Every finding on record at Ridgeview Rehabilitation and Skilled Nursing

Based on observation, interviews, and record review, the facility failed to prepare food by methods that conserve nutritive value and flavor for pureed diets for 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to ensure DS B refrained from adding water to spaghetti pureed meals during lunch service on 12/9/2025.This failure could place residents who received a puree diet at risk for diminished or altered nutritional status and potential weight loss.Observation on 12/9/2023 at 11:14 AM revealed DS B poured water into the spaghetti noodles and sauce to assist in achieving the proper puree consistency. Observation on 12/9/2025 at 11:15 AM revealed DS A correcting DS B in her use of water for puree meals and instructed DS B to use broth. DS A was observed checking the consistency of the puree and advised DS B to continue using the food processor to achieve a smoothsmooth consistency. In an interview on 12/9/2025 at 11:16 AM, DS B stated that she returned to the facility several months ago as the cook but worked at the facility for some time prior. DS B stated that she had years of cumulative experience in the kitchen and as a cook in facilities and elsewhere. DS B stated that she had the proper training and education to do her job at the facility. DS B stated that she felt supported by her supervisor and management and received the things she needed to do her job well. DS B stated that her use of water instead of milk, broth, or melted butter was a mistake. DS B stated that she got nervous and grabbed for the water, but realized it was a mistake immediately after she poured it. DS B stated that she never used water for puree dishes. DS B stated that she understood that the use of water removes nutritive value of the food. In an interview on 12/9/2025 at 11:17 AM. DS A stated that she had been promoted to Dietary Supervisor several months ago. She stated that she had years of experience in the kitchen. She stated that she felt she had the training, education and experience needed to effectively do her job. She stated that her employees in the kitchen wereare properly trained and educated in proper kitchen practices as well. She agreed that water should not be used to puree dishes. Instead, DS A suggested broth be used in the dish to achieve the puree consistency, preserve the nutritive value of the food, and preserve the taste of the dish. DS A stated that the kitchen utilizesd puree recipes that should be followed. DS A stated that she does did not feel staff are were not trained on the process. DS A stated that she agreed that DS B acted out of haste and nervousness, but that is not her usual practice. DS A corrected the puree dish and reinforced with DS B the importance of the use of proper liquids. DS A stated that DS B is her lead kitchen personnelpersonnel, and she hads always managed the kitchen well with no concerns noted by DS A or others. In an interview on 12/11/2025 at 4:10 PM, the ADM stated that his expectation regarding pureed foods is that staff will follow recipes and not go from memory. The ADM stated that he had no concerns that kitchen staff lacked proper training or experience in the kitchen to conduct tasks such as pureeing food. The ADM stated that there hadve been no problems noted or reported with pureed foods in the past. The ADM stated that he had no concerns that the use of water in pureed foods negatively impacted the residents. The ADM stated that the only negative aspects of using water to puree food would have beenbe how it affected the taste only. The ADM disagreed that the use of water in puree would reduced the nutritive value of the food. In an interview on 12/11/2025 at 4:10 PM, the CNO stated her expectation regarding pureed foods would have been be that staff would have followed approved recipes. The CNO stated using water to puree foods produced no negative impact other than possibly reducing the salt or seasoning of the dish. The CNO stated that kitchen staff typically used broth or other flavored liquids in the puree process, but DS B got nervous and used water. The CNO stated that wasis not their typical process. The CNO denied the use of water reduced the nutritive value of the food because the dish still containeds all the same main ingredients. Record review of the facility's Pureed Foods Guidelines provided by DS A on 12/11/2025 at 3PM reflected the following in part: To prepare pureed foods: 3. Add appropriate liquid (ex: reserved liquid, broth, juice, milk), if needed, to assist with pureeing. A chart also listed examples of liquid to use for different pureed foods (subject to diet order). Water was not listed. It was also noted that the sauce or gravy used should complement the dish being pureed.

Based on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #5) of 8 residents reviewed for care plans. The facility failed to ensure Resident #5's nutritional status and needs, including orders for a puree diet and orders for thickened liquids, were addressed in the comprehensive care plan.This failure could place the resident at risk of not receiving necessary care or receiving incorrect care and services related to their identified needs to maintain or reach their highest practicable physical, mental, and psychosocial wellbeing.Record review of Resident #5's admission record printed on 12/11/2025 reflected an [AGE] year-old male admitted on [DATE]. Diagnoses included: other acute Osteomyelitis, left ankle and foot (an infection in a bone), memory deficit following cerebral infarction (problems with memory and thinking following a stroke), Dysphagia following cerebral infarction (difficulty swallowing following a stroke), and Dysphagia, Oropharyngeal Phase (difficulty in initiating a swallow leading to challenges in eating and drinking). Record review of Resident #5's comprehensive MDS assessment dated [DATE] reflected a BIMS score of 14 indicating moderate cognitive impairment. Section K indicated signs and symptoms of a possible swallowing disorder, including holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain with swallowing. Section K indicated the resident was on a mechanically altered diet (pureed food, thickened liquids) on admission and while a resident. Section V-Care Area Assessment (CAA) Summary indicated that the Nutritional Status care area was triggered and was addressed in the care plan and that information related to this care area could be found in the diet order. Record review of Resident #5's Physician's Orders reflected an order dated 11/1/2025 which revealed, Regular diet Pureed texture, Nectar consistency. Record review of Resident #5's Physician's Orders reflected an order dated 12/10/2025 which revealed, Speech Therapy to re-eval for possible advance diet. Record review of Resident #5's Care Plan Report on 12/11/2025, reflected no Focus areas, Goals, or Interventions/Tasks related to the resident's nutritional status, including his swallowing disorder and mechanically altered diet. In an observation and interview of Resident #5 on 12/11/2025 at 11:00 AM, Resident #5 stated he was on a puree and thickened liquid diet and had been since admission. Resident #5 stated that he is concerned about his recent weight loss, and he attributed his weight loss to his puree diet solely. Resident #5 stated that he does not care for drinking thickened liquids either. The resident stated that OT had been monitoring his swallowing for the last 2 days prior in hopes in consideration of upgrading the consistency of his diet. The resident stated that a swallow study was being conducted that afternoon at 1 PM. The resident stated that he had no concerns about the care he received in the facility, and his needs were being met. He stated that he is was impressed with the staff of the facility, and he was treated well. He stated that he felt included in his treatment planning and process and was kept up to date with services and treatments provided. In an interview on 12/11/2025 at 11:27 AM, RN C stated that she has had been employed with the facility since April 2025. She stated that resident care was good here and she has had no concerns for the treatment and care of residents. RN C stated that today it was her first time caring for Resident #5, so she was not as familiar with the resident as she was with others. RN C stated that all pertinent care information can be found in the resident's care plan and it was also shared during report at shift change. RN C stated if a resident was on an altered diet and thickened liquids, this that would need to be included in the resident's care plan. RN C said this that it was important to know so that the resident it was not provided with something that could make him choke, such as giving medications with regular water. RN C stated that she had been told during report that Resident #5 was on thickened liquids. RN C stated that she feels felt information in the care plans was usually accurate and comprehensive. RN C stated that she had received orientation, education, and regular in-service to effectively do her job. RN C stated that she feels felt supported by management and staff at the facility. In an interview on 12/11/2025 at 3:47 PM, DON stated that she is was currently the interim DON and has had been since July 2025. Prior to assuming the DON position, she was an ADON at the facility since June 2024. The DON stated the creation and revision of care plans is was a team effort. The DON stated that care plans should reflect the care and needs of the resident based on the assessment and doctor's orders. The DON stated that care plans are not the only source of information available to staff in determining a resident's care and needs, and care plans should not be the only information staff should rely on. In an interview on 12/11/2025 at 3:37 PM, ADON stated that she has been employed with the facility since April 2021. She was previously a floor nurse, wound care nurse, and staffing nurse. She stated when providing clinical care to a resident, the entire clinical picture and documents were considered. She stated that a care plan that doesn't completely address a resident's condition or physician's orders doesn't necessarily mean the resident's needs were not addressed or met. The ADON confirmed that Resident #5's diet and supplements were not care planned and should have been. The ADON stated it is important that care plans are were accurate and inclusive of all care needs to make sure the residents get got all the care necessary to meet their needs. The ADON stated there would have been no negative impact on the resident if their care plan was not complete and accurate because that it was not the only source of information available to staff. The ADON stated that staff are were not to solely rely on care plans to get the full clinical picture of the residents. In an interview with the CNO on 12/11/2025 at 4:10 PM, the CNO stated that care plans are considered living documents and should accurately reflect the resident's clinical picture; but care plans aren't the only source of information that staff rely on to provide for the needs of the residents. The CNO stated that her expectation would be that care plans are all inclusive In an interview with the ADM on 12/11/2025 at 4:10 PM, the ADM stated that their MDS Coordinators were responsible for ensuring the correct information it was included in residents' care plans. The ADM stated that it was his expectation that care plans would accurately reflected residents' care needs. ADM agreed that care plans aren't the only source of information that staff relied on to provide for the needs of residents, therefore, there was limited negative impact on the residents. Record review of the facility's policy regarding Care Plans, Comprehensive Person Centered, Revised December 2016, reflected, 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. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being; .g Incorporate identified problem areas.h. Incorporate risk factors associated with identified problems.

Based on observation, interviews and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 8 residents (Resident #2) reviewed for accuracy of assessments.The facility failed to ensure Resident #2's MDS assessment dated [DATE] was accurately coded for the use and indication of high-risk medications, specifically an antiplatelet medication.This failure could place residents at risk of not receiving the appropriate care, treatment, and services due to inaccurate assessments.Record review of Resident #2's admission record printed on 12/11/2025, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Hypotension (low blood pressure), dehydration (lost fluids not being replaced), weakness, memory deficit following Cerebral Infarction (problems with memory and thinking after a stroke), and other Cerebral Infarction due to Occlusion or Stenosis of Small Artery (type of stroke caused by blockage of the small arteries in the brain). Record review of Resident #2's physician's orders reflected an order dated 11/25/2025 to monitor anticoagulant (blood thinner) medication, but no anticoagulant medication was ordered. However, review of the physician's orders reflected an order for Clopidogrel (Plavix), an antiplatelet medication (medications that prevent blood clots) instead. Record review of Resident #2's MDS assessment dated [DATE] reflected a BIMS of 11 indicating moderate cognitive impairment. In Section N-Medications, N0415 High Risk Drug Classes, the assessment reflected use and indication of anticoagulant medication, but no use or indication of antiplatelet medication. Record review of Resident #2's Care Plan Report initiated on 11/25/2025, and printed on 12/11/2025, reflected the Problem: [Resident #2] is on anticoagulant therapy r/t Disease process HX of CVA It reflected The Goal: The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. It also reflected Interventions: Administer ANTICOAGULANT medications as ordered by the physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN adverse reactions of ANTICOAGULANT therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s. Observation and interview of Resident #2 on 12/9/2025 at 2:13 PM, revealed the resident to be clean and comfortable with no distress noted. The resident expressed no concerns, and no obvious concerns were noted. In an interview with DON on 12/11/2025 at 3:47 PM, DON stated that she could not speak on MDS assessments and referred the surveyor to the MDS Coordinators. In an interview with ADON on 12/11/2025 at 3:47 PM, ADON stated that she was not comfortable speaking on the process of conducting and coding MDS assessments and deferred to the MDS Coordinators. In an interview on 12/11/2025 at 4:01 PM, MDS A stated that she had been employed as an MDS Coordinator with the facility for 1 year. Prior to her employment with the facility, she was employed with a sister facility as an MDS Coordinator. MDS A stated that she had eighteen years of experience with the MDS process. MDS A stated that the MDS should accurately reflect the resident's needs, including proper classification of medications the resident was taking. MDS A stated that the use of antiplatelet medications should be indicated on the MDS if ordered. MDS A stated that the MDS should not reflect the use of an anticoagulant medication if one was not used or ordered. MDS A stated that she coded Resident #2's MDS incorrectly and that was an oversight on her part, not her regular practice. MDS A stated that she consulted the RAI manual if she had questions and for updated information. MDS A stated that she also utilized co-workers with knowledge and experience with the MDS process. MDS A stated that a possible negative outcome from miscoding MDS assessments would was that the OIG would discover the mistake and reduce reimbursements for services. MDS A stated in this case, no real harm came of the mistake because the outcomes are the same for both anticoagulant and antiplatelet medications. MDS A stated that a correction of Resident #2's MDS would be initiated by her immediately. MDS A stated that she had been trained and educated on the MDS process and regularly received in-service and ongoing training as updates were available. MDS A stated that she felt supported by management and other staff in her role. In an interview on 12/11/2025 at 4:01 PM, MDS B stated that she had been employed with this the facility since February 2025. MDS B stated that she had 10 years of experience with the MDS assessment process. MDS B stated that the MDS should accurately reflect the resident's needs, including proper classification of medications the resident was taking. MDS B stated that the use of antiplatelet medications should have been indicated on the MDS if ordered. MDS B stated that the MDS should not have reflected the use of an anticoagulant medication if one is was not used or ordered. MDS B stated they utilized ZPAX (an auditing software) to check the accuracy of their assessment submissions. This system alerted if something was possibly miscoded. Also, MDS B stated that they utilized other staff and the RAI manual when questions arise arose regarding the MDS process. MDS B stated that she had received proper education and training on the MDS process and felt supported by management and staff. In an interview on 12/11/2025 at 4:10 PM, CNO stated that MDS Coordinators received regular training and updates on the MDS process, and they utilized software that assisted in auditing the accuracy of MDS entries. The CNO also stated that MDS Coordinators had access to a staff member who was is considered a person of advanced knowledge regarding the MDS process. The staff member also audited submissions to ensure accuracy of MDS assessments. The CNO deferred to the MDS Coordinators for specific impact and outcomes this type of error may have had on residents. In an interview on 12/11/2025 at 4:10 PM, ADM stated MDS Coordinators were responsible for correct coding and data entry. ADM stated that miscoded assessments could have had an impact on how care needs are were reflected in residents' care plans. The ADM deferred to MDS Coordinators regarding specific MDS process related questions. Record review of the facility's policy on Comprehensive Assessments, Revised March 2022, reflected, Comprehensive assessments are conducted to assist in developing person-centered care plans. 1. Comprehensive assessments are conducted in accordance with criteria and timeframes established in theResident Assessment Instrument (RAI) User Manual.10. Comprehensive assessments are conducted and coordinated by a registered nurse with appropriateparticipation of other health professionals on the interdisciplinary team. Record review of the Long-Term Care Facility RAI 3.0 User's Manual last revised October 2024 reflected, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that: (1) the assessment accurately reflects the resident's status

Based on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 1 of 5 residents (Resident #49) reviewed for resident rights.The facility failed to ensure Resident's #49's call light was within reach on 12/09/25.This failure could place residents at risk of needs not being met. Findings included: Record Review of Resident #49's face sheet dated 12/11/25 reflected the resident was a [AGE] year-old female admitted on [DATE]. Her diagnoses included Alzheimer's disease (a neurodegenerative disease that usually starts slowly and progressively worsens), anxiety (intense, excessive, and persistent worry and fear about everyday situations), insomnia (a common sleep disorder marked by persistent difficulty falling asleep, staying asleep, or getting quality rest, leading to daytime fatigue, irritability, poor concentration, and mood issues, and it can be short-term (acute, from stress) or long-term (chronic, lasting months), and peripheral vascular disease, also known as peripheral artery disease (a condition that occurs when blood vessels narrow or become blocked, reducing blood flow to the body. Peripheral vascular disease can affect any blood vessel outside of the heart, but it most commonly affects the legs and feet).Record Review of Resident #49's Quarterly MDS assessment dated [DATE] reflected Resident #49 was dependent on staff for showering, toileting, and personal hygiene and required partial/moderate assistance for eating. The MDS reflected Resident #49 had a BIMS score of 01 which indicated Resident #49 was severely cognitively impaired.Record review of Resident #49's care plan dated 04/23/24 and revised on 09/18/24 reflected: Resident was at risk for falls due to limited mobility, poor cognition & poor safety awareness. Goal: Resident #49 would be free of falls through the review date. [Resident #49] would not sustain serious injury through the review date.Interventions included: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.In an observation and interview on 12/09/25 at 2:27 PM Resident #49 was in bed asleep, slightly awakened to name call, and mumbled yes when asked if she was ok. Resident #49 was not showing any signs of pain or distress and appeared to be clean and groomed. The room was clean, and no foul odors were noticed. The resident's call light was not within her reach and was lying with cord going under the nightstand and cord continued over to the side of nightstand away from resident. Resident did not wake up enough to follow directions or attempt to demonstrate if she could have reached the call light. In an interview on 12/09/25 at 2:36 PM with CNA F, he stated in the location where Resident #49's call light was placed, she would not have been able to reach it. He stated he believed the call light had fallen off the bed. He stated he had been trained on call light's being placed within resident's reach at all times. He stated if a resident's call light was not within their reach, resident may have tried to reach for the call light and fell, or the resident could have had an emergency and not have been able to call for help. In an interview on 12/09/25 at 2:44 PM with RN B, she stated all residents' call lights should have been within reach at all times. She stated she had been trained on residents' call light being within their reach at all times. She stated if a resident's call light was not in their reach it could have caused a resident to fall. In an interview on 12/11/25 at 10:18 AM, the DON stated it was her expectation that all residents' call lights be within the resident's reach at all times. She stated all staff had been trained on residents' call lights being within reach at all times. She stated if a resident's call light was not within their reach, their needs may not be met in a timely manner.In an interview on 12/11/25 at 10:27 AM, the CNO stated it was her expectation that all residents call lights be within the resident's s reach at all times. She stated all staff had been trained on residents' call lights being within reach at all times. She stated if a resident's call light was not within their reach, there could be an increased risk of falls.In an interview on 12/11/25 at 10:44 AM, the ADM stated it was his expectation that all residents' call lights be within the residents reach at all times. He stated all staff had been trained on residents' call lights being within reach at all times. He stated if a resident's call light was not within their reach, they wouldn't be able to alert or request needed items.Record review of facility policy titled Answering the Call Light and dated 2001 (revised September 2022) reflected Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines: 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 of 1 medication storage room reviewed for drug storage. The facility failed to ensure expired lab supplies and needles used for biologicals were removed from the medication storage room. This failure could place residents at risk for inaccurate diagnoses from defective labs, ineffective treatments and unnecessary infections.Findings include: Observation on [DATE] at 2:58 PM of the Medication Storage room revealed: 5 Culture Swabs expired [DATE] 2 Blue Top Lab Tubes expired [DATE] 1 Lab Transport Tube expired [DATE] 4 Gold Top Lab Tubes expired [DATE] 4 Red Top Lab Tubes expired [DATE] 10 Precision Glide Needles expired [DATE] In an interview on [DATE] at 9:33 AM RN A stated the policy for expired medication supplies was to get rid of them. She stated that it was important not to use expired supplies for treatments and medications because it may not be safe. She stated if expired lab tubes, lab swabs, or needles were accidentally used, the residents could have inaccurate lab results and that could cause a wrong diagnosis and wrong medications for their condition. In an interview on [DATE] at 9:50 AM LVN D stated the policy for expired medication supplies was to let the DON know so she could discard them. She stated it was important not to use expired supplies for treatments and medications because the potency may not be good, and it may not work correctly. She stated if expired lab tubes, lab swabs, or needles were accidentally used, the resident could have a false positive or false elevated lab. She stated that if labs were incorrect, that could cause the doctor to treat the resident for something they do not have or not to treat for something they did have, and they could get septic (severe infection). In an interview on [DATE] at 9:58 AM CNA E stated the policy for expired supplies was to get rid of them and make sure they were taken out of circulation. She stated it was important not to use expired supplies because they may not be effective. In an interview on [DATE] at 10:10 AM MA G stated, the policy for expired medication supplies was to report and remove them. She stated it was important to not use expired supplies for treatments and medications because they may not be good anymore. She stated, if expired lab tubes, lab swabs, or needles were accidentally used, the resident could get contaminated which could result in an infection. In an interview on [DATE] at 10:28 AM the CNO stated the policy for expired medication supplies was to remove them from the pharmacy to destroy and medical supplies were thrown out. She stated it was important not to use expired supplies for treatments and medications because they could be faulty. She stated if expired lab tubes, lab swabs, or needles were accidentally used, the resident could get inaccurate lab results. She stated inaccurate lab results could cause the doctor to miss elevated lab results and result in incorrect treatments. She stated an example was if they missed elevated [NAME] Blood Cells they would not be able to treat and start antibiotics timely. Record Review of the facility Medication Labeling and Storage policy dated 2001 and revised 2023 reflected: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has outdated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observations, interviews, and record review, the facility failed to notify residents on how to file a grievance in an anonymous manner, and the contact information of the Grievance Official for 4 confidential residents out of 4 residents interviewed for grievances. 1.The facility failed to notify Residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. 2.The facility failed to communicate to the residents who the facility identified as the Grievance Official. These failures could affect resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to request a written decision regarding the resolution of their grievance.Observation on 08/30/2025 at 3:31 PM of a sign posted on a wall near the activities room titled, Social Services Policies and Procedures Complaints/Grievances Process revealed: Grievances/Complaints are accepted by the following, but not limited to:A. AdministratorB. Department manager or his/her designeeC. SupervisorD. Unit manager3. The receiver of the grievance/complaint instructs the complainant to complete appropriate sections of the Complaint/Grievance Report. If the complainant is unable to complete these sections, the social worker/designee is contacted to provide assistance m documenting the grievance/complaint issue.There were no blank grievance forms observed near the posting or anywhere in the facility where residents or their representatives could obtain a grievance form and/or turn in grievance forms anonymously. A Grievance Official and their contact information was also not indicated on the posting. In confidential interviews on 08/30/2025 between 2:00 PM - 3:45 PM with four residents who were members of and not members of Resident Counsel revealed that the residents did not know how to file grievances anonymously due to having to obtain grievance forms from department heads and the forms were in those respective staff offices. They stated there was not a place to obtain blank grievance forms by themselves or during weekends/holidays when department heads may not be available. The residents stated that they did not know they had the right to file grievances/complaints anonymously, or who the designated grievance official was. They also stated that if they had a grievance about a specific staff member, they would not want to have to turn the grievance into that person but would rather there be a way to discreetly turn it in so that the staff member would not know about it. In an interview on 08/30/2025 at 2:15 PM with the AD she stated she had worked at the facility for 3 years, and that residents were to file grievances with the ADM. She stated that if a resident came to her wanting to file a grievance, she would go get a grievance form from the ADM, fill it out, then give it back to the ADM. She stated she was not aware of a grievance box or a place in the facility where residents could turn in anonymous grievances. She stated the staff would slip the completed grievance form under the ADM's door if he was not at the facility. She stated during resident council, they would read off resident rights before the start of the meetings. She stated she had never thought of how a resident could fill out a grievance privately if it all went through the ADM. In an interview on 08/30/2025 at 2:20 PM with the SW, she stated that sometimes residents would go to her to make a grievance, where she would write it out for them. She stated residents must physically obtain the form from her and she would help them fill it out. She stated that residents could slip the completed grievance forms under her door if they chose to fill it out themselves, and that there was no box for residents to access for anonymous grievances. She said that if a grievance was turned into her, she would give it to the appropriate department head and the yellow copy (attached to the back) was turned into the ADM. In an interview on 08/30/2025 with the DON and ADM at 2:25 PM when asked where residents could obtain grievance forms from, they stated that the residents could ask any department head for a grievance form, or they could ask the resident council president who would obtain the form on behalf of the resident requesting one. They stated that all managers had the forms in their offices. They stated that they have never had a discreet place for the residents to obtain grievance forms from or turn them into, and the grievances had to be turned into a department head. The DON stated that the ADM was the grievance official.Review of the facility's policy titled; Grievances/Notification of Grievance Policies/Grievance Procedures dated September 2024 revealed that: 3. The facility will notify patients and their representative orally or through postings around the facility in prominent locations on; B. Who the facility grievance official is and their contact information.D. Their right to file a grievance in an anonymous mannerE. How to file an anonymous grievanceReview of the facility's policy titled; Resident Rights dated December 2016 revealed that: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:t. privacy and confidentialityu. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal;

Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Residents #1, #2, #3, and #4) of 7 residents reviewed for comprehensive care plans. The facility failed to care plan the use of Residents #1, #2, #3, and #4's urinary catheters. This failure placed residents that had urinary catheters at risk of not having their need for assistance met and increased susceptibility to UTI's. The findings included: Review of Resident #1's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included stroke (poor blood flow to part of the brain causing cell death), high blood pressure, diabetes, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #1's initial care plan dated 04/23/2025 reflected no indication the resident had an indwelling catheter. In an observation on 05/16/2025 at 9:37 AM, Resident #1 was wheeling down the hallway with her urinary catheter bag clipped to the side of her wheelchair and approximately 1/4 of the way full of bright yellow urine. In an interview on 05/16/2025 at 9:45 AM with Resident #1, she stated that she almost never had a privacy cover on her catheter bag, and that it just hung off the side of her wheelchair for anyone to see. Review of Resident #2's closed record comprehensive MDS assessment dated [DATE] reflected an-[AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included heart failure, high blood pressure, obstructive uropathy (a blockage that prevents urine from flowing naturally through the urinary system), hyperlipidemia (high levels of fats in the blood), osteoporosis (bones disease), aphasia (impairment in speech production, comprehension, reading and/or writing), non-Alzheimer's dementia (memory impairment), depression (sadness), and encounter for surgical aftercare following surgery on the digestive system. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #2's care plan date closed on 05/09/2025 due to discharge reflected no indication the resident had an indwelling catheter. Review of Resident #2's physician's orders revealed no orders for a Foley catheter or catheter care. Review of Resident #2's hospital record dated 04/07/2025 reflected, Patient placed on Foley catheter by urology, plan to DC with Foley catheter and follow-up with urology. Hydronephrosis (a condition where a kidney swells due to urine buildup caused by an obstruction) significant improvement of right hydronephrosis after manual reduction. -Foley catheter. Renal Function okay. Follow-up with urology. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included heart failure, high blood pressure, urinary tract infection, diabetes, depression, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having none of the above when asked if the resident had an indwelling catheter, external catheter, ostomy, or intermittent catheterization. Review of Resident #3's care plan last revised 05/14/2025 reflected no indication that the resident had an indwelling catheter or intermittent catheterization. Review of Resident #3's physician's orders revealed an order for Foley Catheter Care every shift, ordered 3/19/25. An order for Indwelling Foley catheter (16F 30cc) to continuous drainage, ordered 3/19/25. An order for Secure catheter tubing with anchor every shift, ordered 3/19/25. An order for Change the Foley catheter every 30 days, ordered 3/19/25. In an observation and interview on 05/16/2025 at 3:00PM of Resident #3 in her room revealed she thought her catheter was coming out and that the bag needed to be changed because it felt full. Observation of her bag hanging on the side furthest from the door revealed an almost full plastic container in front of an almost empty catheter bag that was not inside of a privacy bag. Review of Resident #4's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included high blood pressure, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #4's care plan last revised 04/29/2025 reflected no indication that the resident had an indwelling catheter. In an interview on 05/16/2025 at 10:33 AM with CNA B she stated that she recalled Resident #2 often yanking on her catheter, asking why she had it, and demanding it be removed from her body. She stated that the importance of having a privacy cover on the catheter bag is so other residents don't see the urine. In an interview on 05/16/2025 at 2:00 PM with the MDSC, she stated that Resident #3's MDS assessment would be updated to reflect a catheter during her next assessment unless she had a significant change before then, and that becoming catheterized did not call for an SCSA. She stated that the resident previously had a catheter, had it removed, had it replaced at another time, and it was failed to be care planned during the most recent insertion. As for the other residents, she stated that she could not provide an answer as she maintained the long-term residents' assessments, and the short term MDSC was out of office for an extended period. In an interview on 05/16/2025 at 3:46 PM with LVN A, she stated that she knew to provide catheter care to Resident #2 because she could see the resident had a catheter. She recalled that the resident would frequently ask for the catheter to be removed and asked the staff why she had it. She stated that she knew what hygienic care to provide because with any resident that has a Foley, they are to provide a standard practice of cleanliness and hygiene when providing incontinent care, including cleaning the pubic area and the tubing surrounding the outside of the pubic area. She stated that she can recall multiple times providing incontinent care to Resident #2 and they also began the toileting program with her. Review of the facility's Care Plans, Comprehensive Person-Centered dated last revised 03/2022 reflected, . The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received treatment and services for 1 of 5 residents (Resident's #1, #2, and #3) reviewed for indwelling urinary catheters. 1. The facility failed to have a physician's order for Resident #2's urinary catheter. 2. The facility failed to ensure Resident #1, Resident #2, and Resident #3's urinary catheter bags were inside a privacy cover while inside and outside of their rooms. This deficient practice could affect any resident with an indwelling urinary catheter and place them at risk of increased UTI's, discomfort, and decreased quality of life. The findings included: Review of Resident #1's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included stroke (poor blood flow to part of the brain causing cell death), high blood pressure, diabetes, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. In an observation on 05/16/2025 at 9:37 AM, Resident #1 was wheeling down the hallway with her urinary catheter bag clipped to the side of her wheelchair and approximately 1/4 of the way full of bright yellow urine. In an interview on 05/16/2025 at 9:45 AM with Resident #1, she stated that she almost never had a privacy cover on her catheter bag, and that it just hung off the side of her wheelchair for anyone to see. In an interview on 05/16/2025 at 10:52 AM with Resident #1's FM, they stated that Resident #1's catheter bag was not usually covered with a privacy bag when they visited the resident. The FM stated that they visited almost daily and that on (5/16/25) was the first time a CNA went in and put a privacy bag over the Resident's catheter bag. Review of Resident #2's closed record comprehensive MDS assessment dated [DATE] reflected an-[AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included heart failure, high blood pressure, obstructive uropathy (a blockage that prevents urine from flowing naturally through the urinary system), hyperlipidemia (high levels of fats in the blood), osteoporosis (bones disease), aphasia (impairment in speech production, comprehension, reading and/or writing), non-Alzheimer's dementia (memory impairment), depression (sadness), and encounter for surgical aftercare following surgery on the digestive system. In Section H - Bladder and Bowel, the resident was marked as having an indwelling catheter. Review of Resident #2's care plan dated closed on 05/09/2025 due to discharge reflected no indication the resident had an indwelling catheter. Review of Resident #2's physician's orders dated active as of 4/11/2025 reflected no orders for an indwelling urinary catheter. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included heart failure, high blood pressure, urinary tract infection, diabetes, depression, hyperlipidemia (high levels of fats in the blood), and encounter for other specified aftercare. In an observation and interview on 05/16/2025 at 3:00 PM of Resident #3 in her room revealed she thought her catheter was coming out and that the bag needed to be changed because it felt full. Observation of her bag hanging on the side furthest from the door revealed an almost full plastic container in front of an almost empty catheter bag that was not inside of a privacy bag. In an interview on 05/16/2025 at 10:33 AM with CNA B she stated that the importance of having a privacy cover on the catheter bag is so other residents don't see the urine. In an interview on 05/16/2025 at 11:30 AM with the DON, she confirmed that the orders for Resident #2's Foley catheter could not be located in the EHR. Additionally, it was confirmed that she was not care planned for a Foley catheter. She stated that she could not understand why the orders were not showing up nor why the care plan would not be showing catheter care, because 'How else would MDS know to mark it?' Regarding catheters having a privacy bag, she stated that those were just there for residents' dignity and that any of the direct care staff can put a privacy cover over a catheter bag. Review of the facility's Catheter Care policy last reviewed December 2023 reflected, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.

Based on observations, interviews, and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one (Resident # 21) of eight residents reviewed for PASRR services. The facility failed to refer Resident #21 for a PASRR level II evaluation to the State-designated authority. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: Record review of Resident #21's face sheet, dated 09/18/24, reflected the resident had a primary diagnosis of chronic obstructive pulmonary disease (common lung disease that makes it difficult to breathe) and other diagnoses were listed as dementia, schizoaffective disorder, bipolar disease. Record review of Resident #21's quarterly MDS Assessment, dated 07/03/24, revealed she was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia, schizophrenia, and bipolar disorder. Resident #21's BIMs score of 15 indicated the resident's cognition was intact and she was able to make decisions for herself. Record review of Resident #21's PASRR Level I screening, dated 03/27/23, reflected the resident did not have a history of mental illness. Record review of Resident #21's Form 1012, Mental Illness/Dementia Resident Review , dated 01/24/20, reflected the resident had a primary diagnosis of dementia. An observation and interview on 09/17/24 at 10:50 AM with Resident #21 revealed she was lying in bed. She was awake, alert, and oriented. She said she did not receive PASRR services and she did not know what PASRR was. An interview on 09/18/24 at 9:53 AM with MDS Nurse B revealed she had worked at the facility since 2008. She said Resident #21 did not have a PASRR Level II screening. She said the PASRR Level 1 screening reflected the resident did not have mental illness. MDS Nurse B said instead of completing a new PASSR Level 1 screening, she filled out a form 1012. She said she did not know she had to do a new PASSR Level 1 screening if the first one was incorrect. She said the form 1012 was a paper form that was not sent to the mental health authority and she did not think that it needed to be sent to them. She said she was the only person in the facility who completed PASRR forms. She said there was a risk that the resident could miss services she was entitled to if the PASRR forms were not filled out correctly. An interview on 09/18/24 at 12:52 PM with the DON revealed she had worked at the facility for the last 6 years. She said MDS Nurse B was responsible for completing PASRR forms and the DON did not oversee the work that she did. The DON said she did not know a whole lot about PASRR. She said she did not know what the PASRR policy said until 09/18/24. An interview on 09/19/24 at 2:24 PM with the Administrator revealed MDS Nurse B was responsible for ensuring PASRR assessments were correct. He said there was no one in the facility who reviewed the work of MDS Nurse B. Record review of the facility policy PASSR Policy and Procedure revised January 2024, reflected: Policy It is the policy of our company to ensure that all PASRR requirements are followed as set forth and regulated by The Texas Department of Health and Human Services and Centers for Medicaid and Medicare Services.

37028 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #19 and Resident #22) out of 8 residents reviewed for care plans. The facility failed to ensure that Resident #19's comprehensive care plan included her diagnosis of pain. The facility failed to ensure that Resident #22's Care Plan was updated to reflect that he no longer had an indwelling catheter. This failure could place residents at risk of having received inadequate interventions not individualized to their care needs and diagnoses. Findings Included: 1.) Record Review of Resident #19's quarterly MDS assessment dated [DATE], revealed she was an [AGE] year-old male who admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (disease of the lungs that makes it difficult to breathe). The resident was receiving scheduled and as needed pain medication. Resident #19 had a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #19's Order Summary Report, dated 09/18/24, reflected: 1. 07/11/23 Biofreeze external gel 4 % (Topical pain medicine). Apply to mid back topically every 8 hours as needed for pain. 2. 04/16/24 Lidocaine external kit 4 % (Topical pain medicine). Apply to both shoulders topically in the morning for right shoulder pain and remove per schedule. 3. 05/20/24 Lidocaine external patch 4 % (Topical pain medicine). Apply to right foot topically as needed for pain. 4. 07/11/23 Mobic oral tablet 15 milligrams (pain medicine). Give 1 tablet by mouth at bedtime for pain. 5. 03/14/24 Tizanidine HCl oral tablet 2 milligrams (pain medicine.) Give 1 tablet by mouth two times a day for pain/muscle spasms. 6. 03/21/24 Tramadol HCl oral tablet 50 milligrams (pain medicine). Give 1 tablet by mouth two times a day for pain. An observation and interview with Resident #19 on 09/17/24 at 12:55 PM revealed she was lying in bed. She said she suffered with chronic pain and took scheduled pain medication. Record Review of Resident #19's comprehensive care plan, no date reflected, reflected she did not have a care plan for pain. An interview on 09/19/24 at 1:55 PM with MDS Nurse D revealed she did not know why Resident #19 did not have a care plan for pain. She said she and the managers were responsible for creating care plans. She said there was a risk to the resident of having increased pain if she did not have a care plan for pain. An interview on 09/18/24 at 4:12 PM with the DON revealed she did not know why Resident #19 did not have a care plan for pain. She said MDS Nurse D was responsible for creating the care plan. The DON said care plans were important because they directed care. 2.) Review of the Resident Face Sheet dated 09/19/24 revealed Resident #22 was an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #22's active diagnoses include: dysphagia (difficulty swallowing), acute cough, allergies, type 2 diabetes mellitus with diabetic polyneuropathy (a complication of diabetes that causes nerve damage in the hands, legs, feet, and arms), chronic obstructive pulmonary disease (ongoing lung condition caused by damaged lungs), acute and chronic respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing low levels of oxygen in the bloody tissues), mood disturbance, psychotic disturbance, dementia, heart failure, heart disease, cataract (a cloudy area in the eye), acute kidney failure, hypokalemia (occurs when the amount of potassium in the blood was low), pulmonary fibrosis (scarring and thickening of the tissue around in the lung between the air sacs), vitamin b deficiency, other retention of urine, abnormalities of gait and mobility, and falls. Review of the Admission MDS assessment dated [DATE] revealed Resident #22's cognition was moderately impaired. Resident #22 required limited assistance with the support of one staff for bed mobility and extensive assistance with the support of one staff for transfers. Resident #22 used a wheelchair for mobility. Resident #22 had an indwelling catheter (including suprapubic catheter and nephrostomy tube - a thin, flexible tube that drains urine directly from the kidney into a bag outside the body). Review of the Care Plan dated 01/12/18 revealed Resident #22 had an indwelling Foley catheter: Neurogenic bladder. Date Initiated: 11/16/2023 Revision on: 05/28/2024 Resident #22's Goal: Resident #22 will be/remain free from catheter-related trauma through review date. Date Initiated: 05/28/2024 Target Date: 05/21/2024 Resident #22's Interventions: Catheter: The resident has 16F 30cc balloon foley catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Date Initiated: 11/16/2023 Revision on: 05/28/2024 Monitor/document for pain/discomfort due to catheter. Date Initiated: 11/16/2023 Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date Initiated: 11/16/2023 Record review of Resident #22's Physician's Order for 06/05/2024 stated, May replace foley catheter for leaking every 24 hours as needed for leaking. Record review of Resident #22's Progress Notes for 08/20/2024 written by LVN G reflected, Nurse talk to Hospice nurse. Regarding catheter reinsertion. Nurse informed her that resident didn't tolerated reinsertion attempt well, even though he was premedicated with Morphine. [Staff] informed nurse that Resident #22's family member was fine with resident remaining in brief for the night and she would come out to attempt reinsertion on 8/21/2024 in am. If reinsertion isn't possible hospice would send him to ER for reinsertion. Record review of Resident #22's Progress Notes for 08/20/2024 written by LVN H revealed, This nurse notifed residents hospice nurse when returned phone call of residents [NAME] on penis from catheter being possible pulled out. This nurse explained to hospice nurse of [NAME] and blood and that the penis was torn. This nurse also explained when trying to insert another catheter resident grimcing in pain. Hospice nurse asked if this nurse could try again to insert another catheter. At 07:00, Nurse was notified by aide that resident was up and walking and catheter on floor. When tried to replace catheter with a new one, resident had no urine returne, small spots of blood. This nurse stopped the catheter insurtion and notified DON and notified hospice . [sic] Record review of Resident #22's Progress Notes for 08/21/24 - 09/05/2024 reflected the resident did not have a catheter. During an observation of Resident #22 on 09/19/24 at 12:55 PM revealed he was sitting on his bed and eating lunch. Resident #22 was observed without a catheter. In an interview on 09/19/2024 at 12:59 PM, Resident #22 stated that he no longer had a catheter. Resident #22 stated that he currently wore underwear, and he no longer needed a catheter. Resident #22 stated that he had some issues with his catheter, and it was causing some pain. He stated that he did not know what kind of issues he was having with his catheter, but it was causing him pain, therefore the staff decided to remove the catheter. In an interview on 09/19/24 at 1:07 PM with CNA F, she confirmed that Resident #22 no longer had an indwelling catheter. She reported approximately 2 months ago Resident #22 had an indwelling catheter and he was getting up from his bed and held onto his wheelchair and he used his bedside table for support and his indwelling catheter ripped out. She stated that staff at the facility attempted a few times to reinsert Resident #22's indwelling catheter but were unsuccessful. CNA F stated that Resident #22's hospice nurse was contacted and stated that she would try to reinsert Resident #22's indwelling catheter and if unsuccessful, she would have Resident #22 sent to the emergency room at the hospital to have his indwelling catheter reinserted. CNA F stated that Resident #22's incontinence hadimproved, and he no longer needed his indwelling catheter, and she did not remember how long Resident #22 had been without his indwelling catheter. She stated that she was unaware that Resident #22's Care Plan and MDS Assessment reflected him still having the indwelling catheter. CNA F stated that the risk the facility's medical records being improperly coded on Resident #22's Care Plan , which reflected that he currently had an indwelling catheter could be a form of neglect. She further stated that if someone was to review Resident #22's Care Plan in PCC (a cloud-based healthcare software provider for long-term and post-acute care) to inquire about his incontinence and the system said that he had an indwelling catheter, it could lead to him having infections. In an interview on 09/19/24 at 1:21 PM with the DON, she stated that Resident #22 had a medical diagnosis of neurogenic bladder, which was a urinary condition that lacked bladder control due to a brain, spinal cord or nerve problem. The DON reported that Resident #22 was on hospice and that he had an incident (unknown timeframe) in which his catheter was accidently ripped out by the resident. She stated that the staff attempted to replace Resident #22's catheter but were unsuccessful and his hospice nurse was notified. She reported that after the incident Resident #22 was wearing briefs and had been without his catheter for 3-4 days and the staff were excited. She stated that Resident #22 was doing well with his incontinence, therefore his hospice provider decided to remove his physician order for the catheter. She stated that the MDS Nurses are responsible for the revisions of residents Care Plan. She stated that she was unaware that Resident #22's Care Plan was not updated. She stated that she did not feel as though there were any risk or harm that could have been done with Resident #22's Care Plan reflecting that he had a catheter. She stated that it would not hurt him and there would be more hurt to Resident #22 if he needed or required a catheter and did not have one. In an interview on 09/19/24 at 1:56 PM, MDS Nurse D, she stated that she was responsible for managing resident Care Plans. She stated that the management at the facility have weekly meetings on Mondays and sometimes Thursdays to discuss the changes that needed to be made, if any to residents Care Plans. She stated that Care Plan meetings were conducted at the facility to ensure that residents Care Plans were accurate or needed to be changed. MDS Nurse D stated that she was unsure when the Care Plan meetings are conducted at the facility, but she knew that they were done. MDS Nurse D stated that she was unaware that Resident #22's Care Plan reflected that he still had a catheter. She stated that she was responsible for documenting the discontinuation of the catheter on Resident #22's Care Plan. She stated that a risk of Resident #22's Care Plan not being properly documented to reflect that he no longer had a catheter would be that he could be overlooked for incontinence checks. She stated that the error on Resident #22's Care Plan could possibly cause harm due to skin breakdown if the staff did not regularly check on him because they thought he had a catheter. In an interview on 09/19/2024 at 2:24 PM, the Administrator stated that he had 2 MDS Nurses (MDS Nurse B and MDS Nurse D) that were responsible for inputting and revising the residents' adjustments made to the Care Plan. The Administrator stated that MDS Nurse B was responsible for the revisions of the residents Care Plan for residents who were at the facility for short term. He stated that MDS Nurse D was responsible for the revisions of the residents Care Plan and for residents who were at the facility for long term, including Resident #22. He stated that there were not a person that oversees the MDS Nurses work, but the facility had QRM a company that helps them oversee the duties that the MDS Nurses perform. He stated that the facility reviewed the recommendations and changes in QA and LOC meeting in which management reviewed things that they covered and caught in the meetings, which could include the oversights from QRM. He stated that both MDS Nurses looked over each other's work to cover themselves. The Administrator stated that he was unaware that Resident #22's Care Plan were not updated to reflect that he no longer had a catheter. He stated that he did not feel as though there were any risks or harm to Resident #22 due to his Care Plan not being updated to reflect that he no longer had a catheter. He confirmed that Resident #22's Care Plan should have been updated to reflect the changes for Resident #22 no longer having a catheter. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered Care Plans, dated March 2022 revealed the following elements: Policy Statement: 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. Policy Interpretation and Implementation: 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. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency and duration of care; g. receive the services and/or items included in the plan of care; and h. see the care plan and sign it after significant changes are made. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma-informed. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 13. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 8 residents (Resident #4) reviewed for quality of care. The facility failed to ensure Resident #4 was not misdiagnosed with schizoaffective disorder. This failure could place residents at a risk of being misdiagnosed and receiving incorrect treatment. Findings included: Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old-female admitted to the facility on [DATE]. The resident had a BIMS score of 3 indicating severe cognitive impairment. The resident's diagnoses included hip fracture, non-Alzheimer's dementia, and schizophrenia. Record review of Resident #4's comprehensive care plan, dated 07/19/24, reflected: Resident uses psychotropic medications related to behavior management, schizoaffective/bipolar type, and dementia with psychotic disturbance. Record review of Resident #4's History and Physical, dated 04/05/24, and completed by Physician E reflected: Patient seen and examined in bed with family present. Per the patient's family, she has had short-term memory issues for the past few months that have been markedly worse since anesthesia following her knee operation. She was given Geodon and Ativan at the hospital and became psychotic. She has a history of poor reaction to these medications in the past. We discussed the need to discontinue Seroquel. Family says that she has never been formally diagnosed with dementia though she clearly exhibits the signs. Admit History: [AGE] year-old female with past medical history of high blood pressure, depression, and advanced dementia who presented to the emergency roiagnom on [DATE] following a ground level fall onto her left side. She underwent surgery which markedly worsened her psychosis from her dementia and possible urinary tract infection. She was treated for urinary tract infection and given Seroquel. She does not have a history of borderline personality disorder or schizophrenia. Psychologic: Normal mood/affect, Insight Impaired. Cognitive Status: Forgetful, confused, dementia. Record review of Resident #4's Behavioral Health Organization Diagnostic Assessment, dated 04/15/24, and completed by the Psychologist reflected: New referral: Patient has a history of depression and schizoaffective disorder. She also has a history of dementia. Patient was referred to determine her ability to benefit from psychological services at this time. Patient denies history of psychiatric hospitalization , depression, and schizoaffective disorder. Patient was a poor historian due to the severity of her cognitive impairment. Clinical Assessment: Based upon clinical interview, brief symptom screening, and a review of records, resident currently meets criteria for major depressive disorder, recurrent episode, mild. In addition, she qualifies for unspecified dementia, moderate, with agitation. Lastly, patient has a historic diagnosis of schizoaffective disorder. Service Plan: No therapy recommended. Record review of Resident #4's Psychiatric Subsequent Assessment, dated 09/05/24, and completed by the Psychiatric-Mental Health Nurse Practitioner reflected: Reason for referral: Agitation, Irritability, Psychosis, Confusion, Short Term Memory Problems, Long Term Memory Problems, Verbal Aggression, Physical Aggression, Medication Evaluation. Psychosis: Staff reports no current symptoms of auditory hallucinations, delusions or disorganized speech. Assessment/Plan: 1. Recurrent depressive disorders is being treated with Zoloft 25 milligrams daily. 2. Dementia in other diseases classified elsewhere, unspecified severity, with agitation is being treated with Namenda 5 milligrams two times a day. 3. Unspecified psychosis being treated with Seroquel 12.5 milligrams every night. No overt symptoms of psychosis noted or reported, will monitor closely. There was no diagnosis of schizoaffective disorder. An observation on 09/17/24 at 10:23 AM revealed Resident #4 was lying in bed asleep. An interview on 09/17/24 at 12:04 PM with the representative party for Resident #4 revealed the resident did not have a history of schizoaffective disorder. An interview on 09/18/24 at 3:09 PM with MDS Nurse B revealed Resident #4 had a diagnosis on the MDS assessment for schizoaffective disorder because it was listed on a psychologist note dated 04/15/24. She said the resident did not have the diagnosis when she was admitted . An interview on 09/18/24 at 3:40 PM with the Medical Director revealed Resident #4 did not have a history of schizophrenia or schizoaffective disorder. An interview on 09/19/24 at 12:14 PM with the Psychologist revealed he documented the resident as having schizoaffective disorder in his note for 04/15/24. He said he later found out it was a false diagnosis and he said he notified an unknown facility staff about the error on unknown date. An interview on 09/19/24 at 2:18 PM with the DON revealed she signed the MDS assessment dated [DATE] for Resident #4. She said that she signed all MDS assessments but did not review every single one and could not remember if she reviewed Resident #4's MDS. She said for Resident #4, the misdiagnosis did not affect the resident. Record review of the facility policy, Antipsychotic Medication Use, dated 2001, reflected: 4. The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions. Record review of the facility policy, MDS Completion and Submission Timeframes, revised July 2017, reflected: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.

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 two (Resident #62 and Resident #188) of 8 residents observed for infection control. 1. LVN A failed to clean the blood pressure cuff after using it on Resident #188 who was on enhanced barrier precautions. LVN A used the same blood pressure cuff on Resident #62. 2. The facility failed to post signage on Resident #188's that he was on enhanced barrier precautions. The failures could place residents at risk for healthcare associated cross contamination and infections. Findings included: Record review of Resident #188's face sheet dated 09/17/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included 3rd degree burns on his left leg and malignant neoplasm of the brain (brain cancer). Record review of Resident #62's face sheet dated 09/17/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy (brain dysfunction). An observation and interview on 09/17/24 at 9:23 AM with LVN A revealed she was administering medications. She said it was her first day as an employee at the facility, but she had worked at the facility before as an agency nurse. LVN A prepared medications for Resident #188. There was no signage or PPE in front of Resident #188's room. LVN A did not wear PPE in Resident #188's room. LVN A took the medications and blood pressure cuff into Resident #188's room and set the medications and blood pressure cuff on the resident's lap tray. LVN A took the resident's blood pressure and administered his medications. LVN A took the blood pressure back to the medication cart and laid it on top of the cart. An observation on 09/17/24 at 9:42 AM revealed two therapy staff put on full PPE and entered Resident #188's room. An observation and interview on 09/17/24 at 9:47 AM revealed LVN A took the blood pressure cuff, that she did not sanitize, and used it on Resident #62. LVN A said she was supposed to clean the blood pressure cuff between using it on residents but forgot to. She said she was supposed to clean it to prevent infection. LVN A left and said she would return shortly. An observation and interview on 09/17/24 at 9:50 AM revealed LVN A returned to the medication cart. She said she found out Resident #188 was supposed to be on enhanced barrier precautions because he had a Foley catheter. She said she did not know because there was no signage on the door and there was no PPE outside of his room. She said she should have worn PPE (gown and gloves) before entering Resident #188's room. A follow-up interview on 09/17/24 at 1:03 PM with LVN A revealed she completed infection control check-offs while she was an agency nurse at the facility. She said she did not know why Resident #188 did not have signage on the door. She said she did not know who was responsible for making sure signage on resident doors. She said she did not know of any other residents who did not have signage and PPE available for enhanced barrier precautions. She said it was important to don PPE for residents on enhanced barrier precautions to prevent the spread of infection. An interview on 09/18/24 at 11:14 AM with the ADON revealed she was able to identify all residents who were on enhanced barrier precautions. She said she did not know why Resident #188 did not have his signage posted on his door. She said it was possible that other residents were taking them down. She said she and the DON were responsible for making sure that residents on enhanced barrier precautions had the proper signage and PPE available. The ADON said there was a risk of infection to residents if PPE was not worn as needed. She said medical equipment was supposed to be cleaned between each resident used to prevent exposure to infection. An interview on 09/18/24 at 1:06 PM with the DON revealed Resident #188 was on enhanced barrier precautions because he had leg wounds. She said she did not know why Resident #188 did not have the signage on his door. She said the facility was going to order a different type of device to hold the signs so that the residents could not take them down. The DON said it was everyone's responsibility to ensure signage was posted on the resident's door. Record review of the facility policy, Infection Control, dated November 2017, reflected: c. Standard and transmission-based precautions to be followed to prevent the spread of infections .

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. There were 17 expired jello cups and an opened carton of expired cranberry juice stored in the reach-in refrigerator. 2. There was a tray of jello that spilled on top of a box of cooked ham stored in the walk-in refrigerator. 3. There were 24 cans of expired cranberry juice stored in the pantry. 4. There was a box of bananas that was not stored in a dry food storage area. 5. There were two small buckets filled with chemicals stored next to a box of bananas. These failures could place residents who received meals, snacks, and/or beverages from the kitchen at risk of foodborne illness. The findings included : Observation on [DATE] at 9:23 a.m. underneath a food preparation table across from the pantry revealed there was a small green plastic bucket next to a carboard box of bananas. The bucket was filled halfway with a liquid and had a blue towel in it. The box of bananas was open, and there was one bundle of five bananas sticking out on top of the box, exposing the bananas to potential contaminants. Observation on [DATE] at 10:12 a.m. underneath the food preparation table across from the pantry revealed there was a small red plastic bucket between the green bucket and cardboard box of bananas. The red bucket was filled halfway with a liquid. Observation on [DATE] at 9:47 a.m. underneath the food preparation table across from the pantry revealed there was a small green plastic bucket and small red plastic bucket next to a carboard box of bananas. The green bucket was filled halfway with a liquid and had a blue towel in it. The red bucket was between the green bucket and cardboard box of bananas. The red bucket was filled halfway with a liquid and had a blue towel in it. The box of bananas was open. There was plastic wrap covering the bananas. Observation on [DATE] at 9:47 a.m. in the reach-in refrigerator revealed: a. There was a carton of thickened cranberry cocktail juice that was opened. The carton had a date indicating it was opened on [DATE] and an expiration date indicating it was best if used by [DATE]. b. There were four packs of sugar free snack-size orange-flavored jello cups and three sugar free snack-size orange-flavored jello cups sitting in an open plastic bin. Each pack had four jello cups. There was one pack that had three jello cups. One jello cup had 11 small green spots on the lid. The jello packs had a shelf date indicating [DATE] and expiration date indicating [DATE]. Observation on [DATE] at 9:58 a.m. in the walk-in refrigerator revealed there was a silver metal tray filled with red jello stored on a silver metal shelf. The jello was covered with brown paper and labeled, Jello - for Supper. There was also a cardboard box stored on the silver metal shelf below the tray of jello. The cardboard box was labeled, Cooked ham and water product. There was some of the red jello that soaked the top of the box. Observation on [DATE] at 10:39 a.m. in the pantry revealed there were two packs of cranberry juice cans. Each pack had 12 cans of cranberry juice. Each can had an expiration date indicating [DATE]. Observation on [DATE] at 1:15 p.m. revealed the DM picked up and discarded the cardboard box of bananas underneath the food preparation table across from the pantry. The DM also picked up and discarded the two 12 packs of cranberry juice cans from the pantry. Interview on [DATE] at 9:42 a.m. with the DM revealed there were two types of small plastic buckets stored underneath each table in the kitchen. The DM stated the small green plastic buckets were filled with soap and water and the small red plastic buckets were filled with a sanitizer. Interview on [DATE] at 10:01 a.m. with Dishwasher A revealed the small red buckets were filled with a sanitizer and the small green buckets were filled with soap and water. Interview on [DATE] at 10:23 a.m. with DA A revealed they were also responsible for stocking the refrigerators. DA A further stated DAs checked the food and beverages stored in the reach-in refrigerator and walk-in refrigerator daily to ensure the items were labeled, dated, and not expired. Interview on [DATE] at 10:40 a.m. with the DM revealed she and the Assistant DM trained the DAs on food storage and safety. The DM stated opened food items were stored in the refrigerators for up to three days. The DM stated the DAs were responsible for checking the expiration dates on the food and beverages stored in the refrigerators and pantry before each shift daily. The DM stated she and the Assistant DM checked the expiration dates on food and beverages every morning and throughout the day daily. Interview on [DATE] at 8:24 a.m. with DA A revealed the afternoon shift DAs were responsible for labeling, dating, and checking the expiration dates on food and beverages stored in the pantry. DA A stated the DM and Assistant DM also checked the food and beverages in the refrigerators and pantry to verify the DAs properly labeled, dated, and checked the expiration dates. Interview on [DATE] at 8:26 a.m. with the DM revealed her and the Assistant DM checked the food and beverages stored in the refrigerators and pantry in the morning and throughout the day to ensure food and beverages were properly labeled, dated, and discarded if expired. Interview on [DATE] at 1:13 p.m. with the DM revealed she was aware there were 17 expired jello cups and an opened carton of expired cranberry juice stored in the reach-in refrigerator. The DM explained she did not conduct her inspection of the food and beverages stored in the reach-in refrigerator at the time the surveyor made the observation. The DM stated she discarded the 17 jello cups and carton of cranberry juice on [DATE]. The DM stated she was not aware there were two 12 packs of expired cranberry juice cans stored in the pantry. The DM stated residents were not served the expired jello cups and expired cranberry juice from the carton and cans. The DM stated residents could become sick if they were served expired food and beverages. The DM stated she was aware there was a tray of jello that spilled on a cardboard box of cooked ham in the walk-in refrigerator. The DM explained one of the DAs spilled the jello when they were placing the tray on a shelf in the walk-in refrigerator. The DM stated she discarded the box and inspected and placed the cooked ham in another container. The DM stated she was aware there was a cardboard box of bananas next to a small red bucket filled with sanitizer and a small green bucket filled with soap and water. The DM explained the box of bananas were always covered and placed next to the buckets. The DM stated the sanitizer could not be rinsed off the bananas with water. The DM stated residents could become sick if they ate food contaminated by the sanitizer. Interview on [DATE] at 1:19 p.m. with Cook A revealed the small green buckets were filled with sanitizer and the small red buckets were filled with soap and water. Cook A stated sanitizer could not be rinsed off the produce with water. Cook A stated residents' health could not be safe if they ate food contaminated by the sanitizer. Cook A stated DAs aides were also responsible for labeling, dating, and checking and discarding expired food and beverages stored in the refrigerators and freezers. Cook A stated dishwashers were responsible for labeling, dating, and checking and discarding expired foods stored in the pantry. Cook A stated afternoon shift DAs checked the food stored in the refrigerators and freezers daily. Cook A stated she was not aware there were expired food and beverages in the refrigerator and pantry because they were on vacation for the last four days. Interview on [DATE] at 1:27 p.m. with DA A revealed they were not aware there was 17 expired jello cups and an opened carton of expired cranberry juice stored in the reach-in refrigerator. DA A stated they were also not aware there were two 12 packs of expired cranberry juice cans stored in the pantry. DA A stated residents could become sick if they ate expired food or beverages. DA A stated they were not aware a tray of jello spilled on a cardboard box of cooked ham stored in the walk-in refrigerator. DA A stated they were aware there was a cardboard box of bananas next to a small red bucket filled with sanitizer and small green bucket filled with soap and water underneath the food preparation table. DA A stated the box was normally more spaced out from the red and green buckets. DA A stated they were not sure if the sanitizer could be rinsed off produce with water. DA A stated they were also not sure if residents could face adverse consequence if they if they ate food contaminated by the sanitizer. Interview on [DATE] at 1:31 p.m. with the Assistant DM revealed she was not aware there was 17 expired jello cups and an opened carton of expired cranberry juice stored in the reach-in refrigerator. The Assistant DM explained she did not conduct her inspection of the food and beverages stored in the reach-in refrigerator at the time the surveyor made the observation. The Assistant DM stated the jello cups and cranberry juice were not served to residents on [DATE]. The Assistant DM stated she was not aware there were two 12 packs of expired cranberry juice cans stored in the pantry. The Assistant DM stated residents could become sick or develop a stomach ache if they ate expired food or beverages. The Assistant DM stated she was not aware there was a tray of jello that spilled on a cardboard box of cooked ham stored in the walk-in refrigerator. The Assistant DM explained she did not conduct her inspection of the food and beverages stored in the walk-in refrigerator at the time the surveyor made the observation. Review of a posting, Daily Kitchen Checklist, week of [DATE] through [DATE], revealed the following tasks were completed daily or after each use: 23. Chemical stored away from food. Staff initialed tasks were completed on [DATE], [DATE], and [DATE]. Review of policy and procedure manual, Food Storage, dated 2019 revealed the following: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 4. Chemicals must be clearly labeled, kept in original containers when possible, kept in a locked area and stored away from food. 7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. Old stock is always used first (first in - first out method). Supervise the person designated to put stock away to make sure it is rotated properly. d. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. 12. Refrigerated food storage f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed. Review of policy and procedure manual, Food Safety and Sanitation, dated 2019 revealed the following: Policy: All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. Procedure: 1. Food and Nutrition Services Department b. The food and nutrition services department will follow regulations as outlined by other official health agencies and organizations with jurisdiction over the facility. 4. Food Storage a. Stored food is handled to prevent contamination and growth of pathogenic organisms. o Poisonous and toxic materials including cleaning agents should be stored (and secured) outside the food storage area. o When a food package is opened, the food item should be marked to indicate the open date. This date is used to determine when to discard the food. o Perishable foods with expiration dates are used prior to the use by date on the package. o Canned or dry foods without expiration dates are used within six months of delivery or according to the manufacturer's guidelines.

Based on observation, interview, and record review, the Facility failed to ensure Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for 2 of 2 residents reviewed. B) Resident #24's comprehensive care plan did not address the resident's right-hand contracture, and call lights assistance C) Resident #35's comprehensive care plan did not address the resident receiving hospice services. This failure could place Residents at risk by failing to meet the resident's preferences, choices, and goals during their stay at the facility. Findings included: A) Record review of Resident #24's admission record dated 07/27/23 documented an [AGE] year-old female admitted on [DATE]. Resident #24's documented diagnoses included: Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter), non st elevation (NSTEM) myocardial infarction (type of heart attack that usually happens when your heart's need for oxygen can't be met), candidiasis (Vaginal yeast infection), lack of coordination (coordination impairment or loss of coordination), type 2 diabetes mellitus without complication (body doesn't make enough insulin or can't use it as well as it should), and age related osteoporosis with current pathological fracture (deterioration in bone mass with increasing risk to fragility fractures. Record review of Resident #24's MDS assessment dated [DATE] revealed resident had a BIMS score of 12 indicating the resident was cognitively moderately impaired. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as bed mobility, dressing, and toilet use. Record review of Resident #24's care plan dated 07/27/23 revealed. Resident #24's care plan did not reveal her right-hand contracture, call light assistance/placement or use of insulin. Observation of Resident #24 on 07/25/23 at 11:52am revealed her right hand was contracted and had a splint on it. Her call light was pinned to her upper right shoulder and out of her reach. Resident #24 stated that she can only reach her call button if it is pinned in the middle of her shirt or the middle of her blanket. Resident #24 stated that her call button is often out of reach. Resident #24 stated that if she needs assistance when her call button is out of reach, she yells so someone can come assistance her. Observation of Resident #24 on 07/25/23 at 12:52pm revealed her call light was pinned to her upper right shoulder and out of her reach. B) Record review of Resident #35's admission record dated 07/27/23 documented an [AGE] year-old female admitted on [DATE]. Resident #35's documented diagnoses included: Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), gastro-esophageal reflux disease without esophagitis (GERD that does not involve inflammation of the esophagus), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems) Record review of Resident #35's MDS assessment dated [DATE] revealed resident had a BIMS score of 03 indicating the resident was severely cognitively impaired. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as bed mobility, transfers, dressing, eating, toilet use and hygiene. Record review of Resident #35's care plan dated 07/27/23 did not reveal she was receiving hospice services. Record review of Resident #35's physician orders dated 07/27/23 revealed Resident #35 was receiving hospice services. There was no start date but a revision date on 06/15/23. Record review of Resident #35's hospice notes revealed that Resident #35 started receiving hospice services on 06/08/23. Resident #35 is receiving the following services from hospice: Changing Linen 3x a week, restock incontinent supplies weekly, report changes in skin, falls, or RNCM when noted, Brush teeth every visit, complete bed bath 2x a week, foot care every visit, Nail care clean, oral care every visit, perineal care every visit, shampoo weekly shower 3 times week, skin care every visit. An interview with the MDS Coordinator on 07/27/23 at 10:50am. MDS Coordinator stated the purpose of the care plan is to know how to take care of the resident. MDS Coordinator stated that residents with contractures should be care planned. MDS Coordinator stated it would be for the resident's care and to be available for staff to see what they should be doing. MDS Coordinator stated if a resident needed a call button to be in a specific location, then that should be care planned. If the resident call button was not care planned, then the resident's call button may not be placed in the location for it to be reached. MDS Coordinator stated care plans are updated when things happen or as needed. An interview with the DON on 07/27/23 at 11:05am. DON stated that care plans are to plan care for residents and available for staff to see what they should be doing for the residents' care. DON stated that contractures should be care planned but it would be up to therapy. DON stated call buttons should not be care planned because call buttons are more of a safety issue. An interview with DON on 07/27/23 at 12:15pm. DON stated that a resident receiving hospice should be care planned for it. DON stated that CNAs could be confused about what care the facility was providing if the resident was not care planned for hospice services. An interview with MDS Coordinator on 07/27/23 at 12:15pm. MDS Coordinator stated that a resident receiving hospice should be care planned for it. MDS Coordinator stated that someone may not know if a resident was receiving hospice services if it was not indicated on the care plan. Record review of facility policy Care Plans, Comprehensive Person-Centered dated 2016 in paragraph 4 and 7, reflected: 4. Each resident comprehensive person-centered care plan will be consistent with the residents' rights to participate in the development and implementations of his or her plan or care, including the right to. 1. Participate in the planning process 2. Identify individual roles to be included 3. Request a meeting 4. Request revisions to the plan of care 5. Participate in the determining the type amount and frequency and duration of care 6. Receive the services and/or items included in the plan of care 7. See the care plan and sign it after significant changes are made 7. The care plan process will: Facilitate residents and /or representative involvement Include an assessment of the residents' strengths and needs Incorporate the residents personal and cultural preferences in developing the goals of care 45957

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to them for 2 of 2 residents (Residents #371 and #12) reviewed for medication administration and 1 of 4 medication carts (the 200 Hall Nurses Medication Cart) reviewed for medication storage. A) The facility failed to ensure over-the-counter medications for Residents #371 and #12 were stored in locked compartments. B) The facility failed to ensure the medication cart was locked when it was left unattended in the common area of the 200-hallway. These deficient practices could place residents at risk of medication misuse or drug diversion. Findings included: A) Record review of Resident # 371's undated Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Hyperlipidemia (high level of fats in the blood), Depression (mood disorder that causes a persistent feeling of sadness and loss of interest), Irritable Bowel Syndrome (an intestinal disorder causing pain in the belly, gas, diarrhea and constipation) with Diarrhea (loose watery stools), Essential Primary Hypertension (high blood pressure), Unspecified (systolic) Congestive Heart Failure (chronic condition in which the heart doesn't pump as well as it should) and acute Kidney Failure (kidneys suddenly become unable to filter waste products from the blood). Record review of Resident # 371's Annual MDS dated [DATE] reflected a BIMS score of 13 indicating intact cognitive status. Record review of Resident # 371's chart reflected there were no Physicians orders for self-administration of medications and no assessments for self-administration of medication. In an observation and interview on 07/26/2023 at 09:38 AM Resident #371 had a bottle of Tylenol 500mg (a medication used to treat aches, pains, and fever) and an empty bottle of Ibuprofen PM 200/20mg (a combination medication used to treat occasional insomnia and pains) on a chest of drawers in his room. Resident #371 stated he had not been trained on those medications and wouldn't remember it if he was trained. Resident #371 stated the medications were obtained from a local grocery store. In an interview on 07/26/2023 at 2:23 PM RN E stated residents having medications in their rooms is not a normal practice. He observed the medication bottles in Resident # 371's room and informed him the nurse would need to put them in a safe place until he could speak with his Physician regarding prescribing them. Record review of Resident # 12's undated Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (a group of thinking and social symptoms that interferes with daily functioning characterized by memory loss and judgement) unspecified severity, Dysphagia (difficulty swallowing), Cognitive Communication Deficit (difficulty with thinking and how someone uses language), Unspecified Macular Degeneration (loss in the center of the field of vision), Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety or fear strong enough to interfere with one's daily activities), and Essential Primary Hypertension (high blood pressure). Record review of Resident # 12's quarterly MDS dated [DATE] reflected a BIMS score of 6 indicating severe cognitive impairment. Record review of Resident # 12's chart reflected there were no Physicians orders for self-administration of medications and no assessments for self-administration of medication. Observation and interview on 07/25/2023 at 11:33 AM in Resident #12's room revealed three opened bottles of over-the-counter saline nasal spray, a bottle of rectal suppositories, an opened tube of ointment with Vitamins A and D, and an unopened tube of triple antibiotic cream on the bedside table. Resident #12 stated she did not know what the tube of antibiotic cream was for, and she had not used it yet. In an interview on 07/26/2023 at 2:23 PM RN E stated We don't normally go through a resident's stuff. I don't know how (Resident #12) accumulated all this stuff. No resident has any medications in their room, not even eye drops or nasal spray. The biggest risk is they could overmedicate. (Resident #12) won't remember when she took her medications. If resident are taking meds in their rooms, they could interact with other meds they are taking. In an interview on 7/27/2023 at 1:42 PM, LVN C stated there were not any residents in the facility that had any Doctors orders to administer their own medications. She further stated if medications were found in rooms, the nurse or staff should remove medications, lock them up, notify the family, place the resident's name on the bottle and have family come get the medications. If the resident was currently taking the unprescribed medication, then they should notify the doctor and get an order for the medication. She stated the risk for residents included overdosing, adverse reactions, another resident could get into the medications, or the resident could administer the medication using the wrong route, for example a nose spray could be put into the mouth. In an interview on 07/27/2023 at 2:35 PM, ADON A stated, We don't currently have anyone who should have any medications in their room. We observe for medications in rooms by making room checks daily either by certified nurse's aide or nurse. She further stated, nurses should go into residents' rooms daily and staff are trained to remove medications if they see them. She stated the risk for medications that were not approved for self-administration included interactions with other medications, adverse reactions, overuse, and residents could become ill. In an interview on 07/27/2023 at 2:29 PM ADON B stated no one with a diagnosis of Dementia should be approved to self-administer medications and the nurse should take any medications found in rooms and notify the family. She stated there were residents who wandered around and if they got the medications, they could be allergic to them. She stated the staff are educated to tell nursing if there are any medications in rooms, however, she couldn't say there was any formal education. She stated there was common sense and word of mouth training between CNAs. In an interview on 07/27/2023 at 2:45 PM, DON stated there are residents' assessment for self-administration of medication. Nurses are instructed to remove medications found in rooms and staff do not go into rooms and look around if residents are not in their rooms. If medications are sitting on top of a bedside table, the nurse should remove them. She further stated the risk to residents of self-administering medications without prior assessment include doubling up on medications and if the resident is educated but cannot remember. She stated Ibuprofen PM and Tylenol can be harmful to residents. Record review of facility policy titled Self-Administration of Medications dated February 2021 and review date of 2/2023, reflected Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment the interdisciplinary team assesses each resident cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. B) Observation on 07/26/2023 at 07:36 AM revealed RN D's medication cart was left unlocked and unattended with the top drawer slightly open. The cart was sitting at a 45-degree angle, easily accessible from the hallway and not flush with a resident's door. Observation on 07/26/2023 at 07:44 AM revealed RN D's medication cart was left unlocked as he went into a room to administer medications and had his back to the door. Interview on 07/26/2023 at 10:42 AM RN D stated by leaving his medication cart open and unlocked someone could get the wrong medications and take them. He stated they might be allergic or could get heart or blood pressure medications leading to illness or death. Interview on 07/27/2023 at 1:45 PM LVN C stated she had worked at the facility since March of 2023. She stated the laptop computer on top of the medication cart should be locked and the medication carts should be kept locked. She stated the cart should be pulled up to the doorway before entering a resident's room and they are trained to keep them locked when they are not with them. She further stated the risk if the medication cart was left open and unattended was a resident or staff could get into it and take medications. She stated the resident could be confused and be allergic to the medication and suffer an injury and they would not know what if anything they took out of the cart. Interview on 07/27/2023 at 2:11 PM ADON A stated she had worked at the facility one year in May of 2023. She stated every time a nurse steps away from their medication cart they should lock the cart and secure the computer too. She further stated residents, other staff or family could access the medications and there are also sharps in the cart. She stated there was a risk of overuse of medication, adverse reactions and people could take things they are not supposed to take. Interview on 07/27/2023 at 2:40 PM the DON stated she had worked at the facility for five years. She stated staff are trained on medication passes a minimum of three days and the cart should be locked unless the nurse is right there. She further stated anyone could get into the cartsa and if medications are consumed there could be an allergic reaction, and overdose, and other adverse reactions. She stated visitors, other nurses, CNAs, or anyone who wanted to steal drugs could get into the unlocked cart. Record review of a facility policy titled Administering Medications dated 2001 and revised August 2019 reflected, During administration of medication, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. 47926

45957 47926 Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 16 (#273, #272, and #24) Residents reviewed for infection control practices. A. RN D placed his ungloved fingers into medication cups prior to administration for Resident's #273 and #272. B. CNA F failed to use proper urinary catheter care techniques when proving perineal hygiene for Resident #24. These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: A) Record review of Resident #273's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar), Pure Hypercholesteremia (high amounts of cholesterol a waxy substance in the blood), Nicotine (a naturally produced alkaloid in the nightshade family of plants, tobacco, and widely used as a stimulant) Dependence, Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), and Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #272's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Essential Primary Hypertension, Emphysema (lung disease that causes breathlessness), Primary Osteoarthritis (type of arthritis that occurs when flexible tissue a the tends of bones wear down causing pain and stiffness), Syncope and collapse (fainting or passing out leading to loss of consciousness and a fall down or over), unspecified Fracture of Sacrum (break in the sacrum bone a large triangular bone that forms the last part of the vertebral column, or spine). Observation on 07/26/2023 at 07:25 AM of RN D preparing medications for Resident #273 revealed he touched the inside of the pill cup with his ungloved finger. Observation on 07/26/2023 at 07:49 AM of RN D preparing medications for Resident #272 revealed he placed his ungloved left thumb in the pill cup. Interview on 07/26/2023 at 10:42 AM RN D stated by putting his fingers into the medication cups he could have had bacteria and microorganisms on his fingers and then transferred those to the residents' medications and then the resident when they took the medications. Interview on 07/27/2023 at 1:45 PM LVN C stated nurses should not touch the inside of medication cups with their bare hands as it increases the risk of infection to the resident. She further stated there could be something going around that could be spread bacteria especially if the nurse didn't wash their hands properly. Interview on 07/27/2023 at 2:11 PM ADON A stated during medication administration the nurse should not touch the inside of the medication cup or around where the resident's mouth touches as the risk is giving them an infection and unnecessary illness. Interview on 07/27/2023 at 2:40 PM the DON revealed it is not standard practice to put our fingers in the medication cups. The risk to the resident is dirty fingers from dirty hands. Hopefully they (nurse) would have washed their hands. Fingers should never be put in med cups. Record review of a facility policy and procedure titled Administering Medications dated 2001 and revised in April 2019 reflected, Staff follows facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. B) Record review of Resident # 24's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of displaced intertrochanteric fracture of left femur (type of hip fracture involving the thigh bone and the pelvis), and unspecified Escherichia-coli (E. Coli bacteria commonly found in the lower intestine) as the cause of diseases. Observation and Interview on 07/26/2023 at 12:43 PM of urinary catheter care performed on Resident #24 revealed CNA F used a bathing wipe on the catheter tubing away from the resident's body and then using the same wipe cleaned up and down the tubing several times. CNA F stated he had been at the facility for 2.5-3 years and stated an ADON had trained him on catheter care. He stated by wiping up and down the tubing with the same wipe there was a risk of introducing infection to the resident and causing a urinary tract infection. Interview on 07/27/2023 at 1:45 PM LVN C stated when performing urinary catheter care a new wipe should be used each time to wipe away from the insertion site. She stated going back up and down with the same wipe could introduce bacteria into the resident. Interview on 07/27/2023 at 2:11 PM ADON A stated regarding urinary catheter care the staff are trained with demonstration and return demonstration if needed, however, she was unsure if they were checked off annually. She stated staff should wipe away from the catheter insertion site and use one wipe at a time. She stated by wiping up and down with the same wipe they could bring bacteria back up which could cause a urinary tract infection and an avoidable illness. Interview on 07/27/2023 at 2:40 PM the DON stated Staff is trained and checked off on catheter care. They should use soap and water or use wipes from the top and away from the body. They could introduce other pathogens on the way up including e-coli which could cause purulent urine, a urinary tract infection and confusion as a result of sepsis. Record review of a facility policy and procedure titled Catheter Care, Urinary dated 2001 and revised in August 2022 reflected The purpose of this procedure is to prevent urinary catheter associated complications, including urinary tract infections. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately four inches outward.

Based on observation, interview, and record review, the facility failed to ensure that each resident had a right to secure and confidential personal and medical records for 5 of 10 residents (Residents #273, #270, #271, #34 and #272) reviewed for medical record confidentiality. The facility failed to ensure confidential medical information was kept private by leaving the computer screen open on the medication cart and leaving the 24-hour report (a report with resident names, diagnoses, and vital signs) on top of the cart and exposed where passersby could read it. This failure could place Residents at risk for breach of confidential information possibly impairing the dignity of the resident by others having pertinent medical information regarding residents' health status. Findings included: Record review of Resident #273's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes (a chronic condition that affects the way the body processes blood sugar), Pure Hypercholesteremia (high amounts of cholesterol a waxy substance in the blood), Nicotine (a naturally produced alkaloid in the nightshade family of plants, tobacco, and widely used as a stimulant) Dependence, Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), and Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems). Record review of Resident #270's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Displaced Bimalleolar Fracture (ankle fracture) of right lower leg, Pressure induced deep tissue damage of left heel, and Pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left heel. Record review of Resident #271's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), Unspecified Dementia (a group of thinking and social symptoms that interferes with daily functioning characterized by memory loss and judgement ), Anxiety (mental health disorder characterized by feelings of worry, anxiety or fear strong enough to interfere with one's daily activities) Depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and Hypertension (high blood pressure). Record review of Resident #34's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Acute Kidney Failure (kidneys suddenly become unable to filter waste products from the blood), Pleural effusion (buildup of fluid between the tissues that line the lungs and the chest), and Covid-19 (infectious illness caused by the SARS-CoV-2 virus). Record review of Resident #272's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Essential Primary Hypertension, Emphysema (lung disease that causes breathlessness), Primary Osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wear down causing pain and stiffness), Syncope and collapse (fainting or passing out leading to loss of consciousness and a fall down or over), unspecified Fracture of Sacrum (break in the sacrum bone a large triangular bone that forms the last part of the vertebral column, or spine). Observation on 07/26/2023 at 07:24 AM revealed while RN D was administering medication to Resident #273 whose bed was on the far side of the room, the medication cart was at an angle to the door and the computer screen with the resident's confidential information was visible from the hallway. Observation on 07/26/2023 at 7:50 AM revealed RN C's 24-hour report (a report with resident names, diagnoses, and vital signs) was on top of the medication cart with resident information for Residents #270, #271, #34 and #272 visible to onlookers. The 24-hour report reflected Resident #270 had a full code (if a person's heart stops beating and /or they stopped breathing, all resuscitation measures will be used to keep them alive) status, had an indwelling urinary catheter (flexible tube that passes through the urethra and into the bladder to drain urine), and new orders for a tall boot (for pressure relief) at all times. Resident #271 had a full code status, with diagnoses of Atrial Fibrillation, Hypertension (high blood pressure), Anxiety and a Urinary Tract (body's drainage system for removing urine) Infection. Resident #34 was noted to be a full code status with diagnoses of Pleural Effusion, Acute Kidney Failure, Covid and was to be discharged home that day at 3:45 PM. Resident #272 was noted to be a full code status, with diagnoses of a Sacral Fracture (break in the sacrum bone a large triangular bone that forms the last part of the vertebral column, or spine) and Syncope (fainting). Resident #272 was also noted to be receiving an antibiotic, Cefdinir. Interview on 07/26/2023 at 10:42 AM with RN D who stated by leaving the computer screen and the 24-hour report open with resident information, it was breaking HIPAA (Health Insurance Portability and Accountability Act) privacy regulations and someone who was unauthorized could see it and obtain private information on the resident. In an interview on 07/27/2023 at 1:42 PM, LVN C stated nurses are trained in privacy and cannot tell just anyone a resident's information. Nurses must check the chart for the responsible party, be aware when talking in hallway, lock screen on medication cart computer, and keep books with confidential information closed. In an interview on 07/27/23 at 2:20 PM, ADON B stated staff are educated on confidentiality, closing the computer screen, and not leaving paperwork visible on a desk or cart. She stated nurses are taught in nursing school first, and with yearly training and the risk of not maintaining confidential resident information is that private information could be viewed resulting in a loss of dignity, could be used in criminal ways, or to belittle someone. In an interview on 07/27/2023 at 2:45 PM, the DON stated that there was a tab on the computers to close them where confidential information cannot be seen when not in use. She stated if a nurse is more than 5 feet from the medication cart, they should close the computer as it would be a HIPAA violation to leave it open. She further stated the risk to a resident would be impaired dignity and leaving the 24-hour report open on top of the cart would be HIPAA violation as well. In a Record review of an undated facility policy titled Health Insurance Portability and Accountability Act, reflected whether the resident health information is on a computer, in an electronic health record, on paper, or in other media providers have the responsibility for safeguarding the information by meeting the requirements of the rules.

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for two of two residents (Residents #3 and #125) reviewed for respiratory care. A) The facility failed to ensure Resident #3's oxygen concentrator filter was clean and her CPAP and nebulizer masks and tubing were covered and dated. B) The facility failed to ensure Resident #125's oxygen concentrator filter was clean and her oxygen tubing were dated. This failure could place all residents who use respiratory equipment at risk for respiratory infections. Findings included: A) Record review of Resident #3's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of acute and chronic Respiratory Failure with Hypoxia (impairment of gas exchange between the lungs and the blood causing shortness of breath, anxiety, confusion). Observation on 07/25/2023 at10:40 AM in Resident #3's room revealed she had an oxygen concentrator with a filter full of white dust. Her CPAP mask and nebulizer mask (used to deliver breathing treatments) were unbagged. Observation on 07/26/2023 at 8:43 AM in Resident #3's room revealed her nebulizer mask and tubing were still unbagged and on her bedside table. The tubing was not dated. Record review of Resident #3's Treatment Administration Record dated 07/02/2023 reflected an order to change O2 tubing and date every night shift every 7 days at 6:00 PM. This order was signed as having been completed on 07/24/2023. There was an order to clean the O2 concentrator filters every night shift every 7 days at 6:00 PM. This order was initialed as having been completed on 07/23/2023. B) Record review of Resident #125's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing related problems). Observation on 07/25/2023 at 10:16 AM in Resident #125's room revealed her oxygen tubing was not dated and her oxygen concentrator filter was covered in white dust. Observation on 07/26/2023 at 12:05 PM revealed Resident #125's oxygen concentrator filter was still covered with white dust and debris. Surveyor ran her finger across the filter and white debris fell from it. Record review of Resident #125's Treatment Administration Record dated 07/16/2023 reflected an order to change O2 tubing and date every night shift every 7 days at 6:00 PM. This order was signed as having been completed on 07/23/2023. There was an order to clean the O2 concentrator filters every night shift every 7 days at 6:00 PM. This order was initialed as having been completed on 07/23/2023. Observation and Interview on 07/26/2023 at 02:14 PM RN E stated he had worked in the facility as needed off and on for 2 years. RN E looked at the concentrator filter and stated It's dusty. I can see where it could cause allergy issues. He stated he was not trained how to clean the oxygen filters and there was always a risk of respiratory infection, and he thought the night staff was trained to clean the filters. He stated the nebulizer masks were supposed to have a bag on them and the night shift was supposed to make sure it was done. Interview on 07/27/2023 at 1:45 PM LVN C stated not bagging the respiratory equipment or cleaning the concentrator filters could cause a respiratory or sinus infection. She stated she did not check on the respiratory equipment while she was doing rounds on her patients. Interview 07/27/2023 at 2:29 PM ADON B stated nursing staff were supposed to change oxygen tubing and date them every Sunday evening and change the concentrator filters. She stated staff should put the nebulizer mask and extra concentrator tubing in a bag to keep it from getting contaminated. She further stated the risk of not doing these things was respiratory infections. Not cleaning or changing the filters could affect the life of the concentrator, the quality of air for the resident and could reduce the amount of air coming through. Interview on 07/27/2023 at 2:40 PM the DON stated, The tubing to respiratory equipment should be changed on Sundays and the filters washed on Sunday nights. She stated the risk to the resident if these procedures were not followed was respiratory infections, decreased air flow from dirty filters, and more pathogens introduced to the residents. She further stated it was their policy to change tubing and clean filters. Record review of a facility policy and procedure titled Departmental (Respiratory Therapy) Prevention of Infection dated 2001 and revised in November 2011 reflected, Change the oxygen cannula and tubing every seven days or as needed. Keep the oxygen cannula and tubing used prn (as needed) in a plastic bag when not in use. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. Infection control considerations related to medication Nebulizers/continuous Nebulizers. Store the circuit in plastic bag, marked with date and residents name between uses.

Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 18 residents (Resident #24) reviewed for call lights in that: Resident #24's call light was not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #24's admission record dated 07/27/23 documented a [AGE] year-old female admitted on [DATE]. Resident #24 documented diagnoses included: Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing (fracture of left leg), non st elevation (NSTEM) myocardial infarction (type of heart attack that usually happens when your heart's need for oxygen can't be met), candidiasis (Vaginal yeast infection), lack of coordination (coordination impairment or loss of coordination), type 2 diabetes mellitus without complication (body doesn't make enough insulin or can't use it as well as it should), and age related osteoporosis with current pathological fracture (deterioration in bone mass with increasing risk to fragility fractures. Record review of Resident #24's MDS assessment dated [DATE] revealed the resident had a BIMS score of 12 indicating the resident was cognitively moderately impaired. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as bed mobility, dressing, and toilet use. Record review of Resident #24's care plan dated 07/27/23 revealed Resident #24 was care planned for her impaired physical mobility and ADL self-care performance deficit r/t s/p L femur fx. Resident #24's care plan did not reveal call light assistance/placement or interventions. Observation and interview of Resident #24 on 07/25/23 at 11:52am revealed her right hand was contracted and had a splint on it. Her call light was pinned to her upper right shoulder and out of her reach. Resident #24 stated that she can only reach her call button if it is pinned in the middle of her shirt or the middle of her blanket. Resident #24 stated that her call button is often out of reach. Resident #24 stated that if she needs assistance when her call button is out of reach, she yells so someone can come assist her. Observation of Resident #24 on 07/25/23 at 12:52pm revealed her call light was pinned to her upper right shoulder and out of her reach. An interview with CNA #A on 07/26/23 at 2:27 pm, revealed CNAs make rounds at least every two hours or as needed. CNA #A stated during the CNAs' rounds they look to see if the resident's call light is in reach. CNA #A stated Resident #24 likes to have her call button to be placed on her left side on the inside of her shirt. CNA #A stated resident #24 told him that she like her call button on the inside of her shirt on the inside . CNA #A stated if Resident #24's call button was placed in any other position then it would be hard for her to access. CNA #A stated if a resident's call button was not in reach, then a resident would not be able to get assistance or the care they may be in need of. An interview with the DON on 07/27/23 at 11:05am. The DON stated anyone that goes into the resident's rooms is responsible for ensuring call buttons are in reach. DON stated if a resident's call button is not in reach then the resident will not be able to ask for assistance when needed. Record review of the facility's Call System policy not dated revealed Policy statement Residents are provided with a means to call staff for assistance through a communication system that directly call a staff member or a centralized work station. Policy interpretation and implementation 1. Each resident is provided with a means to call staff directly of assistance from his/her bed, for toileting/bathing facilities and from the floor. 4. If the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided.

Based on interview and record review, the facility failed to not admit any new residents with a mental disorder unless the State mental health authority has determined based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission that because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility for (Resident #38) of one of four resident reviewed for PASARR screenings. The facility failed to ensure Resident #38 PASARR Level One screening accurately reflected their diagnoses of mental illness. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Review of Resident #38's Admission Face Sheet dated July 26, 2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included Type 2 Diabetes Mellitus without Complications (a chronic disease that causes a person's blood glucose levels to rise too high), Essential (Primary) Hypertension (abnormally high blood pressure that's not the result of a medical condition), Unspecified Dementia, Mild, without behavioral disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), Unspecified Psychosis not due to a substance or known Physiological condition (Psychosis is a mental state characterized by a loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes), Generalized Anxiety Disorder (a mental condition characterized by excessive or unrealistic anxiety about two or more aspects of life (work, social relationships, financial matters, etc.), accompanied by symptoms such as increased muscle tension, impaired concentration, and insomnia), Anxiety disorder (people frequently have intense, excessive and persistent worry and fear about everyday situations. Often, anxiety disorders involve repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks)). Review of the most recent MDS assessment dated [DATE] reflected Resident #38 had a BIMS score of 6. In an interview on 7/27/2023 with MDS Coordinator she stated admission imports the PL1 from the hospital. If it is a negative then it is scanned into the resident chart, input into Simple (which is a program the facility uses). If the PASSAR is positive, once it is in Simple, it notifies the PASSAR to do an evaluation. She stated she is not sure if admission has been trained to do anything else with the PASSAR. Admission inputs whatever comes from the hospital. If the resident is coming from home, she will contact the family and ask them the questions needed to complete the PASSAR. She stated sometimes they get a few PASSAR forms that are not correct and the MDS coordinator will fill out a 1012 correction form. The MDS coordinator stated if the resident's PASSAR is not completed correctly, they will not get the services they may qualify for. MDS coordinator stated if there is a change in diagnosis like psych, another evaluation is completed. MDS coordinator stated if the resident goes to the hospital and they aren't gone more than 30 days, a new evaluation will not need to be completed. MDS coordinator was asked why resident #38 did not have a PASSAR II, she stated she guess she must have overlooked the resident psychosis. She stated she will put in another evaluation in for the Resident #38. In an interview on 7/27/2023 with Admissions Coordinator she stated the resident must come from the hospital with a PASSAR. AC stated she enters the PASSAR once she receives it. AC stated she has not been trained on reading the PASSAR. She stated once she enters the information, the MDS coordinator will catch the corrections and fill out a form to have corrections done. If the resident must have a special care plan, they will assess the resident and provide additional services. The AC stated if a PASSAR is not completed correctly, the resident can miss the additional services they may qualify for. The AC stated but if it is missed, she feels the facility has adequate services within in the building they can provide to the resident. Interview on 7/27/2023 with DON stated the AC must upload the PASSAR into Simple, it then alerts Pecan Valley, and they must come out and evaluate the residents. If the PASSAR is negative, it is uploaded with nothing further. If there is an error, the AC uploads the PASSAR, and a correction form will be done. DON stated the AC and the MDS coordinator are trained to do PASSAR's. DON stated if there is a mistake on the residents PASSAR and not corrected, they cannot get the treatment or services they need or qualify for. Review of the facility's PASSAR clinical policy dated March 2019 read in part, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) the admitting nurse notifies the social services department when a resident I identified as having a possible (or evident) MD, ID, o RD. (2) the social worker is responsible for making referrals to the appropriate state-designated authority.) c. Upon completion of the level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. the state PASARR representative provides a copy of the report to the facility.

Based on observations, interviews, and record review, the facility failed to identify and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. for one (Resident #62) of five residents reviewed for physician orders. LVN C failed to immediately start and continuously provide CPR when she determined Resident #64 did not have a pulse or respirations on [DATE]. LVN C left Resident #64 unattended in her room after finding her unresponsive in order to retrieve a co-worker to start CPR. The facility failed to follow physician orders [REDACTED]. LVN I failed to follow physician orders [REDACTED].) while asleep. LVN C failed to immediately start and continuously provide CPR when she determined Resident #64 did not have a pulse or respirations on [DATE]. LVN C left Resident #64 unattended in her room after finding her unresponsive in order to retrieve a co-worker to start CPR. Resident #64 expired at the facility on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures could affect the residents by placing them at risk for not receiving life-saving treatments as desired, which could result in death. Findings included: Review of Resident #64's Face Sheet, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #64 had [DIAGNOSES REDACTED]. Review of Resident #64's Admission Data, recorded date of [DATE], revealed Resident #64 requested to be a code status of full code, she was alert, oriented to person, place, and time, and required extensive assistance with most ADLs. Review of EMT (Emergency Medical Technician) Patient Care Report regarding Resident #64, dated [DATE], revealed the 911 call was received by dispatch at 5:01 AM on [DATE] and the EMS team arrived at the facility on [DATE] at 5:07 AM. The notes included, E-285 and M-285 arrived on scene to find NH (Nursing Home) staff doing compressions and rescue breaths to an elderly female. Pt (Patient) had signs of obvious death to include: Cold skin, dependent lividity, Rigor-mortis and pooling on the bottoms of her arms and legs. Resuscitation attempts were ceased at 0510 due to these findings. Review of Supravital Reactions in the Estimation of the Time Since Death (TSD) from the Human Body Decomposition, dated (YEAR) and retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/rigor-mortis on [DATE] and https://www.sciencedirect.com/topics/medicine-and-dentistry/livor-mortis, reflected, Rigor Mortis .The phenomenon of rigor mortis .consists of a sustained contraction of the muscles of the body, which begins at ,[DATE] hours after death, persists for ,[DATE] hours . Livor Mortis .Livor mortis or lividity is the gravitational pooling of blood in the dependent parts of the body, both externally in the skin capillaries and venules but also in the internal organs. Its onset is variable but it is usually most evident about 2 hours after death, although it is stated to occur as soon as 15 minutes after death (Clark et al., 1997). Initially the color is red but it later becomes purple as oxygen dissociates from the hemoglobin, changing it to purple-colored deoxyhemoglobin. On [DATE] at 3:00 PM, an interview with the DON revealed she got a phone call in the early morning around 5:50 AM on [DATE] regarding Resident #64. When she arrived at the facility on the morning of [DATE], LVN C was very upset since Resident #64 was her first resident who had expired during her shift. The DON also stated LVN C reported that she did not have any experience on performing CPR on a real person, but LVN D was helping to perform CPR on Resident #64. The DON said she did not interview LVN D and she did not have any red flags that would have prompted her to take action regarding Resident #64's death. She stated there was no incident report and no further investigation had been conducted regarding about Resident #64. At 11:56 AM on [DATE], a follow up interview with the DON revealed she expected staff to perform CPR immediately, as soon as the staff found the resident was unresponsive or not breathing. She added the code status of the residents should be in the EHR (Electronic Health Record) and she expected the code status information should be updated within 24 hours from the admission. If the resident or the family chose a DNR (Do Not Resuscitate) status for a resident, the physician still had to sign the DNR order for the status to be considered enacted. If the resident's status was undecided or the staff did not have a signed DNR document, the resident was automatically considered as a full code, or an automatic resuscitation status. She said the facility did not provide CPR certification training for the staff members. On [DATE] at 7:20 PM, a telephone interview with LVN C revealed she worked the 10:00 PM to 6:00 AM shift on [DATE] and she did not receive any change of condition information regarding Resident #64 from LVN E, the previous shift nurse. She stated she had checked on Resident #64 every couple hours, and the aide on the floor also checked on the resident. She stated she went and checked on the resident when the family member called the facility around 4:30 AM on [DATE] and found the resident was unresponsive. She stated she did not recall the details of the incident. She stated she called 911 and her co-worker, LVN D performed CPR. During the telephone conversation with LVN C, she confirmed that she did not perform CPR immediately when she found the resident was unresponsive. On [DATE] at 9:38 AM, a follow up telephone interview with LVN C revealed she did not recall the night of [DATE] in detail. Further interview revealed she initiated CPR on Resident #64 when she found Resident #64 had no pulse, no respiration, and was unresponsive. She then said she yelled for help from Resident #64's room and LVN D and CNA J came into the room and took over CPR while she went outside the room and called 911. LVN C's statement was not consistent from the previous interview. A telephone interview with CNA K, Resident #64's floor aide on the night of [DATE] but who no longer worked at the facility, was attempted on [DATE] at 9:44 AM. CNA K could not be reached. On [DATE] at 10:07 AM, a telephone interview with CNA J revealed she worked the 10:00 PM to 6:00 AM shift on [DATE]. She said another aide, CNA K, was assigned to take care of Resident #64 on the night of [DATE]. She stated she got a report from CNA K that Resident #64 was complaining about diaphoresis (sweating heavily). On [DATE] around 11:30 PM, CNA J sated she got report from CNA K that the resident appeared asleep when CNA K checked on Resident #64. Around 2:00 AM on [DATE], CNA J stated she saw LVN C sleeping inside her car, which parked next to LVN C's car in the parking lot. She added she did not see LVN C from 12:40 AM to 3:30 AM on [DATE] on the floor, but she was not sure LVN C stayed off of the floor all that time. Around 4:00 AM, CNA J saw LVN C at the nurses' station. CNA J stated she was working at the 400 hall with LVN D and doing round. Then, LVN D requested to assist CPR on Resident #64 on the 200 hall and she went and help LVN D. CNA J said LVN C did not initiate CPR on Resident #64, and LVN D performed CPR. CNA J said she saw LVN C was making a phone call at the nurses' station while they were performing CPR on Resident #64 in the resident room. On [DATE] at 10:48 AM, an interview with LVN D revealed the incident began when LVN C walked toward her from the 200 hall to the 400 hall where LVN D was checking on the residents Resident #64 resided on the 200 hall. Then, LVN C, who was assigned to Resident #64 stated, My resident might be dead. She had gotten a call from the resident's daughter to check on the resident. It was around 4:30 AM on [DATE]. When LVN C told LVN D about Resident #64's condition, LVN D ran into Resident #64's room and checked on her. She found Resident #64 had no pulse and no respirations and asked LVN C about the resident's code status. LVN C did not know the information and LVN D checked Resident #64's code status in the computer system but could not locate it immediately. After searching, LVN D was able to locate the code status from a code report. The resident was designated as a full code. As soon as LVN D knew the resident's code status, LVN D initiated CPR for Resident #64 with the help of CNA J. CNA J brought the crash cart to the room and LVN C left the room and made a phone call. She also added LVN C had no urgency to initiate CPR or call 911. Then, EMS arrived to the building and pronounced Resident #64's death. LVN D confirmed that LVN C did not initiate CPR for Resident #64 as soon as the resident was found unresponsive. LVN D was unable to identify a timeline of how long it took to search the code status and when she actually initiated CPR on for Resident #64. LVN D also stated Resident #64's daughter arrived at the facility on the morning of [DATE] and LVN C did not give a report to the daughter about Resident #64's change of condition and need for CPR, emergency services, and subsequent death. Regarding Resident #64's death, LVN D said the DON did not conduct interview with her about the incident. LVN D saw the DON talk to LVN C in her office on [DATE] and she said she thought it was taken care of with all the reports regarding about #64's death. LVN D stated she was aware of LVN C taking an extended-break during the shift that night, but was not exactly sure of the timeframe. CNA J had reported to her that LVN C was sleeping in the car as well. Before LVN C took a break, LVN C told LVN D that she had too much bread and needed to take a nap. On [DATE] at 10:14 AM, a telephone interview with Resident #64's daughter revealed she started calling the resident's personal cell phone, which was kept next to the resident, at 1:30 AM on [DATE] but Resident #64 did not pick up her phone. She stated she had worried and started to call the facility. She said she called about six times in the early morning of [DATE], but no one answered the facility phone. Finally, someone answered the facility's phone around 4:30 AM on [DATE]; it was LVN C and the daughter requested for the resident to be checked since she had not been answering her personal cell phone. After 18 minutes waiting on hold, LVN C came back to the phone and told the daughter that Resident #64 was in distress and they were working on it. Review of LVN C's CPR certification record reflected she was CPR certified through the American Heart Association on [DATE] and it was recommended for renewal on [DATE]. Review of a Corrective Action Form for LVN C, dated [DATE], revealed LVN C was terminated due to failure to administer CPR and call EMS immediately after Resident #64 was found unresponsive on [DATE]. Review of a Corrective Action Form for LVN D, dated [DATE], revealed LVN D was given a final warning on [DATE] for failure to report a co-worker violating the facility policies and failure to follow facility policy on CPR for Resident #64. Review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation policy, revised (MONTH) (YEAR), revealed, General Guidelines .6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in APR/BLS shall initiate CPR. The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ retrieved on [DATE] reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions. The Administrator was notified on [DATE] at 2:30 PM that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 10:10 PM and included: Cardiopulmonary Resuscitation reeducation started with Licensed Nurses on [DATE] and will be completed by [DATE] by 4:30 PM. The licensed nurse involved in the Immediate Jeopardy (LVN C) was terminated on [DATE]. Social Worker reviewed residents with Full Code status for accuracy on [DATE] at 12:17 PM. Cardiopulmonary Resuscitation Cards were reviewed by the Director of Nursing on [DATE] and were up to date. Licensed Nurses were re-educated provided by RN G on the Cardiopulmonary Resuscitation Policy and process to include the following: 1. Neglect 2. Significant change in a resident. Utilization of the SBAR - 3. Prompt administration of CPR when a resident is full code and identified as non-responsive: To include not leaving the resident alone or unattended. 4. When to call EMS - Immediately 5. The process established on [DATE] related to red names on the door. 6. Staff will be educated on the warning signs that CPR may be needed by Monday [DATE]. These warning signs included sudden collapse, unconsciousness, limited or no breathing, no pulse, Pallor. The implementation of red names on the resident doors to readily identify a DNR resident beginning [DATE] was completed and the Social Worker will oversee the compliance of the system. The updating of the residents' code status will be discussed in a clinical meeting for follow up and to validate implementation of the processes. Newly hired nurses will demonstrate CPR competencies on a mannequin during the orientation process. Mock Emergency Drill will be completed with Licensed Nurses by [DATE] by 4:30 PM and once a month, minimum. All new admission orders [REDACTED]. Based on the order, the staff entered the code status which auto populates to the resident profile. The appropriate color name tag will be placed on the resident's door upon admission. Residents are to be monitored a minimum of every 2 hours by a member of the clinical staff. The check will consist of a visual observation including walking into the resident room if they appear to be lying down or sleeping and listening and watching for respirations or other changes in condition as listed above. If changes in condition are observed a physical assessment will be completed by the charge nurse or nurse manager to include but not limited to vital sign, breath sounds, and level of consciousness. The administrator will oversee compliance of this plan. On [DATE] at 1:45 PM, an interview with the Administrator revealed she had started working at the facility on [DATE] and the facility had provided an additional training on how to perform CPR for LVN C on [DATE]. The Administrator stated she conducted an interview with LVN C in person in her office on [DATE] and LVN C only reported the situation according to the facility's policies, but did not report the details of what had actually happened on [DATE] regarding Resident #64's death. The Administrator stated LVN C did not express any emotional distress during the conversation and she knew she had to terminate her employment immediately. The Administrator said there would be zero tolerance for staff members neglecting the residents. Individual interviews with facility staff representing multiple shifts (LVN F, LVN B, LVN H, LVN I, CNA L, CNA M, CNA N, CNA O, Laundry P, and Laundry Q) on [DATE] between 11:09 AM and 1:16 PM revealed they had received in-service training and understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse. The staff had sufficient knowledge of their roles in a code blue (resident code) emergency situation. Staff revealed they were trained to not leave an unresponsive resident or stop compressions until the paramedics were ready to take over. Staff were trained to identify the red name on the door as a DNR status. The staff were also in-serviced to always call out a code blue in order to alert the other nursing staff that assistance was needed during an emergency. No concerns were noted during the interviews. On [DATE] at 4:00 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. Review of Resident #62's MDS Admission assessment dated [DATE] reflected Resident #62 was an [AGE] year-old male who admitted to the facility on [DATE] from an acute hospital. His assessment reflected he had clear speech with the ability to make himself understood to others and to understand others. He was moderately impaired with cognitive skills for daily decision making. He required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene he and required limited assistance with transfers. The assessment revealed he had [DIAGNOSES REDACTED]. The MDS reported he had a fall history that resulted in a fracture. His MDS Assessment did not indicate that he was receiving skin condition treatments which included applications of ointments/medications or nonsurgical dressings at the time of admission. The assessment also reported Resident #62 used a [MEDICAL CONDITION] ventilator. His assessment triggered care area for Falls. Observation on [DATE] at 10:02 AM revealed Resident #62 had an extra-large sticky bandage that covered the right side of his temple, which extended to the middle of his forehead, pushing into his hairline. Review of Resident #62's Emergency Department Discharge Papers dated [DATE] revealed his care timeline of 2:58 to 4:20 AM in the emergency department for a fall causing a [MEDICAL CONDITION]. Notes reflected: Patient was sitting up and was leaning over to get something and fell over and hit his head on his night stand. He rates his pain ,[DATE]. Discharge Papers reflected a laceration to his right temple located on his frontal scalp measuring 2.5cm, which required a complex repair that resulted in five staples. The report reflected he tolerated the procedure with difficulty. Discharge Papers further noted the resident was a high fall risk due to a history of more than one fall within six months before admission. Review of Nurses Notes for [DATE] for Resident #62 did not indicate the resident had a fall which resulted in him going to the Emergency Department; furthermore, notes did not reflect the resident ever leaving the facility and or returning to the facility with new treatment orders. Review of Resident #62's Fall Risk Evaluation Post Fall, dated [DATE] and completed at 3:09 AM, reflected he was alert and did not have a history of falls. The assessment did not reflect a fall that resulted in injury requiring staples. The evaluation did reveal the resident was high risk for potential falls, and it recommended a prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #62's Clinical Physician order [REDACTED]. The order instructed to cleanse the area to the forehead with normal saline, pat dry, apply ointment, cover with non-stick pad, and secure with tape. The order was prescribed on [DATE]. Review of the Treatment Administration Record (TAR) dated ,[DATE]-[DATE] reflected Resident #62 did not receive [MEDICATION NAME] Ointment as ordered TAR indicated one signature of treatment being conducted which resulted in a total of 12 undocumented spaces that were blank. Missed treatments were confirmed by the DON. In an interview with Resident #62 on [DATE] at 11:32 AM, he said he had fallen, a whole bunch of times, with his last fall causing him to go to the emergency room (ER) because he had hit his head (motioning to his night stand next to his bed) trying to reach for something. Resident #62 said he could not recall what he was looking for but said he was groggy and confused. He said he was bleeding badly, and the ER could not deaden his cut because they needed to close it shut and staple it together for it to stop bleeding. He said it hurt badly. Resident #62 stated he could not recall how many staples he received but said he put a bandage on it himself. He also said the facility had not touched it since he had left from the hospital. When asked why, he said he did not know. Resident #62 also mentioned during the interview that he wore a [MEDICAL CONDITION] while sleeping and that it was important to wear it while he slept. The resident said sometimes he slept without putting it on. He said he knew how to put his mask on, but if he forgets to put it on he would love if staff woke him up and asked him to put it on. He denied staff ever waking him up asking him to wear it. In an interview on [DATE] at 5:04 PM, LVN I confirmed she was Resident #62's nurse and she had not provided any treatments to his laceration. She said she would have been responsible for his treatment. LVN I said she noticed he had to have fallen because he a band aid on the right side of his face and a skin tear to his right arm, but she was unsure how he received it exactly. LVN I said she did receive morning report, but the relieving nurse did not report the resident had fallen She said she could look in the resident's notes and get more information. At 5:08 PM, LVN I looked in Resident #62's medical chart, and after looking for approximately ten to twelve minutes, she said she did not see anything reporting he had fallen. She confirmed he had physician orders [REDACTED].#62 told her he had fallen and hit his head on his nightstand which resulted in him going to the ER for treatment where he received staples. In an interview on [DATE] at 1:17 PM, the DON confirmed Resident #62's physician order [REDACTED]. The DON said it should have been done because it could cause all sort of bad things to happen to the wound, but she was unsure why it was not completed. Observation on [DATE] at 9:57 AM and 10:30 AM revealed Resident #62 was in bed asleep, and he did not open his eyes or respond to a knock at the door or his name being called. Resident #62 did not have on his [MEDICAL CONDITION] mask. It was observed draped across his nightstand with his machine powered off. Observation on [DATE] at 10:04 AM revealed LVN I entered Resident #62's room. She spoke out knock-knock, but the resident did not respond. She touched him on his right hand and asked if she could check his blood pressure. He opened his eyes and replied yes. After LVN I finished checking his vitals and she asked Resident #62 if he wanted the light to remain on. He replied, it don't matter anyway because I'm asleep, and as he spoke those words he coughed a few times and closed his eyes. LVN I left his room without asking if he wanted to wear his [MEDICAL CONDITION]. Review of Resident #62's Clinical Physician order [REDACTED]. Review of Resident #62's Care Plan revealed [MEDICAL CONDITION] was not care planed. Interview on [DATE] at 10:07 AM with LVN I confirmed Resident #62 was asleep whenever she entered his room and he was not wearing his [MEDICAL CONDITION]. She confirmed it was powered off. LVN I said she did not offer if resident wanted to put on his mask and said, he knows how to put it on. Interview on [DATE] at 12:55 PM with the DON confirmed Resident #62 had an order to wear a [MEDICAL CONDITION] while asleep and at bedtime. She said she expected him to wear it according to physician's orders [REDACTED]. The DON said he was capable of putting his own machine on, but it should be offered by the nurses as well. Review of Revised (MONTH) (YEAR) Policy [MEDICAL CONDITION]/[MEDICAL CONDITION] Support reflected to document in resident's medical record: General assessment prior to procedure; Time it was started and duration of the therapy; Mode and settings, Oxygen concentration and flow, if used; how the resident tolerated the procedure; and Oxygen saturation during therapy. The policy also reflected to notify the physician if the resident refuses the procedure.

Based on interviews and record reviews, the facility failed to provide basic life support, including CPR, to a resident requiring emergency care with for one (Resident #64) of seven residents reviewed for CPR. LVN C failed to immediately start and continuously provide CPR when she determined Resident #64 did not have a pulse or respirations on [DATE]. LVN C left Resident #64 unattended in her room after finding her unresponsive in order to retrieve a co-worker to start CPR. Resident #64 expired at the facility on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of isolated because the facility was still monitoring the Plan of Removal. These failures could affect the residents by placing them at risk for not receiving CPR and further life-saving treatments as desired, which could result in death. Findings included: Review of Resident #64's Face Sheet, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #64 had [DIAGNOSES REDACTED]. Review of Resident #64's Admission Data, recorded date of [DATE], revealed Resident #64 requested to be a code status of full code, she was alert, oriented to person, place, and time, and required extensive assistance with most ADLs. Review of EMT (Emergency Medical Technician) Patient Care Report regarding Resident #64, dated [DATE], revealed the 911 call was received by dispatch at 5:01 AM on [DATE] and the EMS team arrived at the facility on [DATE] at 5:07 AM. The notes included, E-285 and M-285 arrived on scene to find NH (Nursing Home) staff doing compressions and rescue breaths to an elderly female. Pt (Patient) had signs of obvious death to include: Cold skin, dependent lividity, Rigor-mortis and pooling on the bottoms of her arms and legs. Resuscitation attempts were ceased at 0510 due to these findings. Review of Supravital Reactions in the Estimation of the Time Since Death (TSD) from the Human Body Decomposition, dated (YEAR) and retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/rigor-mortis on [DATE] and https://www.sciencedirect.com/topics/medicine-and-dentistry/livor-mortis, reflected, Rigor Mortis .The phenomenon of rigor mortis .consists of a sustained contraction of the muscles of the body, which begins at ,[DATE] hours after death, persists for ,[DATE] hours . Livor Mortis .Livor mortis or lividity is the gravitational pooling of blood in the dependent parts of the body, both externally in the skin capillaries and venules but also in the internal organs. Its onset is variable but it is usually most evident about 2 hours after death, although it is stated to occur as soon as 15 minutes after death (Clark et al., 1997). Initially the color is red but it later becomes purple as oxygen dissociates from the hemoglobin, changing it to purple-colored deoxyhemoglobin. On [DATE] at 3:00 PM, an interview with the DON revealed she got a phone call in the early morning around 5:50 AM on [DATE] regarding Resident #64. When she arrived at the facility on the morning of [DATE], LVN C was very upset since Resident #64 was her first resident who had expired during her shift. The DON also stated LVN C reported that she did not have any experience on performing CPR on a real person, but LVN D was helping to perform CPR on Resident #64. The DON said she did not interview LVN D and she did not have any red flags that would have prompted her to take action regarding Resident #64's death. She stated there was no incident report and no further investigation had been conducted regarding about Resident #64. At 11:56 AM on [DATE], a follow up interview with the DON revealed she expected staff to perform CPR immediately, as soon as the staff found the resident was unresponsive or not breathing. She added the code status of the residents should be in the EHR (Electronic Health Record) and she expected the code status information should be updated within 24 hours from the admission. If the resident or the family chose a DNR (Do Not Resuscitate) status for a resident, the physician still had to sign the DNR order for the status to be considered enacted. If the resident's status was undecided or the staff did not have a signed DNR document, the resident was automatically considered as a full code, or an automatic resuscitation status. She said the facility did not provide CPR certification training for the staff members. On [DATE] at 7:20 PM, a telephone interview with LVN C revealed she worked the 10:00 PM to 6:00 AM shift on [DATE] and she did not receive any change of condition information regarding Resident #64 from LVN E, the previous shift nurse. She stated she had checked on Resident #64 every couple hours, and the aide on the floor also checked on the resident. She stated she went and checked on the resident when the family member called the facility around 4:30 AM on [DATE] and found the resident was unresponsive. She stated she did not recall the details of the incident. She stated she called 911 and her co-worker, LVN D performed CPR. During the telephone conversation with LVN C, she confirmed that she did not perform CPR immediately when she found the resident was unresponsive. On [DATE] at 9:38 AM, a follow up telephone interview with LVN C revealed she did not recall the night of [DATE] in detail. Further interview revealed she initiated CPR on Resident #64 when she found Resident #64 had no pulse, no respiration, and was unresponsive. She then said she yelled for help from Resident #64's room and LVN D and CNA J came into the room and took over CPR while she went outside the room and called 911. LVN C's statement was not consistent from the previous interview. A telephone interview with CNA K, Resident #64's floor aide on the night of [DATE] but who no longer worked at the facility, was attempted on [DATE] at 9:44 AM. CNA K could not be reached. On [DATE] at 10:07 AM, a telephone interview with CNA J revealed she worked the 10:00 PM to 6:00 AM shift on [DATE]. She said another aide, CNA K, was assigned to take care of Resident #64 on the night of [DATE]. She stated she got a report from CNA K that Resident #64 was complaining about diaphoresis (sweating heavily). On [DATE] around 11:30 PM, CNA J sated she got report from CNA K that the resident appeared asleep when CNA K checked on Resident #64. Around 2:00 AM on [DATE], CNA J stated she saw LVN C sleeping inside her car, which parked next to LVN C's car in the parking lot. She added she did not see LVN C from 12:40 AM to 3:30 AM on [DATE] on the floor, but she was not sure LVN C stayed off of the floor all that time. Around 4:00 AM, CNA J saw LVN C at the nurses' station. CNA J stated she was working at the 400 hall with LVN D and doing round. Then, LVN D requested to assist CPR on Resident #64 on the 200 hall and she went and help LVN D. CNA J said LVN C did not initiate CPR on Resident #64, and LVN D performed CPR. CNA J said she saw LVN C was making a phone call at the nurses' station while they were performing CPR on Resident #64 in the resident room. On [DATE] at 10:48 AM, an interview with LVN D revealed the incident began when LVN C walked toward her from the 200 hall to the 400 hall where LVN D was checking on the residents Resident #64 resided on the 200 hall. Then, LVN C, who was assigned to Resident #64 stated, My resident might be dead. She had gotten a call from the resident's daughter to check on the resident. It was around 4:30 AM on [DATE]. When LVN C told LVN D about Resident #64's condition, LVN D ran into Resident #64's room and checked on her. She found Resident #64 had no pulse and no respirations and asked LVN C about the resident's code status. LVN C did not know the information and LVN D checked Resident #64's code status in the computer system but could not locate it immediately. After searching, LVN D was able to locate the code status from a code report. The resident was designated as a full code. As soon as LVN D knew the resident's code status, LVN D initiated CPR for Resident #64 with the help of CNA J. CNA J brought the crash cart to the room and LVN C left the room and made a phone call. She also added LVN C had no urgency to initiate CPR or call 911. Then, EMS arrived to the building and pronounced Resident #64's death. LVN D confirmed that LVN C did not initiate CPR for Resident #64 as soon as the resident was found unresponsive. LVN D was unable to identify a timeline of how long it took to search the code status and when she actually initiated CPR on for Resident #64. LVN D also stated Resident #64's daughter arrived at the facility on the morning of [DATE] and LVN C did not give a report to the daughter about Resident #64's change of condition and need for CPR, emergency services, and subsequent death. Regarding Resident #64's death, LVN D said the DON did not conduct interview with her about the incident. LVN D saw the DON talk to LVN C in her office on [DATE] and she said she thought it was taken care of with all the reports regarding about #64's death. LVN D stated she was aware of LVN C taking an extended-break during the shift that night, but was not exactly sure of the timeframe. CNA J had reported to her that LVN C was sleeping in the car as well. Before LVN C took a break, LVN C told LVN D that she had too much bread and needed to take a nap. On [DATE] at 10:14 AM, a telephone interview with Resident #64's daughter revealed she started calling the resident's personal cell phone, which was kept next to the resident, at 1:30 AM on [DATE] but Resident #64 did not pick up her phone. She stated she had worried and started to call the facility. She said she called about six times in the early morning of [DATE], but no one answered the facility phone. Finally, someone answered the facility's phone around 4:30 AM on [DATE]; it was LVN C and the daughter requested for the resident to be checked since she had not been answering her personal cell phone. After 18 minutes waiting on hold, LVN C came back to the phone and told the daughter that Resident #64 was in distress and they were working on it. Review of LVN C's CPR certification record reflected she was CPR certified through the American Heart Association on [DATE] and it was recommended for renewal on [DATE]. Review of a Corrective Action Form for LVN C, dated [DATE], revealed LVN C was terminated due to failure to administer CPR and call EMS immediately after Resident #64 was found unresponsive on [DATE]. Review of a Corrective Action Form for LVN D, dated [DATE], revealed LVN D was given a final warning on [DATE] for failure to report a co-worker violating the facility policies and failure to follow facility policy on CPR for Resident #64. Review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation policy, revised (MONTH) (YEAR), revealed, General Guidelines .6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in APR/BLS shall initiate CPR. The American Heart Association Adult Basic Life Support and Cardiopulmonary Resuscitation Quality information, obtained from https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-5-adult-basic-life-support-and-cardiopulmonary-resuscitation-quality/ retrieved on [DATE] reflected, Begin chest compressions as quickly as possible after recognition of [MEDICAL CONDITION]. The 2010 Guidelines included a major change for trained rescuers, who were instructed to begin the CPR sequence with chest compressions rather than breaths (C-A-B versus A-B-C) to minimize the time to initiation of chest compressions. The Administrator was notified on [DATE] at 2:30 PM that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on [DATE] at 10:10 PM and included: Cardiopulmonary Resuscitation reeducation started with Licensed Nurses on [DATE] and will be completed by [DATE] by 4:30 PM. The licensed nurse involved in the Immediate Jeopardy (LVN C) was terminated on [DATE]. Social Worker reviewed residents with Full Code status for accuracy on [DATE] at 12:17 PM. Cardiopulmonary Resuscitation Cards were reviewed by the Director of Nursing on [DATE] and were up to date. Licensed Nurses were re-educated provided by RN G on the Cardiopulmonary Resuscitation Policy and process to include the following: 1. Neglect 2. Significant change in a resident. Utilization of the SBAR - 3. Prompt administration of CPR when a resident is full code and identified as non-responsive: To include not leaving the resident alone or unattended. 4. When to call EMS - Immediately 5. The process established on [DATE] related to red names on the door. 6. Staff will be educated on the warning signs that CPR may be needed by Monday [DATE]. These warning signs included sudden collapse, unconsciousness, limited or no breathing, no pulse, Pallor. The implementation of red names on the resident doors to readily identify a DNR resident beginning [DATE] was completed and the Social Worker will oversee the compliance of the system. The updating of the residents' code status will be discussed in a clinical meeting for follow up and to validate implementation of the processes. Newly hired nurses will demonstrate CPR competencies on a mannequin during the orientation process. Mock Emergency Drill will be completed with Licensed Nurses by [DATE] by 4:30 PM and once a month, minimum. All new admission orders [REDACTED]. Based on the order, the staff entered the code status which auto populates to the resident profile. The appropriate color name tag will be placed on the resident's door upon admission. Residents are to be monitored a minimum of every 2 hours by a member of the clinical staff. The check will consist of a visual observation including walking into the resident room if they appear to be lying down or sleeping and listening and watching for respirations or other changes in condition as listed above. If changes in condition are observed a physical assessment will be completed by the charge nurse or nurse manager to include but not limited to vital sign, breath sounds, and level of consciousness. The administrator will oversee compliance of this plan. On [DATE] at 1:45 PM, an interview with the Administrator revealed she had started working at the facility on [DATE] and the facility had provided an additional training on how to perform CPR for LVN C on [DATE]. The Administrator stated she conducted an interview with LVN C in person in her office on [DATE] and LVN C only reported the situation according to the facility's policies, but did not report the details of what had actually happened on [DATE] regarding Resident #64's death. The Administrator stated LVN C did not express any emotional distress during the conversation and she knew she had to terminate her employment immediately. The Administrator said there would be zero tolerance for staff members neglecting the residents. Individual interviews with facility staff representing multiple shifts (LVN F, LVN B, LVN H, LVN I, CNA L, CNA M, CNA N, CNA O, Laundry P, and Laundry Q) on [DATE] between 11:09 AM and 1:16 PM revealed they had received in-service training and understood to initiate CPR immediately on a full code resident when he or she was unresponsive with no pulse. The staff had sufficient knowledge of their roles in a code blue (resident code) emergency situation. Staff revealed they were trained to not leave an unresponsive resident or stop compressions until the paramedics were ready to take over. Staff were trained to identify the red name on the door as a DNR status. The staff were also in-serviced to always call out a code blue in order to alert the other nursing staff that assistance was needed during an emergency. No concerns were noted during the interviews. On [DATE] at 4:00 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each of the residents. 1. The Administrator and DON failed to follow their policy and CDC guidelines for a[DIAGNOSES REDACTED] outbreak when three staff members (CNA A, CNA B, and Dishwasher C) exposed residents to the[DIAGNOSES REDACTED] and the illness complications such as swelling of the brain and [DIAGNOSES REDACTED]. 2. The Administrator failed to supervise and monitor the DON to ensure she carried out her responsibilities in the areas of assessment and monitoring of infections, including Physician notifications of communicable disease outbreaks. An Immediate Jeopardy situation was identified on 01/30/17. The Immediate Jeopardy was removed on 02/01/17. The facility remained out of compliance at severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 80 residents at risk of contracting the[DIAGNOSES REDACTED] and further complications such as [DIAGNOSES REDACTED], meningitis (swelling of the brain and spinal cord), and inflammation of the brain Findings included: 1. Interview with the Administrator and the DON on 01/30/17 at 8:55 a.m. revealed they had three confirmed cases of the[DIAGNOSES REDACTED] among the staff members. The residents were first exposed to the[DIAGNOSES REDACTED] through CNA A in December of 2016. The Department of State Health Services (DSHS) called the facility on 12/28/16 and notified ADON D that CNA A was a confirmed case of the[DIAGNOSES REDACTED]. The Administrator and DON stated they had not known CNA A had had the[DIAGNOSES REDACTED] prior to DSHS calling them. On 12/29/16, during a phone call with DSHS, ADON D was informed to assess any residents for signs and symptoms of the[DIAGNOSES REDACTED] who had come into contact with CNA A. The DON also revealed DSHS recommended they follow CDC guidelines regarding a[DIAGNOSES REDACTED] outbreak and in-service all of the staff on the signs and symptoms of the[DIAGNOSES REDACTED]. The DON stated she had been on vacation, but she assumed the nurses were told to assess the residents. The DON stated she was told about the[DIAGNOSES REDACTED] outbreak when she returned from her vacation in the beginning of January. The DON and Administrator stated they had no documented assessments of the residents after the first exposure to the[DIAGNOSES REDACTED]. The DON stated an in-service was held with the staff at the end of December about the signs and symptoms of the[DIAGNOSES REDACTED]. The DON stated CNA A worked mainly on 400 hall, but did help serve all the residents in the dining room during dinner. The Administrator stated CNA B had gotten the[DIAGNOSES REDACTED] in late December and the facility had been contacted again by DSHS. The DON and Administrator stated they did not remember DSHS making any recommendations, but if they did, ADON D would know. The Administrator and DON stated a third case of[DIAGNOSES REDACTED] was discovered when a dishwasher went to the hospital in the middle of January. The DON stated after each confirmed case, they had not notified DSHS, DADS, or any other state entity. The Administrator stated an epidemiologist from DSHS came to the facility on [DATE] and made further recommendations because of the third case of confirmed[DIAGNOSES REDACTED]. DSHS recommended the facility identify staff immunity to[DIAGNOSES REDACTED] through records or titer checks (blood testing to check for immunity antibodies). The DON stated they did not start asking staff for immunization records until 01/26/17. DSHS recommended the facility identify resident immunity to[DIAGNOSES REDACTED] through either records or interviews. The DON stated they had asked the nurses to assess residents for signs and symptoms of[DIAGNOSES REDACTED], but there was no documentation of the assessments that she knew of. DSHS also recommended again on 01/26/17 the staff be re-educated on the signs and symptoms of[DIAGNOSES REDACTED], proper PPE usage, and isolation precautions. The Administrator and DON stated they had only done one in-service in December with staff and it only covered the signs and symptoms of the[DIAGNOSES REDACTED]. DSHS also requested on 01/26/17 the facility educate the residents, families, and visitors on the signs and symptoms of[DIAGNOSES REDACTED] and who to notify. The Administrator stated they were planning on putting a small paragraph in the Resident Newsletter called the 'Daily Chronicle', but they had yet to do so. DSHS also requested the facility contact them every day to let them know of the progress regarding the recommendations. The DON stated ADON D was responsible for daily contact with DSHS. The DON stated she was responsible for infection control in the facility. Interview with the Administrator on 01/31/17 at 12:30 p.m. revealed they did not have a specific policy regarding communicable disease outbreaks. She stated they would follow CDC guidelines and the State Health Department's (DSHS) recommendations in any outbreak scenario. Interview with ADON D on 01/31/17 at 9:35 a.m. revealed she did not know about CNA A's case of[DIAGNOSES REDACTED] until after DSHS had informed her at the end of December. She stated when DSHS called at the end of December they recommended the facility monitor any residents who had come into contact with CNA A for signs and symptoms of the[DIAGNOSES REDACTED], and to educate all the staff on the signs and symptoms. ADON D stated she assumed the nurses had assessed the residents for signs and symptoms of the[DIAGNOSES REDACTED] on every shift, though she did not inform the staff to assess the residents. She stated she had assumed the DON or the person doing the December in-service had told them to assess all the residents. ADON D stated DSHS did sent a link via electronic mail of the CDC guidelines for health care providers regarding[DIAGNOSES REDACTED] outbreaks in health care facilities. DSHS had stated to follow all CDC guidelines plus the Health Department recommendations. ADON D stated the Administrator and the DON had been copied on all the emails between her and DSHS. ADON D revealed the facility knew about the second case of[DIAGNOSES REDACTED] with CNA B but did not inform DSHS or DADS. She stated DSHS called again and stated they knew about the second case of[DIAGNOSES REDACTED] and recommended the facility follow the CDC guidelines and assess all residents for signs and symptoms of the[DIAGNOSES REDACTED]. ADON D stated DSHS told her to ask all residents born before 1957 whether they had[DIAGNOSES REDACTED] as a child, but she did not ask any residents or inform the nursing staff to ask. She stated she had been very busy and did not follow what DSHS had told her. She further revealed she did not inform the nursing staff to assess the residents for the signs and symptoms of[DIAGNOSES REDACTED] after the second and third cases of[DIAGNOSES REDACTED] amongst the staff. ADON D stated they did not follow the CDC guidelines or the DSHS recommendations. She further revealed the physicians of all of the residents were never informed by the facility prior to 01/30/17. Interview with the DSHS Epidemiologist on 01/30/17 at 4:23 p.m. revealed she had been in contact with the facility about the[DIAGNOSES REDACTED] outbreak since the end of December. She revealed she was informed from by the hospital that CNA A had the[DIAGNOSES REDACTED], so she called the facility since it was listed as her place of employment. She stated she first told the facility about CNA A's[DIAGNOSES REDACTED] [DIAGNOSES REDACTED]. The DSHS Epidemiologist stated she had been in contact with ADON D and the DON about all of the recommendations. She stated she sent the CDC recommendations to the facility at the end of December. The DSHS Epidemiologist recommended they begin getting staff immunization records because the CDC recommends staff exposed to[DIAGNOSES REDACTED] that are not immunized be excused from work. The DSHS Epidemiologist was informed by ADON D that they did not and would not request immunization records from the facility staff. The DSHS Epidemiologist revealed she become aware of the second case of[DIAGNOSES REDACTED] by the hospital and called the facility around 01/04/17 to make further recommendations. ADON D had informed her that they were aware of the case of[DIAGNOSES REDACTED] prior to her call, and yet they did not report it to DSHS. The DSHS Epidemiologist once again recommended on 01/04/17 that the facility monitor all residents for signs and symptoms of[DIAGNOSES REDACTED], including residents born before 1957 unless there was documented immunity and to get staff immunization records. She stated she recommended the facility monitor residents born before 1957, even though the CDC stated that people born before 1957 were considered immune, because there were a few cases in a nearby county of elderly residents getting the[DIAGNOSES REDACTED]. She stated she made these recommendations multiple times throughout January 2017 and on 01/26/17. The DSHS Epidemiologist also requested the facility contact her every day with updates on any new staff or residents showing signs and symptoms of the[DIAGNOSES REDACTED]. She stated they never contacted her daily as requested. She was informed once again from the hospital about the third case of[DIAGNOSES REDACTED] among the staff. The DSHS Epidemiologist visited the facility on 01/26/17 and once again recommended the facility monitor all residents unless there was documented immunity, retrieve staff immunization records, re-educate staff again on[DIAGNOSES REDACTED] signs and symptoms and prevention, inform residents, families, and visitors about the signs and symptoms of[DIAGNOSES REDACTED], and provide daily reports. The DSHS Epidemiologist revealed the facility had not done any of her previous recommendations nor followed any of the CDC guidelines prior to her visit on 01/26/17. Review of the DSHS recommendations sent via email to the DON, Administrator, and ADON D on 01/26/17 after an onsite visit reflected the following: Provide education on[DIAGNOSES REDACTED] disease, transmission, and prevention and control measures to residents, family members, facility staff, and physicians. Provide documentation of staff training . Daily assessment of residents for signs and symptoms of[DIAGNOSES REDACTED] until February 4 . Per CDC recommendations, healthcare staff who do not have documented[DIAGNOSES REDACTED] immunity should be excluded from work from the 12th to 25th day after unprotected exposure. Recommend that facility obtain[DIAGNOSES REDACTED] titers for staff. If unable to obtain titers, recommend staff obtain an additional MMR (mumps vaccine) if they do not have documentation of 2 doses . Provide daily status update of new symptomatic staff, residents, or visitors to DSHS epidemiologist. Interviews with LVN E, LVN F, LVN G, RN H and LVN I on 01/30/17 from 3:05 p.m. to 4:09 p.m. revealed the nursing staff had received an in-service over[DIAGNOSES REDACTED] signs and symptoms at the end of December. All of the nursing staff had only been informed that they were reviewing[DIAGNOSES REDACTED] signs and symptoms because of the recent outbreak in the community. The staff were never informed they might have been exposed to[DIAGNOSES REDACTED] or had been asked for their immunization records prior to 01/26/17. They all stated they were never asked to assess any residents for signs or symptoms of the[DIAGNOSES REDACTED]. Interviews with LVN J and LVN K on 01/31/17 between 10:38 a.m. and 10:47 a.m. revealed they were never informed that they and the residents might have been exposed to[DIAGNOSES REDACTED]. They both stated they did not assess any residents for signs or symptoms of[DIAGNOSES REDACTED] or were asked for their immunization records. Interview with the DON and Administrator on 01/30/17 at 8:55 a.m. revealed they had not informed any of the physicians or medical director of the[DIAGNOSES REDACTED] outbreak, and that the residents had been exposed to the[DIAGNOSES REDACTED]. Review of clinical records for Resident #1, Resident #2, Resident #3, Resident #11, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, and Resident #22 reflected no documented assessments for signs and symptoms of the[DIAGNOSES REDACTED] in December 2016 and January 2017. There were no immunization records for the[DIAGNOSES REDACTED] in any of the sampled resident's clinical records. There were no documented interviews about[DIAGNOSES REDACTED] immunity in any of the sampled resident's clinical records. 3. The CDC guidelines for Healthcare Providers during a[DIAGNOSES REDACTED] outbreak reflected the following: Prevention and control strategies should be applied in all healthcare settings, including outpatient and long-term care facilities. These measures include: 1.assessment of presumptive evidence of immunity of healthcare personnel, including documented administration of two doses of live[DIAGNOSES REDACTED] virus vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957 (refer to next section, Healthcare personnel presumptive evidence of immunity for footnotes), 2.vaccination of those without evidence of immunity, 3.exclusion of healthcare personnel with active[DIAGNOSES REDACTED] illness, as well as healthcare personnel who do not have presumptive evidence of immunity who are exposed to persons with[DIAGNOSES REDACTED], 4.isolation of patients in whom[DIAGNOSES REDACTED] is suspected, and 5.implementation of droplet precautions, in addition to standard precautions. In the event that a nosocomial outbreak occurs, healthcare facilities should have a plan in place for the implementation of the two-dose recommendation for all healthcare personnel, including those who were born before 1957 and lack laboratory evidence of immunity or laboratory confirmation of disease. Review of DSHS' Texas Notifiable Conditions revised on 01/2017 reflected any suspected or confirmed cases of[DIAGNOSES REDACTED] must be reported to DSHS within one working day. The facility's undated policy titled, Resident Abuse: Does it Really Exist?, reflected the following: Neglect is a .failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident. Review of the facility's infection control manual revealed there was no facility policy regarding communicable disease outbreak scenarios. An Immediate Jeopardy (IJ) was identified on 01/30/17 at 11:27 a.m. The Administrator and DON were informed of the IJ on 01/30/17 at 11:44 a.m. and a Plan of Removal was requested at that time. The facility's Plan of Removal reflected: 1) All residents in the facility were assessed and looked at starting on 1/30/17 and completed on 1/31/17 by nursing staff of (The Facility) by the names of (LVN K), (LVN J), (LVN G), (LVN F), (LVN I), (RN L), (RN H), and (LVN M) for signs and symptoms of the[DIAGNOSES REDACTED]. The staff above as well as other staff in the building have been trained and in-serviced by using the Department of State Health Services Mump Fact sheet as well as using the CDC information on[DIAGNOSES REDACTED], Chapter 9 from the manual for the Surveillance of Vaccine-Preventable Diseases. All residents in the facility are at risk due to exposure. 2) Staff are going to take vital signs, temperatures and monitor for signs and symptoms of the[DIAGNOSES REDACTED]. This will be implemented on 1/30/17 and completed by 1/31/17 and be ongoing through 2/14/17 q shift. 3) Staff is being in-serviced for signs and symptoms, transmission and prevention of the[DIAGNOSES REDACTED], proper use of PPE for standard and droplet precautions. There are handouts on[DIAGNOSES REDACTED] and a test given to the staff. Staff have been in-serviced on our abuse and neglect policy. This will continue until all staff have been in-serviced. The in-servicing was started on 1/30/17 and will be completed by 1/31/17. Staff that is not in-serviced will not be allowed to work until they complete the in-service beginning on 1/31/17. A sign has been posted on the front door that about information in regard to signs and symptoms of the[DIAGNOSES REDACTED] on 1/30/17. Visitors are requested to not visit if they have signs and symptoms of the[DIAGNOSES REDACTED]. Visitors are required to sign in on the visitor log and additional information in regard to the[DIAGNOSES REDACTED] is provided at the visitor sign-in log at the receptionist desk. The Receptionist and ABOM are responsible that visitors sign in and are made aware of the[DIAGNOSES REDACTED] outbreak and given needed information that is at the visitor sign-in log. This started on 1/30/17 and will remain in place until 2/14/17. All families or resident responsible parties have been notified by phone calls about the signs and symptoms, transmission and prevention of the[DIAGNOSES REDACTED] and that they should seek information from their local physician or go to the emergency room if they have symptoms. They have also been asked to not visit if they have any signs or symptoms of the[DIAGNOSES REDACTED]. This was completed on 1/30/17 with only six families that could not be reached. The Social Worker will continue to attempt to contact them on 1/31/17 until they are reached or an alternate responsible party or the resident themselves is reached. They are being notified that we had an employee that was symptomatic on 1/12/17 and precautions should continue through 2/7/17. A letter was mailed on 1/30/17 to each resident ' s family member or responsible party that is listed on their face sheet as follow-up to the phone calls with the same information. All residents in the facility on 1/30/17 have been given a notice by hand delivery that describes the signs and symptoms of the[DIAGNOSES REDACTED] and asks that they notify nursing staff, or any other staff to assist them in getting medical attention to monitor their symptoms if they have signs and symptoms of[DIAGNOSES REDACTED]. (Physician A), (Physician B), and (Physician C) that see residents here in the facility have been notified by the Administrator and the DON of the signs and symptoms of the[DIAGNOSES REDACTED] and advised by telephone and of the situation of exposure to the residents. The physicians have been hand-delivered or faxed over the Department of State Health Services Mump Fact sheet as well as the CDC information on[DIAGNOSES REDACTED], Chapter 9 from the manual for the Surveillance of Vaccine-Preventable Diseases which is the same information used in the in-servicing of the nursing staff. This information is printed and available to the charge nurses at the nurses' station for a reference if speaking with a physician. This was completed on 1/31/17. The facility is currently getting all immunization records of all staff and if they do not have these records they must be scheduled for an immunization from their local physician or at the local health department. This was started on 1/26/17 and will continue through 2/3/17. Any staff that have not complied with the immunization records request and that has not been immunized will be removed from their schedule of working here on 2/3/17 until they have done one of the above items. 4) The MAR indicated [REDACTED]. If there is an additional case of the[DIAGNOSES REDACTED], the end date for the daily assessment and monitoring will be 25 days from the latest exposure date. The DON or designee will monitor that this is being done and documented daily starting 1/31/17. During morning clinical meeting the DON and ADON will review any residents that have signs and symptoms of the[DIAGNOSES REDACTED] and follow up with the physician immediately starting on 1/31/17. The physician, DON and family will be notified of any findings of signs and symptoms of the[DIAGNOSES REDACTED] by the nurses when they complete their daily assessments of the residents starting 1/30/17. The nursing staff will continue to monitor for signs and symptoms of the[DIAGNOSES REDACTED] daily q shift until 2/14/17 per CDC guidelines. The DON and ADON D will follow up daily that this is taking place per plan. The physician will make a determination of a [DIAGNOSES REDACTED]. The health department will notified accordingly. These issues will be monitored by the QA team weekly through 2/14/17 for compliance and thereafter monthly for next 4 months to ensure compliance. The DON and Administrator have be in-serviced on 1/30/17 by the RNC about [MEDICATION NAME], understanding of the Provider letter 14-13 and notifiables to DHHS . Interviews with Residents #6, #7, #8, #9, #10, #11, #12, and #13 on 01/31/17 between 1:00 p.m. and 1:25 p.m. confirmed they had received a letter and education about the signs and symptoms of the[DIAGNOSES REDACTED]. Interviews with LVN F, CNA N, Hostess O, LVN E, RN H, and LVN G revealed they had received an in-service over the signs and symptoms of the[DIAGNOSES REDACTED], proper use of PPE, and the transmission and prevention of the[DIAGNOSES REDACTED]. Observation of the front entrance on 02/01/17 at 9:00 a.m. revealed there was a letter detailing the signs and symptoms of the[DIAGNOSES REDACTED] and warning visitors to go see a physician if they are experiencing any of the signs or symptoms. Interviews with the families of Resident #14 and Resident #15 on 02/01/17 between 10:12 a.m. and 10:17 a.m. revealed they had been notified on 01/31/17 that their family member had been exposed to the[DIAGNOSES REDACTED]. They were informed about the signs and symptoms of the[DIAGNOSES REDACTED]. Review of fax confirmations dated 01/31/17 to Physicians A, B, and C revealed they had been notified of the facility[DIAGNOSES REDACTED] outbreak and given the CDC recommendations. Observation of the nurse's desk on 02/01/17 at 9:15 a.m. revealed there was a list of the signs and symptoms of the[DIAGNOSES REDACTED] and a change of condition form available to nurses when they spoke to a resident's physician. Review of the Medication Administration Record [REDACTED]. Each resident on all halls had been assessed for the signs and symptoms of the[DIAGNOSES REDACTED]. Review of in-service records, dated 01/30/17, revealed the DON and Administrator were educated on Provider Letter 14-13, which identified issues needing to be reported to DADS. They were also educated on notifiable conditions for DSHS. On 02/01/17 the Administrator and the DON were informed the IJ was removed. While the IJ was removed on 02/01/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. The Resident Daily Census dated 01/30/17 provided by the DON reflected a census of 80.

Based on interview and record review, the facility failed to establish a comprehensive infection prevention and control program that must include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all of the facility's residents. 1. The facility failed to have a comprehensive infection control policy to help prevent, identify, report, investigate, and control communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services. 2. The facility failed to protect all residents, staff, and visitors from further infection by failing to follow DSHS and CDC guidelines for a[DIAGNOSES REDACTED] outbreak and assess residents for signs and symptoms. An Immediate Jeopardy situation was identified on 01/30/17. The Immediate Jeopardy was removed on 02/01/17. The facility remained out of compliance at severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 80 residents at risk of contracting the[DIAGNOSES REDACTED] and further complications such as [DIAGNOSES REDACTED], meningitis (swelling of the brain and spinal cord), and inflammation of the brain. Findings included: 1. Interview with the Administrator and the DON on 01/30/17 at 8:55 a.m. revealed they had three confirmed cases of the[DIAGNOSES REDACTED] among the staff members. The residents were first exposed to the[DIAGNOSES REDACTED] through CNA A in December of 2016. The Department of State Health Services (DSHS) called the facility on 12/28/16 and notified ADON D that CNA A was a confirmed case of the[DIAGNOSES REDACTED]. The Administrator and DON stated they had not known CNA A had had the[DIAGNOSES REDACTED] prior to DSHS calling them. On 12/29/16, during a phone call with DSHS, ADON D was informed to assess any residents for signs and symptoms of the[DIAGNOSES REDACTED] who had come into contact with CNA A. The DON also revealed DSHS recommended they follow CDC guidelines regarding a[DIAGNOSES REDACTED] outbreak and in-service all of the staff on the signs and symptoms of the[DIAGNOSES REDACTED]. The DON stated she had been on vacation, but she assumed the nurses were told to assess the residents. The DON stated she was told about the[DIAGNOSES REDACTED] outbreak when she returned from her vacation in the beginning of January. The DON and Administrator stated they had no documented assessments of the residents after the first exposure to the[DIAGNOSES REDACTED]. The DON stated an in-service was held with the staff at the end of December about the signs and symptoms of the[DIAGNOSES REDACTED]. The DON stated CNA A worked mainly on 400 hall, but did help serve all the residents in the dining room during dinner. The Administrator stated CNA B had gotten the[DIAGNOSES REDACTED] in late December and the facility had been contacted again by DSHS. The DON and Administrator stated they did not remember DSHS making any recommendations, but if they did, ADON D would know. The Administrator and DON stated a third case of[DIAGNOSES REDACTED] was discovered when a dishwasher went to the hospital in the middle of January. The DON stated after each confirmed case, they had not notified DSHS, DADS, or any other state entity. The Administrator stated an epidemiologist from DSHS came to the facility on [DATE] and made further recommendations because of the third case of confirmed[DIAGNOSES REDACTED]. DSHS recommended the facility identify staff immunity to[DIAGNOSES REDACTED] through records or titer checks (blood testing to check for immunity antibodies). The DON stated they did not start asking staff for immunization records until 01/26/17. DSHS recommended the facility identify resident immunity to[DIAGNOSES REDACTED] through either records or interviews. The DON stated they had asked the nurses to assess residents for signs and symptoms of[DIAGNOSES REDACTED], but there was no documentation of the assessments that she knew of. DSHS also recommended again on 01/26/17 the staff be re-educated on the signs and symptoms of[DIAGNOSES REDACTED], proper PPE usage, and isolation precautions. The Administrator and DON stated they had only done one in-service in December with staff and it only covered the signs and symptoms of the[DIAGNOSES REDACTED]. DSHS also requested on 01/26/17 the facility educate the residents, families, and visitors on the signs and symptoms of[DIAGNOSES REDACTED] and who to notify. The Administrator stated they were planning on putting a small paragraph in the Resident Newsletter called the 'Daily Chronicle', but they had yet to do so. DSHS also requested the facility to contact them every day to let them know of the progress regarding the recommendations. The DON stated ADON D was responsible for daily contact with DSHS. Interview with the Administrator on 01/31/17 at 12:30 p.m. revealed they did not have a specific policy regarding communicable disease outbreaks. She stated they would follow CDC guidelines and the State Health Department's (DSHS) recommendations in any outbreak scenario. She stated they did not have a good reason for why they did not follow CDC or DSHS guidelines. Interview with ADON D on 01/31/17 at 9:35 a.m. revealed she did not know about CNA A's case of[DIAGNOSES REDACTED] until after DSHS had informed her at the end of December. She stated when DSHS called at the end of December they recommended the facility monitor any residents who had come into contact with CNA A for signs and symptoms of the[DIAGNOSES REDACTED], and to educate all the staff on the signs and symptoms. ADON D stated she assumed the nurses had assessed the residents for signs and symptoms of the[DIAGNOSES REDACTED] on every shift, though she did not inform the staff to assess the residents. She stated she had assumed the DON or the person doing the December in-service had told them to assess all the residents. ADON D stated DSHS did sent a link via electronic mail of the CDC guidelines for health care providers regarding[DIAGNOSES REDACTED] outbreaks in health care facilities. DSHS had stated to follow all CDC guidelines plus the Health Department recommendations. ADON D stated the Administrator and the DON had been copied on all the emails between her and DSHS. ADON D revealed the facility knew about the second case of[DIAGNOSES REDACTED] with CNA B but did not inform DSHS or DADS. She stated DSHS called again and stated they knew about the second case of[DIAGNOSES REDACTED] and recommended the facility follow the CDC guidelines and assess all residents for signs and symptoms of the[DIAGNOSES REDACTED]. ADON D stated DSHS told her to ask all residents born before 1957 whether they had[DIAGNOSES REDACTED] as a child, but she did not ask any residents or inform the nursing staff to ask. She stated she had been very busy and did not follow what DSHS had told her. She further revealed she did not inform the nursing staff to assess the residents for the signs and symptoms of[DIAGNOSES REDACTED] after the second and third cases of[DIAGNOSES REDACTED] amongst the staff. ADON D stated they did not follow the CDC guidelines or the DSHS recommendations. She further revealed the physicians of all of the residents were never informed by the facility prior to 01/30/17. Interview with the DSHS Epidemiologist on 01/30/17 at 4:23 p.m. revealed she had been in contact with the facility about the[DIAGNOSES REDACTED] outbreak since the end of December. She revealed she was informed from by the hospital about that CNA A had the[DIAGNOSES REDACTED], so she called the facility since it was listed as her place of employment. She stated she first told the facility about CNA A's[DIAGNOSES REDACTED] [DIAGNOSES REDACTED]. of the[DIAGNOSES REDACTED]. The DSHS Epidemiologist stated she had been in contact with ADON D and the DON about all of the recommendations. She stated she sent the CDC recommendations to the facility at the end of December. The DSHS Epidemiologist recommended they begin getting staff immunization records because the CDC recommends staff exposed to[DIAGNOSES REDACTED] that are not immunized be excused from work. The DSHS Epidemiologist was informed by ADON D that they did not and would not request immunization records from the facility staff. The DSHS Epidemiologist revealed she become aware of the second case of[DIAGNOSES REDACTED] by the hospital and called the facility around 01/04/17 to make further recommendations. ADON D had informed her that they were aware of the case of[DIAGNOSES REDACTED] prior to her call, and yet they did not report it to DSHS. The DSHS Epidemiologist once again recommended on 01/04/17 that the facility monitor all residents for signs and symptoms of[DIAGNOSES REDACTED], including residents born before 1957 unless there was documented immunity and to get staff immunization records. She stated she recommended the facility monitor residents born before 1957, even though the CDC stated that people born before 1957 were considered immune, because there were a few cases in a nearby county of elderly residents getting the[DIAGNOSES REDACTED]. She stated she made these recommendations multiple times throughout January 2017 and on 01/26/17. The DSHS Epidemiologist also requested the facility contact her every day with updates on any new staff or residents showing signs and symptoms of the[DIAGNOSES REDACTED]. She stated they never contacted her daily as requested. She was informed once again from the hospital about the third case of[DIAGNOSES REDACTED] among the staff. The DSHS Epidemiologist visited the facility on 01/26/17 and once again recommended the facility monitor all residents unless there was documented immunity, retrieve staff immunization records, re-educate staff again on[DIAGNOSES REDACTED] signs and symptoms and prevention, inform residents, families, and visitors about the signs and symptoms of[DIAGNOSES REDACTED], and provide daily reports. The DSHS Epidemiologist revealed the facility had not done any of her previous recommendations nor followed any of the CDC guidelines prior to her visit on 01/26/17. Review of the DSHS recommendations sent via email to the DON, Administrator, and ADON D on 01/26/17 after an onsite visit reflected the following: Provide education on[DIAGNOSES REDACTED] disease, transmission, and prevention and control measures to residents, family members, facility staff, and physicians. Provide documentation of staff training . Daily assessment of residents for signs and symptoms of[DIAGNOSES REDACTED] until February 4 . Per CDC recommendations, healthcare staff who do not have documented[DIAGNOSES REDACTED] immunity should be excluded from work from the 12th to 25th day after unprotected exposure. Recommend that facility obtain[DIAGNOSES REDACTED] titers for staff. If unable to obtain titers, recommend staff obtain an additional MMR (mumps vaccine) if they do not have documentation of 2 doses . Provide daily status update of new symptomatic staff, residents, or visitors to DSHS epidemiologist. Interviews with LVN E, LVN F, LVN G, RN H and LVN I on 01/30/17 from 3:05 p.m. to 4:09 p.m. revealed the nursing staff had received an in-service regarding[DIAGNOSES REDACTED] signs and symptoms at the end of December. All of the nursing staff had only been informed that they were reviewing[DIAGNOSES REDACTED] signs and symptoms because of the recent outbreak in the community. The staff were never informed they might have been exposed to[DIAGNOSES REDACTED] or had been asked for their immunization records prior to 01/26/17. They all stated they were never asked to assess any residents for signs or symptoms of the[DIAGNOSES REDACTED]. Interviews with LVN J and LVN K on 01/31/17 between 10:38 a.m. and 10:47 a.m. revealed they were never informed that they and the residents might have been exposed to[DIAGNOSES REDACTED]. They both stated they did not assess any residents for signs or symptoms of[DIAGNOSES REDACTED] or were asked for their immunization records. Interview with the DON and Administrator on 01/30/17 at 8:55 a.m. revealed they had not informed any of the physicians or medical director of the[DIAGNOSES REDACTED] outbreak, and that the residents had been exposed to the[DIAGNOSES REDACTED]. Review of clinical records for Resident #1, Resident #2, Resident #3, Resident #11, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, and Resident #22 reflected no documented assessments for signs and symptoms of the[DIAGNOSES REDACTED] in December 2016 and January 2017. There were no immunization records for the[DIAGNOSES REDACTED] in any of the sampled resident's clinical records. There were no documented interviews about[DIAGNOSES REDACTED] immunity in any of the sampled resident's clinical records. 3. The CDC guidelines for Healthcare Providers during a[DIAGNOSES REDACTED] outbreak reflected the following: Prevention and control strategies should be applied in all healthcare settings, including outpatient and long-term care facilities. These measures include: 1.assessment of presumptive evidence of immunity of healthcare personnel, including documented administration of two doses of live[DIAGNOSES REDACTED] virus vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957 (refer to next section, Healthcare personnel presumptive evidence of immunity for footnotes), 2.vaccination of those without evidence of immunity, 3.exclusion of healthcare personnel with active[DIAGNOSES REDACTED] illness, as well as healthcare personnel who do not have presumptive evidence of immunity who are exposed to persons with[DIAGNOSES REDACTED], 4.isolation of patients in whom[DIAGNOSES REDACTED] is suspected, and 5.implementation of droplet precautions, in addition to standard precautions. In the event that a nosocomial outbreak occurs, healthcare facilities should have a plan in place for the implementation of the two-dose recommendation for all healthcare personnel, including those who were born before 1957 and lack laboratory evidence of immunity or laboratory confirmation of disease. The facility's undated policy titled, Resident Abuse: Does it Really Exist?, reflected the following: Neglect is a .failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident. Review of the facility's infection control manual revealed there was no facility policy regarding communicable disease outbreak scenarios. An Immediate Jeopardy (IJ) was identified on 01/30/17 at 11:27 a.m. The Administrator and DON were informed of the IJ on 01/30/17 at 11:44 a.m. and a Plan of Removal was requested at that time. The facility's Plan of Removal reflected: 1) All residents in the facility were assessed and looked at starting on 1/30/17 and completed on 1/31/17 by nursing staff of Ridgeview Rehabilitation (The Facility) by the names of (LVN K), (LVN J), (LVN G), (LVN F), (LVN I), (RN L), (RN H), and (LVN M) for signs and symptoms of the[DIAGNOSES REDACTED]. The staff above as well as other staff in the building have been trained and in-serviced by using the Department of State Health Services Mump Fact sheet as well as using the CDC information on[DIAGNOSES REDACTED], Chapter 9 from the manual for the Surveillance of Vaccine-Preventable Diseases. All residents in the facility are at risk due to exposure. 2) Staff are going to take vital signs, temperatures and monitor for signs and symptoms of the[DIAGNOSES REDACTED]. This will be implemented on 1/30/17 and completed by 1/31/17 and be ongoing through 2/14/17 q shift. 3) Staff is being in-serviced for signs and symptoms, transmission and prevention of the[DIAGNOSES REDACTED], proper use of PPE for standard and droplet precautions. There are handouts on[DIAGNOSES REDACTED] and a test given to the staff. Staff have been in-serviced on our abuse and neglect policy. This will continue until all staff have been in-serviced. The in-servicing was started on 1/30/17 and will be completed by 1/31/17. Staff that is not in-serviced will not be allowed to work until they complete the in-service beginning on 1/31/17. A sign has been posted on the front door that about information in regard to signs and symptoms of the[DIAGNOSES REDACTED] on 1/30/17. Visitors are requested to not visit if they have signs and symptoms of the[DIAGNOSES REDACTED]. Visitors are required to sign in on the visitor log and additional information in regard to the[DIAGNOSES REDACTED] is provided at the visitor sign-in log at the receptionist desk. The Receptionist and ABOM are responsible that visitors sign in and are made aware of the[DIAGNOSES REDACTED] outbreak and given needed information that is at the visitor sign-in log. This started on 1/30/17 and will remain in place until 2/14/17. All families or resident responsible parties have been notified by phone calls about the signs and symptoms, transmission and prevention of the[DIAGNOSES REDACTED] and that they should seek information from their local physician or go to the emergency room if they have symptoms. They have also been asked to not visit if they have any signs or symptoms of the[DIAGNOSES REDACTED]. This was completed on 1/30/17 with only six families that could not be reached. The Social Worker will continue to attempt to contact them on 1/31/17 until they are reached or an alternate responsible party or the resident themselves is reached. They are being notified that we had an employee that was symptomatic on 1/12/17 and precautions should continue through 2/7/17. A letter was mailed on 1/30/17 to each resident ' s family member or responsible party that is listed on their face sheet as follow-up to the phone calls with the same information. All residents in the facility on 1/30/17 have been given a notice by hand delivery that describes the signs and symptoms of the[DIAGNOSES REDACTED] and asks that they notify nursing staff, or any other staff to assist them in getting medical attention to monitor their symptoms if they have signs and symptoms of[DIAGNOSES REDACTED]. (Physician A), (Physician B), and (Physician C) that see residents here in the facility have been notified by the Administrator and the DON of the signs and symptoms of the[DIAGNOSES REDACTED] and advised by telephone and of the situation of exposure to the residents. The physicians have been hand-delivered or faxed over the Department of State Health Services Mump Fact sheet as well as the CDC information on[DIAGNOSES REDACTED], Chapter 9 from the manual for the Surveillance of Vaccine-Preventable Diseases which is the same information used in the in-servicing of the nursing staff. This information is printed and available to the charge nurses at the nurses' station for a reference if speaking with a physician. This was completed on 1/31/17. The facility is currently getting all immunization records of all staff and if they do not have these records they must be scheduled for an immunization from their local physician or at the local health department. This was started on 1/26/17 and will continue through 2/3/17. Any staff that have not complied with the immunization records request and that has not been immunized will be removed from their schedule of working here on 2/3/17 until they have done one of the above items. 4) The MAR is having special requirements added for nursing staff to monitor for signs and symptoms of the[DIAGNOSES REDACTED] for the residents each shift through 2/14/17. If there is an additional case of the[DIAGNOSES REDACTED], the end date for the daily assessment and monitoring will be 25 days from the latest exposure date. The DON or designee will monitor that this is being done and documented daily starting 1/31/17. During morning clinical meeting the DON and ADON will review any residents that have signs and symptoms of the[DIAGNOSES REDACTED] and follow up with the physician immediately starting on 1/31/17. The physician, DON and family will be notified of any findings of signs and symptoms of the[DIAGNOSES REDACTED] by the nurses when they complete their daily assessments of the residents starting 1/30/17. The nursing staff will continue to monitor for signs and symptoms of the[DIAGNOSES REDACTED] daily q shift until 2/14/17 per CDC guidelines. The DON and ADON D will follow up daily that this is taking place per plan. The physician will make a determination of a [DIAGNOSES REDACTED]. The health department will notified accordingly. These issues will be monitored by the QA team weekly through 2/14/17 for compliance and thereafter monthly for next 4 months to ensure compliance. The DON and Administrator have be in-serviced on 1/30/17 by the RNC about [MEDICATION NAME], understanding of the Provider letter 14-13 and notifiables to DHHS . Interviews with Residents #6, #7, #8, #9, #10, #11, #12, and #13 on 01/31/17 between 1:00 p.m. and 1:25 p.m. confirmed they had received a letter and education about the signs and symptoms of the[DIAGNOSES REDACTED]. Interviews with LVN F, CNA N, Hostess O, LVN E, RN H, and LVN G revealed they had received an in-service over the signs and symptoms of the[DIAGNOSES REDACTED], proper use of PPE, and the transmission and prevention of the[DIAGNOSES REDACTED]. Observation of the front entrance on 02/01/17 at 9:00 a.m. revealed there was a letter detailing the signs and symptoms of the[DIAGNOSES REDACTED] and warning visitors to go see a physician if they are experiencing any of the signs or symptoms. Interviews with the families of Resident #14 and Resident #15 on 02/01/17 between 10:12 a.m. and 10:17 a.m. revealed they had been notified on 01/31/17 that their family member had been exposed to the[DIAGNOSES REDACTED]. They were informed about the signs and symptoms of the[DIAGNOSES REDACTED]. Review of fax confirmations dated 01/31/17 to Physicians A, B, and C revealed they had been notified of the facility[DIAGNOSES REDACTED] outbreak and given the CDC recommendations. Observation of the nurse's desk on 02/01/17 at 9:15 a.m. revealed there was a list of the signs and symptoms of the[DIAGNOSES REDACTED] and a change of condition form available to nurses when they spoke to a resident's physician. Review of the Medication Administration Record (MAR) located in the electronic medical record revealed a special section for[DIAGNOSES REDACTED] monitoring which had been started on 01/30/17. Each resident on all halls had been assessed for the signs and symptoms of the[DIAGNOSES REDACTED]. Review of in-service records, dated 01/30/17, revealed the DON and Administrator were educated on Provider Letter 14-13, which identified issues needing to be reported to DADS. They were also educated on notifiable conditions for DSHS. On 02/01/17 the Administrator and the DON were informed the IJ was removed. While the IJ was removed on 02/01/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. The Resident Daily Census dated 01/30/17 provided by the DON reflected a census of 80.

Based on interview and record review, the facility failed to develop and implement policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property for ten (Resident #1, Resident #2, Resident #3, Resident #11, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, and Resident #22) of ten residents reviewed for neglect. The facility failed to follow their policy and CDC guidelines for a[DIAGNOSES REDACTED] outbreak when three staff members (CNA A, CNA B, and Dishwasher C) exposed residents to the[DIAGNOSES REDACTED] and complications of the illness such as meningitis (swelling of the brain and spinal cord), and inflammation of the brain. An Immediate Jeopardy situation was identified on 01/30/17. The Immediate Jeopardy was removed on 02/01/17. The facility remained out of compliance at severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. This failure placed all 80 residents at risk of contracting the[DIAGNOSES REDACTED] and further complications such as [DIAGNOSES REDACTED], meningitis (swelling of the brain and spinal cord), and inflammation of the brain. Findings included: The facility's undated policy titled, Resident Abuse: Does it Really Exist? reflected the following: Neglect is a .failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident. The CDC guidelines for Healthcare Providers during a[DIAGNOSES REDACTED] outbreak reflected the following: Prevention and control strategies should be applied in all healthcare settings, including outpatient and long-term care facilities. These measures include: 1.assessment of presumptive evidence of immunity of healthcare personnel, including documented administration of two doses of live[DIAGNOSES REDACTED] virus vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957 (refer to next section, Healthcare personnel presumptive evidence of immunity for footnotes), 2.vaccination of those without evidence of immunity, 3.exclusion of healthcare personnel with active[DIAGNOSES REDACTED] illness, as well as healthcare personnel who do not have presumptive evidence of immunity who are exposed to persons with[DIAGNOSES REDACTED], 4.isolation of patients in whom[DIAGNOSES REDACTED] is suspected, and 5.implementation of droplet precautions, in addition to standard precautions. In the event that a nosocomial outbreak occurs, healthcare facilities should have a plan in place for the implementation of the two-dose recommendation for all healthcare personnel, including those who were born before 1957 and lack laboratory evidence of immunity or laboratory confirmation of disease. Review of the facility's infection control manual revealed there was no facility policy regarding communicable disease outbreak scenarios. 1. Interview with the Administrator and the DON on 01/30/17 at 8:55 a.m. revealed they had three confirmed cases of the[DIAGNOSES REDACTED] among the staff members. The residents were first exposed to the[DIAGNOSES REDACTED] through CNA A in December of 2016. The Department of State Health Services (DSHS) called the facility on 12/28/16 and notified ADON D that CNA A was a confirmed case of the[DIAGNOSES REDACTED]. The Administrator and DON stated they had not known CNA A had had the[DIAGNOSES REDACTED] prior to DSHS calling them. On 12/29/16, during a phone call with DSHS, ADON D was informed to assess any residents for signs and symptoms of the[DIAGNOSES REDACTED] who had come into contact with CNA A. The DON also revealed DSHS recommended they follow CDC guidelines regarding a[DIAGNOSES REDACTED] outbreak and in-service all of the staff on the signs and symptoms of the[DIAGNOSES REDACTED]. The DON stated she had been on vacation, but she assumed the nurses were told to assess the residents. The DON stated she was told about the[DIAGNOSES REDACTED] outbreak when she returned from her vacation in the beginning of January. The DON and Administrator stated they had no documented assessments of the residents after the first exposure to the[DIAGNOSES REDACTED]. The DON stated an in-service was held with the staff at the end of December about the signs and symptoms of the[DIAGNOSES REDACTED]. The DON stated CNA A worked mainly on 400 hall, but did help serve all the residents in the dining room during dinner. The Administrator stated CNA B had gotten the[DIAGNOSES REDACTED] in late December and the facility had been contacted again by DSHS. The DON and Administrator stated they did not remember DSHS making any recommendations, but if they did, ADON D would know. The Administrator and DON stated a third case of[DIAGNOSES REDACTED] was discovered when a dishwasher went to the hospital in the middle of January. The DON stated after each confirmed case, they had not notified DSHS, DADS, or any other state entity. The Administrator stated an epidemiologist from DSHS came to the facility on [DATE] and made further recommendations because of the third case of confirmed[DIAGNOSES REDACTED]. DSHS recommended the facility identify staff immunity to[DIAGNOSES REDACTED] through records or titer checks (blood testing to check for immunity antibodies). The DON stated they did not start asking staff for immunization records until 01/26/17. DSHS recommended the facility identify resident immunity to[DIAGNOSES REDACTED] through either records or interviews. The DON stated they had asked the nurses to assess residents for signs and symptoms of[DIAGNOSES REDACTED], but there was no documentation of the assessments that she knew of. DSHS also recommended again on 01/26/17 the staff be re-educated on the signs and symptoms of[DIAGNOSES REDACTED], proper PPE usage, and isolation precautions. The Administrator and DON stated they had only done one in-service in December with staff and it only covered the signs and symptoms of the[DIAGNOSES REDACTED]. DSHS also requested on 01/26/17 the facility educate the residents, families, and visitors on the signs and symptoms of[DIAGNOSES REDACTED] and who to notify. The Administrator stated they were planning on putting a small paragraph in the Resident Newsletter called the 'Daily Chronicle', but they had yet to do so. DSHS also requested the facility to contact them every day to let them know of the progress regarding the recommendations. The DON stated ADON D was responsible for daily contact with DSHS. Interview with the Administrator on 01/31/17 at 12:30 p.m. revealed they did not have a specific policy regarding communicable disease outbreaks. She stated they would follow CDC guidelines and the State Health Department's (DSHS) recommendations in any outbreak scenario. She stated they did not have a good reason for why they did not follow CDC or DSHS guidelines. Interview with ADON D on 01/31/17 at 9:35 a.m. revealed she did not know about CNA A's case of[DIAGNOSES REDACTED] until after DSHS had informed her at the end of December. She stated when DSHS called at the end of December they recommended the facility monitor any residents who had come into contact with CNA A for signs and symptoms of the[DIAGNOSES REDACTED], and to educate all the staff on the signs and symptoms. ADON D stated she assumed the nurses had assessed the residents for signs and symptoms of the[DIAGNOSES REDACTED] on every shift, though she did not inform the staff to assess the residents. She stated she had assumed the DON or the person doing the December in-service had told them to assess all the residents. ADON D stated DSHS did sent a link via electronic mail of the CDC guidelines for health care providers regarding[DIAGNOSES REDACTED] outbreaks in health care facilities. DSHS had stated to follow all CDC guidelines plus the Health Department recommendations. ADON D stated the Administrator and the DON had been copied on all the emails between her and DSHS. ADON D revealed the facility knew about the second case of[DIAGNOSES REDACTED] with CNA B but did not inform DSHS or DADS. She stated DSHS called again and stated they knew about the second case of[DIAGNOSES REDACTED] and recommended the facility follow the CDC guidelines and assess all residents for signs and symptoms of the[DIAGNOSES REDACTED]. ADON D stated DSHS told her to ask all residents born before 1957 whether they had[DIAGNOSES REDACTED] as a child, but she did not ask any residents or inform the nursing staff to ask. She stated she had been very busy and did not follow what DSHS had told her. She further revealed she did not inform the nursing staff to assess the residents for the signs and symptoms of[DIAGNOSES REDACTED] after the second and third cases of[DIAGNOSES REDACTED] amongst the staff. ADON D stated they did not follow the CDC guidelines or the DSHS recommendations. She further revealed the physicians of all of the residents were never informed by the facility prior to 01/30/17. Interview with the DSHS Epidemiologist on 01/30/17 at 4:23 p.m. revealed she had been in contact with the facility about the[DIAGNOSES REDACTED] outbreak since the end of December. She revealed she was informed from by the hospital that CNA A had the[DIAGNOSES REDACTED], so she called the facility since it was listed as her place of employment. She stated she first told the facility about CNA A's[DIAGNOSES REDACTED] [DIAGNOSES REDACTED]. The DSHS Epidemiologist stated she had been in contact with ADON D and the DON about all of the recommendations. She stated she sent the CDC recommendations to the facility at the end of December. The DSHS Epidemiologist recommended they begin getting staff immunization records because the CDC recommends staff exposed to[DIAGNOSES REDACTED] that are not immunized be excused from work. The DSHS Epidemiologist was informed by ADON D that they did not and would not request immunization records from the facility staff. The DSHS Epidemiologist revealed she become aware of the second case of[DIAGNOSES REDACTED] by the hospital and called the facility around 01/04/17 to make further recommendations. ADON D had informed her that they were aware of the case of[DIAGNOSES REDACTED] prior to her call, and yet they did not report it to DSHS. The DSHS Epidemiologist once again recommended on 01/04/17 that the facility monitor all residents for signs and symptoms of[DIAGNOSES REDACTED], including residents born before 1957 unless there was documented immunity and to get staff immunization records. She stated she recommended the facility monitor residents born before 1957, even though the CDC stated that people born before 1957 were considered immune, because there were a few cases in a nearby county of elderly residents getting the[DIAGNOSES REDACTED]. She stated she made these recommendations multiple times throughout January 2017 and on 01/26/17. The DSHS Epidemiologist also requested the facility contact her every day with updates on any new staff or residents showing signs and symptoms of the[DIAGNOSES REDACTED]. She stated they never contacted her daily as requested. She was informed once again from the hospital about the third case of[DIAGNOSES REDACTED] among the staff. The DSHS Epidemiologist visited the facility on 01/26/17 and once again recommended the facility monitor all residents unless there was documented immunity, retrieve staff immunization records, re-educate staff again on[DIAGNOSES REDACTED] signs and symptoms and prevention, inform residents, families, and visitors about the signs and symptoms of[DIAGNOSES REDACTED], and provide daily reports. The DSHS Epidemiologist revealed the facility had not done any of her previous recommendations nor followed any of the CDC guidelines prior to her visit on 01/26/17. Review of the DSHS recommendations sent via email to the DON, Administrator, and ADON D on 01/26/17 after an onsite visit reflected the following: Provide education on[DIAGNOSES REDACTED] disease, transmission, and prevention and control measures to residents, family members, facility staff, and physicians. Provide documentation of staff training . Daily assessment of residents for signs and symptoms of[DIAGNOSES REDACTED] until February 4 . Per CDC recommendations, healthcare staff who do not have documented[DIAGNOSES REDACTED] immunity should be excluded from work from the 12th to 25th day after unprotected exposure. Recommend that facility obtain[DIAGNOSES REDACTED] titers for staff. If unable to obtain titers, recommend staff obtain an additional MMR (mumps vaccine) if they do not have documentation of 2 doses . Provide daily status update of new symptomatic staff, residents, or visitors to DSHS epidemiologist. Interviews with LVN E, LVN F, LVN G, RN H and LVN I on 01/30/17 from 3:05 p.m. to 4:09 p.m. revealed the nursing staff had received an in-service regarding[DIAGNOSES REDACTED] signs and symptoms at the end of December. All of the nursing staff had only been informed that they were reviewing[DIAGNOSES REDACTED] signs and symptoms because of the recent outbreak in the community. The staff were never informed they might have been exposed to[DIAGNOSES REDACTED] or had been asked for their immunization records prior to 01/26/17. They all stated they were never asked to assess any residents for signs or symptoms of the[DIAGNOSES REDACTED]. Interviews with LVN J and LVN K on 01/31/17 between 10:38 a.m. and 10:47 a.m. revealed they were never informed that they and the residents might have been exposed to[DIAGNOSES REDACTED]. They both stated they did not assess any residents for signs or symptoms of[DIAGNOSES REDACTED] or were asked for their immunization records. Interview with the DON and Administrator on 01/30/17 at 8:55 a.m. revealed they had not informed any of the physicians or medical director of the[DIAGNOSES REDACTED] outbreak, and that the residents had been exposed to the[DIAGNOSES REDACTED]. Review of clinical records for Resident #1, Resident #2, Resident #3, Resident #11, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, and Resident #22 reflected no documented assessments for signs and symptoms of the[DIAGNOSES REDACTED] in December 2016 and January 2017. There were no immunization records for the[DIAGNOSES REDACTED] in any of the sampled resident's clinical records. There were no documented interviews about[DIAGNOSES REDACTED] immunity in any of the sampled resident's clinical records. The facility's undated policy titled, Resident Abuse: Does it Really Exist?, reflected the following: Neglect is a .failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident. Review of the facility's infection control manual revealed there was no facility policy regarding communicable disease outbreak scenarios. An Immediate Jeopardy (IJ) was identified on 01/30/17 at 11:27 a.m. The Administrator and DON were informed of the IJ on 01/30/17 at 11:44 a.m. and a Plan of Removal was requested at that time. The facility's Plan of Removal: 1) All residents in the facility were assessed and looked at starting on 1/30/17 and completed on 1/31/17 by nursing staff of Ridgeview Rehabilitation (The Facility) by the names of (LVN K), (LVN J), (LVN G), (LVN F), (LVN I), (RN L), (RN H), and (LVN M) for signs and symptoms of the[DIAGNOSES REDACTED]. The staff above as well as other staff in the building have been trained and in-serviced by using the Department of State Health Services Mump Fact sheet as well as using the CDC information on[DIAGNOSES REDACTED], Chapter 9 from the manual for the Surveillance of Vaccine-Preventable Diseases. All residents in the facility are at risk due to exposure. 2) Staff are going to take vital signs, temperatures and monitor for signs and symptoms of the[DIAGNOSES REDACTED]. This will be implemented on 1/30/17 and completed by 1/31/17 and be ongoing through 2/14/17 q shift. 3) Staff is being in-serviced for signs and symptoms, transmission and prevention of the[DIAGNOSES REDACTED], proper use of PPE for standard and droplet precautions. There are handouts on[DIAGNOSES REDACTED] and a test given to the staff. Staff have been in-serviced on our abuse and neglect policy. This will continue until all staff have been in-serviced. The in-servicing was started on 1/30/17 and will be completed by 1/31/17. Staff that is not in-serviced will not be allowed to work until they complete the in-service beginning on 1/31/17. A sign has been posted on the front door that about information in regard to signs and symptoms of the[DIAGNOSES REDACTED] on 1/30/17. Visitors are requested to not visit if they have signs and symptoms of the[DIAGNOSES REDACTED]. Visitors are required to sign in on the visitor log and additional information in regard to the[DIAGNOSES REDACTED] is provided at the visitor sign-in log at the receptionist desk. The Receptionist and ABOM are responsible that visitors sign in and are made aware of the[DIAGNOSES REDACTED] outbreak and given needed information that is at the visitor sign-in log. This started on 1/30/17 and will remain in place until 2/14/17. All families or resident responsible parties have been notified by phone calls about the signs and symptoms, transmission and prevention of the[DIAGNOSES REDACTED] and that they should seek information from their local physician or go to the emergency room if they have symptoms. They have also been asked to not visit if they have any signs or symptoms of the[DIAGNOSES REDACTED]. This was completed on 1/30/17 with only six families that could not be reached. The Social Worker will continue to attempt to contact them on 1/31/17 until they are reached or an alternate responsible party or the resident themselves is reached. They are being notified that we had an employee that was symptomatic on 1/12/17 and precautions should continue through 2/7/17. A letter was mailed on 1/30/17 to each resident ' s family member or responsible party that is listed on their face sheet as follow-up to the phone calls with the same information. All residents in the facility on 1/30/17 have been given a notice by hand delivery that describes the signs and symptoms of the[DIAGNOSES REDACTED] and asks that they notify nursing staff, or any other staff to assist them in getting medical attention to monitor their symptoms if they have signs and symptoms of[DIAGNOSES REDACTED]. (Physician A), (Physician B), and (Physician C) that see residents here in the facility have been notified by the Administrator and the DON of the signs and symptoms of the[DIAGNOSES REDACTED] and advised by telephone and of the situation of exposure to the residents. The physicians have been hand-delivered or faxed over the Department of State Health Services Mump Fact sheet as well as the CDC information on[DIAGNOSES REDACTED], Chapter 9 from the manual for the Surveillance of Vaccine-Preventable Diseases which is the same information used in the in-servicing of the nursing staff. This information is printed and available to the charge nurses at the nurses' station for a reference if speaking with a physician. This was completed on 1/31/17. The facility is currently getting all immunization records of all staff and if they do not have these records they must be scheduled for an immunization from their local physician or at the local health department. This was started on 1/26/17 and will continue through 2/3/17. Any staff that have not complied with the immunization records request and that has not been immunized will be removed from their schedule of working here on 2/3/17 until they have done one of the above items. 4) The MAR indicated [REDACTED]. If there is an additional case of the[DIAGNOSES REDACTED], the end date for the daily assessment and monitoring will be 25 days from the latest exposure date. The DON or designee will monitor that this is being done and documented daily starting 1/31/17. During morning clinical meeting the DON and ADON will review any residents that have signs and symptoms of the[DIAGNOSES REDACTED] and follow up with the physician immediately starting on 1/31/17. The physician, DON and family will be notified of any findings of signs and symptoms of the[DIAGNOSES REDACTED] by the nurses when they complete their daily assessments of the residents starting 1/30/17. The nursing staff will continue to monitor for signs and symptoms of the[DIAGNOSES REDACTED] daily q shift until 2/14/17 per CDC guidelines. The DON and ADON D will follow up daily that this is taking place per plan. The physician will make a determination of a [DIAGNOSES REDACTED]. The health department will notified accordingly. These issues will be monitored by the QA team weekly through 2/14/17 for compliance and thereafter monthly for next 4 months to ensure compliance. The DON and Administrator have be in-serviced on 1/30/17 by the RNC about [MEDICATION NAME], understanding of the Provider letter 14-13 and notifiables to DHHS . Interviews with Residents #6, #7, #8, #9, #10, #11, #12, and #13 on 01/31/17 between 1:00 p.m. and 1:25 p.m. confirmed they had received a letter and education about the signs and symptoms of the[DIAGNOSES REDACTED]. Interviews with LVN F, CNA N, Hostess O, LVN E, RN H, and LVN G revealed they had received an in-service over the signs and symptoms of the[DIAGNOSES REDACTED], proper use of PPE, and the transmission and prevention of the[DIAGNOSES REDACTED]. Observation of the front entrance on 02/01/17 at 9:00 a.m. revealed there was a letter detailing the signs and symptoms of the[DIAGNOSES REDACTED] and warning visitors to go see a physician if they are experiencing any of the signs or symptoms. Interviews with the families of Resident #14 and Resident #15 on 02/01/17 between 10:12 a.m. and 10:17 a.m. revealed they had been notified on 01/31/17 that their family member had been exposed to the[DIAGNOSES REDACTED]. They were informed about the signs and symptoms of the[DIAGNOSES REDACTED]. Review of fax confirmations dated 01/31/17 to Physicians A, B, and C revealed they had been notified of the facility[DIAGNOSES REDACTED] outbreak and given the CDC recommendations. Observation of the nurse's desk on 02/01/17 at 9:15 a.m. revealed there was a list of the signs and symptoms of the[DIAGNOSES REDACTED] and a change of condition form available to nurses when they spoke to a resident's physician. Review of the Medication Administration Record [REDACTED]. Each resident on all halls had been assessed for the signs and symptoms of the[DIAGNOSES REDACTED]. Review of in-service records, dated 01/30/17, revealed the DON and Administrator were educated on Provider Letter 14-13, which identified issues needing to be reported to DADS. They were also educated on notifiable conditions for DSHS. On 02/01/17 the Administrator and the DON were informed the IJ was removed. While the IJ was removed on 02/01/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. The Resident Daily Census dated 01/30/17 provided by the DON reflected a census of 80.

Based on interview and record review, the facility failed to ensure each resident was free from neglect for ten (Resident #1, Resident #2, Resident #3, Resident #11, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, and Resident #22) of ten residents reviewed for neglect. 1. The facility failed to assess all facility residents for signs and symptoms of[DIAGNOSES REDACTED] after being exposed to the illness from CNA A, CNA B, and Dishwasher C. 2. The facility failed to inform any resident physicians there had been a[DIAGNOSES REDACTED] outbreak amongst staff, or that any residents had been exposed. An Immediate Jeopardy situation was identified on 01/30/17. The Immediate Jeopardy was removed on 02/01/17. The facility remained out of compliance at severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. These failures placed all 80 residents at risk of contracting the[DIAGNOSES REDACTED] and further complications such as [DIAGNOSES REDACTED], meningitis (swelling of the brain and spinal cord), and inflammation of the brain. Findings included: 1. Interview with the Administrator and the DON on 01/30/17 at 8:55 a.m. revealed they had three confirmed cases of the[DIAGNOSES REDACTED] among the staff members. The residents were first exposed to the[DIAGNOSES REDACTED] through CNA A in December of 2016. The Department of State Health Services (DSHS) called the facility on 12/28/16 and notified ADON D that CNA A was a confirmed case of the[DIAGNOSES REDACTED]. The Administrator and DON stated they had not known CNA A had had the[DIAGNOSES REDACTED] prior to DSHS calling them. On 12/29/16, during a phone call with DSHS, ADON D was informed to assess any residents for signs and symptoms of the[DIAGNOSES REDACTED] who had come into contact with CNA A. The DON also revealed DSHS recommended they follow CDC guidelines regarding a[DIAGNOSES REDACTED] outbreak and in-service all of the staff on the signs and symptoms of the[DIAGNOSES REDACTED]. The DON stated she had been on vacation, but she assumed the nurses were told to assess the residents. The DON stated she was told about the[DIAGNOSES REDACTED] outbreak when she returned from her vacation in the beginning of January. The DON and Administrator stated they had no documented assessments of the residents after the first exposure to the[DIAGNOSES REDACTED]. The DON stated an in-service was held with the staff at the end of December about the signs and symptoms of the[DIAGNOSES REDACTED]. The DON stated CNA A worked mainly on 400 hall, but did help serve all the residents in the dining room during dinner. The Administrator stated CNA B had gotten the[DIAGNOSES REDACTED] in late December and the facility had been contacted again by DSHS. The DON and Administrator stated they did not remember DSHS making any recommendations, but if they did, ADON D would know. The Administrator and DON stated a third case of[DIAGNOSES REDACTED] was discovered when a dishwasher went to the hospital in the middle of January. The DON stated after each confirmed case, they had not notified DSHS, DADS, or any other state entity. The Administrator stated an epidemiologist from DSHS came to the facility on [DATE] and made further recommendations because of the third case of confirmed[DIAGNOSES REDACTED]. DSHS recommended the facility identify staff immunity to[DIAGNOSES REDACTED] through records or titer checks (blood testing to check for immunity antibodies). The DON stated they did not start asking staff for immunization records until 01/26/17. DSHS recommended the facility identify resident immunity to[DIAGNOSES REDACTED] through either records or interviews. The DON stated they had asked the nurses to assess residents for signs and symptoms of[DIAGNOSES REDACTED], but there was no documentation of the assessments that she knew of. DSHS also recommended again on 01/26/17 the staff be re-educated on the signs and symptoms of[DIAGNOSES REDACTED], proper PPE usage, and isolation precautions. The Administrator and DON stated they had only done one in-service in December with staff and it only covered the signs and symptoms of the[DIAGNOSES REDACTED]. DSHS also requested on 01/26/17 the facility educate the residents, families, and visitors on the signs and symptoms of[DIAGNOSES REDACTED] and who to notify. The Administrator stated they were planning on putting a small paragraph in the Resident Newsletter called the 'Daily Chronicle', but they had yet to do so. DSHS also requested the facility to contact them every day to let them know of the progress regarding the recommendations. The DON stated ADON D was responsible for daily contact with DSHS. Interview with the Administrator on 01/31/17 at 12:30 p.m. revealed they did not have a specific policy regarding communicable disease outbreaks. She stated they would follow CDC guidelines and the State Health Department's (DSHS) recommendations in any outbreak scenario. Interview with ADON D on 01/31/17 at 9:35 a.m. revealed she did not know about CNA A's case of[DIAGNOSES REDACTED] until after DSHS had informed her at the end of December. She stated when DSHS called at the end of December they recommended the facility monitor any residents who had come into contact with CNA A for signs and symptoms of the[DIAGNOSES REDACTED], and to educate all the staff on the signs and symptoms. ADON D stated she assumed the nurses had assessed the residents for signs and symptoms of the[DIAGNOSES REDACTED] on every shift, though she did not inform the staff to assess the residents. She stated she had assumed the DON or the person doing the December in-service had told them to assess all the residents. ADON D stated DSHS did sent a link via electronic mail of the CDC guidelines for health care providers regarding[DIAGNOSES REDACTED] outbreaks in health care facilities. DSHS had stated to follow all CDC guidelines plus the Health Department recommendations. ADON D stated the Administrator and the DON had been copied on all the emails between her and DSHS. ADON D revealed the facility knew about the second case of[DIAGNOSES REDACTED] with CNA B but did not inform DSHS or DADS. She stated DSHS called again and stated they knew about the second case of[DIAGNOSES REDACTED] and recommended the facility follow the CDC guidelines and assess all residents for signs and symptoms of the[DIAGNOSES REDACTED]. ADON D stated DSHS told her to ask all residents born before 1957 whether they had[DIAGNOSES REDACTED] as a child, but she did not ask any residents or inform the nursing staff to ask. She stated she had been very busy and did not follow what DSHS had told her. She further revealed she did not inform the nursing staff to assess the residents for the signs and symptoms of[DIAGNOSES REDACTED] after the second and third cases of[DIAGNOSES REDACTED] amongst the staff. ADON D stated they did not follow the CDC guidelines or the DSHS recommendations. She further revealed the physicians of all of the residents were never informed by the facility prior to 01/30/17. Interview with the DSHS Epidemiologist on 01/30/17 at 4:23 p.m. revealed she had been in contact with the facility about the[DIAGNOSES REDACTED] outbreak since the end of December. She revealed she was informed from by the hospital that CNA A had the[DIAGNOSES REDACTED], so she called the facility since it was listed as her place of employment. She stated she first told the facility about CNA A's[DIAGNOSES REDACTED] [DIAGNOSES REDACTED]. The DSHS Epidemiologist stated she had been in contact with ADON D and the DON about all of the recommendations. She stated she sent the CDC recommendations to the facility at the end of December. The DSHS Epidemiologist recommended they begin getting staff immunization records because the CDC recommends staff exposed to[DIAGNOSES REDACTED] that are not immunized be excused from work. The DSHS Epidemiologist was informed by ADON D that they did not and would not request immunization records from the facility staff. The DSHS Epidemiologist revealed she become aware of the second case of[DIAGNOSES REDACTED] by the hospital and called the facility around 01/04/17 to make further recommendations. ADON D had informed her that they were aware of the case of[DIAGNOSES REDACTED] prior to her call, and yet they did not report it to DSHS. The DSHS Epidemiologist once again recommended on 01/04/17 that the facility monitor all residents for signs and symptoms of[DIAGNOSES REDACTED], including residents born before 1957 unless there was documented immunity and to get staff immunization records. She stated she recommended the facility monitor residents born before 1957, even though the CDC stated that people born before 1957 were considered immune, because there were a few cases in a nearby county of elderly residents getting the[DIAGNOSES REDACTED]. She stated she made these recommendations multiple times throughout January 2017 and on 01/26/17. The DSHS Epidemiologist also requested the facility contact her every day with updates on any new staff or residents showing signs and symptoms of the[DIAGNOSES REDACTED]. She stated they never contacted her daily as requested. She was informed once again from the hospital about the third case of[DIAGNOSES REDACTED] among the staff. The DSHS Epidemiologist visited the facility on 01/26/17 and once again recommended the facility monitor all residents unless there was documented immunity, retrieve staff immunization records, re-educate staff again on[DIAGNOSES REDACTED] signs and symptoms and prevention, inform residents, families, and visitors about the signs and symptoms of[DIAGNOSES REDACTED], and provide daily reports. The DSHS Epidemiologist revealed the facility had not done any of her previous recommendations nor followed any of the CDC guidelines prior to her visit on 01/26/17. Review of the DSHS recommendations sent via email to the DON, Administrator, and ADON D on 01/26/17 after an onsite visit reflected the following: Provide education on[DIAGNOSES REDACTED] disease, transmission, and prevention and control measures to residents, family members, facility staff, and physicians. Provide documentation of staff training . Daily assessment of residents for signs and symptoms of[DIAGNOSES REDACTED] until February 4 . Per CDC recommendations, healthcare staff who do not have documented[DIAGNOSES REDACTED] immunity should be excluded from work from the 12th to 25th day after unprotected exposure. Recommend that facility obtain[DIAGNOSES REDACTED] titers for staff. If unable to obtain titers, recommend staff obtain an additional MMR (mumps vaccine) if they do not have documentation of 2 doses . Provide daily status update of new symptomatic staff, residents, or visitors to DSHS epidemiologist. Interviews with LVN E, LVN F, LVN G, RN H and LVN I on 01/30/17 from 3:05 p.m. to 4:09 p.m. revealed the nursing staff had received an in-service regarding the signs and symptoms of the[DIAGNOSES REDACTED] at the end of December. All of the nursing staff had only been informed that they were reviewing[DIAGNOSES REDACTED] signs and symptoms because of the recent outbreak in the community. The staff were never informed they might have been exposed to[DIAGNOSES REDACTED] or had been asked for their immunization records prior to 01/26/17. They all stated they were never asked to assess any residents for signs or symptoms of the[DIAGNOSES REDACTED]. Interviews with LVN J and LVN K on 01/31/17 between 10:38 a.m. and 10:47 a.m. revealed they were never informed that they and the residents might have been exposed to[DIAGNOSES REDACTED]. They both stated they did not assess any residents for signs or symptoms of[DIAGNOSES REDACTED] or were asked for their immunization records. Interview with the DON and Administrator on 01/30/17 at 8:55 a.m. revealed they had not informed any of the physicians or medical director of the[DIAGNOSES REDACTED] outbreak, and that the residents had been exposed to the[DIAGNOSES REDACTED]. Review of clinical records for Resident #1, Resident #2, Resident #3, Resident #11, Resident #17, Resident #18, Resident #19, Resident #20, Resident #21, and Resident #22 reflected no documented assessments for signs and symptoms of the[DIAGNOSES REDACTED] in December 2016 and January 2017. There were no immunization records for the[DIAGNOSES REDACTED] in any of the sampled resident's clinical records. There were no documented interviews about[DIAGNOSES REDACTED] immunity in any of the sampled resident's clinical records. 3. The CDC guidelines for Healthcare Providers during a[DIAGNOSES REDACTED] outbreak reflected the following: Prevention and control strategies should be applied in all healthcare settings, including outpatient and long-term care facilities. These measures include: 1.assessment of presumptive evidence of immunity of healthcare personnel, including documented administration of two doses of live[DIAGNOSES REDACTED] virus vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957 (refer to next section, Healthcare personnel presumptive evidence of immunity for footnotes), 2.vaccination of those without evidence of immunity, 3.exclusion of healthcare personnel with active[DIAGNOSES REDACTED] illness, as well as healthcare personnel who do not have presumptive evidence of immunity who are exposed to persons with[DIAGNOSES REDACTED], 4.isolation of patients in whom[DIAGNOSES REDACTED] is suspected, and 5.implementation of droplet precautions, in addition to standard precautions. In the event that a nosocomial outbreak occurs, healthcare facilities should have a plan in place for the implementation of the two-dose recommendation for all healthcare personnel, including those who were born before 1957 and lack laboratory evidence of immunity or laboratory confirmation of disease. The facility's undated policy titled, Resident Abuse: Does it Really Exist?, reflected the following: Neglect is a .failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident. Review of the facility's infection control manual revealed there was no facility policy regarding communicable disease outbreak scenarios. An Immediate Jeopardy (IJ) was identified on 01/30/17 at 11:27 a.m. The Administrator and DON were informed of the IJ on 01/30/17 at 11:44 a.m. and a Plan of Removal was requested at that time. The facility's Plan of Removal reflected: 1) All residents in the facility were assessed and looked at starting on 1/30/17 and completed on 1/31/17 by nursing staff of (The Facility) by the names of (LVN K), (LVN J), (LVN G), (LVN F), (LVN I), (RN L), (RN H), and (LVN M) for signs and symptoms of the[DIAGNOSES REDACTED]. The staff above as well as other staff in the building have been trained and in-serviced by using the Department of State Health Services Mump Fact sheet as well as using the CDC information on[DIAGNOSES REDACTED], Chapter 9 from the manual for the Surveillance of Vaccine-Preventable Diseases. All residents in the facility are at risk due to exposure. 2) Staff are going to take vital signs, temperatures and monitor for signs and symptoms of the[DIAGNOSES REDACTED]. This will be implemented on 1/30/17 and completed by 1/31/17 and be ongoing through 2/14/17 q shift. 3) Staff is being in-serviced for signs and symptoms, transmission and prevention of the[DIAGNOSES REDACTED], proper use of PPE for standard and droplet precautions. There are handouts on[DIAGNOSES REDACTED] and a test given to the staff. Staff have been in-serviced on our abuse and neglect policy. This will continue until all staff have been in-serviced. The in-servicing was started on 1/30/17 and will be completed by 1/31/17. Staff that is not in-serviced will not be allowed to work until they complete the in-service beginning on 1/31/17. A sign has been posted on the front door that about information in regard to signs and symptoms of the[DIAGNOSES REDACTED] on 1/30/17. Visitors are requested to not visit if they have signs and symptoms of the[DIAGNOSES REDACTED]. Visitors are required to sign in on the visitor log and additional information in regard to the[DIAGNOSES REDACTED] is provided at the visitor sign-in log at the receptionist desk. The Receptionist and ABOM are responsible that visitors sign in and are made aware of the[DIAGNOSES REDACTED] outbreak and given needed information that is at the visitor sign-in log. This started on 1/30/17 and will remain in place until 2/14/17. All families or resident responsible parties have been notified by phone calls about the signs and symptoms, transmission and prevention of the[DIAGNOSES REDACTED] and that they should seek information from their local physician or go to the emergency room if they have symptoms. They have also been asked to not visit if they have any signs or symptoms of the[DIAGNOSES REDACTED]. This was completed on 1/30/17 with only six families that could not be reached. The Social Worker will continue to attempt to contact them on 1/31/17 until they are reached or an alternate responsible party or the resident themselves is reached. They are being notified that we had an employee that was symptomatic on 1/12/17 and precautions should continue through 2/7/17. A letter was mailed on 1/30/17 to each resident ' s family member or responsible party that is listed on their face sheet as follow-up to the phone calls with the same information. All residents in the facility on 1/30/17 have been given a notice by hand delivery that describes the signs and symptoms of the[DIAGNOSES REDACTED] and asks that they notify nursing staff, or any other staff to assist them in getting medical attention to monitor their symptoms if they have signs and symptoms of[DIAGNOSES REDACTED]. (Physician A), (Physician B), and (Physician C) that see residents here in the facility have been notified by the Administrator and the DON of the signs and symptoms of the[DIAGNOSES REDACTED] and advised by telephone and of the situation of exposure to the residents. The physicians have been hand-delivered or faxed over the Department of State Health Services Mump Fact sheet as well as the CDC information on[DIAGNOSES REDACTED], Chapter 9 from the manual for the Surveillance of Vaccine-Preventable Diseases which is the same information used in the in-servicing of the nursing staff. This information is printed and available to the charge nurses at the nurses' station for a reference if speaking with a physician. This was completed on 1/31/17. The facility is currently getting all immunization records of all staff and if they do not have these records they must be scheduled for an immunization from their local physician or at the local health department. This was started on 1/26/17 and will continue through 2/3/17. Any staff that have not complied with the immunization records request and that has not been immunized will be removed from their schedule of working here on 2/3/17 until they have done one of the above items. 4) The MAR indicated [REDACTED]. If there is an additional case of the[DIAGNOSES REDACTED], the end date for the daily assessment and monitoring will be 25 days from the latest exposure date. The DON or designee will monitor that this is being done and documented daily starting 1/31/17. During morning clinical meeting the DON and ADON will review any residents that have signs and symptoms of the[DIAGNOSES REDACTED] and follow up with the physician immediately starting on 1/31/17. The physician, DON and family will be notified of any findings of signs and symptoms of the[DIAGNOSES REDACTED] by the nurses when they complete their daily assessments of the residents starting 1/30/17. The nursing staff will continue to monitor for signs and symptoms of the[DIAGNOSES REDACTED] daily q shift until 2/14/17 per CDC guidelines. The DON and ADON D will follow up daily that this is taking place per plan. The physician will make a determination of a [DIAGNOSES REDACTED]. The health department will notified accordingly. These issues will be monitored by the QA team weekly through 2/14/17 for compliance and thereafter monthly for next 4 months to ensure compliance. The DON and Administrator have be in-serviced on 1/30/17 by the RNC about [MEDICATION NAME], understanding of the Provider letter 14-13 and notifiables to DHHS . Interviews with Residents #6, #7, #8, #9, #10, #11, #12, and #13 on 01/31/17 between 1:00 p.m. and 1:25 p.m. confirmed they had received a letter and education about the signs and symptoms of the[DIAGNOSES REDACTED]. Interviews with LVN F, CNA N, Hostess O, LVN E, RN H, and LVN G revealed they had received an in-service over the signs and symptoms of the[DIAGNOSES REDACTED], proper use of PPE, and the transmission and prevention of the[DIAGNOSES REDACTED]. Observation of the front entrance on 02/01/17 at 9:00 a.m. revealed there was a letter detailing the signs and symptoms of the[DIAGNOSES REDACTED] and warning visitors to go see a physician if they are experiencing any of the signs or symptoms. Interviews with the families of Resident #14 and Resident #15 on 02/01/17 between 10:12 a.m. and 10:17 a.m. revealed they had been notified on 01/31/17 that their family member had been exposed to the[DIAGNOSES REDACTED]. They were informed about the signs and symptoms of the[DIAGNOSES REDACTED]. Review of fax confirmations dated 01/31/17 to Physicians A, B, and C revealed they had been notified of the facility[DIAGNOSES REDACTED] outbreak and given the CDC recommendations. Observation of the nurse's desk on 02/01/17 at 9:15 a.m. revealed there was a list of the signs and symptoms of the[DIAGNOSES REDACTED] and a change of condition form available to nurses when they spoke to a resident's physician. Review of the Medication Administration Record [REDACTED]. Each resident on all halls had been assessed for the signs and symptoms of the[DIAGNOSES REDACTED]. Review of in-service records, dated 01/30/17, revealed the DON and Administrator were educated on Provider Letter 14-13, which identified issues needing to be reported to DADS. They were also educated on notifiable conditions for DSHS. On 02/01/17 the Administrator and the DON were informed the IJ was removed. While the IJ was removed on 02/01/17, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of widespread because the facility was still monitoring the implementation of the Plan of Removal. The Resident Daily Census dated 01/30/17 provided by the DON reflected a census of 80.

Based on Observation, interview and record review, the facility failed to ensure two (Residents #2 and #14) of nine residents reviewed for falls received adequate supervision and assistance devices to prevent falls and/or accidents. 1) Resident #14 experienced seven falls from June to September 2013 resulting in a fracture of the wrist and a fracture of the toe on two separate occurrences. the majority of Resident #14's falls were when she was trying to go to the bathroom, but despite being identified as a candidate for a bowel and bladder program, she was not ever put on a bowel and bladder program. Despite orders for PT (physical therapy) and OT (occupational therapy) to evaluate and treat, Resident #14 was not provided therapy services due to funding. 2) Despite Resident #2 sustaining two falls and sustaining lacerations, the facility failed to assess the resident for implementation of new interventions to address these issues and try to increase the resident's safety and reduce falls with injuries. These failures to implement new interventions to prevent the potential for falls could affect the facility's 20 residents identified with falls, including Resident #2 and #14, and placed them all at risk for continuing to fall, sustaining injuries, which could be life-threatening and result in loss of cognition, the need for further medical treatment and hospitalization . Findings included: 1) Resident #14's Admission MDS assessment, dated 04/30/13, reflected Resident #14 required extensive assistance of two-person for transfer. An MDS assessment dated [DATE] reflected Resident #14, a [AGE] year-old female, was readmitted to the facility on [DATE]. Resident #14 spoke clearly, was able to make herself understood and had the ability to understand others. Resident #14 was moderately impaired cognitively. Resident #14 was assessed and required extensive assistance of two-person physical assist for toileting. Resident #14 was not steady, only able to stabilize with staff assistance for balance during transitions and walking, moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, Moving on and off toilet, Surface-to- surface transfer (transfer between bed and chair or wheel chair.) Active [DIAGNOSES REDACTED]. Resident #14's care plans, dated 04/30/13, reflected, "has Dx. (diagnosis) of Parkinson's. Resident at risk for injuries related to disease, Dx. psychosis and osteoporosis, potential for falls r/t weakness Approach: "Uses rollator (rolling walker with a seat) to ambulate." Resident #14's Assessment of Risk for Falls, dated 05/27/13, reflected a total score of 8, which indicated she was at high risk for falls. On 09/16/13 at 10: 26 a.m. during initial tour, Resident # 14 was observed lying in bed wearing a right wrist support while holding her telephone. On 09/16/13 at 1:04 p.m. Resident #14 was observed ambulating in the hallway using a rolling walker with no staff assistance. On 09/18/13 at 3:20 p.m. Resident #14 was observed ambulating in the hallway using a rolling walker with no staff assistance. The facility's Incident/Accident report, dated 06/01/13 at 3:15 p.m., reflected Resident #14 was walking back to her bed from her front door and lost her balance. She fell backwards and hit her head on the air conditioner. Resident #14 sustained a skin tear to her left elbow and wrist. Ice was applied to her head and left foot. The Report also reflected staff asked Resident #14 if she was using her walker, and she said, "No." Nurse's note, dated 06/01/13 at 3:15 p.m. ,reflected Resident #14 had a "3 x 2 light purple bruise to the left side of her scalp above her left ear, abrasion to her left elbow, abrasion to her left wrist, redness and swelling to her left 4th and 5th toes and top of her foot. Resident#14's care plan ,dated 06/01/13, reflected "Problem: Fall/Goal: Resident will be free of complications related to falls. Approach: Notify physician and family /responsible person, Monitor x 72 hours for possible injury Related to fall, Neuro checks x 72 hours if appropriate, document assessments. Encourage resident to use call light, assist as needed. Report changes in endurance, ambulation, transfer, etc. Assess for proper fitting clothing items, if appropriate." Nurse's note dated 06/02/13 at 12:33 p.m. reflected "6/2/13 at 7 a.m. Res (Resident #14's) left foot bruised and tender, slightly swollen, X-ray ordered. (Resident #14) able to bear weight but, says it is tender. Nurse's note, dated 06/02/13 at 12:37 p.m., reflect X-ray here to x-ray. "At 12 p.m. spoke with Nurse Practitioner x-ray results showed 5th metatarsal neck fracture. " "New order to send Resident #14 to emergency room to evaluate and treat as indicated." Resident #14's Assessment of Risk of Falls, dated 06/03/13, reflected a total score 11, which indicated she was at high risk for falls. The Assessment also reflected, "Regardless of score, any resident with previous falls should be considered high risk until 'fall free' for 6 months." Resident #14's Therapy Screening Form, dated 06/03/13 through 06/04/13, reflected Physical Therapy recommendations for Skilled therapy evaluation, restorative nursing service, restorative nursing plan revisions were not indicated. The form also reflected to rescreen the resident, but the area for weeks/months was blank. Occupational Therapy Recommendations (were for) skilled therapy evaluation, restorative nursing services, restorative nursing plan revisions was not indicated and re-screen, but the time frame was blank. The facility's Incident/Accident report, dated 07/18/13 at 3:30 p.m., reflected Resident #14 was ambulating independently without her walker, lost her balance and fell trying to go to the bathroom. It was documented on the report the resident was at high risk for falls. The Follow-up/Implementation/Disposition section of the Report reflected, "Instructed Resident to wear shoes to ambulate,Therapy Screen and Instructed Resident to use her walker." Resident# 14's Assessment of Risk of Falls, dated 07/18/13, reflected a total score of 7, which indicated she was at high risk for falls, and "Regardless of score, any resident with previous falls should be considered high risk until 'fall free' for 6 months." Resident#14's care plan, dated 07/19/13 , reflected " Problem: Fall/Goal: resident will be free of complications related to falls. Approach: Notify physician and family /responsible person, Monitor x 72 hours for possible injury related to fall, Neuro checks x 72 hours if appropriate,document assessments. Encourage resident to use call light,assist as needed. Report changes in endurance, ambulation, transfer, etc. Assess for proper fitting clothing items, if appropriate. Monitor at frequent intervals, reposition for comfort and safety. Assess for medications which may be a contributing factor." The facility's Incident/Accident report, dated 07/19/13 at 3:00 p.m., reflected Resident #14 was ambulating back from the bathroom in her bare feet using her cane, lost her balance and fell , and complained of pain to her right wrist. The physician ordered a STAT (now) x-ray. The Follow-up/Implementation/Disposition section of the report reflected, "Therapy to screen, staff to remove cane, Resident to ambulate with walker, Resident sent to emergency roiagnom on [DATE] 1600 (4:00 p.m.) Fractured wrist." Emergency Service Record, dated 07/19/13 at 4:51 p.m., reflected Resident #14 "complained right wrist pain with obvious deformity second to a fall one hour ago. Patient felt her wrist crack and the pain radiated up her arm. Patient fell yesterday as well but Patient just fell on her bottom and was just sore this morning. Patient reported a ten /ten pain." Nurse's Notes, dated 07/20/2013 at 12:28 p.m. for 07/19/13 at 3:00 p.m., reflected Resident #14 was lying in the bathroom floor with her head at the bathroom doorway, and her cane on the floor next to her. She complained of severe pain to her right wrist. Resident #14 indicated while she was ambulating to the bathroom, her cane slipped, and she fell on the floor. The Nurse's Note also reflected her wrist had some swelling, but no redness, and the physician ordered a STAT x-ray. Orthopedics Consult Note MD H, dated 07/21/13, reflected reason for consult right wrist fracture. "Patient has multiple medical issues and Dementia with frequent falls." A telephone order, dated 07/21/13, reflected instructions to readmit Resident #14 to the facility for Rehabilitation, and Physical Therapy, and Occupational Therapy needed to evaluate and treat her as indicated. The order also reflected to follow-up with Dr. Harmon on Monday 07/22/13 and Fall Precautions. Resident #14's Hospital Facility Transfer Physician orders, dated 07/21/13, reflected Fall Precautions, Bed, Alarm/wheel chair alarm to prevent falls. The facility's Incident/Accident report, dated 07/25/13 at 10:05 p.m., reflected Resident #14 fell when she ambulated to the closet. She stated "her legs crossed and went out from under her." She complained of neck pain, back pain, right shoulder pain, right anterior rib cage pain. The report reflected there resident had increased confusion and was shaking with pain. The Follow-up/Implementation/Disposition section reflected MD E placed the resident on Exelon on 07/26/13. Nurse's Note, dated 07/25/13 at 8:51 a.m., reflected " 12:15 a.m. on 07/25/13 called to Resident #14's room and saw her sitting on the floor facing the bathroom door with her legs bent. " The note reflected when the resident was asked what she was doing when she fell , she replied " going to the bathroom. " Further review of the Nurse's Notes revealed her call light was not on. X-Ray results, dated 07/25/13, reflected Resident #14 had no fractures but her cervical spine bones were osteoporotic. Resident #14's care plan, dated 07/25/13, reflected Problem: Fall / Goal: Resident will be free of complications related to falls. / Approach: Notify physician and family, responsible person, Monitor x 72 hours for possible injury elated to fall, Neuro checks x 72 hours if appropriate, document assessments. Encourage resident to use call light, assist as needed. Report changes in endurance, ambulation, transfer, etc. Assess for proper fitting clothing items, if appropriate. Monitor at frequent intervals, reposition for comfort and safety. Assess for medications which may be a contributing factor. " Resident #14's Therapy Screening Form, dated 07/26/13, reflected Physical Therapy Recommendations for Skilled therapy evaluation, Restorative nursing service, Restorative nursing plan revisions and Rescreen in ( ) weeks/ month areas was not indicated. Occupational Therapy Recommendations for Skilled therapy evaluation indicated, Restorative nursing services Restorative nursing plan revisions and Re-screen in ( ) weeks /month was not indicated. Resident #14's Physician's Telephone Order, dated 07/29/13, reflected Physical and Occupational Therapy to evaluate and treat for falls. Resident #14 Assessment of Risk of falls, dated 07/21/13 and 07/29/13, reflected a total score of 9 and 7, respectively, which indicated she was at high risk for falls. The Assessments also reflected, "Regardless of score,any resident with previous falls should be considered high risk until 'fall free' for 6 months." Resident #14's care plan update, dated 07/31/13, reflected "has potential for falls r/t weakness and confusion. She has had mult. Falls, has dx. Parkinson's resident at risk for injuries related to disease." "Approaches: Will not call for assist every fifteen minute checks." Nurse's Notes, dated 08/18/13 at 7:54 a.m., reflected Resident #14 "sitting on floor in doorway of room. When asked what she was doing when she fell , Resident was not able to give me an answer. States did not hit head. Floor around doorway dry, full head to toe assessment performed with no sign of injury noted, Assisted back to bed by one staff." Incident/Accident report dated 08/18/13 at 4:12 p.m. reflected Resident #14 "in wellness room Resident attempted to sit on walker but walker breaks are non-functional therefore walker rolled back as resident tried to sit on it and Resident fell on floor butt first." Intervention/ Treatment at time of incident: "Advised Resident not to sit on walker any more, "resident to sit in chair. Alert,awake,oriented times 3. Follow-up/ Implementation / Disposition: Therapy to screen. Resident#14 Assessment of Risk Falls dated 08/18/13 reflect a total score of 8. Score: 07-18 Resident is high risk. "Regardless of score, any resident with previous falls should be considered high risk until "fall free" for 6 months." Resident #14's Care Plans, dated 08/18/13, reflected Problem: Fall / Goal: Resident will be free of complications related to fall. Resident#14 care plan dated 07/25/13 reflected Problem: Fall/Goal: Resident will be free of complications related to falls. Approach: Notify physician and family, responsible person, Monitor x 72 hours for possible injury elated to fall, Neuro checks x 72 hours if appropriate, document assessments. Encourage resident to use call light, assist as needed. Report changes in endurance, ambulation, transfer, etc. Assess for proper fitting clothing items, if appropriate. Monitor at frequent intervals, reposition for comfort and safety. Assess for medications which may be a contributing factor. " Resident has dementia. She has poor safety awareness and gets up without assist. Staff must redirect her, toilet her, offer fluids, snack. Resident #14's Therapy Screening Form, dated 08/19/13, reflected Physical Therapy Recommendations for Skilled therapy evaluation, Restorative nursing service, Restorative nursing plan revisions and Rescreen in ( ) weeks/ month areas was blank. Occupational Therapy Recommendations for Skilled therapy evaluation, Restorative nursing services. Restorative nursing plan revisions and Re-screen in ( ) weeks / month was not indicated. Incident/Accident report, dated 09/10/13 at 7:00 p.m., reflected Resident #14 CNA (certified nurse aide) witnessed Resident lower herself to her knees, then sit on the floor. Resident stated she was in pain and sat down due to her knees hurting. An interview on 09/18/13 at 12:20 p.m. with LVN (licensed vocational nurse) F revealed Resident #14 had several falls occurring in the evening. LVN F stated, "(MD D) and (MD E) were adjusting her medications." When asked if Resident #14 was on a Bowel and Bladder program, LVN F replied, "I'm not sure. I do not think so. I would have to look in the book." When asked what else was being done to prevent Resident #14's falls, LVN F replied, "She was on every fifteen minute checks, until just a few days ago." When asked if she could describe the every 15 minute checks, LVN F responded, "We see if she needs to go to the bathroom, help reaching something, turning television and help with phone." When asked if there were any other interventions to prevent falls, LVN F replied, "No. Just checking every 2 hours just like everyone else." An interview on 09/18/13 at 12:20 p.m. with the Director of Therapy Services, who was a Physical Therapist, revealed, Resident #14 "was screened. We cannot treat if there is no funding and she does not have any. We write a restorative plan of care sometimes if they do not have funding." When asked if Physical Therapy or Occupational Therapy evaluated Resident #14 as ordered by the physician on 07/21/13 and 07/29/13, the Director replied, "No. I did not know about the Physician evaluation order." Resident #14's Assessments for Bowel and Bladder Training reflected Resident #14 was scored as a "Good candidate for individual training." The assessments included: a score of 4 on 05/27/13, a score of 4 on 06/03/13, a score of 2 on 07/18/13, and a score of 6 07/21/13. A score of 00- 06 indicated Resident #1 was a good candidate for individual training. An interview on 09/18/13 at 1:40 p.m. with LVN G, the MDS Coordinator, revealed when asked if she had Restorative Nursing Notes for Resident #14, she replied, "She is not on restorative. She was admitted ,[DATE] and has not been on Therapy." Resident #14's Nurse's Notes, dated 07/29/13 at 3:37, reflected New order for Physical Therapy and Occupational Therapy to evaluate and Treat for falls Resident #14 Nurses Notes dated 07/29/13 at 3:37 reflected New order for Physical Therapy and Occupational Therapy to evaluate and Treat for falls. On 09/18/13 at 1:20 p.m. during an interview with LVN F said she did remembered receiving an order on 07/29/13 for Physical Therapy and Occupational Therapy to evaluate and treat for falls. The Surveyor asked what did you do with the order. LVN F said "I completed a communication form made a copy of the Doctor's order. I took it to therapy department that day. I can't remember who I gave it to. I remember taking it to the Therapy Department and I gave it to one of them and I documented in the Nurses Notes. Review of. 3) These failures to implement new interventions to prevent the potential for falls could affect the facility's 20 residents identified with falls, including Resident #2 and #14, and placed them all at risk for continuing to fall, sustaining injuries, which could be life- threatening and result in loss of cognition, the need for further medical treatment and hospitalization . Findings included: (1) The Face Sheet date 08/01/13 reflected Resident #2 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS assessment dated [DATE] reflected Resident #2's ability to understand others reflected she was easily distracted on a daily basis, sometimes understands, and would respond to simple, direct communication only; and had short term memory problems; and was moderately impaired cognitively with poor decision-making ability and required cues and supervision. The MDS assessment reflected Resident #2 required the extensive assistance of two people for transfers, and bed mobility. The MDS assessment reflected Resident #2's balance was not steady, during surface to surface transfer, but able to stabilize without staff assistance. The quarterly MDS dated [DATE] reflected Resident #2's ability to understand others reflected she was easily distracted on a daily basis, sometimes understands, and would respond to simple, direct communication only; and had short term memory problems; and was moderately impaired cognitively with poor decision making ability and required cues and supervision. The MDS reflected Resident #2 required the extensive assistance of two people for transfers, and bed mobility. The MDS reflected Resident #2's balance was not steady, during to surface to surface transfers, but able to stabilize without staff assistance. According to the MDS assessment, Resident #2 had not fallen since admission or readmission. Resident #2's Assessment of Risk for Falls dated 09/06/13 reflected a score of 12 and on 06/05/13, a score of 12, both of which indicated the resident was a high risk for falls. The form reflected the resident should be considered a high risk for falls until being free from falls for six months. The Assessment included the resident had no changes in the past quarter, and no reflection of falls was documented. Further review of Resident #2's clinical record reflected a general health/mobility assessment dated [DATE] reflecting Resident #2 had basic mobility while in a chair, maximum assist for transfer, and limited use of lower extremities. The facility's Incident/Accident Log reflected the following falls from June 2013 through 09/16/13 for Resident #2: 07/09/13 and 09/4/13. Review of Resident #2's Care Plans revealed there were three care plans, two with onset dates of 07/27/12, one with onset date of 07/09/13, and two care plans that had no onset dates related to: 1. Risk for injury related to the resident's history of hip fracture/weakness. Interventions/approaches included: keep call light in reach in room and encourage her to call for help, monitor frequent and keep frequently used items in reach, therapy as ordered, assist with ADL needs as needed, supplements as ordered, winged mattress, wheelchair alarm, bed alarm, and low bed with mat. Care Plan was updated on 10/17/12, 01/09/13, 03/27/13, 06/12/13, and 08/20/13. There were no updates for 07/09/13 and 09/04/13. 2. At risk for falls related to Resident #2's needs for assist with daily care. Interventions/approaches included: monitor resident for high risk of falls. Care Plan was updated 10/17/12, 01/09/13, 03/27/23, 06/12/13, and 08/20/13. There were no updates for 07/09/13 and 09/04/13. 3. Resident #2 will be free of complications related to fall. Intervention/ approaches included: encourage resident to use call light, assist as needed, report changes in endurance, ambulation, transfers, etc., monitor at frequent intervals, reposition for comfort and safety. This care plan was dated 07/09/13 with no updates. 4. Resident #2 is on Restorative care (no plan was available or provided) to meet highest practicable level of function. Interventions included: follow programs as written by therapist (no programs available or were provided by therapist), report to therapy/nursing as needed for improvements/decline, and adjust programs as needed to fit resident abilities (no programs were provided by therapy or nursing). This care plan was undated with no updates for 07/09/13 or 09/04/13. 5. Resident will be free of complications related to fall. Interventions/approaches included: encourage resident to use call light, assist, as needed, report changes in endurance, ambulation, transfers, etc., and monitor at frequent intervals, reposition for comfort. This care plan was located in Resident #2's clinical record with no name on the care plan and was undated. 6. Review of care plan conference summary dated 09/04/13 reflected areas discussed: nursing restorative program (no plan was available or provided), and rehab not on service at this time. Observation during initial tour on 09/16/13 at 9:30 a.m. revealed Resident #2 was in a low bed with mats on the floor on each side of the bed, sleeping. There were no alarms observed at this time on the bed. Observation on 09/16/13 at 12:45 p.m. revealed Resident #2 in her room in her low bed eating lunch meal, interview with CNA A revealed Resident #2 stays in the bed and gets up between meals now, because she eats better when in the bed. Observation on 09/17/13 at 9:45 a.m. revealed Resident #2 sitting her wheelchair in the library area, leaning over in wheelchair, asleep, while in an activity. No alarms were observed on the wheelchair. During this observation there was a cushion noted in Resident #2's wheelchair. Interview on 09/17/13 at 12:45 p.m. with LVN B revealed this was a pressure reducing cushion, a lot of resident have those types of cushions here. Interview on 09/17/13 at 1:00 p.m. with two unidentified staff members in the therapy department revealed the did not really handle the residents that had falls, but did know there were therapy screens done with in the first 24 hours after the fall and then treatment was done if necessary. The screens on each resident were done monthly or quarterly, but the Director of therapy handled those. Interview on 09/17/13 at 1:56 p.m. with LVN B revealed she was worried about Resident #2 in the bed all the time, because she felt she would do better if she was up some, but she was afraid of her falling out of her wheelchair. The surveyor queried concerning does therapy involve themselves in making suggestions to the nursing staff concerning devices for safety, LVN B said , well I know they do screens when somebody falls, but that is all I know. LVN B said, I had thought about getting her one of those wheelchairs that lean back, but I never did ask anybody about that. Interview on 09/18/13 at 10:07 a.m. with CNA A revealed the staff use to get Resident #2 up for meals, but when she does gets up we had to put her back to bed, because she could fall forward out of her wheelchair, because she leans over in her chair. Interview on 09/18/13 at 11:20 a.m. revealed the Rehab Director said they discuss each fall in the morning meeting, they screen the resident, and then the Rehab Director checks with the business office to confirm payer source, and then they evaluate for treatment depending on the payer source. The surveyor queried what the Rehab Director meant by "depending on the payer source." The Rehab Director said, "We do not treat any resident that does not have a payer source. we put them on restorative program." The surveyor queried concerning the therapy screens for Resident #2. The Rehab Director said we dropped the seat of her wheelchair. When asked to show the surveyor the documentation of that screening, none was provided. The Rehab Director was informed the screens were completed on Resident #2. The Rehab Director said she was aware of one (07/09/13), but not the other screen (08/19/13). The surveyor asked the Rehab Director if she was aware of interventions recommended by therapy. She said she could not remember. The surveyor read the screening, which indicated no skilled intervention was warranted at this time. Change cushion in wheelchair to one that is less "slick." (Rehab Director did not comment.) 7. Review of Accident/Incident Report dated 07/19/13 reflected Resident #2 "slid" from wheelchair onto floor sustaining an abrasion 1.5 centimeters by 2.0 centimeters to right knee. Further review reflected Resident #2 lies down immediately after meals, so she does not get tired and slouch in chair. Resident #2 has Dementia and has poor safety awareness. Therapy to screen and staff to monitor closely when up in wheelchair. Encourage use of call light while in room were listed as actions and interventions. Underlying Medical Problems identified: balance problems, Functional Straus: impaired sitting balance and Psychological status: evidence of impaired judgment was all identified. 8. Review of Resident Screening Form dated 07/11/13 and signed by Rehab Director reflected recommendations: No skilled interventions warranted at this time. Change cushion in wheelchair to one that is less slick. 9. Review of nurse's notes dated 07/11/13 reflected no documentation that a less "slick " cushion had been placed in the wheelchair. 10. Review of Accident/Incident date 09/04/13 reflected Resident #2 fell on the floor from wheelchair, leaned over until fell hit head on leg of over bed table sustaining a 1 centimeter laceration to middle of her forehead. Interventions and Follow-up: CNA left room to get linen for Resident #2, CNA said the resident was leaning forward, instructed CNA that when a resident is not safely positioned to not walk away from resident. CNA is to call for assist to get linen instead to prevent fall. Further review reflected Underlying Medical Problems: Balance problems, and Functional Status: Impaired sitting balance. Action taken: resident assisted to bed. (No resident Screening Form) 11. Review of nurse's notes dated 09/04/13 reflected when the responsible party of Resident #2 was notified of the fall, the responsible party suggested that Resident #2 should have her pain medication reviewed because she was taking stronger than what she had taken before. The nurse in charge at that time spoke with the physician and the physician change the pain medication from daily three times per day to as needed. Interview on 09/04/13 at 1:45 p.m. with CNA A revealed she was working on the day Resident #2 fell from her wheelchair. CNA A said she was orientating a new CNA and she told the CNA to take Resident #2 back to her room from the dining room after lunch and she would be there to help her. CNA A said she had to get another resident back to their room that required assistance. CNA A said the new CNA left Resident #2 in her room to go get some linen and when CNA A arrived back to the room Resident #2 had fallen and hit her head and had a cut on it. The surveyor queried CNA A if Resident #2 had ever had a different cushion or chair since she had fallen back in July, CNA A said, "No." Surveyor asked CNA A was she ever asked what would be good for the resident's safety, CNA A said, "you mean the big wigs up front, no they never ask us anything about that." CNA A said it is not like you can raise your hand and say I know what Resident #2 needs, one of those chairs that lean back. Interview on 09/18/133 at 2:48 p.m. with Administrator, and DON revealed the Administrator said, "I can tell you the payer source does not affect any residents from receiving therapy if they need it." The DON said, "I am pretty sure Resident #2 had restorative therapy, the restorative program is in accu-nurse" , the surveyor asked the DON to provide this information to the survey team, at the end of survey on 09/19/13 no information had been provided. During this interview the surveyor queried concerning bed/chair alarms the DON and the Administrator both said this facility does not use any kind of alarm. When surveyor stated it was noted in Resident #2's current care plan, the DON said, well that must have been before. Interview on 09/19/13 at 10:42 a.m. with DON revealed at the nurse's station there was a "box" which had been there forever, in the box was cards, which allowed the nurses to review to know what to do in certain situations. The DON said, "It is like our protocols." 12. The facility's P/P entitled Fall Prevention and Management Program Policy undated provided by the Administrator on 09/19/13 and identified as current. A Fall Prevention Program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Procedures: 1. A Fall Assessment is completed within 24 hours following admission, using the Fall Risk Assessment. An interim Care Plan will be initiated for residents determined to be at risk. 2. Each resident will be assessed upon admission, readmission, after 48 hours. 3. If triggered on the MDS, the Resident Assessment Protocol for falls is completed. 4. Individualized care plan interventions will be implemented for residents found to be at high risk for falls. Interventions should include: a. Immediate assessment after falls. b. Assess need for therapy evaluation. c. Implement a communication system whereby all caregivers are alerted to the fact that certain residents are at high risk for falls, ... d. Provide resident and family education relative to the resident's particular situation. (Transfer needs, medication side effects, need for assistive devices, etc.) f. Offer frequent toileting or follow individualized toileting schedule, if appropriate. h. Assess need for bed alarms .... i. Personal alarms attached to chair or bed. k. Restorative program to improve mobility and/or lower extremity strengthening. 5. When a fall occurs, staff must immediately: assess the injury, if any; treat the injury; and identify the cause of the fall. Initiate the Comprehensive Assessment Following a fall form. Initiate Interdisciplinary Assessment/Intervention Checklist. 6. Document on the Checklist the interventions and the date implemented. 9. Negative Outcome Review: a. Falls should be reviewed DAILY. Stand-up meetings should include interdisciplinary discussion of all falls occurring within the 24 hours. b. Documentation should be reviewed. c. Assure the immediate interventions are in place. d. Assure the care plan has been updated. 13. The facility's Protocols provided by the DON on 09/19/13 undated reflected: FALL Symptom or Sign/Fall: Immediate: notify as soon as possible, with any suspected serious injury, any hip pain, or more than minor pain elsewhere. Non-immediate: Notify no later than the next work day, fall with only insignificant injury. Routine: Notify no later than the next regular visit or phone or fax communication, number of falls in patient since last visit. 14. The facility's Form CMS-802, Roster/Sample Matrix provided on 08/16/13 by the DON reflected a total of 1