Every finding on record at St. Francis Nursing Home

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 resident hall (Hall 200) of 4 resident halls reviewed, in that:Potentially harmful cleaning materials were unsecured in resident Hall 200.This deficient practice could result in an unsafe environment for residents, staff, and the public.The findings were:Observation on 01/20/2026 at 12:18 p.m. revealed a can of disinfectant spray on top of a cart located at the far end of Hall 200. Further observation revealed the disinfectant was labeled, Caution, keep out of reach of children. Further observation revealed no residents were present in the hallway at the time.During an interview with LVN C on 01/20/2026 at 12:20 p.m., LVN C confirmed the disinfectant spray with a caution label was potentially within reach of residents, stated that at least one resident from Hall 200 had a history of wandering, and confirmed the spray should have been secured so that no residents came into contact with it.Observation on 01/23/2026 at 11:05 a.m. revealed a container of disinfecting wipes on top of a cart located at the near end of Hall 200. Further observation revealed the container was labeled, Caution, keep out of reach of children, hazardous to humans and domestic animals, caution causes moderate eye irritation. Further observation revealed no residents were present in the hallway at the time.During an interview with LVN C on 01/23/2026 at 11:05 a.m., LVN C confirmed the disinfectant wipes with a caution label was potentially within reach of residents, stated that at least one resident from Hall 200 had a history of wandering, and confirmed the spray should have been secured so that no residents came into contact with it.During an interview with the DON on 01/23/2026 at 12:05 p.m., the DON stated she expected that potentially harmful cleaning materials remain secured when not in use so that residents would not come into contact with them.Record review of the facility policy, Policy and Procedure: Maintenance of Physical Environment - Safe Storage of Disinfectants and Alcohol-Based Products, reviewed 03/14/2025, revealed, [The facility] is committed to maintaining a safe, clean, and hazard-free physical environment for all residents, staff, and visitors. All disinfectants, alcohol-based products, and chemical agents shall be properly stored, labeled, secured and used in accordance with manufacturer instructions.

Based on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for one (Resident 40) of twenty-five residents reviewed, in that:Resident #40's OOH-DNR was not fully signed by Witness #1 and was therefore invalid.This deficient practice could result in residents' end of life wishes being unknown or dishonored.The findings were:Record review of Resident #40's facesheet, dated 01/23/2026, revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified dementia, hyperlipidemia, and vitamin deficiency.Record review of Resident #40's annual MDS, dated [DATE], revealed the resident was rarely/never understood and a staff assessment for mental status was performed which indicated both short and long term memory problems.Record review of Resident #40's care plan, revised 12/10/2025, revealed Request for DNR measures [related to] resident /family choice.Record review of Resident #40's OOH-DNR form, dated 12/03/2025, revealed Witness #1's signature was incomplete. Witness #1 signed only her first name. The witness did not sign her last name, nor did she include the date of signing or her full printed name.During an interview with the Social Worker on 01/23/2026 11:07 a.m., the Social Worker stated she was responsible for advanced directives and confirmed Resident #40 OOH-DNR form was witnessed incorrectly. The Social Worker stated the error was an oversight and would be corrected.During an interview with the DON on 01/23/2026 12:05 p.m., the DON stated her expectation was that all OOH-DNR forms be completed fully and correctly.Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated 03/25/2019, revealed, An OOH DNR Order form must be properly executed.to be considered a valid form by emergency medical services personnel. The OOH-DNR Order must be signed and dated by two competent adult witnesses. Completing the Texas Out of Hospital Do Not Resuscitate Form: When Using Two Witnesses. Two witnesses or a notary public must sign that they have witnessed the patient's signature or the signature of a person(s) acting on the patient's behalf. Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly.Record review of the facility policy, Advance Directive Policy, undated, revealed, Residents have the right to.formulate an advance directive.

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 and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Residents #14, and #78) reviewed for infection control, in that: 1. The facility failed to ensure CNA A sanitize her hands while providing incontinent care for Resident #14 2.The facility failed to ensure Medication Aide B did not touch medications without wearing gloves while administering medications to Resident #78. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1.Record review of Resident #14's face sheet, dated 01/22/2026, revealed the resident was admitted to the facility on [DATE] and, readmitted on [DATE], with diagnoses which included: Quadriplegia (Paralysis of both the arms and legs), Chronic pain, Dementia (decline in cognitive abilities), Anxiety Disorder (A group of mental illnesses that cause constant fear and worry), Huntington's disease (causes nerve cells in the brain to decay over time. The disease affects a person's movements, thinking ability and mental health). Record review of Resident #14's Quarterly MDS, dated [DATE], revealed the resident had no BIMS score and, was indicated as severely cognitively impaired. Resident #14 required total care and was always incontinent of bowel and bladder. Record review of Resident #14's care plan, dated 04/09/2025, revealed a problem of Altered elimination R/T cognitive and mobilitydeficits AMB incontinent of bowel & bladder and, an intervention of Provide incontinent care every 2 hours & PRN after each incontinent episode Observation on 01/22/26 at 10:38 AM revealed while providing incontinent care for resident #14, CNA A was using two basins. One basin contained soapy water and the other contained clear water. After using the soapy water to clean Resident #14 who had a bowel movement, CNA did not change her gloves and put her gloved hands in the clear water to retrieve a washcloth. Her gloves were soiled from cleaning the resident. She, then, used the washcloth to rinse the resident's skin. During an interview with CNA A on 01/22/2026 at 10:42 AM, she stated she did not change her gloves before using the clear water because she did not realize she would potentially contaminate the water with the gloves she was using. She stated they had had a talk about infection control the day before and had receive infection control and incontinent care training. During an interview with the DON on 01/22/2026 at 2:18 PM, she stated the CNA should have changed her gloves before touching the clear water to rinse the resident. She contaminated the water with her soiled gloves and could cause an infection for the resident. She stated infection control and incontinent care training were provided at least yearly. Record review of the facility's policy titled, Hand Washing, dated February 2024, revealed Use an alcohol-based hand rub [ .] for the following situations: [ .] Before handling clean or soiled dressing [ .] before moving from contaminated body site to a clean body site during resident care. 2. Record review of Resident #78's face sheet, dated 01/22/2026, revealed the resident was admitted to the facility on [DATE], with diagnoses which included: Heart failure, Cellulitis (Skin infection), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (high blood pressure), Osteoporosis (weak and brittle bones). Record review of Resident #78's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 13 which indicated minimal cognitive impairment. Resident #78 required moderate assistance with care. Observation on 01/22/2026 at 9:10 AM, revealed while administering medications for Resident #78, Medication Aide B touched a pill with her bare fingers to separate the pill from the other pills in the cup. During an interview on 01/22/2026 at 9:12AM, Medication Aide B stated she touched the pill with her fingers, but she had sanitized her hands. She stated she was not wearing gloves and understood the risk of contaminating the medication before giving it to the resident. During an Interview on 01/22/2026 at 2:18PM with the DON, she stated the Medication aide should have worn gloves to touch the pills or use a utensil to pick up the pill from the cup. She confirmed the risk of infection for the resident. She stated infection control training was done at least annually. Record review of the facility's policy titled, Medication Administration, undated, revealed Nurse follows facility infection control policies and procedures.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for two of three refuse containers (Dumpster #1 and Dumpster #2 used for recyclable refuse) on the loading dock.The facility failed to ensure the doors to Dumpster #1 and Dumpster #2 were closed.This deficient practice could place residents at risk for illness from exposure to germs and diseases carried by vermin and rodents.The findings included: An observation on 01/23/2026 at 10:19 AM revealed Dumpster #1 and Dumpster #2 used for recyclable waste. Both dumpsters had V-shaped pull-down doors in front of the dumpsters, and the doors were in the open position for both dumpsters. Dumpster #1 was approximately halfway full and dumpster #2 was approximately 1/3 full. Both dumpsters contained food-related waste. During an interview on 01/23/2026 at 10:40 AM, the Maintenance Director stated the dumpsters were intended to be used strictly for recyclable waste but staff occasionally tossed regular waste inside them. It was possible to close the dumpsters doors by lifting the top lid, then lifting up the V-shaped door, and finally closing the top lid on top of the door and securing it with a latch. The doors should be closed at all times to keep pests out of the dumpsters, and he will educate staff on how to keep the dumpsters closed. Record review of the facility's policy Dietary Department Infection Control: General Procedures, undated, revealed: Handling and Disposing of Trash and Waste. Garbage containers should be leakproof, pest-proof, and easily cleaned. Lids should fit tightly. Appropriate control measures to eliminate insects and rodents should be used. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 5-501.113 Covering Receptacles. Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the food establishment. 5-501.116 Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. 5-403.12 Other Liquid Waste and Rainwater. Liquid food wastes and rainwater can provide a source of bacterial contamination and support populations of pests. Proper storage and disposal of wastes and drainage of rainwater eliminate these conditions.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1), reviewed for quality of care. The facility failed to supervise Resident #1 when she was left unattended during care while CNA A retrieved supplies and resulted in a fall with a head injury, scalp laceration, hematoma/contusion to the forehead/scalp, traumatic subarachnoid hemorrhage and fracture to the C-1 vertebrae of her neck. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/23/25. The noncompliance began on 4/16/2025 and ended on 4/22/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of accidents, and could result in serious injury, harm, impairment, and death. The findings were: Record review of Resident #1's face sheet, dated 4/22/2025 revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: history of falling, altered mental status and unsteadiness on feet. Record review of Resident #1's initial History and Physical report dated 11/14/2024 revealed the resident was alert and oriented x 2, legally blind, wheelchair dependent and needed assistance with all ADL's. Record review of Resident #1's Care Plan last revised 11/21/2024 revealed she required assistance with mobility, positioning, transfers in bed, wheelchair, and walker, personal hygiene including bathing, dressing, grooming and hygiene. The Care Plan indicated Resident #1 utilized a bed hand rail x 1 to assist with transfers. Record review of Resident #1's Care Plan last revised 11/21/2024 revealed she was at risk for falls and injury related to impaired physical mobility, impaired vision, and history of falling with interventions which included anticipate and assist with ADLs, assist with transfers, call light in reach and ensure proper footwear. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS of 99 which indicated a severe cognitive impairment with both long- and short-term memory problems and was severely impaired. The assessment indicated Resident #1 was dependent on staff for all ADL care and substantial assistance for movement. Record review of Resident #1's Fall Risk assessment dated [DATE] revealed she was at High Risk for falls due to the following contributing factors: intermittent confusion, history of 1-2 falls in past 3 months, chair bound with a note the resident could rise from chair with use of arms, legally blind, taking 3-4 medications considered at risk for falls, and had 1-2 predisposing diseases that increased the risk of falls. Record review of Resident #1's nurse progress notes dated 4/16/2025 at 6:30 p.m., stated a CNA (CNA A) informed LVN B the resident was on the floor. LVN B noted Resident #1 lying next to her bed with the wheelchair at the foot of the bed. The resident had a laceration on the scalp with a large amount of bleeding. Towels were applied on the scalp to stop the bleeding. LVN B further documented the resident was turned and a sling was positioned under her. Resident #1 was then transferred to bed with a mechanical lift. LVN B documented Resident #1 refused ice on the laceration to the scalp and the mass above her right eyebrow that was greater than 5 cm. LVN B documented vital signs of 182/120 (normal 120/80 or lower) HR 91 (normal 60-100), respirations 22 (normal 16-29), temperature 97.3, oxygen saturation 92% (normal 90-100) on room air. LVN B documented Resident #1 refused neuro checks to be done and she responded to verbal stimuli with clear speech to answer yes/no questions. Record review of Resident #1's nurse progress notes dated 4/16/2025 at 7:00 p.m. written by LVN B revealed Resident #1's physician was informed of the resident's condition with orders to send to the hospital for head trauma. Record review of Resident #1's progress notes dated 4/16/2025 at 7:45 p.m., LVN B documented EMS arrived and was transferred to the hospital. Record Review of Resident #1's hospital record revealed she was treated a laceration to scalp requiring 6 sutures (stitches) and 5 staples to close, multiple traumatic subarachnoid hemorrhages, and a C1 [NAME] fracture as a result of an unattended fall at the NF. During her hospital she had a CT head scan which revealed: 1. Focal subarachnoid hemorrhage (bleeding in the space that surrounds the brain and is considered a medical emergency) 2. Acute C-1 cervical vertebral fracture/Jefferson fracture (fracture of the first spinal vertebrae) 2. Contusion/hematoma of right front scalp (bruising and swelling). During her hospital stay a follow up CT scan showed slight enlargement of the bleed (subarachnoid) with multiple new small subarachnoid bleeds, new edema (swelling) to the C1 fracture area, edema noted to other parts of the spine concerning for subtle compression fractures requiring ICU (intensive care) observation and care. Resident #1 was started on the medication Keppra (anti-convulsant medication) as a seizure prophylaxis (to prevent the occurrence of seizure activity). Record review of CNA A's Consultation Form, dated 4/21/2025, revealed a finding of fall with neglect when CNA A left Resident #1 on the bed and went to the bathroom to get a towel that was unintentional. The document indicated CNA reported she transferred the resident to bed; the resident was sitting on the bed while holding the handrail. CNA A turned and walked away a little toward the bathroom when she heard a loud thump, when she returned Resident #1 was on the floor. The form indicated CNA A notified the nurse immediately. The form indicated Resident #1 should not have left the resident unattended and the fall could have been prevented. The form indicated CNA A was re-educated on the facility's procedure on safe transfer and handling a resident with limitations. Record review of a facility document titled Investigation: Injury of Unknown Source, dated 4/17/2025, revealed: -On 4/16/2025 at 6:34 p.m. security cameras showed CNA A entered the resident's room. Per the CNA's statement she left resident at bedside while she retrieved items from the bathroom in the room. CNA A heard fall and returned immediately to room. -On 4/16/2025 at 6:38 p.m. security cameras show CNA A rush from room and return with LVN B, eleven seconds later. -At 7:45 p.m. EMS arrived and transported Resident #1 by stretcher to a local hospital. Record review of a written statement by CNA A (undated) revealed on 4/16/2025 around 7:30 p.m., she took Resident #1 to the room getting her ready for bed, she indicated she sat the resident on the bed and went to grab a washcloth from her restroom when all of a sudden, she heard a loud fall. CNA A wrote she saw the resident on the floor and went to grab LVN B quick. During an observation and interview on 4/22/2025 at 11:30 a.m., Resident #1 was observed at a local hospital. She was in bed with a hard c-collar in place. Her eyes were puffy and swollen and she was unable to fully open them. She had a bandage in place at the top of her scalp where the forehead met the hairline. She had severe bruising to her forehead with noted swelling to the forehead. She had bilateral peri -orbital bruising (bruising around both eyes). All bruising was noted to be black and varying shades of purple with some dark shades of yellow/green near the edges. Resident #1 attempted to open her eyes when spoken to. She acknowledged she was being spoken to but was unable to answer any interview questions. She responded by making noises and grunting only. During an observation and interview on 4/23/2025 at 10:35 a.m., Resident #1 was observed in bed at the nursing facility. The head of her bed was elevated to 75 degrees. She had on a hard c-collar. Her face was bruised in varying shades of black, purple, green, and yellow with the largest portion of bruises noted to her forehead and eyes and mid-face. She had a bandage to her upper forehead and swelling to the upper forehead. Resident #1's bed was in low position with a staff member at bedside. Resident #1 did not respond responded with grunts and sounds only when spoken to. During an interview on 4/22/2025 at 7:05 p.m., Resident #1's RP stated he was notified on 4/16/2025 at 7:15 p.m. by an unknown nurse that his family member had fallen from her wheelchair, hit her head and was on the way to the hospital. He stated he had concerns about the seriousness of Resident #1's injuries which he stated he had discussed with NF head staff. He stated Resident #1 would return to the facility today (4/22/2025). During an interview on 4/23/3035 at 11:48 p.m., the SW stated she participated in the investigation of Resident #1's fall injury. She stated she interviewed other residents on the unit (safe surveys). She stated she asked how everyone was treating them and if they felt safe. She asked specifically about care provided after noon and dinner shift. She started she asked about CNA A and LVN B and if there were any patterns to care. She stated during her investigation no concerns were voiced about care or about CNA A or LVN B. During an interview on 4/23/2025 at 12:31 p.m., CNA A stated she took Resident #1 to her room to put her to bed on 4/16/2025. She stated she put Resident #1 on the bed and removed the wheelchair. She stated she left Resident #1 sitting near the (hand) rail with her legs handing off the bed but her feet kind of touching the floor. CNA A stated she then walked away to get a towel from the bathroom, realizing there were none and heard a big sound. CNA A stated she did not think Resident #1 was going to fall. CNA A stated Resident #1's bottom was not all the way on the bed, but on the edge and little further back. CNA A stated Resident #1 usually held the handrail, but she did not know if the resident was holding it. CNA A stated she thought Resident #1 was going to hold the handrail but was not certain if she grabbed it and let go or not. CNA A stated she heard the fall. CNA A stated she was so scared and ran and got LVN B. She stated she told LVN B to hurry and she came right away. CNA A stated they found her on the floor. She stated Resident #1's arms looked twisted, with one arm under her body and the other one with the wrist bend. CNA A stated she did not know what happened or how Resident #1 hit the floor. She stated she did not see the fall; she just heard it. CNA A stated Resident #1 did not call out before the fall. She described the resident as not able to talk. She stated the resident just says, no no no and was confused. CNA A stated Resident #1 was blind and was not able to see at all. CNA stated she also noted blood by Resident #1's head, like a little pool of blood. CNA A stated she did not see any other injuries because LVN B stated she did not need anything else and she left the room. She stated she saw LVN B take vitals signs and they helped Resident #1 back to bed by use of a mechanical lift. CNA A stated she was trained in fall prevention. She stated there was an in-service every month. She stated she received training and counseling after the incident as well. CNA A stated she was taught to be careful with people and make sure to do the right thing. She stated she reviewed transfers and making sure the resident had a safe place where they could not fall. She stated she was also trained to wait for the resident if they were using the toilet or were somewhere they could fall. CNA A stated she was in a hurry because she had other people to put in bed. She stated she was not thinking about a fall, she just moved away, and Resident #1 fell . CNA A stated she felt so ugly that this occurred because Resident #1 was in her care. She stated she could not believe it happened and it was her fault. CNA A stated going forward she would be very very careful with everyone and was not going to rush. CNA A stated after the fall occurred the Administrator told her next time, never leave a resident like that and to always think about the worst things that could happen. CNA A stated the Administrator counseled her to be more careful and to make sure she was safe before leaving the room. CNA A stated she also received a training on how to care for Resident #1 now that she was back from the hospital. She stated they had to roll her because of her neck and her spin had to always be in alignment. CNA A stated two CNAs and a nurse had to supervise so that three people all at the same time cared for her, so she was safe. During an interview on 4/23/2025 at 12:50 p.m., LVN B stated on 4/16/2025 at 6:30 p.m., CNA A came shouting in the hallway that Resident #1 was on the floor. LVN B stated she went immediately and found Resident #1 next to the bed with the wheelchair at the foot of the bed. She stated Resident #1 had excess bleeding. LVN B stated at 7:40 p.m., Resident #1 was transferred by EMS to the hospital. LVN B stated Resident #1 was not able to move by herself because of weakness on her right side. She stated she did not move by herself. LVN B stated she asked CNA A what happened, and CNA A stated she turned to get a towel and Resident #1 fell . LVN B stated her expectation of the CNA was for her to bring the resident to the nurses' station or ask for assistance if she forgot something so Resident #1 would be supervised for her safety. LVN B stated she received training post incident on fall prevention which included not leaving residents unattended. LVN B stated she also received training on resident's with head injuries and first aide training which included not moving the resident and calling 911 as soon as possible. LVN B stated she received a training for caring for Resident #1 after returning from the hospital which included repositioning, log rolling, not moving her without assistance. During an interview on 4/23/2025 at 1:46 p.m., the DON stated Resident #1 was blind, mostly responded to yes/no questions and was confused. The DON stated on 4/16/2025 Resident #1 had a very bad accident while CNA A was caring for her. The DON stated according to CNA A's statement the resident fell while sitting on the bed. The DON stated CNA A acknowledged she left the resident unattended. The DON stated the next day (4/17/2025) she learned the severity of Resident #1's injuries. The DON stated the CNA was negligent in leaving the resident unattended. She stated no one should be left on the edge of the bed. The DON stated she did not know why it occurred because Resident #1 did not move and did not stand up. She stated it was so unexpected because the resident normally obeyed and stayed put. The DON stated Resident #1 was a fall risk and required one staff person for assistance. The DON stated she thought CNA A would change what had occurred if she could. The DON stated her expectation of staff was to never, ever leave a resident unattended if they were not ready and prepared to provide care. The DON stated it would have taken just a second to put Resident #1's legs on the bed. She stated fall precautions were important because of the risk for falls. The DON stated the facility wished it had never happened, but they worked to provide in-service training to all staff on fall precautions which included never leaving a resident unattended. The DON stated all staff had been educated on 4/18/2025 with the exception of 4 staff who were on leave and not available. The DON stated the SW and Administrator would have additional information about what was done to correct the situation. During an interview on 4/23/2025 at 2:20 p.m., the Administrator stated on 4/16/2025 she saw the fire department at the facility, so she went to the facility. She stated the DON was already there and she learned Resident #1 had been on the floor with a head injury. The Administrator stated she immediately started an investigation because she was told it was an unwitnessed fall by CNA A. She stated as she investigated, she found that CNA A was not with Resident #1 when she fell and CNA A only heard a loud thump, turned and found the resident on the floor. The Administrator stated she interviewed CNA A in person. She stated CNA A was in distress and stated originally that Resident #1 had fallen from her wheelchair, and she thought the resident misunderstood her and was trying to get up. The Administrator stated she interviewed staff about how the resident transfers and how she stood up and if she was able to move at all. The Administrator stated after talking to Resident #1's family member who told her the resident was unable to get up and other CNAs who stated she followed direction and was afraid to get up, she called CNA A to discuss the incident again. The Administrator stated CNA A told her she was in shock originally and admitted to leaving the resident sitting on the edge of her bed and walking away. The Administrator stated CNA A said she was going to get washcloths. The Administrator stated she told CNA A that was not how we did it. She stated she asked CNA A if she did it on purpose or had ill intentions. She stated CNA A said no and was very upset. She stated she did not know what she was thinking. The Administrator stated CNA A stated Resident #1 never moves but she was aware she was not supposed to leave the resident like that. The Administrator stated she was not supposed to walk away from the resident. She stated CNA A had been a CNA for a long time and stated I do not know what got into her. She made a wrong judgement. The Administrator stated she told CNA this could not happen. She stated she completed an investigation prior to the state surveyors arrival on 4/22/2025 and found she was not neglecting other residents and she was allowed to come back to work after two days because she believed CNA A had an error of judgement. The Administrator stated she consulted with the Medical Director about the incident. She stated she educated staff on fall precautions, trauma and first aide and made sure the facility had a protocol that could be followed. The Administrator stated she monitored staff by providing training and in-services, by competency checks and daily meetings where the ADON, DON and herself met with staff daily and talked to them. The Administrator stated the administration team lived right across the street and they ensured staff knew they were available 24/7 (24 hours a day, 7 days a week) so the staff knew they were supported. The Administrator stated CNA A had no prior disciplinary issues, was reliable and had no resident complaints. She stated CNA A had not been scheduled for two days after the incident and was counseled and retrained. The Administrator stated the following actions were immediately taken by the facility to correct the action which was completed on 4/22/2025 prior to the state surveyor arrival. They included: 1. Same day in-service on fall prevention to all staff 101 of 105 (4 staff on leave) which included ensuring all proper supplies were gathered prior to care and included not leaving residents unattended. 2. A consultation of counseling and training was provided on 4/21/2025 to CNA A to ensure she understood what she did wrong. The training included facility procedures for fall precautions, safe transfers, handling residents with limitations which included not leaving residents alone when providing care. 3. A protocol was developed and training provided to CNA staff on fall precautions, ensuring things were set up before providing care and never leave the resident unattended . 4. Consulted with the Medical Director on 4/18/2025 for guidance on the incident which included: training of staff on first aide care and a protocol/procedures for First Aide and Response to Head Trauma protocol was approved. 5. An in-service was provided to all direct care staff assigned to Resident #1 post hospitalization completed on 4/22/2025 to included how to care for a resident in a c-collar and spinal stabilization during care. 6. The SW conducted safe surveyors to ensure residents needs were met and the residents felt safe and to ensure there was no pattern of care that could lead to increased risk for falls. During interviews on 4/23/2025 3 LVNS (LVNs C, G and H) and 8 CNA (CNAs D, E, F, I, J, K, L and M) and 2 LVN staff stated they received the in-service training on fall prevention which included ensuring needed supplies were gathered prior to initiating care and residents should not be left unattended during care, residents should utilize appropriate non-slip footwear, and have a call light within reach. During an interview on 4/23/2025 at 2:20 p.m., the Administrator stated the staff who were on leave for the training would be required to report to her before working and would not be allowed to work until all training was completed. During interviews on 4/23/2025 interviews with four licensed staff (LVN B, C, G and H) revealed they received the in-service training on First Aide and Response to Head Trauma protocol. They stated they were trained not to move a resident with a head injury, ask for assistance and immediately notify 911 to prevent further injury. During an interview on 4/23/2025 at 2:57 p.m., the Medical Director stated Resident #1 should have been left on the floor and EMS should have been summoned immediately. He stated he agreed the facility should not have lifted the resident or delayed care. He stated a resident with a visual impairment and cognitive impairment would have a significantly increased risk for falls. He stated staffing at the facility was adequate and not an issue. He stated the issue was an employee issue as to why it occurred. He stated he had no concerns for neglect at the facility. The Medical Director stated confirmation that he had discussed the incident and what should have occurred with the Administrator. Record review of an in-service training dated 4/17/2025 was completed by 101 of 105 staff (4 staff on leave) which included ensuring all proper supplies were gathered prior to care and including not leaving a resident unattended. The training included: common causes of nursing home falls, common protocols for preventing nursing home falls which included implementation of a resident-centered fall prevention plan. Record review of an in-service training dated 4/18/2025 revealed 20 of 22 licensed staff (2 staff on leave) had signed they had completed the in-service training for Head Trauma and First Aide which included: Call 911 for someone who has a serious head injury, facial bleeding, bleeding or fluid leakage from the nose/ears, change in consciousness for longer than a few seconds, no breathing, confusion, agitation or restlessness that continues to get worst, loss of balance, weakness or not being able to use an arm or leg, one pupil bigger than the other, slurred speech, seizures. The training also included: keep the person still, do not move the person unless necessary and avoid moving the person's neck. Stop any bleeding, watch for changes in breathing and alertness . Record review of an in-service training dated 4/22/2024 and ongoing as new staff assigned to care for Resident #1 revealed, the staff were trained on caring for a resident in a c-collar and keeping the spine aligned during care which was provided to 18 staff members on all shifts. The in-service included the following: 1. Ensure the resident does not flex, extend, or rotate the neck. 2. Maintain strict spinal precautions at all times with staff assistance x 3 3. Do not remove the c-collar. 4. Log rolling the resident for all turning and repositioning. Record review of an untiled document dated 4/18/2025, the Administrator documented on 4/18/2025 at 9:00 a.m., she had a meeting with the facilities Medical Director to review and approve the protocol and procedures for First Aide and Response to Head Trauma. She wrote it was established that a call to 911 should be placed immediately after finding resident on the floor. First Aide for Head Trauma was approved. Record review of the facility's, undated, policy, titled Fall Prevention revealed: Residents who have a history of frequent falls or have high risk factors for falling will be identified in an effort to prevent falls. All residents will be assessed for risk of fall upon admission, with reassessments routinely performed to determine ongoing need for fall prevention precautions. Any resident determined to be at risk for fall will be placed on fall prevention precautions. Residents in the fall prevention program will be closely monitored.

Based on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure appropriate and timely care when Resident #1 had a fall on 4/16/2025 and was diagnosis with a fractured C1 vertebrae, traumatic subarachnoid hemorrhage, scalp laceration requiring repair and hematoma/contusion. 2. The facility failed to ensure LVN B did not move Resident #1 with a mechanical lift after a fall on 04/16/2025. 3. The facility failed to ensure LVN B immediately notified 911 after Resident #1 sustained a head injury with a laceration and excess bleeding, a large hematoma to the forehead, facial bruising, altered vital signs and was uncooperative. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/23/25. The noncompliance began on 4/16/2025 and ended on 4/22/2025. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or additional injury, paralysis or death. The findings included: Record review of Resident #1's face sheet, dated 4/22/2025 revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: history of falling, altered mental status and unsteadiness on feet. Record review of Resident #1's initial History and Physical report, dated 11/14/2024, revealed the resident was alert and oriented x 2, legally blind, wheelchair dependent and needed assistance with all ADL's. Record review of Resident #1's Care Plan, last revised 11/21/2024, revealed she required assistance with mobility, positioning, transfers in bed, wheelchair, and walker, personal hygiene which included bathing, dressing, grooming and hygiene. The Care Plan indicated Resident #1 utilized a bed hand rail x 1 to assist with transfers. Record review of Resident #1's Care Plan last revised 11/21/2024, revealed she was at risk for falls and injury related to impaired physical mobility, impaired vision, and history of falling with interventions which included anticipate and assist with ADLs, assist with transfers, call light in reach and ensure proper footwear. Record review of Resident #1's quarterly MDS assessment, dated 2/17/2025, revealed a BIMS of 99 which indicated a severe cognitive impairment with both long- and short-term memory problems and was severely impaired. The assessment indicated Resident #1 was dependent on staff for all ADL care and substantial assistance for movement. Record review of Resident #1's Fall Risk Assessment, dated 3/09/2025, revealed she was at High Risk for falls due to the following contributing factors: intermittent confusion, history of 1-2 falls in past 3 months, chair bound with a note the resident could rise from chair with use of arms, legally blind, taking 3-4 medications considered at risk for falls, and had 1-2 predisposing diseases that increased the risk of falls. Record review of Resident #1's nurse progress notes, dated 4/16/2025 at 6:30 p.m., documented a CNA (CNA A) informed LVN B the resident was on the floor. LVN B noted Resident #1 lying next to her bed with the wheelchair at the foot of the bed. The resident had a laceration on the scalp with a large amount of bleeding. Towels were applied on the scalp to stop the bleeding. LVN B further documented the resident was turned and a sling was positioned under her. Resident #1 was then transferred to bed with a mechanical lift. LVN B documented Resident #1 refused ice on the laceration to the scalp and the mass above her right eyebrow that was greater than 5 cm. LVN B documented vital signs of 182/120 (normal 120/80 or lower) HR 91 (normal 60-100), respirations 22 (normal 16-29), temperature 97.3, oxygen saturation 92% (normal 90-100) on room air. LVN B documented Resident #1 refused neuro checks to be done and she responded to verbal stimuli with clear speech to answer yes/no questions. Record review of Resident #1's nurse progress notes, dated 4/16/2025 at 7:00 p.m., written by LVN B revealed Resident #1's physician was informed of the resident's condition with orders to send to the hospital for head trauma. Record review of Resident #1's nurse progress notes dated 4/16/2025 at 7:30 p.m., written by LVN B, revealed Resident #1 continued to refuse ice packs on mass, indicating the towels on laceration, the bleeding had decreased some. Vital signs 168/107, pulse 88, respirations 18, oxygen saturation 94% on room air. Record review of Resident #1's nurse progress notes, dated 4/16/2025 at 7:38 p.m., LVN B documented the DON aware of resident's condition. EMS services on their way. Record review of Resident #1's progress notes, dated 4/16/2025 at 7:45 p.m., LVN B documented EMS arrived. Record Review of Resident #1's hospital record dated 4/16/2025 revealed she was treated a laceration to scalp requiring 6 sutures (stitches) and 5 staples to close, multiple traumatic subarachnoid hemorrhages, and a C1 [NAME] fracture as a result of an unattended fall at the NF. During her hospital she had a CT head scan which revealed: 1. Focal subarachnoid hemorrhage (bleeding in the space that surrounds the brain and is considered a medical emergency) 2. Acute C-1 cervical vertebral fracture/Jefferson fracture (fracture of the first spinal vertebrae) 2. Contusion/hematoma of right front scalp (bruising and swelling). During her hospital stay a follow up CT scan showed slight enlargement of the bleed (subarachnoid) with multiple new small subarachnoid bleeds, new edema (swelling) to the C1 fracture area, edema noted to other parts of the spine concerning for subtle compression fractures requiring ICU (intensive care) observation and care. Resident #1 was started on the medication Keppra (anti-convulsant medication) as a seizure prophylaxis (to prevent the occurrence of seizure activity). Record review of LVN B's Consultation Form, dated 4/18/2025, revealed LVN B received a consultation for a fall with head injury. The DON documented LVN B did not use proper nursing judgement to Resident #1 who had a head injury and fractured neck. The DON wrote LVN B should have immediately called EMS and left the resident without repositioning to the bed. During an observation and interview on 4/22/2025 at 11:30 a.m., Resident #1 was observed at a local hospital. She was in bed with a hard c-collar in place. Her eyes were puffy and swollen and she was unable to fully open them. She had a bandage in place at the top of her scalp where the forehead met the hairline. She had severe bruising to her forehead with noted swelling to the forehead. She had a bilateral peri -orbital bruising. All bruising was noted to be black and varying shades of purple with some dark shades of yellow/green near the edges. Resident #1 attempted to open her eyes when spoken to. She acknowledged she was being spoken to but was unable to answer any interview questions. She responded by making noises and grunting only. During an observation and interview on 4/23/2025 at 10:35 a.m., Resident #1 was observed in bed at the nursing facility. The head of her bed was elevated to 75 degrees. She had on a hard c-collar. Her face was bruised in varying shades of black, purple, green, and yellow with the largest portion of bruises noted to her forehead and eyes and mid-face. She had a bandage to her upper forehead and swelling to the upper forehead. Resident #1's bed was in the low position with a staff member at the bedside. Resident #1 only responded with grunts and sounds when spoken to. During an interview on 4/22/2025 at 7:05 p.m., Resident #1's RP stated he was notified on 4/16/2025 at 7:15 p.m. by an unknown nurse that his family member had fallen from her wheelchair, hit her head and was on the way to the hospital. He stated he had concerns about the seriousness of Resident #1's injuries which he stated he had discussed with the NF head staff. He stated Resident #1 would return to the facility today (4/22/2025). During an interview on 4/23/2025 at 12:50 p.m., LVN B stated on 4/16/2025 at 6:30 p.m., CNA A came shouting in the hallway Resident #1 was on the floor. LVN B stated she responded and found Resident #1 lying face down on the floor with an open wound to her forehead. LVN B stated Resident #1 had a lot of bleeding. She stated the wheelchair was at the foot of the bed and Resident #1 was next to the bed. LVN B stated her main concern was getting Resident #1 stabilized by putting pressure on her forehead. She stated she utilized a mechanical lift to pick Resident #1 off the floor and transfer her to the bed before calling the MD or 911. LVN B stated there was blood all over the floor and she (LVN B) did not want to fall because of it. She stated she was focused on applying pressure and stopping the bleeding. LVN B stated she did not call the MD until approximately 7:00 p.m. (which was approximately 30 minutes after the fall), then she called the DON around 7:30 p.m. (approximately 1 hour after the fall) who told her to call 911 . LVN B stated she called EMS around 7:35 p.m. LVN B stated at that time Resident #1's blood pressure was very elevated at 200/180, with an increased pulse over 100, increased respiratory rate of 24-26. LVN B stated EMS services arrived at approximately 7:40 p.m. and transferred the resident to the hospital. LVN B stated she was trained to keep a resident with a head injury spine in alignment by log rolling her and moving her carefully. She stated Resident #1's spine was not kept in alignment when she utilized a sling to transfer the resident with the mechanical lift because her priority was to stop the bleeding. LVN B stated she knew it was important not to move a resident with a head injury so it would not damage them anymore. LVN B stated Resident #1 had a big mass, a big hematoma to her forehead and was not cooperative with the assessment or with the care. She stated she was trying to put an ice pack on her forehead but Resident #1 would not cooperate. LVN B stated she waited over an hour to call 911 because she was trying to stabilize the bleeding. LVN B stated at the time, she thought she was doing everything she could for Resident #1 but admitted she did not ask for assistance. She stated in hindsight, she should have called another nurse to help her, and she should have called the DON as soon as possible. LVN B stated after the incident, the facility tried to figure out what happened. She stated she received a nurse consultation from the DON. She stated in the consultation she told the DON her main concern was to stop the bleeding. LVN B stated she learned in the consultation she should have called 911 as soon as possible with a head injury, especially with one from a fall of this magnitude. LVN B stated in addition to the discipline, she received additional training on not moving the resident at all and calling 911 immediately. LVN B stated she was also trained on log rolling residents in a c-collar, repositioning residents was completed before she was allowed to work again (unknown date). She stated she was also re-trained to ask for help, especially from another nurse who was also working and she knew what she did wrong. During an interview on 4/23/2025 at 1:46 p.m., the DON stated Resident #1 was blind, was able to mainly respond to yes/no questions, but not use too many words and was confused. She stated on 4/16/2025, Resident #1 had a very bad accident while CNA A was taking care of her from a fall. The DON stated she was not in the facility when the fall occurred. She stated she found out about it when she received a text from LVN B. The DON stated she came to the facility and Resident #1 was still there and 911 had already been called. The DON stated Resident #1 looked terrible. She had a bump on her head, and she had blood all over. The DON stated there was a delay in calling 911 for assistance. She stated the incident had occurred at 6 something and EMS came over an hour later. The DON stated she did not know why it happened. She stated she thought LVN B panicked because she kept talking about the blood. The DON stated LVN B should have called 911 immediately and she should not have moved Resident #1 from the position she was found in. The DON stated LVN B stated she felt very bad about transferring the resident after the accident. The DON stated staff were trained prior, that if there was an injury to the resident, they call 911 and do not move them. The DON stated now the NF knew of Resident #1's injuries, she could have been paralyzed. The DON stated she monitored staff by being present and ensuring the residents were not neglected. She stated she was at the facility all the time and worked late. She stated she was also available any time and she ensured the staff had the training and competencies. The DON stated post incident, the LVN received additional counseling and training and the Administrator, who conducted the investigation and would have additional information. During an interview on 4/23/2025 at 2:20 p.m., the Administrator stated she was coming from the store when she saw the fire department on 4/16/2025, so she went to the facility. She stated the DON was already there and found out Resident #1 had been on the floor with a head injury. She stated the resident had already left the building when she arrived. The Administrator stated she did not know what to think about LVN B's actions. She stated she thought LVN panicked . The Administrator stated during her investigation while talking with her, LVN B knew right away she did not do a good job. She stated LVN B told her (Administrator) what she did wrong. The Administrator stated LVN B stated she should not have moved or lifted the resident but there was blood gushing, so she was aware. The Administrator stated if LVN B could call the MD or the DON, she could have called 911 right away. The Administrator stated there was a delay in care. The Administrator stated LVN B did not neglect the resident because she stayed with her and was helping her. The Administrator stated it was lack of judgement on LVN B's part because she should not have moved a resident with a head injury, and she should have called 911 right away. The Administrator stated after the incident, LVN B was counseled on her clinical judgement to ensure she knew what she did wrong. The Administrator stated she consulted with the Medical Director about the incident to get clear direction for how to go forward. She stated based on the Medical Directors recommendation she educated LVN B on trauma and gave her additional training on the protocol that should have followed. The Administrator stated she monitored the staff by ensuring they were trained through in-service training, competency checks and the ADON, DON and herself met with staff daily and told them the Administration all lived across the street and were available 24/7 (24 hours a day, 7 days a week), so they knew the staff had the support. The Administrator stated LVN B was not scheduled for the two days following the incident and was counseled and retrained. The Administrator stated LVN B did not have any prior disciplinary action and no resident complaints. The Administrator stated to correct the incident the facility did the following, completed 4/22/2025 prior to state surveyor entrance: 1. Consulted with the Medical Director on 4/18/2025 for guidance on the incident which included: training of staff on first aide care and a protocol/procedures for First Aide and Response to Head Trauma protocol was approved. 2. A consultation of counseling and training was provided on 4/18/2025 to LVN B to ensure she understood what she did wrong. The training included training on first aide care to resident with head injuries. The training on first aide care to residents included not moving the resident and notifying 911 immediately. 3. An in-service training was provided to licensed staff on 4/18/2025 titled Training on First Aide and Response to head Trauma. 4. Information was added to the electronic medical records with instructions for licensed staff response to a head injury. 5. An in-service was provided to all direct care staff assigned to Resident #1 post hospitalization completed on 4/22/2025 to included how to care for a resident in a c-collar and spinal stabilization during care . During interviews on 4/23/2025 8 CNA (CNA's D, E, F, I, J, K, L and M) and 3 LVN (LVNs C, G, and H) staff stated they received the in-service training on fall prevention which included ensuring needed supplies were gathered prior to initiating care and residents should not be left unattended during care, residents should utilize appropriate non-slip footwear, have a call light within reach . CNAs stated they should immediately notify the charge nurse without moving the resident. The licensed staff stated they should notify 911 immediatley without moving the patient after assessment for a resident with a head injury. During interviews on 4/23/2025 interviews with four licensed staff (LVN B, C, G and H)evealed they received the in-service training on First Aide and Response to Head Trauma protocol. They stated they were trained not to move a resident with a head injury, ask for assistance and immediately notify 911 to prevent further injury. During an interview on 4/23/2025 at 2:57 p.m., the Medical Director stated Resident #1 should have been left on the floor and EMS should have been summoned immediately. He stated he agreed the facility should not have lifted the resident or delayed care. He stated a resident with a visual impairment and cognitive impairment would have a significantly increased risk for falls. He stated staffing at the facility was adequate and not an issue. He stated the issue was an employee issue as to why it occurred. He stated he had no concerns for neglect at the facility. The Medical Director stated confirmation that he had discussed the incident and what should have occurred with the Administrator. Record review of an in-service training, dated 4/17/2025, reflected it was completed by 101 of 105 staff (4 staff on leave) which included ensuring all proper supplies were gathered prior to care and including not leaving a resident unattended. The training included: common causes of nursing home falls, common protocols for preventing nursing home falls which included implementation of a resident-centered fall prevention plan. Record review of an in-service training, dated 4/18/2025, reflected 20 of 22 licensed staff (2 staff on leave) had signed they had completed the in-service training for Head Trauma and First Aide which included: Call 911 for someone who has a serious head injury, facial bleeding, bleeding or fluid leakage from the nose/ears, change in consciousness for longer than a few seconds, no breathing, confusion, agitation or restlessness that continues to get worst, loss of balance, weakness or not being able to use an arm or leg, one pupil bigger than the other, slurred speech, seizures. The training also included: keep the person still, do not move the person unless necessary and avoid moving the person's neck. Stop any bleeding, watch for changes in breathing and alertness. Record review of an in-service training, dated 4/22/2024 and ongoing as new staff assigned to care for Resident #1, reflected, the staff were trained on caring for a resident in a c-collar and keeping the spine aligned during care which was provided to 18 staff members on all shifts. The in-service included the following: 1. Ensure the resident does not flex, extend, or rotate the neck. 2. Maintain strict spinal precautions at all times with staff assistance x 3 3. Do not remove the c-collar. 4. Log rolling the resident for all turning and repositioning. Record review of a untitled document, dated 4/18/2025, the Administrator documented on 4/18/2025 at 9:00 a.m., she had a meeting with the facility's Medical Director to review and approve the protocol and procedures for First Aide and Response to Head Trauma. She wrote it was established that a call to 911 should be placed immediately after finding resident on the floor. First Aide for Head Trauma was approved. Record review of the facility's, undated, policy, titled Fall Prevention reflected: Steps in the procedure after a fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. 2. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aide. 3. Once as assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position and then document relevant details. 4. Nursing staff will notify the resident's attending physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nursing staff will notify the attending physician and Administrator immediately by phone .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility reviewed for effective pest control, in that: The facility failed to ensure the facility was free from live rodents. This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents. The findings include: Observation on 10/15/2024 at 8:54 AM in the dry storage room of the kitchen revealed a rat running out of the dry storage room into the kitchen. During an interview on 10/17/2024 at 11:30 AM, the assistant KS stated she observed the rat as it exited the dry storage room. During an interview on 10/18/2024 at 11:05 AM, the KS and assistant KS stated neither of them had ever seen a rat in the kitchen prior to that day. There was no evidence of any food packages that were chewed open by a rat anywhere in the kitchen. Rodents could carry diseases and contaminate food. During an interview on 10/18/2024 at 11:20 AM, the Maintenance Director stated Pest Control came to the facility twice per month to treat for rodents and pests. A small opening in the drywall was found in the mechanical room that housed the compressors for the cooler and freezer, but the opening did not lead to the outside and he did not believe the rat entered from this opening. The Maintenance Director did not know how the rat could have possibly entered the facility. There had never been a rat sighting in the facility prior to this one. Record review of the contracts provided by the facility revealed the facility had a contract with a pest control company and the facility was serviced for roaches and pests twice per month. The most recent visit was 4 days prior to the sighting of the rodent, on 10/11/2024. The contractor serviced every area of the facility, including exterior areas and the kitchen. Record review of the facility policy, Pest Control Policy, undated, revealed: 3. Definitions: Pests: Includes rodents, insects, and other unwanted organisms that may affect the health of the residents. 4. Responsibilities: Management: Oversee pest control measures and ensure compliance with health regulations. Staff: Report pest sightings. Pest Control Contractor: Conduct regular inspections and treatments, adhering to safety measures.

Based on observation, interview, and record review, the facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption of residents' food items for 4 of 5 resident refrigerators (refrigerators in resident Rooms 115, 208, 213, and 215) reviewed for personal food policy, in that: 1. The personal refrigerators in three residents' Rooms (115, 208, and 215) contained food items which were unlabeled and undated. 2. The internal temperature of the refrigerator on resident room [ROOM NUMBER] exceeded 41 degrees Fahrenheit. These deficient practices could place residents at risk of foodborne illness due to consuming foods which were spoiled. The findings were: 1. a. Observation on 10/15/24 at 10:28 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER] contained melted ice cream shake in refrigerator which was unlabeled and undated. Observation on 10/15/24 at 11:10 a.m., revealed undated and unlabeled melted ice cream shake in resident room [ROOM NUMBER] personal refrigerator was still present. During an Interview with CNA A on 10/15/24 at 11:20 a.m., revealed personal refrigerator in resident's room [ROOM NUMBER] contained undated and unlabeled melted ice cream shake. b. Observation on 10/15/24 at 11:20 a.m. revealed the personal refrigerator in residents' room [ROOM NUMBER] contained sliced apples that were undated and unlabeled Observation on 10/15/24 at 11:30 a.m., revealed unlabeled and undated sliced apples in resident's room [ROOM NUMBER] personal refrigerator was still present. c. Observation on 10/15/24 at 11:35 a.m. revealed the personal refrigerator in resident's room [ROOM NUMBER] contained hard boiled eggs that were undated and unlabeled. Observation on 10/15/24 at 10:37 a.m. revealed the unlabeled and undated hard-boiled eggs in residents room [ROOM NUMBER] personal refrigerator was still present. During an Interview with CNA B on 10/15/24 at 11:45 a.m. revealed the personal refrigerator in rooms [ROOM NUMBERS] contained food that was undated and unlabeled. During an interview with the DON and ADON on 10/15/24 at 12:25 p.m., the DON and ADON stated perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled foods. The DON stated housekeeping were responsible for overseeing this and currently this was not being monitored. 2. Observation on 10/15/2024 at 11:06 a.m. of the thermometer inside the refrigerator revealed it read 53 degrees Fahrenheit. During an interview on 10/15/2024 at 11:15 a.m., LVN E stated the thermometer inside the refrigerator read 55 degrees and was too high. LVN E also stated according to the temperature log, the temperature of the refrigerator had exceeded the acceptable range for several days and nothing had been done about it. The night shift took and recorded the temperatures; however, it was also his responsibility to monitor the temperatures to ensure they were in the proper range and sometimes these things got overlooked. Record review of the Refrigerator Temperature Log for October 2024 placed inside a document protector taped to the right side of the refrigerator inside room [ROOM NUMBER] revealed the temperature recorded every day from 10/01/2024 - 10/14/2024 was 50 degrees Fahrenheit. Record review of the facility's undated policy, Foods Brought by Family/Visitors, reflected, .Food brought to the facility by visitors and family is permitted. The nursing staff will discard perishable foods on or before the use by date Record review of the facility's undated In-Room Refrigerator Policy, reflected, The housekeeping supervisor, or her designee, will also inspect in-room refrigerators monthly and keep a written log of all in-room refrigerators and the dates they are inspected .In room refrigerators must be kept clean and in good working condition . 46131

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, in that: 1. The facility failed to store, label and date food items properly in the walk-in cooler, freezer, and dry storage room. 2. The facility failed to store a dented can in a separate location in the dry storage room. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. a. Observation on 10/15/2024 at 8:40 AM in the walk-in cooler revealed a half-gallon container of Lactose-Free whole milk. The container had been opened with approximately 1/2 of the milk remaining in the container. There was no label or marking indicating the date the container had been opened or a use-by date. b. Observation on 10/15/2024 in the walk-in freezer 8:46 AM revealed a plastic bag containing six biscuits. The bag was sealed with a knot and there was no label or marking indicating the date stored or use-by date. c. Observation on 10/15/2024 at 8:52 AM in the dry storage room revealed a plastic storage bin containing brown sugar. The transparent plastic lid of the bin was ajar, exposing the sugar to the ambient air in the dry storage room. 2. Observation on 10/15/2024 at 8:50 AM in the dry storage room revealed a dented 6 lb. can of Mandarin oranges. The can of oranges was stored on a shelf with other cans that were not dented in the middle of the room. During an interview on 10/18/2024 at 11:05 AM, the KS and assistant KS stated the milk, biscuits and sugar were all used for the breakfast meal that morning and were placed in the cooler and freezer immediately after use. They were not labeled immediately due to the time constraint of preparing and serving the meal. The dented can was received with the other cans that morning and staff had not had an opportunity to separate it from the others. They stated the risk of serving residents food that was not labeled and dated was potential food borne illness from bacteria due to not knowing how long the food had been opened. The risk of having a dented can on the same shelf with other cans before it was segregated with the other dented cans in a separate place was potentially causing foodborne illness. The risk of an opened bin of sugar in the dry storage room was the potential for contamination by rodents. Rodents could carry diseases and contaminate food. Staff was trained on food service topics every month by the KS, assistant KS, or consultant RD. Record review of facility policy, Dietary Department Infection Control General Procedures, undated, revealed: The following activities of dietary personnel may involve or have an effect on the risk of infection for residents and personnel of the nursing home. Storing Food. All food items should be checked for expiration dates on a periodic basis. Opened containers of food (e.g., flour, sugar) should be stored in clean bins with tightly sealed lids. Planning of Menus: 3. The walk-in refrigerator is checked daily for over-ripe or decaying fruits and vegetables. All foods that are left over must be labeled, dated, and covered with a tightly fitted lid and placed in the dietary refrigerator for use within 24 hours. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record eview review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-101.11, Safe, Unadulterated, and Honestly Presented. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning was provided such care, consistent with professional standards of practice, for 2 of 3 residents (Residents #6 and #23) reviewed for respiratory care in that: The facility failed to ensure Residents #6 and #23's, oxygen tubing was dated. This deficient practice could place residents at risk for an increase in respiratory complications. The findings were: 1. Record review of Resident #6's face sheet, dated 10/17/24, reflected a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included: Hypertension (a condition where the pressure in your blood vessels is persistently high), Heart Failure (long term condition that occurs when the heart can not pump enough blood to meet the body's need's), and Hearing loss (Inability to hear sound in one or both ears). Record review of Resident #6's Quarterly MDS, dated [DATE], reflected a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #6's care plan, dated 8/13/24, reflected the resident received oxygen therapy with interventions of administer oxygen as ordered. Record review of Resident #6 monthly physician orders for The month of October 2024, reflected an order to change oxygen tubing weekly on Sunday. Observation and interview on 10/17/24 at 9:45 a.m. revealed Resident #6 in her room reading with the oxygen tubing which was undated. Resident #6 stated she did not recall if the tubing was ever dated. 2. Record review of Resident #23's face sheet dated 10/17/24, reflected a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included: General Anxiety (feeling of fear, dread and uneasiness that can be a normal reaction to stress), Congestive Heart Failure (serious condition that occurs when the heart cant pump enough blood to meet the needs of body), and Dependent on Oxygen (requirement of supplemental oxygen constantly). Record review of Resident #23's Quarterly MDS, dated [DATE], reflected a BIMS score of 13 which indicated moderate cognitive impairment. Record review of Resident #23's care plan, dated 4/10/24, reflected the resident was on continuous oxygen related to shortness of breath. Record review of Resident #23's monthly physician orders for the month of October 2024, reflected an order to change oxygen tubing weekly on Sunday. Observation and interview with Resident #23 on 10/17/24 at 11:25 a.m., in the dining room revealed Resident #23 waiting to be served lunch wearing a portable oxygen tank with oxygen tubing which was undated. Resident #23 stated, I don't recall if oxygen tubing gets changed. During an interview with LVN C on 10/17/24 at 12:28 p.m., LVN C stated she was the assigned LVN for Residents #6 and #23 and stated there was no date on the oxygen tubing for both residents. LVN C stated she did not know why the residents' oxygen tubing was undated and revealed night shift nurses usually dated and changed oxygen tubing weekly. LVN C stated, if the oxygen tubing was undated, we would not know when it was last changed which could cause a possible respiratory infection. During an interview with the DON on 10/18/24 at 2:27 p.m., the DON confirmed Residents #6 and #23 should have had their oxygen tubing changed and dated by the night shift. The DON stated Residents #6 and #23 risked a possible respiratory infection due to the oxygen tubing being undated as no one would know when it was last changed. The DON stated she was responsible for over seeing this task was completed and would have the ADON start monitoring this weekly moving forward. Record review of the facility's policy titled, Oxygen Equipment, undated, revealed, label all equipment such as oxygen tubing with date / time / initials.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #3) reviewed for privacy, in that: The facility failed to ensure MA D locked the computer, which exposed Resident #3's morning medication list after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings include: Record review of Resident #3's face sheet dated 10/16/24 reflected an 86 - year old female who was admitted to the facility on [DATE] with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Depressive Disorder (a mood disorder that can affect a person's thoughts, feelings, and ability to perform daily activities), and Dementia (condition characterized by loss of brain functions such as memory loss). Record review of Resident #3's Quarterly MDS assessment, dated 8/05/24, reflected a BIMS score of 3 which indicated severe cognition impairment. Observation on 10/17/24 at 9:12 AM, revealed MA D prepared Resident's #3's morning medication and ,walked away from the computer, MA D did not lock the computer screen. During an interview on 10/17/24 at 9:20 AM, MA D stated she was not aware of the option to lock the computer screen and believed minimizing the screen was sufficient. MA D stated when she stepped away from the computer, Resident #3's private medical information may have been exposed. During an interview on 10/17/24 at 11:41 AM, the DON stated she was not aware Resident #3's records were left open and unattended. The DON stated it was her expectation for the facility nursing staff to uphold HIPAA regulations and lock computer screens when they were away from them. The DON emphasized that all staff members were responsible for ensuring the protection of residents' information. The DON expressed concern that leaving residents' charts open and unattended could lead to unauthorized access. The DON also stated the ADON would be responsible for overseeing compliance with this task, and she would monitor it by conducting random computer screen checks. Record review of the facility's policy titled, Privacy of Computers during medication pass, dated March 2014, reflected: all patient information accessed during the medication pass shall be positioned to minimize visibility.

Based on Observation, Interview, and Record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 5 (Residents #3 and #49) reviewed for resident rights, in that: The facility failed to ensure Resident #3's and Resident #49's call light was within reach. This failure could place residents at risk of not achieving independent functioning, dignity, and well-being. Findings include: 1. Record review of Resident #3's face sheet dated 10/16/24 reflected an 86 - year old female who was admitted to the facility on [DATE] with diagnoses which included: Chronic Obstructive Pulmonary Disease (lung disease that damages the airways or other parts of the lungs, making it difficult to breathe), Depressive Disorder (a mood disorder that can affect a person's thoughts, feelings, and ability to perform daily activities), and Dementia (condition characterized by loss of brain functions such as memory loss). Record review of Resident #3's Quarterly MDS assessment, dated 8/05/24, reflected a BIMS score of 3 which indicated severe cognition impairment. Record review of Resident 3's care plan, dated 2/14/24, reflected Impaired mobility related to Dementia interventions keep call light within reach. Observation and interview on 10/16/24 in Resident #3's room at 10:20 AM revealed the call light was found on the night stand out of arms reach. Resident # 3 stated, They will come check on me if call light is out of reach. 2. Record review of Resident #49's face sheet, dated 10/16/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: Heart Failure (a condition in which heart doesn't pump as well as it should), Osteoarthritis (a degenerative joint disease that occurs when the cartilage that cushions the end of bones breaks down over time), and Hyperlipidemia (a condition where there are high levels of lipids in the blood) . Record review of Resident #49's Quarterly MDS assessment, dated 7/30/24, reflected a BIMS score of 12 which indicated moderate cognition impairment. Record review of Resident #49's care plan, dated 11/8/23, reflected Impaired physical mobility related to decreased strength with interventions keep essential items call light within reach. Observation and interview on 10/16/24 in Resident #49's room at 10:45 AM, revealed the call light was on the night stand out of arm's length. Resident #49 stated they work so hard they forgot to move that thing (call light) close to me, I will have to send smoke signals if I need help. During an interview on 10/16/24 at 11:00 AM, CNA A stated she was the assigned nursing assistant for Resident #3, and Resident #49 she mentioned she did not know how Resident #3's and Resident # 49's call light ended up on the nightstand, but she always clipped call light to the residents' clothes when they were up out of bed. CNA A also noted if Resident #3 and Resident #49 lacked access to the call light, it could potentially lead to a possible fall if they requested assistance. During an interview with the DON on 10/17/24, at 8:35 AM, the DON emphasized the importance of ensuring the call light was accessible to all residents, and stated that the lack of accessibility to a call light for any resident could lead to a potential negative outcome if assistance is needed. The DON also mentioned charge nurses currently monitored this task during their morning rounds daily, and she and her ADON were responsible for overseeing this process. Record review of the facility's policy titled, Answering Call Light, undated, revealed, when a resident is in bed or confined to a wheel chair be sure call light is with in reach.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident (Resident #6) reviewed for infection control, in that: The facility failed to ensure LVN C changed her gloves when moving from a dirty to clean task and failed to use appropriate hand hygiene between glove changes when she provided wound care to Resident #6. This deficient practice could place residents at risk for infection . The findings include: Record review of Resident #6's face sheet, dated 10/17/24, reflected a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses which included: Hypertension (a condition where the pressure in your blood vessels is persistently high), Heart Failure (long term condition that occurs when the heart cannot pump enough blood to meet the body's need's), and Hearing loss (Inability to hear sound in one or both ears). Record review of Resident #6's Quarterly MDS, dated [DATE], reflected a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #6's Physician Monthly Orders for the month of October 2024 reflected an order dated 10/4/24, sacral / Coccyx wound : clean with normal saline pat dry with 4x4 gauze, apply silver collagen to wound bed daily. Observation on 10/16/24 at 10:35 a.m., during wound care revealed LVN A removed Resident #6's old dressing, and did not remove her gloves, did not wash hands, or sanitize her hands and put on a new pair of gloves. LVN C then obtained a clean dressing and placed it on the resident's wound. LVN C then removed her gloves, washed her hands, and left the bedside to document. During an interview on 10/16/24 at 10:51 a.m., LVN C stated she did not realize she had not changed her gloves after removing Resident #6's soiled dressing and before touching and applying the clean dressing. LVN C stated she did not sanitize her hands and change gloves after removing the old dressing because she was nervous as she was being observed by the State Surveyor. LVN C added it was an infection control issue not washing her hands after touching the dirty dressing LVN C stated she was in-serviced and had competency training on infection control recently. During an interview on 10/17/24 at 12:58 p.m., the DON stated there was hand washing between glove changes, after touching a dirty dressing and then a clean dressing were potential causes for the spread of infection due to improper infection control practices. The DON stated she and the ADON currently monitored infection control practices at random, which included monthly in-services, and she was responsible for overseeing that this was completed. Record review of LVN C's clinical competency validation document for Hand Hygiene, dated 10/1/24, reflected LVN C had satisfied the requirement for proper hand hygiene. Record review of the facility's policy titled, Infection Prevention practices policy, undated, revealed, wearing clean gloves to avoid direct contact with contaminated infectious materials.

Based on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days , except if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 3 residents (Resident #41) reviewed for pharmacy services, in that: The facility failed to ensure Resident #41 had a stop date for PRN Xanax 0.25 mg (a medicine used to treat the symptoms of anxiety). This failure could place residents at risk of receiving unnecessary psychotropic medications. The findings include: Record review of Resident #41's face sheet, dated 10/16/24, reflected an 84- year old female who was admitted to the facility on [DATE] with diagnoses which included: Anxiety (a feeling of fear, dread, and uneasiness), Dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities), and Hypertension (when the pressure in your blood vessels is too high). Record review of Resident #41's most recent comprehensive MDS assessment, dated 10/08/24, revealed the resident was severely cognitively impaired for daily decision-making skills and was treated with anti-anxiety medications. Record review of Resident #41's comprehensive care plan dated 10/16/24 reflected the resident had a diagnosis of anxiety and used antianxiety medication as ordered by the physician. Record review of Resident #41's Order Summary Report, dated 10/16/24, reflected the following: - Xanax Oral Tablet 0.25 MG, give 1 tablet by mouth twice a day as needed for anxiety disorder, with start date 10/11/24 and no stop date. Record review of Resident #41's Medication Administration Record for October 2024 revealed Xanax 0.25 mg was not administered PRN all month in October 2024. During an observation and interview on 10/16/24 at 12:17 p.m. Resident #41 was observed in wheelchair awake and alert. Resident #41 stated she did not recall if she had been administered any medications. During an interview on 10/16/24 at 12:25 p.m., LVN C disclosed she did not recall if she had administered Xanax to Resident #41 to help with anxiety. LVN C stated psychotropic medications like Xanax should be used for a limited time, usually up to 14 days. After 14 days, the nurse was required to contact the physician to reassess the resident's need for the medication. LVN C stated she was unsure why the order for Xanax for Resident #41 was written for an indefinite period, and she expressed concern the resident was at risk of falls by taking the medication for more than 14 days. During an interview and record review on 10/17/24 at 2:10 p.m., the DON revealed Resident #41 required the use of Xanax as recommended by the physician due to the resident's diagnosis. The DON stated if the medication was taken all the time, it could result in Resident #41 being overmedicated. After reviewing Resident #41's order summary, the DON confirmed there was no stop date on the order for prn Xanax . The DON revealed she was unaware Xanax should only be ordered for 14 days and then reassessed by a physician for continued use. The DON stated moving forward she would be responsible for overseeing that psychotropic drugs were limited to 14 days, and her Assistant Director of Nursing was to start monitoring this daily moving forward to prevent this from occurring again. Record review of the facility's policy and procedure titled, Antipsychotic Medication, undated, revealed, PRN antipsychotics: 14 day limitation on all PRN orders, order may not be extended beyond the 14 day limit.

Based on observation, interviews, and record reviews, the facility failed to post information on a daily basis regarding the total number of the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for registered nurses, licensed practical nurses or licensed vocational nurses, certified nurses aides and resident census for 1 of 1 facility reviewed for posting. The facility failed to include the actual hours worked for the nursing staff on the nursing daily staff posting This deficient practice could place residents at risk or missed or inadequate care. The findings were: Observation on 10/16/24 at 9:30 a.m., revealed the facility had a daily nursing staffing posting for 10/16/24 in a visible area on the wall adjoining the main entrance to the facility. The daily nursing staffing posting included the following: 1- the hours of each of the nursing shifts for the 24 hour period, 2- the staff working on the shift which included registered nurses, licensed vocational nurses, certified nurses aides, restorative aides, and medications aides, 3-the number of the staff by discipline who worked on the shift, 4- the total hours worked for each group of staff during the shift, and 5- the summary of the total hours worked for that nursing discipline during the shift, and 6-the resident census for the day. During an interview with the HR Director on 10/18/24 at 12:15 p.m. the HR Director stated the hours worked by licensed and unlicensed nursing staff usually exceeded the number of hours for these disciplines that were posted. The HR Director provided sample documentation for the dates of 10/11/24, 10/12/24, 10/13/24, 10/14/24, 10/15/24, and 10/16/24 which reflected licensed and unlicensed staff, on those days, had actual hours worked that exceeded the number of hours that were posted for that day. The HR Director stated the licensed and unlicensed staff generally stayed at the facility longer than required in order to ensure a more thorough change of shift. During an interview with the Administrator on 10/18/24 at 12:30 p.m., the Administrator stated the facility always posted the daily nurse staffing form in a visible location and the nursing hours posted was usually less than the actual hours worked. The Administrator stated she felt the nursing staff hours that were posted demonstrated staffing levels that met the needs of the residents. Record review of the facility's posted daily nursing staffing forms for the time period 9/1/24 through 10/16/24 reflected the daily staffing postings did not include the actual hours worked for the licensed and unlicensed nursing staff Record review of the facility's undated policy on Staffing reflected, Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Our facility furnishes information from payroll records setting forth the actual recorded time, and types of personnel on each day of each quarter to appropriate state agencies.

Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder or related condition for level II resident review upon a significant change in status assessment for 1 of 1 Resident (Resident #2) reviewed for PASARR eligibility, in that: The facility failed to refer Resident #2 for a PASARR level II evaluation after being diagnosed with Major Depressive Disorder (MDD) and Bipolar Disorder. This deficient practice could affect residents with new mental illness diagnoses and it could result in residents not receiving services as needed. The findings were: Review of Resident #2's face sheet, undated, revealed she was admitted to the facility on [DATE] with diagnoses including (MDD), Major Depressive Disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest). Further review revealed during 2017 Resident #2 was diagnosed with Bipolar Disorder (mental health condition defined by periods (or episodes) of extreme mood disturbances that affect mood, thoughts, and behavior). Review of Resident #2's annual MDS assessment, 6/26/23, revealed she had a BIMS of 3 indicative of severe cognitive impairment, and diagnoses of depression and Bipolar. Review of Resident #2's Care Plan, dated 6/28/23, revealed Resident #2 had Depression and Bipolar and receiving psychotropic medications for these conditions. Review of Resident #2's EHR revealed she had a PASARR pre-screening completed prior to admission but there was no evidence she had a PASARR level II evaluation since being diagnosed with MDD and Bipolar. Interview on 09/07/23 at 02:27 PM with the SW revealed she was in charge of the ensuring the PASARR process was completed for the residents. However, stated she was not familiar with it. The SW stated she had an entry level PASARR but had never referred anyone for a Level II evaluation including Resident #2 because she had Dementia. Upon the SW's review of Resident #2's diagnoses she confirmed Resident #2 had MDD upon admission; diagnosed with Bipolar during 2017 and diagnosed with Dementia during 2018. The SW confirmed this information and stated she understood qualifying residents received services through the local authority but again stated she had not referred Resident #2 for a Level II evaluation. The SW stated she had not received training since 2019 and was not familiar with the current requirements or processes in place. Interview on 09/08/23 at 01:15 PM with the DON revealed she read the licensing standards for PASARR level II screening and confirmed staff should have submitted a request for a level II screening for Resident #2 related to her diagnosis of MDD and then Bipolar Disorder. She stated she completed PASARR training before COVID but neither she nor staff had received recent training. The DON stated she understood if Resident #2 met the level 11 requirements then she would qualify for services and this was why it was important to request the screening. Review of a facility policy title, PASARR Policy., undated, read: Preadmission Screening and Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that Medicaid-certified nursing facilities: 1. Evaluate all applicants for serious mental illness (SMI) and/or intellectual disability (ID). 2. Offered all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings). 3. Provide all applicants the services they need in those settings.

Based on interview and record review the facility failed to ensure when the facility anticipates discharge, a resident must have a discharge summary that includes a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 2 residents (Resident #1) reviewed for discharge requirement, in that: The facility failed to ensure residents had a discharge summary that included a recapitulation of the resident's stay which included, but was not limited to diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. This deficient practice could affect resdients discharged from the facility due to improper discharge summary. Findings Include: Record review of Resident #1's Admission record, dated 08/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included osteoarthritis (condition that affects the joints, causing pain, stiffness and reduced movement), restlessness and agitation, insomnia (Trouble falling and/or staying asleep), unspecific intracranial injury with loss of consciousness of unspecified duration (unknow head injury with lack of awareness of self and the environment for an unknown amount of time), chronic kidney disease (A condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic. Disease progression occurs slowly over a period.), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), and unspecified dementia unspecified severity with psychotic disturbance (Dementia psychotic behavior refers to the behavioral and psychotic symptoms of dementia that occur in moderate- to- severe stages of the disease. These symptoms may include hallucinations, delusions, paranoia, aggression, agitation, depression, and wandering. Hallucinations are false perceptions of sensory stimuli, delusions are false beliefs, and paranoia is irrational suspicion). Record review of Resident #1's care plan, last revised on 10/21/23, revealed care area problems for psychotropic drug use, resident had physical behavioral symptoms directed towards others, Category: Behavioral Symptoms Risk for agitation RT Unspecified dementia, unspecified severity, with psychotic disturbance, Psychotropic Drug Use Risk for side effects from psychotropic drug use: (lorazepam), Category: Behavioral Symptoms Wandering behavior R/T confusion secondary Unspecified dementia with psychotic disturbance AMB wandering around facility seeking exit doors, Category: Psychotropic Drug Use Risk for side effects from psychotropic drug use: Seroquel (quetiapine) Condition treated: Unspecified dementia with psychotic disturbance, Category: Psychotropic Drug Use Risk for side effects from Lexapro use Condition treated: depression, Category: Mood State Risk for Depression RT Debility, Category: Psychosocial Well-Being Relocation Stress Syndrome R/T nursing home placement as manifested by change of environment, Category: Communication deficit related to cognitive impaired AMB memory loss and confusion, and Category: Cognitive Loss / Dementia Altered thought process R/T cognitive loss secondary to Unspecified dementia with psychotic disturbance as manifested by disorientation, forgetfulness, confusion and memory loss. During an interview on 08/17/23 at 3:15 p.m., LVN A stated Resident #1 attacked her at the nurse's station on 11/3/23. LVN A stated like many of the residents, Resident #1 was confused and forgetful and the staff would try to reorient him back. LVN A stated Resident #1 would ball up his fist, but he did not actually hit anyone. LVN A stated to her knowledge no other residents were harmed by Resident #1. LVN A stated on 11/03/23 Resident #1 walked into the nurse's station like he normally did. LVN A stated he was a fall risk, so she tried to redirect him out of the station and to use his walker. LVN A stated Resident #1 became angry and irate, got in her face, and grabbed her by both of her wrist. LVN A stated Resident #1 told her do not tell me what to do and would not let her go or move. LVN A stated Resident #1 was also pushed her back into the counter at the nurse's station and it left a mark on her back. LVN A recalled other staff helped get Resident #1 off her and then called the police. During an interview on 08/17/23 at 9:45 a.m. the Social Worker stated the Resident #1's family member brought Resident #1 to the facility and stated she needed a break. The SW stated the resident initially was confused and asked for his family member. The SW stated the family member did not answer or come visit for over a week. The SW stated the resident became more aggressive by ripping the wander guard alarm off a wall and throwing his walker. The SW stated no other residents were harmed or injured that she could recall. The SW stated Resident #1's family member did come back to visit and initially stated the resident never had aggressive behaviors before. The SW stated they were concerned to hear this, but the family member stated he had hit her and pushed her before. The SW stated the aggressive behaviors were constant daily and they tried to find alternate placement for him for men with behavior problems. The SW showed a list of places from a file in her office of places she had tried to transfer Resident #1 to. The SW stated no other facility would accept the resident because of his behavior issues. The SW stated the resident was combative with staff. The SW stated Resident #1 attacked a nurse at the nurses' station by grabbing her and throwing her. The SW stated on 11/03/22 they called the police for a psychiatric evaluation after the resident attacked the nurse. The SW stated the police did not want to take Resident #1 and stated the facility took him and it was their problem. The SW stated after an hour and a half they finally took him to a local ER for an emergency detention and mental evaluation. The SW stated the local ER tried to return Resident #1 back to the facility that day. The SW stated they refused to accept Resident #1 back from the ER and stated they could not care for him in that condition. The SW stated the ER threatened to call the state on them if they did not accept Resident #1 back. The SW stated they wanted him to at least go for a 10 day hold and be treated. The SW stated the resident did not go with any discharge paperwork because the officer did not want to take it and stated they would call for the paperwork. The SW stated they were actively trying to discharge Resident #1, they did not want him back, and they would take their licks if they got them for not accepting him back. During an interview on 08/17/23 at 9:30 a.m., the Administrator stated Resident #1's family member brought him to the facility to be admitted in October of 2022. The Administrator stated the resident's family member did not tell them the full truth about the resident's behaviors and the medicine the provider had prescribed was not working. The Administrator stated on 11/03/22 Resident #1 attacked a nurse at the nurse's station. The Administrator stated they called the police, and the police did not want to take the resident initially. The Administrator stated finally the officer tried to ask the resident if he felt suicidal and the resident stated yes. The Administrator stated Resident #1 had dementia and did not know what he was answering yes to. The Administrator stated once the resident answered yes to having thoughts of suicide the police were able to take him to an ER for an emergency mental evaluation. The Administrator stated they would have accepted Resident #1 back if he was treated and did not come back with the same behaviors. She said did not have documentation because she was not planning on discharging Resident #1 when he went to hospital. She stated she did not have the following: 1) Resident/Representative verbal or written notice of intent to leave the facility. 2) Comprehensive care plan that includes the resident's goals for admission and discharge 3) Discharge planning process 4) Discharge summary 5) Signed physician order of discharge 6) Notice to Adult Protective Service (APS) 7) Meeting with Interdisciplinary Team (IDT) about discharge 8) Required 30-day notice to Resident #1 9) No communication with receiving facility Record review of Resident #1's progress notes, dated 08/17/23, revealed the following: -On 10/05/22 the resident arrived to the facility and was pleasant and cooperative on that day. -On 10/05/22 another note states he was forgetful and follows redirection. -On 10/06/23 Resident was pleasant to talk with and was looking for his family member. -Another note on 10/06/22 stated resident was searching for his family member all the time, he his with his walker, sometimes he forgets his walker, and needs cues. -On 10/07/22 a note stated patient was adjusting well to the facility, no behaviors noted, continues on Lexapro and Seroquel, no exit seeking, patient did get up from area and would walk around, easily redirected, and family member had been visiting. -On 10/12/22 a note stated resident was trying to go out and was wandering in all residents' room.Sometime more aggressive. - On 10/12/22 a note stated Spoke with MD new orders for lorazepam 0.5 mg tab PO BID and order for UA c/s. Note from 10/12/23 resident attempted to hit another resident. -On 10/15/22 a note stated Resident was agitated and wandered without his walker. He was hitting staff and swinging at staff and was not redirectable. Resident gets upset and agitated when told that he needed to use his walker and needed to sit down. -On 10/20/22 a note stated resident stood in the dining room, suddenly started to slap himself on both sides of his face with both hands. -On 10/20/22 a note stated MD assessed the resident's new orders for d/c singulair, d/c lorazepam 0.5 mg BID PRN, start lorazepam 0.5 mg 1-2 tabs po BID prn anxiety, divalproex 125 mg po BID mood D/O. Notes continue to document similar behaviors. -On 10/27/22 a note from the MD updated on resident behaviors new orders to increase lorazepam 0.5 mg TID and lorazepam 0.5 TID PRN, and divalproex 125 mg TID. -On 11/01/22 a note stated the resident was trying to walk fast without his walker fell and hit his head. -On 11/02/22 a note stated the resident was aggressive and walking without his walker. He hit staff with hand. He was going to the first floor via staircase staff followed him. Four staff tried to redirect and sit in the wheelchair. -On 11/02/22 a note from LVN A stated CNA attempted to assist resident to bathroom, however resident became agitated and combative, grabbing CNA by the wrist. CNA's hand and wrist is red. -A note on 11/02/22 revealed new telephone orders from MD d/c lorazepam 0.5 mg tab po TID, give Ativan 1 mg 1 tab po TID for restlessness and agitation. -A note from 11/03/22 revealed Resident #1 was aggressive and agitated, he was walking the whole way without his walker. He cannot able to stay any place. He want to go out. He was looking for the door and elevator. New order 1. D/C lorazepam 1 mg TID, start lorazepam 1 mg QID may hold if he is over sedation and hold RR <10, Quetipine 50 mg 1 tab BID, D/C Quetipine 50 mg 1 tab PO QHS. -On 11/03/22 a note from the DON stated around 4:00 PM resident became very agitated and combative. All of a sudden, he went around the nurses' station, and without any reason, he grabbed the nurse unexpectedly. He got very close to her and pushed her on the nurse's desk. All staff immediately intervened, however, all the residents gathered at the nurses' station were terrified and started to yell for help. Slowly, staff was able to calm the residents down and take him away from this nurse he was still agitated and was hitting his head with his shoe. Other staff members who tried to encourage him to sit in the wheelchair was hit with a shoe as well. Afterwards he was taken outside the building and was supervised by staff. Administrator and social worker called police to make the report. The police arrived at the facility and interviewed the resident as well as a nurse who claimed assault. He was taken in the police car to emergency detention center for further evaluation. RP [Family Member] and MD were notified. Resident discharge. Record review of facility's, undated, policy titled Admission, Transfer and Discharge Policy, stated .II. Procedure: .B. Transfer and Discharge requirements. The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless: 1. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .3. The safety of individuals in the facility are in danger. 4. The health of individuals in the facility would otherwise be endangered .C. Transfers or Discharges: 1. when the facility transfers or discharges a resident under any of the above circumstances, appropriate documentation shall be made in the residence clinical record. The attending physician shall document the reasons for transfer/discharge when a resident is transferred or discharged for reasons 1, 2 and 4 above .D. Notification: before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative or the resident of the transfer or discharge. This notice shall be in a language and manner they understand. This notice shall be in writing and should include the reasons for transfer. The notice will be made at least 30 days before a resident is transferred or discharged unless: 1. the safety of individuals in the facility would be endangered, 2. the health of the individuals would be endangered, 3. The resident's health improves to allow more immediate transfer or discharge, 4. an immediate transfer or discharge is required by the residence urgent medical needs, or 5. the resident has not resided in the facility for 30 days, 6. in the above situations, the notice will be made as soon as practical before transfer or discharge. E. Contents of the transfer notice: the notice of transfer/discharge shall include: 1. the reason for transfer/ discharge, 2. the effective date of transfer/ discharge, 3. the location to which the resident is transferred/ discharge, 4. a statement that the resident has a right to appeal the action to the state . F. Orientation for transfer or discharge. the facility provides sufficient preparation and orientation to residents to ensure safe and orderly transfer discharge. The contents of the transfer notice will be explained to the resident or the resident's representative. Transfer/ discharge procedures will be explained, and the resident will be assisted with transportation arrangements, if necessary

Based on interview and record review the facility failed to ensure before transferring or discharging a resident, the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged for 1 of 2 residents (Resident #1) reviewed for discharge requirement. There was no documentation from the physician which indicated the resident had specific needs that could not be met in the facility. This deficient practice could affect residents discharged from the facility due to improper discharge. Findings Include: Record review of Resident #1's Admission record, dated 08/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included osteoarthritis (condition that affects the joints, causing pain, stiffness and reduced movement), restlessness and agitation, insomnia (Trouble falling and/or staying asleep), unspecific intracranial injury with loss of consciousness of unspecified duration (unknow head injury with lack of awareness of self and the environment for an unknown amount of time), chronic kidney disease (A condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic. Disease progression occurs slowly over a period.), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), and unspecified dementia unspecified severity with psychotic disturbance (Dementia psychotic behavior refers to the behavioral and psychotic symptoms of dementia that occur in moderate- to- severe stages of the disease. These symptoms may include hallucinations, delusions, paranoia, aggression, agitation, depression, and wandering. Hallucinations are false perceptions of sensory stimuli, delusions are false beliefs, and paranoia is irrational suspicion). Record review of Resident #1's care plan, last revised on 10/21/23, revealed care area problems for psychotropic drug use, resident had physical behavioral symptoms directed towards others, Category: Behavioral Symptoms Risk for agitation RT Unspecified dementia, unspecified severity, with psychotic disturbance, Psychotropic Drug Use Risk for side effects from psychotropic drug use: (lorazepam), Category: Behavioral Symptoms Wandering behavior R/T confusion secondary Unspecified dementia with psychotic disturbance AMB wandering around facility seeking exit doors, Category: Psychotropic Drug Use Risk for side effects from psychotropic drug use: Seroquel (quetiapine) Condition treated: Unspecified dementia with psychotic disturbance, Category: Psychotropic Drug Use Risk for side effects from Lexapro use Condition treated: depression, Category: Mood State Risk for Depression RT Debility, Category: Psychosocial Well-Being Relocation Stress Syndrome R/T nursing home placement as manifested by change of environment, Category: Communication deficit related to cognitive impaired AMB memory loss and confusion, and Category: Cognitive Loss / Dementia Altered thought process R/T cognitive loss secondary to Unspecified dementia with psychotic disturbance as manifested by disorientation, forgetfulness, confusion and memory loss. During an interview on 08/17/23 at 3:15 p.m., LVN A stated Resident #1 attacked her at the nurse's station on 11/3/23. LVN A stated like many of the residents, Resident #1 was confused and forgetful and the staff would try to reorient him back. LVN A stated Resident #1 would ball up his fist, but he did not actually hit anyone. LVN A stated to her knowledge no other residents were harmed by Resident #1. LVN A stated on 11/03/23 Resident #1 walked into the nurse's station like he normally did. LVN A stated he was a fall risk, so she tried to redirect him out of the station and to use his walker. LVN A stated Resident #1 became angry and irate, got in her face, and grabbed her by both of her wrist. LVN A stated Resident #1 told her do not tell me what to do and would not let her go or move. LVN A stated Resident #1 was also pushed her back into the counter at the nurse's station and it left a mark on her back. LVN A recalled other staff helped get Resident #1 off her and then called the police. During an interview on 08/17/23 at 9:45 a.m. the Social Worker stated the Resident #1's family member brought Resident #1 to the facility and stated she needed a break. The SW stated the resident initially was confused and asked for his family member. The SW stated the family member did not answer or come visit for over a week. The SW stated the resident became more aggressive by ripping the wander guard alarm off a wall and throwing his walker. The SW stated no other residents were harmed or injured that she could recall. The SW stated Resident #1's family member did come back to visit and initially stated the resident never had aggressive behaviors before. The SW stated they were concerned to hear this, but the family member stated he had hit her and pushed her before. The SW stated the aggressive behaviors were constant daily and they tried to find alternate placement for him for men with behavior problems. The SW showed a list of places from a file in her office of places she had tried to transfer Resident #1 to. The SW stated no other facility would accept the resident because of his behavior issues. The SW stated the resident was combative with staff. The SW stated Resident #1 attacked a nurse at the nurses' station by grabbing her and throwing her. The SW stated on 11/03/22 they called the police for a psychiatric evaluation after the resident attacked the nurse. The SW stated the police did not want to take Resident #1 and stated the facility took him and it was their problem. The SW stated after an hour and a half they finally took him to a local ER for an emergency detention and mental evaluation. The SW stated the local ER tried to return Resident #1 back to the facility that day. The SW stated they refused to accept Resident #1 back from the ER and stated they could not care for him in that condition. The SW stated the ER threatened to call the state on them if they did not accept Resident #1 back. The SW stated they wanted him to at least go for a 10 day hold and be treated. The SW stated the resident did not go with any discharge paperwork because the officer did not want to take it and stated they would call for the paperwork. The SW stated they were actively trying to discharge Resident #1, they did not want him back, and they would take their licks if they got them for not accepting him back. During an interview on 08/17/23 at 9:30 a.m., the Administrator stated Resident #1's family member brought him to the facility to be admitted in October of 2022. The Administrator stated the resident's family member did not tell them the full truth about the resident's behaviors and the medicine the provider had prescribed was not working. The Administrator stated on 11/03/22 Resident #1 attacked a nurse at the nurse's station. The Administrator stated they called the police, and the police did not want to take the resident initially. The Administrator stated finally the officer tried to ask the resident if he felt suicidal and the resident stated yes. The Administrator stated Resident #1 had dementia and did not know what he was answering yes to. The Administrator stated once the resident answered yes to having thoughts of suicide the police were able to take him to an ER for an emergency mental evaluation. The Administrator stated they would have accepted Resident #1 back if he was treated and did not come back with the same behaviors. She said did not have documentation because she was not planning on discharging Resident #1 when he went to hospital. She stated she did not have the following: 1) Resident/Representative verbal or written notice of intent to leave the facility. 2) Comprehensive care plan that includes the resident's goals for admission and discharge 3) Discharge planning process 4) Discharge summary 5) Signed physician order of discharge 6) Notice to Adult Protective Service (APS) 7) Meeting with Interdisciplinary Team (IDT) about discharge 8) Required 30-day notice to Resident #1 9) No communication with receiving facility Record review of Resident #1's progress notes, dated 08/17/23, revealed the following: -On 10/05/22 the resident arrived to the facility and was pleasant and cooperative on that day. -On 10/05/22 another note states he was forgetful and follows redirection. -On 10/06/23 Resident was pleasant to talk with and was looking for his family member. -Another note on 10/06/22 stated resident was searching for his family member all the time, he his with his walker, sometimes he forgets his walker, and needs cues. -On 10/07/22 a note stated patient was adjusting well to the facility, no behaviors noted, continues on Lexapro and Seroquel, no exit seeking, patient did get up from area and would walk around, easily redirected, and family member had been visiting. -On 10/12/22 a note stated resident was trying to go out and was wandering in all residents' room.Sometime more aggressive. - On 10/12/22 a note stated Spoke with MD new orders for lorazepam 0.5 mg tab PO BID and order for UA c/s. Note from 10/12/23 resident attempted to hit another resident. -On 10/15/22 a note stated Resident was agitated and wandered without his walker. He was hitting staff and swinging at staff and was not redirectable. Resident gets upset and agitated when told that he needed to use his walker and needed to sit down. -On 10/20/22 a note stated resident stood in the dining room, suddenly started to slap himself on both sides of his face with both hands. -On 10/20/22 a note stated MD assessed the resident's new orders for d/c singulair, d/c lorazepam 0.5 mg BID PRN, start lorazepam 0.5 mg 1-2 tabs po BID prn anxiety, divalproex 125 mg po BID mood D/O. Notes continue to document similar behaviors. -On 10/27/22 a note from the MD updated on resident behaviors new orders to increase lorazepam 0.5 mg TID and lorazepam 0.5 TID PRN, and divalproex 125 mg TID. -On 11/01/22 a note stated the resident was trying to walk fast without his walker fell and hit his head. -On 11/02/22 a note stated the resident was aggressive and walking without his walker. He hit staff with hand. He was going to the first floor via staircase staff followed him. Four staff tried to redirect and sit in the wheelchair. -On 11/02/22 a note from LVN A stated CNA attempted to assist resident to bathroom, however resident became agitated and combative, grabbing CNA by the wrist. CNA's hand and wrist is red. -A note on 11/02/22 revealed new telephone orders from MD d/c lorazepam 0.5 mg tab po TID, give Ativan 1 mg 1 tab po TID for restlessness and agitation. -A note from 11/03/22 revealed Resident #1 was aggressive and agitated, he was walking the whole way without his walker. He cannot able to stay any place. He want to go out. He was looking for the door and elevator. New order 1. D/C lorazepam 1 mg TID, start lorazepam 1 mg QID may hold if he is over sedation and hold RR <10, Quetipine 50 mg 1 tab BID, D/C Quetipine 50 mg 1 tab PO QHS. -On 11/03/22 a note from the DON stated around 4:00 PM resident became very agitated and combative. All of a sudden, he went around the nurses' station, and without any reason, he grabbed the nurse unexpectedly. He got very close to her and pushed her on the nurse's desk. All staff immediately intervened, however, all the residents gathered at the nurses' station were terrified and started to yell for help. Slowly, staff was able to calm the residents down and take him away from this nurse he was still agitated and was hitting his head with his shoe. Other staff members who tried to encourage him to sit in the wheelchair was hit with a shoe as well. Afterwards he was taken outside the building and was supervised by staff. Administrator and social worker called police to make the report. The police arrived at the facility and interviewed the resident as well as a nurse who claimed assault. He was taken in the police car to emergency detention center for further evaluation. RP [Family Member] and MD were notified. Resident discharge. Record review of facility's, undated, policy titled Admission, Transfer and Discharge Policy, stated .II. Procedure: .B. Transfer and Discharge requirements. The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless: 1. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .3. The safety of individuals in the facility are in danger. 4. The health of individuals in the facility would otherwise be endangered .C. Transfers or Discharges: 1. when the facility transfers or discharges a resident under any of the above circumstances, appropriate documentation shall be made in the residence clinical record. The attending physician shall document the reasons for transfer/discharge when a resident is transferred or discharged for reasons 1, 2 and 4 above .D. Notification: before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative or the resident of the transfer or discharge. This notice shall be in a language and manner they understand. This notice shall be in writing and should include the reasons for transfer. The notice will be made at least 30 days before a resident is transferred or discharged unless: 1. the safety of individuals in the facility would be endangered, 2. the health of the individuals would be endangered, 3. The resident's health improves to allow more immediate transfer or discharge, 4. an immediate transfer or discharge is required by the residence urgent medical needs, or 5. the resident has not resided in the facility for 30 days, 6. in the above situations, the notice will be made as soon as practical before transfer or discharge. E. Contents of the transfer notice: the notice of transfer/discharge shall include: 1. the reason for transfer/ discharge, 2. the effective date of transfer/ discharge, 3. the location to which the resident is transferred/ discharge, 4. a statement that the resident has a right to appeal the action to the state . F. Orientation for transfer or discharge. the facility provides sufficient preparation and orientation to residents to ensure safe and orderly transfer discharge. The contents of the transfer notice will be explained to the resident or the resident's representative. Transfer/ discharge procedures will be explained, and the resident will be assisted with transportation arrangements, if necessary

Based on interview and record review the facility failed to ensure before transferring or discharging a resident, the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged for 1 of 2 residents (Resident #1) reviewed for discharge requirement, in that: 1. The facility failed and refused to readmit Resident #1 from the hospital where he was transferred for evaluation and treatment. 2. The facility did not give Resident #1 or the representative a discharge notice when he was transferred to another facility from the hospital. 3. The facility did not permit Resident #1 to remain in the facility and failed to initiate a 30-day discharge based upon the facility's ability to meet the resident's needs and welfare. These failures could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal process. Findings Include: Record review of Resident #1's Admission record, dated 08/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included osteoarthritis (condition that affects the joints, causing pain, stiffness and reduced movement), restlessness and agitation, insomnia (Trouble falling and/or staying asleep), unspecific intracranial injury with loss of consciousness of unspecified duration (unknow head injury with lack of awareness of self and the environment for an unknown amount of time), chronic kidney disease (A condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic. Disease progression occurs slowly over a period.), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), and unspecified dementia unspecified severity with psychotic disturbance (Dementia psychotic behavior refers to the behavioral and psychotic symptoms of dementia that occur in moderate- to- severe stages of the disease. These symptoms may include hallucinations, delusions, paranoia, aggression, agitation, depression, and wandering. Hallucinations are false perceptions of sensory stimuli, delusions are false beliefs, and paranoia is irrational suspicion). Record review of Resident #1's care plan, last revised on 10/21/23, revealed care area problems for psychotropic drug use, resident had physical behavioral symptoms directed towards others, Category: Behavioral Symptoms Risk for agitation RT Unspecified dementia, unspecified severity, with psychotic disturbance, Psychotropic Drug Use Risk for side effects from psychotropic drug use: (lorazepam), Category: Behavioral Symptoms Wandering behavior R/T confusion secondary Unspecified dementia with psychotic disturbance AMB wandering around facility seeking exit doors, Category: Psychotropic Drug Use Risk for side effects from psychotropic drug use: Seroquel (quetiapine) Condition treated: Unspecified dementia with psychotic disturbance, Category: Psychotropic Drug Use Risk for side effects from Lexapro use Condition treated: depression, Category: Mood State Risk for Depression RT Debility, Category: Psychosocial Well-Being Relocation Stress Syndrome R/T nursing home placement as manifested by change of environment, Category: Communication deficit related to cognitive impaired AMB memory loss and confusion, and Category: Cognitive Loss / Dementia Altered thought process R/T cognitive loss secondary to Unspecified dementia with psychotic disturbance as manifested by disorientation, forgetfulness, confusion and memory loss. During an interview on 08/17/23 at 3:15 p.m., LVN A stated Resident #1 attacked her at the nurse's station on 11/3/23. LVN A stated like many of the residents, Resident #1 was confused and forgetful and the staff would try to reorient him back. LVN A stated Resident #1 would ball up his fist, but he did not actually hit anyone. LVN A stated to her knowledge no other residents were harmed by Resident #1. LVN A stated on 11/03/23 Resident #1 walked into the nurse's station like he normally did. LVN A stated he was a fall risk, so she tried to redirect him out of the station and to use his walker. LVN A stated Resident #1 became angry and irate, got in her face, and grabbed her by both of her wrist. LVN A stated Resident #1 told her do not tell me what to do and would not let her go or move. LVN A stated Resident #1 was also pushed her back into the counter at the nurse's station and it left a mark on her back. LVN A recalled other staff helped get Resident #1 off her and then called the police. During an interview on 08/17/23 at 9:45 a.m. the Social Worker stated the Resident #1's family member brought Resident #1 to the facility and stated she needed a break. The SW stated the resident initially was confused and asked for his family member. The SW stated the family member did not answer or come visit for over a week. The SW stated the resident became more aggressive by ripping the wander guard alarm off a wall and throwing his walker. The SW stated no other residents were harmed or injured that she could recall. The SW stated Resident #1's family member did come back to visit and initially stated the resident never had aggressive behaviors before. The SW stated they were concerned to hear this, but the family member stated he had hit her and pushed her before. The SW stated the aggressive behaviors were constant daily and they tried to find alternate placement for him for men with behavior problems. The SW showed a list of places from a file in her office of places she had tried to transfer Resident #1 to. The SW stated no other facility would accept the resident because of his behavior issues. The SW stated the resident was combative with staff. The SW stated Resident #1 attacked a nurse at the nurses' station by grabbing her and throwing her. The SW stated on 11/03/22 they called the police for a psychiatric evaluation after the resident attacked the nurse. The SW stated the police did not want to take Resident #1 and stated the facility took him and it was their problem. The SW stated after an hour and a half they finally took him to a local ER for an emergency detention and mental evaluation. The SW stated the local ER tried to return Resident #1 back to the facility that day. The SW stated they refused to accept Resident #1 back from the ER and stated they could not care for him in that condition. The SW stated the ER threatened to call the state on them if they did not accept Resident #1 back. The SW stated they wanted him to at least go for a 10 day hold and be treated. The SW stated the resident did not go with any discharge paperwork because the officer did not want to take it and stated they would call for the paperwork. The SW stated they were actively trying to discharge Resident #1, they did not want him back, and they would take their licks if they got them for not accepting him back. During an interview on 08/17/23 at 9:30 a.m., the Administrator stated Resident #1's family member brought him to the facility to be admitted in October of 2022. The Administrator stated the resident's family member did not tell them the full truth about the resident's behaviors and the medicine the provider had prescribed was not working. The Administrator stated on 11/03/22 Resident #1 attacked a nurse at the nurse's station. The Administrator stated they called the police, and the police did not want to take the resident initially. The Administrator stated finally the officer tried to ask the resident if he felt suicidal and the resident stated yes. The Administrator stated Resident #1 had dementia and did not know what he was answering yes to. The Administrator stated once the resident answered yes to having thoughts of suicide the police were able to take him to an ER for an emergency mental evaluation. The Administrator stated they would have accepted Resident #1 back if he was treated and did not come back with the same behaviors. She said did not have documentation because she was not planning on discharging Resident #1 when he went to hospital. She stated she did not have the following: 1) Resident/Representative verbal or written notice of intent to leave the facility. 2) Comprehensive care plan that includes the resident's goals for admission and discharge 3) Discharge planning process 4) Discharge summary 5) Signed physician order of discharge 6) Notice to Adult Protective Service (APS) 7) Meeting with Interdisciplinary Team (IDT) about discharge 8) Required 30-day notice to Resident #1 9) No communication with receiving facility Record review of Resident #1's progress notes, dated 08/17/23, revealed the following: -On 10/05/22 the resident arrived to the facility and was pleasant and cooperative on that day. -On 10/05/22 another note states he was forgetful and follows redirection. -On 10/06/23 Resident was pleasant to talk with and was looking for his family member. -Another note on 10/06/22 stated resident was searching for his family member all the time, he his with his walker, sometimes he forgets his walker, and needs cues. -On 10/07/22 a note stated patient was adjusting well to the facility, no behaviors noted, continues on Lexapro and Seroquel, no exit seeking, patient did get up from area and would walk around, easily redirected, and family member had been visiting. -On 10/12/22 a note stated resident was trying to go out and was wandering in all residents' room.Sometime more aggressive. - On 10/12/22 a note stated Spoke with MD new orders for lorazepam 0.5 mg tab PO BID and order for UA c/s. Note from 10/12/23 resident attempted to hit another resident. -On 10/15/22 a note stated Resident was agitated and wandered without his walker. He was hitting staff and swinging at staff and was not redirectable. Resident gets upset and agitated when told that he needed to use his walker and needed to sit down. -On 10/20/22 a note stated resident stood in the dining room, suddenly started to slap himself on both sides of his face with both hands. -On 10/20/22 a note stated MD assessed the resident's new orders for d/c singulair, d/c lorazepam 0.5 mg BID PRN, start lorazepam 0.5 mg 1-2 tabs po BID prn anxiety, divalproex 125 mg po BID mood D/O. Notes continue to document similar behaviors. -On 10/27/22 a note from the MD updated on resident behaviors new orders to increase lorazepam 0.5 mg TID and lorazepam 0.5 TID PRN, and divalproex 125 mg TID. -On 11/01/22 a note stated the resident was trying to walk fast without his walker fell and hit his head. -On 11/02/22 a note stated the resident was aggressive and walking without his walker. He hit staff with hand. He was going to the first floor via staircase staff followed him. Four staff tried to redirect and sit in the wheelchair. -On 11/02/22 a note from LVN A stated CNA attempted to assist resident to bathroom, however resident became agitated and combative, grabbing CNA by the wrist. CNA's hand and wrist is red. -A note on 11/02/22 revealed new telephone orders from MD d/c lorazepam 0.5 mg tab po TID, give Ativan 1 mg 1 tab po TID for restlessness and agitation. -A note from 11/03/22 revealed Resident #1 was aggressive and agitated, he was walking the whole way without his walker. He cannot able to stay any place. He want to go out. He was looking for the door and elevator. New order 1. D/C lorazepam 1 mg TID, start lorazepam 1 mg QID may hold if he is over sedation and hold RR <10, Quetipine 50 mg 1 tab BID, D/C Quetipine 50 mg 1 tab PO QHS. -On 11/03/22 a note from the DON stated around 4:00 PM resident became very agitated and combative. All of a sudden, he went around the nurses' station, and without any reason, he grabbed the nurse unexpectedly. He got very close to her and pushed her on the nurse's desk. All staff immediately intervened, however, all the residents gathered at the nurses' station were terrified and started to yell for help. Slowly, staff was able to calm the residents down and take him away from this nurse he was still agitated and was hitting his head with his shoe. Other staff members who tried to encourage him to sit in the wheelchair was hit with a shoe as well. Afterwards he was taken outside the building and was supervised by staff. Administrator and social worker called police to make the report. The police arrived at the facility and interviewed the resident as well as a nurse who claimed assault. He was taken in the police car to emergency detention center for further evaluation. RP [Family Member] and MD were notified. Resident discharge. Record review of facility's, undated, policy titled Admission, Transfer and Discharge Policy, stated .II. Procedure: .B. Transfer and Discharge requirements. The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless: 1. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .3. The safety of individuals in the facility are in danger. 4. The health of individuals in the facility would otherwise be endangered .C. Transfers or Discharges: 1. when the facility transfers or discharges a resident under any of the above circumstances, appropriate documentation shall be made in the residence clinical record. The attending physician shall document the reasons for transfer/discharge when a resident is transferred or discharged for reasons 1, 2 and 4 above .D. Notification: before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative or the resident of the transfer or discharge. This notice shall be in a language and manner they understand. This notice shall be in writing and should include the reasons for transfer. The notice will be made at least 30 days before a resident is transferred or discharged unless: 1. the safety of individuals in the facility would be endangered, 2. the health of the individuals would be endangered, 3. The resident's health improves to allow more immediate transfer or discharge, 4. an immediate transfer or discharge is required by the residence urgent medical needs, or 5. the resident has not resided in the facility for 30 days, 6. in the above situations, the notice will be made as soon as practical before transfer or discharge. E. Contents of the transfer notice: the notice of transfer/discharge shall include: 1. the reason for transfer/ discharge, 2. the effective date of transfer/ discharge, 3. the location to which the resident is transferred/ discharge, 4. a statement that the resident has a right to appeal the action to the state . F. Orientation for transfer or discharge. the facility provides sufficient preparation and orientation to residents to ensure safe and orderly transfer discharge. The contents of the transfer notice will be explained to the resident or the resident's representative. Transfer/ discharge procedures will be explained, and the resident will be assisted with transportation arrangements, if necessary

Based on interview and record review the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 of 2 residents (Resident #1) reviewed for discharge requirement, in that: 1. The facility failed and refused to readmit Resident #1 from the hospital where he was transferred for evaluation and treatment. 2. The facility failed to establish and follow a written policy on permitting the resident to return to the facility after he was hospitalized . These deficient practices could affect residents discharged from the facility and their ability to return to the facility. Findings Include: Record review of Resident #1's Admission record, dated 08/17/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included osteoarthritis (condition that affects the joints, causing pain, stiffness and reduced movement), restlessness and agitation, insomnia (Trouble falling and/or staying asleep), unspecific intracranial injury with loss of consciousness of unspecified duration (unknow head injury with lack of awareness of self and the environment for an unknown amount of time), chronic kidney disease (A condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic. Disease progression occurs slowly over a period.), depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), and unspecified dementia unspecified severity with psychotic disturbance (Dementia psychotic behavior refers to the behavioral and psychotic symptoms of dementia that occur in moderate- to- severe stages of the disease. These symptoms may include hallucinations, delusions, paranoia, aggression, agitation, depression, and wandering. Hallucinations are false perceptions of sensory stimuli, delusions are false beliefs, and paranoia is irrational suspicion). Record review of Resident #1's care plan, last revised on 10/21/23, revealed care area problems for psychotropic drug use, resident had physical behavioral symptoms directed towards others, Category: Behavioral Symptoms Risk for agitation RT Unspecified dementia, unspecified severity, with psychotic disturbance, Psychotropic Drug Use Risk for side effects from psychotropic drug use: (lorazepam), Category: Behavioral Symptoms Wandering behavior R/T confusion secondary Unspecified dementia with psychotic disturbance AMB wandering around facility seeking exit doors, Category: Psychotropic Drug Use Risk for side effects from psychotropic drug use: Seroquel (quetiapine) Condition treated: Unspecified dementia with psychotic disturbance, Category: Psychotropic Drug Use Risk for side effects from Lexapro use Condition treated: depression, Category: Mood State Risk for Depression RT Debility, Category: Psychosocial Well-Being Relocation Stress Syndrome R/T nursing home placement as manifested by change of environment, Category: Communication deficit related to cognitive impaired AMB memory loss and confusion, and Category: Cognitive Loss / Dementia Altered thought process R/T cognitive loss secondary to Unspecified dementia with psychotic disturbance as manifested by disorientation, forgetfulness, confusion and memory loss. During an interview on 08/17/23 at 3:15 p.m., LVN A stated Resident #1 attacked her at the nurse's station on 11/3/23. LVN A stated like many of the residents, Resident #1 was confused and forgetful and the staff would try to reorient him back. LVN A stated Resident #1 would ball up his fist, but he did not actually hit anyone. LVN A stated to her knowledge no other residents were harmed by Resident #1. LVN A stated on 11/03/23 Resident #1 walked into the nurse's station like he normally did. LVN A stated he was a fall risk, so she tried to redirect him out of the station and to use his walker. LVN A stated Resident #1 became angry and irate, got in her face, and grabbed her by both of her wrist. LVN A stated Resident #1 told her do not tell me what to do and would not let her go or move. LVN A stated Resident #1 was also pushed her back into the counter at the nurse's station and it left a mark on her back. LVN A recalled other staff helped get Resident #1 off her and then called the police. During an interview on 08/17/23 at 9:45 a.m. the Social Worker stated the Resident #1's family member brought Resident #1 to the facility and stated she needed a break. The SW stated the resident initially was confused and asked for his family member. The SW stated the family member did not answer or come visit for over a week. The SW stated the resident became more aggressive by ripping the wander guard alarm off a wall and throwing his walker. The SW stated no other residents were harmed or injured that she could recall. The SW stated Resident #1's family member did come back to visit and initially stated the resident never had aggressive behaviors before. The SW stated they were concerned to hear this, but the family member stated he had hit her and pushed her before. The SW stated the aggressive behaviors were constant daily and they tried to find alternate placement for him for men with behavior problems. The SW showed a list of places from a file in her office of places she had tried to transfer Resident #1 to. The SW stated no other facility would accept the resident because of his behavior issues. The SW stated the resident was combative with staff. The SW stated Resident #1 attacked a nurse at the nurses' station by grabbing her and throwing her. The SW stated on 11/03/22 they called the police for a psychiatric evaluation after the resident attacked the nurse. The SW stated the police did not want to take Resident #1 and stated the facility took him and it was their problem. The SW stated after an hour and a half they finally took him to a local ER for an emergency detention and mental evaluation. The SW stated the local ER tried to return Resident #1 back to the facility that day. The SW stated they refused to accept Resident #1 back from the ER and stated they could not care for him in that condition. The SW stated the ER threatened to call the state on them if they did not accept Resident #1 back. The SW stated they wanted him to at least go for a 10 day hold and be treated. The SW stated the resident did not go with any discharge paperwork because the officer did not want to take it and stated they would call for the paperwork. The SW stated they were actively trying to discharge Resident #1, they did not want him back, and they would take their licks if they got them for not accepting him back. During an interview on 08/17/23 at 9:30 a.m., the Administrator stated Resident #1's family member brought him to the facility to be admitted in October of 2022. The Administrator stated the resident's family member did not tell them the full truth about the resident's behaviors and the medicine the provider had prescribed was not working. The Administrator stated on 11/03/22 Resident #1 attacked a nurse at the nurse's station. The Administrator stated they called the police, and the police did not want to take the resident initially. The Administrator stated finally the officer tried to ask the resident if he felt suicidal and the resident stated yes. The Administrator stated Resident #1 had dementia and did not know what he was answering yes to. The Administrator stated once the resident answered yes to having thoughts of suicide the police were able to take him to an ER for an emergency mental evaluation. The Administrator stated they would have accepted Resident #1 back if he was treated and did not come back with the same behaviors. She said did not have documentation because she was not planning on discharging Resident #1 when he went to hospital. She stated she did not have the following: 1) Resident/Representative verbal or written notice of intent to leave the facility. 2) Comprehensive care plan that includes the resident's goals for admission and discharge 3) Discharge planning process 4) Discharge summary 5) Signed physician order of discharge 6) Notice to Adult Protective Service (APS) 7) Meeting with Interdisciplinary Team (IDT) about discharge 8) Required 30-day notice to Resident #1 9) No communication with receiving facility Record review of Resident #1's progress notes, dated 08/17/23, revealed the following: -On 10/05/22 the resident arrived to the facility and was pleasant and cooperative on that day. -On 10/05/22 another note states he was forgetful and follows redirection. -On 10/06/23 Resident was pleasant to talk with and was looking for his family member. -Another note on 10/06/22 stated resident was searching for his family member all the time, he his with his walker, sometimes he forgets his walker, and needs cues. -On 10/07/22 a note stated patient was adjusting well to the facility, no behaviors noted, continues on Lexapro and Seroquel, no exit seeking, patient did get up from area and would walk around, easily redirected, and family member had been visiting. -On 10/12/22 a note stated resident was trying to go out and was wandering in all residents' room.Sometime more aggressive. - On 10/12/22 a note stated Spoke with MD new orders for lorazepam 0.5 mg tab PO BID and order for UA c/s. Note from 10/12/23 resident attempted to hit another resident. -On 10/15/22 a note stated Resident was agitated and wandered without his walker. He was hitting staff and swinging at staff and was not redirectable. Resident gets upset and agitated when told that he needed to use his walker and needed to sit down. -On 10/20/22 a note stated resident stood in the dining room, suddenly started to slap himself on both sides of his face with both hands. -On 10/20/22 a note stated MD assessed the resident's new orders for d/c singulair, d/c lorazepam 0.5 mg BID PRN, start lorazepam 0.5 mg 1-2 tabs po BID prn anxiety, divalproex 125 mg po BID mood D/O. Notes continue to document similar behaviors. -On 10/27/22 a note from the MD updated on resident behaviors new orders to increase lorazepam 0.5 mg TID and lorazepam 0.5 TID PRN, and divalproex 125 mg TID. -On 11/01/22 a note stated the resident was trying to walk fast without his walker fell and hit his head. -On 11/02/22 a note stated the resident was aggressive and walking without his walker. He hit staff with hand. He was going to the first floor via staircase staff followed him. Four staff tried to redirect and sit in the wheelchair. -On 11/02/22 a note from LVN A stated CNA attempted to assist resident to bathroom, however resident became agitated and combative, grabbing CNA by the wrist. CNA's hand and wrist is red. -A note on 11/02/22 revealed new telephone orders from MD d/c lorazepam 0.5 mg tab po TID, give Ativan 1 mg 1 tab po TID for restlessness and agitation. -A note from 11/03/22 revealed Resident #1 was aggressive and agitated, he was walking the whole way without his walker. He cannot able to stay any place. He want to go out. He was looking for the door and elevator. New order 1. D/C lorazepam 1 mg TID, start lorazepam 1 mg QID may hold if he is over sedation and hold RR <10, Quetipine 50 mg 1 tab BID, D/C Quetipine 50 mg 1 tab PO QHS. -On 11/03/22 a note from the DON stated around 4:00 PM resident became very agitated and combative. All of a sudden, he went around the nurses' station, and without any reason, he grabbed the nurse unexpectedly. He got very close to her and pushed her on the nurse's desk. All staff immediately intervened, however, all the residents gathered at the nurses' station were terrified and started to yell for help. Slowly, staff was able to calm the residents down and take him away from this nurse he was still agitated and was hitting his head with his shoe. Other staff members who tried to encourage him to sit in the wheelchair was hit with a shoe as well. Afterwards he was taken outside the building and was supervised by staff. Administrator and social worker called police to make the report. The police arrived at the facility and interviewed the resident as well as a nurse who claimed assault. He was taken in the police car to emergency detention center for further evaluation. RP [Family Member] and MD were notified. Resident discharge. Record review of facility's, undated, policy titled Admission, Transfer and Discharge Policy, stated .II. Procedure: .B. Transfer and Discharge requirements. The facility permits each resident to remain in the facility and will not transfer or discharge the resident unless: 1. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .3. The safety of individuals in the facility are in danger. 4. The health of individuals in the facility would otherwise be endangered .C. Transfers or Discharges: 1. when the facility transfers or discharges a resident under any of the above circumstances, appropriate documentation shall be made in the residence clinical record. The attending physician shall document the reasons for transfer/discharge when a resident is transferred or discharged for reasons 1, 2 and 4 above .D. Notification: before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative or the resident of the transfer or discharge. This notice shall be in a language and manner they understand. This notice shall be in writing and should include the reasons for transfer. The notice will be made at least 30 days before a resident is transferred or discharged unless: 1. the safety of individuals in the facility would be endangered, 2. the health of the individuals would be endangered, 3. The resident's health improves to allow more immediate transfer or discharge, 4. an immediate transfer or discharge is required by the residence urgent medical needs, or 5. the resident has not resided in the facility for 30 days, 6. in the above situations, the notice will be made as soon as practical before transfer or discharge. E. Contents of the transfer notice: the notice of transfer/discharge shall include: 1. the reason for transfer/ discharge, 2. the effective date of transfer/ discharge, 3. the location to which the resident is transferred/ discharge, 4. a statement that the resident has a right to appeal the action to the state . F. Orientation for transfer or discharge. the facility provides sufficient preparation and orientation to residents to ensure safe and orderly transfer discharge. The contents of the transfer notice will be explained to the resident or the resident's representative. Transfer/ discharge procedures will be explained, and the resident will be assisted with transportation arrangements, if necessary