Every finding on record at Sabine Heights Nursing and Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for two (Resident #1 and Resident #2) of two residents reviewed for quality of care. The facility failed to transfer Resident #1 safely and appropriately, leaving her armpit, arm, and chest area bruised. The facility failed to transfer Resident #2 safely when they failed to ensure the gait belt was not too loose to use appropriately and lifted the resident mostly under her armpits when transferring her from the bed to the wheelchair on 05/01/26. This failure could affect the residents by placing the residents at risk for discomfort, pain, and/or injury. Findings included: 1. Record review of Resident #1's face sheet, dated 05/01/26, reflected an admission date of 11/04/25. Resident #1's active diagnoses included iron deficiency anemia (blood disorder defined by low hemoglobin level caused by insufficient iron, resulting in reduced oxygen delivery to body tissues), muscle weakness, lack of coordination, and muscle wasting and atrophy (loss of muscle tissue, resulting in decreased muscle size and strength). Record review of Resident #1's quarterly MDS assessment, dated 02/05/26, reflected a BIMS summary score of 09, which indicated moderate cognitive impairment. The functional abilities section under mobility for sit to stand reflected 02, which indicated substantial/maximal assistance - helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort. Record review of Resident #1's ADL care plan, initiated 11/12/21, reflected .[Resident #1] has an ADL self-care performance deficit r/t impaired balance and Chronic bilateral (both sides) knee pain secondary to osteoarthritis (degenerative joint disease) . Record review of Resident #1's skin related incident report, dated 04/24/26, reflected .Nurse was called to the resident?s (sic) room by CNA. Upon assessment, the resident was noted to have bruising to the right upper arm and right upper chest area. The resident complained of pain in the affected areas. The resident stated that the bruising occurred after being transferred from bed to wheelchair. When they moved me to my w/c yesterday it got there.bruise.right shoulder (front). Record review of Resident #1's weekly skin review/assessment, dated 04/24/26, reflected .site 6) right shoulder (front). res has bruising on the right shoulder. Record review of Resident #1's head to toe skin check, dated 04/29/26, reflected .intact skin.existing bruise (s). Resident has bruising to right upper arm and right upper chest that is starting to fade.12) Chest.15) Right antecubital (transition zone between the arm and forearm) . During an interview with Resident #1 on 05/01/26 at 09:26 a.m., she stated she was always assisted by two people. She stated she had bruising and revealed a deep purple bruise under her armpit extending to her bicep that covered most of her bicep. She stated the bruising extended to her chest and down her side. She was unable to give an exact date of the incident, but said two people assisted her from her bed to her wheelchair by holding her under her arms. She stated, I got bruised.yes it hurt.my arm is bruised. She was unable to recall which staff assisted her. 2. Record review of Resident #2's face sheet, dated 05/04/26, reflected an admission date of 04/11/26. Resident #1's active diagnoses included displaced fracture on right foot, muscle weakness, lack of coordination, and hemiplegia and hemiparesis following a stroke affecting the left side (paralysis and weakness on one side). Record review of Resident #2's quarterly MDS assessment, dated 04/16/26, reflected a BIMS summary score of 12, which indicated moderate cognitive impairment. The section for mobility devices included use of a walker and wheelchair. Record review of Resident #2's ADL care plan, initiated 04/21/26, reflected . The resident has an ADL self-careperformance deficit r/t FRACTURE OF UNSPECIFIED METATARSAL BONE(S) (bone in the midfoot that connects ankle to toes), RIGHT FOOT, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH DELAYED HEALING. During an observation on 05/01/26 at 09:35 a.m., CNA A and CNA B were assisting Resident #2 to her wheelchair. The wheelchair was tilted facing the bed and the wheels were locked. There was a gait belt around the resident. When the two CNAs grabbed the gait belt, it was way too loose as evidenced by a huge gap when they attempted to hold it. It was loose enough; it went up to the armpit immediately. There was a CNA on each side of the resident, holding under each armpit and the resident was pivoted into the wheelchair. There were no signs of pain or other issues seen from Resident #2. The transfer was completed, successfully. During an interview on 05/01/26 at 9:38 a.m. with CNA A, she stated she had received training on transfers. CNA A stated gait belts were to be used on all transfers. She stated two fingers should be able to fit under the gait belt. The gait belt should not be too loose or too tight. She stated the gait belt was not tight enough during the observed transfer. She stated improper transfers could cause a fall, bruising, or possibly a shoulder dislocation. During an interview on 05/01/26 at 9:47 a.m. with CNA B, she stated she had received training on transfers. CNA A stated gait belts were to be used on all transfers. She stated two fingers should be able to fit under the gait belt. The gait belt should not be too loose or too tight and should be around the midsection or abdomen area. She stated most of the weight during the transfer was on Resident #2's underarms. She stated improper transfers could cause bruising, or a skin tear. During an interview on 05/01/26 at 11:53 a.m. with CNA A, she stated she worked the day the facility thought the bruising happened with Resident #1. She stated she transferred the resident twice that day with another CNA. She stated she always used a gait belt. She said she had no idea Resident #1 was hurt that day. She never saw any bruising that day, and Resident #1 did not say anything to her that day about pain in her arm. During an interview on 05/01/26 at 11:57 a.m. with PT C, he stated the protocol was to use gait belts during transfers. PT C stated, staff must be careful when using the gait belt, it can put too much stress on the upper body and chest area of the resident and could cause dislocation. The gait belt should be placed at the waist area, and one hand should fit under the gait belt. The gait belt should not be too loose or too tight. There should be one hand at the belt and one at the arm, and most of the weight should be supported by the gait belt. PT C stated improper placement of the belt could cause bruising or more. During an interview on 05/01/26 at 01:18 p.m., the DON stated the gait belt was not put on tight enough for Resident #2's transfer. He stated CNA A and CAN B were probably nervous. He stated the gait belt should be on the lower waist and fit only a couple fingers underneath to not cut off circulation but also should not have slack either. He stated during the observed transfer, the gait belt was loose and once Resident #2 stood up, the gait belt served no purpose. The DON stated Resident #1 was anemic, and that could be the reason for the extensive bruising. The DON stated improper transfers could cause a fall, bruising, or pulling of the skin. The DON stated in-services were initiated for all staff regarding transfers after Resident #1's bruising was found. Review of the facility in-service, CNA - Safely Moving Residents - Lifting and Transferring, assigned 04/28/26, indicated CNA A completed the in-service on 04/28/26 and CNA B had completed the in-service on 04/29/26. Review of the facility's policy, Safe Lifting and Movement Residents, revised July 2017, reflected, .the facility uses appropriate techniques and devices to lift and move residents.5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen (Kitchen #1) reviewed for kitchen sanitation. The facility failed to ensure the current menu for 01/11/2026- 01/17/2026 was posted for residents to see.The facility failed to ensure the wall above the food in the kitchen prep area was not coated with grey dust and debris. The facility failed to ensure the storage food rack in the kitchen food prep area was free from visible dust, yellow and brown sticky colored residue.The facility failed to ensure [NAME] A followed the facility recipe for stewed okra/ tomatoes. These failures could place residents at risk for cross contamination and food-borne illness.Findings Include: During an observation on 01/13/2026 at 9:45 a.m. indicated the menu for week 01/04/2026- 01/10/2026 was posted in the dining area. During an observation in the kitchen on 01/13/2026 at 9:50 a.m. indicated the wall above an uncovered pan of rice in the kitchen prep area was coated with grey dust and debris. The storage/ seasoning rack in the kitchen prep area was coated with dust, and yellow/ brown sticky colored residue. During an observation on 01/13/2026 at 10:15 a.m. indicated stewed okra and there were no tomatoes nor onions in the stewed Okra/ tomatoes. During an interview on 01/13/2026 at 10:20 a.m. with the Dietary Manager, she said she was responsible for updating the menu every Monday. She said she was off Monday 01/12/2026 and was unable to change the schedule. She said she did not have a backup staff member who updated the menu when she was not there. She said the current weeks menu should always be posted so residents would know what to expect to eat at mealtime. She said she could not remember the last time the wall or storage/ seasoning rack in the kitchen prep area was cleaned. She said there is no set time it should be cleaned. The Dietary Manager said it should be cleaned when visible debris or dust is seen. She said she was responsible for ensuring the kitchen was clean and sanitary. The Dietary Manager said she was responsible for contacting maintenance and informing them that the high wall in the prep area needed cleaning. She said the potential associated risk would be for dust to get in the resident's food. She said [NAME] A did not follow the recipe for the stewed okra and tomatoes. She said she told [NAME] A to add sausage to the okra for extra flavor. She said the potential associated risk would be residents not receiving proper nutrient. During interview with Resident #1 on 01/13/2026 at 10:35 a.m. she said the menu had not been posted for approximately 1-2 weeks. Resident #1 said when the menu was posted it was not the correct week. She said it made her upset that she did not know what she is going to eat for the day and week. During an interview on 01/13/2026 at 12:15 p.m. with the Maintenance Regional Supervisor, he said the wall above the food in the kitchen prep area should not have had any grey dust or debris on it. He said the storage/ seasoning rack in the kitchen food prep area should have been free from dust and sticky residue. He said the potential associated risk would be food contamination. He said maintenance staff were responsible for cleaning the high ceiling walls, ensuring they were free from debris. During an interview on 01/13/2026 at 1:30 p.m. with [NAME] A, she said she did not follow the recipe for the stewed okra with tomatoes. She said a lot of residents did not like tomatoes in their okra. She said she put tomato sauce, white vinegar, sausage, and seasoning for the okra. She said the Dietary Manager instructed the cooks what to add or take away from the recipes. During an interview on 01/13/2026 at 1:45 p.m. with the Administrator, he said the menu posted should be current for residents. He said he expected everything in the kitchen to be cleaned daily and free of debris and dust. He said all kitchen staff were responsible for keeping the kitchen clean. He said maintenance was responsible for cleaning the walls above the wall storage/ seasoning rack. He said recipes should be followed. He said the potential associated risks would be residents not knowing what they'll ate for the day, getting dust in their food, and them not getting their approved diet. During record review of the stewed okra/ tomatoes recipe on 01/13/2026 at 2:00 p.m., indicated diced tomatoes, okra, onions chopped, granulated sugar, and black pepper were the needed ingredients. During record review of the facility's policy title Sanitation, dated November 2022, indicated in part: Policy Statement: The food service area is maintained in a clean and sanitary manner.Policy Interpretation and Implementation-All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair.All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. During record review of the FDA Food and Code dated year of 2022 entitled: 3. Assessing Contaminated Equipment and Potential for Cross- Contamination. Indicated in- part: This risk factor involves the proper storage and use of food products and equipment to prevent cross-contamination. The cleaning, sanitization, and storage of food-contact surfaces of equipment and utensils in a manner to prevent transmission of foodborne pathogens or contamination is also included in this risk factor.

Based on interviews and record review, the facility failed to provide required Quality Assurance Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program, for 9 of 18 (LVN E, LVN F, LVN G, LVN H, CNA J, CNA K, CNA L, CNA M, and CNA N) staff sampled for licensure and training. The facility failed to ensure that LVN E, LVN F, LVN G, LVN H, CNA J, CNA K, CNA L, CNA M, and CNA N had completed their mandatory QAPI training. This failure could place residents at risk of being care for by untrained staff.The findings included: Review of the facility's training log, undated, showed no evidence of training for QAPI for LVN E, LVN F, LVN G, LVN H, CNA J, CNA K, CNA L, CNA M, and CNA N. Record review of employee files indicated the following staff had not completed QAPI training during orientation or annually:* LVN E, hire date 12/12/25;* LVN F, hire date 05/12/25;* LVN G, hire date 07/16/25;* LVN H, hire date 12/04/25;* CNA J, hire date 07/03/25; * CNA K, hire date 10/28/25;* CNA L, hire date 12/30/23; and* CNA M, hire date 10/30/23;* CNA N, hire date 10/29/25. During an interview on 01/07/26 at 11:00 a.m., HR said she was not aware of the new requirement for QAPI training. She said she would check with the interim DON and the Administrator. During an interview on 01/07/26 at 11:30 a.m., the interim DON said she thought the last DON should have completed the QAPI training on the staff however she said she was unable to locate any documentation. During an interview on 01/07/26 at 1:10 p.m., the Administrator said his expectation for the QAPI training was it would have been included in their computerized training system. He said if they do not receive the mandatory training the staff might not be fully trained. Record review of the undated Quality Assurance and Performance Improvement (QAPI) Program Plan indicated . Facility employees are provided the necessary training to enable them to perform their jobs effectively. Topics covered in the training program include but are not limited to: . Regulatory requirements . The QAPI Coordinator is responsible for: Leading the QAPI committee.Facilitating staff education on QAPI principles and practices.

Based on interview and record review, the facility failed to ensure the hired Social Worker had the required qualifications for 1 of 1 facility reviewed for social worker qualifications.The social worker hired on 10/06/25, as a full-time social worker was not licensed by the Texas State Board of Social Worker Examiners. This failure could place all residents at risk for unmet social services and psychosocial needs.The findings included: Record review of employee file on 01/07/26 indicated the SW was not a licensed social worker and held a bachelor's degree in social work. The facility hired her as a social worker on 10/06/25. Review of facility's job description dated 10/06/25 for Social Worker position indicated Qualifications: Minimum of a bachelor's degree in social work or in human services fields. Licensed per state requirements or eligible for licensure. Record review of the ASWB licensure examinations website process indicated the following:To become a licensed social worker in Texas, you must earn a CSWE-accredited degree in social work, complete a Texas specific jurisprudence exam, pass the relevant Association of Social work boards (ASWB) exam, undergo a fingerprint background check, and fulfill supervised practice hours for clinical licenses, all while applying through the Texas Board of Social Worker Examiners (part of the Texas Behavioral Health Executive Council) to maintain your license. During an interview on 01/07/26 at 12:00 p.m., the Administrator said the SW had been employed at the facility since 10/06/25. The Administrator said the SW had a Bachelor of Science degree in Psychology and had been preparing to take the licensure exam. He said currently, the SW was not licensed. The Administrator said he wanted her to obtain certification for Texas but did not feel it would change anything except she would receive a pay increase. During an interview on 01/07/26 at 1:00 p.m., the SW said she had researched the application process for certification requirement for the state of Texas, however she had not applied yet. Review of CMS Form 3740, Bed Classification dated 01/07/26 indicated the facility was certified for 150 beds.

Based on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment for 1 of 16 residents reviewed for notification of changes. (Resident #5) The facility did not consult with Resident #5's physician about the pattern of low blood pressure over consecutive days and of the blood pressure medication being held for 15 of 31 opportunities in December 2025 or 3 of 6 opportunities for January 2026. This failure could place residents at risk for complications due to delayed or failed physician intervention.Findings included: Record review of the face sheet dated 01/06/2026 indicated Resident #5 was an [AGE] year-old female admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (a lung condition causing airflow blockage, making it hard to breathe) and high blood pressure (common condition where the force of blood against artery walls are consistently too high, making the heart work harder). Record review of physician orders dated September 2024 indicated the orders for Resident #5 included 25 mg carvedilol once daily for high blood pressure. Parameters set by the physician were to hold carvedilol 25 mg if SBP less than 120, DBP less than 60 or heart rate less than 60. (SBP -the top number -is your systolic pressure-that's the force of the blood flow when blood is pumped out of the heart. DBP - the bottom number - is your diastolic pressure which is measured between heartbeats when the heart is filling with blood) Record review of a quarterly MDS assessment dated [DATE] for Resident #5 included diagnoses of high blood pressure and renal disease (Kidneys are damaged and can't filter waste and extra fluid from blood effectively). Her BIMS was 15 which indicated she was cognitively intact. Record review of the care plan dated 07/07/2024 for Resident #5 indicated she had hypertension. The interventions included giving hypertensive medications as ordered. Hold for SBP below 120, DBP below 60 or heart rate less than 60. Record review of the MARs dated December 2025 and January 2026 indicated carvedilol 25 mg once daily for Resident #5 and to hold the medication if SBP less than 120, DBP less than 60 or heart rate less than 60. On the following dates, the dose of the carvedilol 25 mg was held when Resident #5's B/P was outside the parameters ordered by the physician: 12/2/2025, B/P 118/67;12/05/2025, B/P 98/63;12/07/2025, B/P 104/51;12/08/2025, B/P 135/58;12/15/2025, B/P 108/57;12/16/2025, B/P 121/57;12/17/2025, B/P 101/62;12/18/2025, B/P 10767; 12/21/2025, B/P 107/56;12/22/2025, B/P 100/67;12/23/2025, B/P 100/67;12/25/2025, B/P 108/74;12/26/2025, B/P 108/69;12/29/2025, B/P 103/63;12/30/2025, B/P 94/61;01/01/2026, B/P was 116/72;01/02/2026, B/P was 100/65; and01/05/2026, B/P was 105/67. During an interview and record review on 01/07/2026 at 12:05 p.m., the DON reviewed Resident #5's December 2025 and January 2026 MARs with surveyor. The DON acknowledged that the carvedilol was documented as held due to the prescribed parameters. She had been unaware of Resident #5's medications being held due to low results outside the parameters. She said best practice would be for nursing staff to notify physician when medications with parameters were held on consecutive occasions. The DON said the nursing staff should document in the resident's electronic record when notifying physician of medications being held and acknowledged Resident #5's electronic record gave no indication the physician had been notified of medications being held. Record review of the nurse's notes for Resident #5 dated from 12/05/2025 to 01/05/2026 indicated no documentation of the physician being notified. During an interview on 01/07/2026 at 2:00 p.m., the Administrator said his expectations were for the physician to be notified when a resident's medications were held, or at least every few times. The Administrator said he expected nursing staff to always follow physician orders, to notify of any changes in condition, and to document notifications. Record review of a Employee In-Service Record dated 07/02/2025 indicated the following: . Provider Notification: If there is a pattern of consistently high or low blood pressure, it is the nurse's responsibility to notify the physician (MD) promptly. Documentation and Family Notification.All actions, changes, and responses must be thoroughly documented in the medical record. Record review of policy dated March 2025 titled Administering Medications indicated the following: . Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders.

Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 4 residents (Resident #14) reviewed for care plans. The facility failed to develop and implement a comprehensive care plan for significant change in condition on 12/04/2025 for Resident #14 when she was placed on hospice. This failure could place residents at risk of receiving inadequate care and services.Findings included: Record review of Resident #14's face sheet dated 01/05/2026 indicated she was a [AGE] year-old female with a re-admission date of 10/24/2025. Pertinent diagnoses included chronic obstructive pulmonary disease (inflammation and damage to lungs.) type 2 diabetes (high blood sugar.) obesity, shortness of breath, hypertension (high blood pressure). Record review of Resident #14's significant change MDS assessment dated [DATE] indicated she had a BIMS of a 15 indicating she was cognitively intact. Section A- Identification Information indicated the type of assessment was (04.) significant change in status assessment for hospice. Record review of Resident #14's care plan had a review start date of 12/1/2025 and a target completion date of 12/17/2025 indicated the care plan was not initiated nor completed for her change in condition related to her being placed on hospice. Record review of Resident #14's census list dated 01/07/2026 indicated she had a payer change on 12/04/2025. Record review of Resident #14's order summary dated 01/05/2026 indicated she had a change in condition on 12/04/2025 when she was admitted to hospice. During an interview on 01/07/2026 at 10:47 a.m. with the Regional Nurse Consultant (interim DON) she said the administrative admission team (MDS, DON, (interim DON), ADON) is responsible for updating residents' care plan. She said her expectation was for significant changes to be added to the care plans in a timely and accurate manner. She said she believed Resident #14's care plan was overlooked by her and the ADON due to the facility's MDS and DON vacancy. She said Resident #14's hospice significant change in condition should have been added to her care plan. She said if significant changes are not added to the care plans, then it could place residents at risk for not receiving needed care. She said the facility did not have a policy on care plans and that they used the RAI manual. During an interview on 01/07/2026 at 11:00 a.m. with the ADON she said the DON, MDS nurse, and herself were responsible for initiating, updating, and completing care plans. She said the Regional Nurse Consultant (interim DON) and herself were responsible for care plans due to the MDS and DON vacancy. She said Resident # 14's care plan should have been done when she was placed on hospice but had been overlooked. She said the potential risk to residents would be a lapse in care if the hospice significant change is not added to the care plans. During an interview on 01/07/2026 at 2:14 p.m. with the Administrator he said he expected care plans to be completed on time. The Administrator said the MDS nurse, the Regional Nurse Consultant (interim DON), and the ADON were responsible for the care plans. He said Resident #14's significant change was when she was placed on hospice. He said the hospice significant change should have been added to her care plan. He said they had a DON and MDS vacancy at that time. He said the potential associated risk would be hospice residents not having a care plan that reflected there current condition. Record review of CMS's RAI Version 3.0 Manual dated October 2025 indicated in part: Significant Change in Status (SCSA) (Comprehensive) A0310A = 04 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). CAA(s) Completion Date + 7 calendar days Care Plan Completion Date + 14 calendar days.Comprehensive Assessments OBRA-required comprehensive assessments include the completion of both the MDS and the CAA process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. They consist of: admission Assessment Annual Assessment Significant Change in Status Assessment Significant Correction to Prior Comprehensive Assessment.

Based on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives necessary services to maintain good grooming and personal hygiene for 1 (Resident #11) of 16 residents reviewed for activities of daily living. The facility failed to remove unwanted facial hair from Resident #11's chin area observed on 01/05/2026. This failure placed residents at risk for psychological embarrassment, sadness, and decrease in quality of life. Findings included:Record review of Resident #11's face sheet dated 01/05/2026, reflected she was a [AGE] year-old female originally admitted on [DATE] with medical diagnoses including type 2 diabetes mellitus (high blood sugar), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), generalized anxiety disorder (prolonged excessive worry), and hypertension (high blood pressure). Record review of Resident #11's MDS dated [DATE] reflected her BIMS as 14 which indicated cognitive ability was intact and she required supervision or assistance for personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). Record review of Resident #11's care plan dated 10/01/2025 reflected ADL self-care performance deficit, with interventions including personal hygiene/oral care requiring staff participation with personal hygiene and oral care. There was no refusal of ADLs, and personal grooming or shaving documented in Resident #11's care plan. Record review of Resident #11's December 2025 aide flowsheet reflected Resident #11 did not refuse baths or personal hygiene. During an observation and interview on 01/05/2026 at 1:00 p.m., Resident #11 said she did not understand why CNA P did not remove her facial hair when she bathed her this morning and said it had been a long time since she was shaved. Resident #11 said she likes her chin hair shaved with her bath. She said she had not complained about it. The hair under her chin was approximately 15 dark curly hairs. During an interview on 01/06/2026 at 8:07 a.m., CNA P said she should have removed the Resident facial hair with her bath yesterday. She said the residents must always be ready for visitors. She said it makes the residents and families feel good about the residents' appearance. During an interview on 01/06/2026 at 8:20 a.m., the interim DON said the residents should be kept without long facial hair unless they refuse. She said she expected the lady residents to be without facial hair. She said she would provide the policy on facial hair and maintaining ADLs. She said the lack of personal hygiene could cause a decline in the resident dignity. During an interview on 01/06/2026 at 8:30 a.m., LVN O said the facial hair should be removed during bath unless the resident refuses. She said Resident #11 does not refuse. During an interview on 01/06/2026 at 1:00 p.m. the Administrator said his expectation was for facial hair to be removed unless the resident refused. Record review of the facility's policy on ADL services last revised March 2018, indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .

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 2 of 4 residents (Resident# 4 and Resident # 6) observed for Enhanced barrier precautions. The facility failed to ensure the enhanced barrier precaution sign was on Resident #4's and Resident #6's door. This failure could place residents and staff at risk for cross-contamination and development of infections.The findings included: Record review of Resident #4's care plan dated initiation of 02/21/2025 indicated he was placed on enhanced barrier precautions for his stage 4 sacrum wound. Enhanced Barrier Precautions (per protocol): Use gloves and gown to provide high contact care use face mask if there is a risk of splash or spray. Record review of Resident #6's care plan revision date of 09/16/2025 indicate she was placed on enhanced barrier precautions for her pressure injurie(s): Stage 2: right superior hip, stage 3: left hip. Enhanced Barrier Precautions (per protocol): Use gloves and gown to provide high contact care use face mask if there is a risk of splash or spray. During observation on 01/05/2026 at 9:30 a.m. there was no enhanced barrier precaution sign on Resident #4 and Resident #6's door.During observation on 01/06/2026 at 12:00 p.m. there was no enhanced barrier precaution sign on Resident #4 and Resident #6's door.During observation on 01/07/2026 at 10:30 a.m. there was no enhanced barrier precaution sign on Resident #4 and Resident #6's door. During interview on 01/07/2026 at 12:30 p.m. LVN A said the enhanced barrier precaution sign was not on the door and said it should have been there so staff would know what needs to be worn during care and to allow the staff and visitors to protect themselves. She said Resident #6 was on enhanced barrier precautions for her tube feedings and wounds on her left and right foot. LVN A said she was responsible for ensuring the enhanced barrier sign was on Resident #6's door for her shift because she is the charge nurse of the residents' assigned hall. She said the associated potential risk was cross contamination. During an interview on 01/07/2026 at 1:05 p.m. with the ADON she said the enhanced barrier precaution sign was not on the door and said it should have been there so staff would know which protective equipment to put on to protect themselves from cross contamination. She said she was the assigned nurse for Resident #4 for the shift and should have noticed the sign was not on the door. She said Resident #4 is on enhanced barrier precautions for his sacrum wound. She said the associated potential risk was cross contamination. During an interview on 01/07/2026 at 1:20 p.m. with the Regional Nurse Consultant (interim DON) she said residents with wounds and tube feedings should be on enhanced barrier precautions. She said the enhanced barrier precautions protect residents and staff from passing germs and infections to each other. She said staff had been educated and in-serviced on enhanced barrier precautions in- person and on computer-based training. She said it was the staff's responsibility to ensure the enhanced barrier precaution signs are on residents' doors that are on enhanced barrier precautions or are high contact residents. She said she expected staff to follow facility policy on enhanced barrier precautions with high contact residents to prevent infection. During an interview on 01/07/2026 at 2:15 p.m. with the Administrator he said he expected enhanced barrier precaution signage to be up for the residents that are required to have it posted. He said it was staff's responsibility to ensure the enhanced barrier precaution signs were on the appropriate residents' doors to avoid the associated potential spread of infection. Record review of facility policy titled Enhanced Barrier Precautions dated August 2022 indicated in part: Policy StatementEnhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents.2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply.1. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).2. Personal protective equipment (PPE) is changed before caring for another resident.3. Face protection may be used if there is also a risk of splash or spray.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:1. dressing;2. bathing/showering;3. transferring;4. providing hygiene;5. changing linens;6. changing briefs or assisting with toileting;7. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and8. wound care (any skin opening requiring a dressing).4. EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with the following:1. Pan-resistant organisms;2. Carbapenemase-producing carbapenem-resistant Enterobacterales;3. Carbapenemase-producing carbapenem-resistant Pseudomonas spp;4. Carbapenemase-producing carbapenem-resistant Acinetobacter baumannii;5. Candida auris;6. Methicillin-resistant Staphylococcus aureus (MRSA);7. ESBL-producing Enterobacterales;8. Vancomycin-resistant Enterococci (VRE);9. Multidrug-resistant Pseudomonas aeruginosa; and10. Drug-resistant Streptococcus pneumonia.5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.7. The use of EBPs does not impose limitations on group activities or room restrictions for residents.8. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status.9. Staff are trained prior to caring for residents on EBPs.10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.11. PPE is available outside of the resident rooms.12. Residents, families and visitors are notified of the implementation of EBPs throughout the facility.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 2 medication carts reviewed for storage of medications and biologicals. (Hall 300 Medication cart and Hall 400 Medication cart) The facility failed to ensure Hall 300 medication cart was free of loose pills at the bottom of the medication cart drawer. The facility failed to ensure Hall 400 medication cart was free of loose pills at the bottom of the medication cart drawer.These failures could place residents at risk of not receiving prescribed drugs.During an observation and interview on [DATE] at 9:00 a.m., an inspection of Hall 300 medication cart with LVN A was discovered 7 whole miscellaneous pills and 6 broken pills loose in drawer 2 of the medication cart. LVN A said she was responsible for the medication cart today. She said the ADON double checks the medication carts weekly for scattered pills and debris. She said they were overlooked. LVN A said she was in-serviced to check her medication cart for loose pills. She said she usually cleans her medication cart later in the day during her shift and had not had time to clean it yet. LVN A said the resident risk of loose pills in the medication cart was that a resident may run out of their medication before they are scheduled for a refill.During an observation and interview on [DATE] at 9:33 a.m., an inspection of Hall 400 Nurse's medication cart with the ADON was discovered 3 whole pills and 1 broken pill loose in drawer 2 of the medication cart. She said she was giving medication to Residents on Hall 400 today and was responsible for the medication cart. The ADON said she was the backup that double checked the medication carts every Friday for cleanliness, loose medication and expired medication. She said the loose pills were overlooked. The ADON said she was in-serviced on cleaning the medication cart and checking for expired medication and loose pills. She said the resident risk of loose pills on a medication cart was that a resident may be short on medication and it may need to be reordered sooner than normal. During an interview on [DATE] at 9:54 a.m., the DON said the nurse giving medication off the medication cart was responsible for ensuring no loose pills were on the medication cart. She said the ADON and DON were the back up to double check the medication carts weekly for loose medication. The DON said she checked the medication room and hall 200 medication cart on Tuesday ([DATE]). She said the loose pills were overlooked. She said the Resident risk was that a resident could need their medication ordered too soon. The DON said her expectation was all medication be administered per physician orders and all medication carts be checked to ensure they were up to standard.During an interview on [DATE] at 11:00 a.m., the Administrator said all nurses giving medication off the medication cart were responsible for ensuring no loose pills were left on the medication cart. He said the ADON and DON were the back up to double check the medication carts weekly for loose medication. The Administrator said the loose pills were overlooked. He said the Resident risk was a resident could need their medication ordered too soon. The Administrator said his expectation was all medication be administered per physician orders and all medication carts be checked to ensure they were up to standard.Record review of a facility policy titled Medication Labeling and Storage dated revised 02/23 indicated, .The facility stores all medication and biologicals in locked compartments under proper temperature, humidity and light controls. 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 30 opportunities, resulting in a 6.67% percent medication error involving 2 of 5 residents reviewed for medication pass. (Resident #54 and Resident #58)LVN D administered an incorrect dose of bupropion HCL ER (used to treat depression) to Resident #54 on 01/06/2026 during medication pass.LVN D administered carvedilol 3.125 mg tablet (used to treat high blood pressure) to Resident #58 when the heart rate was outside the parameters ordered by the physician.These failures could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life.1. Record review of a face sheet for Resident #54 indicated admitted to facility on 02/20/2021 with diagnoses including paranoid schizophrenia and major depressive disorder.Record review of Resident #54's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 which indicated intact cognition. She required partial/moderate assistance from staff with ADL care.Record review of Resident #54's care plan updated 12/03/2025 indicated use of psychotropic medications related to depression and schizophrenia. Interventions included administering psychotropic medications as ordered by physician. Observe for and report to nurse any side effects and effectiveness.Record review of Resident #54's Physician Orders dated January 2026 indicated Resident #54 was to receive bupropion HCL ER 150 mg. tablet. Instructions indicated to give 2 tablets by mouth one time a day for depression.Record review of Resident #54's MAR dated January 2026 indicated an order of bupropion HCL ER 150 mg. tablet. Give 2 tablets by mouth one time a day for depression.During an observation of the medication pass on 01/06/2026 at 08:19 a.m., LVN D prepared and administered 2 bupropion HCL ER 300 mg. tablets to Resident #54.During a record review and interview on 01/06/2026 at 09:00 a.m., LVN D acknowledged she had administered an incorrect dose of bupropion HCL ER to Resident #54 during today's medication pass at 08:19 a.m. Resident #54's MAR dated January 2026 indicated an order of bupropion HCL ER 150 mg. tablet. Give 2 tablets by mouth one time a day for depression. Resident #54's medication blister pack indicated bupropion 300 mg tablets were available. She said she gave two 300 mg tablets when she should have given one of the 300 mg tablets. LVN D said she should have noticed the blister pack containing bupropion HCL ER 300 mg. tablets and not the 150 mg.During an interview on 01/07/2026 at 12:05 p.m., the DON said she expected medications to be available and administered by physician orders. She said Resident #54 had been receiving two bupropion 150 mg HCL ER tablets to equal 300 mg. She said when the pharmacy later sent bupropion 300 mg HCL ER tablets, nursing should have been aware and reflected the dosage on the MAR to avoid mistakes. She said she had completed a Med Error report, and the physician had been notified. Resident #54 had been monitored for negative outcomes with none noted.During a phone conversation on 01/07/2026 at 12:10 p.m., the Pharmacy Consultant was interviewed re: Resident #54 having received an incorrect dose of bupropion 300 mg HCL ER. He said since it had been over 24 hours, since the incident had occurred, most likely if there were any negative outcomes, they would have already occurred. He said bupropion 300 mg HCL ER was eliminated quickly in the body. The pharmacy consultant added that the facility was correct in having monitored for standard side effects.2. Record review of a face sheet for Resident #58 indicated admitted to facility on 04/24/2025 with diagnoses including heart failure and hypertension.Record review of Resident #58's quarterly MDS assessment dated [DATE] indicated a BIMS score of 13 which indicated intact cognition. She required substantial - partial/moderate assistance from staff with ADL care.Record review of Resident #58's care plan 05/29/2025 indicated use of antihypertensive medications used to treat high blood pressure. Interventions included giving anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate. Hold for BP 110/60 or heart rate 60.Record review of Resident #58's Physician Orders dated January 2026 indicated Resident #58 was to receive carvedilol 3.125 mg twice daily related to hypertension. Instructions included hold for B/P less than 110/60 or heart rate less than 60.Record review of Resident #58's MAR dated January 2026 indicated an order of carvedilol 3.125 mg twice daily related to hypertension. Instructions included hold for B/P less than 110/60 or heart rate less than 60.During an observation of the medication pass on 01/06/2026 at 08:09 a.m., LVN D prepared and administered carvedilol 3.125 mg to Resident #54. Prior to administration, LVN D was observed obtaining Resident #58's B/P and heart rate which were B/P 167/82 and heart rate of 58.During an interview on 01/06/2026 at 09:00 a.m., LVN D acknowledged she had administered carvedilol 3.125 mg Resident #58 during today's medication pass at 08:19 a.m. when the medication should have been held due to heart rate below 60. LVN D said she had overlooked the parameters and made a mistake in administering. She said she had been educated on parameters prescribed by the physicians and to follow physician orders when administering medications. During an interview on 01/07/2026 at 12:05 p.m., the DON said she expected medications to be administered by physician orders. She said Resident #58 had physician ordered parameters regarding administration of the carvedilol 3.125 mg. She said her expectations were for the nursing staff administering medications to be diligent in following the prescribed orders while observing parameters. She said she had completed a Med Error report, and the physician had been notified. Resident #58 had been monitored for negative outcomes with none noted.During a phone conversation on 01/07/2026 at 12:10 p.m., the Pharmacy Consultant was interviewed re: Resident #58 having received the carvedilol 3.125 mg. when the heart rate was outside the prescribed parameters. He said a possible negative outcome was bradycardia (when your heart beats too slowly, typically under 60 beats per minute for adults). The pharmacy consultant said carvedilol's elimination half-life was short (usually 7-10 hours). The pharmacy consultant added that the facility was correct in having monitored for standard side effects. Record review of the facility's Administering Medications policy dated March 2025 indicated the following: . Medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescribers' orders. 10. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview and record review, the facility failed to conduct a comprehensive assessment of a resident within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition for 1 of 16 residents (Resident #34) reviewed for comprehensive assessments and timing.The facility failed to ensure an MDS Significant change Assessment for Resident #34 was completed within 14 days after hospice admission.This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.Findings included:Record review of a face sheet dated 01/05/26 indicated Resident #34 was an [AGE] year-old- male admitted on [DATE] and readmitted [DATE]. His diagnoses included heart failure (the heart cannot pump enough oxygen rich blood to meet the body's needs and causing shortness of breath), cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood causing it to become enlarged and leading to symptoms including shortness of breath), cerebral infarct (an area of tissue death due to blood vessel blockage in the brain) and chronic obstructive pulmonary disease (a progressive lung condition that blocks airflow, making it hard to breathe).Record review of the most recent significant change MDS assessment dated [DATE] indicated Resident #34 had a BIMS score of 13 indicating intact cognition and active diagnoses including chronic obstructive pulmonary disease, heart failure, cerebral infarct and cardiomyopathy and indicated did not receive hospice services. Record review of an undated list of MDSs for Resident #34 included an open quarterly MDS assessment dated [DATE], a completed significant change MDS assessment dated [DATE] and a completed entry MDS assessment dated [DATE]. Record review of a physician's order dated 12/13/25 indicated Resident #34 was admitted on hospice services for congestive heart failure (heart's inability to pump blood effectively due to structural or functional impairments). Record review of physician's orders dated 01/05/26 indicated Resident #34 was admitted to hospice services for congestive heart failure with an order date of 12/12/25. Record review of Resident #34's care plans with a target date of 02/10/26 indicated he had a terminal prognosis and received hospice services for congestive heart failure. During an observation on 01/05/2026 at 9:07 a.m., Resident #34 was lying in bed, and said he received hospice services but was unsure which one.During an interview on 01/07/26 at 10:00 a.m., LVN A said she was providing care for Resident #34 today. She said he received hospice services. During an interview on 01/07/2026 at 10:27 a.m., MDS Nurse B said 01/05/26 was her first day of training on completing MDSs. She said she was now responsible for the MDSs in the facility. She said the backup was the Senior Director of Reimbursement that double checked some MDSs for accuracy. She said MDS Nurse C gave notice on 12/12/25 and was now PRN. MDS Nurse B said she was in the process of being trained to complete MDSs. She said the Significant change MDS for Resident #34 was overlooked when he admitted to hospice services and should have already been completed. MDS Nurse B said the resident risk of a significant change assessment not being completed for a resident admitted on hospice services was not following facility policy. During an interview on 01/07/2026 at 10:55 a.m., the DON said MDS Nurse B was responsible for the MDSs in the facility. She said MDS Nurse B started training on 01/05/26. She said the Senior Director of Reimbursement was the back up. The DON said Resident #34's significant change MDS was overlooked during the period of vacancy of the MDS and DON positions. The DON said the resident risk of a significant change MDS not completed after a resident signed on hospice services was not following facility policy. She said her expectation was all MDSs be completed per RAI manual. She said the facility followed the RAI for a facility policy on MDS. During an interview on 01/07/2026 at 11:05 a.m., the Administrator said MDS Nurse B was responsible for the MDSs in the facility, and she started training on 01/05/26. He said the Senior Director of Reimbursement was the back up. He said Resident #34's significant change MDS was overlooked during the period of vacancy of the MDS and DON positions. The Administrator said the resident risk of a significant change MDS not completed after a resident admitted on hospice services was not following facility policy. He said his expectation was all MDSs be completed per the RAI manual. During an interview on 01/07/2026 at 1:11 p.m., Senior Director of Reimbursement said MDS Nurse C was responsible for completing MDS in the facility in December 2025. She said MDS Nurse B was currently in training and had not started completing MDSs. She said she was the backup and did routine accuracy checks on random MDSs. Senior Director of Reimbursement said she did not check every MDS for accuracy. She said she opened MDS in the system and MDS Nurse C completed them. She said the facility did not notify her Resident #34 admitted on hospice services, so she did not open a significant change MDS and it was overlooked. Senior Director of Reimbursement said the resident risk was not following facility policy by not completing a significant change MDS when a resident was admitted on hospice services. During an interview on 01/07/26 at 1:35 p.m., MDS Nurse C said her last full-time day was 12/04/25 and she was currently PRN but had only worked a few days since then. MDS Nurse C said she was unaware Resident #34 had been admitted on hospice service and the backup; Senior Director of Reimbursement did not open a significant change MDS in the system for Resident #34. She said it was overlooked. She said she was educated on the completion of MDSs and was the MDS nurse for 4 years in the facility. MDS Nurse C said the resident risk was that the Resident's care plan may not be updated with the changes from the Significant change MDS due to the care plan was triggered by the MDS. She said there was no direct resident risk. Record review of the mds-3.0-rai-manual-v1.19.1_October_2024 indicated . An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing. The ARD must be less than or equal to 14 days after the IDT's determination that the criteria for an SCSA are met (determination date + 14 calendar days). The MDS completion date . must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than.

Based on interview, and record review, the facility failed to ensure that alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 of 5 residents (Resident #14) reviewed for reporting abuse and neglect. CNA F failed to report Resident #14's complaint of neglect (Resident #14 told LVN E that she was having shortness of breath and requested a breathing treatment. LVN E allegedly told her she could breathe because she just talked on the phone) to the Administrator on 12/25/2025 at 4:00 p.m. when the incident occurred. This failure could potentially result in residents' complaints or incidents of abuse not being reported to the Administrator. The findings include: Record review of Resident #14's face sheet dated 01/05/2026 indicated she was a [AGE] year-old female with a re-admission date of 10/24/2025. Pertinent diagnoses included chronic obstructive pulmonary disease (inflammation and damage to lungs.) type 2 diabetes (high blood sugar.) obesity, shortness of breath, hypertension (high blood pressure). Record review of Resident #14's quarterly MDS assessment dated [DATE] indicated she had a BIMS of a 15 indicating she was cognitively intact. In section B - Hearing, Speech, and Vision indicated Resident #14 had the ability to hear adequately with no difficulty. She could make herself understood. Record review of Resident #14's care plan dated 09/15/2025 indicated she had an altered respiratory status related to her chronic obstructive pulmonary disease with a goal of: maintaining normal breathing pattern. Interventions: position resident with proper body alignment for optimal breathing pattern (to be completed by- LPN, RN). She had asthma with a goal of: remaining free from complications of asthma. Interventions: give medications as ordered. Monitor/ document side effects and effectiveness. (to be completed by- LPN, RN.) Give nebulizer treatments and oxygen therapy as ordered. (to be completed by- LPN, RN.) Monitor vital signs per physician orders, skin color, pulse oximetry, airway functioning and degree of restlessness which may indicate hypoxia (low oxygen in the body). (to be completed by-CNA, LPN, RN.) Record review of Resident #14's nurses' notes written in the month of November and December 2025 indicated there were no documented complaints or incidents. Record review of the facility's Grievance log dated November and December 2025 indicated there was no grievance report for Resident #14 regarding her complaint/ incident involving LVN E. Record review of the facility's Incident report dated November and December 2025 indicated there was no incident report for Resident #14 regarding her complaint/ incident involving LVN E. During an interview with Resident #14 on 01/05/2026 at 10:40 a.m. she said she does not like how LVN E talked to her a couple of days ago when she had shortness of breath. She said she told LVN E that she was having shortness- of breath and requested a breathing treatment. She said LVN E told her she could breathe because she was just talking on the phone. She said LVN E had given her the breathing treatment but told her she could not get her scheduled one. She said she reported her complaint to CNA F the day it happened on the a.m. shift. During an interview with CNA F on 01/05/2026 at 11:07 a.m. she said Resident #14 verbally reported to her that she wanted to talk to someone about LVN E talking mean to her. CNA F said Resident #14 told her she could not breathe but LVN E told her she was breathing fine while on the phone so she could breathe. CNA F said she reported Resident #14's complaint/ incident to the Social Worker immediately. CNA F said she told the Social Worker Resident#14 had a complaint but did not tell her the details of what was told to her. She said administration did not come to her to discuss or investigate the complaint nor was she asked to write a statement on what was reported to her by Resident #14. CNA F said she had been trained on abuse and neglect and knew the complaint should have been reported to the abuse coordinator within 2 hours of becoming aware of the complaint. She said she did not report the complaint/ incident to the Administrator who is the Abuse Coordinator. She said, he was not in the facility so that was why she did not tell the Administrator. CNA F said she is responsible for reporting to the abuse coordinator about any abuse or neglect complaints immediately. She said she did not tell LVN E about the complaint. During an interview with the Administrator on 01/05/2026 at 11:25 a.m. he said he did not have any reportable incidents or intakes. He said he had not been aware of any grievances or incidents involving interactions between residents and staff, nor any complaints involving Resident #14. He said he is the abuse coordinator and had educated staff on when and how to report any complaints or incidents involving abuse and neglect. He said his phone number is posted in clear sight for anyone to call and report any complaint or incident. He said CNA F should have made him aware of the complaint/ incident between Resident #14 and LVN E immediately. He said staff is responsible for reporting any complaint/ incident to him. The Administrator said the associated potential risk was Resident complaints and incidents would go unreported to him resulting in complaints not being investigated. During an interview with the Social Worker on 01/05/2026 at 11:40 a.m. she said when she received a complaint, she goes to talk to the resident about the complaint. After she gathered the details of the complaint, she completes a written grievance report and presents it at the morning meeting. The Social Worker said she sends the written grievance report to the department heads. She said she logs all complaints in the grievance book. The Social Worker said she did not recall any grievances from Resident #14. She said CNA F never reported anything to her regarding LVN E and Resident #14's incident. She said if she had been made aware of the complaint/ incident she would have interviewed Resident #14, filed the complaint and reported it to the interim DON and the Administrator. She said she was responsible for filing the complaints and presented them at the meeting. She said it was staff's responsibility to report any complaints/ grievances to the abuse coordinator immediately. The Social Worker said the associated potential risk was Resident complaints and incidents would not be investigated. During an interview on 01/05/2026 at 4:49 p.m. with LVN E she said she had worked for the facility for 4.5 months. She said she had residents with asthma before and knows how to care for them. She said residents can experience shortness- of- breath while talking. She said Resident #14 is one of the residents she watches because she can go from breathing good to having difficulty breathing in a split second. She said she worked with Resident #14 over the past 3 days and had to administer PRN breathing treatments every shift because she had been sick. She said Resident #14 had her Breathing treatment orders changed from every 6 hours to 4 hours due to her difficulty breathing. She said the resident asked for the breathing treatment after she got off the phone, and she said she gave the scheduled one instead of the PRN. She said Resident #14 had no signs or symptoms of difficulty breathing. She said her oxygen level was 98% while on 2 liters of oxygen. She said she never told Resident #14 that she was on the phone so she could breathe. She said she never had any issues with the residents. She said she never felt like Resident #14 had any issues with her. During an interview on 01/06/2026 at 9:10 a.m. with the Regional Nurse Consultant (interim DON) she said she was not made aware of any complaints/ incidents involving Resident #14 and LVN E. She said had she been made aware of the complaint/ incident, she would have reported it to the abuse coordinator and assisted in the investigation process. She said the potential associated risk is complaints going unreported and uninvestigated. She said all staff were responsible to report complaints/ incidents to the abuse coordinator. Record review of the facility's policy Abuse and Neglect - Clinical Protocol review dated: March 2018 indicated in part: Definitions1. Abuse is defined at 83.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 2. Neglect, as defined {483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Treatment/Management:1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.2. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for comprehensive person-centered care plans. Resident #1 did not have a care plan completed for her diagnosis of generalized anxiety. Resident #1 did not have a care plan completed after she was prescribed Buspirone/Buspar (anti-anxiety medication) on 10/16/25 for anxiety. This failure could place residents at risk for not receiving proper care and services. Findings included: Record review of Resident #1's face sheet dated 11/19/25 indicated she was an [AGE] year old female, admitted on [DATE], and her diagnoses included Parkinsonism (conditions that affect movement), diabetes (condition that affects blood sugar levels), cognitive communication deficit (difficulties in communication due to impaired cognitive function), and generalized anxiety disorder-onset 02/01/23 (a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things). Record review of Resident #1's annual MDS assessment dated [DATE] indicated she usually made herself understood, usually understood others, and had moderate cognitive impairment (BIMS-11). Resident #1's active diagnoses included anxiety disorder. Resident #1 was taking an antianxiety medication. Record review of Resident #1's care plans dated 11/01/24 through 11/20/25 indicated there was no care plan related to Resident #1's diagnosis of generalized anxiety disorder or Buspirone/Buspar start date or discontinuation. Record review of Resident #1's physician orders dated 10/16/25 indicated Buspirone tablet 5 mg 1 tablet by mouth BID for anxiety. Record review of Resident #1's behavioral assessment dated [DATE], completed by LPC J indicated Resident #1 was referred for psychology and psychiatric services due to memory loss, short term memory problems and long term memory problems. Her diagnoses included generalized anxiety disorder. She was alert, coherent and oriented. She was pleasant and cooperative. Resident #1 indicated living at the nursing home was difficult for her. She demonstrated anxious behavior, such as unable to stay in places long. She was open to therapy sessions to help her adjust to being at the nursing home and learn to reduce and manage her anxiety. Resident #1 had the cognitive ability to learn and apply interventions to help with adjustment, reduce anxiety, memory loss and improve quality of life at the nursing home. She had mild anxiety and the goal for therapy was reduction of anxiety. Her treatment plan would address: adjustment, anxiety, confusion, depression, irritability, loss of pleasure/interest, memory loss, nervous/worried, pain, stress, and withdrawal. Record review of Resident #1's Psychological Service Progress Note dated 10/14/25, completed by LPC J, indicated Resident #1 was alert, coherent and oriented. The patient appeared anxious, nervous and unable to remain still. The assessment plan indicated generalized anxiety disorder would be treated with Buspar 1 tablet 5 mg. Record review of Resident #1's psychiatric assessment dated [DATE], completed by PMHNP O, indicated Resident #1 presented in an anxious state. Resident #1 endorsed current symptoms of excessive worry, restlessness, irritability/agitation and impaired concentration During an interview on 11/19/25 at 1:55 p.m., Resident #1 said she doesn't remember all of the names of her medications. She said the medications help her. She said the medications do not make her feel bad. She said if she needed medication for anxiety or depression she would take it. She said she enjoyed talking with LPC J and PMHNP O. During an interview on 11/19/25 at 3:36 p.m., PMHNP O indicated Resident #1 presented with increased anxiety during her psychological visits. She said she prescribed the Buspar on10/16/25 to assist with anxiety management. She said LVN P reported the medication appeared to be effective. She said the medication was discontinued on 11/12/25 at the request of Resident #1's family member. During an interview on 11/20/25 at 8:10 a.m., the DON said she did not know why Resident #1's care plan did not include generalized anxiety or the medication Buspar to address the anxiety. She said normally the MDS Coordinator would update the care plans. She said the MDS Coordinator was not informed of the changes. She said it was just missed. She said typically acute care plans were done by the nurses. She said LVN P should have completed a care plan for Resident #1's Buspar. She said she (the DON) and the ADON reviewed resident charts and the dashboard in the electronic record to ensure the care plans were updated and current. She said it was her expectations the care plans were completed as required. She said residents were at risk of not receiving required services if the care plans were not completed. During an interview on 11/20/25 at 9:10 a.m., the ADON said said she did not know why Resident #1's care plan did not include her anxiety diagnosis or the Buspar. She said the nurse who received the order, LVN P, should have completed the care plan and the IDT should have reviewed it to ensure it was completed. She said residents were at risk of not receiving required services if the care plans were not completed. The surveyor attempted to contact LVN P on 11/19/25 at 2:13 p.m. LVN P did not respond as of the investigation survey exit. Record review of the facility's policy Using the Care Plan dated 2001 (revised 2006) indicated . 5. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made. Record review of the facility's undated Facility Care plan Process Overview-From New Admit to Long-term Resident indicated Continual Care Planning Process from New Admit to Longterm Resident: .Days 21-100, and on-going for duration of resident's stay- Daily Clinical MeetingsReview Order changes, new diagnoses, new or altered conditions, behaviors, etc., for care plan needsUnit managers, wound nurse, IP nurse, dietitian, and DON are to complete thosecare plan updates during those meetings and with changes in condition.Weekly Clinical Meetings/Sub-Committee Meetings to update care plans per each focus area of the meeting .psychotropic/ Anti-psychotic: new meds, interventions, behaviors, etc.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 19 residents reviewed for significant medication errors. (Resident #2)The facility must ensure that its residents are free of any significant medication errors. Resident #2 received multiple doses of medications that were not prescribed to her to include 2 blood thinners and blood pressure medications. Also, Resident #2 did not receive prescribed breathing treatments and anti-inflammatory medications and was re-hospitalized with COPD.The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. The facility had corrected the noncompliance before the state's investigation began.This failure could place residents at risk for not receiving medications as ordered by their physician or per manufacturer's directions. Findings included:Record review of Resident #2's PPS MDS assessment dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), COPD (a group of lung diseases that block airflow and make it difficult to breathe). The MDS also indicated a BIMS score of 14 (suggested no cognitive impairment).Record review of Resident #2's baseline care plan dated 02/07/2025 indicated Resident #2 used oxygen continuously due to COPD.Record review of Resident #2's hospital H&P dated 02/04/2025 (prior to facility admission) indicated Resident #2 was admitted to the hospital on [DATE] for complaints of a 2-3-week history of gradual worsening shortness of breath, cough, and wheezing. Resident #2 was hypoxic (an inadequate supply of oxygen o the body's tissues) and was placed on BIPAP (a non-invasive ventilation therapy that uses 2 different levels of air pressure to assist breathing). Record review of Resident #2's hospital Discharge summary dated [DATE] indicated 3 new medications upon discharge: -budesonide 0.5 mg/2 ml (breathing treatment) per nebulizer twice daily;-prednisone 20 mg(anti-inflammatory) by mouth before breakfast; and-levalbuterol HCL 0.63mg/3 ml (breathing treatment) every 6 hours via nebulizer.Additionally, Resident #2 was to continue previous home medications:-omeprazole 20 (reduces stomach acid) mg daily;-Levothyroxine 100 mcg (used to treat underactive thyroid) daily;-Memantine 10 mg (used to treat moderate to severe Alzheimer's) daily;-hydrochlorothiazide 12.5 mg (used to treat high blood pressure and fluid retention) daily;-Magnesium oxide 400 mg (supplement used to regulate muscle and nerve function) daily;-Duloxetine 30 mg (used to treat mood disorders and chronic pain) twice daily;-Ibuprofen 600 mg (anti0inflammatory) twice daily as needed;-losartan 25 mg (for blood pressure) daily;-atorvastatin 40 mg (used to reduce cholesterol levels) every evening; and-tramadol 50 mg (for pain) four times daily. Record review of Resident #2's admission orders and MAR dated 02/07/2025 indicated the facility ordered and administered 11 medications that were not Resident #2's discharge medications with multiple doses to Resident #2 from 02/07/25-02/10/25. Resident #2 was administered the following: *Amiodarone 200 mg 5 doses (blood pressure) -Plavix 75 mg 3 doses (blood thinner),-Eliquis 5 mg 5 doses (blood thinner),-Lexapro 5 mg 3 doses (anti-depressant),-Lasix 40 mg 3 doses (diuretic), -Metolazone 5 mg 3 doses (diuretic),- Gemtesa 75 mg 3 doses (for bladder spasms),-Valsartan 320 mg 3 doses (blood pressure) ,-Levothyroxine 137 mcg 2 doses(for thyroid - receives 100 mcg at home),-Docusate 100 mg 2 doses (stool softener) and,-Melatonin 5 mg 2 doses (helps sleep).Record review of Resident #2's nurses notes written by LVN P indicated Resident #2 experienced shortness of breath and anxiety within 72 hours of admission to facility, resulting in decreasing oxygen saturation levels and Resident #2 being transferred to hospital for evaluation. She was admitted to the hospital on [DATE] with an exacerbation of COPD and anxiety. Record review of a Medication Error form completed by the corporate nurse and dated 02/10/2025 for Resident #2 indicated the following: . Family brought to the facilities attention that the medications that [Resident #2] was receiving at the facility did not match their understanding of what medications the resident should be on. Upon investigation, it was discovered that the 2 pages (pages 33 and 34) of the hospital paperwork containing the discharge medications that the family brought to the facility with the resident had a different resident's name on them. This resulted in [Resident #2] being placed on the wrong medications from 2/7 through 2/10. During an interview on 09/17/2025 at 09:30 a.m., the regional nurse said Resident #2's family member came to the facility and had asked if Resident #2 had been given her breathing treatment over the weekend. The corporate nurse said upon review of Resident #2's medical record, she had noticed the diagnoses, and the medication list did not look right. Upon further reviewing, the corporate nurse said out of the 60+ pages, she found that the medication list provided by the discharging hospital had a different person's medication list and discovered the facility had inadvertently missed and had written the wrong medications for Resident #2. In addition, the 3 new medications upon discharge from hospital had been overlooked and were omitted. She said the staff nurses were in-serviced on medication errors, ensuring correct residents were listed on their discharge papers, verifying correctness of orders, etc. She said they did an audit of all admission within the 30 days prior and there were no new identifiable errors. She said they did QAPI and monitored all new admissions for 3 months with no errors. During a phone interview on 09/19/2025 at 10:45 a.m., Physician H, who was the attending physician for Resident #2's most recent hospital visit, said it was difficult to say if Resident #2 having received the wrong medications would have contributed to her hospital stay. He said it was very important for facilities to provide accurate medication lists when transferring residents to the hospital.During an interview on 09/19/2025 at 10:50 a.m., LVN E reported she completed Resident #2's admission Assessment, but denied transcription of the medication orders that were included in the discharge paperwork from the hospital. LVN E said she had noticed Resident #2 crying at times, and felt it was due to being a new admission to the facility. During a phone interview on 09/19/2025 at 11:00 a.m., NP J said he was employed as Physician K's NP (who was also the facility Medical Director). He said he had not seen Resident #2 while she was in the facility, and he recalled receiving a call from nursing staff saying Resident #2 was having shortness of breath. He said he gave orders to send to ER for evaluation. NP J said in his opinion, Resident #2's shortness of breath could have been contributed to having been administered the wrong medications, and added the error should have been caught on admission. He said he and physician attend monthly QA meetings at facility and he vaguely recalled the entire incident.During an interview on 09/19/2025 at 11:50 a.m., the DON said the admitting nurse was responsible for reconciling the medications with the physician, and the ADON was to ensure the medications were accurately transcribed. The DON said she was not employed at the facility at the time of this incident. She was hired one month later. The DON said the facility had a Standards of Care meeting weekly at which time new admissions, wounds, change in conditions were discussed and acted upon. The DON said this failure could negatively affect the residents as the wrong medications could cause harm, allergic reactions, or adverse reactions. She said her expectations were for nursing staff to make sure the correct resident's names and date of birth were on all paperwork from the hospital or physician offices.During an interview on 09/19/2025 at 12:20 p.m., the regional nurse said the staff had failed to transcribe and administer Resident #2's breathing treatments as prescribed upon discharge from hospital on [DATE]. She said staff failed to verify the names on Resident #2's discharge papers from the hospital. She said the admitting nurse was responsible for transcribing physician orders, and the ADON was responsible to ensure correctness. If a resident was admitted over the weekend, the orders were to be checked on the next workday. During a joint interview on 09/19/2025 at 12:55 p.m., LVN F said she had been employed at facility since April 2025. LVN F said she had been trained in admissions. She said anytime she would be expecting admission, she would request all discharge records prior to transfer. She said she would verify the resident's name, date of birth , and medications. She said upon arrival at the facility, a verification was made by asking residents their name and date of birth , or by looking at hospital bracelets, or verify if the family was present. LVN G agreed with LVN F comments and added when notifying physician of admission and verification of medications, she would also ensure the resident orders were complete as in route, frequency, rationale, and duration. LVN F said anytime medications were questioned, the physicians were quick to respond to calls made by nursing staff. LVN G said when notifying physician to verify medications, they name every medication to the physician.Review of facility policy titled Reconciliation of Medications on Admission, with a revision date of July 2017, indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Review the list carefully to determine if there are discrepancies/conflicts.The facility took the following actions to correct the noncompliance prior to the investigation:-Record review of an Employee In-service Record dated 02/10/2025 indicated the facility in-serviced the staff on verifying all information on new admissions as correct and with the correct residents' information. The in-service was conducted by LVN F with an audience of licensed staff. Seventeen licensed staff were in-serviced. - During an interview on 09/19/2025 at 11:50 a.m., the DON said nursing administration implemented for the ADON to perform daily medication checks with orders for newly ordered medications and new admissions during the morning meetings. -Record review of an audit of new admissions indicated the facility monitored 16 new admissions from 01/21/2025 through 02/10/2025 for accuracy 5 times/week for 4 weeks with no negative outcome. -During interviews throughout the investigation from 02/16/2025 at 08:30 a.m. through 02/22/2025 at 5:15 p.m., the licensed staff were aware to verify new medications or new admission residents' medications by calling the physician to verify. (ADON, LVN A, LVN B, LVN E, LVN F, LVN G, LVN H, LVN J, and LVN K) -Record review of 19 new resident admission's clinical record from 09/21/2025 -09/22/2025, revealed the Order Summary, discharge paperwork from recent hospital visits, MAR, history and physicals, etc. indicated no errors in transcribing orders or orders being overlooked. (Resident #s 2, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18, 19, 20, and 21) The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. The facility had corrected the noncompliance before the state's investigation began.

Based on interview and record review, the facility failed to provide pharmaceutical services (the process of receiving and interpreting prescriber's orders and to provide procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs) to meet the needs of each resident for one (Resident #2) of four residents reviewed for pharmaceutical services.The facility failed to ensure Resident #2's hospital discharged medication regimen was accurately reviewed and implemented. Resident #2 was readmitted to the hospital with respiratory failure and COPD. The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. The facility had corrected the noncompliance before the state's investigation began.This failure could place residents at risk for not receiving medications as ordered by their physician or per manufacturer's directions. Findings included:Record review of Resident #2's PPS MDS assessment dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), COPD (a group of lung diseases that block airflow and make it difficult to breathe). The MDS also indicated a BIMS score of 14 (suggested no cognitive impairment).Record review of Resident #2's baseline care plan dated 02/07/2025 indicated Resident #2 used oxygen continuously due to COPD. Record review of Resident #2's hospital H&P dated 02/04/2025 (prior to facility admission) indicated Resident #2 was admitted to the hospital on [DATE] for complaints of a 2-3-week history of gradual worsening shortness of breath, cough, and wheezing. Resident #2 was hypoxic (an inadequate supply of oxygen o the body's tissues) and was placed on BIPAP (a non-invasive ventilation therapy that uses 2 different levels of air pressure to assist breathing). Record review of Resident #2's hospital Discharge summary dated [DATE] indicated 3 new medications upon discharge: -budesonide 0.5 mg/2 ml (breathing treatment) per nebulizer twice daily;-prednisone 20 mg(anti-inflammatory) by mouth before breakfast; and-levalbuterol HCL 0.63mg/3 ml (breathing treatment) every 6 hours via nebulizer. Additionally, Resident #2 was to continue previous home medications:-omeprazole 20 (reduces stomach acid) mg daily;-Levothyroxine 100 mcg (used to treat underactive thyroid) daily;-Memantine 10 mg (used to treat moderate to severe Alzheimer's) daily;-hydrochlorothiazide 12.5 mg (used to treat high blood pressure and fluid retention) daily;-Magnesium oxide 400 mg (supplement used to regulate muscle and nerve function) daily;-Duloxetine 30 mg (used to treat mood disorders and chronic pain) twice daily;-Ibuprofen 600 mg (anti0inflammatory) twice daily as needed;-losartan 25 mg (for blood pressure) daily; -atorvastatin 40 mg (used to reduce cholesterol levels) every evening; and -tramadol 50 mg (for pain) four times daily. Record review of Resident #2's admission orders and MAR dated 02/07/2025 indicated the facility ordered and administered 11 medications that were not Resident #2's discharge medications with multiple doses to Resident #2 from 02/07/25-02/10/25. Resident #2 was administered the following: *Amiodarone 200 mg 5 doses (blood pressure) -Plavix 75 mg 3 doses (blood thinner), -Eliquis 5 mg 5 doses (blood thinner), -Lexapro 5 mg 3 doses (anti-depressant), -Lasix 40 mg 3 doses (diuretic), -Metolazone 5 mg 3 doses (diuretic), - Gemtesa 75 mg 3 doses (for bladder spasms), -Valsartan 320 mg 3 doses (blood pressure) ,-Levothyroxine 137 mcg 2 doses(for thyroid - receives 100 mcg at home), -Docusate 100 mg 2 doses (stool softener) and,-Melatonin 5 mg 2 doses (helps sleep).Record review of Resident #2's nurses notes written by LVN P indicated Resident #2 experienced shortness of breath and anxiety within 72 hours of admission to facility, resulting in decreasing oxygen saturation levels and Resident #2 being transferred to hospital for evaluation. She was admitted to the hospital on [DATE] with an exacerbation of COPD and anxiety. Record review of a Medication Error form completed by the corporate nurse and dated 02/10/2025 for Resident #2 indicated the following: . Family brought to the facilities attention that the medications that [Resident #2] was receiving at the facility did not match their understanding of what medications the resident should be on. Upon investigation, it was discovered that the 2 pages (pages 33 and 34) of the hospital paperwork containing the discharge medications that the family brought to the facility with the resident had a different resident's name on them. This resulted in [Resident #2] being placed on the wrong medications from 2/7 through 2/10. During an interview on 09/17/2025 at 09:30 a.m., the regional nurse said Resident #2's family member came to the facility and had asked if Resident #2 had been given her breathing treatment over the weekend. The corporate nurse said upon review of Resident #2's medical record, she had noticed the diagnoses, and the medication list did not look right. Upon further reviewing, the corporate nurse said out of the 60+ pages, she found that the medication list provided by the discharging hospital had a different person's medication list and discovered the facility had inadvertently missed and had written the wrong medications for Resident #2. In addition, the 3 new medications upon discharge from hospital had been overlooked and were omitted. She said the staff nurses were in-serviced on medication errors, ensuring correct residents were listed on their discharge papers, verifying correctness of orders, etc. She said they did an audit of all admission within the 30 days prior and there were no new identifiable errors. She said they did QAPI and monitored all new admissions for 3 months with no errors. During a phone interview on 09/19/2025 at 10:45 a.m., Physician H, who was the attending physician for Resident #2's most recent hospital visit, said it was difficult to say if Resident #2 having received the wrong medications would have contributed to her hospital stay. He said it was very important for facilities to provide accurate medication lists when transferring residents to the hospital. During an interview on 09/19/2025 at 10:50 a.m., LVN E reported she completed Resident #2's admission Assessment, but denied transcription of the medication orders that were included in the discharge paperwork from the hospital. LVN E said she had noticed Resident #2 crying at times, and felt it was due to being a new admission to the facility. During a phone interview on 09/19/2025 at 11:00 a.m., NP J said he was employed as Physician K's NP (who was also the facility Medical Director). He said he had not seen Resident #2 while she was in the facility, and he recalled receiving a call from nursing staff saying Resident #2 was having shortness of breath. He said he gave orders to send to ER for evaluation. NP J said in his opinion, Resident #2's shortness of breath could have been contributed to having been administered the wrong medications, and added the error should have been caught on admission. He said he and physician attend monthly QA meetings at facility and he vaguely recalled the entire incident. During an interview on 09/19/2025 at 11:50 a.m., the DON said the admitting nurse was responsible for reconciling the medications with the physician, and the ADON was to ensure the medications were accurately transcribed. The DON said she was not employed at the facility at the time of this incident. She was hired one month later. The DON said the facility had a Standards of Care meeting weekly at which time new admissions, wounds, change in conditions were discussed and acted upon. The DON said this failure could negatively affect the residents as the wrong medications could cause harm, allergic reactions, or adverse reactions. She said her expectations were for nursing staff to make sure the correct resident's names and date of birth were on all paperwork from the hospital or physician offices. During an interview on 09/19/2025 at 12:20 p.m., the regional nurse said the staff had failed to transcribe and administer Resident #2's breathing treatments as prescribed upon discharge from hospital on [DATE]. She said staff failed to verify the names on Resident #2's discharge papers from the hospital. She said the admitting nurse was responsible for transcribing physician orders, and the ADON was responsible to ensure correctness. If a resident was admitted over the weekend, the orders were to be checked on the next workday. During a joint interview on 09/19/2025 at 12:55 p.m., LVN F said she had been employed at facility since April 2025. LVN F said she had been trained in admissions. She said anytime she would be expecting admission, she would request all discharge records prior to transfer. She said she would verify the resident's name, date of birth , and medications. She said upon arrival at the facility, a verification was made by asking residents their name and date of birth , or by looking at hospital bracelets, or verify if the family was present. LVN G agreed with LVN F comments and added when notifying physician of admission and verification of medications, she would also ensure the resident orders were complete as in route, frequency, rationale, and duration. LVN F said anytime medications were questioned, the physicians were quick to respond to calls made by nursing staff. LVN G said when notifying physician to verify medications, they name every medication to the physician. Review of facility policy titled Reconciliation of Medications on Admission, with a revision date of July 2017, indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Review the list carefully to determine if there are discrepancies/conflicts.The facility took the following actions to correct the noncompliance prior to the investigation:-Record review of an Employee In-service Record dated 02/10/2025 indicated the facility in-serviced the staff on verifying all information on new admissions as correct and with the correct residents' information. The in-service was conducted by LVN F with an audience of licensed staff. Seventeen licensed staff were in-serviced. - During an interview on 09/19/2025 at 11:50 a.m., the DON said nursing administration implemented for the ADON to perform daily medication checks with orders for newly ordered medications and new admissions during the morning meetings. -Record review of an audit of new admissions indicated the facility monitored 16 new admissions from 01/21/2025 through 02/10/2025 for accuracy 5 times/week for 4 weeks with no negative outcome. -During interviews throughout the investigation from 02/16/2025 at 08:30 a.m. through 02/22/2025 at 5:15 p.m., the licensed staff were aware to verify new medications or new admission residents' medications by calling the physician to verify. (ADON, LVN A, LVN B, LVN E, LVN F, LVN G, LVN H, LVN J, and LVN K) -Record review of 19 new resident admission's clinical record from 09/21/2025 -09/22/2025, revealed the Order Summary, discharge paperwork from recent hospital visits, MAR, history and physicals, etc. indicated no errors in transcribing orders or orders being overlooked. (Resident #s 2, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18, 19, 20, and 21) The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. The facility had corrected the noncompliance before the state's investigation began.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for 1 of 7 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility on 09/14/2025 and was located by facility staff approximately 50 feet off facility premises in a tall grassy area with rocks, uneven ground, and cut trees. An IJ was identified on 09/14/2025. The IJ template was provided to the facility on [DATE] at 4:10 p.m. While the IJ was removed on 09/19/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on Elopement. This failure could prevent residents from receiving appropriate supervision which could lead to residents sustaining serious injury, harm, or death. Findings included: Record review of Resident #1's electronic facility face sheet dated 09/17/ 2025, indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis of cognitive communication deficit generalized anxiety disorder, unspecified symptoms and signs involving cognitive functions. Record review of Resident #1's quarterly MDS assessment, dated 08/10/2025 indicated a BIMS score of 06 indicating Resident #1 was severely cognitive impaired. Resident #1 ambulated independently with no mobilities devices needed. MDS indicated Resident #1 had behaviors related to rejecting care that typically occurred 1 to 3 days. Record review of Resident #1's care plan dated 08/22/2025 indicated he had a behavior problem (Delusions) related to impaired thought process and impaired cognition following Cerebrovascular accident (stroke). Interventions: Anticipate and meet the resident's needs and if reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. On 09/15/2025 the facility added a new focus to Resident #1 care plan indicating he is an elopement risk/wanderer related to his history of attempting to leave the facility unattended and exit seeking. Interventions: Send to the behavior hospital for evaluation and treat. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Monitor location every (15) min. Record review of Resident #1's Wandering Risk Scale dated 08/04/2025 indicated a score of 4- low risk. Record review of Resident #1's NSG: Additional admission Assessments (Braden, Morse, etc.) dated 08/05/2025 indicated a low wander risk. Record review of Resident #1's Wandering Risk Scale dated 09/15/2025 indicated a score of 15- high risk. Record review of Resident #1 nursing note dated 09/14/2025 at 5:24 p.m. indicated LVN A documented the following: Resident noted to be wandering the grounds of facility behind the building near a field with high grass. This nurse and other staff approached the resident to guide this resident back into the facility, Resident became belligerent and aggressive stating that he does not need to be in the nursing facility. The resident begins waving his arms and not allowing staff to hold his hands to guide him back into the building. This nurse explained to the resident it is very hot outdoors and dangerous temperatures to be wandering away from the facility. Resident did not want to hear what this nurse was saying but finally was able to get resident back in facility. Record review of LVN A nursing note dated 09/14/2025 at 6:30 p.m. indicated the following: Resident #1 was placed on 15-minute monitoring checks from the dates of 09/13/2025-09/14/2025 starting at 6:00 p.m. Record review of the fifteen-minute monitoring sheet indicated Resident #1's monitoring was initiated on 09/13/2025 at 6:00 a.m. by LVN A. - On the time slot for 10:45 a.m. - 11:45 a.m. there was no staff initials on the line to confirm Resident #1 was being monitored.- On the time slot for 6:00 p.m.- 11:45 a.m. there was a line from 6:00 p.m. to 11:45 a.m. stating no issues. - On the time slot for 7:45 p.m. stated no issues. - On the time slot for 11:00 p.m. stated no issues.- The monitoring sheets were dated for: 09/13/2025- 09/18/2025. Record review of Resident #1's witness statement completed on 09/19/2025, by LVN A indicated This nurse went to do 15 min check on Resident #1 at about 4:45 p.m. and noted resident was not in his room. I started looking around the halls and other staff did as well. Once nobody could find the resident in the building, several staff went outdoors to look for resident, I was walking down towards the (redacted) on 9th avenue by the fields. I looked by the ditches and trees; I did not see him. LVN A wrote in her statement that Resident #1 was walking back from the field where the ground was uneven and had tall grass. Once staff was able to get him back onto facility grounds and inside, he stated why am I here and he needs to go. Resident did state he does not need to be here, nor does he need to be evaluated for any behaviors. During an interview on 09/16/2025 at 4:00 p.m., the DON said Resident #1 had aggressive behaviors present on admission. On 09/13/2025 he chased staff, cussed at them, tried to hit them, and was very aggressive with staff. The DON said she initially planned to send Resident #1 to a behavioral hospital on [DATE] but decided to cancel the transfer because his behaviors calmed down some. The DON said she initiated 15-minute monitoring checks for Resident #1. The DON did not give specific instructions to staff on how to monitor, nor what behaviors to look for in Resident #1. The DON did not designate a staff member to monitor Resident #1 but said she expected nurses to complete the checks. Resident #1 eloped from the facility on 09/14/2025 while the 15-minute monitoring checks were still in place. The DON said she didn't know the exact location of Resident #1 but hoped he's in his room. The DON said the facility does not have wander guards or any keycodes on any of the doors inside the facility. The DON said the residents can go in and out of the facility freely. During interview on 09/17/2025 at 10:01 a.m. LVN A said she last laid eyes on Resident #1 09/14/2025 at 4:45 p.m. and did not locate him till 5:08 p.m. on 09/14/2025. LVN A said Resident #1 was off facility property. It had taken a minimum of 3 staff members to get him back into the building due to his cussing and combativeness. During interview on 09/17/2025 at 10:15 a.m. Resident #1 said he went out of an unlocked facility door because he did not want to be there. Resident #1 said if the door was locked, he would not have been able to get out of the facility. Resident #1 said he doesn't want to be at the facility and should not be there. During interview on 09/17/2025 at 10:53 a.m., LVN B said on 09/13/2025 Resident #1 came out of his room yelling at her and began chasing her down the hall and around the nurse's station. The LVN B was unable to say why or what triggered Resident #1's aggressive behavior episode. The LVN B said he balled his fist up and attempted to hit her and then began yelling at other staff at the nurse's station. LVN B said the DON and the Administrator were notified. She said the DON told her and LVN A to start 15-minute monitoring checks on Resident #1. The LVN B said the DON did not designate a staff member to oversee the 15-minute monitoring checks nor what behaviors they should be looking for while Resident #1 was on the 15-minute monitoring checks. During interview on 09/17/2025 at 11:05 a.m., LVN A said she started looking for Resident #1 on 09/14/2025 at 4:45 pm because the 15- minute monitoring check was due and noticed he was not in his room nor in the facility. She said she located Resident #1 off facility grounds near (YMCA- redacted) in an uneven ground field with high grass, and cut trees laid everywhere. During interview on 09/17/2025 at 11:53 a.m., LVN B said Resident #1 would attempt to elope again because he states he should not be here, he did not want to be here and wanted to leave. During interview on 09/17/2025 at 11:58 a.m., LVN A said Resident #1 would attempt to elope again because now he knows the laundry and front door are unlocked and knows how to exit the facility. She said there was no way she can monitor all her assigned residents, give medications, and monitor Resident #1 at the same time. LVN A said when she gave medications on hall 300, she was unable to complete the 15- minute monitor checks on Resident #1 all at the same time. She said she already missed the 12- noon 15-minute monitor check because she was doing medication pass on her second assigned hall (hall-300). LVN A said while she was on her hour lunch break there was not another nurse watching Resident #1. During interview on 09/17/2025 at 12:12 p.m., CNA C said on 09/13/2025 she was not made aware Resident #1 was on 15-mintute monitoring checks. CNA C said she did not see any staff checking on him during her shift on 09/13/2025 from 6 a.m.- 6 p.m. During interview on 09/17/2025 at 12:30 p.m., CNA D said Resident #1 was wandering inside the facility on 09/13/2025. She said once Resident #1 was located by staff he kept saying the city hired him to pick up all the cut down trees in the field. She said she was not made aware Resident #1 was on 15-mintute monitoring checks. During interview on 09/17/2025 at 12:45 p.m., the CNA Supervisor said on 09/13/2025 Resident #1 was very aggressive stating I don't want to f***ing be here. She said Resident #1 had been saying he did not want to be at the facility since admission. She said she reported Resident #1 behaviors to the DON. She said she was not made aware Resident #1 was on 15-mintute monitoring checks. During interview on 09/17/2025 at 2:40 p.m., the DON said Resident #1 was admitted with behaviors and was very confused. The DON said Resident #1's behavior was reported to her on 09/13/2025 approximately 11:30 a.m. The DON said she along with the Administrator made the decision to place Resident #1 on 15-mintue monitor checks. She said the 15-mintue monitor checks were supposed to start approximately at 11:30a.m. She said the corporate nurse agreed to place him on 15-mintue monitor checks. The DON said she expected the nurses to do 15-mintue monitor checks, know where Resident #1 was at, and report to her any changes. The DON said she was responsible for following up on the 15-mintue monitor checks to ensure they are completed accurately. She said a high elopement risk was someone saying they want to leave the facility and start having exit seeking behaviors. She said a low elopement risk was someone wandering around the facility but not exit seeking. The DON said LVN A notified the Physician about Resident #1s behavior on 09/13/2025. The DON was unable to provide documentation of the physician being notified because the nurse did not document her calling. The DON said they do not have an assigned staff member to sit at the receptionist desk. During interview on 09/17/2025 at 4:05 p.m., the Administrator said Resident #1 had no payor source and stated, who's going to pay for a 1:1 sitter? During observation on 09/17/2025 at 11:15 a.m. Resident #1 was in his room sitting on the bed. Resident #1 had no wander guard on. The facility does not have nor use the wander guard system. During an observation on 09/17/2025 at 11:18 a.m. indicated the facility was located on a busy commercial 4 lane road with a speed limit of 45 mph. LVN A walked outside of facility and showed surveyor where Resident #1 was found when he eloped. LVN A showed surveyor location approximately 50 feet off facility premises in a tall grassy area with rocks, uneven ground, and cut trees. During an observation on 09/17/2025 at 11:20 a.m. LVN B showed surveyor an exit door on hall 200 was not locked and had no keycode or alarming sound on door. She said Resident #1 could also go out of the entrance door of the facility. LVN B said both doors lead to were Resident #1 was located off facility premise. Record review of website www.wunderground.com accessed 09/17/2025 indicated the outside temperature at the time of the elopement 09/14/2025 was approximately 96 degrees.Record review of an Elopement Policy with revision date of March 2019, indicated, Policy: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 3. If a resident is missing, initiate the elopement/missing resident emergency procedure:1. Determine if the resident is out on an authorized leave or pass;2. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and3. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.). 4. When the resident returns to the facility, the director of nursing services or charge nurse shall:1. examine the resident for injuries;2. contact the attending physician and report findings and conditions of the resident;3. notify the resident's legal representative (sponsor);4. notify search teams that the resident has been located; 5. complete and file an incident report; and document relevant information in the resident's medical record. The Administrator and DON were notified on 09/17/2025 at 4:10 p.m., that a noncompliance Immediate Jeopardy situation had been identified due to the above failures and were given a copy of the Immediate Jeopardy template and a Plan of Removal (POR) was requested. The facility's POR for the Immediate Jeopardy was accepted on 09/18/2025 at 6:34 a.m. and reflected the following: 1.Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred:Action: Resident #1 placed on 1:1 monitoring to be in place until Interdisciplinary team determines that monitoring can be decreased or alternate placement is found in a secure environment. The 1:1 will be 24 hours per day. Resident #1 will be within direct visual observation to ensure safety and immediate response. The person doing the 1:1 monitoring will only have that responsibility. Currently staff are signing up for 2-hour intervals and will not require a meal break. Staff will be required to document the 1:1 on the monitoring form.Person(s) Responsible: Director of Nursing, and/or Designee.Date: By 09/17/2025. Action: Facility audit of all residents to ensure a wander risk assessment was completed within the last quarter. Any resident who has not had a wandering assessment completed will have an updated one completed by 9/17/2025. Person(s) Responsible: Director of Nursing, and/or Designee Date: By 09/17/2025. Action: Ad-Hoc QAPI was conducted on 9/17/2025 with the Medical Director present by telephone. Person(s) Responsible: Administrator and Director of Nursing.Date: 09/17/2025. Action: Referrals to be sent for alternate placement.Person(s) Responsible: Director of Nursing or Assistant Director of Nursing.Date: 09/17/2025. Action: Education provided to the Director of Nursing on 9/17/25 related to interventions when a resident at risk for elopement expresses desires to elope, or an actual elopement occurs. Person(s) Responsible: Regional Nurse.Date: 09/17/2025. Action: Education to be initiated with all staff related to monitoring and safety of residents as well as appropriate steps to take when a resident expresses desire to leave or an actual elopement occurs. This training for all staff will be validated by completion of a post-training test, to be dated and signed by each staff member. Person(s) Responsible: Director of Nursing, and or/ Designee.Date:09/17/2025. Action: Residents requiring 1:1 monitoring or 15-minute checks will be relayed to staff on the daily assignment sheet.Person(s) Responsible: Updated by Nursing Management.Date: 09/17/2025. Action: Staff will be re-educated on the elopement policy and elopement drills will be performed by policy.Date: OngoingPerson(s) Responsible: Director of Nursing, and or/ Designee. Action: Education to be completed with all nursing staff working. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training.Person(s) Responsible: Director of Nursing, and or/ Designee.Date:09/17/2025. Action: Door chimes will be installed on the laundry door and front door to alert staff when someone is coming in or going out. The staff will re-direct any resident that has been deemed at risk for elopement.Date: To be completed by 09/18/2025 at 12:00 p.m. The facility's verification of the POR was as follows: During observation 09/17/2025 at 4:30 p.m. Resident #1 was placed on 1:1 monitoring with assigned staff. Resident #1 had a staff member outside of his room. During observation on 09/18/2025 at 10:00 a.m. door chimes were on the laundry door and front door. Door chimes sounded every time it was opened. Record review on 09/18/2025 of wander risk audit dated 09/17/2025 indicated a facility audit was conducted on all residents ensuring a wander risk assessment had been completed within the last quarter. Record review of the QAPI sign-in roster dated 09/17/2025 indicated an in-person attendance at the meeting from the Administrator, Assistant director of nursing, regional nurse, DON, and attendance by telephone from the Physician. Record review on 09/18/2025 at 10:00 a.m. of the DON training indicated the DON was trained 9/17/2025 on What is Elopement and Wandering and Elopements policy revised date: March 2019 and took a Elopement in Long- Term Care Quiz on 09/17/2025, by the Regional nurse. The Regional nurse educated the DON on the interventions when a resident at risk for elopement expresses desires to elope, or an actual elopement occurs. Record review on 09/18/2025 at 11:15 a.m. of an Employee In- service Record indicated 20 CNAs, 8 nurses (DON & ADON) included), 7 housekeepers, 2 dietary, 2 cooks, 2 admission staff, and 2 transport staff were educated on the elopement binder, residents at high risk for elopement, (interventions when a resident is exit seeking or attempting to elope.) communication of residents that are requiring 1:1 or 15 minute monitoring (will be indicated on the daily assignment sheet.) Record review on 09/18/2025 at 12:10 p.m. of A Mock elopement drill sign-in sheet and elopement drill observer checklist dated 09/18/2025 indicated 7 CNA's, 6 housekeepers, 1 transport staff, 5 nurses (DON & ADON included) 1 admissions staff, Administrator, and the MDS Coordinator participated in a mock elopement drill with Regional nurse, as the drill observer. Record review on 09/18/2025 2:00 p.m. of facility staff schedules dated 09/18/2025 indicated new rotate staff were all educated on the elopement policy, the elopement binder, and which residents are at high risk for elopement. All staff and took a post test on elopement. Record review of elopement assessments completed on 09/18/2025 reflected 75 assessments were completed. In an interview with the Maintenance Director on 09/18/2025 at 2:13 p.m. indicated he had received an in-service regarding elopement and learned how to identify exit seeking behaviors, look for missing residents, and redirecting exit seeking residents. took a post test on elopement. He said he added chimes to the laundry door and front door so everyone would know whose going in and out of the facility. In an interview with the Administrator on 09/18/2025 at 3:00 p.m., he stated he performed an education in-service with all department heads regarding elopement. He said he would follow up with the DON to ensure compliance with their elopement policy. In an interview with the Administrator on 09/18/2025 at 3:30 p.m., he said all residents who had positive elopement screenings had re-evaluations of their care plans. Staff interviews conducted on 09/18/2025 from 12:00 p.m. to 2:30 p.m., representing staff from (6:00 a.m.- 6:00 p.m.) and (6:00 p.m.- 6:00 a.m.) included: Administrator, DON,ADON, LVN A, LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, LVN I, CNA Supervisor, OT #1, PT #1, LVN F, LVN G, LVN H, LVN J, LVN K, LVN L, LVN P, LVN O, Housekeeper AA, Housekeeper BB, Housekeeper CC, Housekeeper DD, Housekeeper EE, Housekeeper Supervisor, [NAME] FF, [NAME] GG, [NAME] HH, [NAME] LL, Dietary aide, Dietary Supervisor, Business Office Manager, Admissions Director, Activities Director, Maintenance Director, Transportation Director. All staff were able to identify what Elopement is, who to report any residents displaying exit seeking behaviors and steps for staff to take to de-escalate resident behaviors. Staff indicated they were to be aware of resident behaviors, monitor for exit seeking behaviors. Staff were able to state elopement risk factors, elopement prevention strategies, required staff response if an elopement occurs, and keys points to remember. All staff were able to identify the responsibilities for supervision and monitoring residents with any exit seeking behaviors. During these interviews, staff stated they had received in-service training about the facility's elopement policies and procedures, including the charge nurse's responsibility and ensure they checked the elopement binder to know who's at risk for elopement. The staff stated they felt confident in identifying exit seeking behaviors. Record review of the 1:1 monitoring document dated 09/17/2025 indicated the documentation was not completed accurately. The 1:1 monitoring document reflected the following:On the time slot for 10:45 a.m. - 11:45 a.m. there was no staff initials on the line to confirm Resident #1 was being monitored.- On the time slot for 6:00 p.m.- 11:45 a.m. there was a line from 6:00 p.m. to 11:45 a.m. stating no issues. - On the time slot for 7:45 p.m. stated no issues. - On the time slot for 11:00 p.m. stated no issues. During an interview on 09/17/2025 at 2:00 p.m. the DON said it was her responsibility to ensure the 1:1 monitoring sheet was being filled out accurately. Resident #1 was transferred to another facility 09/18/2025 at 5:15 p.m. An IJ was identified on 09/14/2025. The IJ template was provided to the facility on [DATE] at 4:10 p.m. While the IJ was removed on 09/19/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on Elopement.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in accordance with currently accepted professional principles for 1 of 3 medication carts (300 hall) reviewed for storage of medication and biologicals.The facility failed to ensure 4 tablets of Ondansetron 8mg (medication used for nausea and vomiting) expired 10/31/24, had been expired for 322 days, were removed from use. The facility failed to ensure 5 tablets of Clonidine 0.1mg (medication used for high blood pressure) expired 07/31/24, had been expired for 414 days, were removed from use.These failures could place residents at risk of adverse reactions to medications, misappropriation of medications, and not receiving therapeutic effects of medication.Findings included:Observation on 09/18/25 at 10:45 a.m. of the facility 300 Hall medication storage cart indicated in the second draw the following:- an individual medication card with 4 untouched tablets of Ondansetron 8mg with an expiration date of 10/31/24 and fill date of 11/06/23, the medication had been expired for 322 days and had not been removed from use in the medication cart. - an individual medication card with 5 tablets of Clonidine 0.1mg (medication used for high blood pressure) expired 07/31/24 and fill date 08/11/23, had been expired for 414 days, were removed from use.During an interview on 09/18/25 at 10:45 a.m. LVN A said the Ondansetron 8mg medication had been expired since 10/31/24 and she said 4 out of 10 tablets were left and 5 out of 30 tablets of Clonidine 0.1mg were left and had expired 07/31/24. LVN A said she was new and had started working with the facility about 3-4 days ago and this was her first day working by herself. LVN A said she was responsible for administering medication out of the 300-hall medication cart but had not given any of the expired Ondansetron or Clonidine. LVN A said she had been trained by the facility on medication storage, making sure meds are not expired before giving medication and keeping the cart stocked, free of expired medications and spills. LVN A said if residents were administered expired medications it could lead to medication poisoning or sickness. LVN A said she would remove the expired medications from the cart.During an interview on 09/18/25 at 1:10 p.m., the DON said there should be no expired medications inside the medication room or inside the medication carts. The DON said the Nurse working on the medication cart checked the medication cart every time they work on the medication cart. The DON said nurses are to check for expired medications and discharged residents' medication to be removed for disposal. The DON said she was responsible in ensuring that the nurses were checking the medication carts for removal and disposal of expired medications and she said was not sure how it got over looked. The DON said if the medication were not given for months then they could expire and be overlooked on the medication cart. She said the effects of expired medications could range from reduced effectiveness to unfavorable side effects.Record Review of the facility pharmacy monthly medication review for storage dates 7/2025 to 9/2025 indicated no evidence of expired medications on the medication carts needing removal.Record review of the facility undated policy titled Medication Storage reflected in part:. Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security.5. Staff should observe proper storage and labeling requirements for all medications and vaccines during the performance of their daily task and should demonstrate safety in regards to the medication's integrity such duties should include but are not limited to: c. Remove any expired medications from active stock and discard medications according to facility policy.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection control for 3 of 4 residents (Resident #3, Resident #4, Resident #5), and 2 of 2 therapists, (PT #1 and OT #2.) The facility failed ensure PT #1 and OT #1 used hygiene and wipe down therapy equipment between Resident's use. These failures could place residents at risk of cross-contamination and development of infections. Findings included: During observation on 09/21/2025 at 4:20 p.m. indicated while in the Physical therapy room, PT#1 touched 3 residents (Resident #3, Resident #4, Resident #5), gait belt, 2 walkers, and 3 residents (Resident #3, Resident #4, Resident #5) wheelchairs while wearing the same pair of used gloves. PT#1 did not take used gloves off nor use hand hygiene after working with residents and touching 2 walkers, and 3 residents (Resident #3, Resident #4, Resident #5) wheelchairs. During observation on 09/21/2025 at 4:28 p.m. PT#1 and OT#1 did not use hand hygiene before assisting a Resident #4 to a standing position from his wheelchair. During observation on 09/21/2025 at 4:38 p.m. PT#1 was working with a Resident #4 on the parallel bars. After the resident completed the exercise, PT#1 put Resident #3 on the parallel bars without disinfecting the parallel bars in-between resident use. During observation on 09/21/2025 at 4:45 p.m. OT#1 was physically working between Resident #4 and Resident #5 and did not use hand hygiene in between residents during their exercise. During observation 09/21/2025 at 4:50 p.m. PT#1 washed his hands then dried his hands with paper towels. PT#1 used the same paper towels he dried his hands with to wipe the visible sweat off his forehead then wiped his hands with the same paper towels. PT#1 did not perform hand hygiene before touching Resident #3 and Resident #4 after wiping his visible sweat off his forehead. During observation 09/21/2025 at 4:45 p.m. PT#1 had an open cut with flesh exposed on his index finger approximately 0.5 inches. PT#1 did not have a band-aid covering on his index finger while working with the resident's. During Interview on 09/21/2025 at 4:50 p.m. PT#1 said he was wearing gloves because one of the residents in therapy was very sweaty and he did not want the sweat to get into the open cut on his finger. PT#1 said he should have had his finger covered especially when working with the residents to prevent the risk of cross contamination. PT#1 said he should have used hand hygiene before and after resident contact to prevent infection. PT#1 said he should not have wiped his hands with used paper towels he used to wipe his sweat off with. PT#1 said he disinfected the used equipment only at the end the day not in-between residents. He said the only time he disinfected equipment during the day was if a Resident was in isolation. PT#1 said he was trained on infection control by hospitals but not by the facility nor by the DON. During Interview on 09/21/2025 at 5:05 p.m. OT#1 said he should have used hand hygiene before and after working with the resident. He said not using hand hygiene or disinfecting used equipment can potentially put staff and Residents at risk of passing and contracting infections. OT#1 said he has completed infection control modules from his contracting company but has not completed a skill check-off on infection control for the facility. During an observation and Interview on 09/21/2025 at 5:20 p.m. the DON said she was the infection control preventionist and has not trained the Rehabilitation department on infection control. The DON observed PT#1 open cut on index finger and said the cut should always be covered to prevent cross contamination. She said PT#1 should have discarded his used paper towels and rewashed his hands to prevent his body fluids getting on the residents. The DON said her expectation was for staff to disinfected used equipment in-between residents. During Interview on 09/22/2025 at 11:55 a.m. the Director of Rehabilitation said she had not completed skill check off's, trainings, nor education on infection control/ hand hygiene. She said most of her staff know to disinfect equipment. The Director of Rehabilitation said all equipment including the parallel bars should be disinfected after each use to prevent the spread of germs. She said the DON told her PT#1 should have had his index finger covered to prevent cross contamination. The Director of Rehab said she has not been in-serviced by the facility on infection control but has completed infection control computer modules. She said her expectation was for her staff to disinfect equipment after each use, wash hands before and after working with the residents. During interview 09/22/2025 at 3:38 p.m. indicated the Administrator said his expectation was for therapy to be in-serviced by the DON on infection control before working with Residents. He said he expected therapy to wash their hands before and after working with the residents and clean equipment between usage. Record review of [company] (online education) Certificate of Course Completion dated 04/25/2025 indicated The Director of Rehabilitation completed Infection Control Microlearning: Standard Precautions for Clinical and Nonclinical Staff. The brief course was an annual refresher training course on infection control. Record review of [company] (online education) Certificate of Course Completion dated 04/04/2025 indicated OT#1 completed Infection Control Microlearning: Standard Precautions for Clinical and Nonclinical Staff. The brief course was an annual refresher training course on infection control. Record review of [company] Certificate of Course Completion dated 9/22/2025 indicated PT#1 completed Personalized Learning: Understanding Infection Control. The brief course was an annual refresher training course on infection control. Record review of Infection Control policy dated: July 2019 indicated: Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to prevent and manage transmission of diseases and infections.1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source.2. The objectives of our infection control policies and practices are tob. Maintain a safe, sanitary, and comfortable, environment for personnel, residents, visitors, and the general public.f. Provide guidelines for the safe cleaning and reprocessing of reusable resident- care equipment. 3. The Quality Assurance and Performance Improvement Committee, through the Infection Control Committee, shall oversee implementation of infection control policies and practices, and help department heads and managers ensure that they are implemented and followed. 4. All personnel will be trained on infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. 6. Inquiries concerning our infection control policies and facility practices should be referred to the Infection Preventionist of Director of Nursing Services.

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 7 residents (Resident #1 and Resident #2) reviewed for abuse.The facility failed to ensure Resident #1 was free from resident to resident sexual abuse when Resident #2 touched her vaginal area inappropriately on 08/14/2025 and was witnessed by Resident #3.The noncompliance was identified as PNC. The IJ began on 08/14/2025 and ended on 08/14/2025. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk for emotional distress, fear, decreased quality of care, and further abuse. Findings include:1. Record review of Resident #1's face sheet, dated 08/16/2025, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included PTSD (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), adjustment disorder with anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), altered mental status (a disorder that affects a person's ability to think, feel, and behave clearly) and auditory and visual hallucinations (seeing and hearing things that are not there).Record review of Resident #1's annual MDS assessment, dated 06/21/2025, indicated she made herself understood and usually understood others. She had severe cognitive impairment, identified with a BIMS score of 4. She required supervision or touching assistance with most activities of daily living.Record review of Resident #1's care plan, dated 06/24/2024 and revised on 08/14/2025, indicated Resident #1 had increased risk for anxiety/acute stress reaction r/t unwanted sexual contact from another resident. She was not having any negative effects from history of anxiety/acute stress. Interventions included to encourage resident to verbalize feelings and provide safe and supportive environment. Social Services to provide counseling and provide emotional support in a private setting.Record review of Resident #1's facility incident report, dated 08/15/2025 at 12:08 p.m., documented in the Resident description section .he (Resident #2) came in here and told me to lie back and when I asked him for what and picked up my teddy bear to put in front of me. He (Resident #2) moved my bear out of the way and put it right the foot of the bed and did like this pushing her shoulder back and put his hand in there and I asked him what are you doing and he said you're going to like it and put his hand in there some more. Nursing description section read in part: .resident noted sitting with her feet dangling over the side of the bed leaning sideways to left towards the foot of her bed using her stuffed animal for support and another resident had his hand in her brief digitally penetrating her. Immediate action taken section read in part: . other resident removed from this resident's room resident educated on resident to resident incidents and was ensured of safety, head to toe assessment as well as pain assessment complete no abnormalities noted social worker, psych-counselor, NP and RP notified. Resident #1 was assessed, and no injuries were noted.Record review of Resident #1's social services notes, dated 08/14/2025 at 1:13 p.m., indicated social services was notified of an alleged incident of non-consensual sexual contact between Resident #1 and Resident #2. Upon interview, Resident #1 stated she was seated on her bed when fellow Resident #2, alleged perpetrator, entered her room sat beside her and placed his hands inside her brief despite her telling him to stop. She denied any vaginal penetration and expressed that she did not consent to the contact she reported feeling upset and surprised as she previously considered him Resident #2 a friend. Social services provided emotional support validated Resident #1's feelings and assured her that steps were being taken to ensure her safety. Resident #1 was informed that Resident #2 would be relocated and instructed her to notify staff immediately if he approaches her. Resident #1 verbalized understanding and agreed to report any further concerns. Social services coordinated with nursing, administration and the investigation team to ensure separation of residents. Witnesses' interviews, completion of body skin assessment and initiation of the formal investigation. Ongoing emotional support and monitoring will be provided.Record review of Resident #1's social services notes, dated 08/14/2025 at 1:40 p.m., indicated Resident #1 carries a diagnosis of dementia which impacts her judgement, impulse control and reliability of self-reported information due to her cognitive impairment, statements made by Resident #1 cannot be considered fully reliable without corroborating information. Social services will continue to monitor Resident #1 for safety, provide redirection as needed and collaborate with nursing and the interdisciplinary team to address ongoing behavioral concerns.Record review of Resident #1's social services notes, dated 08/15/2025 at 10:02 a.m., indicated social services met with Resident #1 to review and have her sign the grievance filed regarding the incident with another resident on 8/14/2025. The grievance and actions taken were explained to her and she expressed that she was pleased with how the matter was addressed Resident #1 was observed to be in good spirits when asked about her well-being following the incident she stated that she was fine. Upon inquiry regarding her relationship with Resident #2, Resident #1 denied being in a relationship she indicated that he had been pursuing her, but she reiterated she denies any desires only friendship. She stated one time before, me and the lady up the road went downstairs and when we came back he was laying in the other bed in my room. This statement demonstrates cognitive impairment as there is no downstairs or lady up the road and she has never had passes outside the facility. Resident #1 was engaged in conversation, understood the discussion regarding the grievance and continued to demonstrate cooperative and appropriate behavior throughout the interaction. Plan continue to monitor interactions with other residents, provide ongoing emotional support and education regarding boundaries and appropriate sexual behavior as needed.2. Record review of Resident #2's face sheet, dated 08/16/2025, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included insomnia due to mental disorder (inability to fall asleep), adjustment disorder with anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Major Depressive Disorder with severe psychotic symptoms (a severe form of depression where a person experiences symptoms of psychosis, such as hallucinations or delusions, often reflecting depressive themes of worthlessness or guilt). discharge date [DATE] at 6:34 p.m. to psychiatric hospital.Record review of Resident #2's quarterly MDS assessment, dated 05/06/2025, indicated he made himself understood and understood others. He had severe cognitive impairment, identified with a BIMS score of 06. He required partial/moderate assist with toileting, personal hygiene and bathing.Record review of Resident #2's care plan, dated 08/14/2025, indicated Resident #2 had potential sexually inappropriate with a resident related to impaired judgement. Intervention was admission to behavioral hospital for evaluation and admission. Place on 1:1 care until transported to behavioral hospital.Record review of Resident #2's facility incident report, dated 08/14/2025 at 12:08 p.m., the Resident description section read in part .when asked Resident #2 about the incident resident stated we are both grown adults, so it is not abnormal for two grown adults to enjoy these types of things, we were both enjoying it. Nursing description section read in part: Resident #2 noted in his wheelchair in another resident's room at her (Resident #1) bedside with his hands in her (Resident #1) brief digitally penetrating the resident (Resident #1). Immediate action taken section read in part: . Resident #2 removed from resident's (Resident #1) room and educated on resident-to-resident incidents, head to toe assessment as well as pain assessment completed no abnormal abnormalities noted. Social worker and psychology counselor made aware nurse practitioner and RP notified. Local Police Department notified 8/14/2025 at 1:23 p.m.Record review of Resident #2's progress notes, dated 08/14/2025 at 12:33 p.m., ( authored by LVN A) indicated Resident was in a female room resident (Resident #2) was sitting in his wheelchair with his fingers inside of the female (Resident #1) vagina going in and out of her vagina with his fingers another resident (Resident #3) was coming down the hall to see what the resident was doing and he called the staff to come down there. This nurse entered the room the female resident (Resident #1) was lying on the bed and the male resident (Resident #2) had his fingers in her vagina I told the resident (Resident #2) he can't be doing that he stated I don't see why not it's nothing wrong with that. This nurse escorted the resident (Resident #2) out the room this nurse and ADON and CNA interviewed the female resident (Resident #1) to ask her did she give the resident (Resident #2) permission to do that to her, she stated no she wanted him (Resident #2) to stop she (Resident #1) asked him (Resident #2) twice to stop and he (Resident #2) kept going and told her, she was going to like it. Notified DON, social worker, administrator and RP. Record review of Resident #2's progress note, dated 08/14/2025 at 12:36 p.m. and authored by ADON, indicated NP made aware of incident and gave the ok to send resident (Resident #2) out to the behavioral hospital.Record review of Resident #2's social services note, dated 08/14/2025, indicated interview investigation completed by social services Resident #2 acknowledged physical contact occurred describing it as consensual and mutually enjoyable. He (Resident #2) stated Resident #1 laid her head back and appeared to enjoy it and denied being told to stop he (Resident #2) expressed that if she (Resident #1) had told him to stop he would have done so immediately. Social services notes Resident #2 demonstrates lapses in memory which may impact the accuracy and consistency of his statements due to these cognitive limitations self-reported information should be interpreted with caution and corroborated with additional sources when possible. Social services will continue to monitor cognitive status collaborate with nursing and therapy staff and provide supportive interventions as appropriate.Record review of Resident #2's progress note, dated 08/14/2025 at 3:35 p.m. and authored by DON, indicated Resident #2 currently isolated on one to one sitting until behavior hospital is here to transport.3. Record review of Resident #3's face sheet, dated 08/16/2025, indicated a [AGE] year-old male admitted to the facility on [DATE]. Resident #3 had diagnoses which included insomnia (inability to fall asleep), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Major Depressive Disorder (a severe form of depression where a person experiences symptoms of reflecting depressive themes of worthlessness or guilt).Record review of Resident #3's quarterly MDS assessment, dated 07/17/2025, indicated he made himself understood and understood others. He had no cognitive impairment, identified with a BIMS score of 15. He required partial/moderate assist with toileting, personal hygiene and bathing.Record review of the facility's PIR (Provider Investigation Report), report to HHSC, dated 08/14/2025, incident category as abuse, Resident #2 with his hand touching Resident #1 in her brief, confirmed and signed by the Administrator. PIR indicated the incident occurred on 08/14/2025 at 12:08 p.m. in Resident #1 room.During an interview on 08/15/2025 at 2:00 p.m. with Resident #3 said he was the one who reported and saw what had happened to Resident #1. Resident #3 said he was rolling down the hall in his wheelchair around noon yesterday (08/14/2025) headed to the dining room for lunch. Resident #3 said he was looking from side to side both ways in rooms and when he got to Resident #1's room he saw Resident #2 pushing his fingers, going in and out of Resident #1's vagina area. Resident #3 said Resident #1 had no underwear on and Resident #2 was holding one leg of Resident #1 with his right hand and using his left hand going in and out of Resident #1's vagina. Resident #3 said he was angry because that could have been his mom or his grandmother. Resident #3 said he started yelling help help stop. Resident #3 said it looked like Resident #1 couldn't move and thought Resident #1 was saying no. Resident #3 said Resident #2 had a smile on his face that looked like an evil laugh. Resident #3 said LVN A arrived, got resident #2 by the wheelchair and took him completely off the hall. Resident #3 said he didn't know what happened after that, but he thought Resident #2 went to a behavior hospital because he hadn't seen him again since then. Resident #3 said Resident #2 usually sat out on the front porch and fed the birds. Resident #3 said he had no concerns of anyone harming him and if someone were too, he'd report it to the Administrator.During an observation and interview on 08/15/2025 at 2:00 p.m., Resident #1 she was sitting on the edge of her bed and said, it all went crazy as far as she was concerned, and she was ok with it. Resident #1 said Resident #2 tried but didn't get into her pants because her dad was a police officer and she knew how to handle men like that. Resident #1 said when Resident #2 stopped touching her vagina she asked him to start again because she did not want him to hurt that young girl. Resident #1 said the young girl was around the age of 12-[AGE] years old. She said Resident #2 only wanted to touch my body because it was so soft and so good. She said she was pregnant and did not want to mess her body up, so she just let Resident #2 touch her legs. Resident #1 stated she felt safe living at the facility and Resident #2 was a friend who was not dangerous. Resident #1 said if she was in danger or hurt she would report it to the office. Resident #1 said there were no witnesses to the incident because no one was on the porch.During an interview on 08/15/2025 at 09:30 a.m., the Administrator said he was the abuse coordinator and was responsible for investigating the incident that occurred yesterday (08/14/2025) between Resident #1 and Resident #2. The Administrator said Resident #2 was not in the facility and was sent to a behavioral hospital the same day of the incident. The Administrator said Residents #1 and #2 were not a couple or in a romantic relationship. The Administrator said Resident #2 liked to go outside and feed the birds and was often seen alone. The Administrator said Resident #3 witnessed the incident and alerted nursing staff and nursing staff immediately separated the two residents. Resident #2 was immediately taken to another hall for 1:1 and interviewed and cleaned up. The Administrator said Resident #2 was seen with his fingers inside of Resident #1's vagina by LVN A and CNA B. The Administrator said when Resident #1 was initially interviewed right after the incident she said she told Resident #2 no, and Resident #2 said Resident #1 did not tell him no or to stop so he thought she was enjoying it. The Administrator said the incident had been reported to the police and they had taken written statements from Residents #1, #2, #3 and LVN A, CNA B and ADON. The Administrator said he started the investigation and reported it to HHSC.During an interview on 08/15/2025 at 5:10 p.m., CNA B said she was also the CNA Supervisor which was like a lead CNA. CNA B said around 12 noon, on 8/14/2025, she was in the dining room passing trays and heard Resident #3 yelling for help. CNA B said when she got to Resident #1's room she saw Resident #1 lying on the bed with her head to the foot of the bed, legs opened and Resident #2 was in his wheelchair between Resident # 1's legs, his right hand on his wheelchair arm, his left hand was twisting inside of Resident #1's vagina. CNA B said Resident #1 looked scared, holding her teddy bear on her chest. CNA B said Resident #1 said she didn't want Resident #2 there. CNA B said this was her first time seeing Resident #2 do something like this and she had never seen Resident #2 naked but he liked to sleep naked. CNA B said she was shocked, Resident #2 was not perverted. CNA B said she saw Residents #1 and #2 talking before in the front foyer, but nothing sexual or romantic with each other or with any other female. CNA B said Resident #2 said he just wanted to make Resident #1 feel good because he knew he would feel good. CNA B said Resident #2 said Resident #1 didn't say he couldn't do it. CNA B said she didn't think Resident #2 knew Resident #1 was confused. CNA B said she and LVN A were the first to show up and that LVN A told Resident #2 to stop and he stopped. LVN A took Resident #2 out of Resident #1's room. CNA B said she really thought Resident #2 didn't think he was doing anything wrong; he was not confused and had his right mind. CNA B said she thought Resident #2 didn't know Resident #1 didn't want him to touch her vaginal area. CNA B said CNA C sat with Resident #2 until CNA D arrived to relieve him. CNA B said after LVN A removed Resident #2 from the room and interviewed Resident #1, she continued with her assignments she didn't know what happened after that. CNA B said she was in-serviced on abuse and neglect and on how to recognize consensual versus non-consensual touching and to report immediately to the Administrator who was the abuse coordinator.During an interview on 08/15/2025 at 5:10 p.m., CNA C said he worked the 2p-10p shift and sat 1:1 with Resident #2 from 2:30 p.m. to about 3:30 p.m. when CNA D arrived and took over the 1:1 until Resident #2 left the building. CNA C said Resident #2 was agitated because he couldn't go back to his hall. CNA C said he and Resident #2 were on hall 100. CNA C said he never worked with Resident #2 before, and Resident #2 kept saying I didn't do anything wrong. CNA C said Resident #2 said he felt like he was being prosecuted because he couldn't go to his room. CNA C said Resident #2 was usually quiet and not get into arguments. CNA C said CNA A instructed him to do 1:1 because of the incident and they were keeping Residents' #1 and #2 separated. CNA C said he washed the resident's hands. CNA C said he did not see the female resident. CNA C said he did not do any documentation because he only had him for an hour to 45 minutes and the Resident didn't go anywhere or do anything. CNA C said he was trained on abuse and neglect, to report immediately to the abuse coordinator who was the Administrator and how to identify signs and symptoms of inappropriate sexual behaviors such as crying, saying no or moving away and what it looks like when someone is consenting versus not consenting to sexual activity such as kissing back or touching back. CNA C said he would report all sexual behavior inappropriate and consenting and non-consenting to the DON and Administrator.During an interview on 08/15/2025 at 5:50 p.m., CNA D said she got to the facility about 3:00 p.m., because CNA B called and asked if she could sit 1:1 with Resident #2. CNA D said when she got to the facility around 3:00 p.m. CNA B told her it was for allegations of inappropriate behavior with Resident #2. CNA D said she didn't document anything because she stayed with Resident #2 the whole time on hall 100 because the residents were to be kept apart until he was transferred to a behavior hospital. CNA D said Resident #2 would say I did not do anything wrong. CNA D said she provided care for Resident #2 before, and she never saw him make any sexual advances towards Resident #1 or towards any other female resident. CNA D said she didn't think they were a couple because she never saw them together and Resident #1 needed constant redirection to where her room was because she had some confusion. CNA D said Resident #2 had very good understanding, but had said he and Resident #1 were in a relationship for a couple of months and in his mind he thought they were in a relationship. CNA D said she didn't think Resident #2 was a danger to anyone else. CNA D said she was in-serviced on and verbalized knowledge of abuse and neglect, resident to resident abuse, sexual encounters and how to recognize consensual and non-consensual sexual advances. CNA D said Resident #2 didn't understand why he had to leave but she overheard the Social Worker explaining to Resident #2 about it being protocol and precautions for both the resident's safety.During an interview on 08/16/2025 at 10:00 a.m., LVN A said Resident #3 alerted him to come to Resident #1's room and when she got to Resident #1's door, it was wide open, and she could see Resident #2 was in his wheelchair in front of Resident #1 who was lying in bed holding her teddy bear tight on her chest. LVN A said Resident #2 had his left hand, three fingers inside Resident #1's vagina moving in a back, forth and circle motion. LVN A said she could see the vaginal hair on Resident #1. LVN A said Resident #1 was lying there doing nothing with a blank stare on her face and it didn't look like Resident #1 was enjoying it. LVN A said Resident #2 looked like he enjoyed it because he had a smile on his face. LVN A said she separated the residents, escorted Resident #2 out of the room to get to safety and to get interviews. LVN A said Resident #2 told her as she was pushing him down to 100 hall, that they both were enjoying it. LVN C said she took Resident #2 to hall 100 to be on 1:1 with CNA C who was also a male. LVN C said she went back to Resident #1's room to assess and interview her with the ADON and CNA B. LVN A said she completed the assessment on Resident #1 and there was no bruising, no blood and no complaints of pain. LVN A said she assessed Resident #1 vaginal area and there was no blood or discharge, no bruising and no open areas. LVN A said Resident #1 said she told Resident #2 to stop twice. LVN A said Resident #2 was more alert than Resident #1. LVN A said she called both the residents RP and left a message for them to call back and notified the DON and the Administrator. LVN A said she was in-service on and was knowledgeable of abuse and neglect, abuse coordinator is the administrator, immediately report abuse and neglect, signs and symptoms on how to identify inappropriate sexual behaviors, how to redirect and residents' rights as it related to consensual and non-consensual sex or intimacy. LVN A said the Police were called and she was interviewed along with ADON, CNA B and the two residents involved.During an interview on 08/16/2025 at 4:08 p.m., the ADON said she was in the conference room and CNA B came and got her. The ADON said she did not see the actual act, but she was headed to the room. She said she saw LVN A was taking Resident #2 out of Resident #1's room by the wheelchair and Resident #2 was asking what's wrong saying he didn't do nothing wrong; we were two consenting adults. The ADON said Residents #1 and #2 were immediately separated. Resident #2 was taken to hall 100 to do 1:1 and she interviewed Resident #1 along with LVN A and CNA B. The ADON said when she saw Resident #1, she did not seem afraid and was not crying and said she did not give consent, he (Resident #2) came into her room and told her to lay back. The ADON said Resident #1 said she grabbed her baby which was a bear and put it on her lap and then he (Resident #2) asked her (Resident #1) to lay back again, and Resident #2 started touching her vaginal area. The ADON said Resident #1 said she wasn't OK with that, when Resident #2 first started touching her vaginal area and she didn't enjoy it at first but then later she said she did start to enjoy it. The ADON said Resident #1 also told her they were friends, and she was not OK at first with him digging in her brief. The ADON she said she interviewed Resident #2 within 10 minutes of the incident. She said Resident #2 told her Resident #1 was fine with him touching her vaginal area and Resident #1 didn't tell him to stop, he didn't ask her if he could touch her, they were two consenting adults, Resident #1 didn't stop me, he figured it was OK because she never told him no and Resident #2 said Resident #1 was his friend. The ADON said the assessment of the resident, the female resident, was done by LVN A and CNA B washed Resident #2's hands. The 1:1 sitter said Resident #1 said she wasn't hurt and didn't want to go to the hospital. They called the RP and at first they had to leave a message but then he showed up the next day and he was notified and didn't want to send Resident #1 to the hospital. The ADON said she called the doctor, and new orders were to send Resident #2 to the behavior hospital. The ADON said the Police were called and she was interviewed along with LVN A, CNA B and the two Residents involved. The facility implemented the following interventions prior to the state surveyors entrance:Interviews conducted on 08/16/2025 from 3:30 p.m. through 08/16/2025 at 5:30 p.m., with the following staff through various shifts (6a-6p, 6p-6a, 6a-2p, 2p-10p, and 10p-6a) the DON, the ADON, LVN A, CNA B, Dietary O, CNA C, CNA D, Admissions, BOM, HR, CNA E, Dietary F, CNA G, CNA H, laundry I, CNA J, Rehab K, CNA L, LVN M, Dietary N, Dietary P, LVN Q, CNA R, LVN S, CNA T, Laundry U, LVN V, CNA W, LVN Y, CNA Z, Rehab AA, LVN X, CNA BB, LVN CC, CNA DD, Housekeeper EE, CS FF, Housekeeper GG, and LVN HH the staff said they were trained on abuse/neglect, abuse reporting, resident rights on hire and at least annually. The staff said they were retrained following the incidents that occurred on 08/14/2025. They were able to voice what to do first such as separate the residents and get help as needed. They said they would report to the Administrator who was the abuse coordinator. They were able to identify different types of abuse (examples of verbal, sexual and physical). Staff said they were trained to be alert to intimate acts between residents and to report to the nurse or management immediately. Staff understood residents had rights to sexual expression if it was consensual and identify those with capacity to consent and to report all acts of sexual expressions to nursing management for review for safety of both residents.Record review indicated on 08/14/2025, the DON held an in-service on the following with 54 employees in attendance:-resident rights,-abuse, neglect, and abuse reporting, -alert to intimate acts between residents, - resident safety and both residents able to give consent, recognizing concerns and,-identifying sexual abuse and capacity to consent.Attendees included 15 licensed nurses, 18 CNAs, 3 rehabilitation staff, 7 dietary staff, 4 housekeepers, 1 SW, 1 laundry, and 5 office personnel.The noncompliance was identified as PNC. The IJ began on 08/14/2025 at 12:08 p.m. and ended on 08/14/2025 at 6:34 p.m. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to use the services of a registered nurse for 8 at least consecutive hours 7 days a week for 1 of 4 quarters of 2023 (Quarter 1 - October 01, 2023, through December 31, 2023) PBJ reports reviewed for RN coverage. The facility did not have RN coverage for 10/07/2023, 11/11/2023, 11/12/23, 11/25/23, 12/03/23, 12/16/23, and 12/17/2023. This failure could place residents at risk of lack of nursing oversight and a higher level of care. Findings included: Record review of the CMS PBJ reports indicated: Quarter 1 2023 (October 01, 2023, through December 31, 2023) there were no RN hours on 10/07/23 (Saturday), 11/11/23 (Saturday), 11/12/23 (Sunday), 11/25/23 (Saturday), 12/03/23 (Sunday), 12/16/23 (Saturday), and 12/17/23 (Sunday). During an interview on 10/14/24 at 2:27 p.m., the Corporate Nurse said PBJ reports were submitted by the facility's corporate office. She said the facility did not have RN coverage for 10/07/23, 11/11/23, 11/12/23, 11/25/23, 12/03/23, 12/16/23, and 12/17/23. She said the possible negative outcome of not having an RN working 8 hours a day 7 days a week was the facility not having a supervisor present in the facility to oversee resident care. During an interview on 10/16/24 at 8:52 a.m., the DON said she could not provide any documentation of RN coverage for 10/07/23, 11/11/23, 11/12/23, 11/25/23, 12/03/23, 12/16/23, and 12/17/23. She said she was not working on those days because she was out on approved leave. During an interview on 10/16/24 at 9:15 a.m. the Administrator said there was not 8 hours of RN coverage for the days noted on the PBJ report. He said the facility had a difficult time hiring RNs due to being a rural area. He said the facility had contracted with a telehealth company that provided 24-hour RN consultation, and his Corporate Nurse (RN) was always available by phone. He said from October 2023 through December 2023 the facility was using agency RNs to provide the needed 8 hours of coverage, but they often did not show up for work. He said there was no possible negative outcome of not providing 8 consecutive hours of RN coverage daily because the nurses always had the Corporate Nurse and the telehealth RNs available. Record review of facility policy titled Departmental Supervision, Nursing, revised August 2022, indicated, . A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medication errors. The facility failed to administer Resident #1's Rivaroxaban (Xarelto-used to prevent blood clots) for 38 days (04/09/24 through 05/17/24). Resident #1's hospital discharge orders were not implemented to include her Rivaroxaban (Xarelto). Resident #1 was admitted to hospital on 05/17/24 and diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24 and passed away on 05/23/24 due to heart failure. An IJ was identified on 06/14/24 at 12:05 p.m. The IJ template was provided to the facility on [DATE] at 12:20 p.m. While the IJ was removed on 06/16/24 at 1:20 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving their medications as ordered, illness, hospitalization s, exacerbation of their disease processes, and death. Findings included: Record review of Resident #1's face sheet dated 06/13/2024 indicated she was a [AGE] year-old female admitted on [DATE]. Resident #1's diagnoses included chronic respiratory failure with hypoxia (not enough oxygen in the body's tissues), hypertension (high blood pressure), cardiac pacemaker, peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), hypertensive heart disease with heart failure, atherosclerotic heart disease of naive coronary artery with unspecified angina pectoris (buildup of fats, cholesterol and other substances in and on artery wall with chest pain), and chronic atrial fibrillation (irregular heart beat). Record review of Resident #1's MDS assessment dated [DATE] indicated she was usually understood and usually understood others. She had severe cognitive impairment (BIMS score 7). The MDS indicated Resident #1 was not taking anticoagulants. Record review of Resident #1's Discharge Home Medication List dated 04/08/24 indicated Continue taking these medications . Rivaroxaban (Xarelto) 15 oral. An unidentified staff indicated the order needed clarification. There was no documentation on the Discharge Home Medication List of the medication clarification. Record review of Resident #1's hospital records dated 04/08/24 indicated Rivaroxaban (Xarelto) 15 mg was started on 04/05/24. Record review of Resident #1's physician orders dated 06/13/24 indicated there was no Rivaroxaban (Xarelto) ordered, started, or discontinued. Record review of Resident #1's April 2024 MAR indicated there was no Xarelto administered. Record review of Resident #1s May 2024 MAR indicated there was no Xarelto administered. Record review of Resident #1's physician progress notes dated 04/09/24 at 5:15 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis (blood thinner medicine that reduces blood clotting) or ASA (Aspirin, also known as acetylsalicylic acid). Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). MD B agreed with NP A's notes and signed as the responsible party on 04/12/24. Record review of Resident #1's physician progress notes dated 05/16/24 at 5:00 p.m., completed by NP A indicated Complaint of discoloration of right foot. Skin: dark erythema to right foot.poor peripheral circulation . STAT arterial and venous doppler of RLE . Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's Extremity Arteries Duplex-Bilateral Lower dated 05/16/24 indicated moderate to severe bilateral low extremity arterial atherosclerosis, occlusive disease in left distal femoral artery and bilateral posterior tibial arteries, and CT angiogram was recommended for further evaluation. Record review of Resident #1's Extremity Veins-Lower Bilateral dated 05/17/24 indicated no deep vein thrombosis was visualized in the left lower extremity. Reduced venous flow was visualized in the right posterior tibial vein and the partial venous thrombosis could not be excluded. The right peroneal vein was not visualized. Short term follow-up was suggested. Record review of Resident #1's progress note dated 05/17/24 at 10:56 a.m., completed by the DON, indicated Resident #1 was administered Eliquis 2.5 mg. related to atherosclerotic heart disease of native coronary with unspecified angina pectoris. Record review of Resident #1's progress note dated 05/17/24 at 4:45 p.m., completed by LVN G indicated Resident #1 was transported to the hospital related coffee ground emesis (vomit). The DON and MD were notified. RP was at bedside. Record review of Resident #1's hospital records dated 05/17/24 indicated Resident #1's legs had become mottled and cool. She was diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24. Record review of Resident #1's hospice records dated 05/23/24 indicated passed away on 05/23/24 of heart failure. During an interview on 06/13/24 at 12:30 p.m., the DON said the admitting nurse (LVN D) was supposed to call and reconcile Resident #1's medications with the MD or NP. She said she was not able to locate documentation or verification that the physician or NP was called to reconcile and verify Resident #1's medication upon admission on 04/08/24. She said if Resident #1 did not receive her Xarelto as ordered, it could result in a blood clot. She said it was the facility's expectation the admitting nurse would reconcile medications with the physician or NP upon resident admission. She said the physician or NP were usually at the facility every Tuesday and Thursday and the medications should have been reconciled. She said she was not able to locate any documentation related to Resident #1's Xarelto. During an interview on 06/13/24 at 1:42 p.m., NP A said Resident #1 was not on Eliquis or ASA upon admission. She said the hospital records were not available for review when Resident #1 was admitted . She said she would not start a resident on a blood thinner if they were not already on the medication. She said Eliquis and Xarelto were similar medications and used for atrial fibrillation. She said the negative outcome of not receiving blood thinner could be blood clots, strokes, and heart attack. She said she never reviewed the hospital records. She said Resident #1 had a doppler on 5/16/24 due to mottling and coolness. She said the Doppler indicated some occlusion. She said she started Resident #1 on Eliquis on 05/17/24. She said Resident #1 was sent to the hospital on 05/17/24 due to vomiting. During an interview on 06/13/24 at 1:58 p.m., MD B said he believed NP A reviewed Resident #1's medications and Resident #1 was not on Xarelto. He said if Resident #1 was on Xarelto prior to admission and her cardiologist wanted her on Xarelto to prevent strokes then the Xarelto should have been continued. He said the process for medication reconciliation upon admission was the staff should call the NP or NP on call to review the medication discharge list. He said everyone was responsible, himself, the nurses, and the hospital at discharge for ensuring residents had the appropriate orders to meet their needs and maintain their safety. He said the negative outcome of not receiving the Xarelto as need could be blood clots, stroke, or heart attack. During an interview on 06/14/24 at 12:30 p.m., the administrator said he expected the facility nurses and attending MD and NP to ensure the residents received the care and medications they required. During an interview on 06/14/24 at 1:12 p.m., MD B said Resident #1's Xarelto was missed. He said he, his NPs, the facility administrator, DON, ADON held IDT meetings every Tuesday to review residents and their care. He said he did not know how the Xarelto was missed. During an interview on 06/15/24 at 2:30 p.m., the DON said NP A notes from 04-09-24 through 05/17/24 indicated Resident #1 required follow up on the Eliquis and ASA. She said NP A never wrote orders for the Eliquis or ASA or Xarelto. During an interview on 06/17/24 at 11:54 a.m., MD F (Resident #1's cardiologist) said Resident #1 was on Xarelto and her condition was stable. He said the medication was prescribed for atrial fibrillation and the prevention of stroke. He said if the medication was not continued, most likely would have resulted in a pulmonary embolism or a blood clot due to DVT. During an interview on 06/18/24 at 6:18 a.m., LVN C said he sent NP A a text with Resident #1's Discharge Home Medication List dated 04/08/24 that included Xarelto. He said the text indicated the medications needed frequency clarification. He said NP A texted back she would be at the facility. He said he did not speak to NP A about the medications and did not hear anything about the medications being reconciled. He said he did not document Resident #1's medications required clarification in the nurse notes. LVN C was no longer employed with the facility and was not available for an interview. Record review of the facility's Medication Therapy policy dated 2001 (revised 2007) indicated 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. 3. All medication orders will be supported by appropriate care processes and practices. Policy Interpretation and Implementation 1. The resident's clinical record must contain a written order for all prescription and over-the-counter medications taken by the resident. 2. All decisions related to medications shall include appropriate elements of the care process, such as: a. Adequately detailed assessment; b. Review of causes of symptoms; c. Consideration of the clinical relevance of symptoms and abnormal diagnostic test results; d. Principles of prescribing for the elderly; and e. Each resident's wishes, values, goals, condition, and prognosis. Record review of the facility's Attending Physicians Responsibilities policy dated 2001 (revised 2014) indicated . Each attending Physician will be responsible for the following: 1. Accepting the responsibility for initial and subsequent resident care; . 5. Providing appropriate, timely medical orders; 6. Providing appropriate, timely, and pertinent documentation; .Accepting Responsibility for Resident Care: . 2. The Attending Physician will seek, provide, analyze information regarding a resident's current status, recent history, and medications and treatments to enable safe, effective continuing care and to support facility compliance with care standards. 4. The attending physician or a covering practitioner will authorize timely admission orders. This was determined to be an Immediate Jeopardy (IJ) on 06/14/24. The Administrator, DON, and ADON were notified. The Administrator was provide with the IJ template on 06/14/24 at 12:20 p.m. The facility's plan of removal was accepted on 06/14/24 at 5:08 p.m. and included the following: Resident #1 was discharged to the hospital on 5/17 24 and no longer resides in the facility. A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 at 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. If a trend is established then we will QAPI the trend and in-service staff on root cause to prevent in the future. In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. DON/ADON will then notify the medical director - All other licensed staff will be in-serviced prior to working next shift. Ad Hoc QAPI meeting completed with IDT and Medical Director on 6.14.24 at 3 pm Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 by 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. Education was completed with the Administrative nursing team by the Regional Nurse Consultant related to completing chart audits of new admissions to assure that orders were transcribed correctly on 6.14.24. In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON if unable to verify orders after 2 attempts. DON/ADON will then notify the medical director. *Education to be completed with all nursing staff working by 6.14.24 at 6 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. On 06/16/24, the surveyor confirmed the facility implement their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility audit completed by the Director of Nursing/Designee on 06/15/24 indicated of all current residents in the facility most recent admission orders were correctly verified and transcribed into the HER. The MD was notified of any orders identified as not properly transcribed the MD and any new orders were implemented. There were no trends identified. Record review of in-services conducted by DON/Designee on 06/15/24 indicated licensed nursing staff were trained related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. The DON/ADON would then notify the medical director. All other licensed staff would be in-serviced prior to their working next shift. The admitting nurse would update the progress note to indicate they reviewed the admission orders with the MD/NP. All new admissions and re-admissions would have orders verified by the admitting physician. Facility nursing staff were to document the notification in the resident record and indicated if there were any medications the physician discontinued. Record review of an Ad Hoc QAPI meeting completed with IDT and Medical Director on 06/14/24 indicated the facility interventions implemented to remove immediate jeopardy included the DON and ADON were educated by the RNC to complete chart audits of new admissions to ensure orders were transcribed correctly. Record review of the resident census dated 06/16/24 indicated here were no new admissions to the facility. Interviews conducted on 06/15/24 from 9:00 a.m. to 11:15 a.m. and included RN H and LVNs G, I, J, K, L, M, N, O, P, and Q, who worked all shifts (6:00 a.m.-6:00 p.m. and 6:00 p.m. to 6:00 a.m.) indicated they were aware they were required to verify and transcribe medications at time of admission and notify of DON/ADON if they were unable to verify orders after 2 attempts within 4 hours. The nursing staff were able to verbalize ensuring residents who were admitted or readmitted to the facility had a medication reconciliation completed with the practitioner and documented in the progress notes. During an interview on 06/15/24 at 9:30 a.m., the DON said she and the ADON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. She said all physicians and NPs were notified of the new system and if the physician was not able to reconcile the orders the resident would be sent out to the hospital. During an interview on 06/15/24 at 9:43 a.m., the ADON said she and the DON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. On 06/16/24 at 1:20 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 10 residents (Resident #1) reviewed for pharmacy services. The facility failed to transcribe Resident #1's discharge orders dated 04/08/24 and failed to follow-up to ensure Resident #1's hospital discharge orders were implemented to include her Rivaroxaban (Xarelto-used to prevent blood clots). Resident #1 was not administered Rivaroxaban (Xarelto) for 38 days. Resident #1 was admitted to hospital on 05/17/24 and diagnosed Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24 and passed away on 05/23/24 due to heart failure. An IJ was identified on 06/14/24 at 12:05 p.m. The IJ template was provided to the facility on [DATE] at 12:20 p.m. While the IJ was removed on 06/16/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition or illness up to and including death. The findings included: Record review of Resident #1's face sheet dated 06/13/2024 indicated she was a [AGE] year-old female admitted on [DATE]. Resident #1's diagnoses included chronic respiratory failure with hypoxia (not enough oxygen in the body's tissues), hypertension (high blood pressure), cardiac pacemaker, peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), hypertensive heart disease with heart failure, atherosclerotic heart disease of naive coronary artery with unspecified angina pectoris (buildup of fats, cholesterol and other substances in and on artery wall with chest pain), and chronic atrial fibrillation (irregular heart beat). Record review of Resident #1's MDS assessment dated [DATE] indicated she was usually understood and usually understood others. She had severe cognitive impairment (BIMS score 7). The MDS indicated Resident #1 was not taking anticoagulants. Record review of Resident #1's hospital records dated 04/08/24 indicated Rivaroxaban (Xarelto) 15 mg was started on 04/05/24. Record review of Resident #1's Discharge Home Medication List dated 04/08/24 indicated Continue taking these medications . Rivaroxaban (Xarelto) 15 oral. Handwriting on this list by an unidentified staff indicated there was no documentation on the Discharge Home Medication List of the medication clarification. Record review of text message dated 04/11/24 at 11:42 a.m. sent by LVN E to NP A included Resident #1's Discharge Home Medication List indicated Resident #1's Discharge Home Medication List needed clarification of frequency. NP A texted back (time not visible) and responded she would be there in a bit. Record review of Resident #1's medication order summary dated 04/08/24 was reconciled on 04/11/24 without Xarelto by MD B. Record review of Resident #1's physician orders dated 06/13/24 indicated there was no Rivaroxaban (Xarelto) ordered, started, or discontinued. Record review of Resident #1's April 2024 MAR indicated there was no Xarelto administered. Record review of Resident #1s May 2024 MAR indicated there was no Xarelto administered. Record review of Resident #1's physician progress notes dated 04/09/24 at 5:15 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis (blood thinner medicine that reduces blood clotting) or ASA (Aspirin, also known as acetylsalicylic acid). Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). MD B agreed with NP A's notes and signed as the responsible party on 04/12/24. Record review of Resident #1's physician progress notes dated 04/10/24 at 8:15 a.m., completed by NP E indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/11/24 5:30 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/16/24 at 2:05 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/17/24 at 10:00 a.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto Record review of Resident #1's physician progress notes dated 04/18/24 at 4:09 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/23/24 9:15 a.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/25/24 4:04 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 04/30/24 at 3:54 p.m., completed by NP A indicated Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's physician progress notes dated 05/16/24 at 5:00 p.m., completed by NP A indicated Complaint of discoloration of right foot. Skin: dark erythema to right foot.poor peripheral circulation . STAT arterial and venous doppler of RLE . Chronic atrial fibrillation-Keep follow-up with cardiologist-currently not on Eliquis or ASA. Will need to review hospital records to see if need to restart med. Rivaroxaban (Xarelto) was not included in the medication list. There was no order to discontinue the Rivaroxaban (Xarelto). Record review of Resident #1's Extremity Arteries Duplex-Bilateral Lower dated 05/16/24 indicated moderate to severe bilateral low extremity arterial atherosclerosis, occlusive disease in left distal femoral artery and bilateral posterior tibial arteries, and CT angiogram was recommended for further evaluation. Record review of Resident #1's Extremity Veins-Lower Bilateral dated 05/17/24 indicated no deep vein thrombosis was visualized in the left lower extremity. Reduced venous flow was visualized in the right posterior tibial vein and the partial venous thrombosis could not be excluded. The right peroneal vein was not visualized. Short term follow-up was suggested. Record review of Resident #1's progress note dated 05/17/24 at 10:56 a.m., completed by the DON, indicated Resident #1 was administered Eliquis 2.5 mg related to atherosclerotic heart disease of native coronary with unspecified angina pectoris. Record review of Resident #1's progress note dated 05/17/24 at 4:45 p.m., completed by LVN G indicated Resident #1 was transported to the hospital related to coffee ground emesis (vomit that looks like coffee grounds)). The DON and MD were notified. RP was at bedside. Record review of Resident #1's hospital records dated 05/17/24 indicated Resident #1's legs have become mottled and cool. She was diagnosed with Iliac artery occlusion (part of the body, usually leg or foot isn't getting enough oxygen-rich blood, a medical emergency). She was discharged on hospice care on 05/18/24. Record review of Resident #1's hospice records dated 05/23/24 indicated resident passed away on 05/23/24 of heart failure. During an interview on 06/13/24 at 12:30 p.m., the DON said the admitting nurse (LVN D) was supposed to call and reconcile Resident #1's medications with the MD or NP. She said she was not able to locate documentation or verification that the physician or NP was called to reconcile and verify Resident #1's medication upon admission on 04/08/24. She said if Resident #1 did not receive her Xarelto as ordered, it could result in a blood clot. She said it was the facility's expectation the admitting nurse would reconcile medications with the physician or NP upon resident admission. She said the physician or NP were usually at the facility every Tuesday and Thursday and the medications should have been reconciled. She said she was not able to locate any documentation related to Resident #1's Xarelto. She said the hospital records were uploaded in Resident #1's EHR on 04/08/24 and available for the MD or NP to review. During an interview on 06/13/24 at 1:42 p.m., NP A said Resident #1 was not on Eliquis or ASA upon admission. She said the hospital records were not available for review when Resident #1 was admitted . She said she would not start a resident on a blood thinner if they were not already on the medication. She said Eliquis and Xarelto were similar medications and used for atrial fibrillation. She said the negative outcome of not receiving blood thinner could be blood clots, strokes, and heart attack. She said she never reviewed the hospital records. She said Resident #1 had a doppler on 5/16/24 due to mottling and coolness and discoloration to her right foot . She said the Doppler indicated some occlusion. She said she started Resident #1 on Eliquis on 05/17/24. She said Resident #1 was sent to the hospital on 05/17/24 due to vomiting. During an interview on 06/13/24 at 1:58 p.m., MD B said he believed NP A reviewed Resident #1's medications and Resident #1 was not on Xarelto. He said if Resident #1 was on Xarelto prior to admission and her cardiologist wanted her on Xarelto to prevent strokes then the Xarelto should have been continued. He said the process for medication reconciliation upon admission was the staff should call the NP or NP on call to review the medication discharge list. He said everyone was responsible, himself, the nurses, and the hospital at discharge for ensuring residents had the appropriate orders to meet their needs and maintain their safety. He said the negative outcome of not receiving the Xarelto as need could be blood clots, stroke, or heart attack. During an interview on 06/14/24 at 10:18 a.m., the DON said she was unable to locate the 24 hour reports and subsequent reviews of Resident #1's admission and medications. During an interview on 06/14/24 at 12:30 p.m., the administrator said he expected the facility nurses and attending MD and NP to ensure the residents received the care and medications they required. During an interview on 06/14/24 at 1:12 p.m., MD B said Resident #1's Xarelto was missed. He said he, his NPs, the facility administrator, DON, ADON held IDT meetings every Tuesday to review residents and their care. He said he did not know how the Xarelto was missed. During an interview on 06/15/24 at 2:30 p.m., the DON said NP A notes from 04-09-24 through 05/17/24 indicated Resident #1 required follow up on the Eliquis and ASA and cardiologist appointment. She said NP A never wrote orders for the Eliquis or ASA or cardiologist follow-up. During an interview on 06/17/24 at 11:54 a.m., MD F (Resident #1's cardiologist) said Resident #1 was on Xarelto and her condition was stable. He said the medication was prescribed for atrial fibrillation and the prevention of stroke. He said if the medication was not continued, most likely would have resulted in a pulmonary embolism (blood clot in the lung that creates a blockage) or a blood clot due to DVT. During an interview on 06/18/24 at 6:18 a.m., LVN C said he sent NP A a text with Resident #1's Discharge Home Medication List dated 04/08/24 that included Xarelto. He said the text indicated the medications needed frequency clarification. He said NP A texted back she would be at the facility. He said he did not speak to NP A about the medications and did not hear anything about the medications being reconciled. He said he did not document Resident #1's medications required clarification in the nurse notes. He said he was trained to document communication with the MD or NP in the progress notes. LVN C was no longer employed with the facility and was not available for an interview. Record review of the facility's Attending Physicians Responsibilities policy dated 2001 (revised 2014) indicated . Each attending Physician will be responsible for the following: 1. Accepting the responsibility for initial and subsequent resident care; . 5. Providing appropriate, timely medical orders; 6. Providing appropriate, timely, and pertinent documentation; .Accepting Responsibility for Resident Care: . 2. The Attending Physician will seek, provide, analyze information regarding a resident's current status, recent history, and medications and treatments to enable safe, effective continuing care and to support facility compliance with care standards. 4. The attending physician or a covering practitioner will authorize timely admission orders. Record review of the facility's Medication Reconciliation Policy dated 2001 (revised 2017) indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list: 1. Discharge summary from referring facility; 2. Admission order sheet; 3. All prescription and supplement information obtained from the resident/family during the medication history; and 4. Most recent medication administration record (MAR), if this is a readmission. 2. Find a quiet place that is free from distractions. General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list. 4. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Steps in the Procedure 1. If a medication history has not been obtained from the resident or family, complete this first. Information from the medication history should include: 1. Prescription medications, including those taken only as needed; 2. Non-prescription/over-the-counter medications, including those taken only as needed; 3. Herbal or dietary supplements, including vitamins and minerals; 4. Patches, eye drops, creams, inhalers, shots, sample medications; 5. Dose, route, frequency and last dose taken for all items; and 6. Reason(s) for taking each medication/supplement. 2. Ask the resident to list all physicians and pharmacies from which he or she has obtained medications. 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 4. List the dose, route and frequency for all medications. 5. Review the list carefully to determine if there are discrepancies/conflicts. For example: 1. The dosage on the discharge summary does not match the dosage from the resident's previous MAR; 2. There is a potential medication interaction between a medication from the admitting orders and a supplement from the resident's medication history; or 3. There is a medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication. 6. If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: 1. Contact the nurse from the referring facility; 2. Contact the physician from the referring facility; 3. Discuss with the resident or family; 4. Contact the resident's primary physician in the community; 5. Contact the resident's secondary physician(s) in the community; 6. Contact the community pharmacy used by the resident; or 7. Contact the admitting and/or Attending Physician. 7. Document findings and actions (see Documentation below). 8. When a resident is transferred to another facility, or within the organization, the reconciled medication list will be sent to the receiving care provider and the communication will be documented. Documentation 1. Document the medication discrepancy on the medication reconciliation form. 2. Document what actions were taken by the nurse to resolve the discrepancy. 3. If the discrepancy was unresolved, document how the discrepancy was communicated to the charge nurse, physician, pharmacy, and/or next shift. 4. If the discrepancy was resolved, document how the discrepancy was resolved. This was determined to be an Immediate Jeopardy (IJ) on 06/14/24. The Administrator, DON, and ADON were notified. The Administrator was provide with the IJ template on 06/14/24 at 12:20 p.m. The facility's plan of removal was accepted on 06/14/24 at 5:08 p.m. and included the following: Resident #1 was discharged to the hospital on 5/17/24 and no longer resides in the facility. A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 at 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. If a trend is established then we will QAPI the trend and in-service staff on root cause to prevent in the future. Facility will implement system changes requiring the admitting nurse to put in a progress note indicating that they have reviewed the admission orders with the MD. Facility will implement a system requiring the primary care physicians to put in a progress note indicating that they have reviewed and reconciled hospital discharge orders with admission orders within 72 hours of admission. PCP's will be made aware of the new system today on 6/14/2024. The DON/Administrator and, or designee will notify all facility PCPs of the new system. If the physician cannot reconcile the orders then the patient will be sent out to the hospital. In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. DON/ADON will then notify the medical director. All other licensed staff will be in-serviced prior to working next shift. Ad Hoc QAPI meeting completed with IDT and Medical Director on 6.14.24 at 3 pm Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: A facility audit to be completed by the Director of Nursing/Designee by 6.15.24 by 7 pm of all residents that are currently admitted in the facility to assure that their most recent admission orders were correctly verified and transcribed into the EHR For any orders identified as not properly transcribed, the MD will be notified of the discrepancy and any new orders implemented. Education was completed with the administrative nursing team by the Regional Nurse Consultant related to completing chart audits of new admissions to assure that orders were transcribed correctly on 6.14.24. In-services initiated by DON/Designee on 6.14.24 with licensed nursing staff present in facility related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. DON/ADON will then notify the medical director. *Education to be completed with all nursing staff working by 6.14.24 at 6 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. On 06/16/24, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the facility audit completed by the Director of Nursing/Designee on 06/15/24 indicated of all current residents in the facility most recent admission orders were correctly verified and transcribed into the EHR. The MD was notified of any orders identified as not properly transcribed the MD and any new orders were implemented. There were no trends identified. Record review of in-services conducted by DON/Designee on 06/15/24 indicated licensed nursing staff were trained related to verifying and transcribing medications at time of admission and notification of DON/ADON if unable to verify orders after 2 attempts within 4 hours. The DON/ADON would then notify the medical director. All other licensed staff would be in-serviced prior to their working next shift. The admitting nurse would update the progress note to indicate they reviewed the admission orders with the MD/NP. All new admissions and re-admissions would have orders verified by the admitting physician. Facility nursing staff were to document the notification in the resident record and indicated if there were any medications the physician discontinued. Record review of an Ad Hoc QAPI meeting completed with IDT and Medical Director on 06/14/24 indicated the facility interventions implemented to remove immediate jeopardy included the DON and ADON were educated by the RNC to complete chart audits of new admissions to ensure orders were transcribed correctly. Record review of the resident census dated 06/16/24 indicated there was no new admissions to the facility. Interviews conducted on 06/15/24 from 9:00 a.m. to 11:15 a.m., included RN H and LVNs G, I, J, K, L, M, N, O, P, and Q, who worked all shifts (6:00 a.m.-6:00 p.m. and 6:00 p.m.-6:00 a.m.) indicated they were aware they were required to verify and transcribe medications at time of admission and notify of DON/ADON if they were unable to verify orders after 2 attempts within 4 hours. The nursing staff were able to verbalize ensuring residents who were admitted or readmitted to the facility had a medication reconciliation completed with the MD or NP and then documented in the progress notes. During an interview on 06/15/24 at 9:30 a.m., the DON said she and the ADON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. She said all physicians and NPs were notified of the new system and if the physician was not able to reconcile the orders the resident would be sent out to the hospital. During an interview on 06/15/24 at 9:43 a.m., the ADON said she and the DON would review all new admits and charts to ensure the medications were reconciled and had orders as required. She said she would contact the NP or MD to address any issues and if she was not able to contact the MD or NP she would contact the medical director. She said the MD and NP visit notes would also be reviewed in the physician's portal to reconcile any medication or consult not ordered. An IJ was identified on 06/14/24. The IJ template was provided to the facility on [DATE] at 12:20 p.m. While the IJ was removed on 06/16/24 at 1:20 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 4 residents reviewed for significant medication errors. (Resident #1) The facility failed to ensure Resident #1's HIV ([human immunodeficiency virus] a virus that attacks the human immune system) medication was available for administration in August 2023 for 11 doses and September 2023 for 3 doses. Resident #1 had a diagnosis of HIV. An Immediate Jeopardy (IJ) situation was identified on 10/02/23 at 4:24 p.m. While the IJ was removed on 10/03/23 at 5:40 p.m., the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy at a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm, impairment, or death from not receiving a significant medication. Findings included: Record review of physician orders dated 10/02/23 indicated Resident #1 was an [AGE] year-old female readmitted on [DATE]. Her diagnoses included HIV, diabetes (a disease in which the body's ability to produce or respond to the insulin hormone is impaired resulting in abnormal metabolism) and pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). The orders indicated the resident was to receive Triumeq (antiviral medications that prevents human immunodeficiency virus (HIV) from multiplying in your body) 600-50-300 mg one tablet every day for antiviral. Record review of a quarterly MDS dated [DATE] indicated Resident #1 was usually able to make herself understood, usually understood others, had moderately impaired cognitive skills and required supervision and set up for transfers and ambulation. She utilized a walker for mobility and had no impairment to upper and lower extremities. Record review of a care plan dated 08/21/23 indicated Resident #1 was at risk for infections related to HIV. The goal indicated the resident would not display any complications related to immunodeficiency. Interventions included to administer medications as ordered and monitor/document and report signs and symptoms. Record review of the August 2023 MAR for Resident #1 indicated the Triumeq medication was coded as follows: *on 08/04/23 the date was coded a 6 and indicated the resident was in the hospital documented by the DON, *on the following dates there was a code 9 on the date indicating other see progress note: 08/08/23 documented by LVN A, 08/09/23 documented by LVN A, 08/10:23 docuemnted by agency staff, 08/12/23 documented by LVN A , 08/13/23 documented by LVN A , 08/14/23 documented by LVN A,08/15/23 documented by LVN A, 08/18/23 documented by LVN A, 08/19/23 documented by LVN A , 08/20/23 documented by LVN A and 08/21/23 documented by LVN A. *on 08/22/23, the date was coded a 6 and indicated the resident was in the hospital documented by LVN G Record review of the September 2023 MAR for Resident #1 indicated the Triumeq medication was coded as follows: *on 09/23/23 the date was coded a 1 and indicated the resident was absent from home without meds., *on 9/24/23 the date was coded a 3 and indicated the resident was absent from home with meds, *on 09/25/23, 9/26/23 documented by LVN E the date was coded a 9 and on 9/28/23 the date was coded a 9 and documented by LVN B and indicated other see progress note. Record review of the nurses' progress notes for Resident #1 indicated the following: *on 08/04/23 the resident was at the hospital. Resident #1 returned from hospital with a new antibiotic for pneumonia, *on 08/08/23 documented by LVN A, 08/09/23 documented by LVN A, 08/12/23 documented by LVN A, 08/13/23 documented by LVN A, 08/14/23 documented by LVN A, 08/15/23 documented by LVN A, 08/18/23 documented by LVN A, 08/19/23 documented by LVN A, 08/20/23 documented by LVN A and 08/21/23 documented by LVN A the Triumeq was on order, *on 08/10/23 signed by LVN D, the documentation for Triumeq did not indicate the medication was not administered, *on 08/22/23, the documentation indicated the resident was in the hospital. *on 09/01/23, documentation indicated the resident was readmitted from the LTAC hospital. *on 09/22/23 to 09/24/23, the resident was out of the facility with family *on 09/25/23 documented by LVN E, 09/26/23 documented by LVN E and 09/28/23 documented by LVN B, the documentation indicated the medication was not available. There was no documentation on the nurses' progress notes to indicate the physician was notified the Triumeq medication was not available or not administered. Record review of a LTAC hospital Interdisciplinary Notes dated 08/23/23 indicated History of Present Ilness: The patient is an [AGE] year-old female who resides at a nursing home, who presented to the emergency roiagnom on [DATE] and was found to have urinary tract infection and pneumonia. She was prescribed Lovenox (a medication used to thin the blood) and Rocephin (an antibiotic medication used to treat infection) and sent back to the nursing home, where she continued to have functional decline. The patient has had increased weakness and falls since her emergency room visit. The patient was transferred to [LTAC] on 08/21/2023 for continuation of antibiotic medical management of above symptoms and strengthening. The patient is currently not able to participate in activities of daily living and mobility as she was prior to her emergency room visit. A consult was performed by Physical Medicine and Rehabilitation physician, who determined the patient was suffering from exacerbation of her Parkinson's disease. The patient wants to come to acute inpatient rehabilitation for aggressive physical and occupational therapy.medication. A LTAC order dated 8/24/23 indicated Resident #1's Triumeq medication was ordered for administration. The order indicated the resident could use own home supply. There was no documentation to indicate the resident did not have the Triumeq available upon admission to the LTAC. During interview on 09/30 23 at 8:45 a.m., the DON said Resident #1 was sent out to the hospital on 08/0423 and returned the same day a diagnosis of pneumonia. She said when the resident returned, she was placed on skilled services. The Triumeq medication was a high-cost medication and was not covered on the insurance once the resident became skilled. She said as soon as the facility received the request for approval for the Triumeq by the administrator, the approval was signed, faxed back and the resident received the medication. She said she was unaware the resident missed doses of the Triumeq. During an observation, interview, and record review on 09/30/23 at 12:51 a.m., LVN A said she was the nurse who worked Hall 300, where Resident #1 resided. During record review of Resident #1's August 2023 MAR with LVN A, she said Resident #1 was out of her Triumeq medication on 08/08/23, 08/09/23, 08/12/23, 08/13/23, 08/14/23 08/15/23, 08/18/23, 08/19/23, 08/20/23 and 08/21/23 where she documented the code 9. She said the resident had gone out to hospital on 8/4/23 but returned the same day and was diagnosed with pneumonia. She said the resident was weak because the diagnoses of pneumonia and did continue to get weaker and was sent out to the LTAC for rehabilitation services on 08/22/23. She said it was her responsibility to administer the medications on Hall 300. She said she should have notified the DON and the physician, when the Triumeq medication was not available. She said she did not know why she did not notify them, but she did not. She said she remembered Resident #1 was out of the Triumeq but did not remember notifying the pharmacy it was out. Observation of the bottle of Resident #1's Triumeq 30 count in the medication cart indicated the bottle was 3/4 full of medication. The bottle was dated 9/28/23. LVN A said it had been refilled on 9/28/23 and only a few tablets had been administered out ot the bottle. She said she should have notified the pharmacy when there were approximately 10 tablets left. LVN A said the possible negative outcome of Resident #1 not receiving her medication would be the resident's HIV could worsen. During an interview on 9/30/23 at 1:20 p.m., the DON said she was unaware Resident #1 did not have the Triumeq medication for 11 days during August 2023. She said the Triumeq was to treat her diagnosis of HIV. She said she and the physician should have been notified the medication was not available. She said she expected the nurses to make sure the residents' medications were available for administration. She denied the resident could suffer increased symptoms by not having the medication available and said the medication was to keep the resident's HIV undetectable. During an interview on 09/30/23 at 1:52 p.m., LVN B said she started orientation on Hall 300 on 09/27/23 last week. She said Resident #1's Triumeq was not available on Wednesday 09/27/23 and Thursday 9/28/23. She said she was in training and did medication pass with LVN C. She said she watched LVN C pass medications on Wednesday 09/27/23 and passed the medications herself on Thursday 09/28/23. She said LVN C told her the Triumeq was a medication that required approval and it was not available. LVN B said if a medication was not available, the physician should be notified. She said she did not notify the physician the medication was not available because she was in training and LVN B had faxed the pharmacy. She said the medication was for Resident #1's HIV. She said the possible negative outcome if the resident did not receive the medication, would be the resident's HIV symptoms could exacerbate. During a confidential interview on 9/30/23 at 2:04 p.m., an individual said the facility did not have Resident #1's Triumeq medication available when the resident went out on pass 9/22/23 to 09/24/23. The individual said the ADON was notified the resident did not have her medication. During an interview on 09/30/23 at 2:22 p.m., the ADON said she was unaware Resident #1 did not have the Triumeq medication with her when she went out on pass 09/22/23 to 09/24/23. She denied staff had informed her the resident's medication was not available. She said Resident #1 should not miss a dose of the Triumeq medication because her HIV could worsen, and she was unaware that she missed doses. During an interview on 09/30/23 at 2:34 p.m., an attempted was made to call LVN D, who documented a code 9 on the August 2023 MAR on 08/10/23, with no answer and the mailbox was full; unable to leave message for call back. During an interview on 09/30/23 at 2:48 p.m., the DON said she was unaware Resident #1 had not received the Triumeq until 09/28/23, when the administrator approved the medication for the pharmacy to refill it and he sent the approval to her, and she ordered the medication stat. She denied knowing the resident also did not have the medication in August 2023. She said she was unaware and did not notify the physician. During an interview and record review on 09/30/23 at 3:12 p.m., LVN C said she worked two days last week on Hall 300, Wednesday 09/27/23 and Thursday 9/28/23, training LVN B. She said Resident #1's medication Triumeq was not available for administration either day. She said she did mark the MAR on 09/27/23 with a check which indicated she had administered the Triumeq, but she did not administer the medication because it was not available. She said she ordered the medication on 9/21/23 and there were pills left in the bottle but when she came back on 9/27/23 there were none left. During an interview and record review of a pharmacy Long Term Care Reorder Form dated 09/21/23, LVN C said she ordered the Triumeq on 09/21/23 and faxed it to the pharmacy and did not receive the fax back until the next day and noticed it said the Triumeq did not have an active order. The pharmacy Long Term Care Reorder form dated 09/21/23 had the Triumeq order request circled and had a label indicating No active order. Please send new order. She said she faxed an order for the Triumeq back to the pharmacy on 9/22/23 and was off the next few days. LVN C then provided an order dated 09/22/23 that indicated the Triumeq was ordered. Written across the bottom of the order was Please Refill. She said when she returned to work on 09/27/23 the resident was out of the Triumeq medication, so she called the pharmacy and asked them why it was not in the facility. She said the pharmacy told her it was a high-cost medication and was not covered and they had faxed over a high cost medication approval request to the administrator but did not receive an approval and the medication could not be refilled until it was approved. She said she did not remember if she reported what the pharmacy said. She said she did not notify Resident #1's physician that the resident did not have the medication available for administration. She said the physician should have been notified. She said the possible negative outcome of the resident not receiving her HIV medication could be the resident's HIV symptoms could worsen. During an interview on 09/30/23 at 3:45 p.m., LVN E, who worked Hall 300 on 9/25/23 and 9/26/23, said Resident #1's Triumeq medication was not available for administration. She said she did not usually work Hall 300 and was filling in, so she assumed someone had already ordered the medication and notified the physician. She said she did not notify the physician the medication was not available to administer. She said she told the ADON and the ADON told her to call the LTAC hospital and make sure they did not have it. She said she knew LVN C had reordered the medication, but the pharmacy sent back the refill request saying it was a high-cost medication and had to be approved before it could be filled. She said the resident's condition could get worse if she did not receive her medication as ordered. During an interview on 09/30/23 at 3:48 p.m., the ADON said the facility had sent Resident #1's Triumeq medication with her to the LTAC on 08/22/23 because the hospital called and said they could not provide the medication. She said when the resident returned on 09/01/23, the facility had to go pick the medication up from the LTAC because the hospital did not send it back with her. She said she was unaware the resident did not have the Triumeq medication for 11 days in August 2023 or the last week of September 2023. She said no one notified her on 09/25/23 or 09/26/23 that Resident #1 did not have the Triumeq medication available for administration. During an interview on 09/30/23 at 4:01 p.m., Pharmacist F said he pulled all of Resident #1's transactions offthe computer and the pharmacy had filled Resident #1's Triumeq and had a signed receipt for 6/29/23 and 8/19/23 but did not find a signed receipt for July 2023. He said they had also sent 30 Triumeq tablets on 09/28/23. He said he had a note that the pharmacy had communicated with the facility on 09/22/23 that the medication was a high dollar medication and could not be refilled without approval, but the administrator, DON and ADON were out of the facility. The pharmacy then refaxed and emailed the information again on 9/25/23, 09/26/23, 09/27/23, and 09/28/23. He said the administrator signed the approval and returned it on 9/28/23 and it was refilled. Pharmacist F was asked why the facility would have possibly not had the Triumeq medication available in August 2023 and he said there was a request from the facility on 07/05/23 for a refill but the medication had already been filled on 6/29/23 and it was too soon. He said there were no other communications found between the pharmacy and the facility regarding Resident #1's Triumeq medication requesting a refill for July 2023 and he did not have a signed receipt for July 2023. The During an interview on 10/02/23 at 10:09 a.m., the Administrator said he did not receive an approval request from the pharmacy until 09/28/23 and he immediately sent it back with his approval to be filled stat as soon as he received the request and Resident #1 received the medication the same day. He said he checked his emails daily and did not receive an approval request from the pharmacy until 09/28/23. He said on 09/28/23 he explained to the daughter of Resident #1 the Triumeq was not covered because the resident was on skilled services, and it required his approval. He said he was not aware the resident did not receive her medication in August 2023 or the last week of September 2023. He said the resident should receive her medication as ordered. He said he notified his medical director, and the medical director told him there would be no negative outcome of missing the Triumeq medication. During an interview and record review on 10/02/23 at 10:10 a.m., the DON provided a document, which she said was the July 2023 receipt for Resident #1's Triumeq. The top of the document had the words on order and Triumeq tablet cut in half indicating the page had been snipped. A pharmacy notes column indicated dispensed 7/26 updated to insurance-BA, 7/25 emailed facility-RR, 7/19 High $ emailed. There was no signature on the document and no year indicated on the document. The DON said she did not have a signed receipt for the Triumeq for July 2023. During an interview on 10/02/23 at 10:35 a.m., a phone call was initiated to the MD. The MD did not answer with a voice message left for callback. No call back was returned. During an interview on 10/02/23 at 11:15 a.m., the NP said she nor Resident #1's physician was notified the resident did not receive the doses of Triumeq in August 2023 and September 2023. She said the resident had to have the Triumeq medication or it would exacerbate her HIV if she did not receive it. She said it was herself that would need to be notified and she did not receive a call and the records did not indicate the facility called the office to report the resident had missed the Triumeq doses. She said the facility had her personal cell phone number to call her. She said the records indicated the office was notified on 08/21/23 of lab work for Resident #1 and the office was notified when the resident fell , but there were no notifications about the resident missing her Triumeq doses. The NP said her notes indicated a family member called and wanted her to go to hospital on 8/21/23 and a family member called the office on 09/28/23 to report the resident did not receive her Triumeq medication last week from 9/22/23 to 9/28/23. She said her nurse called the ADON on 09/28/23 and spoke with her about Resident #1 not receiving the medication. During an interview on 10/02/23 at 11:20 a.m., the ADON said no one from Resident #1's physician's office notified her that the resident's Triumeq medication was not available, and she was not aware of it. During an interview on 10/02/23 at 1:02 p.m., the DON said she realized the emails from the pharmacy, requesting approval for Resident #1's medications on 09/25/23, 09/26/23, 09/27/23 and 09/28/23, were going to the other box and not the in box of her emails. She said she had just looked and the emails from the pharmacy were in the other box and she had not checked the other box for incoming emails. During an interview on 10/03/23 at 3:08 p.m., the MD said the ADM had called him either Saturday 9/30/23 or Sunday 10/01/23 and notified him Resident #1 did not receive her Triumeq medication. He said he had not previously been notified. He said it was his understanding that Resident #1 only missed 3 days of the Triumeq medication and that would not be a problem, but he did not understand the resident missed multiple doses in August 2023. He said approximately 15 doses could potentially cause a problem for the resident. Record review of https://www.drugs.com/triumeq.html, updated June 9, 2022, accessed on 10/03/23 indicated: Triumeq contains a combination of abacavir, dolutegravir, and lamivudine. Abacavir, dolutegravir, and lamivudine are antiviral medications that prevents human immunodeficiency virus (HIV) from multiplying in your body. Triumeq is used to treat human immunodeficiency virus (HIV), the virus that can cause acquired immunodeficiency syndrome (AIDS). Take Triumeq exactly as prescribed by your doctor. Use all HIV medications as directed and read all medication guides you receive. Do not change your dose or stop using a medicine without your doctor's advice. Every person with HIV should remain under the care of a doctor. Usual Adult Dose for HIV Infection: 1 tablet orally once a day. Use: For the treatment of HIV-1 infection. Get your prescription refilled before you run out of medicine completely. If you miss several doses, you may have a dangerous or even fatal allergic reaction once you start taking this medication again. Record review of the Administering Medications policy revised April 2019 indicated: Medications are administered in a safe and timely manner. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescribed orders, including any required time frame. Medication errors are documented, reported and reviewed by the QAPI committee. Record review of the Pharmacy Services policy revised April 2019 indicated: Policy Statement: The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist. 2. The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of prac [NAME], and meet state and federal requirements. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. An Immediate Jeopardy (IJ) situation was identified on 10/02/23. The IJ template was provided to the Administrator on 10/02/23 at 4:30 p.m. The facility's POR dated 10/02/23 and accepted 10/03/23 at 3:00 p.m. indicated: Resident #1 medication was ordered and received by the facility on 9/28/2023. Primary care physician notified of the identified missed doses of medication on 10/2/23. The Medical Director also notified. There were not consequences associated or directly correlated with missed doses of the resident's medication. A viral load test has been ordered STAT for the resident. A facility audit to be completed by the Director of Nursing/Designee by 10/2/2023 of all residents with missed doses of medication in the past 7 days to assure that the medication was not held due to unavailability. For any medication identified as not given due to not available, the MD will be notified, and pharmacy will be contacted if the medication continues to not be available in the facility. If trends established, then we will QAPI the trend and in-service staff on root cause to prevent in the future. No other issues have been identified. In-services initiated by DON/Designee on 9/30/23 with licensed nursing staff present in facility related to timely reordering of medications within one week of running out, contacting pharmacy when medication is not in facility, notification of MD and DON. All other licensed staff will be in-serviced prior to working the next shift. The regional nurse consultant in serviced the DON and Administrator on checking all email folders for notifications of high-cost medications or refills from the pharmacy. Ad Hoc QAPI meeting completed with IDT and Medical Director on 10/2/2023. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: Audit to be completed 10/2/23 by DON/Designee to identify any residents that did not receive medications due to availability, pharmacy was contacted, and MD notified. This audit included the med cart, med room and MARS. There were no other residents identified that missed doses due to medication unavailability. We did identify new admits on the weekend were at a risk due to pharmacy hours of operation and ordering cut off time at 6PM. These orders will be sent to the local pharmacy and then delivered to the facility. Education was completed with the administrative nursing team by the Regional Nurse Consultant related to supervision to prevent missed medication administrations on 9/30/23. This includes checking all eFax's, and fax machines at the nurse's station. In-services initiated by DON/Designee on 9/30/23 with licensed nursing staff present in facility related to timely reordering of medications within one week of running out, contacting pharmacy when medication is not in facility, notification of MD and DON. Staff will be responsible for contacting the MD/PCP for any missed doses. The DON and or designee will follow up in the morning clinical meeting to ensure compliance. LVN A has been given disciplinary action and trained one on one by the DON. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working by 10/3/2023 at 2 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. On 10/03/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During observation on 09/30/23 at 12:51 p.m., Resident #1's Triumeq medication was dated 09/28/23 and available in the Hall 300 nurses' medication cart. During interviews on 10/03/23 from 3:18 p.m. to 3:28 p.m., Resident #1's NP and the MD said they were notified of Resident #1's missed doses of Triumeq. Record review of the audit tool completed by the DON indicated residents were identified that did not have their medications available in the last 7 days. The medications were unavailable for 9 residents and the physician was notified on 09/30/23, 10/02/23 and 10/03/23. No new orders were implemented. Record review of signed in-services dated 10/02/23 and 10/03/23 to LVNs indicated the LVNs were trained on documenting missed doses of medications, who to notify, and notification of the physician with posttests taken and dated 10/02/23 and 10/03/23. Record review of in-services dated 09/30/23 to 10/03/23 indicated LVNs were trained on supervision to prevent missed medication administration. Record review of the regional nurse consultant's in-service to the DON and ADM dated 10/03/23 indicated the DON and ADM were trained to check all email folders for notifications of high-cost medications or refills from the pharmacy. Record review of a counseling note dated 10/03/23 indicated LVN A was counseled on documentation, notification, and medications not available. During an interview on 10/03/23 at 3:53 p.m., the DON was able to verbalize how to check emails for pharmacy notifications. During Interviews on 10/03/23 from 4:20 p.m. to 5:20 p.m., three day shift LVNs, 3 evening shift LVNs and 2 night shift LVNs were able to verbalize the appropriate interventions to put in place to ensure the medications were available, refilled timely, weekend admits received their medications, the physician and DON were notified timely if medications were not available for administration and when to notify the pharmacy. On 10/03/23 at 5:40 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); for 1 of 4 residents reviewed for notification. (Resident #1) The facility failed to consult with Resident #1's physician, when Resident #1's HIV (a virus that attacks the human immune system) medication Triumeq (a medication used to treat HIV; discontinuation or interruption of antiretroviral therapy (ART) may result in viral rebound, immune decompensation, and/or clinical progression) was not available for administration in August 2023 for 11 doses and September 2023 for 3 doses. An Immediate Jeopardy (IJ) situation was identified on 10/02/23 at 4:24 p.m. While the IJ was removed on 10/03/23 at 5:40 p.m., the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of a pattern due the facility's nned to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and could cause, or likely continue to cause, harm, impairment, or death. Findings included : Record review of physician's orders dated 10/02/23 indicated Resident #1 was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses included HIV, diabetes (a disease in which the body's ability to produce or respond to the insulin hormone is impaired resulting in abnormal metabolism) and pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). The orders indicated the resident was to receive Triumeq (antiviral medications that prevents human immunodeficiency virus (HIV) from multiplying in your body) 600-50-300 mg one tablet every day for antiviral. Record review of the quarterly MDS dated [DATE] indicated Resident #1 was usually able to make herself understood, usually understood others, had moderately impaired cognitive skills and required supervision and set up for transfers and ambulation. She utilized a walker for mobility and had no impairment to upper and lower extremities. Record review of the care plan dated 08/21/23 indicated Resident #1 was at risk for infections related to HIV. The goal indicated the resident would not display any complications related to immunodeficiency. Interventions included to administer medications as ordered and monitor/document and report signs and symptoms. Record review of the August 2023 MAR for Resident #1 indicated the Triumeq medication was coded as follows: *on 08/04/23 the date was coded a 6 and indicated the resident was in the hospital documented by the DON, *on the following dates there was a code 9 on the date indicating other see progress note: 08/08/23 documented by LVN A, 08/09/23 documented by LVN A, 08/10:23 documented by agency staff, 08/12/23 documented by LVN A, 08/13/23 documented by LVN A, 08/14/23 documented by LVN A,08/15/23 documented by LVN A, 08/18/23 documented by LVN A, 08/19/23 documented by LVN A, 08/20/23 documented by LVN A and 08/21/23 documented by LVN A. *on 08/22/23, the date was coded a 6 and indicated the resident was in the hospital. Record review of the September 2023 MAR for Resident #1 indicated the Triumeq medication was coded as follows: *on 09/23/23 the date was coded a 1 and indicated the resident was absent from home without meds *on 9/24/23 the date was coded a 3 and indicated the resident was absent from home with meds *on 09/25/23, 9/26/23 documented by LVN E the date was coded a 9 and on 9/28/23 the date was coded a 9 documented by LVN B and indicated other see progress note Record review of the nurses' progress notes for Resident #1 indicated the following: *on 08/04/23 the resident was at the hospital. Resident #1 returned from hospital with a new antibiotic for pneumonia, *on 08/08/23 documented by LVN A, 08/09/23 documented by LVN A, 08/12/23 documented by LVN A, 08/13/23 documented by LVN A, 08/14/23 documented by LVN A, 08/15/23 documented by LVN A, 08/18/23 documented by LVN A, 08/19/23 documented by LVN A, 08/20/23 documented by LVN A and 08/21/23 documented by LVN A the Triumeq was on order, *on 08/10/23 signed by LVN D, the documentation for Triumeq did not indicate the medication was not administered, *on 08/22/23, the documentation indicated the resident was in the hospital. *on 09/01/23, documentation indicated the resident was readmitted from the LTAC hospital. *on 09/22/23 to 09/24/23, the resident was out of the facility with family *on 09/25/23 documented by LVN E, 09/26/23 documented by LVN E and 09/28/23 documented by LVN B, the documentation indicated the medication was not available. There was no documentation on the nurses' progress notes to indicate the physician was notified the Triumeq medication was not available or not administered. Record review of a LTAC hospital Interdisciplinary Notes for Resident #1 dated 08/23/23 indicated, History of Present Illness: The patient is an [AGE] year-old female who resides at a nursing home, who presented to the emergency roiagnom on [DATE] and was found to have urinary tract infection and pneumonia. She was prescribed Lovenox (a medication used to thin the blood) and Rocephin (an antibiotic to treat infection) and sent back to the nursing home, where she continued to have functional decline. The patient has had increased weakness and falls since her emergency room visit. The patient was transferred to LTAC on 08/21/2023 for continuation of antibiotic medical management of above symptoms and strengthening. The patient is currently not able to participate in activities of daily living and mobility as she was prior to her emergency room visit. A consult was performed by Physical Medicine and Rehabilitation physician, who determined the patient was suffering from exacerbation of her Parkinson's disease. The patient wants to come to acute inpatient rehabilitation for aggressive physical and occupational therapy. medication. An order dated 8/24/23 indicated Resident #1's Triumeq medication was ordered for administration. The order indicated the resident could use own home supply. There was no documentation to indicate the resident did not have the Triumeq available upon admission to the LTAC. During interview on 09/30 23 at 8:45 a.m., the DON said Resident #1 had gone out to the hospital on 08/0423 and returned the same day a diagnosis of pneumonia. She said when the resident returned, she was placed on skilled services. The Triumeq medication was a high-cost medication and was not covered on the insurance once the resident became skilled. She said as soon as the facility received the request for approval by the administrator, the approval was signed, faxed back and the resident received the medication. She said she was unaware the resident missed any doses of the Triumeq. During an observation, interview and record review on 09/30/23 at 12:51 a.m., LVN A said she was the nurse who worked Hall 300, where Resident #1 resided. During a record review of Resident #1's August 2023 MAR with LVN A, she said Resident #1 was out of her Triumeq medication on 08/08/23, 08/09/23, 08/12/23, 08/13/23, 08/14/23 08/15/23, 08/18/23, 08/19/23, 08/20/23 and 08/21/23 where she documented the code 9. She said the resident had gone to the hospital on 8/4/23 but returned the same day and was diagnosed with pneumonia. She said the resident was weak because of the diagnoses of pneumonia and did continue to get weaker and was sent out to the LTAC for rehabilitation services on 08/22/23. She said it was her responsibility to administer the medications on Hall 300. She said she should have notified the DON and the physician when the Triumeq medication was not available. She said she did not know why she did not notify them, but she did not. She said she remembered Resident #1 was out of the Triumeq but did not remember notifying the pharmacy it was out. Observation of the bottle of Resident #1's Triumeq 30 count in the medication cart indicated the bottle was 3/4 full of medication. The bottle was dated 9/28/23. LVN A said it had been refilled on 9/28/23 and only a few pills had been administered out of the bottle. She said she should have notified the pharmacy when there were approximately 10 tablets left. LVN A said the possible negative outcome of not notifying the physician would be the resident's condition could worsen and the physician would not know the resident had missed her medication. During an interview on 9/30 23 at 1:20 p.m., the DON said she was unaware Resident #1 did not have the Triumeq medication for 11 days during August 2023. She said the Triumeq was to treat her diagnosis of HIV. She said she and the physician should have been notified the medication was not available. She said she and the physician required notification, so interventions could be put in place to have the medication available for administration to the resident. She denied the resident could suffer increased symptoms by not having the medication available and said the medication was to keep the resident's HIV undetectable. During an interview on 09/30/23 at 1:52 p.m., LVN B said she started orientation on Hall 300 on 09/27/23 last week. She said Resident #1's Triumeq was not available on Wednesday 09/27/23 and Thursday 9/28/23. She said she was in training and did medication pass with LVN C. She said she watched LVN C pass medications on Wednesday 09/27/23 and passed the medications herself on Thursday 09/28/23. She said LVN C told her the Triumeq was a medication that required approval from the administrator and it was not available. LVN B said if a medication was not available the physician should be notified. She said she did not notify the physician the medication was not available because she was in training and LVN B had faxed the pharmacy. She said the medication was for Resident #1's HIV. She said the possible negative outcome of not notifying the physician could be the physician would not be aware the resident did not receive the medication and the resident's HIV symptoms could exacerbate. During a confidential interview on 9/30/23 at 2:04 p.m., an individual said the facility did not have Resident #1's Triumeq medication available when the resident went out on pass 9/22/23 to 09/24/23. The individual said the ADON was notified the resident did not have her medication. During an interview on 09/30/23 at 2:22 p.m., the ADON said she was unaware Resident #1 did not have the Triumeq medication with her when she went out on pass 09/22/23 to 09/24/23. She denied staff had informed her the resident's medication was not available. She said Resident #1 should not miss a dose of the Triumeq medication and she was unaware that she did. She said staff should have called the pharmacy if the medication was not available. She said herself, the DON and the physician should be notified. During an interview on 09/30/23 at 2:34 p.m., an attempt was made to call LVN D, who documented a code 9 on the August 2023 MAR on 08/10/23, with no answer and the mailbox was full; unable to leave message for call back. During an interview on 09/30/23 at 2:48 p.m., the DON said she was unaware Resident #1 had not received the Triumeq until 09/28/23, when the administrator approved the medication for the pharmacy to refill it and he sent the approval to her, and she ordered the medication stat. She denied knowing the resident also did not have the medication in August 2023. She said she was unaware and did not notify the physician. During an interview and record review on 09/30/23 at 3:12 p.m., LVN C said she worked two days last week on Hall 300, Wednesday 09/27/23 and Thursday 9/28/23, training LVN B. She said Resident #1's medication Triumeq was not available for administration either day. She said she did mark the MAR on 09/27/23 with a check which indicated she had administered the Triumeq, but she did not administer the medication because it was not available. She said she ordered the medication on 9/21/23 and there were pills left in the bottle but when she came back on 9/27/23 there were none left. During an interview and record review of a pharmacy Long Term Care Reorder Form dated 09/21/23, LVN C said she ordered the Triumeq on 09/21/23 and faxed it to the pharmacy and did not receive the fax back until the next day and noticed it said the Triumeq did not have an active order. The pharmacy Long Term Care Reorder form dated 09/21/23 had the Triumeq order request circled and had a label indicating No active order. Please send new order. She said she faxed an order for the Triumeq back to the pharmacy on 9/22/23 and was off the next few days. LVN C then provided an order dated 09/22/23 that indicated the Triumeq was ordered. Written across the bottom of the order was Please Refill. She said when she returned to work on 09/27/23 the resident was out of the Triumeq medication, so she called the pharmacy and asked them why it was not in the facility. She said the pharmacy told her it was a high-cost medication and was not covered and they had faxed over a high- cost medication approval request to the administrator but did not receive an approval and the medication could not be refilled until it was approved. She said she did not remember if she reported what the pharmacy said. She said she did not notify Resident #1's physician that the resident did not have the medication available for administration. She said the physician should have been notified. She said the physician would not have known the resident was out of her medication and could not intervene to make sure she received it. During an interview on 09/30/23 at 3:45 p.m., LVN E, who worked Hall 300 on 9/25/23 and 9/26/23, said Resident #1's Triumeq medication was not available for administration. She said she did not usually work Hall 300 and was filling in, so she assumed someone had already ordered the medication and notified the physician. She said she did not notify the physician the medication was not available to administer. She said she told the ADON and the ADON told her to call the LTAC and make sure they did not have it. She said she knew LVN C had reordered the medication, but the pharmacy sent back the refill request saying it was a high-cost medication and had to be approved before it could be filled. During an interview on 09/30/23 at 3:48 p.m., the ADON said the facility had sent Resident #1's Triumeq medication with her to the LTAC hospital on 08/22/23 because the hospital called and said they could not provide the medication. She said when the resident returned on 09/01/23, the facility had to go pick the medication up from the LTAC because the hospital did not send it back with her . She said she was unaware the resident did not have the Triumeq medication for 11 days in August 2023 or the last week of September 2023. She said no one notified her on 09/25/23 or 09/26/23 that Resident #1 did not have the Triumeq medication available for administration. During an interview on 09/30/23 at 4:01 p.m., Pharmacist F said he pulled all of Resident #1's transactions off of the computer and the pharmacy had refilled Resident #1's Triumeq and had a signed receipt for 6/29/23 and 8/19/23, but did not find a signed receipt for July 2023. He said they had also sent 30 Triumeq tablets to the nursing facility on 09/28/23 . He said he had a note the pharmacy had communicated with the facility on 09/22/23 that the medication was a high dollar medication and could not be refilled without approval, but the Administrator , DON and ADON were out of the facility. He said the pharmacy then refaxed and emailed the information again on 9/25/23, 09/26/23, 09/27/23, and 09/28/23. He said the administrator signed the approval and returned it on 9/28/23 and it was refilled. Pharmacist F was asked why the facility would have possibly not had the Triumeq medication available in August 2023 and he said there was a refill request for the Triumeq from the facility on 07/05/23 but the medication had already been filled on 6/29/23 and it was too soon. He said there were no other communications found between the pharmacy and the facility regarding Resident #1's Triumeq medication requesting a refill for July 2023 and he did not have a signed receipt for July 2023. During an interview on 10/02/23 at 10:09 a.m., the Administrator said he did not receive an approval request from the pharmacy until 09/28/23 and he immediately sent it back that day with his approval to be filled stat and Resident #1 received the medication the same day. He said he checked his emails daily and did not receive an approval request from the pharmacy until 09/28/23. He said on 09/28/23 he explained to the family member of Resident #1 the Triumeq was not covered because the resident was on skilled services, and it required his approval. He said he was not aware the resident did not receive her medication in August 2023 or the last week of September 2023. He said the resident should receive her medication as ordered. He said he notified his medical director, and the medical director told him there would be no negative outcome of missing the Triumeq medication. During an interview and record review on 10/02/23 at 10:10 a.m., the DON provided a document, which she said was the July 2023 receipt for Resident #1's Triumeq. The top of the document had the words on order and Triumeq tablet cut in half indicating the page had been snipped. A pharmacy notes column indicated dispensed 7/26 updated to insurance-BA, 7/25 emailed facility-RR, 7/19 High $ emailed. There was no signature on the document. The DON said she did not have a signed receipt for the Triumeq for July 2023. During an interview on 10/02/23 at 11:15 a.m., the NP said she nor Resident #1's physician was notified the resident did not receive the doses of Triumeq in August 2023 and September 2023. She said the resident had to have the Triumeq medication or it would exacerbate her HIV if she did not receive it. She said it was herself that would need to be notified and she did not receive a call and the records did not indicate the facility called the office to report the resident had missed the Triumeq doses. She said the facility had her personal cell phone number to call her. She said the records indicated the office was notified on 08/21/23 of lab work for Resident #1 and the office was notified when the resident fell , but there were no notifications about the resident missing her Triumeq doses. The NP said her notes indicated a family member called and wanted her to go to hospital on 8/21/23 and a family member called the office on 09/28/23 to report the resident did not receive her Triumeq medication last week from 9/22/23 to 9/28/23. She said her nurse called the ADON on 09/28/23 and spoke with her about Resident #1 not receiving the medication. During an interview on 10/02/23 at 11:20 a.m., the ADON said no one from Resident #1's physician's office notified her that the resident's Triumeq medication was not available, and she was not aware of it. During an interview on 10/02/23 at 1:02 p.m., the DON said she realized the emails from the pharmacy, requesting approval for Resident #1's medications on 09/25/23, 09/26/23, 09/27/23 and 09/28/23, were going to the other box and not the in box of her emails. She said she had just looked and the emails from the pharmacy were in the other box, and she had not checked the other box for incoming emails. During an interview on 10/03/23 at 3:08 p.m., the MD said the ADM had called him either Saturday 9/30/23 or Sunday 10/01/23 and notified him Resident #1 did not receive her Triumeq medication. He said he had not previously been notified. He said it was his understanding that Resident #1 only missed 3 days of the Triumeq medication and that would not be a problem, but he did not understand the resident missed multiple doses in August 2023. He said approximately 15 doses could potentially cause a problem for the resident. Record review of https://www.drugs.com/triumeq.html, last updated June 9, 2022, accessed on 10/03/23 indicated: Triumeq contains a combination of abacavir, dolutegravir, and lamivudine. Abacavir, dolutegravir, and lamivudine are antiviral medications that prevents human immunodeficiency virus (HIV) from multiplying in your body. Triumeq is used to treat human immunodeficiency virus (HIV), the virus that can cause acquired immunodeficiency syndrome (AIDS). Take Triumeq exactly as prescribed by your doctor. Use all HIV medications as directed and read all medication guides you receive. Do not change your dose or stop using a medicine without your doctor's advice. Every person with HIV should remain under the care of a doctor. Usual Adult Dose for HIV Infection: 1 tablet orally once a day. Use: For the treatment of HIV-1 infection. Get your prescription refilled before you run out of medicine completely. If you miss several doses, you may have a dangerous or even fatal allergic reaction once you start taking this medication again. Record review of an Adverse Consequences and Medication Errors policy revised April 2014 indicated . Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. Record review of an Adverse Consequences and Medication Errors policy revised April 2014 indicated . Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. An Immediate Jeopardy (IJ) situation was identified on 10/02/23. The IJ template was provided to the Administrator on 10/02/23 at 4:30 p.m and the POR was requested. The facility's POR dated 10/02/23 and accepted on 10/03/23 at 3:00 p.m. indicated: [Resident #1] medication was ordered and received by the facility on 9/28/2023. Primary care physician notified of the identified missed doses of medication on 10/2/23. The Medical Director also notified. There were not consequences associated or directly correlated with missed doses of the resident's medication. A viral load test has been ordered STAT for the resident. A facility audit to be completed by the Director of Nursing/Designee by 10/2/2023 of all residents with missed doses of medication in the past 7 days to assure that the medication was not held due to unavailability. For any medication identified as not given due to not available, the MD will be notified, and pharmacy will be contacted if the medication continues to not be available in the facility. If trends established, then we will QAPI the trend and in-service staff on root cause to prevent in the future. No other issues have been identified. In-services initiated by DON/Designee on 9/30/23 with licensed nursing staff present in facility related to timely reordering of medications within one week of running out, contacting pharmacy when medication is not in facility, notification of MD and DON. All other licensed staff will be in-serviced prior to working the next shift. The regional nurse consultant in serviced the DON and Administrator on checking all email folders for notifications of high-cost medications or refills from the pharmacy. Ad Hoc QAPI meeting completed with IDT and Medical Director on 10/2/2023. Facilities Plan to ensure compliance quickly: Facility interventions were implemented to remove immediate jeopardy: Audit to be completed 10/2/23 by DON/Designee to identify any residents that did not receive medications due to availability, pharmacy was contacted, and MD notified. This audit included the med cart, med room and MARS. There were no other residents identified that missed doses due to medication unavailability. We did identify new admits on the weekend were at a risk due to pharmacy hours of operation and ordering cut off time at 6PM. These orders will be sent to the local pharmacy and then delivered to the facility. Education was completed with the administrative nursing team by the Regional Nurse Consultant related to supervision to prevent missed medication administrations on 9/30/23. This includes checking all eFax's, and fax machines at the nurse's station. In-services initiated by DON/Designee on 9/30/23 with licensed nursing staff present in facility related to timely reordering of medications within one week of running out, contacting pharmacy when medication is not in facility, notification of MD and DON. Staff will be responsible for contacting the MD/PCP for any missed doses. The DON and or designee will follow up in the morning clinical meeting to ensure compliance. LVN A has been given disciplinary action and trained one on one by the DON. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. *Education to be completed with all nursing staff working by 10/3/2023 at 2 PM either in person or via phone call. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the training. On 10/03/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During observation on 09/30/23 at 12:51 p.m., Resident #1's Triumeq medication was dated 09/28/23 and available in the Hall 300 nurses' medication cart. During interviews on 10/03/23 from 3:18 p.m. to 3:28 p.m., Resident #1's NP and the MD said they were notified of Resident #1's missed doses of Triumeq. Record review of the audit tool completed by the DON indicated residents were identified that did not have their medications available. The medications were unavailable for 9 residents and the physicians were notified on 09/30/23, 10/02/23 and 10/03/23. No new orders were implemented. Record review of signed in-services to LVNs indicated the LVNs were trained on documenting missed doses of medications, who to notify, and notification of the physician with posttests taken and dated 10/02/23 and 10/03/23. Record review of in-services dated 09/30/23 to 10/03/23 indicated the LVNs were trained on supervision to prevent missed medication administration. Record review of the Regional Nurse Consultant's in-service to the DON and ADM dated 10/03/23 indicated the DON and ADM were trained to check all email folders for notifications of high cost medications or refills from the pharmacy. Record review of a counseling note dated 10/03/23 indicated LVN A was counseled on documentation, notification, and medications not being available. During an interview on 10/03/23 at 3:53 p.m., the DON was able to verbalize how to check emails for pharmacy notifications. During interviews on 10/03/23 from 4:20 p.m. to 5:20 p.m., three day shift LVNs, 3 evening shift LVNs and 2 night shift LVNs were able to verbalize the appropriate interventions to put in place to ensure the medications were available, refilled timely, weekend admits received their medications, the physician and DON were notified timely if medications were not available for administration and when to notify the pharmacy. On 10/03/23 at 5:40 p.m., the Administrator was informed the IJ was removed; however; the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents. The facility failed to ensure CNA A and OT B transferred Resident #1 from her bed to her wheelchair with a mechanical lift. Resident #1 sustained a fractured left tibia (the shinbone). This failure could place residents at risk of injuries. Findings included: Record review of a face sheet dated 08/02/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels), morbid obesity, contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right hand, lack of coordination, other specified disorders of bone density and structure of left lower leg, contracture of left knee, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), and fracture of upper end of left tibia (the shinbone). Record review of an MDS assessment dated [DATE] indicated Resident #1 was able to make herself understood and understand others, had a BIMS of 11 (moderate cognitive impairment), and she required extensive assist of two staff for bed mobility, dressing, and personal hygiene. She had impaired range of motion of her upper and lower extremities. She utilized a wheelchair for mobility. Transfers were not performed. Record review of Resident #2's care plan dated 02/09/22 indicated she required the following: o BED MOBILITY: extensive assistance by (2) staff to turn and reposition in bed. Date Initiated: 02/09/2022 o DRESSING: extensive assistance by 2 staff to dress. Date Initiated: 01/13/2023 o PERSONAL HYGIENE: extensive assistance by (2) staff with personal hygiene and oral care. Date Initiated: 02/09/2022 o BATHING/SHOWERING: totally dependent on 2 staff to provide CNA bath three times a week and as necessary. Date Initiated: 01/13/2023 o TOILET USE: total dependence by (2) staff for toileting. Date Initiated: 02/09/2022 o TRANSFER: totally dependent on 2 staff for transferring using a mechanical lift. Date Initiated: 01/13/2023. Record review of care plan dated 02/09/22 indicated Resident #1 had limited mobility related to CVA. Interventions included Resident #1 was non-weight bearing. Record review of the Kardex (electronic care record) dated 08/02/23 indicated Resident #1 required two staff for bed mobility, dressing, toilet use, and transfers with a mechanical lift. Record review of an incident report dated 07/18/23 indicated CNA B reported Resident #1 complained of pain in the left leg after getting Resident #1 out of bed. Resident #1 was sitting in her wheelchair. OTA B and CNA A transferred Resident #1 to her bed. Resident #1 stated she had pain in the left leg and felt the pain during the transfer by OTA B and CNA A. Resident #1 was assessed and provided pain medication. The physician was notified and order for an x-ray was obtained. Record review of an x-ray dated 07/18/23 indicated Resident #1 sustained an acute-appearing fracture of the proximal left tibia. There was mild displacement of the distal fragment. There was osteopenia (loss of bone mineral density that weakens bones). Record review of a progress note dated 07/18/23 at 11:53 a.m., completed by LVN C indicated Resident #1 complained of leg pain. Left leg was swollen. PCP notified and verbal orders for x-rays obtained. Record review of a progress note dated 07/18/23 at 4:50 p.m., completed by LVN D indicated x-ray results indicated Resident #1 had a fracture of the left proximal tibia and mild displacement of the distal fragment. Results reported and faxed to the physician. Waiting for new orders. Record review of a progress noted dated 07/18/23 at 5:51 p.m., completed by LVN D indicated Resident #1 was sent to hospital for evaluation and treatment. Record review of progress note dated 07/19/23 at 2:05 a.m. indicated Resident #1 returned from the hospital. She was given Tylenol #3 for pain. She had on a left leg immobilizer. Resident #1 was to have a follow up appointment with her physician. Record review of a progress note dated 07/25/23 at 10:25 a.m., Resident #1 returned from follow-up appointment with orthopedic physician. No new orders. During an observation and interview on 08/01/23 at 11:10 a.m., Resident #1 was lying in her bed. She had a brace on her left leg. When asked what happened to her leg, she said CNA A stood her up by her bed. She said she almost fell . She said her leg got tangled and twisted. She said she was in pain. She said CNA A and OTA B finally got her in her wheelchair. She said her left broke when she was stood up and turned to the wheelchair. She said she was usually lifted in a mechanical lift with two staff. She said she was not having surgery for her leg. Resident #1 said the fracture was on left side that was paralyzed. She said it was painful but received pain medication. She said she was in pain before the fracture of her left leg and it was not worse pain. During an interview on 08/01/23 at 10:40 a.m. the DON said CNA A and OTA B transferred Resident #1 from her bed to her wheelchair. She said Resident #1's leg was not positioned right and she complained of pain. She said OTA B repositioned Resident #1's foot and she was taken to therapy by CNA A. She said therapy staff returned her to the nurse station due to not being scheduled. She said Resident #1 was given pain medication. She said Resident #1 was transferred back into her bed from her wheelchair but CNA A and OTA B. She said CNA A reported to LVN C that Resident #1's leg was swollen after Resident #1 was transferred back to her bed. She said LVN C assessed Resident #1 and notified the physician. She said the physician ordered x-rays. X-rays showed a fractured tibia. The DON said Resident #1 was sent to the hospital for evaluation and treatment. She said Resident #1 returned with no surgery and follow up with orthopedic. She said it was the facility's expectation the staff follow the resident plan of care. During an interview on 08/02/23 at 11:01 a.m., CNA A said Resident #1 indicated she wanted to go to therapy. He said he asked her how she wanted to get up and Resident #1 said to slide her into her wheelchair. He said he was hesitant to do it and went to get some assistance. He said he saw OTA B in the hall pushing another resident to therapy and asked him for assistance. She said he asked OTA B if he should get a mechanical left and OTA B said we could transfer Resident #1 without a lift. CNA A said Resident #1 was paralyzed on her left side. He said he got her seated on the bed and got her from seated position to standing position. He said her legs dragged a bit as OTA B assisted to transfer Resident #1 to the wheelchair. He said Resident #1's left leg was a bit twisted and OTA moved the leg and put it on the leg rest. He said Resident #1 indicated her leg hurt. CNA A said he indicated he was not going to touch Resident #1 again and OTA B said everything was good and Resident #1 told him not to touch her anymore and put him out of the room. CNA A said LVN C came in the room and placed a pillow under Resident #1's foot on the foot rest. He said he brought Resident #1 to therapy and went out for a break He said he came back in from his break and was told Resident #1 was not on the therapy list and was pushed back to the nurse station. Resident #1 wanted to go back to bed. He said OTA B came back to assist with putting Resident #1 back in bed. He said he and OTA B picked Resident #1 up from the wheelchair and transferred her back into the bed without a mechanical lift. He said Resident #1 was given a pain pill and still complained of pain. He said she looked at her left leg and it didn't look right so he got the nurse. CNA A said two nurses came in and said Resident #1's leg looked swollen and ordered an x-ray. He said he was trained on resident care and was aware he should have looked at the Kardex prior to attempting to transfer Resident #1. He said he assumed the OTA B was the expert and knew what he was doing so he did not question OTA B's okay to transfer without the mechanical left. He said he did not look at the Kardex prior to transferring Resident #1. During an interview on 08/01/23 at 11:51 a.m., OTA B said he was escorting another resident to therapy when CNA A requested his assistance to transfer Resident #1 from her bed to her wheelchair. He said he stood by the left side of the wheelchair. He said CNA A did a sit to stand without a gait belt with max assist. He said CNA A should have used a gait belt with a sit to stand transfer. He said he made sure Resident #1's Body got into the wheelchair. He said Resident #1 said her left leg was hurting. OTA B said he elevated Resident #1's left leg to the leg rest and left the room to take the other resident to therapy. He said 10-15 minutes later, CNA A brought Resident #1 to the therapy gym. He said she was asking for pain medication so he took her to the nurse station. He said 30 to 45 minutes later he was requested to assist with putting Resident #1 back in bed. He said CNA A had Resident #1's right side and he had Resident #1's left side and they did a max transfer from the wheelchair to the bed. OTA B said once Resident #1 was positioned he left the room. He said if he had known Resident #1 require a mechanical lift he would not have transferred without the lift. He said it appeared CNA A knew what he was doing and he was only helping. OTA B said if Resident #1 was non-weight bearing, sit to stand transfers should not be done. He said he believed Resident #1's leg was twisted and fractured during the sit to stand and transfer to the wheelchair. He said Resident #1 was complaining of pain before he lifted her foot from the floor and placed it on the footrest. During an interview on 08/03/23 at 1:23 p.m., LVN C said CNA A reported Resident #1 complained of pain. She said she administered Resident #1's pain medication. She said Resident #1 came back from therapy and was put in bed by CNA and OTA B. She said CNA A reported Resident #1's leg hurt. LVN C said Resident #1's leg was swollen and she contacted the physician. She said she received new orders for an x-ray. She said staff were to follow resident plan of care for transfers. LVN C said she was not aware CNA A and OTA B had not followed Resident #1's plan of care for two person transfer with a mechanical lift. She said she monitored the care staff during her shift while making rounds to ensure the staff were following resident care plans. During an interview on 08/03/23 at 10:54 a.m., the DON said it was the facility's expectation staff follow resident plan of care for transfers. She said not following plan of care for transfers could place residents at risk of injury. She said staff were monitored on a daily basis by charge nurses and supervisory staff. Record review of staff in-service initiated on 06/27/23 indicated CNA A was trained on 07/13/23 to check the Kardex (electronic care record) prior to start of shift to ensure proper assist to residents. CNA A's signature was on the in-service. Record review of the facility investigation indicated dated 07/23/23 CNA A was retrained on 07/21/23 on transfers (including gait belt and mechanical lift). CNA A's signature was on the in-service. Record review of facility investigation dated 07/25/23 indicated OTA B was educated on 07/21/23 that included Review of proper resources of patient diagnosis and current precautions/recommendations prior to initiation and completion of treatment and/or transfers,. Review, comprehension, and adherence to documented discipline specific plan of care. Practicing at the top of one's license . only addressing residents documented plan of care . Record review of the facility policy Safety and Supervision of Residents dated 2001 (revised July 2023) indicated Our facility strives to make the environment free from accident hazards as possible. Resident safety and supervision and assistance to prevent accident are facility-wide priorities.3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.4. Implementing interventions to reduce accident risks and hazards shall include the following: a. communicating specific interventions to all relevant staff; d. ensuring interventions are implemented . Resident Risks and Environmental Hazards-1. Due to their complexity and scope, certain risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: .b. Safe Lifting and Movement of Residents .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure CNA A and OTA B used a mechanical lift when transferring Resident #1. This failure could place residents at risk of inadequate care and injury. The findings included: Record review of a face sheet dated 08/02/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness), cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels), morbid obesity, contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right hand, lack of coordination, other specified disorders of bone density and structure of left lower leg, contracture of left knee, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), and fracture of upper end of left tibia (the shinbone). Record review of an MDS assessment dated [DATE] indicated Resident #1 was able to make herself understood and understand others, had a BIMS of 11 (moderate cognitive impairment), and she required extensive assist of two staff for bed mobility, dressing, and personal hygiene. She had impaired range of motion of her upper and lower extremities. She utilized a wheelchair for mobility. Transfers were not performed. Record review of Resident #2's care plan dated 02/09/22 indicated she required the following: o BED MOBILITY: extensive assistance by 2 staff to turn and reposition in bed. Date Initiated: 02/09/2022 o TRANSFER: totally dependent on 2 staff for transferring using a mechanical lift. Date Initiated: 01/13/2023. Record review of a care plan dated 02/09/22 indicated Resident #1 had limited mobility related to CVA. Interventions included Resident #1 was non-weight bearing. Record review of the Kardex (electronic care record) dated 08/02/23 indicated Resident #1 required two staff for bed mobility and transfers with a mechanical lift. Record review of an incident report dated 07/18/23 indicated CNA B reported Resident #1 complained of pain in the left leg after getting Resident #1 out of bed. Resident #1 was sitting in her wheelchair. OTA B and CNA A transferred Resident #1 to her bed. Resident #1 stated she had pain in the left leg and felt the pain during the transfer by OTA B and CNA A. Resident #1 was assessed and provided pain medication. The physician was notified and order for an x-ray was obtained. Record review of x-ray dated 07/18/23 indicated Resident #1 sustained an acute-appearing fracture of the proximal left tibia. There was mild displacement of the distal fragment. There was osteopenia (loss of bone mineral density that weakens bones). Record review of a progress noted dated 07/18/23 at 5:51 p.m., completed by LVN D indicated Resident #1 was sent to hospital for evaluation and treatment. Record review of progress note dated 07/19/23 at 2:05 a.m. indicated Resident #1 returned from the hospital. She was given Tylenol #3 for pain. She had on a left leg immobilizer. Resident #1 was to have a follow up appointment with her physician. Record review of staff in-service initiated on 06/27/23 indicated CNA A was trained on 07/13/23 to check the Kardex (electronic care record) prior to start of shift to ensure proper assist to residents. CNA A's signature was on the in-service. Record review of the facility investigation indicated dated 07/23/23 CNA A was retrained on 07/21/23 on transfers (including gait belt and mechanical lift). CNA A's signature was on the in-service. Record review of facility investigation dated 07/25/23 indicated OTA B was educated on 07/21/23 that included Review of proper resources of patient diagnosis and current precautions/recommendations prior to initiation and completion of treatment and/or transfers,. Review, comprehension, and adherence to documented discipline specific plan of care. Practicing at the top of one's license . only addressing residents documented plan of care . During an observation and interview on 08/01/23 at 11:10 a.m., Resident #1 was lying in her bed. She had a brace on her left leg. When asked what happened to her leg, she said CNA A stood her up by her bed. She said she almost fell . She said her leg got tangled and twisted. She said she was in pain. She said CNA A and OTA B finally got her in her wheelchair. She said her left broke when she was stood up and turned to the wheelchair. She said she was usually lifted in a mechanical lift with two staff. She said she was not having surgery for her leg. She said the fracture was on left side that was paralyzed. She said it was painful but received pain medication. She said she was in pain before the fracture of her left leg and it was not worse pain. During an interview on 08/01/23 at 10:40 a.m. the DON said CNA A and OTA B transferred Resident #1 from her bed to her wheelchair without using a mechanical lift. She said Resident #1's leg was not positioned right and she complained of pain. She said Resident #1 was transferred back into her bed from her wheelchair by CNA A and OTA B without a mechanical lift. She said CNA A reported to LVN C that Resident #1's leg was swollen after Resident #1 was transferred back to her bed. She said LVN C assessed Resident #1 and notified the physician. She said the physician ordered x-rays. X-rays showed a fractured tibia. The DON said Resident #1 was sent to the hospital for evaluation and treatment. She said Resident #1 returned with no surgery and follow up with orthopedic. She said Resident #1 should have been transferred with a mechanical lift per her plan of care. She said it was the facility's expectation the staff follow the resident plan of care. During an interview on 08/02/23 at 11:01 a.m., CNA A said Resident #1 indicated she wanted to go to therapy. He said he asked her how she wanted to get up and Resident #1 said to slide her into her wheelchair. He said he was hesitant to do it and went to get some assistance. He said he saw OTA B in the hall pushing another resident to therapy and asked him for assistance. She said he asked OTA B if he should get a mechanical left and OTA B said we could transfer Resident #1 without a lift. He said Resident #1 was paralyzed on her left side. He said he got her seated on the bed and got her from seated position to standing position. He said her legs dragged a bit as OTA B assisted to transfer Resident #1 to the wheelchair. He said Resident #1's left leg was a bit twisted and OTA moved the leg and put it on the leg rest. He said Resident #1 indicated her leg hurt. CNA A said he indicated he was not going to touch Resident #1 again and OTA B said everything was good and Resident #1 told him not to touch her anymore and put him out of the room. He said LVN C came in the room and placed a pillow under Resident #1's foot on the foot rest. He said he brought Resident #1 to therapy and went out for a break He said he came back in from his break and was told Resident #1 was not on the therapy list and was pushed back to the nurse station. Resident #1 wanted to go back to bed. CNA A said OTA B came back to assist with putting Resident #1 back in bed. He said he and OTA B picked Resident #1 up from the wheelchair and transferred her back into the bed without a mechanical lift. He said Resident #1 was given a pain pill and still complained of pain. He said she looked at her left leg and it didn't look right so he got the nurse. He said two nurses came in and said Resident #1's leg looked swollen and ordered an x-ray. CNA A said he was trained on resident care and was aware he should have looked at the Kardex prior to attempting to transfer Resident #1. He said he assumed the OTA B was the expert and knew what he was doing, so he did not question OTA B's okay to transfer without the mechanical left. He said he did not look at the Kardex prior to transferring Resident #1. During an interview on 08/01/23 at 11:51 a.m., OTA B said he was escorting another resident to therapy when CNA A requested his assistance to transfer Resident #1 from her bed to her wheelchair. He said he stood by the left side of the wheelchair. He said CNA A did a sit to stand without a gait belt with max assist. He said CNA A should have used a gait belt with a sit to stand transfer. He said he made sure Resident #1's body got into the wheelchair. He said Resident #1 said her left leg was hurting. OTA B said he elevated Resident #1's left leg to the leg rest and left the room to take the other resident to therapy. He said 10-15 minutes later, CNA A brought Resident #1 to the therapy gym. He said she was asking for pain medication so he took her to the nurse station. He said 30 to 45 minutes later he was requested to assist with putting Resident #1 back in bed. OTA B said CNA A had Resident #1's right side and he had Resident #1's left side and they did a max transfer from the wheelchair to the bed. He said once Resident #1 was positioned, he left the room. He said if he had known Resident #1 required a mechanical lift, he would not have transferred without the lift. He said it appeared CNA A knew what he was doing and he was only helping. OTA B said if Resident #1 was non-weight bearing, sit to stand transfers should not be done. He said he believed Resident #1's leg was twisted and fractured during the sit to stand and transfer to the wheelchair. He said Resident #1 was complaining of pain before he lifted her foot from the floor and placed it on the footrest. During an interview on 08/03/23 at 10:54 a.m., the DON said it was the facility's expectation staff follow residents' plan of care for transfers. She said not following the plan of care for transfers could place residents at risk of injury. She said staff were monitored on a daily basis by charge nurses and supervisory staff. During an interview on 08/03/23 at 1:23 p.m., LVN C said CNA A reported Resident #1 complained of pain. She said she administered Resident #1's pain medication. She said Resident #1 came back from therapy and was put in bed by CNA and OTA B. She said CNA A reported Resident #1's leg hurt. LVN C said Resident #1's leg was swollen and she contacted the physician. She said she received new orders for an x-ray. She said staff were to follow residents' plan of care for transfers. She said she was not aware CNA A and OTA B had not followed Resident #1's plan of care for two-person transfer with a mechanical lift. She said she monitored the care staff during her shift while making rounds to ensure the staff were following resident care plans. Record review of the facility's care plan policy dated 10/24/22 indicated .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 11 residents (Resident #5) reviewed for accidents. CNA C did not use 2 people during incontinent care as per care plan. Resident #5 rolled out of bed and sustained multiple fractures requiring surgical intervention. An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for falls resulting in injury, pain, and hospitalization . Findings included: Record review of face sheet dated 04/11/23, indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, (fibromyalgia a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, depression, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away). Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed). Record review of Resident #5's most current care plan initiated 05/26/22 and revised on 06/15/22 indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene. Record review of Kardex (electronic care needs) printed on 04/12/23 indicated Resident #5 required extensive assistance by two staff for bed mobility. During an observation and interview on 04/12/23 at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said she was sent to the hospital. Resident #5 said she had two broken legs and two broken kneecaps. She said had pain before the fall but it was worse after she sustained the two broken legs and two broken kneecaps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. Record review of an incident report dated 01/16/23, completed by LVN A indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Head to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. LVN A did not indicate Resident #5 was a 2-person assist. Record review of progress note dated 01/16/23 completed by LVN A, indicated CNA C was changing Resident #5 and CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. Record review of hospital records dated 01/16/23 indicated Resident #5 had sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur metadiaphysis, right knee- minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are still broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture, because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla hematoma. Her diagnoses included diffuse osteoporosis and osteopenia. Record review of hospital discharge summary dated 01/23/23 indicated Resident #5 bilateral femoral fractures were repaired surgically. During an interview on 04/11/23 at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on 01/28/23 after the facility received a call from a family member alleging neglect. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries. During an interview on 04/11/23 at 2:47 p.m., LVN A said she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B came to me and said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said Resident #5 complained of pain in her legs and she was given pain medication. LVN A said Resident #5's daughter came up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said she was waiting for a response from the physician to send Resident #5 to the hospital. She said Resident #5 was transported to the hospital. She said Resident #5 was a 2-person assist for all ADLS. She said staff were supposed to follow the resident plan of care and what was indicated in the Kardex. She said if staff did not use 2-person assist when required it could result in injury or death of a resident. During an interview on 04/11/23 at 3:00 p.m. the DON said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there was two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed. She said staff are required to follow the resident plan of care and what is indicated in the Kardex. She said if staff did not use 2-person assist, it could result in serious injury or death of a resident. During an interview on 4/11/23 at 3:26 p.m., CNA C said on 01/16/23 at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 lay down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the Kardex indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the Kardex the day after the fall. She said the DON said it was not her fault because the Kardex was not updated. During an interview on 04/11/23 at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the Kardex was not updated. She said the Kardex was populated by the care plan. She said Resident #5's care plan was in place from 06/15/22 and the Kardex was not changed. During an interview on 04/11/23 at 3:45 p.m., the Administrator said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware The DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the Kardex. During an interview on 04/12/23 at 10:56 a.m., the Administrator said he did not know if all facility staff were trained on resident fall prevention and the number of staff required for ADL care after Resident #5 fell . He said the incident was mentioned in QAPI that they conducted training and continued to monitor the Kardex and do retraining. He said he did not recognize the incident as neglect because it was a witnessed fall. During an interview on 04/12/23 at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the Kardex for a resident's level of care. She said she received retraining after the incident on the Kardex system and bed mobility prior to 01/16/23 and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the Kardex and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the Kardex. She said if staff did not follow the Kardex for care needs the resident could have serious injuries or die. During record review and interview on 04/12/23 at 1:04 p.m., the DON said they believed all staff were re-trained to check the Kardex for level of resident assistance required after Resident #5's fall. She said she and the ADON monitored the care plans and Kardex weekly to ensure the level of staff assistance was correct. The ADON provided a list that indicated 16 facility nursing staff were not trained or did not sign the training. The DON said the same situation could occur if the facility staff did not recognize abuse or neglect. During an interview on 04/12/23 at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the Kardex system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the Kardex. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on 04/12/23 at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS before the fall. She said Resident #5 was weak on her left side. She said Resident #5 was not able to use her legs. She said resident care information was in the Kardex system. She said she was retrained on the Kardex system and bed mobility after the incident. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on 04/12/23 at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS before her fall. She said the information was in the Kardex system. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on 04/12/23 at 1:38 p.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the Kardex system and bed mobility but forgot to sign. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. Record review of the facility's Falls-Clinical Protocol revised 03/2018 indicated: .2. In addition, the nurse shall assess and document/report the following: .h. Precipitating factors, details on how fall occurred; . Falls Prevention-Potential Interventions - Nursing Measures . proper positioning . Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy indicated : The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. The Administrator and DON were notified of the Immediate Jeopardy on 04/12/23 at 11:48 a.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/13/23 at 12:35 p.m. and reflected the following: 1* It is the intent of the facility to ensure all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. 2* Corrective Action Nursing administration will review care plans and Kardex's for all residents to ensure they match with the resident's level of assistance required. This process began 4/12/23 and will be complete by 10 AM on 4/13/23. All areas of concerns have been addressed and all care plans match all Kardex's for all residents. All nursing staff will be in-service on where to find a resident's level of assistance in the Kardex. This training began on 4/12/23 and will be completed by 10AM on 4/13/23. Staff will be in-service via in-person training or via phone training with nursing administration. All nursing staff will be in-service on abuse and neglect. This training began on 4/12/23 and will be completed by 10AM on 4/13/23. Staff will be in-service via in-person training or via phone training with nursing administration. The in-service focuses on following the resident(s) plan of care to provide them goods/services and choosing to not do it or not knowing to check the Kardex/CP and then providing care could result in harm to a resident and this could be abuse/neglect. Staff Abuse/neglect also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff have the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from the resident(s), which could result in care deficits to the resident. All current and new staff will be trained during in-service and initial orientation prior to working their first shift on where to find a resident's level of assistance. This will be documented on a skills check-off list and quiz. A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of Kardex knowledge. This will be completed by 4/13/23 at 12 PM. The Kardex showed that resident #5 was a 2 person assist. The C.N.A. received disciplinary action and was retrained by DON/ADON. Other nursing staff were retrained also on use of the Kardex. The administrator has been in-service by Regional Operations director on self-report guidelines as directed in the long-term care regulatory letter. This has been completed as of 4/12/23 4:30 PM. 3* Identification of Others The facility recognizes that all residents have the potential to experience Neglect. An assessment to be completed by 4/13/23 of all facility residents' administrative nurses. Assessment will compare care plans to Kardex. The Abuse Coordinator/Designee will report any allegations of neglect to the State Survey Agency in accordance with self-report guidelines. In this incident, there was no immediate allegation of neglect, but suspicion as the resident's plan of care was not followed that resulted in the resident's serious bodily injuries during/from care. A facility record audit of residents Kardex and care plans will be completed by Director of Nursing/Designee by 4/13/2023 10 AM. 4* Plan to prevent from recurring Intervention for Neglect: DON/designee to evaluate care plan and Kardex for all residents and each new resident within 48 hrs. of admission and review and update as needed. Staff both existing and new will have a check-off sheet showing competencies on Kardex and levels of assistance prior to working the first shift. This is to be completed during orientation. Training Plan Initial Trainings: Facility to Initiate Training by 4/12/2023 3:30 PM from training materials provided by DON/ADON. This training will be done with all available staff working 4/12/2023, and then staff who were unable to attend will be provided with the training prior to working their next scheduled shift by 4/13/23 10AM via in person on telephone training. All current and new hires will be trained during in-service and initial orientation and documented on their skills check-off sheet. A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of Kardex knowledge. This will be completed by 4/13/23 at 12 PM. Previous falls have been investigated and there is no correlation related to lack of staff supervision. There are no similar situations. 5* Ongoing Monitoring Facility neglect rounds to be done by Abuse Coordinator/Designee to review sufficient staff are in place to provide resident care. This rounding will be done daily on all three shifts until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done on all three shifts (AM, PM, Night) weekly to ensure interventions are in place. Audit to be done weekly x 8 weeks and then reviewed by the QA Committee to determine frequency of future audits. Audit will be documented on a check-off sheet for staff. This check-off will ask staff to demonstrate Kardex knowledge during rounds. 6* QAPI In regard to immediacy, this POR will be reviewed in an ad Hoc QAPI meeting completed 4/12/23 by 9 PM. Follow up on training will be reviewed in routine QAPI for 3 months. Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. On 04/13/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations, interviews, and record reviews were conducted on 04/13/23 from 12:35 p.m. through 3:10 p.m. and included 3 alert residents, nurses including 1 RN, 8 LVNs, and 16 CNAs, 1 NA, 1 RNA (who work all shifts), SW, ADON, and DON. Staff were able to identify residents' the care plans, the Kardex system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Staff were able to discuss the required level of staff assistance for ADLs. Staff were able to demonstrate the use of the Kardex system for resident care needs. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. Kardex for 11 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the Kardex. Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the Kardex. Nursing staff were in-serviced on where to find a resident's level of assistance in the Kardex. The training was completed on 04/13/23. Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. Staff were in-service on abuse and neglect. The training was completed on 04/13/23. Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. The 5-question quiz of Kardex knowledge given to all tested staff indicated all staff scored 100%. The Kardex showed that resident #5 was a 2 person assist. CNA C received disciplinary action and was retrained by DON/ADON on 01/17/23. The administrator was in-service on 04/12/23 by Regional Operations Director on self-report guidelines as directed in the long-term care regulatory letter. There were no additional allegations of neglect or abuse identified during the investigation. During an interview on 04/13/23 at 2:40 p.m., the Administrator said he recognized all allegations and suspicion of allegations of abuse and neglect were reportable. During an interview on 04/13/23 at 2:50 p.m., The DON said the audit of all residents' care plans and Kardex revealed no issues or concerns, She said she believed Resident #5's fall was reportable when it occurred because the staff member could continue to work with other residents and harm other residents. A facility record audit dated 04/13/23 of residents' Kardex and care plans revealed no issues or concerns. Staffing was reviewed for the previous two weeks and for 01/16/23. There was no concerns noted. Five residents indicated they were afraid during care or had complaints of their care. The facility Administrator and the DON were provided education on abuse/neglect and bed mobility on 04/12/23. An Immediate Jeopardy (IJ) situation was identified on 04/12/23 at 11:38 a.m. While the IJ was removed on 04/13/23, the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse and neglect for 2 of 11 residents (Resident #5 and #4) reviewed for abuse and neglect. 1. CNA C did not use 2 people during incontinent care as per care plan. Resident #5 rolled out of bed and sustained multiple fractures requiring surgical intervention. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:38 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. 2. Resident #4 sustained a laceration to his left eyebrow and had blood in his mouth. Resident #4 indicated he fought with an unidentified staff. He was sent to the ER and received sutures. The facility identified the staff as CNA K. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of face sheet dated [DATE], indicated Resident #5 was a [AGE] year-old female, admitted on [DATE] and her diagnoses included need for assistance with personal care, heart failure, fibromyalgia (a chronic (long-lasting) disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping), long-term use of anticoagulants (prevent blood clots), anxiety, heredity and idiopathic neuropathy (inherited condition that causes numbness, tingling and muscle weakness in the limbs of unknown cause), seizures, hypertension (blood pressure that is higher than normal), end stage renal disease, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination, and muscle wasting and atrophy (partial or complete wasting away). Record review of MDS dated [DATE] indicated Resident #5 was able to express ideas and wants, was able to understand others, had moderate impaired cognition, required extensive physical assistance of 2+ persons for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed). Record review of Resident #5's current care plan initiated [DATE] and revised on [DATE] indicated she required extensive assist by two staff to turn and reposition in bed, toileting, and personal hygiene. Record review of Kardex (electronic care needs) printed on [DATE] indicated Resident #5 required extensive assistance by two staff for bed mobility. Record review of an incident report dated [DATE], completed by LVN A indicated CNA C was providing incontinent care for Resident #5. CNA C stated Resident #5 rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Heads to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. Record review of progress note dated [DATE] completed by LVN A, indicated CNA C was changing Resident #5 and she rolled out of the bed. Resident #5 was lying on her buttocks on the floor with a pillow under her head. Head to toe assessment initiated. Resident #5 was alert with clear speech, no change in orientation or LOC and moved all extremities freely. There were no visible injuries noted. Resident #5 stated her head and knees hurt. Resident #5 was given Tramadol. The DON, RP and Physician were notified. Resident #5 was sent to the hospital for evaluation and left the facility at 12:00 p.m. Record review of hospital records dated [DATE] indicated Resident #5 sustained numerous fractures including: right thigh-mildly displaced transverse fracture of the femur (thigh bone) metadiaphysis (the diaphysis (shaft or primary ossification centre), metaphysis (where the bone flares), right knee-minimally displaced transverse fracture of the femur distal metadiaphysis, and acute nondisplaced transverse fracture of the patella a flat, inverted triangular bone, situated on the front of the knee-joint proximal pole, left knee- acute comminuted displaced and angulated fracture of the tibia distal metadiaphysis, and left femur- acute comminuted displaced fracture of the distal left femur. (A displaced fracture means the pieces of bone moved so much that a gap formed around the fracture when the bone broke. Non-displaced fractures are broken bones, but the pieces were not moved far enough during the break to be out of alignment. Comminuted fractures are a more severe type of fracture because the bone breaks into several pieces. could have other damage with this type of fracture, due to the multiple bone shards). She also had a left lateral chest wall/axilla the space below the shoulder through which vessels and nerves enter and leave the upper arm; a person's armpit hematoma (A pool of clotted blood that forms in an organ, tissue, or body space). Her diagnoses included diffuse osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes) and osteopenia (a condition that begins as you lose bone mass and your bones get weaker). Record review of hospital discharge summary dated [DATE] indicated the fractures of Resident #5's left and right thigh bones were both repaired surgically. During an interview on [DATE] at 10:18 a.m., the Administrator said he did not consider the incident abuse or neglect or reportable because it was a witnessed fall. He said it was reported on [DATE] after the facility received a call from a family member alleging neglect. He said he did not know who made an allegation of neglect. He said there was no abuse or neglect. He said Resident #5 had osteoporosis that caused the injuries. During an interview on [DATE] at 2:47 p.m., LVN A said on [DATE] at 10:00 a.m. she was in the hall getting ready to go into a resident's room to check blood pressure. She said she saw CNA B come out of another resident's room. She said she heard CNA C scream for CNA B. She said CNA B said Resident #5 was on the floor. LVN A said she found Resident #5 lying on the floor on her back with a pillow under her head. She said CNA C said she was providing incontinent care and Resident #5 fell from the bed. She checked Resident #5 for injuries and there was no visible injuries. She said the aides brought the Hoyer and picked up Resident #5 from the floor and put her back in bed. She said at the time of the incident, Resident #5 complained of pain in her legs and she was given pain medication. LVN A said Resident #5's daughter came up the hall (who worked in laundry) and she was informed of what happened. She said a second daughter arrived and said Resident #5 needed to go to the hospital. She said she was waiting for a response from the physician to send Resident #5 to the hospital. She said Resident #5 was transported to the hospital at 12:00 p.m. She said Resident #5 was a 2-person assist for all ADLS. She said staff were supposed to follow the resident plan of care and what was indicated in the Kardex. She said if staff did not use 2-person assist when required it could result in injury or death of a resident. During an interview on [DATE] at 3:00 p.m. the DON said Resident #5's fall was reported to the Administrator on [DATE]. She said the Administrator said it was not reportable because it was a witnessed fall and not abuse. She said Resident #5 was a 2-person assist for care and transfers. She said CNA C said there were two staff at first but then changed her story and said she was the only aide to provide care for Resident #5 when she fell off the bed. She said staff were required to follow the resident plan of care and what was indicated in the Kardex. She said if staff did not use 2-person assist, it could result in serious injury or death of a resident. She said the nurses were expected to monitor the aides to ensure care was provided per the care plans. During an interview on [DATE] at 3:26 p.m., CNA C said on [DATE] at approximately 10:00 a.m., Resident #5 reported she had a BM and required care. She said she did not know what happened but maybe her (Resident #5) leg fell off the bed and then Resident #5 fell off the bed. She said she tried to catch Resident #5 and prevent the fall. She said Resident #5 landed on her knees. She said Resident #5 laid down on the floor and she put a pillow under Resident #5's head. CNA C said Resident #5's care plan and the Kardex indicated Resident #5 was a 1-person assist. She said she had just completed her orientation days. She said she was retrained on the Kardex the day after the fall. She said the DON said it was not her fault because the Kardex was not updated. During an interview on [DATE] at 3:45 p.m., the DON said she did not tell CNA C the fall was not her fault because the Kardex was not updated. She said the Kardex was populated by the care plan. She said Resident #5's care plan was in place from [DATE] and the Kardex was not changed. During an interview on [DATE] at 3:45 p.m., the Administrator said Resident #5's fall off the bed on [DATE] was not reported because it was a witnessed fall. He said he did not suspect abuse or neglect. He said he was not aware Resident #5 was a 2-person assist for ADLS. He said he was aware the DON and ADON conducted in-service training on abuse and neglect and staff assist of residents. He said he was aware CNA C was also re-trained on client care including abuse and neglect and bed mobility and the Kardex. He said CNA C was terminated on [DATE] for not calling and not showing for shifts. During an observation and interview on [DATE] at 9:15 a.m., Resident #5 was lying in bed. She said CNA C did not have a second staff with her while she provided care before she fell off the bed. She said CNA C had wiped her on her left side. She said she told CNA C she was falling but CNA C said she was not falling and she would not let her (Resident #5) fall. She said she kept rolling and looked down, saw the floor and fell on the floor. She said CNA C did not stop what she was doing to prevent her from falling off the bed to the floor. She said CNA C left her on the floor and looked nervous. She said CNA C left and came back with the nurse and the nurse asked what had happened. She said the facility staff used a Hoyer and picked her up off the floor. She said she was in a lot of pain and the nurse gave her a pain medication. She said she was sent to the hospital. Resident #5 said she had two broken legs and two broken kneecaps. She said she had pain before the fall but it was worse after she sustained the two broken legs and two broken kneecaps. She said she told the CNA C she should have a second staff but CNA C did not call for any staff to help her until after she fell on the floor. During an interview on [DATE] at 10:56 a.m., the Administrator said he did not know if all facility staff were trained on resident fall prevention and the number of staff required for ADL care after Resident #5 fell . He said the incident was mentioned in QAPI that they conducted training and continued to monitor the Kardex and do retraining. He said he did not recognize the incident as neglect because it was a witnessed fall. He said the same situation could happen again if the facility did not recognize abuse or neglect. During an interview on [DATE] at 12:52 p.m., CNA D said Resident #5 was a 2-person assist for ADLS. She said all staff were supposed to check the Kardex for a resident's level of care. She said she received retraining on [DATE] after the incident on the Kardex system and bed mobility prior to [DATE] and after the incident but could not recall the date. She said she did not sign the training but did recall the DON conducted the training. She said she could only chart in the Kardex and was not able to make changes on level of care. She said staff are supposed to follow the resident plan of care and what is indicated in the Kardex. She said if staff did not follow the Kardex for care needs the resident could have serious injuries or die. During an interview and record review on [DATE] at 1:04 p.m., the DON said they believed all staff were trained on [DATE] and [DATE] to check the Kardex for level of resident assistance required. She said she and the ADON monitored the care plans and Kardex weekly to ensure the level of staff assistance was correct. The ADON provided a list that indicated 16 facility nursing staff were not trained or did not sign the training. The DON said the same situation could occur if the facility staff did not recognize abuse or neglect. During an interview on [DATE] at 1:16 p.m., CNA E said Resident #5 was a 2-person assist for ADLS. She said the information was in the Kardex system and on her care plan. She said she was not in the facility when Resident #5 fell out of the bed. She said she had worked with Resident #5 and was aware she was always a 2-person assist. She said staff are supposed to follow the care needs in the Kardex. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on [DATE] at 1:22 p.m., CNA F said she was not working when Resident #5 fell out of the bed. She said Resident #5 was a 2-person assist for ADLS. She said Resident #5 was weak and paralyzed on her left side before the fall on [DATE]. She said Resident #5 was not able to use her legs. She said resident care information was in the Kardex system. She said she was retrained on the Kardex system and bed mobility after the incident. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on [DATE] at 1:32 p.m., CNA G said she had worked with Resident #5 in the past. She said Resident #5 was a 2-person assist for ADLS. She said the information was in the Kardex system. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on [DATE] at 1:38 p.m., CNA H said Resident #5 was a 2-person assist for ADLS. She said she received training after Resident #5 fell out of the bed on the Kardex system and bed mobility but forgot to sign. She said if staff did not follow the Kardex for care needs then residents could get seriously injured. During an interview on [DATE] at 2:45 p.m., the RNC said she received an anonymous call from a blocked number. She said she was told of Resident #5's fall. She said she looked at Resident #5's clinical record and the hospital record. She said she called the CNO who told her the incident was reportable. She said she called the Administrator and told him the incident was reportable. She said the Administrator wanted the COO to review the incident. She said the COO agreed the incident was reportable as an allegation of neglect. During an interview on [DATE] at 2:50 p.m., the DON said the incident of Resident #5's fall and injuries on [DATE] was neglect and reportable. During an interview on [DATE] at 2:50 p.m. the ADON said incident of Resident #5's fall and injuries on [DATE] was neglect and reportable. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Property Prohibition policy indicated: The administrator will ensure that the residents residing in the facility will remain free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of resident property.1. Abuse-The will infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. This also included the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, caused physical harm, pain or mental anguish.7. Neglect- Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Record review of the facility Resident Rights policy revised ,d+[DATE] indicated Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and implementation 1. Federal Law state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . c. be free from abuse, neglect, misappropriation of property, and exploitation; . The Administrator and the DON as notified of the Immediate Jeopardy on [DATE] at 11:48 a.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] at 12:35 p.m. and reflected the following: 1* It is the intent of the facility to ensure all residents are free from abuse, neglect, misappropriation of resident property, and exploitation. 2* Corrective Action Nursing administration will review care plans and Kardex's for all residents to ensure they match with the resident's level of assistance required. This process began [DATE] and will be complete by 10 AM on [DATE]. All areas of concerns have been addressed and all care plans match all Kardex's for all residents. All nursing staff will be in-service on where to find a resident's level of assistance in the Kardex. This training began on [DATE] and will be completed by 10AM on [DATE]. Staff will be in-service via in-person training or via phone training with nursing administration. All nursing staff will be in-service on abuse and neglect. This training began on [DATE] and will be completed by 10AM on [DATE]. Staff will be in-service via in-person training or via phone training with nursing administration. The in-service focuses on following the resident(s) plan of care to provide them goods/services and choosing to not do it or not knowing to check the Kardex/CP and then providing care could result in harm to a resident and this could be abuse/neglect. Staff Abuse/neglect also includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff have the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from the resident(s), which could result in care deficits to the resident. All current and new staff will be trained during in-service and initial orientation prior to working their first shift on where to find a resident's level of assistance. This will be documented on a skills check-off list and quiz. A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of Kardex knowledge. This will be completed by [DATE] at 12 PM. The Kardex showed that resident #5 was a 2 person assist. The C.N.A. received disciplinary action and was retrained by DON/ADON. Other nursing staff were retrained also on use of the Kardex. The administrator has been in-service by Regional Operations director on self-report guidelines as directed in the long-term care regulatory letter. This has been completed as of [DATE] 4:30 PM. 3* Identification of Others The facility recognizes that all residents have the potential to experience Neglect. An assessment to be completed by [DATE] of all facility residents' administrative nurses. Assessment will compare care plans to Kardex. The Abuse Coordinator/Designee will report any allegations of neglect to the State Survey Agency in accordance with self-report guidelines. In this incident, there was no immediate allegation of neglect, but suspicion as the resident's plan of care was not followed that resulted in the resident's serious bodily injuries during/from care. A facility record audit of residents Kardex and care plans will be completed by Director of Nursing/Designee by [DATE] 10 AM. 4* Plan to prevent from recurring Intervention for Neglect: DON/designee to evaluate care plan and Kardex for all residents and each new resident within 48 hrs. of admission and review and update as needed. Staff both existing and new will have a check-off sheet showing competencies on Kardex and levels of assistance prior to working the first shift. This is to be completed during orientation. Training Plan Initial Trainings: Facility to Initiate Training by [DATE] 3:30 PM from training materials provided by DON/ADON. This training will be done with all available staff working [DATE], and then staff who were unable to attend will be provided with the training prior to working their next scheduled shift by [DATE] 10AM via in person on telephone training. All current and new hires will be trained during in-service and initial orientation and documented on their skills check-off sheet. A 5-question quiz will be given to all staff that they must pass at a 100% rate demonstrating their retainment of Kardex knowledge. This will be completed by [DATE] at 12 PM. Previous falls have been investigated and there is no correlation related to lack of staff supervision. There are no similar situations. 5* Ongoing Monitoring Facility neglect rounds to be done by Abuse Coordinator/Designee to review sufficient staff are in place to provide resident care. This rounding will be done daily on all three shifts until the Immediate Jeopardy Conditions are resolved. Thereafter, facility audit rounds to be done on all three shifts (AM, PM, Night) weekly to ensure interventions are in place. Audit to be done weekly x 8 weeks and then reviewed by the QA Committee to determine frequency of future audits. Audit will be documented on a check-off sheet for staff. This check-off will ask staff to demonstrate Kardex knowledge during rounds. 6* QAPI In regard to immediacy, this POR will be reviewed in an ad Hoc QAPI meeting completed [DATE] by 9 PM. Follow up on training will be reviewed in routine QAPI for 3 months. Identified trends will be reviewed/ reported to the facility Quality Assurance Committee monthly and as needed until lesser frequency is deemed appropriate. On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations, interviews, and record reviews were conducted on [DATE] from 12:35 p.m. through 3:10 p.m. and included 3 alert residents, nurses including 1 RN, 8 LVNs, and 16 CNAs, 1 NA, 1 RNA (who work all shifts), SW, ADON, and DON. Staff were able to identify residents' the care plans, the Kardex system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Staff were able to discuss the required level of staff assistance for ADLs. Staff were able to demonstrate the use of the Kardex system for resident care needs. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. Kardex for 11 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the Kardex. Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the Kardex. Review of staff training indicated nursing staff were in-serviced on where to find a resident's level of assistance in the Kardex. The training was completed on [DATE]. Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. Staff were in-service on abuse and neglect. The training was completed on [DATE]. The 5-question quiz of Kardex knowledge given to all tested staff indicated all staff scored 100%. The Kardex showed that Resident #5 was a 2 person assist. CNA C received disciplinary action and was retrained by DON/ADON on [DATE]. The administrator was in-service on [DATE] by Regional Operations Director on self-report guidelines as directed in the long-term care regulatory letter. There were no additional allegations of neglect or abuse identified during the investigation. During an interview on [DATE] at 2:40 p.m., the Administrator said he recognized all allegations and suspicion of allegations of abuse and neglect were reportable. During an interview on [DATE] at 2:50 p.m., The DON said the audit of all residents' care plans and Kardex revealed no issues or concerns, She said she believed Resident #5's fall was reportable when it occurred because the staff member could continue to work with other residents and harm other residents. A facility record audit dated [DATE] of residents' Kardex and care plans revealed no issues or concerns. Staffing was reviewed for the previous two weeks and for [DATE]. There was no concerns noted. Five residents said they were not afraid during care or had complaints of their care. The facility Administrator and the DON were provided education on abuse/neglect and bed mobility on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:38 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. On [DATE] at 3:12 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. 2. Record review of face sheet dated [DATE] indicated Resident #4 was a [AGE] year-old male, admitted on [DATE], and his diagnoses included vascular dementia, diabetes, cognitive communication deficit, muscle weakness, muscle wasting and atrophy, and need for assistance with personal care. Record review of MDS dated [DATE] indicated Resident #4 was usually able to express ideas and wants and able to understand others, had severe cognitive impairment, and required extensive assist of 1 persons for bed mobility and toilet use, 2+ person for transfers and personal hygiene. He was incontinent of bladder and bowel. There were no noted behaviors. Record review of Resident #4's care plan indicated no care plans developed for aggression or behaviors. Record review of incident report dated [DATE] and completed by LVN J indicated CNA K came to the nurse station and reported the resident had blood on his forehead. LVN J observed Resident #4 lying in bed with an open wound over his left eye with dried blood around the wound. When Resident #4 was asked what happened, Resident #4 said he said he had a fight with a nurse. Resident #4 was transported to the hospital. Record review of Resident #4's hospital record dated [DATE] indicated Resident #4 said someone punched him.here for a fall according to (facility). Someone put Resident #4 back to bed, but no one knows who. Something happened last night that went unreported per EMS. 2 cm wound sutured with 4 sutures . Clinical impression: assault, facial laceration .SW was called to the ER to assist Resident #4 with possible NH abuse. Apparently the EMS staff advised LVN L that I (Resident #4) kicked a nurse and she hit me' . Communicating with Resident #4 is very difficult due to him being hard of hearing. The SW found Resident #4 to be awake and alert, just slow to respond. (In fact, he told the SW to please slow down. I might be old, but if I take my time I can get it all out. Resident #4 stated, I kicked my nurse and she hit me. I guess I made her mad. Resident #4 stated he was embarrassed that he kicked a woman and was remorseful for the event even occurring. Record review of the facility investigation dated [DATE] indicated LVN J said CNA K came to the nurse station on [DATE] 15 minutes prior to the end of shift and reported Resident #4 had blood on his forehead. CNA K left the facility the immediately after she reported the blood on Resident #4. LVN O (day shift nurse) assisted with assessment. Resident #4 was lying in bed neatly tucked in bed. LVN O stated it looked staged how neatly Resident #4 was tucked in. Resident #4 sustained a laceration to his left eye and hematoma. There appeared to be blood in his mouth. There was a large amount of fresh blood on the privacy curtain adjacent to Resident #4's bed. When asked what happened, Resident #4 said he got in a fight with the nurse. Resident #4 was sent to the hospital for evaluation and assessment. CNA K was the only aide to provide care for Resident #4 on the night shift. The Administrator received a call from the SW at the hospital who reported Resident #4's injuries seemed suspicious to the hospital staff and Resident #4 told the EMS staff he got in a fight with the nurse. SW N interviewed Resident #4 and asked what happened. Resident #4 said he got in a fight with a nurse and said he had kicked the nurse as she hurt him when she moved him and she did not like that he kicked her. Resident #4 was not able to give a name or description. He received sutures above his eye and returned to the facility the same day. The night nurse and all CNAs were suspended. It was noted Resident #4 refers to all staff as nurse and did not differentiate between aides and nurses. The administrator observed a large amount of blood on the privacy curtain. It was bright red and appeared fresh. CNA K was the only staff identified to provide care for Resident #4 on [DATE]. CNA K returned to the facility to give her statement. She appeared nervous and fidgeted during the interview. She had black bandages on the middle and ring finger of her right hand. The ADON noted scratches on the fingers. CNA K indicated she was right-handed. CNA K refused to remove the bandages. CNA K said she did not know what happened to Resident #4. CNA K changed her statement to reporting the incident to the nurse early in the shift and then changed it back to the end of her shift. She denied Resident #4 had a fall or if there was an argument or a scuffle. Progress note dated [DATE] indicated Resident #4 expired after testing positive for Covid-19 on [DATE] (unrelated to the abuse). The investigator attempted to call CNA K on [DATE] at 12:27 p.m. The person who answered the phone said no when the investigator asked to speak to CNA K and disconnected the call. The investigator left a text message at 12:31 p.m. for CNA K at the same number and received no response. Record review of CNA K's statement (undated) indicated she checked on Resident #4 and noticed dried up blood on his face and reported to the charge nurse. She checked on him a second time with CNA N, there was still blood on Resident #4 but she assumed LVN J had reported it. Record review of LVN O's statement dated [DATE] indicated she arrived at the facility on [DATE] at approximately 5:45 a.m. She started rounds and observed Resident #4 lying in bed with blood and hematoma noted above his left eye. Blood was also noted in Resid [TRUNCATED]