used during aseptic procedures. (Aseptic: using strict sterile techniques to prevent contamination from microorganisms) Wound Care: 2. Physician orders [REDACTED].#101, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. During observation of wound care for Resident #101 by treatment nurses LVN C and D, on 5/19/16 at 3:35 p.m., the following was observed: *prior to entering the room LVN C her washed hands, cleaned top of treatment cart with disinfectant, laid wax paper on top, and placed supplies on top of wax paper; *LVN D placed a handful of clean gloves on top of the wax paper and opened one package of gauze without performing hand hygiene; *LVN C entered Resident #101's room, and without performing hand hygiene cleaned the residents' bedside table and then left room without performing hand hygiene; *LVN D pushed the trash down into red biohazard bag that was attached to side of treatment cart with ungloved hands, picked up the wax paper (at this point the clean field was contaminated) with clean supplies from top of treatment cart and walk into resident room placing them on Resident #101's bedside table, washed his hands, put on gloves, secured red bag to the bedside table, took gloves off and left room without performing hand hygiene; *LVN C removed Resident #101's multipodus boots, removed gloves, donned new gloves without washing hands, and then opened saline containers; *LVN C did not prepare a clean field on Resident #101's bed prior to wound care. LVN C cleansed a wound on right foot and laid foot down on bed linens. The uncovered toes were touching the sheet and a blanket at foot of bed. LVN C used same soiled gloves to cleanse wound and apply triple antibiotic ointment to wound. *LVN D exited room without removing his soiled gloves and returned to room with ungloved hands carrying clean gloves and placing them on the wax paper on the bedside table. LVN D then washed hands and donned gloves; *After completing wound care on right foot, LVN C began wrapping right foot with gauze. Surveyor intervened and LVN C acknowledged the triple antibiotic had not been applied to great toe wound; *LVN C again cleansed right great toe, applied new gauze without washing hands and changing gloves, and did not re-apply triple antibiotic ointment to right heel; *Throughout wound care on right foot, LVN C laid Resident #101's foot on the unclean bed linens and feet were touching the blankets. During an interview on 5/20/16 at 10:20 a.m., LVN D said an applicator such as a cotton tipped applicator should have been used instead of gloved finger to apply antibiotic ointment. LVN D said Resident #101's feet should not have been on the top of linens and there should have been a clean field to work on. LVN D also acknowledged leaving room without washing hands but did not realize I had done that so many times. During an interview on 5/20/16 at 10:21 a.m., LVN C acknowledged using gloved finger to apply antibiotic ointment and said should have used cotton tipped applicator. LVN C acknowledged that she repeatedly placed residents foot back on soiled linen after cleaning and that she did not perform hand hygiene correctly. 3. Physician orders [REDACTED].#25, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. During an observation of wound care on 5/17/16 at 3:30 p.m., LVN D rolled a bedside table to the doorway of Resident #25's room. The bedside table had a large, red biohazard bag taped to the side of it, containing dirty dressings and trash. LVN C set up clean supplies on the table then rolled it into Resident #25's room. LVNs C and D did not perform hand hygiene after entering the resident's room but proceeded to perform the wound care. LVN C cleaned an open area of yellow slough on the top of the resident's left foot with gauze moistened with normal saline. Using the same soiled gauze, he wiped the resident's blackened toes, then wiped back over the open area of slough using the same gauze. The soiled dressings were discarded in the red bag taped to the bedside table. When the wound care was completed, LVN D rolled the table out of the room and wiped the top with a disinfectant. He then rolled it down the hall, leaving the red bag attached. During an interview on 5/17/16 at 3:45 p.m., LVN D said they always used the same table and biohazard bag, bringing it into each resident's room during wound care. 4. Physician orders [REDACTED].#24, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. During observation of wound care on 5/18/16 at 9:43 a.m., LVN D rolled a bedside table down the hall to the doorway of Resident #24's room. The bedside table had a large, red biohazard bag taped to the side of it, already containing dirty dressings and trash. LVN C set up clean supplies on the table then rolled it into Resident #24's room. Soiled dressings were placed in the red biohazard bag during the procedure. After completing the dressing, LVN C rolled the bedside table out of the room, wiped the top of it with disinfectant, leaving the same biohazard bag taped to the table, now approximately 3/4 full of trash and soiled dressings. 5. Physician orders [REDACTED].#59, admitted on [DATE] and re-admitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. There was an order to clean pressure ulcer to right foot every day and as needed. During an observation of wound care on 5/18/16 at 8:08 a.m., both LVN C and D did not perform hand hygiene after treatment for [REDACTED]. The bedside table had a large, red biohazard bag taped to the side of it, containing soiled dressings and trash. LVN D rolled the table into the hallway and did not disinfect the top before set up for the next resident's wound care. During an interview on 5/18/16 at 10:17 a.m., both LVN C and D acknowledged they should have washed hands before leaving the room after performing wound care for Resident # 59. LVN D acknowledged the bedside table should have been disinfected between Resident #59 wound care prior to set up for the next resident's wound care. A policy titled, Hand Hygiene dated 2012 indicated The purpose was to decrease the risk of transmission of infection by appropriate hand hygiene. Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. During an interview on 5/19/16 at 4:10 p.m., the DON said the bedside table and biohazard bag should not be taken in and out of residents' rooms for wound care. He said staff should use the resident's own table. During an interview on 5/20/16 at 4:40 p.m., LVN D acknowledged using the same bedside table and trash bag room to room could increase the chance of spreading infection. LVN D said he had not had any special training in wound care. During an interview on 5/19/16 at 3:20 p.m., the ADON said it was common knowledge the treatment nurses used the same table and biohazard bag from room to room. She acknowledged this practice could cause cross-contamination. During an interview on 5/19/16 at 3:35 p.m., the ICP (Infection control preventionist) said she was unaware the treatment nurses were bringing the same table and biohazard bag in and out of resident rooms when performing wound care. She said she had not had any formal training regarding the infection control program. The former ICP showed her how to fill out the forms for tracking and that was all she knew to do. During an interview on 5/19/16 at 4:10 p.m., the DON said he was unaware of issues with the infection control program. He said the ICP had not had any formal training on tracking and trending infections or educating the staff. A policy titled Wound Care/Treatment Guidelines indicated the following: Purpose: To provide excellent wound care to promote healing. Guidelines: .II. The cart should be left in the hall and locked . V. Supplies should be placed on a clean surface. A blue pad or wax paper provides a nice clean barrier. VI. Hand hygiene should be performed as outlined in the procedure XI. Trash is bagged in the room and again in the bag on the cart. This bag is disposed in the soiled utility room. Incontinent Care 6. Physician orders [REDACTED].#105 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. During an observation on 5/17/16 at 2:56 p.m., CNA N checked Resident #105 for incontinence. CNA N positioned Resident #105 in bed and pulled the resident's incontinent brief down. CNA N checked the brief for incontinence of bowel or bladder. CNA N then put the brief back in place, repositioned the resident, removed gloves and left the resident's room without performing hand hygiene. During an interview on 5/17/16 at 3:05 p.m., CNA N acknowledged hand hygiene was not performed after checking Resident #105 for incontinence but should have been. 7. Physician orders [REDACTED].#104, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. During an observation on 5/18/16 at 3:53 p.m., LVN C performed a total skin assessment on Resident #104. LVN C removed Resident #104's incontinent brief and touched the resident's genitals and buttocks to assess the skin. LVN C proceeded to reposition and check the resident's skin while re-arranging the clothing and linens. LVN C did not change gloves or perform hand hygiene after touching the resident's genitals and buttocks. During an interview on 5/18/16 at 3:10 p.m., LVN C acknowledged she did not perform hand hygiene after touching Resident #104's genitals and buttocks and before re-arranging the resident's clothing and linens but should have done so. 8. Physician orders [REDACTED].#8, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #8 was always incontinent of urine/bowel and required total assistance with hygiene and bathing. During observations of incontinent care on 5/19/16 at 9:15 a.m., CNA A performed incontinent care for Resident #8 without performing hand hygiene or changing gloves as follows: *positioned resident on back, pulled diaper down and began cleaning the resident's vaginal area: *turned resident to the left side; touching resident and clothing; *performed incontinent care to buttock's, not cleaning the right buttock; *pulled the soiled diaper from underneath the resident and placed it in the garbage bag lying on the resident's bed; and *retrieved the clean diaper, turned the resident and placed the diaper on the resident. During an interview on 5/19/16 at 9:40 a.m., CNA A said he should have washed his hands and changed his gloves when they became soiled during incontinent care for Resident #8. He acknowledged he did not perform hand hygiene between dirty and clean and did not clean the resident's right buttock during care. Catheter Care 9. During an observation on 5/19/16 at 1:00 p.m. of indwelling foley catheter care for Resident #66, CNA F did not perform hand hygiene after entering the resident's room. CNA F did not clean the perineal area in the correct direction. She wiped down and back up with the same wipe. During an interview on 5/19/16 at 1:10 p.m., CNA F said I did the best I could do. The policy and procedure dated 2012 for Catheter Care, Indwelling Catheter indicated: NOTE: Hand washing remains the single most important step in preventing the spread of infection. 4. Wash perineum well . taking care to wash from front to back. 10. Physician orders [REDACTED].#24, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. During an observation on 5/18/16 at 8:38 a.m., CNAs L and M entered Resident #24's room and performed catheter care. After cleaning the perineal area, CNA L removed the soiled gloves, took a bottle of hand sanitizer out of her pocket and after cleaning her hands, set the bottle on the resident's bedside table. During the rest of the procedure, she and CNA M used the sanitizer, leaving it on the table. When the procedure was finished, CNA L placed the bottle of hand sanitizer back in her pocket without sanitizing it. While turning Resident #24 to the right side, CNA M raised the catheter drainage bag approximately 18 inches above the bladder level, allowing urine to flow back toward the bladder. During an observation of a Hoyer lift transfer on 5/18/16 at 10:15 a.m., for Resident #24, CNA M raised the catheter bag approximately 18 inches above the level of the bladder 3 times, allowing urine to flow back toward the bladder. During an interview on 5/19/16 at 9:50 a.m., CNA L acknowledged she should have disinfected the sanitizer bottle she brought in and out of Resident #24's room. The website, <http://www.cdc.gov/hicpac/cauti/002_cauti_sumORecom.html>, accessed 5/26/16 indicated the following: .Maintain unobstructed urine flow .Keep the collecting bag below the level of the bladder at all times . Devices 11. During an observation on 5/18/16 at 4:15 p.m., LVN J performed a glucometer check for blood sugar level. Afterwards he placed the Assure glucometer in the medication cart drawer without sanitizing the meter. During an interview on 5/18/16 at 4:18 p.m., LVN J acknowledged he had not sanitized the glucometer before placing the meter in the medication cart drawer. There was no documentation availabe to indicate the ICP nurse was monitoring glucometer techniques. The policy and procedure for Glucometer Decontamination dated 2012 indicated: The glucometer shall be decontaminated with the facility approved wipes following use on each resident. Gloves will be worn and the manufacturer's recommendations will be followed. The Assure blood glucose meter approved cleaning and disinfecting procedures obtained from the Internet on 5/23/16 indicated: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. Medications 12. During an observation on 5/19/16 at 7:15 a.m., LVN H obtained a bottle of normal saline spray, 2 boxes containing bottles of nasal spray ([MEDICATION NAME] and [MEDICATION NAME]) from the medication cart. He placed these items on the resident bed linens before administering the medications. After administering the medications, he returned the bottle and two boxes to the medication cart. There was no layer of protection to prevent cross contamination. During an interview on 5/19/16 at 8:55 a.m., LVN H acknowledged the bottle of normal saline spray and 2 boxes should not have been placed on the bed linens and the boxes should not have gone into the room. 13. The following observations during initial rounds on 5/17/16 were noted: *at 8:28 a.m., room [ROOM NUMBER] A had O2 tubing laying on the floor and an undated water bottle on the concentrator; a blanket was laying on the floor by the foot ot the bed; *at 8:44 a.m., room [ROOM NUMBER] had an uncovered, undated nebulizer mask and an O2 water bottle undated on the concentrator; *at 9:30 a.m., room [ROOM NUMBER] had an uncovered C-pap mask on the bedside table; *at 9:38 a.m., room [ROOM NUMBER] had an O2 concentrator with an undated water bottle; *at 9:16 a.m., room [ROOM NUMBER] had clothing on the floor of the closet; *at 8:36 a.m., room [ROOM NUMBER] had five uncovered pillows and resident clothing was on the floor of the closet; *at 8:53 a.m., room [ROOM NUMBER] had blue covered pads along wall at the bedside with cracks, rendering it unable to be sanitized; *at 8:57 a.m., room [ROOM NUMBER] had resident clothing on the floor of the closet; *at 9:10 a.m., room [ROOM NUMBER] had resident clothing on the floor of the closet; *at 9:12 a.m., room [ROOM NUMBER] had resident clothing on the floor of the closet; and *at 9:20 a.m., room [ROOM NUMBER] had resident clothing on the floor of the closet. The policy titled Administering Medications through a Small Volume (Handheld) Nebulizer dated October 2010 indicated: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. and .29. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 30. Change equipment and tubing every seven days, or according to facility protocol. The Infection Prevention Program Overview dated 2012 stated the following: Goals: The goals of the infection prevention program are to: A. Decrease the risk of infectgion to residents and personnel. B. Monitor for occcurrence of infection and implement appropriate control measures. C. Identify and correct problems relatin to infection prevention practices. D. Maintain compliance with state and federal regulations relating to infection prevention Prevention of spread of infections is accomplished by use of hand hygiene, standard precautions and other barriers, appropriate treatment and follow-up, and employee work restrictions for illness . Consultation: The infection preventionist serves as a resource for all staff and all departments relating to prevention of infections. The administrator and the DON were notified on 5/19/16 at 5:25 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 5/20/16 at 10:51 a.m. and included: .3. Assessed all residents for signs/symptoms of infection. No new infections identified since most recent surveillance forms provided to survey team on May 19, 2016. Completed. 4. Education: A. Handwashing: (1) Education of Nursing Staff will be initiated on May 19th/20th, 2016. (2) Hand Hygiene; Infection Prevention Manual for Long Term Care (3) Skills competency returned demonstration will be completed for all nursing staff by May 22, 2016. Return demonstration will be observed by DON/designee. (4) Additionally, RN Instructor, of Memorial, will be contracted for continued training and skills competency return demonstrations. (5) Compliance to be monitored daily through direct observation of staff by nursing admin staff. B. Wound Care: (1) Education of Licensed and Registered Nurses will be initiated on May 19th, 2016. (2) Education will cover: (A) Wound Care dressing change; including infection control. (3) Wound Care skills competency initiated May 20th, 2016 by DON/designee. Training/competency will be completed by May 22, 2016. Should any Registered or Licensed Nurse miss this deadline, they will not be scheduled to work until training and skills competency is completed. Wound Care competency and training will be part of orientation and training for all licensed and registered nurses. (4) Additionally, Wound specialist, AMT Wound Care, and RN Instructor contracted to provide continued training and skills competency return demonstrations. (5) Wound care will be provided by Director of Nursing and/or RN designee pending LVN Treatment nurses being trained and competency checks performed by RN Instructor. (6) Compliance to be monitored through observation of Treatment Nurses by Director of Nursing and/or designee and AMT Wound Care and/or RN Instructor. C. Tracheostomy Care: (1) Education of Licensed and Registered Nurses will be initiated on May19th, 2016. (2) Education will cover: (A) Tracheostomy Care; including infection control. (3) Tracheostomy Care competency initiated on May 20th, 2016, by DON/designee. Training/competency will be completed by May 22, 2016. Should any Registered or Licensed Nurse miss the deadline, they will not be scheduled to work until training and skills competency is completed. Tracheostomy care competency and training will be part of the orientation and training for all licensed and registered nurse. (4) RN Instructor will be contracted for continued Tracheostomy Care training and return skills competency demonstration. (5) Tracheostomy care will be provided by Director of Nursing and/or RN designee pending LVN staff being trained and competency checks performed by RN Instructor. (6) Compliance to be monitored through observation of Licensed Nursing Staff by Director of Nursing and/or designee and/or RN Instructor. 5. Compliance of Handwashing skills, Wound care, and Tracheostomy care will be reviewed through monthly QAPI meeting. On 5/20/16, the surveyors confirmed the POR had been implemented sufficiently to remove the Immediat Jeopardy by: A list provided by the facility dated 5/20/16, indicated all residents were assessed by the nurses for signs/symptoms of infections with no new infections noted. Inservice documentation was reviewed that indicated staff in-services regarding hand hygiene had been initiated 5/19/16 and was continuing. The DON said he received tracheostomy care education and skills check-off by the RN Instructor. The DON was observed performing tracheostomy care and hand hygiene. Both tasks were performed appropriately by the DON. The ADON and the DON said they received wound care education and skills check off by the RN Instructor. The ADON and DON were observed performing wound care and hand hygiene. Both were able to perform the tasks properly. 6 CNAs were interviewed and said they received inservice training on infection control and handwashing. 4 LVNs were interviewed and said they received inservice training on infection control and handwashing. They said they were to receive tracheostomy and wound care training prior to performing the tasks for residents. On 5/20/16 at 3:50 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to ensure all in-service training was completed and evaluate the effectiveness of the corrective systems. The CMS 672 dated 5/17/16 indicated a census of 108.

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident #66) received the proper treatment and care for tracheostomies and 2 of 5 residents (Resident #s 66 and 101) requiring respiratory treatments. 1. LVN E did not maintain aseptic (clean) technique during Resident #66's [MEDICAL CONDITION] (surgical opening in the throat to enable breathing) care. 2. LVN E did not obtain an oxygen saturation level for Resident #66 after a breathing treatment was administered. 3. The facility did not have oxygen or a nebulizer machine for Resident #101. An Immediate Jeopardy situation was identified on 5/19/16 at 5:25 p.m. The Immediate Jeopardy was removed on 5/20/16. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure affected 1 of 3 residents with tracheostomies and 2 of 5 residents requiring respiratory treatments at risk for infection and ineffective airway management. Findings included: 1. Physician orders [REDACTED].#66, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED].#6 Shiley (size of the cannula). The most recent MDS dated [DATE] indicated Resident #66 had severe cognitive impairment and was totally dependent on staff for all ADLs. [DIAGNOSES REDACTED]. Treatments included [MEDICAL CONDITION] care, suctioning and oxygen therapy. Care plans dated 4/27/16 indicated Resident #66 required [MEDICAL CONDITION] care. There were no specific interventions for management of the [MEDICAL CONDITION]. During observation on 5/18/16 at 8:30 a.m. of Resident #66's [MEDICAL CONDITION] care, LVN E did not wash or sanitize her hands after entering the resident's room and [MEDICAL CONDITION] supplies on the bed without a sterile field. The sterile towel fell on the floor. LVN E picked up the sterile towel off the floor and put it on the bed. LVN E said, It only hit the bottom, and continued to use the contaminated towel. She placed 4 x 4 gauze, a split 4 x 4, 2 containers for the hydrogen peroxide and normal saline on the contaminated towel. LVN E did not place a sterile field under the resident's [MEDICAL CONDITION] site. She proceeded to wet the contaminated 4 x 4 gauze with hydrogen peroxide and normal saline in two separate stacks. She changed gloves and picked up the wet gauze and began to clean the [MEDICAL CONDITION] site which contained a thick mucous secretions by wiping under the tubing collecting secretions on the gauze pads. She then separated the wet gauze and used the next layer of 4 x 4's from the first pass around the resident's [MEDICAL CONDITION] and removed the inner cannula. LVN E donned sterile gloves, opened the inner cannula package with sterile gloves, thus contaminating the gloves then handled the inner cannula. She then placed the cannula in the [MEDICAL CONDITION] opening and placed the split 4 x 4 gauze under the outer neck plate. During an interview on 5/18/16 at 8:30 a.m., LVN E said she did not maintain sterile technique or perform hand hygiene during [MEDICAL CONDITION] care for Resident #66. LVN E said, What did I make, a zero? LVN E said she did not have any formal training [MEDICAL CONDITION] only instructions with the infection control preventionist nurse. An In-Service Training Report dated 3/23/16 indicated LVN E did not sign-in as attending the in-service conducted for [MEDICAL CONDITION] care, suctioning airway, nebulizer treatment . The policy and procedure dated February 2014 for [MEDICAL CONDITION] Care indicated: . Aseptic technique must be used: . c. During [MEDICAL CONDITION] changes, either reusable or disposable. Sterile gloves must be used during aseptic procedures. 2. Physician orders [REDACTED].#66, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED].#6 Shiley (size of the cannula). She was to be administered respiratory (breathing) treatments of [MEDICATION NAME] (a corticorsteroid: used to treat symptoms of shortness of breath and/or wheezing) every 12 hours. The most recent MDS dated [DATE] indicated Resident #66 had severe cognitive impairment and was totally dependent on staff for all ADLs. There were [DIAGNOSES REDACTED]. Treatments included [MEDICAL CONDITION] care, suctioning, oxygen therapy and respiratory treatments. Care plans dated 4/27/16 indicated Resident #66 required respiratory therapy for ineffective airway clearance. There were no specific interventions for administering respiratory treatment per nebulizer (a device to deliver inhalerant medications). During an observation on 5/18/16 at 8:50 a.m., LVN E administered Resident #66 a breathing treatment of [REDACTED]. The nebulizer MAR indicated [REDACTED]. During an interview on 5/18/16 at 9:10 a.m., when asked by the surveyor if she was finished she said yes. After surveyor intervention, LVN E said she had not assessed the oxygen saturation level for Resident #66. 3. Physicians orders dated May 2016 indicated Resident #101, admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. Further orders indicated [MEDICATION NAME] one unit dose per nebulizer three times daily. Resident #101's clinical record indicated a receipt from a medical equipment indicating oxygen concentrator and nebulizer had been removed from facility on 5/9/16. During observation on initial rounds on 5/17/16 at 9:28 a.m., Resident 101's open, undated, oxygen tubing was lying uncovered on cabinet beside bed. There was no oxygen concentrator or nebulizer present in room. The most recent MDS dated [DATE] indicated Resident #101 was to receive oxygen therapy. A care plan dated 5/17/16 indicated Resident #101 required oxygen therapy. Approaches included: *administer my oxygen as ordered, and *ensure that my supply is available at all times. During an interview on 5/18/16 at 3:00 p.m., LVN G said Resident #101 was to receive next breathing treatment at 5:00 p.m. LVN G pulled the medication from the medication cart to show surveyor. LVN G acknowledged order for continuous oxygen. LVN G said she had given breathing treatment on her last day of work which was 5/15/16. During an observation of Resident #101's room on 5/18/16 at 3:01 p.m. with LVN G, she acknowledged there was no oxygen or nebulizer available in his room. During an interview on 5/18/16 at 3:10 p.m., LVN H said hospice services had taken nebulizer and oxygen from Resident #101's room yesterday and 'haven't had chance to replace the nebulizer yet. During interview on 5/19/16 at 11:30 a.m., the DON said Resident #101 needed the nebulizer and an oxygen concentrator at bedside for the nurses to be able to give the oyxgen and breathing treatment as ordered. The administrator and the DON were notified on 5/19/16 at 5:25 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 5/20/16 at 10:51 a.m. and included: 4. Education: A. Handwashing: (1) Education of Nursing Staff will be initiated on May 19th/20th, 2016. (2) Hand Hygiene; Infection Prevention Manual for Long Term Care (3) Skills competency returned demonstration will be completed for all nursing staff by May 22, 2016. Return demonstration will be observed by DON/designee. (4) Additionally, RN Instructor, of Memorial, will be contracted for continued training and skills competency return demonstrations. (5) Compliance to be monitored daily through direct observation of staff by nursing admin staff. C. [MEDICAL CONDITION] Care: (1) Education of Licensed and Registered Nurses will be initiated on May19th, 2016. (2) Education will cover: (A) [MEDICAL CONDITION] Care; including infection control. (3) [MEDICAL CONDITION] Care competency initiated on May 20th, 2016, by DON/designee. Training/competency will be completed by May 22, 2016. Should any Registered or Licensed Nurse miss the deadline, they will not be scheduled to work until training and skills competency is completed. [MEDICAL CONDITION] care competency and training will be part of the orientation and training for all licensed and registered nurse. (4) RN Instructor will be contracted for continued [MEDICAL CONDITION] Care training and return skills competency demonstration. (5) [MEDICAL CONDITION] care will be provided by Director of Nursing and/or RN designee pending LVN staff being trained and competency checks performed by RN Instructor. (6) Compliance to be monitored through observation of Licensed Nursing Staff by Director of Nursing and/or designee and/or RN Instructor. 5. Compliance of Handwashing skills, Wound care, and [MEDICAL CONDITION] care will be reviewed through monthly QAPI meeting. On 5/20/16, the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediat Jeopardy by: A list provided by the facility, dated 5/20/16, indicated all residents were assessed by the nurses for signs/symptoms of infections with no new infections noted. Inservice documentation was reviewed that indicated staff in-services regarding hand hygiene had been initiated 5/19/16 and was continuing. The DON said he received [MEDICAL CONDITION] care education and skills check-off by the RN Instructor. The DON was observed performing [MEDICAL CONDITION] care and hand hygiene. Both tasks were performed appropriately by the DON. The ADON and the DON said they received wound care education and skills check off by the RN Instructor. The ADON and DON were observed performing wound care and hand hygiene. Both were able to perform the tasks properly. 6 CNAs were interviewed and said they received inservice training on infectiuon control and handwashing. 4 LVNs were interviewed and said they received inservice training on infectiuon control and handwashing. They said they were to receive [MEDICAL CONDITION] and wound care training prior to performing the tasks for residents. On 5/20/16 at 3:50 p.m., the administrator and DON were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to ensure all in-service training was completed and evaluate the effectiveness of the corrective systems. The CMS 672 dated 5/17/16 indicated 3 residents required [MEDICAL CONDITION] care and 5 residents required respiratory treatments.

Based on observation, interview, and record review, the facility failed to assess, evaluate, and revise pain relief interventions to ensure adequate pain relief for 1 of 3 residents reviewed for pain. (Resident #1) Resident # 1 experienced increased pain in both feet due to pressure sores. The facility did not evaluate and assess their interventions to ensure pain control. The facility did not assess the resident to determine which level of pain medication the resident required. This failure could place 34 residents receiving pain management at risk for unrelieved pain. Findings included: Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1 required extensive assistance with bed mobility and toilet use and was incontinent of bowel and bladder. The resident had minimal problems in the area of mental status and no behavior problems. Resident # 1 had no pressure sores or pain at the time of this assessment. A telephone order dated 4/20/16 indicated Resident #1 was to have [MEDICATION NAME] 325 mg, two tablets every four hours as needed for general discomfort or temperature above 100.5 degrees. Observation of the Medication Administration Record [REDACTED]. A telephone order dated 4/21/16 indicated Resident #1 was to have [MEDICATION NAME] ([MEDICATION NAME]) 20mg/ml, give 0.25-1ml every two hours by mouth or sublingual as needed for pain or shortness of breath. During an observation on 5/2/16 at 9:15 a.m., LVN A and the DON transferred Resident # 1 to his bed. Resident # 1 said his feet were hurting and he asked staff to be careful. He cried out and said he was hurting bad on the end of his feet. After surveyor intervention, LVN A said he would make sure Resident #1 received something for pain before the treatment was continued. During an observation on 5/2/16 at 10:07 a.m., LVN A measured Resident #1's wounds on his heels. When LVN A touched the resident's heels, He cried out in pain, saying it hurts right there. The treatment records dated April 2016 indicated the treatment to Resident #1's heels was done daily. During an observation on 5/2/16 at 9:25 a.m., the bottle of [MEDICATION NAME] for Resident #1 still had the seal in place. LVN B said she had given Resident #1 Tylenol for his pain. She said she had not asked the resident about his level of pain. She went back and asked the resident about his pain. She documented the resident complained of pain at a level of 9 on a scale of 1-10. She administered 0.25ml of [MEDICATION NAME] as ordered. During an interview on 5/2/16 at 11:00 a.m., LVN A said Resident # 1 complained of foot pain when the pressure sores opened up on 4/19/16. He said he complained of pain each time his feet were touched. The most recent weekly skin assessment dated [DATE] indicated Resident #1 had pain associated with the heel pain/pressure sores. During an interview on 5/2/16 at 11:15 a.m., the DON said Resident #1 had the [MEDICATION NAME] available for pain and should have received the [MEDICATION NAME], instead of [MEDICATION NAME]. The CMS 672 dated 4/29/16 indicated 34 residents received pain management.