Every finding on record at San Pedro Manor

Based on observations, record review and interview the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 4 medication refrigerators reviewed (2nd floor medication room refrigerator identified as Med/Black). The facility failed to maintain medication storage refrigerator temperatures between 35-45 degrees Fahrenheit for the 2nd floor medication room refrigerator identified as Med/Black, when temperatures read 50.0 degrees Fahrenheit with facility thermometer and 50.1 degrees Fahrenheit with externally applied thermometer. This failure could result in decreased medication stability leading to residents receiving medication with reduce efficacy. The Findings Include:Observation on 08/30/2026 @ 1140am, LVN A stated the 200 Hall medication room refrigerator labeled Med/Black, had a thermometer inside located at the right back corner of the refrigerator with a temperature reading of 50.0 degrees Fahrenheit. An ambient thermometer was placed on the single middle rack for 3 minutes and read a temperature of 50.1 degrees Fahrenheit. Observation revealed 1 unopened Lantus Solostar Insulin Pen 100units/ml (medication used to control blood glucose levels), 1 unopened Humalog KwikPen 100units/ml (medication used to control blood glucose levels). Record review of a temperature log sheet titled Refrigerator and Freezer Temperature Log (Med/Black), dated 2026, placed on the outside of the refrigerator revealed temperatures of the refrigerator should be maintained at 35-40 degrees Fahrenheit. Interview with LVN A on 08/30/2026 at 1145am, LVN A stated the refrigerator should be kept within the noted ranges listed on the temperature log at 30-40 degrees Fahrenheit. LVN A stated that the medication in the refrigerator was Insulin (medication used to control blood glucose levels). LVN A stated it was important to keep medications at proper temperatures to maintain the medications stability and effectiveness. LVN A stated he did not know what temperature the insulin should be kept at but that it should be kept within the ranges noted on the temperature log. LVN A stated if he identified that the refrigerator was not within the expected temperature ranges, he would immediately notify the manager. LVN A stated he would not use medication that was not kept at proper temperature since it could have reduced effects for the residents receiving the medication. Interview with DON on 08/30/2026 at 3:20pm, the DON stated medication refrigerator temperatures are checked every night shift. DON stated any recorded deviations from the noted ranges of 35-40 degrees Fahrenheit should be reported to a manger. The DON stated medication kept outside the manufacture ranges should not be administered and discarded. DON stated medications stored at improper temperatures could affect the medications effectiveness when administered. The DON stated nursing staff are trained upon hire and quarterly on medication administration and storage. Review of manufacture medication insert for Lantus Solostar published by Sanofi-Aventis U.S. LLC, revised 2025, titled Full Prescribing Information under storage section 16.2 states Dispense in the original sealed carton with the enclosed Instructions for Use. Store unused LANTUS in a refrigerator between 36 Fahrenheit and 46 Fahrenheit (2 Celcius and 8 Celcius). Do not freeze. Discard LANTUS if it has been frozen.Review of manufacture medication insert for Humalog Kwikpen published by [NAME] Lilly and Company, revised May/2025, titled Full Prescribing Information under Storage and Handling section 16.2 states Dispense in the original sealed carton with the enclosed instructions for use. Protect from direct heat and light. Do not freeze and do not use if it has been frozen. 3ml Single-Patient-Use Humalog KwikPen, Not In-Use (Unopened) Refrigerated (36 to 46 Fahrenheit [2 to 8 Celcius]).Record review of facility policy titled Nursing Clinical, Subject; Medication Access and Storage, dated 05/2007 revealed: Policy; It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. #11 Medications requiring refrigeration or temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring.

Based on interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 8 residents (Resident #1) reviewed for resident rights. The facility failed to notify Resident #1's representative when staff reported a skin tear . This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. The findings included: Record review of Resident #1's face sheet dated 4/28/26 revealed a [AGE] year-old male admitted to the facility on [DATE] and with diagnoses that included anxiety disorder ( persistent, excessive, and uncontrollable worry or fear that interferes with daily life) , Hypertension, (high blood pressure, is a chronic condition where the force of blood against artery walls is consistently too high) and Benign Prostatic Hyperplasia ( is a common, non-cancerous enlargement of the prostate gland). Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS of 12, which indicated moderate cognitive impairment. Record review of Resident #1's care plan, dated 4/2/2026, revealed: ST to left lateral shin, keep skin clean and dry . Review of facility incident and accident report from January 2026-April 2026 revealed Resident #1's name associated with the incident Skin Tear on 4/2/2026. Record review of Resident #1's physician's telephone orders, 4/2/26, revealed the following:Cleanse affected areas with normal saline, pat dry, apply skin prep, and xeroform to open areas, daily. Record review of Resident #1's progress notes from 4/2/26 , 2:20 PM ; written by LVN A revealed skin tear/abrasion noted to left lower shin; attempted to call daughter / POA; no answer noted. Record review of Resident # 1 electronic record progress notes from 4/3/2026, written by the treatment nurse, revealed this nurse was notified that Resident # 1 had a skin tear to the left lower shin, 8x6 CM. Interview with the RP on 4/29/2026 at 10:15 AM revealed she was never contacted by facility nursing staff; she was notified of the incident by Resident # 1 when she came to visit on 4/3/2026 and noted the skin tear to left lower shin. Interview with LVN A on 4/29/2026 at 10:30 AM revealed she called family but was unable to leave a voicemail, but was under the impression that the treatment nurse would call the family of Resident # 1. An interview with the treatment nurse on 4/29/2026 at 11:06 AM revealed that LVN A notified her of a skin tear for Resident #1 on 4/3/2026. The treatment nurse stated she called the MD, wrote orders, and did not contact family, as per the facility's culture; the charge nurse was responsible for contacting family. An interview with the DON on 4/29/2026 at 2:00 PM revealed that she became aware that the family was not notified of the skin tear that occurred on 4/2/2026, and that on 4/3/2026, when RP came to speak to her, an investigation was conducted. The DON stated that the RP should have been notified per the significant change policy. She said failure to notify the RP of an incident could lead to a breakdown of trust between RP and the facility. The DON stated both LVN A and the wound care nurse should have ensured the RP was contacted. The DON also stated her ADONs would be responsible for supervising compliance with this task, and she would monitor it by conducting random incident report checks Interview with the Administrator on 4/2/2026 at 2:30 PM revealed, We should have notified the doctor, but we did not. The staff prioritized Resident #1 at that moment and provided care. Moving forward, all staff must contact RP with any change in condition, as failure to do so could breach the trust between the facility and RP. Record review of the undated facility policy titled. Significant change in condition, revealed in part: The Resident representee will be notified of the change in condition .

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 resident (Residents #12 and #92 ) reviewed for incontinent care, in that: 1.While providing incontinent care, CNA G made multiple passes with the same wipe while cleaning Resident #12's buttocks. 2. While providing incontinent care for Resident #92, CNA E did not separate Resident #92's labias to clean the meatus (urinary opening) This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: 1.Record review of Resident #12's face sheet, dated 08/07/2025, revealed an admission date of 04/25/2024, and, a readmission date of 07/29/2025, with diagnoses which included: Type 2 diabetes mellitus (high level of sugar in the blood) , Dysphagia (difficulty swallowing), Hemiplegia (Paralysis of one side of the body), Resistance to multiple antimicrobial drugs, Hyperlipidemia(Elevated level of any or all lipids(fat) in the blood), Hypertension (high blood pressure), Chronic kidney disease stage 2 (gradual loss of kidney function). Record review of Resident #12's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 00 indicating severe cognitive impairment. Resident #12 required total assistance and was always incontinent of bowel. The resident had an indwelling catheter. Review of Resident #12's care plan, dated 05/09/2025, revealed a problem of has an indwelling urinary catheter due to urinary obstruction and an intervention of Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 08/07/2025 at 10:48 a.m. revealed while providing incontinent care for Resident #12, CNA G wiped Resident #12's buttocks making multiple passes with the same wet wipe. During an interview on 08/07/2025 at 11:07 a.m. CNA G, he said he had wiped Resident #12's buttocks making multiple passes with the same wet wipe. He said he was nervous and he knew to only do one pass per wipe. He stated doing multiple passes could cause a risk for infection for the resident. CNA G confirmed receiving training on incontinent care from the facility. During an interview with the DON on 08/07/2025 at 3:40 p.m., she confirmed a wet wipe should only be used for one pass, during perineal care. She stated doing multiple passes could possibly cause an infection. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were checked yearly. The DON said she spot checked the staff while they provide care for infection control and quality of care. Review of annual skills check revealed CNA G passed competency for Perineal care/incontinent care on 01/20/2025. Review of facility policy, titled Perineal care, undated, revealed wash peri-area using front to back strokes. 2.Record review of Resident #92's face sheet, dated 08/07/2025, revealed an admission date of 01/09/2025, with diagnoses which included: Wernicke's encephalopathy (brain and memory disorder due to a lack of vitamin B1), Dysphagia (difficulty swallowing), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), and Asthma (Long-term inflammatory disease of the airways restricting airflow). Record review of Resident #92's Quarterly MDS assessment, dated 07/08/2025, revealed the resident had a BIMS score of 08, indicating she was moderately cognitively impaired. Resident #92 was always incontinent of bladder and bowel and, required total assistance with her ADLs. Record review of Resident #92's care plan, dated 01/17/2025, revealed a problem of has ADL Self Care Performance Deficit related to Wernicke's encephalopathy, Muscle weakness, with an intervention of Toileting Hygiene: Dependent. Observation on 08/07/2025 at 3:24 p.m., revealed while providing incontinent care for Resident #92, CNA E did not separate Resident #92's labia to clean the meatus (urinary opening). During an interview on 08/07/2025 at 3:37 a.m. CNA E, said she did not separate Resident #92's labia. She said she was nervous but she knew she had to clean between the resident's labia. She stated not cleaning between the labia could cause a risk for infection for the resident. She said she received training on incontinent care from the facility. During an interview with the DON on 08/07/2025 at 3:40 p.m., the DON said the staff had to clean between the resident's labia during female incontinent care. She stated not cleaning between the labia could cause a risk for infection for the resident. The DON revealed the staff received training on infection control and incontinent care at least annually. The DON said the staff skills were checked yearly. The DON said she spot checked the staff while they provided care for infection control and quality of care. Review of annual skills check revealed CNA E passed competency for Perineal care/incontinent care on 02/19/2025. Review of Facility's policy Perineal care - female, undated, revealed First separate inner labia and wash down the center over the urethral area.

Based on observation, interviews, and record reviews, the facility failed to 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 disease and infection for 1 of 6 residents (Resident #92 ) reviewed for infection control, in that: The facility failed to ensure CNA E used proper infection control while providing incontinent care for Resident #92. These deficient practices could place residents at-risk for infection due to improper care practices The findings include: Record review of Resident #92's face sheet, dated 08/07/2025, revealed an admission date of 01/09/2025, with diagnoses which included: Wernicke's encephalopathy (brain and memory disorder due to a lack fo vitamin B1), Dysphagia (difficulty swallowing), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), Asthma (Long-term inflammatory disease of the airways restricting airflow). Record review of Resident #92's Quarterly MDS assessment, dated 07/08/2025, revealed the resident had a BIMS score of 08, indicating she was moderately cognitively impaired. Resident #92 was always incontinent of bladder and bowel and, required total assistance with her ADLs. Record review of Resident #92's care plan, dated 01/17/2025, revealed a problem of has ADL Self Care Performance Deficit related to Wernicke's encephalopathy, Muscle weakness, with an intervention of Toileting Hygiene: Dependent. Observation on 08/07/2025 at 3:24 p.m. revealed CNA E, after washing her hands, touched the room's door with her bare hands, did not sanitize her hands before putting gloves on and started to provide care for Resident #92. While providing incontinent care for Resident #92, CNA E changed her gloves multiple times but did not sanitize between change of gloves. After cleaning Resident #92's buttocks, CNA E removed the soiled briefs and without changing gloves and sanitizing her hands, she touched the clean brief to place them on Resident #92. During an interview with CNA E on 08/07/2025 at 3:38 p.m., CNA E stated she forgot to sanitize her hands before putting gloves on and between change of gloves because she was nervous. She stated not sanitizing her hands and change gloves could cause a risk of infection for the resident. She stated she received infection control from the DON with the last year. During an interview with the DON on 08/07/2025 at 3:40 p.m., the DON stated the door of the room was considered dirty and the CNA should have sanitized her hands prior to put her gloves on. The DON stated, the staf needed to sanitize their hands between change of gloves and they needed to change gloves and sanitize when going from a soiled area to a clean one. She confirmed the staff had received training on infection control within the year and the training was provided by herself. They also check the staff skills annually and as needed. Review of Facility's policy, titled Infection control, dated 03/2024, revealed Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include:a. Proper selection and use of PPE, such as gowns, gloves, facemasks, respirators, and eye protectioni. Use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated).b. Hand hygiene; [ .]

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility in that: 1. The facility failed to replace or clean dirty overhead ceiling vents in the main kitchen area. 2. The facility failed to clean a rusty overhead ceiling vent cover in the dish room. These failures could place residents at risk for food borne illness. The findings included: Observation on 08/05/2025 from 9:20am until 9:45am of the kitchen with the Food Service Director revealed the following: a. There were 7 ceiling vents which each measured approximately 2x2 ft in the main kitchen area with visible dirt and dust particles and was stained. One of the 7 ceiling vents which was located over the standing floor freezer was not completely attached to the ceiling surface.b. There was a vent cover over the dish machine located in the dish room that had several spots of rust accumulation on the inside and outside of the vent cover. During an interview on 08/05/25 at 9:50am, the Food Service Director stated that she had placed a work order for the ceiling vents to be either cleaned/replaced but was not sure of the work order date. The Food Service Director stated she was responsible to submitting the work order request and having the ceiling vents cleaned or replaced which would promote cleanliness in the food service environment. During an interview on 8/5/25 at 10:50am the Maintenance Director stated that he had received a work order request to clean or replace the kitchen ceiling vents but did not know the date of the work order. The Maintenance Director stated that having clean ceiling vents would promote kitchen cleanliness in the food service environment. Record review of facility policy which referenced Texas Food Establishment Rules effective date 10/11/25 , Section 228.114 page 109 revealed the kitchen environment will be kept clean for all non-food contact surfaces. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observations, interviews, and record reviews the facility failed to prepare and provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, for 3 of 29 residents (Resident #6, #43, and #93) reviewed for palatable and appetizing food, in that: 1. The facility served Resident #6 meals that were cold. 2. The facility served Resident #43 meals that were cold 3. The facility served Resident #93 meals that were cold. These failures could place residents at risk for a diminished quality of life by not receiving food and drink that is palatable, attractive, and at a safe and appetizing temperature. The findings included: 1. A record review of Resident #6's face sheet dated 08/05/25 revealed the latest admission date of 3/26/25 for a 54- year -old male with diagnoses which included type 2 diabetes mellitus( a condition in which the body has trouble controlling blood sugar), depression disorder (a condition in which there is persistent feeling of sadness) and chronic kidney disease( a condition in which the kidney function is impaired). A record review of Resident #6's quarterly MDS assessment dated [DATE] revealed Resident #6 had a BIMS of 15 (a condition in which the cognition is intact). A record review of Resident #6's care plan initiated on 2/28/21 revealed a deficit in activities of daily living. A record review of Resident #43's face sheet dated 8/5/25 revealed an admission date of 5/29/24 for a [AGE] year old male with diagnoses of anemia (a condition in which there is not enough red blood cells), COPD (a condition in which the lung function is diminished) , and muscle weakness ( a condition in which the muscle strength is poor). 2. A record review of Resident #43's annual MDS completed on 5/29/25 revealed a BIMS score of 13 (a condition in which the cognition is intact). A record review of Resident #43's care plan initiated on 7/4/23 revealed a deficit in activities of daily living. A record review of Resident #93's face sheet dated 8/5/25 revealed an admission date of 4/25/24 for a [AGE] year old female resident with diagnoses of blindness in the right eye, ( a loss of vision in one eye), essential hypertension ( a condition in which the blood pressure is high), and syncope ( a condition of temporary loss of consciousness) 3. A record review of Resident #93's quarterly MDS dated [DATE] revealed a BIMS of 13 (a condition in which cognition is intact). A record review of Resident #93's care plan initiated on 4/30/24 revealed a deficit in activities of daily living. During an interview on 8/5/25 at 12:15pm Resident # 6 stated that he eats in his room and his meals are often cold when served. Resident #6 stated that today's lunch was cold and he did not want to eat it. During an interview on 8/5/25 at 1:15pm Resident #93 stated she eats in the room and the breakfast when served is almost always cold. During an interview on 8/6/25 at 7:25am C.N.A.-A stated that the food tray racks have a plastic cover which is removed and when on the resident hallways the food trays are held in an open tray rack cart. During an observation on 8/6/25 at 7:40 am revealed a resident's serving of eggs had a recorded temperature of 94.82F (eggs per CMS should be maintained at 135F) and a resident's serving of sausage had a recorded temperature of 90.32F ( sausage per CMS should be maintained at 140F) During a phone interview on 8/6/25 at 10:15am a family member for Resident #93 stated the meals served are often cold. During a phone interview on 8/6/25 at 11:10am Resident #43 stated he eats in his room and the lunch and supper meals when served are sometimes cold. During an interview on 8/6/25 at 2:45pm the Activity Director stated that resident council meetings were held on 5/5/25 and 8/5/25 in which multiple residents reported that food is often cold when served. Record review of facility dietary policy noted under the Texas Food Establishment Rules dated 10/11/25 pages 68-73 revealed that food served would follow the established guidelines for temperature control.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #92) reviewed for privacy, in that: CNA E and CNA F did not close completely Resident #92's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.The findings include: Record review of Resident #92's face sheet, dated 08/07/2025, revealed an admission date of 01/09/2025, with diagnoses which included: Wernicke's encephalopathy (brain and memory disorder due to a lack of vitamin B1), Dysphagia (difficulty swallowing), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Hypertension (High blood pressure), and Asthma (Long-term inflammatory disease of the airways restricting airflow). Record review of Resident #92's Quarterly MDS assessment, dated 07/08/2025, revealed the resident had a BIMS score of 08, indicating she was moderately cognitively impaired. Resident #92 was always incontinent of bladder and bowel and, required total assistance with her ADLs. Record review of Resident #92's care plan, dated 01/17/2025, revealed a problem of has ADL Self Care Performance Deficit related to Wernicke's encephalopathy, Muscle weakness, with an intervention of Toileting Hygiene: Dependent. Observation on 08/07/2025 at 3:24 p.m. revealed CNA E and CNA F did not completely close the privacy curtains while they provided incontinent care for Resident #92, exposing the resident who could be seen if somebody entered the room. The privacy curtain was broken and was blocked on the rail, it could only be halfway closed. During an interview with CNA E and CNA F on 08/07/2025 at 3:38 p.m., CNA F confirmed the privacy curtains was not completely closed while they provided care for Resident #92 but it should have been to protect the resident's privacy. They did not know how long the privacy curtain had been broken. They confirmed they received resident rights training within the year. During an interview with the DON on 08/07/2025 at 3:40 p.m., she said privacy must be provided during care and Resident #92's privacy curtains should have been closed completely. She said she provided training, the staff received training on resident rights within the year and they do staff skills checks annually and as needed. Review of a policy, titled Resident Rights, undated, revealed They also will have the right to privacy, maintain privacy curtains for dressing and when providing care.

Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 5 of 5 residents (confidential residents) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. These findings included: During a confidential resident council meeting, 5 of 5 residents present stated that they do not get mail on Saturdays, if mail comes on Saturday, it is not given out until Monday. During an interview via phone call on 8/7/2025 at 10:00 am Receptionist D-stated she worked weekends and the mail on the weekends usually comes in bulk and has a rubber band on it. She stated she does not go through the mail, and she puts it in the drawer for them to distribute on Monday. During a staff interview on 8/7 2025 at 11:12 am Receptionist C -stated that she worked Monday through Friday and every third weekend. She stated that on weekends, the mail is put in the drawer for distribution on Monday by the social worker. During a staff interview on 8/7 2025 at 11:17 am HR-stated mail is supposed to be distributed on Saturdays. She said she was not sure why it was not being done. She stated it is the residents right to receive their mail on Saturdays. During a staff interview on 8/7 2025 at 11:40 am SS -stated that residents should get their mail on Saturday. She stated they should be holding the facility mail and giving resident mail to activities for distribution. Record review of Resident Mail Policy revealed, When mail is delivered to the facility for residents, it is given to Activities Dept. Activities Dept. will hand deliver to resident rooms day of delivery.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #8) reviewed for infection control, in that: The facility failed on 07-29-2025 when CNA D failed to wear a gown while caring for Resident #8 who had a surgical chest incision and required the use of PPE., In-addition there was no EBP sign posted outside or inside the resident's room or no PPE readily available for staff or visitors use. This failure placed residents at risk of transmission of communicable diseases, a decline in health status, and hospitalization. Findings included: Record review of Resident #8's admission record dated 07/29/2025 reflected an [AGE] year-old male with an admission date of 07/24/2025. Record review of Resident #8's Medical Diagnosis tab in the EHR dated 07/29/2025, reflected diagnoses which included malignant neoplasm of retroperitoneum, chronic lymphocytic leukemia of B-Cell type, and rheumatoid arthritis. Record review of Resident #8's IDT-BIMS form, dated 07/25/2025, reflected no documented BIMS score, although all questions were answered. Further review of the document reflected Resident #8 was cognitively intact (no problems making decisions about care or activities that affected daily life). Record review of Resident #8's Initial Baseline Care Plan, dated 07/25/2025, documented a focus on skin due to the potential for pressure ulcer development, with interventions including:- Educating the resident, family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning.- Monitor nutritional status. Serve diet as ordered, monitor intake and record.- Weekly head to toe skin at risk assessment Record review of Resident #8's Order Summary Report, dated 07/29/2025, reflected doctor's orders, including the following:- Surgical Incision to abdomen: change dry dressing and monitor for s/s of infection Q MWF (Monday, Wednesday, Friday).and pm as needed, dated 07/25/2025.- Surgical incision to abdomen: change dry dressing and monitor for s/s of infection Q MWF and pm one time a day every Mon, Wed, Fri (Monday, Wednesday, Friday). During an observation on 07/29/2025 at 12:55 p.m. outside Resident #8's room, there was no EBP sign to indicate to staff that the resident required staff to wear extra PPE for high-contact care activities and no PPE readily available, Resident #8 was in the room getting assistance from CNA D to change clothes and get re-dressed, Resident #8's shirt was open and a long vertical dressing was noted to the middle of his chest. During an interview on 07/29/2025 at 12:55 p.m. Resident #8 was A & O x 4 (person, place, time, and situation) stated he had dropped cobbler all over his clothes, CNA D was present for assistance with changing the resident's clothes Resident #8 stated the staff changed the dressing to the middle of his chest about every other day, but he had not seen staff wear a gown before. During an interview on 07/29/2025 at 1:00 p.m., the MDS RN stated residents with wounds and who received high-contact care activity should be on EBP, due to Resident #8's wounds and high care activities. The MDS RN stated PPE was not readily available near the Resident's door at that time, and the risks of not using PPE for a resident who needed EBP was the risk of infection, and decreased protection of the resident. During an interview and observation at the same time the ADON stated Resident #8 should have been on EBP, and that the nurse aides and other staff would know that if there was a sign posted to let them know the resident required EBP, but there was not a sign. When asked where the PPE for EBP was, the ADON stated, it was usually on the nurse aide's clean linen carts. During an observation the ADON and MDS RN checked both nurse aide clean carts and there were no disposable gowns available. Continued observation revealed gowns were in a locked linen closet on the opposite side of the hall from where Resident #8 was. During an interview and observation on 7/29/25 at 1:05 p.m. the ADON reviewed the facility's Infection Control Policy for transmission-based precautions and stated that EBP should be used for residents with wounds during high contact activities such as dressing. transferring. providing hygiene. During an interview on 07/29/2025 at 1:07 p.m. CNA D stated he assisted Resident #8 with getting dressed and positioning in bed. CNA D was able to demonstrate knowledge of EBP, but stated he did not see a sign outside or inside Resident #8's room so he did not know to put on a gown to assist Resident #8. CNA D stated he did not know if any risks to the resident if he did not wear EBP PPE. Record review of an example of the facility's Enhanced Barrier Precautions posting, with no date, revealed providers and staff must also: wear gloves and a gown for the following high-contact resident care activities. Record review of the facility's policy titled . Standard and Transmission-Based Precautions, dated March 2024, reflected that EBP applied to . Wounds and/or indwelling medical devices. and PPE (gloves and gown) should be used during Dressing. transferring. Providing hygiene. Record review of the facility's In-service Education Record, dated 07/23/2025, reflected multiple areas of infection control were discussed with the staff, including EBP. Further review showed CNA D and MDS RN signed the in-service as attended, there was no documented evidence that the ADON attended the training.

Based on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 4 residents (Resident #1) reviewed for documentation. Resident #1's electronic medical record did not contain complete and accurate documentation regarding whether his falls on 5/28/25 and 7/12/25 were witnessed by nursing staff or unwitnessed. This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the interdisciplinary team as to whether a resident fall was witnessed or unwitnessed. The findings were:Record review of Resident #1's face sheet, dated 7/17/25, reflected resident was a male aged 74 admitted on [DATE] and re-admitted [DATE] and discharged [DATE] (hospital) with diagnoses that included: nontraumatic intracranial hemorrhage (residual effects from a stroke), epilepsy (seizure disorder), abnormalities of gait and mobility (difficulty with ambulation), lack of coordination, and tinnitus (ringing in the ear). The RP was listed as: Guardian. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident's BIMS score was 1 which indicated severe cognitive impairment. The resident required set-up for transfer and had no impairments in range of motion. W/C was listed as an assistive device. Record review of Resident #1's fall risk score dated 7/12/25 reflected a score of 11 which indicated high risk for fall. Record review of Resident #1's Nurse Note dated 5/28/25 authored by LVN A reflected: resident had a witnessed fall without injury in the common area. Record review of Resident #1's CP dated 5/28/25 reflected witnessed fall with the new intervention of staff to be in-serviced, and optometry referral. Record review of Resident #1's Incident report authored by LVN A documented a conflict on whether the resident's fall on 5/28/25 was witnessed or unwitnessed. The incident report Box for fall was checked for unwitnessed. Record review of Resident #1's CP dated 7/12/25 reflected an unwitnessed fall with no injury; intervention was the placement of Dycem (adhesive) on the resident's W/C. Record review of Resident #1's Nurse Note dated 7/12/25 at 5:45 PM authored by LVN B reflected the fall was witnessed. Record review of the Resident's Incident Report dated 7/12/25 reflected the fall was not witnessed. Observation and interview of Resident #1 on 7/16/25 at 1:00 PM reflected, resident was in an ICU bed, alert and oriented to self. An O2 pulse meter was placed on the resident's head. His left elbow had multiple scratches and generalized bruising and was red in color. The resident could not recall any information regarding his falls on 5/28/25 and 7/12/25. The resident was able to state that he was not abused or neglected in the facility. The resident was unable to state any fall prevention measures that were in place at the nursing home. During an interview on 7/16/25 at 1:05 PM, the ICU RN stated: Resident #1 was admitted on [DATE] around midnight and given a CT scan at 2:00 AM. The CT scan revealed a small hemorrhagic contusion in the right frontal lobe (small bleeding in the front of the brain) not requiring a surgical intervention, The RN stated that the resident had dementia and was confused most of the time. The RN stated that the resident had a history of stroke in the year 2022. The RN stated the resident was scheduled to be transferred to a medical bed out of ICU on 7/16/25. Record review of Resident #1's ER report dated 713/25 at 26 minutes past midnight reflected: resident presented to ER from fall from his W/C on 7/12/25 around 10:20 PM. CT scan performed; no acute neurosurgical intervention was indicated at the time. The CT scan reflected a small hemorrhagic contusion in the anterior lateral inferior right frontal lobe (section of the brain involved in speech). Lab results reflected the resident had low potassium and high sodium [indicators of confusion]. Diagnoses included: hemorrhagic contusion after fall, history of CVA, and dementia. During an interview on 7/17/25 at 2:23 PM, LVN C (MDS) stated that: for the 5/28/25 fall there was a conflict in the incident report with the other documents (CP and Nurse Note). LVN C stated he could not explain the inaccurate documentation for the 5/28/25 fall. Regarding the fall incident on 7/12/25 at 5:45 PM, LVN C stated he could not explain why there was inaccurate documentation between the nurse note and the CP and the incident report. During an interview on 7/17/25 at 3:00 PM, the DON stated she was not aware of the inaccurate documentation for Resident #1's fall on 5/28/25. Regarding the inaccurate documentation on 7/12/25, the DON stated the MDS Nurse (LVN C) made an error in documentation that was immediately corrected on 7/17/25 [surveyor entered the facility on 7/16/25] which reflected that Resident #1's fall on 7/12/25 at 5:45 PM was witnessed. The DON stated that documentation required that the fall assessment, CP, and Kardex (nursing tool that summarizes resident information) were to be accurate. The DON stated the facility kept a binder of high-risk residents at the Nurse Station which captured the interventions for high fall risk residents. During a telephone interview on 7/17/25 at 3:18 PM, LVN A stated the nurse note for Resident #1 for the fall on 5/28/25 was accurate. LVN A stated, Resident #1's fall was witnessed by a CNA [LVN A could not recall the name of the CNA [CNA E] in the common (front lobby) and there was no injury to the resident. LVN A stated Resident #1 tried to ambulate and tripped on a W/C footrest. LVN A stated she documented the fall was witnessed; but could not explain why the box in the incident report was not checked which resulted in the fall being listed as unwitnessed. Attempted telephone interview on 7/17/25 at 3:25 PM, message left for CNA E to return call to surveyor. During a telephone interview on 7/17/25 at 3:28 PM, LVN B stated the note written on 7/12/25 at 5:45 PM was accurate regarding Resident #1's fall on 7/12/25 at 5:45 PM. LVN B stated Resident #1's fall was witnessed by CNA D. LVN stated the fall was without injury. LVN B stated she accurately documented the fall in Resident #1's clinical record. Attempted telephone interview on 7/17/25 at 3:30 PM, message left for CNA D to return call to surveyor. During an interview on 7/17/25 at 4:23 PM, the Administrator stated: regarding the finding of inaccurate clinical records for Resident #1's falls on 5/28/25 and 7/12/25, he had no explanation and would in-service staff on accuracy of clinical records. Record review of facility's Nursing Documentation policy, undated, read: It is the policy of this facility to document pertinent information in the resident chart.Change of Condition.Incidents.

Based on observations, interviews, and record reviews the facility failed establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (3rd floor)community shower rooms in that: The 3rd floor shower room had 2 shower stalls that had drains with gobs of hair. There was brown substance under 1 shower chair, and floors were dirty with darkened areas and brown substance droppings on 1 of the shower stalls. 30 possible residents could use the 3rd floor shower room. This could affect all resident that shower in the 3rd floor shared shower and could result in infections. The Findings were: Observation on 5/6/2025 at 4:21 PM The 3rd floor shower room had 2 shower stalls that had drains with gobs of hair. There was brown substance under 1 shower chair, and floors were dirty with darkened areas and brown substance droppings on 1 of the shower stalls. Interview on 5/6/2025 at 4:22 PM with CNA A stated he provided a resident a shower earlier today, he cleaned the shower chair with shampoo and had not disinfectant the shower chair, because the facility did not have anymore products to disinfect the shower chair. CNA A stated the night shifts were to stock the shower rooms. CNA A stated after each resident use, the shower chairs were cleaned between residents. CNA A stated the hsk staff clean the shower stalls and the CNAs clean any feces and shower chairs. Interview on 5/6/2025 at 4:31 PM with RN B observed the 3rd floor shower room, floors were dirty, shower grates had lots of hair, and feces on the shower room floor. RN B notified maintenance the shower room on 3rd floor needed a deep cleaning. Interview on 5/6/2025 at 4:36 PM, the ADON stated CNAs were supposed wipe the resident shower chairs after each use with disinfectant wipes. The Hsk clean the shower stalls, floors, and drainage. The ADON stated the Hsk staff leaves at 4:00 PM. The ADON stated the DON was in charge of the nursing task and the Maintenance/Hsk supervisor was in charge of the hsk task in the shower rooms. Interview on 5/6/2025 at 4:42 PM, the Maintenance Assistant C stated staff were supposed to use disinfected wipes to disinfect the resident shower chairs, between use. Hsk did not clean up feces, the CNAs do. Maintenance Assistant C stated the Hsk staff cleaned the shower rooms and mop the floor. He stated the hsk staff had left for the day. Interview on 5/6/2025 at 5:00 PM with the ADM and DON, the ADM and DON stated they would make sure the Maintenance/Hsk supervisor was aware and to educate the staff on cleaning/disinfecting resident shower rooms. Interview on 5/8/25 at 12:59 PM a with Maintenance/Hsk Supervisor stated the resident Showers floors had buildup. He cleaned the floors before lunch, and the floor tech does the floors before he leaves between 4:00-5:00 PM. The Hsk sanitizes everything in the shower room, take-out trash, touch up shower chairs, sanitize using 9name of company) chemical. The floor tech checks the floors before-4pm, one last time before he leaves for the day. The Maintenance/Hsk Supervisor stated he was not sure about the buildup on the floors, he cleans the dirt build up and he used a cleaning product that was easy to clean up. The Maintenance/Hsk Supervisor stated the CNAs were responsible for cleaning up the resident feces and urine. The Maintenance/Hsk Supervisor stated the [NAME] staff disinfect and move the cover/grates/drains and clean out the hairs. The Maintenance/Hsk Supervisor stated the female residents had quite a bit of hair that was caked up hair/shampoo on shower drains. The Maintenance/Hsk Supervisor stated the CNAs clean the shower chairs between use with the disinfectant wipes at nurse's station. Policy for CNA responsibilities for cleaning/disinfecting the shower rooms between staff was not provided before exit by the ADM/DON. Record review of policy for Housekeeping Services (no date) was documented Policy: It is the policy of this facility to maintain a clean environment for the residents. 7. Floors, are cleaned according to an established schedule. 8. Cleaning agents approved by the Infections Control Committee are in areas known to be contaminated with pathogenic bacteria. Record review of policy Cleaning Checklist for Housekeeping, (no date) was documented floor care: sweep the floor, and mop the floor, Shower area task: remove hair form drains, and disinfect shower stalls.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #40) reviewed for accidents. The transportation driver failed to ensure Resident #40 was safely transferred onto the transportation van on 06/21/24 when he was picked up for dialysis. The resident sprained his foot when it got caught in the van gap where the ramp met the van. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Record review of Resident #40's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included end stage renal disease (kidney failure), diabetes, osteoporosis, stroke, and seizure disorder. The MDS further Resident #40 had a BIMS of 14, which indicated his cognition was intact. Resident #40 used a manual wheelchair. Record review of Resident #40's care plan, dated 08/29/23, reflected he had osteoporosis and interventions included to protect the resident from injury avoiding sudden bumps, jarring with transfers. The care plan further reflected Resident #40 attended dialysis Mondays, Wednesdays, and Fridays. Record review of Resident #40's progress note, dated 06/21/24, documented by LVN A, reflected the following: Notified by 1st floor nurse that resident had an incident getting onto the transportation bus. This nurse went down to the 1st floor to assess the resident noted resident sitting in wheelchair, leaned over holding onto right foot, when assessed the right foot noted swelling to the right ankle, very sensitive to touch, able to wiggle toes and pedal pulse 3+. Took resident to his room, assisted him to bed, resident cannot bare weight on right foot .Resident stated 'driver of the van was pushing me onto the ramp but had to push me a little fast because there's a little bump to get over on the ramp when my foot got caught in the ramp and pushed my foot all the way back.' MD notified ordered STAT x-ray to right foot .Asked resident pain level from 0-10 resident stated a 10, administered Acetaminophen-Codeine Tablet 300-30MG per resident request for pain. Record review of radiology results, dated 06/21/24, reflected there were no fractures and no new orders given. Record review of the Transportation Company's Accident/Incident Report Form, dated 06/21/24, reflected the following: .Incident Information Incident Description [Resident #40] right ankle was injured while being rolled into the rear ramp of the wheelchair van by driver, [Driver]. As [Resident #40] crested the top of the ramp to enter the van, his right foot was not high enough, which caused his foot to roll under the leg. Driver took [Resident #40] back into the facility for examination by a nurse to determine the severity of his injury. Observation and interview with Resident #40 on 06/25/24 at 11:23 AM revealed when he was picked up for dialysis last Friday, 06/21/24, the transportation driver pushed him into the transportation van too fast and his foot got caught where the lift and the van connected. The resident said he immediately felt pain because it sprained his ankle. The facility ordered x-rays to ensure it was not broken due to the swelling. Observation of Resident #40's ankle revealed there was some swelling but there was no bruising noted at the time, but there was a pain patch on his ankle. The resident said he got some pain relief with the pain medications and pain patch. Resident #40 said the same transportation driver took him to dialysis on Monday, 06/24/24. Interview on 06/26/24 at 4:04 PM with LVN B revealed the transportation van had arrived to pick up Resident #40 to take him to dialysis on, 06/21/24, and they were loading the resident into the van. Shortly after, the transportation driver brought Resident #40 back into the facility and said as he was pushing the resident into the van, his foot had gotten caught and twisted up on the ramp and Resident #40 had immediately expressed pain. LVN B said she looked at the resident's ankle and noticed swelling on the outer side so she called to let his nurse, LVN A, know what had occurred. Interview on 06/26/24 at 2:51 PM with LVN A revealed she got a call from LVN B on, 06/21/24, and said Resident #40 had hurt his ankle when the transportation driver was pushing him up the ramp into the van. When she was downstairs she asked the resident what had occurred and he said the transportation had pushed him faster to get onto the van, causing his foot to get stuck in the gap where the ramp meets the van and his foot had bent back. LVN A said she assessed the resident's ankle and noted swelling around it. Resident #40 told LVN A he was having pain to his ankle and he was medicated and they ordered x-rays to ensure it was not fractured. Interview with the DON on 06/26/24 at 3:20 PM revealed she was told about Resident #40's incident and they had called the doctor for x-rays to ensure his ankle was not broken. The DON stated she called the transportation company to find out what happened but said she had not heard back but would be calling them again for a statement. Record review of the facility's policy titled Transportation to and from an off-site certified dialysis facility revised November 2017 reflected the following: POLICY: It is the policy of this facility to assist residents in arranging transportation to/from an off-site dialysis facility.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the ceiling vents. This failure could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 06/25/24 at 8:43 AM revealed five air conditioning vents over the food preparation area in the kitchen were observed to have built-up fuzz and dust stuck to them. Interview on 06/25/24 at 11:18 AM with [NAME] revealed a couple of months ago, exact date unknown, the kitchen was remodeled. He stated he could not recall if the air vents were replaced or cleaned but that was the last time the air vents were cleaned. He stated it was the responsibility of the maintenance staff to clean the air vents. He stated he had not reported to maintenance staff that air vents needed to be cleaned. [NAME] stated the risk of air vents not being cleaned could lead to build-up falling in the food. Interview on 06/25/24 at 11:23 AM with the Dietary Supervisor revealed the facility kitchen was remodeled and the air vents were cleaned and painted. The Dietary Supervisor could not recall when the kitchen was remodeled, it had been a couple of months ago. She stated air vents should be cleaned once a month or as needed by maintenance staff. She stated air vents were last cleaned May 2024. She stated the risk of air vents not being cleaned could lead into dust falling in the food. Interview on 06/25/24 at 11:36 AM with the Maintenance Supervisor revealed the air vents in the kitchen were cleaned by the kitchen staff. He stated kitchen staff were responsible to clean the air vents unless they asked for help to assist on cleaning them. He stated kitchen staff have not reported anything to him regarding the air vents needing to be cleaned . Record review of the facility's policy titled General Sanitation of Kitchen dated 2013, reflected the following: The staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. 1. Cleaning and sanitation tasks for the kitchen will be recorded. 2. Tasks will be assigned to be the responsibility of specific positions. 3. Frequency of cleaning for each task will be defined. Record review of the Federal Food Code 2022 reflected the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

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 (Residents # 57 and # 185) of 8 residents reviewed for infection control. Staff failed to don appropriate Personal Protective Equipment (PPE) while providing care to Resident #57, who had a colostomy, and Resident #185, who had a catheter. This failure could place residents at risk of contracting an infection from residents on Enhanced Barrier Precautions (EBP). Findings included: Record review of Resident #57's undated Admission Record reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included spinal bifiida (birth defect causing the spinal cord to not develop), paraplegia (paralysis below the waist), and bowel impairment requiring a colostomy (bag for collecting stooll, attached to the abdomen). Record review of Resident #57's quarterly MDS, dated [DATE], reflected a BIMS score of 12 which indicated she was cognitively intact. Her Functional Status reflected she was dependent on staff for all of her ADLs except eating and hygiene. Her Bowel and Bladder Assessment indicated she was always incontinent and had a colostomy. Record review of Resident #57's care plan, dated0 4/15/24, reflected she had an alteration in her gastro-intestinal status related to colostomy. It also indicated she was incontinent of bladder related to her paraplegia. Observation on 06/25/24 at 110:17 AM Resident revealed #57 had signage outside her room which indicated she was on EBP and staff should wear a gown and gloves while providing care. CNA C entered the resident's room to empty the resident's colostomy bag. CNA C donned gloves only, no gown, and provided the care to Resident #57. CNA C continued to care for other residents after completing Resident #57's care. Record review of Resident #185's undated Admission Record reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included stroke, diabetes, and high blood pressure. Record review of Resident #185's admission MDS, dated [DATE], revealed a BIMS score of 4 indicating severe cognitive impairment. His Bowel and Bladder assessment indicated he was admitted with an indwelling catheter. Record review of Resident #185's baseline care plan revealed he had a self-care deficit, and had an indwelling catheter. Observation on 06/27/24 at 10:54 AM of peri care and catheter care provided by LVN D and CNA E revealed both donned gloves, but no gowns. Care was provided appropriately with proper hand hygiene observed. Per facility policy, the resident also required EBP due to the catheter. Interview on 06/27/24 at 11:00 AM both LVN D and CNA E stated they were in-serviced on infection control recently. Neither one of them could say why they did not don the appropriate PPE based on the signage on the door. LVN D stated PPE was available on the nurse cart as well as the linen cart on the hall. Interview on 06/27/24 at 11:20 AM the Infection Preventionist stated she performed an in-service on Infection Prevention on 06/19/24 at the All Staff meeting. She stated there was no reason the staff should not know the appropriate use of PPE between her in-service and the signage posted outside the resident's room. The Infection Preventionist stated the risk of not wearing the appropriate PPE was spreading infection to other residents. Interview on 06/27/24 at 12:15 PM the DON stated there was no cause for the staff not to use PPE when needed. She stated staff were in-serviced frequently on infection control, but were obviously not retaining the knowledge. She stated the risk of not wearing appropriate PPE was spreading infections. Record review of the facility's policy IPCP Standard and Transmission-Based Precautions, dated December 2023, reflected: .3. Enhanced Barrier Precautions (EBP) expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities .(e.g., residents with wounds and indwelling medical devices .)

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit, prevent abuse, neglect and exploitation of residents for three of three incidents (Resident #40, Resident #36, and Resident #9) reviewed for reporting. 1. The facility failed to follow their policy to report to the State Survey Agency when Resident #40 sprained his ankle when he got his foot caught in the van ramp while being pushed by the transportation driver. 2. The facility failed to follow their policy to report to the State Survey Agency when Resident #36 was found to have ant bites on her body. 3. The facility failed to follow their policy to report to the State Survey Agency when Resident #9 was given the wrong medications on 04/22/24. These failures could place residents at risk of lacking timely reporting of incidents. Findings include: 1. Record review of the facility's, undated, policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment reflected the following: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: .The State Survey Agency Record review of Resident #40's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included end stage renal disease (kidney failure), diabetes, osteoporosis, stroke, and seizure disorder. The MDS further reflected Resident #40 had a BIMS of 14, which indicated his cognition was intact. Resident #40 used a manual wheelchair. Record review of Resident #40's care plan, dated 08/29/23, reflected he had osteoporosis and interventions included to protect the resident from injury avoiding sudden bumps, jarring with transfers. The care plan further reflected Resident #40 attended dialysis Mondays, Wednesdays, and Fridays. Record review of Resident #40's progress note, dated 06/21/24, documented by LVN A, reflected the following: Notified by 1st floor nurse that resident had an incident getting onto the transportation bus. This nurse went down to the 1st floor to assess the resident noted resident sitting in wheelchair, leaned over holding onto right foot, when assessed the right foot noted swelling to the right ankle, very sensitive to touch, able to wiggle toes and pedal pulse 3+. Took resident to his room, assisted him to bed, resident cannot bare weight on right foot . Resident stated 'driver of the van was pushing me onto the ramp but had to push me a little fast because there's a little bump to get over on the ramp when my foot got caught in the ramp and pushed my foot all the way back.' MD notified ordered STAT x-ray to right foot Asked resident pain level from 0-10 resident stated a 10, administered Acetaminophen-Codeine Tablet 300-30MG per resident request for pain. Record review of radiology results dated 06/21/24, reflected there were no fractures and no new orders given. Record Review of the Transportation Company's Accident/Incident Report Form, dated 06/21/24, reflected the following: Incident Information Incident Description [Resident #40] right ankle was injured while being rolled into the rear ramp of the wheelchair van by driver, [Driver]. As [Resident #40] crested the top of the ramp to enter the van, his right foot was not high enough, which caused his foot to roll under the leg. Driver took [Resident #40] back into the facility for examination by a nurse to determine the severity of his injury. Observation and interview with Resident #40 on 06/25/24 at 11:23 AM revealed when he was picked up for dialysis last Friday, 06/21/24, the transportation driver pushed him into the transportation van too fast and his foot got caught where the lift and the van connected. The resident said he immediately felt pain because it sprained his ankle. The facility ordered x-rays to ensure it was not broken due to the swelling. Observation of Resident #40's ankle revealed there was some swelling but there was no bruising noted at the time, but there was a pain patch on his ankle. The resident said he got some pain relief with the pain medications and pain patch. Resident #40 said the same transportation driver took him to dialysis on Monday, 06/24/24. Interview on 06/26/24 at 4:04 PM with LVN B revealed the transportation van arrived to pick up Resident #40 to take him to dialysis on 06/21/24, and they were loading the resident into the van. Shortly after, the transportation driver brought Resident #40 back into the facility and said as he was pushing the resident into the van, his foot got caught and twisted up on the ramp and Resident #40 immediately expressed pain. LVN B said she looked at the resident's ankle and noticed swelling on the outer side so she called to let his nurse, LVN A, know what had occurred. Interview on 06/26/24 at 2:51 PM with LVN A revealed she got a call from LVN B on 06/21/24, and said Resident #40 had hurt his ankle when the transportation driver was pushing him up the ramp into the van. When she was downstairs, she asked the resident what occurred and he said the transportation had pushed him faster to get onto the van, causing his foot to get stuck in the gap where the ramp meets the van and his foot had bent back. LVN A said she assessed the resident's ankle and noted swelling around it. Resident #40 told LVN A he was having pain to his ankle and he was medicated and they ordered x-rays to ensure it was not fractured. Interview with the DON on 06/26/24 at 3:20 PM revealed she was told about Resident #40's incident and they called the doctor for x-rays to ensure his ankle was not broken. The DON stated she called the transportation company to find out what happened but said she had not heard back but would be calling them again for a statement. 2. Record review of Resident #36's, undated, Admission Record reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had with diagnoses which included diabetes, stroke, and muscle wasting. Record review of Resident #36's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Her Functional Status reflected she required total assistance with all of her ADLs except eating and oral hygiene. Record review of Resident #36's care plan, dated 05/24/24, reflected the resident had behaviors of scratching and picking at her legs, and delusions involving staff and family. Record review of Resident #36's nursing notes reflected documentation on 05/12/24 resident with sugar ants all over her bed, moved resident to bed A temporarily, residents left arm with red raised itchy bumps. This Nurse notified MD new T.O.: Benadryl 25 mg PO PRN q8hours. DON was also informed. Interview on 06/25/24 at 10:28 AM revealed Resident #36 stated she had ants in her bed a few weeks ago, and she had ant bites all over her legs and arms. The facility treated her room, and she had no problems since then. Interview on 06/27//24 at 2:30 PM, the DON stated the incident with Resident #36 and the ants was not reported because the resident was able to tell them what happened. The DON did not feel reporting the injury to the resident was significant enough to rise to the level of reporting. Record review of the facility's pest control logs for January-June 2024 reflected the facility was treated for ants twice a month. 3. Record review of Resident #9's face sheet, dated 06/27/24, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #9's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated cognition was severely impairment. She had active diagnoses which included chronic obstructive pulmonary disease (lung disease), dysphagia (difficulty swallowing), gastro-esophageal reflux disease (acid reflux), type 2 diabetes mellitus (high blood sugar) with diabetic neuropathy (nerve damage) and essential hypertension (high blood pressure). Record review of Resident #9's care plan, revised on 05/07/24, reflected: Focus: [Resident #9] is taking medication for the management of GERD (Gastroesophageal Reflux Disease). Goal: Will remain free from discomfort, complications or s/sx related to dx of GERD through review date. Interventions: Give medications as ordered. Monitor/document side effects and effectiveness. Focus: [Resident #9] is on Pain medication Therapy r/t back, joint and muscle pain secondary to CVA (stroke) and DM (diabetic) Neuropathy. Goal: Will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions: Administer medication as ordered. Record review of Resident #9's April 2024 MAR reflected: Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day for GERD ***DO NOT CRUSH*** and traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours for Pain were held on 04/22/24 and to see nurses' notes. Record review of Resident #9's progress notes, dated 04/22/24 at 05:39 AM, by LNV A, reflected: Resident was given wrong medications, resident was supposed to be give PANTOPRAZOLE SOD DR 40 MG TAB, and TRAMADOL HCL 50 MG tablet for 6am medication. Instead, was given ALPRAZolam Oral Tablet 0.5 MG, and HYDROCODONE- ACETAMIN 10-325 MG. Resident has no known allergies to the medications. Resident lying in bed, eyes closed, respirations even and unlabored vitals within normal ranges BP 121/52, P 63, O2 97, R 18, T 97.5. Dr. [Name] notified wants patient monitored for any reactions to medications, DON notified as well. Interview on 06/25/24 at 2:55 PM with Resident #9 revealed he was doing well. Resident #9 did not appear to recall or know if he was given the wrong medication in April. Interview on 06/26/24 at 4:32 PM with LVN A revealed she administered Resident #9 the wrong medications the morning of 04/22/24. She stated she was giving morning medication pass and was prepping another resident medication when a staff went up to her to ask her a question, she got distracted and gave the medications to Resident #9 instead of the other resident. She stated she administered Resident #9 a narcotic pain pill and a Xanax. She stated she made the mistake of not double checking the resident and ended up giving the medication to Resident #9. She stated she realized the mistake and notified the doctor and the DON. She stated Resident #9 was monitored for 72 hours. She stated Resident #9 was not allergic to the medications and there were no side effects to the medications. She stated she was in-serviced the same day (04/22/24) on medication errors. She stated the risk of giving a resident the wrong medication could lead to side effects or resident being allergic to it. Interview on 06/27/24 at 2:02 PM with the DON revealed she could not recall all the details; however, LVN A administered Resident #9 the wrong medication back in April 2024. She stated LVN A contacted her right away and informed her she had given the wrong medication to Resident #9. She stated Resident #9 was placed on observation for 72 hours. She stated she in-serviced all the nursing staff on medication administration. The DON stated the risk of giving the wrong medication could lead to unconsciousness or an allergic reaction. The DON stated it was her and the Operational Manager responsibility to report any incidents to the state survey agency. She stated since there was no harm to Resident #9 and resident did not need to be sent to the hospital, they did not feel it needed to be reported to the state. Interview on 06/27/24 at 3:49 PM with the Operations Manager revealed she was the abuse coordinator, and it was her and the DON responsibility to report to the state survey agency. She stated she could not recall if she was notified that Resident # 9 was given the wrong medication. She stated she was unsure if it was something that needed to be reported to the state, she stated she would have to look into it. 44140

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for 1 of 1 facility kitchen and 1 (Resident #36) of 5 residents reviewed for pest control. 1. Resident #36 repored her bed was infested with ants and she had numerous bites to her arms and legs. 2. There were multiple gnats observed in the kitchen food preparation area, storage area room, dishwasher room and floor drain This failure could place residents at risk of a decreased quality of life and cross contamination of food. Findings include: 1. Record review of Resident #36's, undated, Admission Record reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had with diagnoses that which included diabetes, stroke, and muscle wasting. Record review of Resident #36's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Her Functional Status reflected she required total assistance with all of her ADLs except eating and oral hygiene. Record review of Resident #36's care plan, dated 05/24/24, reflected the resident had behaviors of scratching and picking at her legs, and delusions involving staff and family. Record review of Resident #36's nursing notes reflected documentation on 05/12/24 resident with sugar ants all over her bed, moved resident to bed A temporarily, residents left arm with red raised itchy bumps. This Nurse notified MD new T.O.: Benadryl 25mg PO PRN q8hours. DON was also informed. Interview and observation on 06/25/24 at 10:28 AM revealed Resident #36 stated she had ants in her bed a few weeks ago, and she had ant bites all over her legs and arms. The facility treated her room, and she had no problems since then. Observed Resident #36 extremities and had no visible bite marks. Interview on 06/27//24 at 2:30 PM, the DON stated the incident with Resident #36 and the ants was not reported because the resident was able to tell them what happened. The DON did not feel reporting the injury to the resident was significant enough to rise to the level of reporting . Record review of the facility's pest control logs for January- June 2024 reflected the facility was treated for ants twice a month. 2. Observation of kitchen area on 06/25/24 at 8:43 AM revealed several gnats in the kitchen food prep area, storage area room and dishwasher room. No food was observed in the prep area. Follow-up observation of kitchen area on 06/25/24 at 10:33 AM revealed staff prepping for lunch, staff were waving their hands in the air to move the gnats. Food was observed on the steam table; however, the food was covered. Interview on 06/25/24 at 11:28 AM with [NAME] revealed they have had an issue with gnats for a couple of months however, it had gotten better. He stated pest control went out about once or twice a month and was treating them. He stated they tried to always keep the kitchen clean to reduce the gnats. He stated the risk of having pests in the kitchen was it could get in the residents' foods. Interview on 06/25/24 at 11:23 AM with the Dietary Supervisor revealed pest control service went by yesterday (06/24/24) to treat the gnats. She stated the gnats used to be worse, and they come and go. She stated maintenance had been addressing the gnats and ensuring pest control services went out. She stated the risk of having pests in the kitchen would be pests getting in the resident's food. Interview on 06/25/24 at 11:36 AM with the Maintenance Supervisor revealed pest control service went out twice a month or as needed. He stated they had a drip system in place where they pour a chemical in the dishwasher room drains. He stated they were responsible to treat and notify the pest control service company when needed. He stated he had not had any complaints regarding pests in the facility . Record review of Pest Control Service Invoices, for 03/04/24 through 06/24/24, reflected evidence of treatment for pests in the kitchen. Record review of the facility's Physical Environment policy, revised May 2007, reflected the following: It is the policy of this facility to provide an environment free of pests. 1. The facility will have a pest control contract that provides frequent treatment of the environment for pests. 2. The pest control visits will occur at least monthly. 3. It will allow for additional visits when a problem is detected. 4. Monitoring of the environment will be done by the facility's staff. 5. Pest control problems will be reported promptly to the administrator.

Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, and neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency in accordance with State law through established procedures for three (Resident #40, Resident #36, and Resident #9) of three incidents (Resident #40, Resident #36, and Resident #9) reviewed for reporting. 1. The facility failed to report to the State Survey Agency when Resident #40 sprained his ankle when he got his foot caught in the van ramp while being pushed by the transportation driver. 2. The facility failed to report to the State Survey Agency when Resident #36 was found to have ant bites on her body. 3. The facility failed to report to the State Survey Agency when Resident #9 was given the wrong medications on 04/22/24. These failures could affect place residents by resulting inat risk of a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. Findings included: 1. Record review of Resident #40's MDS dated [DATE] reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included end stage renal disease, diabetes, osteoporosis, stroke, and seizure disorder. The MDS further reflected Resident #40 had a BIMS of 14, whick indicated his cognition was intact, and used a manual wheelchair. Record review of Resident #40's care plan dated 08/29/23 reflected he had osteoporosis and interventions included to protect the resident from injury avoiding sudden bumps, jarring with transfers. The care plan further reflected Resident #40 attended dialysis Mondays, Wednesdays, and Fridays. Record review of Resident #40's progress note dated 06/21/24 documented by LVN A revealed the following: Notified by 1st floor nurse that resident had an incident getting onto the transportation bus. This nurse went down to the 1st floor to assess the resident noted resident sitting in wheelchair, leaned over holding onto right foot, when assessed the right foot noted swelling to the right ankle, very sensitive to touch, able to wiggle toes and pedal pulse 3+. Took resident to his room, assisted him to bed, resident can not bare [sic] weight on right foot Resident stated 'driver of the van was pushing me onto the ramp but had to push me a little fast because there's a little bump to get over on the ramp when my foot got caught in the ramp and pushed my foot all the way back.' MD notified ordered STAT x-ray to right foot Asked resident pain level from 0-10 resident stated a 10, administered Acetaminophen-Codeine Tablet 300-30MG per resident request for pain. Record review of radiology results dated 06/21/24 revealed there were no fractures and no new orders given. Record review of the Transportation Company's Accident/Incident Report Form dated 06/21/24 reflected the following: .Incident Information Incident Description [Resident #40] right ankle was injured while being rolled into the rear ramp of the wheelchair van by driver, [Driver]. As [Resident #40] crested the top of the ramp to enter the van, his right foot was not high enough, which caused his foot to roll under the leg. Driver took [Resident #40] back into the facility for examination by a nurse to determine the severity of his injury. Observation and interview with Resident #40 on 06/25/24 at 11:23 AM revealed when he was picked up for dialysis last Friday, 06/21/24, the transportation driver pushed him into the transportation van too fast and his foot got caught where the lift and the van connected. The resident said he immediately felt pain because it sprained his ankle. The facility ordered x-rays to ensure it was not broken due to the swelling. Observation of Resident #40's ankle revealed there was some swelling but there was no bruising noted at the time, but there was a pain patch on his ankle. The resident said he got some pain relief with the pain medications and pain patch. Resident #40 said the same transportation driver took him to dialysis on Monday, 06/24/24. Interview on 06/26/24 at 4:04 PM with LVN B revealed the transportation van had arrived to pick up Resident #40 to take him to dialysis on, 06/21/24, and they were loading the resident into the van. Shortly after, the transportation driver brought Resident #40 back into the facility and said as he was pushing the resident into the van, his foot had got caught and twisted up on the ramp and Resident #40 immediately expressed pain. LVN B said she looked at the resident's ankle and noticed swelling on the outer side so she called to let his nurse, LVN A, know what had occurred. Interview on 06/26/24 at 2:51 PM with LVN A revealed she got a call from LVN B, 06/21/24, and said Resident #40 had hurt his ankle when the transportation driver was pushing him up the ramp into the van. When she was downstairs she asked the resident what had occurred and he said the transportation had pushed him faster to get onto the van, causing his foot to get stuck in the gap where the ramp meets the van and his foot had bent back. LVN A said she assessed the resident's ankle and noted swelling around it. Resident #40 told LVN A he was having pain to his ankle and he was medicated and they ordered x-rays to ensure it was not fractured. Interview with the DON on 06/26/24 at 3:20 PM revealed she was told about Resident #40 incident and they had called the doctor for x-rays to ensure his ankle was not broke. The DON stated she called the transportation company to find out what happened but said she had not heard back but would be calling them again for a statement. 2. Record review of Resident #36's, undated, Admission Record reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had diagnoses which included diabetes, stroke, and muscle wasting. Record review of Resident #36's quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Her Functional Status reflected she required total assistance with all of her ADLs except eating and oral hygiene. Record review of Resident #36's care plan, dated 05/24/24, reflected the resident had behaviors of scratching and picking at her legs, and delusions involving staff and family. Record review of Resident #36's nursing notes reflected documentation on 05/12/24 resident with sugar ants all over her bed, moved resident to bed A temporarily, residents left arm with red raised itchy bumps. This Nurse notified MD new T.O: Benadryl 25mg PO PRN q8hours. DON was also informed. Interview on 06/25/24 at 10:28 AM with Resident #36 revealed she had ants in her bed a few weeks ago, and she had ant bites all over her legs and arms. The facility treated her room, and she had no problems since then. Interview on 06/27//24 at 2:30 PM, the DON stated the incident with Resident #36 and the ants was not reported because the resident was able to tell them what happened. The DON did not feel reporting the injury to the resident was significant enough to rise to the level of reporting. Record review of the facility's pest control logs for January-June 2024 reflected the facility was treated for ants twice a month. 3. Record review of Resident #9's face sheet, dated 06/27/24, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #9's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated cognition was severely impairment. She had active diagnoses which included chronic obstructive pulmonary disease (lung disease), dysphagia (difficulty swallowing), gastro-esophageal reflux disease (acid reflux), type 2 diabetes mellitus (high blood sugar) with diabetic neuropathy (nerve damage) and essential hypertension (high blood pressure). Record review of Resident #9's care plan, revised on 05/07/24, reflected: Focus: [Resident #9] is taking medication for the management of GERD (Gastroesophageal Reflux Disease). Goal: Will remain free from discomfort, complications or s/sx related to dx of GERD through review date. Interventions: Give medications as ordered. Monitor/document side effects and effectiveness. Focus: [Resident #9] is on Pain medication Therapy r/t back, joint and muscle pain secondary to CVA (stroke) and DM (diabetic) Neuropathy. Goal: Will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions: Administer medication as ordered. Record review of Resident #9's April 2024 MAR reflected: Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day for GERD ***DO NOT CRUSH*** and traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours for Pain were held on 04/22/24 and to see nurses' notes. Record review of Resident #9's progress notes, dated 04/22/24 at 05:39 AM, by LNV A, reflected: Resident was given wrong medications, resident was supposed to be give PANTOPRAZOLE SOD DR 40 MG TAB, and TRAMADOL HCL 50 MG tablet for 6am medication. Instead, was given ALPRAZolam Oral Tablet 0.5 MG, and HYDROCODONE- ACETAMIN 10-325 MG. Resident has no known allergies to the medications. Resident lying in bed, eyes closed, respirations even and unlabored vitals within normal ranges BP 121/52, P 63, O2 97, R 18, T 97.5. Dr. [Name] notified wants patient monitored for any reactions to medications, DON notified as well. Interview on 06/25/24 at 2:55 PM with Resident #9 revealed he was doing well. Resident #9 did not appear to recall or know if he was given the wrong medication in April. Interview on 06/26/24 at 4:32 PM with LVN A revealed she administered Resident #9 the wrong medications the morning of 04/22/24. She stated she was giving morning medication pass and was prepping another resident medication when a staff went up to her to ask her a question, she got distracted and gave the medications to Resident #9 instead of the other resident. She stated she administered Resident #9 a narcotic pain pill and a Xanax. She stated she made the mistake of not double checking the resident and ended up giving the medication to Resident #9. She stated she realized the mistake and notified the doctor and the DON. She stated Resident #9 was monitored for 72 hours. She stated Resident #9 was not allergic to the medications and there were no side effects to the medications. She stated she was in-serviced the same day (04/22/24) on medication errors. She stated the risk of giving a resident the wrong medication could lead to side effects or resident being allergic to it. Interview on 06/27/24 at 2:02 PM with the DON revealed she could not recall all the details; however, LVN A administered Resident #9 the wrong medication back in April 2024. She stated LVN A contacted her right away and informed her she had given the wrong medication to Resident #9. She stated Resident #9 was placed on observation for 72 hours. She stated she in-serviced all the nursing staff on medication administration. The DON stated the risk of giving the wrong medication could lead to unconsciousness or an allergic reaction. The DON stated it was her and the Operational Manager responsibility to report any incidents to the state survey agency. She stated since there was no harm to Resident #9 and resident did not need to be sent to the hospital, they did not feel it needed to be reported to the state. Interview on 06/27/24 at 3:49 PM with the Operations Manager revealed she was the Abuse Coordinator, and it was her and the DON responsibility to report to the State Survey Agency. She stated she could not recall if she was notified that Resident # 9 was given the wrong medication. She stated she was unsure if it was something that needed to be reported to the state, she stated she would have to look into it. Review of the facility's undated policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation, or Mistreatment reflected the following: Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment .Resident must not be subjected to abuse by anyone, including, but not limited to Facility staff, other resident representatives, consultants, or volunteers, staff of other agencies serving the resident representatives, families, friends, or other individuals. .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: .The State Survey Agency . 44140

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 6 residents (Resident #8) reviewed for safe and functional equipment. The facility failed to ensure Resident #8's bed was in proper working condition. This failure could place residents at risk for skin tears, injury, falls and discomfort during transfers. Findings included: Record review of Resident #8's face sheet, dated 06/27/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #8's quarterly MDS, dated [DATE], reflected she had a BIMS score of 15, which indicated cognition was intact. Resident #8 had active diagnoses which included biliary cirrhosis (chronic liver disease), chronic pain syndrome, fibromyalgia (pain and tenderness all over the body). Resident #8 required the use of a wheelchair and required assistance of 2 or more helpers with bed mobility, toileting, transfers and dressing. Record review of Resident #8's care plan, revised on 05/07/24, reflected: Focus: ADL Self Care Performance Deficit r/t generalized weakness. Goal: Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene with modified independence through the review date. Interventions: Bed Mobility (Roll Left And Right, Sit To Lying, Lying To Sitting On Side Of Bed): Requires staff participation to reposition and turn in bed. Focus: [Resident #8] has Liver Disease r/t Biliary Cirrhosis. Focus: Will be free from s/sx of liver complications, including infection, abnormal or unexplained bleeding, malnutrition, anemia, cognitive decline or mental status changes through review date. Interventions: Monitor/document/report to MD s/sx of complications: Malaise (discomfort), Fatigue (tiredness), Anorexia (eating disorder), Weight loss, Edema (fluid buildup), Nosebleeds, Bleeding gums, constipation or diarrhea, Ascites (fluid in abdomen, Altered LOC (level of consciousness), Confusion/disorientation. Observation and interview on 06/25/24 at 10:18 AM revealed Resident #8 sitting in her wheelchair. She stated she was doing well. Resident #8 stated she had been at the facility for 3 months and her bed had not been fixed. She stated her bed did not go up or down. Observed Resident #8 use the bed remote to adjust the end of the bed, however, it would only make a noise and would not move. She stated she would like to be able to elevate her legs at night due to her edema while lying in bed. She stated she needed her bed to work. Resident #8 stated she told the staff and a maintenance person but could not recall names. Interview on 06/27/24 at 1:50 PM with CNA G revealed she was the CNA assigned to Resident #8. She stated a couple of weeks ago Resident #8 mentioned to her that her bed was not working. She stated she notified the Maintenance Director and she believed the Maintenance Director looked at it but she was unsure if he fixed it. She stated when Resident #8 went to bed they elevated her legs with pillows. Interview on 06/27/24 at 2:42 PM with RN H revealed Resident #8 had not mentioned anything to her regarding her bed not working. She stated Resident #8 was able to voice her needs and the resident was known to report any concerns to management. She stated she had not noticed Resident #8's bed not working, she stated they elevated Resident #8 legs with pillows at night. She stated there was no risk to the resident since the resident legs were being elevated with pillows. She stated as far as she knew the bed was working last week. Interview on 06/27/24 at 2:50 PM with the DON revealed she was not aware Resident #8's bed was not working. She stated staff had not mentioned anything to her regarding Resident #8's bed. She stated they had an online system where they log any maintenance concerns and they choose the priority. She stated all staff were responsible to notify maintenance. Interview on 06/27/24 at 3:51 PM with the Operations Manager revealed Resident #8 had not mentioned anything to her regarding her bed. She stated all staff were responsible to notify maintenance of any environmental concerns. She stated they had an online system staff used to input work orders and maintenance staff were responsible to review the report. She stated all staff had access to it. She stated she had not seen anything regarding Resident #8 bed. Interview on 06/27/24 at 4:48 PM with the Maintenance Director revealed about a month ago Resident #8 mentioned something about her bed not working. He stated he went to check the bed and the head of the bed was working properly. He stated he was unaware the end of the bed was the part that was not working. He stated they had an online system where staff were able to input any work order s and he reviewed it daily . Record review of facility Work Orders from 04/01/24 - 06/21/24 revealed no orders pertaining Resident #8's bed. Record review of the facility's, undated, policy titled Environmental Service reflected the following: It is the policy of this facility to maintain a clean and comfortable environment .3. When a maintenance issue arises, the resident, staff member or family member must put in a work order at the front desk with the receptionist. 4. The maintenance department will complete the work order or find a resolution within 72 hours from the time it was reported.

Based on interview and record review, the facility to ensure a new resident was not admitted with a mental disorder, unless the state mental health authority determined, based on an independent physical and mental evaluation performed by a person or entity other then the State mental health authority prior to admission for one of six residents (Resident #63) reviewed for Preadmission Screening and Resident Review (PASRR) screening . The Social Worker failed to ensure Resident #63's PL1 was accurate with the proper metal illness diagnosis when he was admitted . This failure could place residents at risk of not receiving specialized services. Findings included: Record review of Resident #63's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder, schizophrenia and depression. Record review of Resident #63's care plan, revised on 11/27/24, reflected the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to schizoaffective disorder. Interventions included social services to provide psychosocial support as needed. Record review of Resident #63's PASRR Level 1 Screening, dated 10/19/23, reflected NO had been marked for the question if there was evidence or an indicator the individual had a mental illness. Interview on 06/26/24 at 3:15 PM with the Social Worker revealed she was responsible for looking at the PASSR Level 1 Screenings before residents were admitted . She stated she did not read through Resident #63's clinical records prior to being admitted so she did not see the resident had a diagnosis of schizophrenia. The Social Worker further said Resident #63 should have been referred to case management for a PASRR Evaluation because the resident could have been overseen for services from the Local Authority . Record review of the facility's policy titled PASRR, revised January 2022, reflected the following: .Policy: The facility will designate an individual to follow up on ALL residents that received a PASRR Level 1 screening. If Facility serves a resident with a positive PASRR Level 1 screening, the facility MUST obtain A PASRR Level II evaluation from the Local Authority or have documented attempts to follow up with the Local Authority to obtain PASRR Level II evaluation.

Based on observation, interview and record review the facility failed to provide comfortable and safe temperature levels between a range of 71 to 81 degrees Fahrenheit for one of ten residents (Resident #2) reviewed for environment. The facility failed to ensure Resident #2's room remained at a comfortable temperature. This failure could place residents at risk of experiencing decreased comfort and could affect the well-being of residents. Findings include: Record review of Resident #2's MDS, dated [DATE], reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included hypertension (high blood pressure), anxiety disorder, and chronic obstructive pulmonary disease. Observation and interview on 06/25/24 at 10:40 AM with Resident #2 revealed he was in his room sitting in his bed. The resident said his room had been hot for a while and he had let the Maintenance Assistant know but the AC in his room had not been fixed. Observation of the thermostat on the wall of his room showed the temperature in the room was 80 degrees Fahrenheit. Resident #2 said he had a fan in his room but said it was not helping him keep cool. Observation on the following dates and times with an ambient thermometer in Resident #2's room revealed the following: 06/25/24 at 2:28 PM - 80 degrees 06/26/24 at 3:28 PM - 82 degrees Interview on 06/27/24 at 5:02 PM with the Maintenance Assistant revealed Resident #2 told him multiple times that his AC was not working, and one of those dates was 06/14/24. The Maintenance Assistant stated every time he checked Resident #2's AC, it was running good. The Maintenance Assistant said when he checked with his thermometer, the temperature out of the vent was 66 degrees. He stated he did not know why Resident #2's room was reading 80 degrees. The Maintenance Assistant further stated he told the Maintenance Director of Resident #2's AC but did not state when. Interview on 06/27/24 at 5:02 PM with the Maintenance Director revealed he was made aware today, 06/27/24, that Resident #2's AC was not working. The Maintenance Director said they had just called in an AC repairman who was still at the facility and he would have Resident #2's AC checked out. Interview on 06/27/24 at 3:42 PM with the Operations Manager revealed she was not made aware Resident #2's AC was not working. She said risks of a hot room could cause the resident to feel uncomfortable in his room. Record review of the facility's, undated, policy titled Environmental Service reflected the following: It is the policy of this facility to maintain a clean and comfortable environment . 2. Temperatures in the common areas must remain between 70F-78F.

Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents and supervision. The facility failed to prevent Resident #1 from eloping on 12/04/2023. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 12/4/2023 and ended on 12/22/2023. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings were: Record review of Resident #1's face sheet, dated 05/14/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: acute kidney failure (occurs when the kidneys suddenly become unable to filter waste products from the blood), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), epilepsy (a condition that causes frequent seizures) and depression (a depressed mood or loss of pleasure or interest in activities for long periods of time). Further review revealed the resident was his own RP. Record review of Resident #1's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 5 which indicated a severe cognitive impairment. Further review revealed resident did not have any behavioral issues and his level of ambulation was independent. Record review of Resident #1's progress notes revealed a note dated 12/04/2023 at 02:30 AM indicated the DON was notified at approximately 1:00 AM the staff could not locate the resident. The code for elopement had already been initiated. A thorough search was conducted in the facility. Two staff members were assigned to drive around the neighborhood. During this process the police department arrived with the resident. The resident was happy to return to the facility and could not verbalize why he had left. A head-to-toe assessment was performed. All vital signs were within normal limits. The resident appeared unharmed and did not verbalize any pain. Record review of Resident #1's medical record revealed he was found at a gas station approximately one quarter of a mile from the facility. Record review of Resident #1's doctor orders, dated 12/04/2023, revealed the resident was placed on 1:1 supervision wherever he went. In addition, the resident was also placed on 15-minute checks from 12/04/2023 - 12/10/2023. Record review of Resident #1's comprehensive care plan dated 10/19/2023 noted resident identified as an elopement risk. The care plan was updated on 12/04/2023 to include the elopement incident. During an interview on 05/14/2024 at 2:00 PM with the DON she stated the charge nurse on the 3rd floor was the last one to see the resident; the resident was sitting in a chair by the nurses' station and she had chatted with him. Shortly thereafter the resident walked past the nurses' station, took the elevator from the 3rd floor to the first floor, and exited the building. The alarm was found to be working but was not heard. During an interview on 05/14/2024 at 2:40 PM with the maintenance director he stated since Resident #1's elopement he conducted three elopement drills. A Code Silver is called. The drills were scheduled in the facility's building management system, like fire drills. During an interview on 05/14/2024 at 3:15 PM with the HR Director she stated that since the elopement incident the hours at the reception desk in the front lobby of the facility were extended to 9:00 PM. During an interview on 05/17/2024 at 12:42 PM with LVN C she stated Resident #1 was able to verbalize his needs, was easily redirected, and had no behaviors. He had never shown any inclination to leave the facility prior to the elopement incident and had not since. He does not leave the 3rd floor and go to the first floor of the facility without a staff member and was able to verbalize to staff when he would like to leave the floor. Observation on 05/15/2024 at 2:30 PM of the alarm response at the front door of the facility revealed it was functional and sufficiently loud to alert the staff of a potential elopement. Observation on 05/15/2024 at 2:40 PM of Resident #1 in his room revealed the resident was alert, oriented and well groomed. In an interview on 05/15/2024 at 2:41 PM with Resident #1 revealed he was very happy at the facility and the staff cared for him well. The DON was notified on 05/15/2024 at 2:45 PM that a past non-compliance IJ situation had been identified due to the above failures. The facility course of action prior to surveyor entrance included: -Resident #1 was initial placed on 1:1 supervision and moved to the closest room next to the nurses' station. -The facility contacted the alarm company, who significantly increased the volume of the alarm system, and changed the method of activating a code so it now goes through the phone system for broadcasting throughout the facility. Since the elopement incident, this resident has not had another elopement attempt and no other resident attempted to elope from the facility. -Immediately after the elopement incident, the reception desk was manned for 24 hours. It was changed to 9:00 PM 2 1/2 weeks later, on 12/22/2023. -The facility increased training on the elopement policy to every other month. Training was conducted on 01/04/2024, 03/27/2024, and 05/08/2024. Record review of an in-service training, dated 12/04/2024, related to Elopement Policy and Protocol revealed 103 of 103 staff member signatures. Interviews were conducted with 22 employees who consisted of: ADONs (2), LVNs (3), Medication Aides (2), CNAs (3), HR Director, Social Worker, Activities Director, Medical Records Manager, Housekeeping Supervisor, OT (1), ST (1), PTA (1), Housekeepers (2), Laundry Aide (1) and Floor Technician (1) on 05/15/2024 from 10:00 AM to 12:30 PM revealed they had received in-services on Elopement Response. All were able to state the key elements of the Emergency Response Plan and elopement policy, which included: If a resident was discovered missing: - Note the last time the resident was seen - verify the resident didn't sign out, is at an appointment or had been discharged . Conduct a census verification and roll call. - Activate emergency response plan - Call Code Silver - Notify Administrator/DON/Maintenance Director - Search for the resident in resident rooms, bathrooms, showers, closets, recreation areas, and outside area - After 30 minutes, if the resident had not been located, call 9-11 - Call the resident's RP

Based on observation, interview and record reviews the facility failed to the ensure the resident received assistance devices to prevent accidents and the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance for 2 of 5 Residents (Resident #1 & Resident #2) whose records were reviewed for falls. 1. Resident #1 had 4 falls within 24 hours upon admission related to nursing staff not providing Resident #1's fall history through report, lack of staffing and staff not initiating appropriate safety interventions to keep Resident #1 as safe as possible. As a result, he sustained multiple fractures. 2. Resident #2 had a history of falling out of his wheelchair. Nursing staff failed to ensure his wheelchair was in the locked position and placed away from his bed to prevent further falls. These deficient practices could affect any resident and potentially contributed to avoidable falls and injuries. The findings were: 1. Review of Resident #1's face sheet, dated 1/19/23, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified Dementia and Chronic Systolic (congestive) Heart Failure. Review of Resident #1's admission assessment, dated 12/30/22 at 3:49 PM, revealed Resident #1 was alert 1-2, understood had memory loss which caused agitation and impulsiveness, complained of dizziness in past 3 days, wore glasses, had moderate hearing impairment, no use of assuasive device noted, history of falls, unable to determine weight bearing limitations and it was noted he had limited range of motion on both legs and feet. Further review revealed LVN F completed the assessment. Review of Resident #1's 5-day MDS, dated [DATE], revealed he had vision impairment; his BIMS was 00 (out of 15) indicative of severe cognitive impairment; he exhibited inattention and disorganized thinking; transfers only happened once or twice by 1 person; he was not steady moving from seated to standing position, moving off and on the toilet and surface to surface transfer; he used a wheelchair for mobility; was incontinent of urine; he had a fall in the last month, 2-6 months, fracture related to a fall in the last 6 months prior to admission and he had a fall since admission; he had one fall with no injury and one fall with a major injury. Review of Resident #1's 48-hour Care Plan, dated 12/30/22, revealed he was a risk for falls related to history of falls, generalized weakness, poor safety awareness and impulsiveness and the intervention implemented was to keep needed items water, etc., in reach. Review of Resident #1's incident log revealed he had a fall on 12/30/22 at 19:51 (7:51 PM), at 12/31/22 at 0:00 (!2 PM) and on 12/31/22 at 10:03 AM. Review of incident report for Resident #1, dated 12/30/22 at 7:51 PM revealed, This writer was called due to roommate hollering. Upon entering the room resident was one foot away from mattress, head pointed towards the wall and feet over by the privacy curtain and laying on the floor on stomach but favoring the right side. Right arm was folded under the resident. Resident still has red slip grip socks from hospital and the roommates bedside table was pulled away from the wall and the small refrigerator was knocked over on the floor. This writer and CNA attempted to assist the resident up but stated that he wanted a moment to lay on the floor because he was in a great deal of pain. Does attempt to explain what he was trying to do but gets lost in thought and cannot recall the right words so he stops explaining and sighs heavily. Immediate action taken: Resident stood himself up and walked himself back to bed and laid down, covered himself and keeps saying, there was something I was going to do. Injury Type: Unable to Determine. Injury Location: Right hand palm. Level of pain based on observing the resident was a 5. Mental Status: Oriented to Person. Notes: Resident has history of falls due to impulsivity. Further review revealed LVN F completed this report. Review of Resident #1's order summary for December 2022 revealed an order dated 12/30/22 for an x-ray to the right shoulder and right hand due to fall and complaint to pain one time only until 12/31/22. Review of an X-ray report for Resident #1, dated 12/30/22, revealed no acute fracture or dislocation of right shoulder and no acute fracture or dislocation of right hand. Interview on 1/19/23 at 11:30 AM with Resident #1's RP revealed she was not happy with the fact Resident #1 fell within 2 hours upon admission and then fell again later. She stated Resident #1 had a history of falling at home because he could not walk on his own and he had severe Dementia. She stated she let nursing staff know about his history of falling. The RP stated she did not believe they took care of him the way he needed. Furthermore, she did not believe he would be safe if he returned to the facility so she secured alternative placement. Interview on 1/19/23 at 1:15 PM with LVN F revealed she admitted Resident #1 on a Friday and no one was with him upon admission from the hospital. He did not have any visitors. A family member called about a visit and she let him know Resident #1's roommate went to bed early and told the son if he visited it would have to be a quick visit or he could visit early next morning. LVN F stated Resident #1 had a communication deficit (lack of expressive language) and would get agitated. She stated the bed was in the lowest position and the urinal was at bedside within reach. She demonstrated how to use the call light; had it pinned to his gown and provided the bed remote. LVN F stated Resident #1 was a 2 person assist and not able bare weight; he could not stand for long without his knees buckling. She stated Resident #1 was thin but tall. He could follow commands and seemed to understand. LVN F stated Resident #1 fell within 2 hours after admission before dinnertime. She had put him to bed about 2 hours prior to the fall and he was talking on the phone. LVN F stated Assistant MS saw Resident #1 on the floor and told her. LVN F stated she talked with Resident #1's RP about the fall and she stated Resident #1 had fallen at home. LVN F stated Resident #1 was sleeping by the time she left at 10 PM. She stated Resident #1 requested that she leave the overhead light on. LVN F stated she asked the MS about fall mats and he told her she could find them in central supply. She stated she did not implement fall mats. Interview on 1/19/23 at 2:13 PM with CNA G revealed she was on duty on 12/30/22 from 2 PM to 10 PM when Resident #1 fell . She stated LVN F told her he was a fall risk. She stated fall protocol usually required the use of a low bed in the lowest position, fall mat, call within reach and more frequent visual checks. She stated she was not sure if the bed was in the lowest position and there was not a fall mat in place. She stated the call light was clipped to Resident #1's gown ad he had 2 urinals by the bedside. CNA B stated Resident #1 got up twice during the shift and did not seem to understand what he was doing. She stated the first time she caught Resident #1 up and she put him back to bed. CNA G stated she thought Resident #1 fell after dinner between 6 PM to 7 PM and had checked on him about an hour before he fell . Resident #1 was found on the floor and he did not say how he fell . He seemed confused. She stated she alerted LVN F who came right away. CNA G stated she thought Resident #1 sustained an injury but could not remember what type of injury. Interview on 1/19/23 at 2:35 PM with LVN F revealed she did not get a fall mat from central supply and did not have the CNA get a fall mat because they were the only ones on duty. She stated she did not implement a fall mat. She stated typically there were 2 aides on duty but was not sure if someone called in or what happened. She stated there were three or four other residents who were a fall risk so it made it difficult for her and the 1 aide to complete tasks and do as many visual checks as required on the residents who were a fall risk. Interview on 1/19/23 at 6:10 PM with LVN F revealed she did not know Resident #1 was a fall risk until he fell . She stated she knew she would be getting a new admission but nursing staff including the AM nurse did not provide any descriptive information about Resident #1. She stated the hospital nurse also did not tell her in report that Resident #1 was a fall risk. She clarified that she asked the MS about the mats to ensure they were available as needed. She stated she did not know enough about Resident #1 to determine whether the use of a fall mat was beneficial or a safety hazard. LVN F confirmed Resident #1 was not able to bare weight and was unsteady on his feet. However, stated he continued to try and walk on his own and was concerned a mat would be more of a safety hazard. LVN F further stated that she believed Resident #1 was going to fall no matter what because he was so unsteady on his feet and could not bare weight for long. Review of incident report for Resident #1, dated 12/31/22 at 0:00 (12 PM) revealed CNA found resident sitting on floor. Immediate action taken: Assessed had small abrasion to forehead. Cleansed with normal saline and pat dried. Bleeding stopped. Vital signs 103/66, 76, 18, 98.2, 97 RM air, Assisted back to bed. Neuros started again. Mental Status: Oriented to Person. Further review revealed the family representative, the resident physician and DON were notified of the incident. Further review revealed LVN D completed this report. Review of Fall Risk Evaluation dated 12/31/22 0:00 (12 PM) revealed Resident #1 was a high risk for falls with a score of 18. He was noted to be disoriented x 2, had poor vision with or without glasses, history of 3 or more falls in the past 3 months and he had balance problems while standing/walking. Review of incident reports for Resident #1 did not reveal an incident report dated 12/31/22 at 2:05 AM. Review of Fall Risk Evaluation dated 12/31/22 2:05 AM revealed Resident #1 was a high risk for falls with a score of 18. He was noted to be disoriented x 2, had poor vision with or without glasses, history of 3 or more falls in the past 3 months, he had balance problems while standing/walking and requires use of assistive devices (i.e., cane, walker or wheelchair). Review of incident report for Resident #1, dated 12/31/22 at 4:30 AM revealed Resident #1's roommate came yelling down hall that resident was on his side and going to fall again. Resident observed holding onto wheelchair very unsteady gait. 'I immediately ran to his side. Resident stated, hurry up get me to bed. Immediate action taken: Resident had to be eased to sitting position too heavy to try continuing to walk to bed as he was not following direction, please slow down and let go of wheelchair. Abrasion to back observed/scratch. Has swelling to head in between eyebrows. Redness to right hip observed. Injury Type: Abrasion. Injury Location: scapula. Mental Status: Oriented to Person. Notes: Abrasion noted to right hip and abrasion to upper back/scratch, swelling now in between eyebrows. NP notified, requested X-RAY to head and Right hip. Further review revealed the family representative, the resident physician and DON were notified of the incident. Further review revealed LVN D completed this report. Review of Fall Risk Evaluation dated 12/31/22 4:30 AM revealed Resident #1 was a high risk for falls with a score of 15. He was noted to be disoriented x 3, had adequate vision, history of 3 or more falls in the past 3 months and he had balance problems while standing/walking. Review of Resident #1's order summary for December 2022 revealed an order dated 12/31/22 for STAT X-RAY to right hand, digits, wrist and forearm. Review of an X-ray report for Resident #1, dated 12/31/22, revealed acute fracture of distal radius of the right forearm; acute fracture of distal radius of the right wrist and of the 5th digit at the PIP joint. Review of hospital transfer form dated 12/31/22 revealed Resident #1 was transferred to the hospital at 2:44 PM. Interview on 1/20/23 at 8:10 AM with LVN D revealed she worked at the overnight shift and worked on 12/30/22 and 12/31/22. She stated Resident #1 was extremely confused, impulsive and did not retain instruction. She stated Resident #1 was difficult to redirect based on impulsiveness. He also seemed anxious and she suspected it was because he was in a new environment. LVN D stated Resident #1 had his first fall during her shift around midnight. She stated the CNA on duty reported Resident #1 was sitting next to his bed. She assessed Resident #1, started neurochecks and transferred him back into bed. LVN D stated the bed was in the lowest position and she educated Resident #1 about using the call light to ask for assistance. She encouraged Resident #1 to allow them to help him so he would not fall. LVN D stated she changed Resident #1 and continued to encourage him to use the call light before getting up. She stated later on in the shift the roommate came out into the hallway yelling that Resident #1 was up and was going to fall. She ran to the room and saw Resident #1 using the roommate's wheelchair to ambulate. He was walking towards his bed but was extremely wobbly. LVN D stated she walked up beside Resident #1 and held on to his arm. He was clinching on to the wheelchair and she attempted to lock the wheelchair cut could not reach to secure the lock. LVN D stated it was not a good situation and was afraid they were both going to fall. She was able to get Resident #1 to release the wheelchair and she eased him down to the floor. The roommate reported that Resident #1 darted up from the bed and fell trying to get to the restroom and hit his head prior to her entering the room. LVN D stated upon assessment she noted redness to his right hip and ordered x-rays. She passed on the events that took place during her shift, in report, to the morning nurse, LVN E LVN D stated she notified the RP about the falls and she stated he fell at the hospital. The RP said Resident #1 had really bad Dementia. LVN D stated Resident #1 required 1 on 1 supervision and was probably a good candidate for a memory care unit. LVN D stated LVN F told her in report she did not use a fall mat because it would be a tripping hazard. She stated based on her experience with Resident #1 the one night she believed he was going to fall no matter what. She also thought a fall mat would probably have been more of a safety/trip hazard because he was on a mission to get up and go. Although, she stated it might have cushioned his fall. LVN D stated she talked with the ADON and DON both and they did not instruct her to implement any other interventions than were already in place: bed to the lowest position, clipped the call light to his gown, continue to instruct to use it and increase visual checks. Interview on 1/20/23 at 9:21 AM with the ADM revealed the Admissions Coordinator would round on the residents in the hospital and get as much information as possible prior to admission. He stated it became obvious very quickly that they were not going to be able to meet his needs in the facility due to Resident #1's impulsivity and not following directives. Interview on 1/20/23 at 10:41 AM with the Admissions Coordinator (AC) revealed he started working for the facility during October 2022. He stated he was also an LVN. The AC stated he would get a referral from the hospital, review the clinical documents, visit the patient at the hospital, talk to the aide, nurse and doctor per availability to determine any special needs/equipment the patient might need. He would also talk with family. The AC stated he would present the patient information to the IDT team (department heads) including ADON, DON, ADM, Rehab Director, MDS Coordinator and the SW. The AC stated Resident #1 was referred for skilled nursing for PT/OT with the plan to return home. He had a history of falls at home and had fallen in the hospital 3 times. The hospital had him on 1 on 1 supervision for a period of time but when he visited Resident #1 he was not on 1 to 1 supervision any longer. The AC stated he talked to the nurse who stated Resident #1 was no longer trying to get out of bed. He also spoke with the case manager, with Resident #1 and the RP around 12/22/22 to 12/23/22. He stated he was in contact with the case manager off and on until Resident #1 was ready to be released to determine his discharge plan. The AC stated Resident #1 seemed really nice, able to answer questions, was always in bed, calm and progressing in therapy at the hospital. Resident #1 did not display any agitation or behavior issues and was compliant with treatments per report from nursing. He stated the case manager stated Resident #1 had been on 1 on 1 supervision and it was discontinued on 12/22/23. The AC stated he was not sure if the supervision was continuous but the nurse told him they would be taking him off 1 to 1 supervision. The AC stated per his own experience the Resident would need to be off 1 to 1 supervision 24 hours prior to placement. The AC stated there was not a facility policy that he knew of regarding the supervision and he had not received direction from the nursing facility. The AC stated he presented Resident #1's information to the IDT team on 12/23/22 or 12/24/22. He stated he did not remember everyone who attended the IDT meeting but again stated it was usually the department heads. The IDT reached a consensus that they would accept Resident #1 but stated the admission took place at the end of the month after they secured the contract with Resident #1's insurance provider. Interview on 1/20/23 at 1:06 PM with LVN H revealed she worked on 12/30/22 from 6 AM to 2 PM. She stated she knew Resident #1 was admitted on ,d+[DATE] but it was not on her shift. LVN H stated she was not provided any information about Resident #1 including that he had a history of falling. Interview on 1/20/23 at 1:43 PM with the Interim DON stated she knew Resident #1 was being admitted but was not sure if she was part of the IDT meeting when staff discussed his appropriateness for placement. She stated the day of admission the floor nurse would receive an admission packet. The first shift nurse would pass on in report that they were expecting a new admission if the resident did not arrive during the first shift and so on. The admitting nurse would document the resident's admission in the 24- hour report and any significant information. Interview on 1/20/23 at 2:10 PM with the ADON revealed she was part of the IDT meeting when they discussed Resident #1's placement. She stated she was not sure who all attended but usually it included the DON, SW, therapy, ADM and the BOM. The ADON stated she told LVN H know about Resident #1's admission on 12/30/22. LVN H worked the 6 AM to 2 PM shift. The ADON stated she would have provided specifics about Resident #1 including that he was a fall risk. LVN H should have passed the information on in report to LVN F. The ADON stated LVN F asked about implementing a fall mat after Resident #1 fell the first time but she advised her to wait until therapy assessed him. She stated Resident #1 was referred for therapy services with the focused areas being strength and mobility. The ADON stated nursing staff would have to get clearance from management before implementing a floor mat. She stated the interventions in place for Resident #1 included clipping the call light to his gown and increasing rounding on him. She stated they did not put the bed in the lowest position because he was a tall man and would often get up on his own. She stated Resident #1 did not have the strength to get up from the bed in the lowest position and it would be considered a restraint. Interview on 1/20/23 at 3:10 PM with the ADM revealed they conducted a fall management in-service on 12/31/22 for the nurses. He stated they had not provided another in-service since to include the CNA's or other staff. Interview on 1/20/23 at 3:15 PM with the SC revealed a CNA called in 12/30/22 for the 2 PM to 10 PM shift. He stated they had to make some changes to the assignments and LVN F and CNA G were the only two staff working the hall from 2 PM to 10 PM shift. The SC stated it would have made it difficult to complete normal tasks and to provide the level of supervision Resident #1 required in addition to the 3 or 4 other residents on the hall that were also a fall risk. He stated the census was probably like over 30 residents. Interview on 1/20/23 at 4 PM with the Interim DON revealed a fall risk assessment was completed for every resident upon admission and after any fall. She stated nursing staff were to gather information to determine the root cause of the fall. Nursing staff was supposed to ask the who, what, when, where and why and implement interventions according to the root cause analysis. Interview on 1/20/23 at 4:09 PM with the Staffing Coordinator (SC) revealed he worked the second floor from 10 PM to 6 AM as a CNA on 12/31/22. He stated upon beginning his shift he would usually make a sweep of all residents, checking on residents to ensure they were in their room, in bed and were ok. He remembered Resident #1 talking to himself and fidgeting with his gown. He asked the Resident if he was ok and the Resident said yes. The SC stated he completed his sweep and then started with incontinent care. He stated Resident #1's roommate came out and asked for help while he was in another resident room by the nurse's station. The SC stated Resident #1 was lying on the floor on his right side by the roommate's bed . Resident #1 said I'm hurting but could not say what happened. The SC stated there was not a fall mat in place. The bed was in the lowest position about 1 foot off the floor. He stated the nurse responded and assessed Resident #1 while on the floor. He and the nurse transferred Resident #1 to bed and the Resident complained of pain to his wrist. The SC stated after the second fall he answered the call light. The roommate was out in the hallway yelling for help. The SC stated when he entered the room he saw Resident #1 crawling on the floor. He stepped out of the room to get the nurse to help and when they returned Resident #1 had put himself back to bed. The SC stated Resident #1 was very confused. The roommate reported he saw Resident #1 crawling on the floor when he woke up. The SC stated he had checked in on Resident #1 about an hour before he was observed crawling on the floor. He stated Resident #1 was wide awake and restless. The SC stated he would round on residents every two hours and in between changing residents. He stated the nurse would also make her own rounds. The SC could not remember if the nurse told him Resident #1 was a fall risk. He stated the fall protocol required they put the resident bed to the lowest position, ensure the environment was clutter free and a fall mat was used if it was not a safety hazard. The SC further stated Resident #1 had the call light clipped to his gown and his overhead light was on. The SC stated Resident #1 was not able to walk and during transfer he was able to bare weight for a short time. He stated the nurse did not implement the use of the fall mat after the additional 2 falls. Interview on 1/20/23 at 4:40 PM with the Interim DON revealed she assumed her position on 12/27/22 or 12/28/22. She stated she reviewed Resident #1's hospital documentation after it was faxed to the facility and stated Resident #1 had 3 falls while at the hospital related to impulsivity. She stated Resident #1 had heart failure and his heart was operating at 30 %. The Interim DON stated LVN F called her late in the evening after Resident #1 had his first fall. She understood Resident #1 was using his bedside table to walk and he fell into the roommate's mini refrigerator. The nurse educated Resident #1 on the use of the call light. She stated X-rays were ordered and they were negative for any fractures. The Interim DON stated staff found Resident #1 sitting next to his bed after his 2nd fall and LVN D reported she guided Resident #1 to the floor which was considered to be his 3rd fall. LVN D stated Resident #1 was using his roommate's wheelchair/ to ambulate and was very unsteady. Interim DON stated the last two falls took place during the overnight shift. She stated Resident #1 had 3 falls altogether while at the facility. The Interim DON stated a 2nd set of X-rays were positive for a fracture but was not sure about the exact location. She stated the interventions in place for Resident #1 included: call light was clipped to his gown; he had 2 urinals at bedside and his overnight light was on. She stated nursing staff believed Resident #1 required 1 to 1 supervision because he was determined to get up and walk. He was able to ambulate somewhat; not safely but he could walk. Interim DON stated they obviously could not provide 1 to 1 supervision. Furthermore, nursing staff was not convinced using a fall mat was a safe intervention which she discussed with nursing staff. The Interim DON stated she did not know who received Resident #1's clinical's to determine whether he was appropriate for placement. Interview on 1/23/23 at 1:39 PM with the SC revealed he confirmed that on Saturday, 12/31/22, he found Resident #1 on the floor after the first fall during the night shift; later he observed Resident #1 crawling on the floor and then LVN D called him over to Resident #1's room to help transfer Resident #1 to bed after reporting she had lowered him to the floor. The SC stated technically Resident #1 had 3 falls during the night shift. Interview on 1/23/23 at 1:42 PM with Resident #4 revealed he remembered Resident #1 after cueing. He stated Resident #1 kept falling. He would get out of bed and would hold on to everything to keep from falling but he fell anyway. Resident #4 stated Resident #1 was not steady and could not walk very good. He stated Resident #1 knocked his mini refrigerator over from on top of his dresser. Resident #4 stated Resident #1 did not want to be in bed. Resident #4 stated he kept calling staff for help because it usually took staff over an hour to respond when he used the call light. He stated the staff responded to his call for help. 2. Review of Resident #2's face sheet, dated 1/23/23, revealed he was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy and repeated falls. Review of Resident #2's admission quarterly MDS, dated [DATE], revealed his BIMS was 8 (out of 15) indicative of severe cognitive impairment; he required extensive assistance by 1 person for bed mobility and transfers; he was unsteady moving from sitting to standing position, on and off the toilet and surface to surface transfer and only able to stabilize with staff assistance. Review of Resident #2's Care Plan, revised 11/8/22, revealed he required extensive assistance by 2 persons for bed mobility and transfers. Resident #2 was identified as being a fall risk and interventions included: anticipate and meet needs, avoid rearranging furniture, be sure the call light is within reach and encourage to use it to call for assistance as needed, educate resident and caregivers about safety reminders and what to do if a fall occurs, maintain a clear pathway, free of obstacles. Further review revealed Resident #2 had a fall on 1/13/23 and the interventions included: Call don't fall signs next to bed, check range of motion, monitor/document /report to MD for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, neuro-checks as ordered and vital signs as ordered. Review of an incident report, dated 1/13/23, revealed LVN E heard Resident #2 yelling out for nurse at 6:30 AM. She found him on the floor laying on his left side with wheelchair beside him. The wheelchair brakes were not locked. The Resident was wearing non-skid socks. Resident #2 was able to make his needs known and stated he hit his head on the floor. Resident #2's description: I don't know, I just fell . Immediate Action Taken: assessed Resident #2 and observed bump on left side of forehead and purple discoloration to left knee upon sitting Resident #2 up. Resident #2 denied pain. He was assisted to the wheelchair by 2 persons and neurochecks initiated. It was noted he did not have any injuries. Further review revealed LVN E notified Resident #2's physician, family member and the DON about the incident. Observation on 1/18/23 at 2:05 PM revealed Resident #2 sitting in a wheelchair by the nurse's station. Further observation revealed he had bruising over his left eye. Interview with Resident #2's family member revealed Resident #3 had a fall. Observation and interview on 1/20/23 at 11:40 AM revealed Resident #2 was lying in bed on his left side with eyes closed and his bed in a low position. The wheelchair was a couple of feet from the bedside. Interview with CNA I revealed she worked Monday through Friday from 8 AM to 5 PM. She stated she noted bruising over Resident #2's left eye on Monday, 1/17/23, and did not know if he had a fall. She stated the nurse did not say anything to her. CNA I stated Resident #2 was able to make his needs known, would use his call light to ask for assistance, was a 1 or 2 person assist with transfers. She stated the following interventions were used when a resident was identified as being a fall risk: call light within reach, low bed to lowest position and talk to nurse about using a fall mat. LVN I stated she would think Resident #2 was a fall risk because she had seen him try to self-transfer without assistance. She stated he was unsteady on his feet. Further observation revealed Resident #2's bed was not in the lowest position. She stated Resident #2 would sit up and the bed was in the position which allowed him to sit up and place his feet on the floor. CNA I stated there was no fall mat and his call light (touch pad) was placed underneath his left hand. Observation and interview on 1/20/23 at 1:06 PM revealed Resident #2 was lying in bed on his left side with eyes closed and his bed in a low position. The wheelchair was a couple of feet from the bedside. Interview with LVN H revealed Resident #2 was a fall risk per nursing report. He required assistance with transfers and stated he was able to pivot at one point but not so much anymore. LVN H stated she was aware Resident #2 had bruising over his left eye but did not talk to CNA I about his fall history because it took place earlier in the month. She stated the information would be available in Resident #2's POC. She stated this was the program the aides documented on which provided them with resident ADL information and any special circumstances. LVN H stated the aides should report any change of condition to them when they noted any changes. She stated CNA I should have reported the bruising over Resident #2's left eye if she had not noted the bruising during her previous shift. LVN H stated she understood LVN E found Resident #2 on the floor by the bed but was not sure if he fell out of the bed or the wheelchair. She did not know all of the details and had not looked at his chart. LVN H stated a low bed to the lowest position would be utilized if Resident #2 fell from the bed and if he fell from the wheelchair then it should be positioned out of the reach/sight from Resident #2 and in the locked position. Further observation revealed Resident #2's bed was not in the lowest position, his wheelchair was by his bedside in front of the night stand, his call light was under his left hand and the bed remote was on the floor. LVN H further stated the wheelchair was not in the locked position and a safety hazard if Resident attempted to transfer to the wheelchair. Interview on 1/20/23 at 1:20 PM with CNA J revealed she and CNA I were working together on the same hall. She stated she did not know Resident #2 had fallen and had not noted the bruising to his forehead. She stated she would ask the nurse on [NAME] [TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #4) reviewed for abuse. 1. The facility failed to protect Resident #4 from being hit by Resident #5 with a walking stick on his right hand on 10/31/22. 2. The facility failed to protect Resident #4 from being fearful (psychosocial harm) of Resident #5 from 10/31/22 through 11/10/22 when Resident #4 filed a grievance. These failures could place residents at risk for continued abuse, undetected abuse, neglect and/or decline in feelings of safety and well-being; and psychosocial harm. Findings were: 1. Record review of Resident # 4's face sheet dated 11/08/2022 revealed a [AGE] year old male with an admitted [DATE] with diagnoses which included: chronic kidney disease stage 3, type 2 diabetes mellitus and major depressive disorder recurrent mild Record review of Resident #4's revised admission MD'S dated 7/31/2022 revealed a BIMs score of 14 (scale of 0-15) which indicated the resident was cognitively intact. As for ADLs: bed mobility was extensive with two staff assistance; transfer was extensive two staff assistance; resident unable to walk. Range of motion: resident had contractures to both legs. Record review of Resident #4's CP, dated 07/26/22, revealed the goal and intervention for a resident to resident incident on 10/31/22 read: Roommate [Resident #5] was moved to different room after alleged altercation on [10/31/22] . Referral to an appropriate psychiatric provider as needed .[no documented referral in the clinical record to deal with Resident #4's fear or psychosocial harm] . Stop and talk with resident when passing by . [CP dated 10/31/22 revealed that no thorough investigation was completed and no new interventions were put in place to protect R#4 from further abuse from R#5]. Record review of Resident #4's Physician Progress Note dated 11/20/22 revealed: no diagnoses of paranoia. The resident was described as pleasant and cooperative, flat affect. Record review of Resident #4's Nurse Progress Notes from 10/31/22 (date of incident) to 12/02/22 (survey exit date) revealed: no documented referral for Psych services or mental status examination focused on the resident's fear (psychosocial harm) and anxiety involving Resident #5. Record review Resident #4's MAR, dated November 2022, revealed the resident received the psychotropic medication fluoxetine 20 mgs daily at bedtime for depression. Record review of a local police report dated 10/31/2022 revealed a call was received on 10/31/2022 at 11:11 p.m. from Resident #4 who stated his male roommate [Resident #5] had been threatening to him and assaulted him with a cane. Resident #4 stated he wanted the incident documented in case something happened later. The local police notified both parties that the light can stay on if one party wants it on and the other party can leave the room if they do not like it. Record review of TULIP (Texas Unified Licensure Information Portal) a computerized program facilities utilize to report incidents to HHSC revealed an allegation of abuse occurred on 10/31/2022 at 1:00 p.m. involving Residents #5 and #4 was reported to HHSC on 11/01/2022 at 11:00 p.m. The incident involved Resident #5 who wanted to go to sleep and asked Resident #4 to turn off the light on his side of the bed. Resident #4 did not want to turn it off and they began arguing about it. Resident #5 were both egging each other on. Resident #4 stated that Resident #5 poked him with his cane in his stomach and hit his hand. Resident #4 called the police, and the police came [to the facility].[Record review of incident report did not reveal effective interventions put in place to deal with mental health referral for R#4 and psychosocial harm]. Record review of Resident #4's grievance filed on 11/10/22 revealed: he was fearful and felt that Resident #5 was sitting outside his room. Facility's actions were: to speak to Resident #5 and to instruct Resident #5 not to visit Resident #4. Resident #4 was informed that Resident #5 did not sit or would not sit outside his door; grievance was recorded as resolved. During an interview on 11/8/2022 at 1:00 p.m., Resident #4 stated Resident #5 had hit him with his cane. He stated he was in his room in bed and [Resident #5] got mad at him because he would not turn his light off. Resident #4 stated the nurses moved Resident #5 to another room. During an interview on 11/8/2022 at 1:30 p.m., Resident #5 stated he did hit Resident #4 with his cane because he wanted the light turned off in his room. During an interview on 11/10/2022 at 12:45 p.m., the Administrator confirmed the abuse incident was not reported within 2 hours. During an observation and interview on 12/01/22 at 10:25 a.m., Resident #4 was in bed with a cellophane. Resident was bedbound. Resident #4 had contractures to both legs. The resident was alert and oriented; no bruises, wounds or skin tears were present. The resident stated that he still did not feel safe because Resident # 5 still roamed the hallway on the first floor of the facility. Resident #4 stated that there have been no incidents with Resident #5 since the 10/31/22 incident of physical abuse. Resident #4 stated he was thinking about moving to another nursing home because the facility was short staff and could not be assured that Resident #5 would not again strike him. Resident #5 had not physically abused him (Resident #4) since 10/31/22, but he was fearful that (R#5) might enter his room at night. His (R#4) medications were not changed after the 10/31/22 incident; and R#4 did not want to see a psychiatrist or psychologist. Likewise, R#4 did not want this room changed. During an interview on 12/01/22 at 12:25 p.m., the SW stated: prior to the incident on 10/31/22, R#5 and R#4 were roommates. According to the SW, the incident of physical abuse was not predicted. After the incident, preventative measures put in placed included: R# 5 was moved to the second floor; a Guardian Angel was posted outside R#4's room during the day Monday through Friday; staff were alerted to monitor R#4's movements; and there had been no other incidents. The SW intended on exploring a discharge plan for R#4 if he continued to remain fearful of R#5; and would explore with him a discharge plan. [SW plan was to explore discharging Resident #4 and keeping Resident #5 in the facility]. During a joint interview on 12/01/22 at 2:20 PM, the DON revealed: preventative measures after the Incident on 10/31/22 included: Resident #5 was moved to another floor; the wooden stick (tall walking stick) used in the incident belonged to Resident #5 and was voluntarily given to the Administrator by Resident #5; close monitoring of the first floor was put in place; when Resident #5 smoked outside near the first floor a staff member was present in the smoking area. As for Resident #4, the facility attempted a Psych referral around the day of the incident but the resident refused. No new medications were added to deal with any signs of paranoia or fear/anxiety exhibited by Resident #4. The DON commented, the Police only investigated a verbal argument over the back light of the room and the sound from the TV or radio. She stated no evidence surfaced that Resident #4 was struck by Resident #5. Resident #4's Skin assessment done on 11/01/22 was negative; and Resident #4 was not sent toER on [DATE]. [Skin assessment was done one day after the incident-reason not given by the DON] From 11/15/22 to 12/01/22, staff have visited Resident #4 and reports he never expressed fear of Resident #5. The Administrator responded that he would make a referral to Psych services to check on Resident #4's fear of Resident #5 and to rule-out paranoia. During an interview on 12/01/22 at 4:40 PM, the facility MD revealed she saw Resident #4 on 11/20/22 and the resident did not express any paranoia or fear of other residents or raised the 10/31/22 incident with her. In the past the resident refused psychiatric evaluations because he stated nothing was wrong with him. The MD said Resident #4) had not expressed any desires for discharge. The intervention the facility put in place was to separate the residents and move Resident #5 to a separate floor. The MD added that the resident was not prescribed medications to control anxiety or his fears because, he did not want to see a psychiatrist. During an interview on 12/01/22 at 4:45 p.m., the Business Office Manager said she made ambassador rounds on Resident #4 (to check on concerns) and he never expressed any fears about other residents or Resident #5. She participated in the discussion on the grievance Resident #4 filed against Resident #5 and the resident revealed he felt safe. She said she spoke to Resident #4 on 11/10/22 about the grievance and on 12/01/22 (day of surveyor's entrance into the facility) as a follow-up on any concerns. She said she did not document her follow-up on 12/1/22, but Resident #4 said he felt safe and did not want to be referred to psychiatric services. She said he did not want any resident wondering into his room; he does not have a roommate. The Business Office Manager stated, given the Responsible Party was the resident and he did not consent to a psychiatric referral we have made none .and there was no special Care Plan meeting to discuss the 10/31/22 incident and possible interventions other than those that were in place. During an interview on 12/01/22 at 4:53 p.m., the SW said she visited Resident #4 as needed from the day of the incident 10/31/22 to the present 12/01/22 to check on concerns and safety; but did not document the encounters with the resident or psychosocial harm. [The SW was trained to document but did not give a reason for not documenting her encounters with Resident #4.] During a joint interview on 12/02/22 at 10:30 a.m., the DON stated a referral was not made for Resident #4 for Psych services because resident rights, she said Resident #4 refused Psych services verbally, but no documentation of refusal was documented in the clinical record. The Administrator stated Resident #4 did not want a Psych referral and he left it up to the clinical staff to document and follow-up on any Psych referral. During an observation and interview on 12/02/22 at 2:50 PM, Resident #4 was in bed trying to fall asleep. Resident #4 revealed that he was still afraid of Resident #5 and that he had been told by other residents that Resident #5 comes down to the first floor. Resident #4 said he does not want his room changed. He said he is weighing whether a transfer to another nursing home was the best option for his fear. He stated, in the best of [NAME], my desire is that Resident #5 would go away . Resident #4 said he will give the facility a chance to see whether they keep him safe before making a final decision on a transfer. During an interview on 12/2/22 at 5:30 PM, the DON said the Elder Care Program was a mental health community provider that visited the facility weekly to provide mental health services to residents. She said Resident #4 and Resident #5 were not provided mental health services because, they refused Psych services. When asked whether a documented referral was made for mental health services to the Elder Care Program, or any other community mental health provider, the DON revealed that no written documentation existed. Record review of Resident #4's wound care physician email dated 12/02/22 at 8:01 AM (after surveyor's entrance) revealed: weekly wound care visits were done and Resident #4 had not expressed any fears of other residents [not documented in the clinical record] to the Wound Care Physician. Record review of Resident #4's grievance filed on 11/10/22 revealed: he was fearful and felt that Resident #5 was sitting outside his room. Facility's actions were: to speak to Resident #5 and to instruct Resident #5 not to visit Resident #4. Resident #4 was informed that Resident #5 did not sit or would not sit outside his door; grievance was recorded as resolved. Record review of the Administrators written note dated 11/01/22 in reference to Resident #4 and incident on 10/31/22 revealed: Resident #4 accused Resident #5 of hitting him in the hand .with a cane the previous night (10/31/22). The DON assessed resident and did not see anything on the hand any redness, swelling, or discoloration . [written statement dated 11/01/22 was not documented in the clinical record.] 2. Record review of Resident #5's face sheet dated 11/09/2022 revealed a [AGE] year-old male with an admitted [DATE] with diagnoses which included: acute pancreatitis without necrosis or infection (inflammation of the pancreas), Chronic obstructive pulmonary disease (persistent respiratory symptoms like progressive breathlessness and cough), diaphragmatic hernia without obstruction or gangrene (hernia in the muscle that separates the lungs from the abdominal cavity) and unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (dementia without behaviors). Record review of Resident #5's revised admission MDS dated [DATE] revealed a BIMs of 11 (scale of 0-15) which indicated a moderate cognitive impairment. As for ADLs: Resident #5 required only supervision for ambulation and transfer. Record review of R#5's CP dated 11/01/22 revealed the goal and intervention around resident-to-resident altercation read: Psychiatric consult as indicated Resident moved to different room r/t (related to) resident to resident on 11/1/22. [record review of CP did not reveal that a thorough investigation was conducted and the interventions put in place to prevent R#5 for wanting to harm R#4; also the CP did not document that a mental health referral was made for R#5 afer the incident on 10/31/22.] Record review of R#5's PT (physical Therapy) certification dated 12/02/22 revealed: resident required a single point cane for ambulation and to prevent falls. Record review of R#5's PT Evaluation and Plan of treatment dated 7/26/22 read: Patient will safely ambulate on level surfaces 100 feet using SPC (single point cane) with Partial/Moderate Assistance . Record review of R#5's SW notes revealed the last SW entry was made on 10/30/22. [no notes documented to evaluate any safety concerns towards R#4 or any referral to Psych services]. Record review of R#5's incident record for falls past 90 days ( 09/1/22 to 12/2/22) revealed the resident had no falls from the use of a walking cane or wheelchair ambulation. Record review of R#5's Wound Care Physician email dated 12/02/22 at 8:01 AM revealed: R#5 used a cane to get out of his wheelchair. Record review of facility's weekly behavior meetings revealed meetings were held in the month of November 2022. Record review of facility's standard of care sign-in sheet (same as weekly behavior meeting) revealed a meeting was held on 11/17/22. [the tracking of residents with behaviors started 11/16/22] R#5 was listed on the Behavior sheet with the comments: hx (history) of physical aggression, does not like to be challenged .interventions: leave him alone when upset .refuses psych services . [The behavior monitoring meeting did not specifically deal with the incident on 10/31/22 and the need for a mental health referral; and protective measures put in placed to protect R#4 from harm from R#5]. Record review of the Administrators written note dated 11/01/22 in reference to R#5 and incident on 10/31/22 revealed: R#5 said that R#4 was a liar. During an interview on 11/08/2022 at 4:00 p.m., CNA I stated that Resident #5 moves around the facility with his wheelchair. He carries a walking single point cane with him. [The cane was used for mobility when the resident was out of the wheelchair. CNA I did not witness Resident #5 striking Resident #4; and she had received training on abuse and neglect.] During an interview on 11/09/2022 at 12:21 p.m. the Administrator acknowledged he was the abuse coordinator. During an observation and interview on 12/01/22 at 10:51 a.m., Resident # 5 was attending bingo. Resident #5 was sitting in a W/C with a walking cane, he spoke in Spanish, was alert and oriented to person and place. Resident #5 had no wounds, bruises or skin tears, he stated that he was treated well, had no fears and denied being struck by other residents. Resident #5 stated that he had no intentions of harming other residents. He recalled the incident with Resident #4 because he was bothering me .I hit him with my cane . He added his room was changed and he has not bothered the other resident (R#4) who was his [former] roommate. He said he only goes down to the first floor to the smoking area and had not had any altercations with other residents. He (R#5) does not hate other residents. He stated that the walking cane helped him with mobility especially when he wanted to get out of the wheelchair. The resident added that he tried to control his anger; and he did not feel unsafe in the facility. [Resident #5 did not want to see a mental health provider because he had no mental health concerns.] During an interview on 12/01/22 at 11:05 AM, LVN E revealed R#5 carried a walking cane while sitting in his wheelchair; the walking cane was used for ambulation. LVN E said interventions the facility put in place for the safety of residents from R#5 included: close monitoring, being aware when he wanted to get a smoke break and staff supervised him at the smoke area; no changes in medications [resident room is at the end of the hall]; hall cameras were present monitored from the DON's office. According to LVN E, R#5 has had no altercations in Hall 200 with other residents. During an interview on 12/01/22 at 12:33 PM, the SW revealed: R#4 and R#5 were roommates; an un-expected incident of resident-to-resident altercation occurred on 10/31/22. After the incident, R# 5 was moved to another floor; no other incidents occurred after the room change. During an interview on 12/01/22 at 5:05 PM, the SW revealed she had not documented in the clinical record (from 10/31/22 to 12/01/22 (entrance date of surveyor) her encounters with R#5 involving safety and any encounters with R#4. During a joint interview on 12/02/22 at 10:50 a.m. , the Director of Rehab and PT O revealed: R#5 had a wheelchair based on a physician's order and a physical therapy assessment. R#4 was ambulatory and had instability when standing; and had impaired endurance. Physical Therapy department had assessed R#5 for the single point cane. The single point cane was necessary for assisting R#5 with ambulation. R#5 did not require physical assistance to transfer out of the W/C. The cane helped the resident avoid falls which he had none in 90 days (September, October, and November 2022). During an observation and interview on 12/02/22 at 3:10 p.m., R#5 was participating in a bingo activity sitting in his wheelchair and holding his walking cane. R#5 agreed to briefly speak to the surveyor. R#5 revealed that he was fine and had no anger towards anyone. He had no complaints and ended the interview and returned to the bingo activity. Record review of grievance log from 11/01/22 to 12/01/22 revealed: only one grievance filed by R#4 on 11/10/22 against R#5 revealing that he (R#4) was afraid that R#5 was sitting outside his room; Resolution: no evidence surfaced that R#4 was not outside the room; and R#5 educated not to visit R#4. Also, staff sat outside R#4's room during the day [Surveyor observed on 12/02/22 a staff member sitting outside of Resident #4's room.] Record review of Incident log from 11/05/22-12/01/22 revealed no incidents involving Resident #4 and #5 after 10/31/22. Record review of facility's Reliance Computer courses on the topics of: behaviors, resident-to Resident, de-escalation revealed 100% of the staff (Total paid staff of 89 (time frame 11/05/22-11/12/22 ) received the training prior to surveyor's entry on 12/01/22. Record review of weekly behavior meetings revealed meetings were held in the month of November 2022. Record review of facility's standard of care sign-in sheet (same as weekly behavior meeting) revealed a meeting was held on 11/17/22. [the tracking of residents with behaviors started on 11/16/22]. Record review of a facility policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment dated 11/28/2017 revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents .Procedures: In response to allegations of abuse, neglect, exploitation or mistreatment, the Facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately but not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. Ensure that all alleged violation involving abuse .are reported to the State Survey Agency.

Based on observation, interview and record review failed to ensure resident receive treatment and care in accordance with professional standards of practice, based on the comprehensive assessment of a resident, the comprehensive person-centered care plan, and the resident's choices for 1 of 10 residents (Resident #2) reviewed for quality of care, in that: 1. The facility did not identify 2 shearing wounds on Resident #2 buttocks prior to surveyor intervention. 2. LVN D did not immediately notify the physician and receive treatment orders for Resident #2 upon identification of open areas on her buttocks. 3. The facility did not implement interventions to prevent further breakdown for Resident #2 after identifying wounds on her buttocks. 4. The facility did not identify 4 more open areas to Resident #2 ' s buttocks 2 days later and prior to surveyor intervention. These deficient practices could result in pressure ulcer development and decline in the resident's physical condition. The findings included: Record review of Resident #2's electronic face sheet with an admitted [DATE] and diagnosis which included cerebral criptococcosis(Cryptococcosis is a disease caused by fungi from the [NAME] Cryptococcus that infect humans and animals, usually by inhalation of the fungus, which results in lung infection that may spread to the brain), rheumatoid arthritis(a chronic inflammatory disorder that can affect more than just your joints.),metabolic encephalopathy(abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain function.), and dysphagia(A condition with difficulty in swallowing food or liquid. This may interfere in a person ' s ability to eat and drink.) Review of Resident #2's admission MDS, dated [DATE] revealed a BIMS score of 8 indicating cognitive impairment. Record review of Resident #2's Care Plan, dated 11/2/2022, revealed, Focus: Has pressure ulcer or for potential pressure ulcer development. Goal: Will have intact skin, free of redness blisters or discoloration through review date. Interventions: Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration during bath or daily care. Weekly head to toe skin assessment. Record review of Resident #2's electronic medical record nursing progress notes dated 11/1, 11/2, 11/4, 11/6,11/7,11/8/2022, documented as: overall skin description is: skin intact with no breakdown noted. There are no active symptoms effecting the integumentary system observed. Record reveiw of Resident #2's Skin evaluation-prn weekly dated 11/2/2022, documented as new admit skin assessment. no redness noted to bilateral heels. Wearing pressure reducing boots. Remaining skin intact. No indication of presure wounds. Record review of Resident #2's electronic medical nursing progress notes from Registered Dietician on 11/9/2022, documented as: No pressure wounds, though with skin tears to bilateral buttocks. Record reveiw of Resident #2's Skin evaluation-prn weekly dated 11/10/2022, documented as groin abdomen, and left front thigh with bruising. No indication of buttock wounds. Record review of wound record provided by DON on 11/9/2022 at 11:30 a.m. revealed no documentation regarding Resident #2 having any wounds. Record review of Resident #2's score on the Braden Scale for predicating pressure risk, dated 10/28/2022 revealed a score of 17, which indicated a low risk. During an interview on 11/8/2022 at 2:15 p.m. with Resident #2 she stated she had sores on her bottom and that they hurt and no one was helping her. When asked how long she had the sores, Resident #2 stated, I do not know, I just know it hurts. Permission was asked by surveyor to see the sores and Resident #2 stated yes. Informed her this surveyor would have staff present. During an observation on 11/8/2022 at 2:24 p.m., Resident #2 had two, 2cm (centimeters) long by 1/2 cm wide oblong open areas to her right upper buttock and one, 2cm long by 1/2cm wide oblong open area to her left buttock. LVN D was present with surveyor during observation of skin on Resident #2. LVN D stated yes there are open areas to her buttocks, she further revealed she was not aware of any open areas to Resident #2's buttocks. She stated I see barrier cream on the areas to the buttocks that the nurse aides must have put on them. LVN D stated she was not told by any nurse aides that Resident #2 had a need for a treatment to her buttocks. She stated the treatment nurse would be in facility tomorrow and would get an order for a treatment. When asked what the charge nurse would do if the treatment nurse was not available, LVN D stated we would call the doctor and do the treatment ourselves. When asked why she did not want to call the doctor today, she said because the resident has barrier cream now and the treatment nurse will be here tomorrow. During an interview on 11/8/2022 at 3:35 p.m. with LVN F she revealed she was aware that Resident #2 had red areas on her buttocks but not aware if they were open. She further revealed she was not aware of any treatment orders for her buttocks . She stated she had not seen Resident #2 on 11/8/2022. During an interview on 11/8/2022 at 3:55 pm CNA I stated the sores on Resident #2 's buttocks were not open when she first came in(admission 10/27/2022). She further revealed they were only red. She stated I told the LVN D and CNA I put barrier cream until the treatment nurse could assess the resident. CNA I revealed she was aware of Resident #2 had blisters type on her right and left buttock . She stated she was to place barrier cream on her, she was told to do this by LVN F. She further revealed we are to turn and change her every 2 hours and as needed. When asked how long the areas have been open to Resident #2's buttocks , CNA I stated, I am not sure exactly but several days. During an interview on 11/10/2022 at 11:01am, Treatment Nurse C stated he worked Monday through Friday 8am to 5 pm normally. He further revealed the Wound Doctor comes every Thursday. He stated he was off work Friday, 11/5//22 and returned to the facility on [DATE]. Treatment Nurse C stated, the nurses do the skin and wound treatments when I am off. The aides have shower sheets that they do on bath days for the residents, and they give those to the charge nurse and then that is given to the DON. He further stated, If I am not here the nurse should call the Dr. and get a treatment for the Residents whenever a skin issue is identified. During an observation on 11/10/2022 at 11:15 am, Resident #2 was in bed. Treatment Nurse and surveyor asked permission to see wounds on the buttocks. Resident #2 agreed. Resident #2 complained of pain during the observation. Observation of Resident #2's buttocks revealed a 2cm long by 1/2 cm wide oblong open areas to her right upper buttock and one, 2cm long by 1/2cm wide oblong open area to her left buttock. There were also 4 new areas open to the buttocks that were not there on initial assessment of 11/8/2022. Treatment Nurse stated he was not aware and had not been told that Resident #2 had any skin issues. He stated he was going to call the Doctor now and get a treatment plan for Resident #2. During an interview on 11/10/2022 at 2:30 p.m. with DON revealed she was not aware that Resident #2 had any open areas to her buttocks. The DON stated nurses should check residents' skin weekly and document in weekly skin report or progress notes in the electronic medical record. She further revealed if there is a treatment nurse on staff then they would document the assessment and call the physician for any orders for the residents. She stated it is her expectation that staff including nurses and nurse aides should notify their superior of any skin changes in residents. The facility DON stated our team of department heads discuss any skin issues in our morning meetings daily, Monday through Friday. Review of facility policy titled Infection Control Policy/Procedure, Section: Resident Care, Subject: Wound Care and Treatment Guidelines: Policy: It is the policy of this facility to provide excellent wound care to promote healing. Procedures: A weekly assessment should be done on all wounds requiring treatment. The careplan should reflect the current status of the wound and appropriate goals.

Based on observation, interview, and record review the facility failed to ensure that acceptable parameters of nutritional status were maintained for 1 of 7 Residents (Resident #1) reviewed for weight loss. The facility failed to ensure Resident #1's significant weight loss was addressed per policy. Resident #1 lost over 30 pounds in a 2-month period. Weekly weights, and appropriate interventions were not made until after surveyor entrance on 6/22/2022. These failures resulted in an Immediate Jeopardy (IJ) on 6/24/2022 at 5:00 p.m. While the IJ was removed on 6/25/2022, the facility remained out of compliance at a severity level of harm at a scope of isolated due to the need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents with significant weight loss at risk for further weight loss and decline in overall medical condition. Findings included: Record review of Resident #1's face sheet, computer dated 6/22/2022, and EMR (electronic medical record) revealed, the resident was admitted initially on 2/1/2022 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Symptoms may include muscle pains, weakness, vomiting, and confusion. There may be tea-colored urine or an irregular heartbeat.) severe intellectual disabilities (a level of functioning severely below age expectations), [CONDITION(S)](a group of disorders that affect movement and muscle tone or posture.), autistic disorder(A neurodevelopment disorder that causes a wide range of impairments in social communication and restricted and repetitive behaviors.), muscle wasting and atrophy(wasting away or progressive decline), dysphagia(A condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink.), cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit. A cognitive-communication disorder results from impaired functioning of one or more cognitive processes.), undifferentiated [CONDITION(S)](mental illness in which a person has symptoms of [CONDITION(S)] that cannot be classified into a particular type), essential hypertension(high blood pressure that doesn't have a known secondary cause.), non-ST elevation [CONDITION(S)](NSTEMI)([CONDITION(S)]),GERD([CONDITION(S)] (GERD) occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach (esophagus).).Resident was a [AGE] year-old male. Record review of Resident #1's Care Plan, date initiated 2/9/2022 revised 2/23/2022 with target date 8/29/2022 revealed: Goal: Will have all ADL needs met through the review date. Interventions: Resident requires assistance for ADLs (a term used by healthcare professionals to refer to the basic self-care tasks an individual does on a day-to-day basis.) as follows: Eating: Extensive Assist-1 person.Observe for fatigue and weight loss. Focus:{Resident #1} is at risk for nutritional deficit and weight loss related to severe IDD, tardive dyskinesia (a side effect of antipsychotic medications. These drugs are used to treat [CONDITION(S)] and other mental health disorders.TD causes stiff, jerky movements of your face and body that you can't control. You might blink your eyes, stick out your tongue, or wave your arms without meaning to do so.), and [CONDITION(S)] and is currently underweight. Date initiated 2/9/2022 revised on 2/23/2022. Goal: Will maintain adequate nutritional status as evidenced by maintaining weight with no signs and symptoms of malnutrition through review date. Date initiated 2/9/2022, revision on 2/23/2022, target date 8/29/2022. Interventions: If eats less than 50% offer meal replacement. Meals in dining room if resident is in agreement. Focus: {Resident #1} has antidepressant medication use related to depression date initiated 2/15/2022 revision on 2/25/2022. Goal: Will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Date initiated: 2/23/2022, Revision on 2/23/2022, target date: 8/29/2022. Interventions: observe for signs and symptoms of following .appetite loss, weight loss, muscle cramps, n/v. date initiated 2/23/2022. Observe /document report to MD, lethargy weight loss. Record review of Resident #1's quarterly MDS , dated 4/20/2022, revealed, a BIMS Score was 0 as resident rarely/never understood. ADLs : B/B incontinent of both bowel and bladder. Transfer and Bed Mobility was extensive two staff assistance. Nutrition: section K, a. loss of liquids /solids from mouth when eating or drinking, documented as yes. Height 69 inches and weight is 122 lbs. no weight loss, mechanically altered diet, therapeutic diet.at risk for pressure ulcers, no wounds. Record review of Resident #1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MARs dated 6/1/2022-6/22/2022 revealed Med Pass 90 ml BID by mouth was being given to Resident #1 by staff. Record review of Resident #1's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's hospital medical records dated 4/12-4/15/22: medical record revealed Resident #1 was sent to the emergency department after being found on the floor after he had a fall. Found to have a laceration wound on the left upper eyelid with swelling in the orbital area. Resident #1 was to have [CONDITION(S)] (Low potassium- can be caused by certain medications, under eating or malnutrition), acute kidney infection and rhabdomyolysis diagnosis. Documented hospital weight was 121.9lbs. CT of maxillofacial and cervical spine were negative. Review of Resident #1's weight record revealed: 2/3/2022-125.4lbs 3/10/2022-123.6lbs 4/4/2022-122.3lbs 5/9/2022-103.0lbs 6/20/2022-88.5lbs Record review of Resident #1's meal intake record revealed: 6/21/2022 A.M. meal documented at 12:57 p.m. ate 0-25% .P.M. meal documented at 9:41 p.m. ate 26%-50%. no other mean documentation for 6/21/2022. 6/20/2022 A.M. meal documented at 10:09 a.m. ate 0-25%. Mid day meal documented at 12:23 p.m. ate 0-25%. Evening meal documented at 7:32 p.m. documented resident refused. 6/19/2022 A.M. meal documented at 10:57 a.m. documented resident refused. Mid day meal documented at 12:51 p.m. ate 0-25%. Evening meal documented at 5:07 p.m. ate 26-50%. Record review of Resident #1's laboratory results revealed collection date: 5/31/2022: Sodium 147 (ref range 136-145), Potassium 3.8 (3.6-5.2) BUN 28 (ref range 3-23) Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 6/23/2022: Sodium 161, potassium 4.1, Bun 51. Iv fluids ordered and given. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6/24/2022: Sodium 158, potassium 3.8 bun 43. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No more IV fluids or labs. Monitor resident output by brief changes. Sodium, potassium and blood urea nitrogen (BUN) are all indicators of a patient's hydration status. They often tell the story of dehydration long before physical symptoms manifest.(https://medlineplus.gov/lab-tests) Record review of Resident #1's consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Med Pass two times a day for supplement ordered 2/18/2022. During an interview on 6/22/2022 at 11:45 a.m. with DON stated, I believe I know why you are here. She stated, Resident #1 had some visitors yesterday (6/21/2022) and I think it might have been regarding him. DON revealed Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON revealed she had self-identified an issue on 5/16/2022 with resident weights not being done correctly by a certified nurse aide(D) who no longer was employed at facility. She stated the QIT (Quality Improvement Team) which consisted of the DON, Dietary Manager, Social Worker, and the Administrator had a corrective plan in place. Review of a document provided by DON on 6/22/2022 revealed QIT started 5/16/2022. When asked how the weights were normally monitored to ensure excessive weight loss or weight gain was properly addressed, she stated I have a report I look at every month, also the RD (registered dietician) reviews the report monthly. When asked why the weights were not being done correctly and why were the weight losses not caught sooner, the DON stated, the CNA (D) was recording wrong weights on (Resident (resident #1).She was just writing the weights down and not actually weighing him.(resident #1) When asked by investigator the DON stated , we (cna's ,charge nurses, adon,don) all as a team watch how the residents eat. The aides document the amount in the intake record of the resident's records. If the resident does not eat well, the aide will tell the charge nurse. The charge nurse will make sure the resident is offered something else. DON further revealed she monitors the weights of residents each month on a monthly weight record. CNA D was responsible for doing the weights on all residents prior to 5/16/2022. Now I have the ADON and the Treatment nurse doing them. DON stated she is responsible for making sure the weights are done on residents correctly and timely. She further revealed the ADON and the Treatment nurse were seen by me to makes sure the weights are done correctly. The ADON and the Treatment nurse are using the same scales to weigh residents. Unable to reach CNA D for an interview during and before exit of investigation. During an observation and interview attempt on 6/22/2022 at 12:15 p.m. revealed Resident #1 was in a reclining mobile chair with helmet (protective type helmet) on at the nurse's station. Resident #1 was unshaved and had loose fitting clothing. During observation of noon meal, staff was feeding Resident #1 regular pureed consistency diet with thin liquids. Resident had health shake on tray. Resident ate approx. 25% of lunch. Telephone call attempt on 6/22/2022 at 12:45 p.m. to Resident #1's responsible party unsuccessful as RP did not answer the phone. During a telephone interview on 6/27/2022 at 3:30 p.m. (after exit) to Resident #1's responsible party revealed RP was made aware of Resident #1 having weight loss on or around 6/15/2022. He stated he had been frustrated as he had not received updated information regarding Resident #1 and his weight loss from the facility staff. He stated he could not remember which staff member informed him. During an interview record review on 6/22/2022 at 1:00p.m. Administrator confirmed a QIT had been done for weights on residents by showing the investigator the form for the QIT of Resident #1. During an interview on 6/22/2022 at 1:10 p.m. CNA A stated she usually worked the 6 a.m. to 2:00 p.m. shift. She stated Resident #1 was totally fed by staff. She further revealed he had good days and bad days where he would eat 100% at a meal and then he would refuse or only eat 25%. She stated she would give him a Health shake if he did not eat well. She further revealed Resident #1 liked sweet food. She stated ever since he had returned from the hospital in April this year he had not eaten well. She stated she would tell the charge nurse when he did not eat well. When asked if she felt Resident #1 was thin for his size, she stated yes, and his clothes were looser than they used be when he first was admitted . When asked what you do if you suspect that a resident was not receiving necessary care and services, she stated she would report it to the charge nurse and the ADON and also the DON if needed. She stated the Administrator was the Abuse Coordinator. CNA A stated they receive in services every couple of months on abuse and neglect. During a telephone interview with Registered Dietician (RD) on 6/23 at 11:50 a.m. stated she had completed 2 nutritional assessments for Resident #1. She stated the nutritional assessments were done in April and June of 2022. RD further revealed she reviewed the weights on 4/17/2022 for Resident #1 in the EMR and there was no significant weight change. When asked when she was told about Resident #1's weight loss she stated in May this year, I am not sure what date, the DON told me there were discrepancies in the weights being done on residents. RD stated that she visually saw Resident #1 in May 2022 but did not document any assessments. When asked if the resident's condition had declined to the point where he may no longer swallow food or fluids, the determination of whether to use artificial nutrition/hydration, had there been any discussion with Resident #1's representative and the attending practitioner, the RD stated she did not know. Record review of Resident #1's Electronic progress notes authored by RD dated 4/17/2022 read: Note Text: Readmit after fall. April weight: 122.3#, no significant weight changes. IBW(ideal body weight): 160#, 76% IBW, BMI(Body mass index (BMI) is a measure of body fat based on height and weight that applies to adult men and women.) 18.1 -underweight However do not expect res to meet IBW due to dx. PMH: [CONDITION(S)], intellectual disabilities, [CONDITION(S)]. No pressure wounds, though with bump to eye. Resident observed at lunch, is fed meals, spills food out of mouth due to neck contracture. Res has fair-good intake. Diet: Mech Soft, thin liquids; 75% meal intakes. Meds: [MEDICATION(S)], vit D, [MEDICATION(S)], [MEDICATION(S)]. No new labs. Est needs based on IBW: 2200 kcal, 73 gm protein, 2200 ml fluids. underweight related to previously inadequate oral intake as evidenced by <100% IBW. Goal - gradual weight gain towards IBW. Rec - med pass 90 ml BID. 6/23/2022 RD note: weight loss. Weight 88.5 (-14.5(14%). IBW 160#BMI 13.1- underweight . However do not expect res to meet IBW due to dx. PMH: [CONDITION(S)], intellectual disabilities, [CONDITION(S)]. No pressure wounds. Res appears thin with wt loss. Res is fed meals, will eat 50% at most. Observed feeding at lunch last week, ate slowly, ate 50%, refused lunch today, though ate 50% of breakfast and accepted health shake. Diet: Puree, thin liquids, health shakes with meals:<50% ,meal intakes. Meds: IV fluids ordered, med pass 90 ml bid, [MEDICATION(S)], vit D, [MEDICATION(S)], [MEDICATION(S)], Labs: 5/31/22 Na 147,k 3.8 glu 69 bun 28 creat 0.9,alb 3.0.Est needs based on IBW:2200 kcal,73 gm protein,2200 ml fluids. PeS: underweight related to previously inadequate oral intake as evidenced by <100%IBW. Goal: gradual weight gain towards IBW. Rec increased med pass to 90 ml QID. MD consider appetite stimulant as needed. 2/3/2022-125.4lbs 3/10/2022-123.6lbs 4/4/2022-122.3lbs 5/9/2022-103.0lbs 6/20/2022-88.5lbs Interview on 6/24/2022 at 2:00 p.m. the Administrator and DON stated for Resident #1, 4/23/2022-5/5/2022 was too long to wait to do weekly weights, and they should have truly started weekly weights after the 5/5/2022 reweighs. The DON said weekly weights started on 6/23/2022. During an interview on 6/24/2022 at 3:00 p.m. the DON revealed Resident #1 went to the hospital on 4/12/2022-4/15/2022. His weight was done 4/4/2022 and he was readmitted on [DATE]. When asked why no weight upon re-admit, the DON stated because he (resident #1) was weighed on 4/4/2022 and then they weighed all residents to have baseline weights on 5/5/2022 and were documented on 5/9/2022. When asked if a weight loss occurred would a resident be weekly weights DON stated, yes. When DON was asked why weekly weights were not started beginning 5/16/2022 through 6/20/2022, DON stated, I just didn't think about it. When asked if the resident's condition had declined to the point where he may no longer swallow food or fluids, the determination of whether to use artificial nutrition/hydration, had there been any discussion with Resident #1's representative and the attending practitioner, the DON stated no. During an interview on 6/25/2022 at 12:36 p.m. CNA B stated regarding dental oral care for Resident #1, I use oral sponges with water to brush his teeth. She further revealed Resident #1 had intact teeth and did not know of any loose teeth or swollen gums this am when she used the oral care sponge. CNA B stated Resident #1 was total assist with all care including eating. She stated if he does not eat well, she would give him a health shake because he likes sweets. CNA B stated she would tell the charge nurse or also the ADON and the DON if she suspected the resident was not receiving necessary care and services. CNA B revealed the Administrator is the abuse coordinator. CNA B stated she received in services frequently throughout the year. When asked CNA B if she noticed Resident #1's clothes were loose or if they had become looser in the past few months, she stated no, she thought they have always been loose. Interview on 6/25/2022 at 12:10p.m. LVN C stated she works on the weekend. She further revealed Resident #1 required total care from staff. She stated he required slow feeding with meals and encouragement. When asked if she was aware of Resident #1's weight loss, she stated she only knew that he was not eating as much as normal, and they give him health shakes and Med pass supplements to help. When asked LVN C if she noticed Resident #1's clothes were loose or if they had become looser in the past few months, she stated no, she had not noticed. What do you do if you suspect that a resident is not receiving necessary care and services? I inform the DON. What training have you received from the facility on neglect identification, prevention, and reporting requirements? We receive training for abuse and neglect during in services throughout the year. When asked if the resident's condition had declined to the point where he may no longer swallow food or fluids, the determination of whether to use artificial nutrition/hydration, had there been any discussion with Resident #1's representative and the attending practitioner, LVN C stated she did not know. She further revealed she had not discussed anything regarding this with the RP. Review of Resident #1's weekly wound record dated 5/26/22, left lateral elbow abcess,0.5x0.8 alginate q day. Record review of Resident #1's electronic progress notes dated 6/22/2022 written by DON read: 16:06 (4:06 p.m.) Called MD and spoke to MD about residents continued weight loss due to decrease in appetite. MD suggested we order labs to include LFTs, CMP, CBC, and UA to be ordered. MD stated that after test were ordered we would look at possible appetite stimulant, dietician was also confirmed to be here on 6/23/22 and will review resident chart. MD also ordered health shakes TID for 30 days. During an interview and observation with facility ADON and Treatment Nurse on 6/25/2022 at 1:00 p.m. the ADON stated we (ADON and treatment nurse) will be doing the weights from now on. We will do them monthly. The ADON further revealed we (ADON and treatment nurse) were assigned weights by the DON on all the residents after a CNA (D) had not documented the weights correctly. An observation of ADON and Treatment Nurse performing a weight on Resident #1 with a Hoyer lift scale revealed his weight was 88.6lbs. During an interview on 6/25/2022 at 2:05 p.m. with facility Social Worker she was asked if Resident #1 had a dental exam to check his oral status. She stated she was not sure but would check. When asked if the resident's condition had declined to the point where he may no longer swallow food or fluids, the determination of whether to use artificial nutrition/hydration, had there been any discussion with Resident #1's representative and the attending practitioner, the SW stated not that she knew of. During an interview and record review on 6/25/2022 at 2:30 p.m. with facility Social Worker, surveyor was provided document with note which read will refer for dental screen on Monday 6/27/2022. Social Worker stated there was no record of Resident #1 having a dental exam since admission of 2/1/2022. Review of facility policy Section: undated, Care and Treatment Subject: Nutrition: Weight Management: It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. 3. Any resident meeting the criteria for weight loss and any resident at risk will be weighed weekly. Review of facility policy, undated Titled Nursing Administration, Section: Resident Rights, Subject: Abuse Prevention, Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Prevention: All personnel, residents, visitors, etc. are encouraged to report incidents and grievances without the fear of retribution. The employees of our facility will [MEDICATION(S)] to protect and prevent abuse and neglect from occurring within the facility by: Staff has knowledge of the individual residents' care needs. Definitions: Neglect is 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. This was determined to be an Immediate Jeopardy (IJ) on 6/24/2022 at 5:00 p.m. The Administrator was notified and provided the IJ template dated 6/24/2022 at 5:00 p.m. The following Plan of Removal submitted by the facility was accepted on 6/25/2022 at 8:48 p.m. Plan of removal 06/24/22 A. Immediate Action Taken 1. Education started by clinical resource/DON on the following topics: - In-services started on 6/24/22 will be ongoing for full time staff until 90% of full-time staff have completed the in-services. The facility goal is to have them completed on 6/25/22. Any full time, part time, PRN employees and agency staff will be in-serviced prior to providing direct care. 1. In-service with all licensed staff and Certified nurse's aides on properly doing weights, to include using the same scale, same time of day. If there is a variance of 3 pounds from last weight either loss/gain will be an automatic reweight. a. When discrepancies of weights occur RD and Physician notifications will be done. b. Proper interventions will be put in place per RD and Physician recommendations c. Notification to family will occur d. Facility policy and procedure for weight management 2. Inservice with all staff regarding Abuse and Neglect 3. CNAs will be in-serviced to notify nurse if a resident eats less than 50% of their meal. If they eat less than 50% of their meal staff will offer a meal replacement. 4. Dietary staff will be in-serviced on including supplements on each meal cart. 2. Resident reweighs done to identify any possible discrepancies from last weight. Started 6/24/22 and completed on 6/25/22. 3. Resident #1 was reweighed; seen by the dietician on 6/23/22 - Interventions per dietary recommendation were put in place for resident #1 On 6/25/2022 the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following Record review and interviews on 6/25/2022 from 11:30 am -3:30 pm revealed: 31 verbal confirmation and record review (17 bedside staff) 14 ancillary staff or directors) 1. Currently there are 6 residents with weight loss identified as of 6/23/22 and 1 resident with weight gain. 2. Dietician has reviewed all 7 residents and recommendations have been completed. Record review on 6/25/2022 of 7 residents (#1,2,3,4,5,6,7) revealed recommendations have been completed and documented in residents EMR. C. Systemic change taken to prevent reoccurrence 1. Based on the reweighs started on 6/24/22 any discrepancies identified the residents will be added to our weight log on 6/25/22. Record review on 6/25/2022 of weight log revealed weight log was in place. 2. DON or designee will review weight log weekly to identify any weight variance for timely notification and intervention of RD and MD recommendations and orders. This was started on 6/24/22. 6/25/2022: Record review and interview on 6/25/2022 with DON confirmed. 3. A weekly weight log will be reviewed at the clinical meeting and will be initialed when all results of weight variance are communicated to physician and RD. This was started on 6/24/22. VERIFICATION:6/25/2022: Record review and interview with DON confirmed. 4. Dietician and physician will be notified for review of identified weight variance. This was started on 6/23/22. VERIFICATION: 6/25/2022: Record review and interview with DON confirmed. 5. A QAPI meeting will be held daily to review summaries of actions taken. - DON, ADON, or designee will review daily the meal intake from the previous day for each resident. - Residents that ate less than 50% of their meal for three consecutive meals will be added to the weekly weight log. - This was started on 6/25/22. VERIFICATION: 6/25/2022 6/25/2022: Record review (resident #1,2,3,4,5,6,7) EMAR) and interview with DON confirmed. 6. The facility will consult the physician and dietician change of condition that could lead to failure to eat/consume fluids/caloric intake. All recommendations will be followed timely. This was started on 6/23/22. VERIFICATION: 6/25/2022-Record review of POR binder and interview with DON confirmed. 7. Once it is determined that a change of condition has occurred, that resident will be added to weekly weights. This was started on 6/23/22. VERIFICATION: 6/25/2022-Record review of POR binder and interview with DON confirmed. 8. DON, ADON, or designee will be responsible for following-up on and monitoring the resident's change of condition that could lead to failure to eat/consume fluids/caloric intake. This was started on 6/23/22. VERIFICATION: 6/25/2022-Record review of POR binder and interview with DON confirmed. 9. Charge nurses will monitor all residents with a change of condition, and any significant change will be notified to the MD. This was started on 6/24/22. VERIFICATION: 6/25/2022-Record review of POR binder included in-services and interview with DON confirmed. 10. Residents identified with a change of condition that could lead to failure to eat/consume fluids/caloric intake will be weighed and monitored weekly until the weight is stable and then every two weeks thereafter until the IDT determines the weight is stable and then the resident will be weighed monthly. This was started on 6/24/22. VERIFICATION:6/25/2022- Record review of POR binder included in-services and interview with DON confirmed. 11. DON, ADON, or designee will follow up and ensure recommendations by the RD/MD will be put in place. This was started on 6/23/22 VERIFICATION: 6/25/2022-Record review of POR binder included in-services and interview with DON/ADON confirmed. Record review of recommendations by RD and MD reviewed. 12. The end date of the in-service trainings that began on 6/24/22 will be completed by 6/25/22. VERIFICATION: 6/25/2022-Record review of POR binder included in-services. 13. RD will visit every resident monthly and those on the weekly weight list twice a month. Any resident identified with a change of condition that could lead to failure to eat/consume fluids/caloric intake will be reviewed within 72 hours of change. This was started on 6/23/22. VERIFICATION: 6/25/2022-Record review of POR binder included in-services and interview with DON/ADON / RD confirmed. Record review of recommendations by RD and MD reviewed. 14. Pharmacist will complete the medication reviews for those identified with a change of condition that could lead to failure to eat/consume fluids/caloric intake within 72 hours. This was started on 6/25/22. VERIFICATION: 6/25/2022- Record review of POR binder and interview with DON/ADON confirmed. Record review of recommendations by RD and MD reviewed. With plan for Pharmacist review. D. Monitoring 1. Weekly review of weights, implementation of recommendations, communication to MD staring. VERIFICATION: 6/25/2022- Record review of POR binder included in-services and interview with DON/ADON confirmed. Record review of weekly weight log done. 2. DON or designee will monitor notifications to physician for all weight variance and recommendations made by RD. VERIFICATION: interview with DON/ADON confirmed. Record review of weekly weight log done in POR binder. 3. Summary of IJ and corrective action to be reviewed by QAPI until substantial compliance is established and continue monthly for 90 days to ensure ongoing compliance. Monthly QAPI meeting will include review of resident weights (monthly, weekly, and variance). VERIFICATION: 6/25/2022- interview with DON/ADON confirmed. Record review of weekly weight log done in POR binder. On 6/25/2022 at 8:48 p.m. the Administrator was informed the IJ was removed however the facility remained out of compliance at a severity level of harm at a scope of isolated due to the need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on Interview and Record Review, the facility failed to ensure that a Resident received CPR (Cardio [MEDICAL CONDITION] Resuscitation) in accordance with Professional Standards of Practice for one (Resident #1) of seven Residents reviewed for CPR. LVN/CN #1 failed to initiate CPR for a Resident who was a Full Code status. The resident expired in the facility. This was determined to be an Immediate Jeopardy at Past Non-Compliance from [DATE] until [DATE], due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. These failures could affect all Full Code Residents who could need CPR by placing them at risk of death. The findings Included: Record Review of Resident #1's Face Sheet dated [DATE] indicated he was [AGE] years old and admitted to the facility [DATE]. [DIAGNOSES REDACTED]. Additional Information, at the bottom of the Face Sheet, included Code Status as Full Code. Record Review of Resident #1's (MONTH) 2019 Physician Orders (valid for 60 days) included an order for [REDACTED].>Record Review of Resident #1's Care Plan dated [DATE] included: Advance Care Planning: I wish to remain a Full Code at this time. My Code Status will be honored and I will be treated with dignity and respect for the next 90 days. One of the interventions reflected; Staff will start CPR should [MEDICAL CONDITION] occur and/or breathing independently cease, call 911 and transport to ER. Record Review of the Provider Investigation Report (PIR) dated [DATE] at 4:31 pm documented that Resident #1 was found unresponsive and CPR procedures were not followed. The PIR further documented that on [DATE] at 7:19 am per the ADON, LVN/CN #1, called the ADON to inform her that Resident #1 had expired. After hanging up the phone call, ADON immediately attempted to get a hold of LVN/CN #1 with additional questions. The ADON was unable to get a hold of anyone on the phone until 7:33 am. CNA #1 answered the phone, the ADON asked what Resident #1's Code Status was, upon finding out he was a Full Code the ADON instructed LVN/CN #1 and CNA #1 to begin CPR and call 911. The Investigation Summary reflected there were inconsistencies in LVN/CN #1's account of what happened verses the account given by other staff members present that morning evidenced by the following: The PIR documented the Administrator and DON interviewed CNA #2, and she revealed she checked on Resident #1 during her last rounds at approximately 5:05 am. CNA #2 stated he had his oxygen on, his head of bed elevated, and she could see that he was breathing The PIR dated [DATE] revealed LVN/CN #1 documented that at 6:40 am on [DATE] she was making rounds and noted Resident #1 was unresponsive. LVN/CN #1 documented she went to the chart and discovered Resident #1 was a Full Code, started CPR and called 911. LVN/CN #1 documented Resident #1 had a blood pressure of ,[DATE], pulse 146 with no respirations, then documented 2 minutes later his blood pressure was ,[DATE], pulse 71 and she continued CPR until EMS (Emergency Medical Services) arrived and took over. According to the PIR the Administrator and DON interviewed LVN/CN #1, and she stated she found Resident #1 unresponsive at 6:40 am while doing rounds. LVN/CN #1 stated Resident #1 had no pulse or breath sounds, that his hands were blue, and his lips appeared dry and white. Further documentation of the PIR reflected LVN/CN #1 told the Administrator and DON that she went to get CNA #1, they went back to his room and began CPR. LVN/CN #1 stated she was in the Resident's room with CNA #1 when she spoke with ADON on the phone. Further review of the PIR, when the Administrator and DON interviewed LVN/CN #2, she stated she received a call at 6:50 am from Resident #1's friend wanting to make sure the Resident was going to [MEDICAL TREATMENT] that morning ([DATE]). LVN/CN #2 relayed the message to LVN/CN #1 who then went to Resident #1's room. The PIR indicated these accounts were verified by CNA #1 to the ADON. In the PIR the CNA #1 also verified that she and LVN/CN #1 were at the nurse's station when they were on the phone with ADON to find out Code Status at 7:33 am. The PIR further documented CNA #1 stated LVN/CN #1 asked the Activity Director to call 911 and a Code Blue when they (CNA #1, LVN/CN #1) were going back into Resident #1's room. Further documentation of the PIR revealed there were multiple staff members present in the building and they heard the Code Blue called on overhead speaker around 7:30 am. LVN/CN #2's call phone call log; she called 911 at 7:36 am. The PIR revealed San(NAME)Police Department confirmed the 911 call was marked as 7:38 am. EMS arrived at 7:41am. The PIR further documented Resident #1 was pronounced dead at 8:00 am. Further documentation of the PIR revealed the Administrator and DON obtained details that were provided during staff interviews that directed them to the conclusion that the Resident was found unresponsive at approximately 6:55 am, that LVN/CN #1 called the ADON at 7:19 am to inform her the Resident had expired. On a phone call at 7:33 am is when CPR was initiated after the ADON instructed LVN/CN #1 to do so. In an interview with the DON and Administrator on [DATE] at 3:20 pm, they said they verified the accounts of their investigation by interviewing all staff present on the day shift Resident #1 passed away, getting staff to write their statements, contacting EMS to find out the time they received a call from facility. The Administrator and DON verified Resident #1 was found without a pulse and not breathing from approximately 6:50 am to 7:30 am. They participated in mock codes, and helped audit 100 % of resident charts for code status with doctor's orders, and face sheet. They stated the facility would have mock codes once a month from now on rotating each shift. In an interview with the ADON on [DATE] at 3:55 pm, the ADON stated LVN/CN #1 called her on [DATE] at 7:19 am and told her that Resident #1 was cold and dead. ADON stated the phone call got dropped (cut off). The ADON said she tried to get ahold of someone at facility and did so at 7:33 am. When CNA #1 answered, her phone is when the ADON asked where LVN/CN #1 was and CNA #1 said right here. The ADON told CNA #1 to ask LVN/CN #1 if he was a Full Code or a DNR. The ADON said she could hear LVN/CN #1 flipping through the chart then said in the background Full Code. The ADON instructed them to call 911 and start CPR. According to the ADON, CNA #1 said okay and the phone hung up. The ADON said she asked LVN/CN #1 why she didn't start CPR, LVN/CN #1 told her well he was Hospice, I thought he was a DNR. Record review of LVN/CN #1's Timecard revealed she did not clock in for work until 6:41 am on [DATE] but documented she found Resident #1 unresponsive at 6:40 am. In an interview with CNA #1 on [DATE] at 8:07 am, CNA #1 stated LVN/CN #1 called her to Resident #1's room (could not recall the exact time) and asked her to confirm that he was dead. CNA #1 said she told LVN/CN #1 she was pretty sure he was dead; he wasn't breathing, he was cold and blue. CNA #1 said LVN/CN #1 stated she was going to go notify people and get him cleaned up. In a telephone interview with LVN/CN #1 on [DATE] at 9:53 am, LVN/CN #1 stated when she entered Resident #1's room (could not recall the exact time) that morning on [DATE] and he didn't look right, he had white stuff dried on his lips. LVN/CN #1 stated she called CNA #1 and LVN/CN #2 to come look and confirm if the Resident was dead or not. LVN/CN #1 said she then called the ADON as required to notify her that Resident #1 was unresponsive. When asked if she started CPR before or after calling the ADON, she replied um, I think it was after. When asked if she thought he was a DNR because he was on Hospice, she stated no, no, no. In an interview with LVN/CN #2 on [DATE] at 12:10 pm, she was asked what she is supposed to do when a Resident is unresponsive she stated to stay with the Resident, yell for help, call for help on walkie talkie if you have one, call Code Blue if resident is a Full Code. She said then someone should bring the chart, Crash Cart, AED, call EMS, start compressions. Someone should call the ADON or DON. LVN/CN #1 didn't do that, she said oh he is Hospice and called Hospice and the friend. Record Review of LVN/CN #1's CPR certification reflected it was issued on (MONTH) (YEAR) with a renewal date of (MONTH) 2020. Record Review of CNA #1's CPR certification reflected it was issued on (MONTH) (YEAR) with a renewal date of (MONTH) 2020. Record Review of all other staff CPR cards reflected their CPR Certification was up to date. Record review of the facilities' in-service dated [DATE] on Nursing Review on Skills that included review on CPR Techniques and Crash Cart review reflected LVN/CN #1 was in attendance. Record review of the facility policy and procedure dated ,[DATE] and titled Emergency Procedure - Cardiopulmonary Resuscitation documented the following: Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden [MEDICAL CONDITION]. General Guidelines: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR. Emergency Procedure - Cardiopulmonary Resuscitation: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). Record review of the facilities' in-services dated [DATE] - [DATE] reflected the following subject areas: Mock Code, response time, do not leave the Resident, call for help, get chart, CPR, what to do with no pulse on a Resident, DNR status, Full Code Status, Hospice patients that are Full Code, advance directive papers, calling 911, Crash Cart, time line, Code Blue, vitals, documentation, how to document on an expired Resident. It was determined this failure placed Residents in an Immediate Jeopardy situation which continued from [DATE] to [DATE]. The facility took the following action to correct the non-compliance: Record Review of the Provider Investigation Report dated [DATE] at 4:31 pm indicated the facility suspended LVN/CN #1 upon knowledge of improper code being conducted. After investigation, LVN/CN #1 was terminated. The facility referred LVN/CN #1's licenses to the Texas Board of Nursing. All staff were in-serviced by the ADON for proper CPR/Full Code procedures, Hospice doesn't always mean a DNR status, expectations of starting CPR, Crash Cart, AED, 100% audit of all Resident charts; checking Code Status on physician orders, face sheet, colored sheet in front of chart, and performed Mock Codes on all shifts. The in-services began on [DATE] and were completed on [DATE]. On [DATE] separate interviews were conducted with LVN/CN #2 at 9:10 am, LVN/CN #3 at 10:00 am, CNA #3 at 10:06 am, LVN/CN #4 at 10:11 am, CNA #4 at 10:16 am, CNA #5 at 10:20 am, LVN/CN #5 at 10:25 am, LVN/CN #6 at 2:20 pm, and LVN/CN #7 at 2:30 pm on the questions below: Each nurse/nurse's aide responded correctly to the following questions: What do you do if you find a Resident unresponsive, what is your procedure? Answer: stay with Resident, yell for help, someone gets the chart to check Code Status; if Full Code - call Code Blue and 911. Start CPR. Someone gets the Crash Cart and AED. Someone calls DON/ADON. Continue CPR until EMS arrive to take over. In an interview with the DON on [DATE] 3:55 pm, the DON was asked what measures were put into place to correct the Past Non-Compliance that occurred with Resident #1. The DON replied LVN/CN #1 was immediately suspended pending investigation. The facility began in-servicing all staff on Code Status, Hospice doesn't always mean a DNR status, expectations of starting CPR, Crash Cart, AED, we did 100% audit of all Resident charts checking Code Status on physician orders, face sheet, colored sheet in front of chart. The DON said, We reviewed LVN/CN #1 service record, she was terminated. We referred her nursing license to the nursing board. In an interview with the Administrator on [DATE] at 9:42 am, the Administrator was asked what measures were put into place to correct the Past Non-Compliance concerning the death of Resident #1. She stated the facility in-serviced on Code Status, initiating CPR, did Mock Codes, evaluated all Hospice Residents Code Status because LVN/CN #1 thought that Hospice meant automatic DNR status but we reviewed all Residents Code Status. The Administrator said they reviewed LVN/CN #1's service record; she had been in-serviced on CPR and Code Status the month before (January). When asked if she felt the interventions had been effective she replied yes. When asked if the facility has had any codes since the [DATE] incident, she said yes they had, it was a Hospice Resident who was a Full Code. She stated staff did what they were supposed to do and that staff revived her and sent her to the hospital.

Based on Interview and Record Review, the facility failed to ensure the Resident's right to be free from Abuse for one (Resident #1) of seven residents reviewed for Abuse. LVN/CN #1 failed to initiate and conduct CPR for a Resident who was a Full Code status. The resident expired in the facility. This was determined to be an Immediate Jeopardy at Past Non-Compliance from [DATE] until [DATE], due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. These failures could affect all Full Code Residents who could need CPR by placing them at risk of death. The findings Included: Record Review of Resident #1's Face Sheet dated [DATE] indicated he was [AGE] years old and admitted to the facility [DATE]. [DIAGNOSES REDACTED]. Additional Information, at the bottom of the Face Sheet, included Code Status as Full Code. Record Review of Resident #1's (MONTH) 2019 Physician Orders (valid for 60 days) included an order for [REDACTED].>Record Review of Resident #1's Care Plan dated [DATE] included: Advance Care Planning: I wish to remain a Full Code at this time. My Code Status will be honored and I will be treated with dignity and respect for the next 90 days. One of the interventions reflected; Staff will start CPR should [MEDICAL CONDITION] occur and/or breathing independently cease, call 911 and transport to ER. Record Review of the Provider Investigation Report (PIR) dated [DATE] at 4:31 pm documented that Resident #1 was found unresponsive and CPR procedures were not followed. The PIR further documented that on [DATE] at 7:19 am per the ADON, LVN/CN #1, called the ADON to inform her that Resident #1 had expired. After hanging up the phone call, ADON immediately attempted to get a hold of LVN/CN #1 with additional questions. The ADON was unable to get a hold of anyone on the phone until 7:33 am. CNA #1 answered the phone, the ADON asked what Resident #1's Code Status was, upon finding out he was a Full Code the ADON instructed LVN/CN #1 and CNA #1 to begin CPR and call 911. The Investigation Summary reflected there were inconsistencies in LVN/CN #1's account of what happened verses the account given by other staff members present that morning evidenced by the following: The PIR documented the Administrator and DON interviewed CNA #2, and she revealed she checked on Resident #1 during her last rounds at approximately 5:05 am. CNA #2 stated he had his oxygen on, his head of bed elevated, and she could see that he was breathing The PIR dated [DATE] revealed LVN/CN #1 documented that at 6:40 am on [DATE] she was making rounds and noted Resident #1 was unresponsive. LVN/CN #1 documented she went to the chart and discovered Resident #1 was a Full Code, started CPR and called 911. LVN/CN #1 documented Resident #1 had a blood pressure of ,[DATE], pulse 146 with no respirations, then documented 2 minutes later his blood pressure was ,[DATE], pulse 71 and she continued CPR until EMS (Emergency Medical Services) arrived and took over. According to the PIR the Administrator and DON interviewed LVN/CN #1, and she stated she found Resident #1 unresponsive at 6:40 am while doing rounds. LVN/CN #1 stated Resident #1 had no pulse or breath sounds, that his hands were blue, and his lips appeared dry and white. Further documentation of the PIR reflected LVN/CN #1 told the Administrator and DON that she went to get CNA #1, they went back to his room and began CPR. LVN/CN #1 stated she was in the Resident's room with CNA #1 when she spoke with ADON on the phone. Further review of the PIR, when the Administrator and DON interviewed LVN/CN #2, she stated she received a call at 6:50 am from Resident #1's friend wanting to make sure the Resident was going to [MEDICAL TREATMENT] that morning ([DATE]). LVN/CN #2 relayed the message to LVN/CN #1 who then went to Resident #1's room. The PIR indicated these accounts were verified by CNA #1 to the ADON. In the PIR the CNA #1 also verified that she and LVN/CN #1 were at the nurse's station when they were on the phone with ADON to find out Code Status at 7:33 am. The PIR further documented CNA #1 stated LVN/CN #1 asked the Activity Director to call 911 and a Code Blue when they (CNA #1, LVN/CN #1) were going back into Resident #1's room. Further documentation of the PIR revealed there were multiple staff members present in the building and they heard the Code Blue called on overhead speaker around 7:30 am. LVN/CN #2's call phone call log; she called 911 at 7:36 am. The PIR revealed San(NAME)Police Department confirmed the 911 call was marked as 7:38 am. EMS arrived at 7:41am. The PIR further documented Resident #1 was pronounced dead at 8:00 am. Further documentation of the PIR revealed the Administrator and DON obtained details that were provided during staff interviews that directed them to the conclusion that the Resident was found unresponsive at approximately 6:55 am, that LVN/CN #1 called the ADON at 7:19 am to inform her the Resident had expired. On a phone call at 7:33 am is when CPR was initiated after the ADON instructed LVN/CN #1 to do so. In an interview with the DON and Administrator on [DATE] at 3:20 pm, they said they verified the accounts of their investigation by interviewing all staff present on the day shift Resident #1 passed away, getting staff to write their statements, contacting EMS to find out the time they received a call from facility. The Administrator and DON verified Resident #1 was found without a pulse and not breathing from approximately 6:50 am to 7:30 am. They participated in mock codes, and helped audit 100 % of resident charts for code status with doctor's orders, and face sheet. They stated the facility would have mock codes once a month from now on rotating each shift. In an interview with the ADON on [DATE] at 3:55 pm, the ADON stated LVN/CN #1 called her on [DATE] at 7:19 am and told her that Resident #1 was cold and dead. ADON stated the phone call got dropped (cut off). The ADON said she tried to get ahold of someone at facility and did so at 7:33 am. When CNA #1 answered, her phone is when the ADON asked where LVN/CN #1 was and CNA #1 said right here. The ADON told CNA #1 to ask LVN/CN #1 if he was a Full Code or a DNR. The ADON said she could hear LVN/CN #1 flipping through the chart then said in the background Full Code. The ADON instructed them to call 911 and start CPR. According to the ADON, CNA #1 said okay and the phone hung up. The ADON said she asked LVN/CN #1 why she didn't start CPR, LVN/CN #1 told her well he was Hospice, I thought he was a DNR. Record review of LVN/CN #1's Timecard revealed she did not clock in for work until 6:41 am on [DATE] but documented she found Resident #1 unresponsive at 6:40 am. In an interview with CNA #1 on [DATE] at 8:07 am, CNA #1 stated LVN/CN #1 called her to Resident #1's room (could not recall the exact time) and asked her to confirm that he was dead. CNA #1 said she told LVN/CN #1 she was pretty sure he was dead; he wasn't breathing, he was cold and blue. CNA #1 said LVN/CN #1 stated she was going to go notify people and get him cleaned up. In a telephone interview with LVN/CN #1 on [DATE] at 9:53 am, LVN/CN #1 stated when she entered Resident #1's room (could not recall the exact time) that morning on [DATE] and he didn't look right, he had white stuff dried on his lips. LVN/CN #1 stated she called CNA #1 and LVN/CN #2 to come look and confirm if the Resident was dead or not. LVN/CN #1 said she then called the ADON as required to notify her that Resident #1 was unresponsive. When asked if she started CPR before or after calling the ADON, she replied um, I think it was after. When asked if she thought he was a DNR because he was on Hospice, she stated no, no, no. In an interview with LVN/CN #2 on [DATE] at 12:10 pm, she was asked what she is supposed to do when a Resident is unresponsive she stated to stay with the Resident, yell for help, call for help on walkie talkie if you have one, call Code Blue if resident is a Full Code. She said then someone should bring the chart, Crash Cart, AED, call EMS, start compressions. Someone should call the ADON or DON. LVN/CN #1 didn't do that, she said oh he is Hospice and called Hospice and the friend. Record Review of LVN/CN #1's CPR certification reflected it was issued on (MONTH) (YEAR) with a renewal date of (MONTH) 2020. Record Review of CNA #1's CPR certification reflected it was issued on (MONTH) (YEAR) with a renewal date of (MONTH) 2020. Record Review of all other staff CPR cards reflected their CPR Certification was up to date. Record review of the facilities' in-service dated [DATE] on Nursing Review on Skills that included review on CPR Techniques and Crash Cart review reflected LVN/CN #1 was in attendance. Record review of the facility policy dated ,[DATE] and titled Abuse Prevention Program documented the following: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other resident, consultants, volunteers, staff from other agencies, family member, legal representatives, friends, visitors, or any other individual. 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Record review of the facility policy and procedure dated ,[DATE] and titled Advance Directives documented the following: Policy Statement: Advance directives will be respected in accordance with state law and facility policy. Record review of the facilities' in-services dated [DATE] - [DATE] reflected the following subject areas: Mock Code, response time, do not leave the Resident, call for help, get chart, CPR, what to do with no pulse on a Resident, DNR status, Full Code Status, Hospice patients that are Full Code, advance directive papers, calling 911, Crash Cart, time line, Code Blue, vitals, documentation, how to document on an expired Resident. It was determined this failure placed Residents in an Immediate Jeopardy situation which continued from [DATE] to [DATE]. The facility took the following action to correct the non-compliance: Record Review of the Provider Investigation Report dated [DATE] at 4:31 pm indicated the facility suspended LVN/CN #1 upon knowledge of improper code being conducted. After investigation, LVN/CN #1 was terminated. The facility referred LVN/CN #1's licenses to the Texas Board of Nursing. All staff were in-serviced by the ADON for proper CPR/Full Code procedures, Hospice doesn't always mean a DNR status, expectations of starting CPR, Crash Cart, AED, 100% audit of all Resident charts checking Code Status on physician orders, face sheet, colored sheet in front of chart, performed Mock Codes on all shifts. The in-services began on [DATE] and were completed on [DATE]. On [DATE] separate interviews were conducted with LVN/CN #2 at 9:10 am, LVN/CN #3 at 10:00 am, CNA #3 at 10:06 am, LVN/CN #4 at 10:11 am, CNA #4 at 10:16 am, CNA #5 at 10:20 am, LVN/CN #5 at 10:25 am, LVN/CN #6 at 2:20 pm, and LVN/CN #7 at 2:30 pm on the questions below: Each nurse/nurse's aide responded correctly to the following questions: What do you do if you find a Resident unresponsive, what is your procedure? Answer: stay with Resident, yell for help, someone gets the chart to check Code Status; if Full Code - call Code Blue and 911. Start CPR. Someone gets the Crash Cart and AED. Someone calls DON/ADON. Continue CPR until EMS arrive to take over. In an interview with the DON on [DATE] 3:55 pm, the DON was asked what measures were put into place to correct the Past Non-Compliance that occurred with Resident #1. The DON replied LVN/CN #1 was immediately suspended pending investigation. The facility began in-servicing all staff on Code Status, Hospice doesn't always mean a DNR status, expectations of starting CPR, Crash Cart, AED, we did 100% audit of all Resident charts checking Code Status on physician orders, face sheet, colored sheet in front of chart. The DON said, We reviewed LVN/CN #1 service record, she was terminated. We referred her nursing license to the nursing board. In an interview with the Administrator on [DATE] at 9:42 am, the Administrator was asked what measure were put into place to correct the Past Non-Compliance concerning the death of Resident #1. She stated the facility in-serviced on Code Status, initiating CPR, did Mock Codes, evaluated all Hospice Residents Code Status because LVN/CN #1 thought that Hospice meant automatic DNR status but we reviewed all Residents Code Status. The Administrator said they reviewed LVN/CN #1's service record; she had been in-serviced on CPR and Code Status the month before (January). When asked if she felt the interventions had been effective she replied yes. When asked if the facility has had any codes since the [DATE] incident, she said yes they had, it was a Hospice Resident who was a Full Code. She stated staff did what they were supposed to do and that staff revived her and sent her to the hospital.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for 1 of 1 resident (#5) reviewed for code status in that: LVN A did not immediately initiate cardiopulmonary resuscitation (CPR) for resident #5 until approximately 15 minutes after she was found pulseless and without respiration. This was determined to be past non-compliance at an immediate jeopardy level due to the facility's implementation of actions that corrected the non-compliance prior to the investigation on [DATE]. The facility was out of compliance from [DATE] through [DATE]. The facility's corrected action was completed on [DATE]. The deficient practice could affect 23 residents who were full code under the care of LVN A on [DATE] and could result in residents not receiving CPR immediately if they required it. The findings were: Record review of resident #5's facesheet ([DATE]) revealed [DIAGNOSES REDACTED]. Record review of a green constructive paper towards the front of the chart revealed resident was full code. Review of resident #5's physicians consolidated order for ,[DATE] revealed resident #5's advance directive was full code. Record review of resident #5's careplan dated [DATE] revealed resident #5 was full code. Record review of the facility's investigative report revealed on [DATE] at 4:10 a.m. LVN A went to resident #5's room to give her medications. LVN discovered resident #5 lying across the bed with one leg on the wheelchair. LVN A checked for a response and the resident did not respond (the report did not indicate how LVN A checked for response). LVN A yelled out to the aides to assist and check her vitals. CNA C came into the room and checked the resident's vital signs. Resident #5 did not have a pulse. The nurse went to the desk and called family and asked RN B for assistance. RN B informed LVN A to call 911 and the ADON. When LVN A called the ADON, she told him to start CPR, the resident was full code. The facility's investigation concluded that there was a delay of approximately ,[DATE] minutes in providing CPR to resident #5. Further review of the provider action taken post-investigation included staff members were re-educated on code blue status and LVN A was terminated. Review of a timeline created by the ADON revealed at 4:42 a.m. revealed she received a call from LVN A and the ADON informed him to get off the phone and start CPR and call 911. Record review of RN B's statement from the facility's investigation (dated [DATE]) revealed at approximately 4:30 a.m. LVN A came to the first floor and asked her who do I call if a patient dies and it is not a hospice patient?. RN B told LVN A that he would call the ADON, the doctor, and the patient's family. LVN A stated he had left a message for the doctor and had spoken to the family. LVN A also stated that he had texted the ADON. RN B told LVN A to call the ADON now! LVN A then left the first floor and went back to the 3rd floor. At approximately 4:46 a.m., RN B received a call from the ADON, who told her to go to the 3rd floor and help LVN A and check to see how he was doing and then call her back. RN B arrived on the 3rd floor and found LVN A in the resident's room performing chest compressions on the resident. RN B then assisted LVN A in the CPR process. Interview with RN B on [DATE] at 11:21 a.m. revealed LVN A went to ask her what to do if a resident died and she was not on hospice, on [DATE] at 4:30 a.m. Further interview revealed the ADON called RN B back at on [DATE] at 4:45 a.m. and instructed RN B to help LVN A. Interview with the DON on [DATE] at 8:40 a.m. confirmed CPR was delayed as LVN A perceived the person was dead and he was aware of resident #5's code status. Interview with the administrator on [DATE] at 10:57 a.m. revealed the facility conducted mock CPR in the past. Further interview revealed the facility encouraged nurses to attend but not required; however, LVN A did not attend. Record review of a training of a training for code blue, [MEDICAL CONDITION], and choking dated [DATE] revealed LVN A was not on the list of nurses that attended the training. Interview with LVN A on [DATE] at 11:02 a.m. revealed around 4:10 - 4:15 a.m. on [DATE] he went into resident #5's room to administer medication. Further interview revealed LVN A found her unresponsive on her bed without a pulse and not breathing. LVN A called out for CNA C , and directed her to take resident #5's vital signs. LVN A went to check resident #5's chart, which indicated she was full code. After CNA C informed LVN A resident #5 did not have vital signs, LVN A (stationed on the 3rd floor) texted the ADON and went down to ask RN B (stationed on the 1st floor) for guidance. RN B was on the first floor, LVN A reported he initiated CPR at approximately 4:25 a.m. on [DATE], after he was directed by the ADON. Further interview with LVN A revealed he didn't initiate CPR immediately because resident #5 did not have any vital signs, so she had already passed away, LVN A reported he was very confused at the time. Interview with CNA C on [DATE] at 11:12 a.m. revealed she was coming out of another room when LVN A told her resident #5 was dead and to check for resident #5's vital signs, which she was not able to obtain. CNA C reported resident #5 did not have vital signs. Further interview revealed she assumed LVN A had checked the code status already, but didn't inform her if resident #5 was full code or no CPR. Interview with CNA D on [DATE] at 11:15 a.m. revealed CNA C came and got her during her last round, around 4 something and informed her that resident #5 had passed away. CNA D informed CNA C that she had just seen her at 3:30 a.m. in the elevator coming up from smoking. Interview with the ADON on [DATE] at 8:50 a.m. revealed she oriented new employees on the resident's code process, DNR, orders, careplans, and colored sheet in front of the chart. Record review of the facility's policy and procedure for cardiopulmonary resuscitation (2012) revealed procedures included 1) determine unresponsiveness by tapping or gently shaking the resident and shouting are you okay, 2) if the resident does not respond, call out for help, and 3) delegate a specific individual to check the resident's orders and careplan for CPR or no CPR order. Have an individual call paramedics, attending physician, and administrative personnel on duty and report back as soon as possible. 4) Notify the attending physician of the resident's condition and request further orders for care. 5) Place the resident on their back, supporting the head and neck, on a hard surface. Perform CPR if the resident is unresponsive and not breathing or no normal breathing. The administrator was informed of the past non-compliance on [DATE] at 8:30 a.m. The facility's corrective action plans included and verified by the surveyor it had taken place: 1. Re-inserviced staff on each shift on [DATE] of the facility's policy and procedure on the code blue and emergency procedure. This included a mock code blue situation. 2. Conducted a 100 % audit of all charts to ensure the code status was in the chart, to include physicians orders, and care plans were in place. 3. Termination of LVN A. 4. Currently on going processes in place included the ADON oriented new employees on the resident's code process, DNR, orders, careplans, and colored sheet in front of the chart. Regular inservices and classes on CPR quarterly and as needed, and the maintenance director provided new employee orientation on different codes (code blue, gray, etc.). The plan of correction was verified by the surveyor through record review of the inservice and interview with 6 CNAs on different shifts, 3 LVNs on different shifts, social worker, house keeper, medication aide, and activities director assistant. The surveyor reviewed and verified with the sampled residents their code status, physician's orders [REDACTED]. Information provided by the administrator revealed LVN A cared for 23 residents who were full code on [DATE].

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 4 residents (#18 & #5) reviewed for falls, and failed to ensure the resident environment remained free of accident hazards for 1 of 1 smoking area, in that: 1. Supervision and interventions were not in place for resident #18 who had 8 falls from November 2013 to April 2014. This resulted in resident #18 falling and fracturing her hip. 2. Supervision of interventions were not in place for resident #5 who had 3 falls from January 2014 to April 2014. 3. The smoking area did not have any ashtrays. This deficient practice could affect 71 residents assessed at risk for falls and could result in injuries resulting from falls. Fourteen residents smoked at the facility and an absence of ashtrays could result in a fire. The findings were: 1. Review of the face sheet, dated 9/9/13, for resident #18 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a History and Physical, dated 8/27/13, for resident #18 revealed she was admitted to the facility due to a left hip fracture repair, was in the facility for rehabilitation, and had decreased range of motion. [DIAGNOSES REDACTED]. Review of an Admission MDS, dated [DATE], for resident #18 revealed she had clear speech, made self-understood and sometimes understood others. Review of the BIMS score revealed a 4 out of 15 (severely impaired cognitive status). During transfers resident #18 needed extensive assistance with one person physical assist. Walk in room for resident #18 was coded as needing limited assistance with one person physical assist. Range of motion revealed no impairment. Review of the fall history revealed resident #18 had no falls or fractures within 6 months before entry to the facility. Review of a Readmission MDS, dated [DATE], for resident #18 revealed she had clear speech, made self-understood and understands others. Review of the BIMS score revealed a 9 out of 15 (moderately impaired). During transfers resident #18 needed extensive assistance with one person physical assist. Walk in room: resident #18 was coded as needing extensive assistance with one person physical assist. Range of motion revealed no impairment. Review of the fall history revealed resident #18 had falls since admit/reentry/prior assessment. Resident #18 was coded as having a fall with a major injury. Review of the Incident & Accident Logs and SBAR Communication Forms revealed the following 8 falls for resident #18: 08/19/13, 11/12/13, 11/27/13, 12/14/13, 03/03/14, 03/10/14, 03/27/14, 04/15/14, and 04/21/14 A. 08/19/13 Fall-Review of SBAR Communication Form revealed resident #18 fell while trying to get out of her wheel chair. Review of initial MDS dated [DATE] revealed " falls since admission " being marked as " no " . Review of 14 day MDS dated [DATE] revealed " falls since admission " being marked as " no " . Review of consolidated physicians orders for September 2013 revealed resident to have " poor safety awareness " and the resident was ordered a wheel chair alarm to be " in place at all times. " Review of the care plan provided revealed no fall interventions for 08/19/13 fall. Review of the Fall Risk Evaluation on 10/9/13 revealed a score of 17 indicating resident #18 as being at high risk for falls (total score of 10 or high or above represents High Risk). A score of 10 or higher indicates high risk for falls. Form stated " A prevention protocol should be initiated immediately and documented on the care plan. " B. 11/12/13 Fall-Review of SBAR Communication Form revealed skin tear as a result of a fall. Review of the care plan provided revealed no fall interventions for 11/12/13 fall. Review of quarterly MDS dated [DATE] revealed " falls since admission " being marked as " no " indicating no falls prior to 11/14/13. C. 11/27/13 Fall-Review of the Fall Risk Evaluation on 11/27/13 revealed a score of 20 (total score of 10 or above represents High Risk). Form states " A prevention protocol should be initiated immediately and documented on the care plan. " Review of the 11/14/13 MDS BIMS score revealed a 6 out of 15 (severely impaired). Review of a care plan, dated 11/27/13, that was both printed and written on for resident #18 revealed fall approaches that included encourage resident to ask for assistance of staff, ensure call light is in reach, answer promptly, anticipate needs, provide prompt assistance. Further review of the care plan revealed columns next to approaches titled " date reviewed " and " status/date " with the code options of " R=resolved " and " C=continued " were blank. Review of Daily Skilled Nurse ' s Notes dated 12/01/13, 12/04/13, 12/06/13, 12/07/13, 12/08/13, and 12/13/13 revealed that " safety maintained " was documented. Notes on what fall prevention protocol or interventions were in place were not documented. D. 12/14/13 Fall-Review of incident log revealed resident #18 had a fall with no apparent injuries. Review of Geriatric Associates of America visit form dated 12/24/13 revealed a request that resident #18 ' s bed be lowered and that the resident receive a floor mat. Review of a care plan, dated 12/14/13, that was both printed and written on for resident #18 revealed fall approaches were the same as the previous fall and included encourage resident to ask for assistance of staff, ensure call light is in reach, answer promptly, anticipate needs, provide prompt assistance. Neither a lowered bed nor floor mat were mentioned in the care plan as a fall intervention. Further review of the care plan revealed columns next to approaches titled " date reviewed " and " status/date " with the code options of " R=resolved " and " C=continued " were blank. Review of the Geriatric Associates of America visit form dated 01/08/14 for resident #18 revealed the resident was " unable to participate in decisions due to dementia " . Review of Nurse ' s Notes and Daily Skilled Nurses Notes for the dates of 12/01/13 to 03/03/14 revealed no mention of fall prevention protocols or interventions in place or the monitoring of fall prevention interventions for resident #18. Review of the Fall Risk Evaluation on 1/2/14 revealed a score of 20 (total score of 10 or above represents High Risk). Form stated " A prevention protocol should be initiated immediately and documented on the care plan. " Review of quarterly MDS dated [DATE] revealed " falls since admission " being marked as " no " incorrectly indicating no falls prior to 02/13/14. E. 03/03/14 Fall-Review of incident log revealed resident #18 had a fall with no apparent injuries. Review of a Physician Telephone Order, dated 3/4/14, for resident #18 revealed an order for [REDACTED]. Review of March 2014 care plan revealed wheel chair alarm was not care planned. Review of consolidated physicians orders for March 2014 revealed that there was no longer an order as had been revealed in past (September 2013) consolidated physician orders [REDACTED]. " Nurse ' s notes on 03/04/14 revealed resident #18 ' s bed was lowered. Review of a care plan, dated 03/03/14, that was both printed and written on for resident #18 revealed fall approaches were the same as the previous care plan that included encourage resident to ask for assistance of staff, ensure call light is in reach, answer promptly, anticipate needs, provide prompt assistance. On 3/3/13 a therapy screen was added to the care plan. On 03/07/13 a bed alarm and scoop mattress were added to the care plan. A wheelchair alarm and monitoring of the alarm every shift is not mentioned in the care plan. A lowered bed or floor mat as a fall intervention was not mentioned in the care plan. Further review of the care plan revealed columns next to approaches titled " date reviewed " and " status/date " with the code options of " R=resolved " and " C=continued " were blank. Review of the care plan for subsequent fall dated 03/10/14 also revealed wheel chair alarm and lowered bed was not care planned. In an interview when asked what fall prevention protocol is used by nurses for residents who are deemed high risk on the fall risk evaluation form, the DON on 05/01/14 at 10:20 a.m. revealed that that there was no protocol and that they " evaluate for the most appropriate measures " for the resident. When asked again in an interview the DON on 05/02/14 at 10:30 a.m. revealed that the " initiative is up to the nurses to set up an immediate prevention protocol. No, I don' t have a falling star program or anything like that. " F. 03/10/14 Fall-Review of incident log revealed resident #18 had a fall with no apparent injuries. Review of a care plan, dated 03/10/14, that was both printed and written on for resident #18 revealed approaches for fall interventions were the same as the previous care plan and did not include additional prevention protocols to address the 03/10/14 fall. These measures included encourage resident to ask for assistance of staff, ensure call light is in reach, answer promptly, anticipate needs, provide prompt assistance, a therapy screen, a bed alarm and monitoring of the alarm every shift, and a scoop mattress. A wheelchair alarm and monitoring of the alarm every shift was not mentioned in the care plan. A lowered bed or floor mat as an intervention was not mentioned in the care plan. Further review of the care plan revealed columns next to the approaches titled " date reviewed " and " status/date " with the code options of " R=resolved " and " C=continued " were blank. G. 03/27/14 Fall-Review of incident log revealed resident #18 had a fall with a fracture. Review of Care Plan had an entry 3/27/2014 which indicated resident fell out of wheelchair while reaching out for the her tray. Review of a Nursing Home to Hospital Transfer Form, dated 3/27/14, revealed resident #18 was transferred to a hospital for possible fracture or break of the femur. Review of the Physician Telephone Orders, dated 4/4/14, for resident #18 revealed she was readmitted to the nursing facility with an order for [REDACTED]. Orders for fall preventions or assessment for potential medical causes for fall were not made by the doctor. Review of a History and Physical, dated 4/8/14, for resident #18 revealed a readmission to the facility on [DATE] from the hospital. She had sustained a fall at the nursing home with subsequent left femur fracture. This report indicated resident #18 was unable to participate in decisions due to dementia. Review of a care plan for April 2014 did not mention any fall prevention interventions for resident #18 ' s readmission to the facility on [DATE]. Additional fall preventions were not listed until 04/15/14, the date of the next fall. Review of Skilled Daily Nurse ' s Notes dated 04/4/14 revealed no mention of fall prevention interventions for resident #18. H. 04/15/14 Fall-Review of a SBAR Communication Form revealed resident #18 had a fall with head trauma. Review of Care Plan dated 4/15/2014 that she fell out of recliner while attempting to self transfer. Review of a Resident Incident Report, dated 4/15/14, for resident #18 revealed she had fallen; she was alert and oriented x 2. Resident #18 had an open wound to the left temple. She was sent to the emergency room and returned with sutures. A wheelchair alarm was initiated with the clip alarm on while up in the recliner. Report mentions that the resident was educated to ask for assistance when transferring and a scoop mattress, bed alarm was implemented and that her room had been moved closer to the nurses ' station. Review of a Fall Risk Evaluation, dated 4/15/14, for resident #18 revealed a score of 20 (total score of 10 or above represents High Risk). Form states " A prevention protocol should be initiated immediately and documented on the care plan. " Review of a care plan, dated 04/15/14, that was both printed and written on for resident #18 revealed approaches that included encourage resident to ask for assistance of staff, ensure call light is in reach, answer promptly, anticipate needs, provide prompt assistance and that a wheel chair alarm was in place. On 4/15 the care plan indicated wheel chair alarm placed, clip alarm placed while up in recliner and educated to ask for assistance before transferring. Further review of the care plan revealed columns next to approaches titled " date reviewed " and " status/date " with the code options of " R=resolved " and " C=continued " were blank. I. 04/21/14 Fall--Review of the nurse's notes, dated 4/22/14 revealed resident #18 had a fall on 4/21/14. X-ray of right hip was negative. Review of a care plan for April 2014 did not mention any fall prevention interventions for resident #18 ' s 04/21/14 fall. Observation on 5/2/14 at 7:40 a.m. of resident #18 revealed was lying in bed, on a scoop mattress, with the bed in low position. A mat was on the floor on the right side. There was a pressure alert pad to the bed. Resident #18 was resting with her eyes closed. Interview with DON on 05/02/14 at 10:30 a.m. revealed that she felt that fall interventions had been adequately added to care plans for residents #18. When asked about timing of fall interventions and the lack of mention in nurses notes on whether they had been implemented she confirmed that she could not confirm whether staff had implemented them. When asked about why the care plans either mentioned fall interventions not mentioned in nurses notes or the doctor ' s orders for the wheelchair alarm and monitoring of the alarm in September 2013 and March 2014 not being care planned until April 2014 she did not have an explanation. When asked if the fall interventions were monitored for effectiveness and tracked per facility policy she confirmed that they were not. When asked how the effectiveness of the fall measures or interventions on the care plan are deemed effective for further prevention of falls the DON revealed that " it is just put on the care plan as the intervention, so success is not tracked " . She explained both the printed care plan notes and handwritten was due to their preferring to use the same care plan each time and they "don't like to reproduce one". When asked how fall interventions are reported to direct care staff she stated that it is primarily through "verbal reports" as the staff has " accunurse headphones " that allow them to hear updates on residents over their headphones. Interview with charge LVN X and regional nurse on 05/02/14 at 9:15 a.m. revealed the process of communication and tracking for interventions for falls. When charge LVN X was asked what prevention protocol is used by nurses for residents who are deemed high risk on the fall risk evaluation form, she explained that the protocol the nurses follow for a fall is to fill out the SBAR at the time of the fall and then place it in the chart so that it can be picked up by MDS nurse. The MDS then triggers a care plan. She explained that the care plan is updated quarterly. When asked how the interventions are clearly shared with nursing staff in between the time the form is filled out and the next care plan is updated with fall interventions they are to implement she said she wasn't sure. The regional nurse agreed that she understood the question about their being a possible gap in the relaying of information to ensure successful interventions or preventions. She also confirmed that she agreed that tracking the effectiveness of an implemented fall interventions would be helpful for filling the gap and knowing if a resident was receiving interventions that were ordered or would prevent further falls. Nurse X also confirmed the facility does not have a means in place to document or track residents ' responses to fall interventions as part of the effort to prevent further falls. In an interview when asked what fall prevention protocol is used by nurses for residents who are deemed high risk on the fall risk evaluation form, the DON on 05/01/14 at 10:20 a.m. revealed that that there is no protocol and that they " evaluate for the most appropriate measures " for the resident. When asked again in an interview the DON on 05/02/14 at 10:30 a.m. revealed that the " initiative is up to the nurses to set up an immediate prevention protocol. No, I don ' t have a falling star program or anything like that. " 2. Review of April 2014 consolidated physician's order [REDACTED]. The resident was ordered to take Seroquel and Lorazepem for schizophrenia and anxiety. Review of an Admission MDS, dated [DATE], for resident #5 revealed a BIMS score of 7 indicating some difficulty with memory recall and orientation. The MDS also revealed he had the ability to transfer and ambulate on his one with setup assistance. Review of the fall history revealed resident #5 had no falls or fractures within 6 months before entry to the facility. Review of the Incident & Accident Logs and care plans revealed the following falls for resident #5. January 2014 -unwitnessed fall with a skin tear to the left cheek on 01/31/14. March 2014 -- a fall with a laceration to the forehead on 03/03/14 while getting out of bed to use the restroom. April 2014 --unwitnessed fall with head pain on 04/14/14. January 2014 --Review of undated SBAR Communication Form and Progress Note revealed resident #5 had a fall with skin tear to the left cheek. Interview with DON on 05/01/14 at 10:20 a.m. revealed the SBAR form is the first form to be filled out at the time of an incident and triggers an incident report. Review of Fall Risk Evaluation for resident #5 with the date of 01/31/14 revealed a score of 11. The form revealed that a score of 10 or above represents the resident to be high risk for falls. Form states " A prevention protocol should be initiated immediately and documented on the care plan. " In an interview with the DON on 05/01/14 at 10:20 a.m. revealed when asked what fall prevention protocol was used by nurses for residents who are deemed high risk on the fall risk evaluation form, that that there is no protocol and that they "evaluate for the most appropriate measures" for the resident. When asked again in an interview the DON on 05/02/14 at 10:30 a.m. revealed that the " initiative is up to the nurses to set up an immediate prevention protocol. No, I don' t have a falling star program or anything like that." In an interview when asked what prevention protocol is used by nurses for residents who are deemed high risk on the fall risk evaluation form, LVN X on 05/02/14 at 9:15 a.m. revealed that she didn' t know. She explained that the protocol the nurses follow for a fall is to fill out the SBAR at the time of the fall and then place it in the chart so that it can be picked up by MDS nurse. The MDS then triggers a care plan. LVN X also confirmed that there was no requirement or designated means to document or track residents response to fall interventions. Review of Resident Incident Report for the 01/31/14 revealed a section titled " medical risk factors possibly related to incident: " . All possible factors including "confusion/disorientation " were left unmarked. Review of undated pain evaluation included in incident report packet was blank in the section that requests that the " cause, origin of pain, radiation of pain ... " be listed. Review of undated care plan with hand written notation of 01/31/14 fall lists " resident education provided on safety awareness " . Further review of care plans revealed columns next to approaches titled " date reviewed " and " status/date " with the code options of " R=resolved " and " C=continued " were blank. When asked on 05/02/14 at 10:30 a.m. in an interview how the effectiveness of the fall measures or interventions on the care plan are deemed effective for further prevention of falls the DON revealed that " it is just put on the care plan as the intervention, so success was not tracked " . Undated and unsigned SBAR Communication Form and Progress Note revealed resident #5 had a wound to the forehead on 03/03/14. No mention of fall were listed in " change of condition " line and the box titled " falls " under " functional status changes " was unmarked. Review of Resident Incident Report for the 03/03/14 (print date of 04/04/14) revealed a section titled "medical risk factors possibly related to incident: " . All possible factors including " fall history " and " confusion/disorientation " were left unmarked. Narrative of the incident in this report was described as "resident was getting himself out of bed to use the toilet when he skipped and fell " . Review of undated pain evaluation included in incident report packet was blank in the section that requests that the " cause, origin of pain, radiation of pain ... " be listed. The name and signature of the nurse who conducted the assessment was blank. Review of Weekly Skin Assessment for resident #5 included in the incident report packet does not have a date for the assessment and was not signed or dated by a nurse. Review of Fall Risk Evaluation for resident #5 with the date of 03/3/14 revealed a score of 7. The section titled " History of Falls " was incorrectly left blank. The score would have been 11 had the correct box of " 1-2 falls in the past 3 months " had been correctly marked. The form reveals that a score of 10 or above represents the resident to be high risk for falls. Form states " A prevention protocol should be initiated immediately and documented on the care plan. " Review of hospice Coordination Notes dated 03/11/14 revealed that hospice was not notified of the resident ' s fall and that the resident " has unsteady gait at this time " . Review of Nurse ' s Notes dated 03/03/14 revealed the nurse "will notify a.m. staff for request of fall mat " . Review of undated care plan with hand written notation of 03/3/14 fall listed " night shift to toilet resident Q2hr since he appears more unsteady on his feet when sleepy " . Fall mat was not mentioned in care plan. Previous fall intervention of "resident education provided on safety awareness " was no longer included in the care plan. Further review of care plans revealed columns next to approaches titled " date reviewed " and " status/date " with the code options of " R=resolved " and " C=continued " were blank. No potential medical causes for history of falls were noted. Undated SBAR Communication Form and Progress Note revealed resident #5 had an unwitnessed fall on 04/14/14. Review of investigation packets for incidents and accidents revealed that no incident report was in the packet. And Incident Investigation form for the 04/14/2014 incident (with a print date of 04/30/14) that summarized the investigation was provided. The Incident Investigation for resident #5 reveals that toileting every 2 hours, a bed alarm and non-skid socks will be provided to resident in response to fall. Review of Fall Risk Evaluation for resident #5 with the date of 03/27/14 revealed a score of 17 and a score of 19 for the date of 04/14/14. The form reveals that a score of 10 or above represents the resident to be high risk for falls. Form states " A prevention protocol should be initiated immediately and documented on the care plan. " Review of undated care plan with hand written notation of 04/14/14 fall listed " resident to be toileted Q2 hr. during nights, place bed alarm at night " . Non-skid socks are not included in care plan. Further review of care plans revealed columns next to approaches titled " date reviewed " and " status/date " with the code options of " R=resolved " and " C=continued " were blank. No potential medical causes for history of falls were noted. Review of Nurses Notes on resident #5 make no mention of care plan intervention of toileting every two hours, bed alarm or non-skid socks having been implemented for the dates of: 03/05/14, 03/06/14, 04/14/14, 04/16/14, 04/17/14. Interview with charge LVN X on 04/29/14 at 9:09 a.m. during initial rounds revealed that the resident did have a bed alarm but that it may have been " dc ' d " . Interview with Activities Director on 04/29/14 at 9:05 a.m. who conducted the first half of the initial rounds revealed that resident #5 was no longer using the bed alarm because it didn' t work. Interview with DON on 05/01/14 at 10:20 a.m. revealed that the bed alarm was no longer being used with resident #5 because he would take it to the nurse ' s station at night and ask for help to turn it off. When asked what else was being implemented to prevent a future fall since the care planned fall intervention had not worked as hoped, she stated that the resident was being observed regularly. When asked if other fall interventions such as non-skid socks or floor mat had been implemented she could not recall a request for these or confirm that they had been implemented for the resident. Interview with nurse X on 05/02/14 at 9:10 a.m. revealed that there was no process for nurses to track residents care planned interventions to determine if carried out or successful as interventions. Observation of resident #5 on 04/29/14 at 09:05 a.m., 05/01/14 at 9:30 a.m. and 11:39 a.m. revealed no floor mat on the floor and bed alarm in the bed. Review of the facility Nursing Services Policy and Procedure Manual pg. 1 revealed that "the nurse shall assess and document/report the following: ....g. frequency and number of falls since last physician visit ....h. precipitating factors ....i. all current medications, especially those associated with dizziness and lethargy .... " Review of the facility Nursing Services Policy and Procedure Manual pg. 1 stated: " 3. The staff will document risk factors for falling in the resident ' s record and discuss the resident ' s fall risk. a. Risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, and illness affecting the central nervous system and blood pressure. " Interview with DON on 05/02/14 at 10:30 a.m. revealed that fall risk factors were not tracked or documented. Interview with charge nurse X on 05/02/14 at 8:45 a.m. revealed that fall risk factors or medical causes were not identified or documented. Review of the facility Nursing Services Policy and Procedure Manual pg. 1 stated: " 4. The physician will identify medical conditions affecting fall risk (for example, a recent stroke or medications associated with increased falling risk) and the risk for significant complications of falls. a. Falls often have medical causes; they are not just a ' nursing issue ' . " Interview with DON on 05/02/14 at 10:30 a.m. revealed that fall risk factors were not tracked or documented to determine medical causes. When asked about identifying medical conditions with the assistance of the doctor she stated that they cannot make them do this. Review of the facility Nursing Services Policy and Procedure Manual pg. 2 stated: "2. a. After more than one fall, the physician should review the resident's gait, balance and current medications that may be associated with dizziness or falling. b. Many categories of medications, especially combinations of medications in several of those categories, increase the risk of falling." Review of the facility Nursing Services Policy and Procedure Manual pg. 3 under Monitoring and Follow-Up stated: "2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 5. As needed, the physician will document the presence of uncorrectable risk factors, including reasons why any additional search for causes is unlikely to be helpful." Interview with charge nurse X on 05/02/14 at 8:45 a.m. revealed potential medical issues are not identified after a resident has multiple falls and that doctors are not asked to help staff identify uncorrectable risk factors. Interview with DON on 05/02/14 at 10:30 a.m. revealed that she felt that fall interventions had been adequately added to care plans for residents #12. When asked about whether the effectiveness of interventions were tracked per facility policy she confirmed that they were not. She explained both the printed care plan notes and handwritten was due to their preferring to use the same care plan each time and they "don't like to reproduce one". When asked how interventions are reported to direct care staff she stated that is primarily through "verbal reports" as the staff has accunurse headphones. Interview with charge LVN X and regional nurse on 05/02/14 at 9:15 a.m. revealed the process of communication for interventions for falls. When charge nurse X was asked what prevention protocol is used by nurses for residents who are deemed high risk on the fall risk evaluation form, she explained that the protocol the nurses follow for a fall is to fill out the SBAR at the time of the fall and then place it in the chart so that it can be picked up by MDS nurse and that the MDS then triggers a care plan. She explained that the care plan is updated quarterly. When asked how the interventions were clearly shared with nursing staff in between the time the form is filled out and the next care plan is updated she said she wasn't sure. The regional nurse agreed that she understood the question about their being a possible gap in the relaying of information to ensure successful interventions or preventions she also confirmed that she agreed that tracking the effectiveness of an implemented intervention would be helpful for filling the gap. LVN X also confirmed the facility does not have a means in place to document or track residents ' responses to interventions as part of the effort to prevent further falls. 4. Observation of the smoking area on 5/1/14 at 9:30 a.m. revealed several tables in the smoking area, but no ashtrays. Interview with resident #10 confirmed there were no ashtrays for the ashes or cigarette butts. He stated he put the ashes on the ground. Interview on 5/2/14 at 8:25 a.m. with the administrator revealed they did not have ash trays because the ash trays got stolen. A handwritten sheet provided by the facility revealed 71 residents assessed at risk for falls and 14 residents who smoked. .

Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as body weight, for 1 of 1 residents reviewed for weight loss in that: Resident #3 sustained a 5% weight loss in 2 weeks (significant) and a 9% weight loss (severe) in 6 weeks with no followup from the dietitian after the initial assessment on 2/28/14 to prevent further weight loss and decline until 4/03/14. This deficient practice resulted in a severe weight loss for resident #3 and could affect 4 residents with weight loss on the 100 hall. The findings were: Record review of the Physician's History and Physical revealed resident #3 was admitted to the facility 2/14/14 for rehabilitation purposes with the goal to return to his home. On 1/7/14 he had a bowel resection with an [MEDICAL CONDITION] for rectal adenocancer. He had recurrent intrabdominal abcesses with two resulting abdominal wounds from surgery. He was admitted with a wound to his leg and thigh. He was admitted with intravenous antibiotics. Record review of the Wound Care Specialist Initial Evaluation dated 2/28/2014 recommended a Multivitamin once a day, Vitamin C 500 mg twice a day and zinc sulfate 220 mg once a day for 14 days for wound care. The report also recommended a dietary consult as the resident's Body Mass Index was 17.37, based on his height of 62" and weight of 95 pounds. Record review of hospital discharge records dated 2/14/2014 revealed a hospital discharge weight of 100 pounds taken on 2/14/14. Weight taken at the facility by the restorative aide and recorded on 2/18/14 was 100 pounds. Weight recorded on 2/25/14 was 95 pounds. Weight on 3/1/14 was recorded as 96 pounds; on 3/17/14 recorded as 94 pounds; on 3/23/14 recorded as 91 pounds, on 4/1/14 recorded as 91 pounds, on 4/14/14 as 92 pounds, on 4/22/14 as 93 pounds and on 5/1/14 as 87 pounds. Record review of nutrition notes revealed a dietary assessment for food preferences was completed on 2/17/14 by the dietary manager. Review of the MDS dated [DATE] revealed in Section K, Swallowing and Nutritional Status, a height of 62" and weight of 100# was noted. Record review of the Consultant Dietitian Reports provided by the facility revealed the resident was not assessed by the registered dietitian on her 2/17/14 visit and was not placed on the 2/17/14 Resident Nutritional Recommendation/Review report, Monthly Weight Review, or Monthly Pressure Ulcer Report for Dietary Intervention. Record review of the medical record revealed a Weight Variance Assessment and Care Plan report completed on 2/27/14 by the DON documenting a weight of 95 pounds reflecting a 5% weight loss in one month, infection, cancer and, "picky eater and not eating." Weekly weights were recommended, snacks three times a day, and the dietitian was to evaluate. This form indicated it was given to the dietary manager. Record review of the registered dietitian's evaluation dated 2/28/14 revealed a "stable weight loss" from 100 pounds to 95 pounds. Nutritional requirements were estimated at 1591 calories and 68 grams of protein daily. The dietitian estimated his diet would provide 2100 calories and 86 grams of protein daily. Record review of the Communication Between the Dietitian and the Attending Physician form dated 2/28/14 revealed the dietitian identified the resident was a picky eater, had a [DIAGNOSES REDACTED]. Recommendations made were to discontinue the current diet order and start a Regular diet with fortified meal plan, begin Zinc Sulfate 220 mg daily for 14 days and Medpass 120cc four times a day for 30 days. The resident's name appeared on the Resident Nutritional Recommendations/Review report for the date of 2/28/14 noting the above information. All recommendations were made except changing the diet to regular. Record review revealed a care plan entry on 3/18/14 stating recent weight loss due to inadequate nutritional intake. Record review of Nursing Weekly Summary Reports completed on 2/19/2014, 3/5/2014, 3/13/14, 3/19/14 and 3/26/14 revealed a reported intake of 75% or more. Record review showed there were no other entries in the nutrition notes by the dietitian or dietary maanger until 4/3/2014 though he was identified as having significant weight loss, weekly weight loss, wounds and nutritional concerns on 2/28/2014. Record review of the registered dietitian note 4/3/14 revealed a response to a consult for low weight. Documented weight by dietitian was 91 pounds. The note did not document a severe weight loss had occured (9% in 5 weeks). [MEDICATION NAME] was started and [MEDICATION NAME] discontinued. The dietitian recommended to continue Medpass 4 times a day, discontinue the low concentrated sweets restriction, discontinue all snacks and offer shakes twice a day between meals but discontinue if he refused more than 3 days in a row. The resident's name was on the Resident Nutritional Recommendation/Review Report dated 4/3/2014. Record review of the Physician's progress note dated 4/8/2014 revealed he discussed placing a feeding tube with the resident's daughter and she agreed. Record review of the Dietitian's Consultation Reports for 4/11/14 revealed the resident was 91 pounds and was listed on the Monthly Weight Review for the first time at 91 pounds and 5.21% weight loss and for the first time on the Monthly Pressure Ulcer Review. The note did not document a severe weight loss had occured. Record review of dietitian's note 4/18/14 confirmed the feeding tube placement and revealed the tube feeding of Glucerna 1.2 at 50 cc per hour for 22 hours in 24 hours would provide 1320 calories and 66 grams of protein. Record review of the Dietary Consultation Reports dated 4/25/14 revealed the resident on the Monthly Weight, Pressure Ulcer and Tube Feeding Reviews. Record review of dietitian's note dated 5/1/14 revealed a weight of 89# and poor food intake. The dietitian recommended to increase tube feeding rate to 55 cc per hour for 22 hours in every 24 hours to provide 1452 calories and 73 grams of protein. Observation of resident #3 on 4/29/14 at 12:40 pm revealed resident #3 did not eat lunch. Observation on 4/30/14 between 8 am and 9:30 am revealed resident #3 with a sheet over his head, stating he was not hungry. Resident #3 received his lunch tray at 12:20 pm and he drank juice and a healthshake. LVN A entered the resident's room at 12:30 pm for an accucheck and commented to him that he had not eaten and asked if he wanted something else to eat. Observation on 5/1/14 at 8:30 am revealed resident #3 again drank fluid from the tray but no solid food. Interview on 5/2/14 at 4:30 pm with the DON revealed a Standards of Excellence committee met weekly to follow residents with weight loss and other issues. She stated that new admits were followed with weekly weights. She confirmed she completed the Weight Variance Assessment and Care Plan report on 2/27/14 regarding resident #3. She stated she would expect the dietitian to follow the resident after a significant weight loss was identified. She stated that she or the wound care nurse filled out the skin report/pressure ulcer report. She stated that any resident that was being followed by the wound care nurse or the wound care doctor was placed on the list for follow up. She stated that residents did not just have to have a pressure ulcer to be on the list. She stated the wound nurse or herself would communicate through the list with the consultant dietitian. The DON stated she did not have a formal written list but it was verbal, on a handwritten note or sometimes sent in a text message. Interview with the dietary manager on 4/30/14 at 8:30 am revealed she attended the weekly weight meetings and passed on information to the dietitian. She stated that she communicated concerns to the dietitian on all of her visits. She stated she communicated with the dietitian on resident #3, regarding the Weight Variance Assessment and Care Plan report of 2/27/14 because she had a consultant visit 2/28/2014. Interview with the Consultant dietitian on 4/30/14 at 3:30 pm and 5/2/14 at 5:00 pm revealed resident #3 did not appear on any of the March monthly reports because he had not been there for a month yet. She stated he was followed after the time of admission and several dietary interventions were tried to improve his oral intake such as changing supplements. She stated that communication with dietary staff and the DON may have been done orally or by text message from cell phones. She stated she did not have these records available. She stated that if a resident was under 100 pounds then they were usually kept on weekly weights. When asked whether his continued weekly weight loss which triggered a severe weight loss would have been documented she stated she couldn't tell me but that she saw him but didn't document on him. When asked about the calories provided by the tube feeding rate being less than what she recommended on the resident's nutritional assessment she stated her first goal was to assure toleration. She stated she recommended a tube feeding rate increase on 5/1/2014. A handwritten note provided by the DON confirmed 4 residents with weight loss were on the 100 hall. .