Every finding on record at St. Teresa Nursing & Rehab Center

Based on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 3 residents (Resident #2) reviewed for enteral feeding.The facility failed to ensure licensed staff provided Resident #2 Gastrostomy Tube Care according to physician's orders on 08/17/26, 08/18/26 and 08/19/26. These failures could place residents receiving enteral feedings at risk of insufficient nutritional supplementation and possible weight loss.Findings include:Review of the admission Record, dated 8/19/26, for Resident #2 revealed an original admission date of 04/22/2026. Review of the History and Physical, dated 04/23/26 for Resident #2, revealed an [AGE] year-old male with diagnoses Dysphagia (difficulty or discomfort when swallowing), Protein Calorie Malnutrition (the body is not getting enough food, calories, or protein to work and repair itself properly) and status post Gastrostomy (a soft flexible tube placed through a small opening in the stomach directly into the stomach). Review of the Quarterly MDS Assessment, dated 07/26/26 for Resident #2, revealed clear speech, usually makes self-understood, usually understand others; BIMs Summary Score 01 (Cognitively severely impaired), Active Diagnoses: Dysphagia and Gastrostomy. Review of the last Care Plan Review, revised on 05/29/26 for Resident #2, revealed the resident has swallowing problems r/t dysphagia. Interventions included administer enteral feedings (a way to deliver liquid food, water, and medicine straight into the stomach or small intestine through a soft plastic tube when a person cannot eat or swallow safely) as ordered. Resident required tube feedings. Interventions included clean insertion site daily as ordered, monitoring for signs and symptoms of infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to MD if symptoms arise. Review of the Physician Order Summary, dated 08/19/26 for Resident #2, revealed an Enteral Feed Order indicating every shift cleanse G-tube site (a small, healed opening in the belly where a feeding tube goes straight into the stomach). Review of an In-Service Training Record, dated 12/09/2025 for Licensed Staff, provided by ADON A on 08/19/26, revealed Topic: G-Tube Care. G-tube care was to be completed Q shift and PRN. Review of the Treatment Administration Record, dated July 2026 for Resident #2, revealed: Every shift cleanse G-tube site. Review of the Treatment Administration Record, dated August 2026 for Resident #2, revealed: Every shift cleanse G-tube site. The Treatment Administration Record documented licensed staff initialed the G-Tube site was cleansed on the day, evening and night shifts on 08/17/26, 08/18/26 and 08/19/26. During a telephone interview on 08/19/26 at 12:19 p.m. with LVN D on the night shift, it was revealed they were trained to clean G-tube sites and clean and change dressing to intravenous sites according to physician's orders. He said they were trained to initial and date the dressing when the treatment was completed.During an observation on 08/19/26 at 4:07 p.m. with ADON B revealed Resident #2 was lying in bed awake and his head of bed was elevated to 45 degrees and had an enteral feeding pump connected to his G-Tube infusing continuous feeding. The resident did not answer simple questions and was able to follow commands. ADON B pulled the sheets back and said, Oh No his G-Tube dressing was last changed on/dated 08/17/26 and was not initialed by the licensed staff when G-Tube care was provided. When the ADON B removed the gauze pad, the resident had light pink colored skin irritation around the stoma where the G-Tube was inserted, no drainage. She said the licensed staff were trained to provide Gastrostomy Tube Care every Shift and as needed according to physician's orders and to date and initial the dressing so that nursing administration could randomly check that Gastrostomy Care was done once a shift according to physician's orders.During an interview on 08/19/26 at 4:15 p.m., with LVN Charge Nurse C, assigned to the 200 Hall, revealed the licensed staff were trained to cleanse the G-Tube site once a shift and apply gauze pad. She said they were trained to date and initial the gauze so the on-coming nurse would know the gastrostomy site was cleaned according to physician's orders.During an interview on 08/19/26 at 4:19 p.m. with the DON revealed the licensed staff were trained to provide G-Tube care every shift according to physician's order, and to date and initial the gauze pads. She said that the ADONs should randomly check that G-Tube care was being done according to physician's orders.Telephone call was placed on 08/19/26 at 5:25 p.m. to LVN D with no answer, left message to call state surveyor. Return call was not received prior to exit.Telephone call was placed on 08/19/26 at 5:27 p.m. to LVN E with no answer, left message to call state surveyor. Return call was not received prior to exit.Telephone call was placed on 08/19/26 at 5:28 p.m. to LVN F with no answer, left message to call state surveyor. Return call was not received prior to exit.Telephone call was placed on 08/19/26 at 5:30 p.m. to LVN G with no answer, left message to call state surveyor. Return call was not received prior to exit.Review of facility's undated Policy and Procedure on Gastrostomy Tube Care revealed: Gastrostomy is a surgically created abdominal opening into the stomach for the purpose of administering feedings. Included in the management of a gastrostomy is the care of the stoma site (surgically created opening). The clean technique is utilized in the feeding procedure with a combination of clean and sterile techniques in the care of the insertion site. Goals: The resident will be free from infection at the gastrostomy site. Perform site or stoma care. If ordered, place gauze dressing on the stoma and tape.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 3 of 7 employees LVN K, LVN L and RT M reviewed for annual employee misconduct registry and nurse aide registry screenings.The facility failed to complete the annual EMR/NAR screenings on LVN K, LVN L and RT M according to facility's policy.This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. Findings included:Review of the facility policy & procedure on Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 revealed Policy Statement: Resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Policy Interpretation and Implementation: Develop and implement policies and procedures to prevent and identify abuse or mistreatment of residents; neglect of resident; and/or; theft, exploitation or misappropriation of resident property. Conduct employee background checks and not knowingly employ or otherwise engage any individual who: has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.Review of the facility's HR Manual's Table of Contents dated October 2025 provided by the HR Manager revealed Section II: Hiring - Preboarding the New Employee revealed: Background Checks: All applicants will be informed that background checks are a part of the hiring process. These include criminal checks, and misconduct registry. EMR (Employee Misconduct Registry) and Employability Status: HHSC-regulated facilities are required to check this before the first day of employment and annually thereafter. During an interview and record review on 08/12/2026 at 4:26 p.m. through 5:20 p.m. with HR N in the presence of the Administrator revealed:-Review of previous EMR/NAR check completed on LVN K was done 6/23/2025; Annual EMR/NAR check was completed on 7/02/2026 HR said the EMR/NAR check was done late.-Review of previous EMR/NAR check completed on LVN L was done 11/20/24; Annual EMR/NAR check was completed on 11/26/2025. HR said the EMR/NAR check was done late.-Review of previous EMR/NAR check completed on RT M was done 06/23/2025; Annual EMR/NAR check was completed on 07/02/26. HR said the EMR/NAR check was done late.In an interview on 08/12/26 at 5:20 p.m. with HR N and Administrator revealed that HR N was still in the process of reviewing personnel files to ensure that all required background checks had been completed on all facility staff. HR N said that she was aware that EMR and NAR were not being done annually or completed within the required annual requirement timeframes.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 (Resident #1, Resident #2 and #3) of 3 residents reviewed for pharmacy services.1-The facility failed to administer Sevelamer HCL800 mg give 1 tablet via G-Tube every 8 hours related to Chronic Kidney Disease Stage 3 that was not administered on 08/01/26 at 8:00 a.m., and 4:00 p.m.; 08/02/26 was not administered at 12 midnight and 08/03/26 was not administered at midnight, to Resident #1 according to physician's orders.2- The facility failed to ensure Zinc Oxide was not administered to Resident #2 without a physician's orders.3- The facility failed to ensure Zinc Oxide-based topical cream was not administered to Resident #3 without a physician's orders.The failure could place residents at risk of inadequate therapeutic outcomes and a decline in health due to not receiving medications as ordered. Findings included:Closed record review of admission Record dated 8/11/26 for Resident #1 revealed, original admission date 3/30/26 and re-admission date 07/09/26.Review of History & Physical dated 7/31/26 for Resident #1 revealed, [AGE] year-old male with past medical history of CVAs with left hemiplegia ((a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die and paralysis on one side), pt. is awake, non-verbal state and CKD (a long-term condition where kidneys gradually lose function, facility to filter waste from blood, often progressing slowly with few initial symptoms leading to end-stage renal failure).Review of admission MDS dated [DATE] for Resident #1 revealed Active Diagnoses: CVA.Review of the Care Plan revised on 07/10/26 for Resident #1 revealed the Care Plan did not address the Redness on the buttocks and/or that Zinc Oxide was being applied to the redness on the buttocks.Review of Lab Report dated 07/31/26 for Resident #1 revealed Phosphorus 5.0 mg/dL High Reference Range 2.5 - 4.5Review of the Physician Order Summary dated 08/11/26 for Resident #1 revealed Sevelamer HCL give 1 tablet by G-Tube (a soft flexible tube placed through a small opening in the stomach directly into the stomach) every 8 hours related to Chronic Kidney Disease, Stage 3. Date Order: 07/30/26.Review of Nursing Progress Note dated 08/01/26 at 8:49 a.m. written by RN E for Resident #1 revealed Sevelamer HCL oral tablet 800 mg give 1 tablet via G-tube every 8 hours for Chronic Kidney Disease Stage 3.Review of Nursing Progress Note dated 08/01/26 at 3:59 p.m. written by RN E for Resident #1 revealed Sevelamer HCL oral tablet 800 mg give 1 tablet via G-tube every 8 hours for Chronic Kidney Disease Stage 3.Review of eMAR - Administration Note dated 08/01/26 at 11:09 p.m. written by LVN F for Resident #1 revealed unavailable. The eMAR did not document what medication was unavailable.Review of eMAR - Administration Note dated 08/02/26 at 11:00 p.m. written by LVN F for Resident #1 revealed unavailable. The eMAR did not document what medication was unavailable.Review of Medication Administration Record dated July 2026 for Resident #1 revealed Sevelamer HCL 800 mg give 1 tablet via G-Tube every 8 hours related to Chronic Kidney Disease Stage 3 was not administered on 07/30/26 at 4:00 p.m.Review of Medication Administration Record dated August 2026 for Resident #1 revealed Sevelamer HCL 800 mg give 1 tablet via G-Tube every 8 hours related to Chronic Kidney Disease Stage 3 was not administered on 08/01/26 at 8:00 a.m., and 4:00 p.m.; 08/02/26 was not administered at 12 midnight and 08/03/26 was not administered at midnight.Review of Physician Progress Note dated 08/05/26 written by Nurse Practitioner G for Resident #1 revealed patient seen and evaluated today per facility request, phosphorus level 5.0.During a telephone interview on 08/12/26 at 9:05 a.m. with LVN F revealed Sevelamer HCL 800 mg was not available to administer every 8 hours scheduled to be administered at 12 midnight during his shift on 08/01/26 and 08/02/26. He said they had been trained to fax the order to the vendor pharmacy after hours for the medication to be delivered to the facility to administer according to physician's orders. He said he had not checked the automated medication management and emergency dispensing system to see if the medication was in the automated medication dispensing system.During an interview on 08/12/26 at 11:12 a.m. with ADON H stated that the nurses had been trained to fax new medications orders to the vendor in-house pharmacy after hours to start the new medication as soon as possible.During an interview on 08/12/26 at 11:18 a.m. with Pharmacy Tech I said that the nurses were aware that they needed to fax new medication orders to the pharmacy after hours even if it was not a stat order, to deliver the prescribed medication as soon as possible. He said that the pharmacy had the Sevelamer HCL on hand and they would have sent the medication right away if the nurses had faxed the new order to the facility.During a telephone interview on 08/12/26 at 1:51 p.m. with the attending physician for Resident #1 revealed the resident had chronic kidney disease and the resident's family member had not agreed to put the resident on dialysis. He said that he expected prescribed medications to be administered according to physician's orders and if the medication was not available to administered that the nurse would need to notify him and/or the Nurse Practitioner.During an interview on 08/12/26 at 5:01 p.m. with the Administrator revealed that she was not aware that Resident #1 had missed several doses of the Sevelamer HCL because the medication was not available to administer, according to physician's orders. She said that if the medication was not in the emergency supply, the nurses had been trained to fax the new medication to the pharmacy after hours to obtain the new medication as soon as possible.During an interview on 08/12/26 at 5:33 p.m. with the DON, revealed she had not found a policy & procedure on ordering medications from the pharmacy.2. Review of admission Record dated 8/12/26 for Resident #2 revealed, original admission date 9/17/19 and re-admission date 07/09/26.Review of History & Physical dated 06/10/26 for Resident #2 revealed, [AGE] year-old male with history of bed-bound status from TBI (a sudden physical damage to the brain, caused by a hard blow, bump, or jolt to the head, or an object piercing the skull) and sacral pressure ulcer wounds (a type of bed sore located on the lower back right above the tailbone) and quadriplegia (paralysis of all four limbs and the torso from neck down) secondary to a fall from a roof in 2018. Plan: Turn every 2 hours while in bed.Review of Quarterly MDS dated [DATE] for Resident #2 revealed, clear speech, makes self-understood, understands others, BIMS Summary Score 15 (Cognitively intact); Functional Limitation in Range of Motion to upper and lower extremities; Wheelchair; Functional Abilities - Mobility dependent with Sit to lying, lying to sitting on side of bed, Chair/bed transfer; Active Diagnoses - Quadriplegia; Stage 4 pressure ulcers (deep, opened wound where the skin and fat are completely gone, showing damaged muscle, tendons, or bare bone underneath).Review of the last Care Plan Review revised on 08/12/26 for Resident #2 revealed, resident had stage 4 pressure ulcers on Left Ischium and Sacrum; MASD to left distal and proximal buttocks, Redness to buttocks. Interventions: Educate resident/family of causative factors and measure to prevent skin injury. Follow facility protocol for treatment of injury. The Care Plan did not address Resident's noncompliance with turning & repositioning or sitting in electric wheelchair for long periods of time and redness to the buttocks.During an observation on 08/11/26 at 4:20 p.m. with the DON, revealed Resident #2 had redness to buttocks, stage 4 pressure ulcer on sacrum, moisture associated skin damage on left distal buttock. The resident had a thin layer of white ointment on buttocks. The DON said she needed to check to see what the white ointment was that had been applied to the buttocks. The DON said that she needed to check if the redness to the buttocks had been care planned.Review of the Physician Order Summary dated 08/12/26 for Resident #2 revealed, there was not an order for Zinc Oxide or barrier cream to apply as needed.During an observation and interview on 08/12/26 at 10:38 a.m. with Wound Care Nurse C revealed Resident #2 was lying in bed on his back. She said Zinc Oxide ointment was applied to the redness on the buttocks and needed to get a physician's order. She said, I need to get a Physician order for the Zinc Oxide. She said she had noted the redness to the buttocks on Monday 08/10/26 when she was doing the treatment to the pressure ulcers and did not know when the redness to the buttocks had started.During an interview on 08/12/26 at 10:52 a.m. with Certified Nurse Aide (CNA) B stated Resident #2 has had the redness to the buttocks since he was re-admitted [DATE]. She said that she had reported this to the nurse and the wound care nurse.During a telephone interview on 8/12/26 at 1:53 p.m. with the attending physician stated that he was aware that Resident #2 sat in his wheelchair for long periods of time, refused to be turned and repositioned every two hours in bed and should only sit for one hour in his wheelchair. He said that the redness on the buttocks was caused by the pressure on his buttocks caused by sitting for extended periods of time in his wheelchair. He said that he had asked the nurses today to complete a Negotiated Risk Assessment to have documentation that he and the facility staff had explained to the resident that the non-compliance of sitting in his wheelchair longer than one hour at a time could cause worsening pressure wounds, possible infections in wounds, and sepsis from infections that could lead to death. The attending physician said that the nurses were aware that they needed a physician's order to apply Zinc Oxide or any other type of skin barrier to prevent skin irritation and breakdown related to incontinence.3. Review of admission Record dated 8/12/26 for Resident #3 revealed, original admission date 12/02/25 and re-admission date 5/01/26.Review of History & Physical dated 02/16/26 for Resident #3 revealed, [AGE] year-old male with history of CVA, and BPH (an enlarged prostate had grown large enough to squeeze the tube that carries urine out of the body, making it impossible or very difficult to empty the bladder, leading to pain and need for a catheter).Review of admission MDS dated [DATE] for Resident #3 revealed, BIMS Score of 6 (severely cognitively impaired); frequently incontinent of bowel and bladder; Active Diagnose: Cognitive Deficit Communication.Review of Care Plan revised on 08/10/26 for Resident #3 revealed, Revision: 08/11/26 Resident has urge bladder incontinence. Interventions: Apply thin layer of barrier cream after each incontinent episode. Date initiated 08/11/26. Incontinent care and apply moisture barrier after each episode. Date initiated 08/11/26.During an observation and interview on 08/11/26 at 4:31 p.m. Resident #3 was sitting in his wheelchair by the side of the bed and he said he had just turned on his call light because he had a bowel movement and needed to be cleaned.Review of the Physician Order Summary dated 08/12/26 revealed for Resident #3 revealed, may apply barrier cream as needed every shift.Review of the Treatment Record dated August 2026 for Resident #3 revealed, there was not an order listed for barrier cream as needed every shift.During an observation on 08/11/26 at 4:39 p.m., Med Aide J entered the room to provide incontinent care. It was observed that the resident had a thin layer of white cream on his perineal area and scrotum. The Med Aide showed the surveyor that there was a disposable plastic cup with a tongue blade, and he said it contained a mixture of zinc oxide that he had applied to the resident perineal area. He said he did not know who had left the cup with the ointments in the resident's room.During an interview on 08/11/26 at 5:01 p.m. with the Administrator and DON revealed that it was not allowed for the nursing staff to leave skin barrier creams in a disposable drinking cup with a tongue blade in the Resident #3's room because it was not safe to leave it in the resident's room.During an interview on 08/12/26 at 11:06 a.m. with the Wound Care Nurse C said, It was me who gave the disposable cup to the CNAs with a tongue blade that contained a mixture of zinc oxide, and moisture barrier with vitamin A, and Vitamin D to apply to the perineal area after incontinent care was provided. I know that we have been trained not to do that. She said that the CNAs should apply a thin layer of ointment to the perineal area.During an observation and interview on 08/12/26 at 11:10 a.m. with the DON revealed that family member for Resident #3 was in the room and the family member said she brought a container of zinc oxide-based topical cream to apply to the resident's perineal area after he had an incontinent episode. She said she used to be an RN and knew how to apply the zinc oxide-based topical cream to prevent skin irritation. The family member said she visited the resident every day.Review of the facility's policy and procedure on Administering Medication Revised April 2019 revealed: Policy heading: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: Medications are administered in accordance with prescriber orders, including any required time frame. Topical mediations used in treatments are recorded on the resident's Treatment Administration Record (TAR).

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #2) reviewed for care plans. -The facility failed to ensure Resident #2's care plan addressed resident's refusal of not allowing the nursing staff to turn & reposition him while in bed every two hours and sitting in his wheelchair for long periods of time. -The facility failed to ensure Resident #2's care plan addressed Resident's suprapubic catheter (a flexible tube placed directly through a small cut in the lower abdomen into the bladder to drain urine) was leaking and to apply Zinc Oxide after each pad change to redness on buttocks.This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included:Review of admission Record dated 8/12/26 for Resident #2 revealed, original admission date 9/17/16 and re-admission date 07/09/26.Review of History & Physical dated 06/10/26 for Resident #2 revealed, [AGE] year-old male with history of bed-bound status from TBI (a sudden physical damage to the brain, caused by a hard blow, bump, or jolt to the head, or an object piercing the skull) and sacral pressure ulcer wounds (a type of bed sore located on the lower back right above the tailbone) and quadriplegia (paralysis of all four limbs and the torso from neck down) secondary to a fall from a roof in 2018. Plan: Turn every 2 hours while in bed.Review of Quarterly MDS dated [DATE] for Resident #2 revealed, clear speech, makes self-understood, understands others, BIMS Summary Score 15 (Cognitively intact); Functional Limitation in Range of Motion to upper and lower extremities; Wheelchair; Functional Abilities - Mobility dependent with Sit to lying, lying to sitting on side of bed, Chair/bed transfer; Active Diagnoses - Quadriplegia; Stage 4 pressure ulcers (deep, opened wound where the skin and fat are completely gone, showing damaged muscle, tendons, or bare bone underneath).Review of the last Care Plan Review revised on 08/11/26 for Resident #2 revealed, resident had stage 4 pressure ulcers on Left Ischium and Sacrum; MASD to left distal and proximal buttocks, Redness to buttocks. Interventions: Educate resident/family of causative factors and measure to prevent skin injury. Follow facility protocol for treatment of injury. The Care Plan did not address Resident's refusal to allow the CNAs to turn & reposition every two hours while in bed and the care plan did not address resident's refusal to sit in his electric wheelchair for over two hours that resulted in redness to the buttocks.Review of the CNAs Bedside Report dated 08/11/26 for Resident #2 revealed follow policies/protocols for the prevention/treatment of skin breakdown. The Bedside Report did not document to turn the resident every two hours while in bed and to encourage the resident not to sit in his wheelchair for more than two hours to prevent redness to the buttocks.Review of Physician Progress Note dated 08/12/26 written by Nurse Practitioner for Resident #2 revealed, Patient has orders to be turned and repositioned every 2 hours and as needed. It has been reported that he refuses to be turned every 2 hours, and he insists on sitting in his wheelchair most of the time without allowing staff to reposition him. We have discussed this issue multiple times with him, and we will be requesting the patient or family member to sign a Risk Assessment Form.Review of Negotiated Risk assessment dated [DATE] for Resident #2 revealed, Negotiated Risk Assessment discussed with resident. Summary of Resident's Current Health and Potential Risk: Resident is bedbound, currently has stagnant wounds on Lt. Ischium (lower left segment of the hip bone) and sacrum, per wound care and is currently not complaint with recommendations. Resident likes to be up in his electric wheelchair every day and does not want to be repositioned to optimal positions in wheelchair and bed to allow wound to properly heal. Possible/Probable Negative Consequences: Worsening pressure wounds, possible infections in wounds, and sepsis from infections that can lead to death. Alternatives/Interventions offered by the facility: Patient will be repositioned in bed and per wound care recommendations to not be in electric wheelchair for long period of time. What is the final agreement? Resident #2 wished to continue to get in electric wheelchair. Facility and physician will not be held responsible for any negative consequences. BIMS Score 15.Review of Physician Telephone Order dated 08/12/26 for Resident #2 revealed, Redness to buttocks. Cleanse with soap and water, pat dry and apply a thin layer of Zinc Oxide ointment after each pad change every shift for Redness.Review of Physician Telephone Order dated 08/12/26 for Resident #2 revealed, may apply barrier cream as needed.Review of the Physician Order Summary dated 08/12/26 for Resident #2 revealed, MASD to left distal/distal buttocks: Cleanse with soap and water, pat dry and apply a thin layer of zinc oxide paste followed by abdominal pad and cover with Island Gauze Border Dressing daily and prn. May apply barrier cream as needed every shift.During an interview on 08/11/26 at 3:30 p.m. with Resident #2 revealed, he was alert, oriented to person, place, time and situation. He said he preferred to sit in his electric wheelchair most of the day. He said he had a pressure ulcer on his sacrum and was treated daily.During an observation and interview on 08/11/26 at 4:20 p.m. with the DON, revealed Resident #2 had redness to buttocks, stage 4 pressure ulcer on sacrum, moisture associated skin damage on left distal buttock. The resident had a thin layer of white ointment on buttocks. The DON said she needed to check to see what the white ointment was that had been applied to the buttocks. The DON said that she needed to check if the redness to the buttocks had been addressed in the care plan.During an observation and interview on 08/12/26 at 10:38 a.m. with Wound Care Nurse C revealed Resident #2 was lying in bed on his back. She said Zinc Oxide ointment was applied to the redness on the buttocks and needed to get a physician's order. She said, I instructed the CNAs to applying the Zinc Oxide to the redness on the buttocks and have not had the time to call the physician or the Nurse Practitioner to get the order for the Zinc Oxide. She said she had been trained to get a physician's order prior to applying any type of skin barrier ointment. She said she had noted the redness to the buttocks on Monday 08/10/26 when she was doing the treatment to the pressure ulcers and did not know when the redness to the buttocks had started. She said that the resident had a physician's order to only sit in the wheelchair for 1-2 hours, but the resident preferred to sit in the wheelchair for most of the day. She said she had found the resident with a disposable brief soaked with urine and wound drainage this morning at 6:00 a.m. at the start of the shift. She said that the Moisture Associated Skin Damage was a new development because the CNAs were not removing the disposable brief when the resident was put back to bed. It was observed that the resident had a suprapubic catheter. She said the doctor had given an order to remove the disposable brief when the resident was put in bed.During an interview on 08/12/26 at 10:52 a.m. with CNA B revealed that she had found the Resident #2 at the start of the shift with the disposable brief, soaked with urine and wound drainage. She said that they had been instructed by the nurses to remove the brief when the resident was put in bed. She said the resident has had the redness to the buttocks since he was re-admitted [DATE]. She said that she had reported this to the nurse and the wound care nurse. She said the resident refused to go back to bed after meals and sat in his wheelchair most of the morning shift. She said the resident also at times refused to be turned and repositioned.During an interview on 08/12/26 at 10:55 a.m. with Resident #2 said that sometimes the CNAs did not turn & reposition him in when in bed every two hours. He said that the CNAs had not removed the disposable brief on 08/11/26 when he was put back to bed during the morning shift and was left on until it was removed this morning.During an interview on 08/12/26 at 11:42 p.m. with DON revealed that care plan interventions are communicated to the CNAs by the CNAs Bedside Report. She said the Kardex for Resident #2 should document the resident should not sit in his wheelchair for extended periods of time. She said that the Nurses should also read the care plan to know that Resident #2 should not be sitting for extended periods of time to prevent worsening of the pressure ulcers and development of new pressure ulcers. She said that she did not know if this was documented in the resident's CNAs Bedside Report.During a telephone interview on 8/12/26 at 1:53 p.m. with the attending physician revealed that he was aware that Resident #2 sat in his wheelchair for long periods of time, refused to be turned and repositioned every two hours in bed and should only sit for one hour in his wheelchair. He said that the redness on the buttocks was caused by the pressure on his buttocks caused by sitting for extended periods of time in his wheelchair. He said that he had asked the nurses today to complete a Negotiated Risk Assessment to have documentation that he and the facility staff had explained to the resident that the non-compliance of sitting in his wheelchair longer than one hour at a time could cause worsening pressure wounds, possible infections in wounds, and sepsis from infections that could lead to death. He said that the nurses were aware that they needed a physician's order to apply Zinc Oxide or any other type of skin barrier to prevent skin irritation and breakdown related to incontinence.During an interview and record review on 08/12/26 at 5:06 p.m. with MDS Nurse D in the presence of the DON revealed the Care Plan revised 07/10/26 for Resident #2 did not address the resident's noncompliance with not allowing the staff to turn & reposition him every two hours while in bed. She also said that the Care Plan also did not address the resident's noncompliance of not sitting in his wheelchair for more than an hour. She said that resident's non-compliance could result in worsening of pressure ulcers and development of new pressure ulcer due to immobility secondary to quadriplegia. She said, I just added the new interventions in the care plan on 08/11/26 to limit the sitting to 60 minutes, risks of sitting in his wheelchair for extended periods of time could impair the healing process and increase the risk for further pressure ulcer development; added to have a brief in place while sitting up in a wheelchair. She said she had not added the order for the Zinc Oxide to the care plan on 08/11/26.Review of the facility's policy and procedure on Care Plans, Comprehensive Person-Centered revised 2022 revealed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: The interdisciplinary team. In conjunction with the resident and his or her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of a comprehensive assessment. The comprehensive, person-

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 3 residents (Resident #3), reviewed for drugs and biologicals.-The facility failed to ensure zinc oxide-based topical ointment in a plastic drinking cup and a tongue depressor in it, was not left unattended on top of the dresser in the Resident#3's room.These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors and medication misuse. Findings included:Review of admission Record dated 8/12/26 for Resident #3 revealed, original admission date 12/02/25 and re-admission date 5/01/26.Review of History & Physical dated 02/16/26 for Resident #3 revealed, [AGE] year-old male with history of CVA, and BPH (an enlarged prostate had grown large enough to squeeze the tube that carries urine out of the body, making it impossible or very difficult to empty the bladder, leading to pain and need for a catheter).Review of admission MDS dated [DATE] for Resident #3 revealed, BIMS Score of 6 (severely cognitively impaired); frequently incontinent of bowel and bladder; Active Diagnose: Cognitive Deficit Communication.Review of Care Plan revised on 08/10/26 for Resident #3 revealed, Revision: 08/11/26 Resident has urge bladder incontinence. Interventions: Apply thin layer of barrier cream after each incontinent episode. Date initiated 08/11/26. Incontinent care and apply moisture barrier after each episode. Date initiated 08/11/26.Review of the Physician Order Summary dated 08/12/26 revealed for Resident #3 revealed, may apply barrier cream as needed every shift.Review of the Treatment Record dated August 2026 for Resident #3 revealed, there was not an order listed for barrier cream as needed every shift.During an observation and interview on 08/11/26 at 4:31 p.m. Resident #3 was sitting in his wheelchair by the side of the bed and he said he had just turned on his call light because he had a bowel movement and needed to be cleaned.During an observation on 08/11/26 at 4:39 p.m., Med Aide J entered the room to provide incontinent care. It was observed that the resident had a thin layer of white cream on his perineal area and scrotum. The Med Aide showed the surveyor that there was a disposable plastic cup with a tongue blade, and he said it contained a mixture of zinc oxide and another skin barrier that he had applied to the resident perineal area. He said he did not know who had left the cup with the ointments in the resident's room.During an interview on 08/11/26 at 5:01 p.m. with the Administrator and DON revealed that it was not allowed for the nursing staff to leave skin barrier creams in a disposable drinking cup with a tongue blade in the resident's room because it was not safe to leave it in the resident's room.During an interview on 08/12/26 at 11:06 a.m. with the Wound Care Nurse C said, It was me who gave the disposable cup to the CNAs with a tongue blade that contained a mixture of zinc oxide, and moisture barrier with vitamin A, and Vitamin D to apply to the perineal area after incontinent care was provided. I know that we have been trained not to do that. She said that the CNAs should apply a thin layer of ointment to the perineal area.During an observation and interview on 08/12/26 at 11:10 a.m. with the DON revealed that family member was in the room and the family member said she brought a container of zinc oxide-based topical ointment from home and kept the container in the top drawer of the dresser to apply to the resident's perineal area after he had an incontinent episode. She said she used to be an RN and knew how to apply the Desitin to prevent skin irritation. She said that she was not aware that the facility needed to have a physician order for her to apply the zinc oxide-based topical ointment to the resident's perineal area. The family member said she visited the resident every day.Review of the facility's policy and procedure on Medication Labeling and Storage revised February 2023 revealed: Policy heading: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Medication Storage: Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. Medications and biologicals are locked when not in use and are not left unattended if opened or otherwise potentially available to others. Medication Labeling: Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. Medications for external use, as well as hazardous drugs and biologicals, are clearly marked as such, and are stored separately from other medications. Medications may not be transferred between containers.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of four community shower rooms, and for one (Resident #2) of four Resident Rooms reviewed for infection control. -The facility failed to ensure clean linen carts were not stored in the community shower rooms where they stored the dirty linen hampers that were full of soiled linen and were not completely sealed. -The facility failed to ensure nursing staff were not storing Resident #2's soiled clothing on the floor in the resident's closet. These failures could result in increased risk of infection to residents. Findings include: Community Showers:During an observation and interview on 07/15/26 at 12:27 p.m. with the Maintenance Director in the shower room in the 500 Hall it was revealed there were 10 dirty linen hampers that contained soiled linen that were not completely covered, and a clean linen cart stored in the shower room. It was observed that the linen cart cover was worn out and the sides of the cart cover were not sealed to prevent cross contamination of the clean linen, gowns, and disposable briefs. The Maintenance Director said that he was not aware that the nursing staff were storing the clean linen carts in the shower rooms.During an observation on 07/15/26 at 12:38 p.m. with the Maintenance Director in the shower room in the 400 Hall revealed there were two clean linen carts stored in the shower room. One of the linen carts that contained gowns, sheets, pillowcases and blankets was uncovered. There were two dirty linen hampers that were full of dirty linen, and one of the hampers was not completely sealed. There was a gallon of body wash stored on the floor in one of the shower stalls.During an observation on 07/15/26 at 12:45 p.m. with the Maintenance Director in the shower room in the 200 Hall revealed there was a clean linen cart with clean linen that was stored in the shower room and there were three dirty linen hampers stored in a shower stall. The linen cover was worn out, with holes and the sides were not sealed.During an observation on 07/15/26 at 12:46 p.m. with the Maintenance Director in the shower room in the 300 Hall revealed there was a clean linen cart with clean linen stored in the shower room and the sides of the cover on the linen cart were not sealed exposing the clean linen. There was a wet towel on top of the right side of the linen cart.During an interview with CNA H on 07/15/26 at 2:18 p.m. on the 6-2 shift she said the CNAs store the clean linen hampers and the dirty linen hampers in the shower rooms when not in use. She said that they had been trained to keep the dirty linen hampers completely covered to prevent cross contamination.During an interview with the DON on 07/15/26 at 3:00 p.m. revealed that the clean linen carts and dirty linen hampers were stored in the shower rooms when not in use. She said the staff had been trained to keep the clean linen carts covered and dirty linen hampers completely sealed to prevent cross contamination. She said the nursing administration were responsible for infection control and monitoring of cross contamination. Resident #2Review of Resident #2's admission Record dated 07/16/26 revealed Resident #2 was admitted on [DATE].Review of the History & Physical dated 04/15/26 for Resident #2 revealed he was an [AGE] year-old male with past medical history of dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, language, problem-solving, judgement, and orientation) and Cognitive Communication Deficit (Difficulty with speech, reading, writing, or listening caused by underline brain based thinking skills).Review of Quarterly MDS dated [DATE] for Resident #2 revealed, unclear speech, rarely makes self-understood and rarely understands others. Short-term and Long-term Memory problems. Frequently incontinent of urine. Incontinent of bowel. Active Diagnoses: Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life).Review of Care Plan revised 06/26/26 for Resident #2 revealed: -Resident has impaired thought process r/t Dementia. Interventions: Keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion.-Resident has a communication problem due to language barriers. Interventions: Anticipate and meet needs. The resident can communicate by using a communication board.-Resident is incontinent of bowel & bladder. Interventions: Incontinent care at least every two hours.During an observation and interview on 07/15/26 at 2:39 p.m. with LVN ADON A revealed there was a sign posted on Resident #2's closet door that said the resident's family washed the resident's clothes. When the ADON opened the closet door, there was a soiled pair of sweatpants and a shirt lying on the floor. There was a strong urine odor in the closet. LVN ADON A said that they had asked the family to bring a container to place the soiled clothing in until they came to pick it up to take home to wash and the family never brought a container. She said the staff had been trained not to place soiled personal clothing on the floor in the closets and had been trained to place the soiled clothing in plastic bags to prevent cross contamination.During an observation and interview on 07/16/26 at 8:48 a.m. with LVN ADON C of Resident #2's closet revealed there was one pair of sweatpants on the floor that was wet with urine, and there were two plastic bags that contained soiled clothing stored on the floor in the resident's closet. The ADON said the staff had been trained not to place soiled clothing on the floor in the closets for those residents whose families do the laundry for the residents to prevent urine odor in the room and prevent cross contamination. ADON C said the DON and ADONs were responsible for Infection Control.During an interview on 07/16/26 at 1:28 p.m. with CNA F on the 2-10 shift revealed the family of Resident #2 took his soiled personal clothing to wash. She said that they placed the soiled clothing in plastic bags and stored them on the floor because the resident did not have a container to place the bags of dirty clothes. She said they had been trained not to store anything on the floors to prevent cross contamination.During an interview on 07/16/26 at 1:34 p.m. with CNA G on the 2-10 shift revealed that Resident #2 was confused, required total assistance with ADLs, and was incontinent of bowel & bladder. She said that the resident's family washed his personal clothes and they placed the resident's soiled clothing in plastic bags and placed the plastic bags on the floor in the resident's closet for the family to pick up when they came to see the resident. She said that they did not have a container in the resident's closet to place the plastic bags that contained soiled personal clothing. She said they had been trained not to place anything on the floor to prevent cross contamination.Review of facility's undated policy and procedures on Fundamentals of Infection Control Precautions revealed: A variety of Infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions to prevent the transmission of infection: Hand Hygiene, Gloving, Resident care equipment and articles. It is important that practices reflect the most current CDC guidelines.

Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 4 of 12 water heaters.The facility failed to maintain 4 of 12 water heaters that provided hot water to 4 of 4 resident units resulting in the water heaters being not operational for over a month.This failure could place the residents at risk of an unsafe environment by not maintaining mechanical equipment in safe operational condition.Findings included:Review of the Water Temperature Logs provided by the Maintenance Director on 07/15/26 revealed the hot water temperatures had not been checked weekly since May 2026 to present.During an interview and record review on 07/15/26 at 3:55 p.m. with the Maintenance Director said they had been having problems with not having hot water in the community shower rooms because one tankless water heaters was down in 4 of 4 resident halls. Review of Estimate from Heating/Air Conditioning company dated 06/19/26 for two tankless water heaters. Review of Estimate from Heating/Air Conditioning company dated 06/19/26 for two tankless water heaters for the 300 Wing. He said, The Administrator is aware of the problem, and I have been working on getting 3 quotes for several weeks as required by company policy to plan for a contractor to come and fix the tankless water heaters in the facility. He said that so far, he only had obtained two quotes.During an interview and record review on 07/15/26 at 4:01 p.m. with the Maintenance Director, he said that he checked hot water temperatures once a week and he had not identified any problems with not having hot water in the shower room in the 500 Hall. Copies of the hot water temperatures checks from May 2026 to present were requested. He said, I need to go and look for them because, I am still in the process of organization my office because the previous maintenance director left a mess. The Maintenance Director provided copies of two quotes to fix the water heaters. One of the quotes was blank and did not have a date or the vendors name.During an observation and interview on 07/15/26 at 4:11 p.m. with the Maintenance Director, it was revealed that the hot water temperature in the shower room in the 200 Hall shower stall was 88.3 degrees Fahrenheit. He said, There are four waterless tanks in the mechanical room in the 200 Hall, and one tankless water heater has not been working for several weeks. During an observation and interview on 07/15/26 at 4:17 p.m. with the Maintenance Director, it was revealed that there were 4 tankless water heaters in the mechanical room in the 200 Hall and one water heater was turned off. He said, It is turned off because it has not been working for several weeks. It was observed that the tank was labeled Replace.During an observation and interview on 07/15/26 at 4:19 p.m. with the Maintenance Director, it was revealed that there were 4 tankless water heaters in the mechanical room in the 300 Hall and one water heater was turned off. He said, It is turned off because it has not been working for several weeks. It was observed that that he attempted to turn the water heater on and kept getting an error message. It was observed that the tank was labeled Replace.During an observation on 07/15/26 at 4:22 p.m. with the Maintenance Director, revealed the hot water temperature in the shower room in the 300 Hall was 103.3 degrees Fahrenheit.During an observation on 07/15/26 at 4:24 p.m. with the Maintenance Director, it was revealed the hot water temperature in the shower room in the 500 Hall was 84.7 degrees Fahrenheit.During an observation and interview on 07/15/26 at 4:26 p.m. with Maintenance Director, it was revealed that there were 4 tankless water heaters in the mechanical room in the 500 Hall and one water heater was turned off. He said, It is turned off because it has not been working for several weeks.During an interview and record review on 07/15/26 at 4:33 p.m. with the Maintenance Director he said that he had the water temperature checks sheet in his office. The Maintenance Director said that he did not have any written documentation to show the water temperatures in the Resident Halls 200, 300, 400, 500 and 600, kitchen and the laundry had not been checked starting May 2026 to present. He said that water temperatures should be checked once a month.During an interview and record review on 07/15/26 at 4:44 p.m. with the Administrator and Regional Compliance Nurse L they confirmed water temperature checks had not been done since May 2026 to present. The Administrator said that she was not aware that there were 1 of 4 tankless water heaters not working in 4 of 4 resident halls. She said the Maintenance Director needed to get 3 quotes to send to the corporate office for review and approval to contact a vendor to fix or replace the tankless water heaters. She said that she did not know how many quotes the Maintenance Director had obtained. She said that she did not know how often Maintenance checked the water temperatures in the facility.

Based on observations and interviews the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #2) of 5 Resident reviewed for Resident Rights. The facility failed to ensure Resident #2's dignity was maintained when he was left in urine-soaked clothing, his bedding was urine soaked, and his room had a strong urine smell. This failure put residents at risk of not being treated with dignity and respect and not being care for in an environment the maintains the resident's quality of life. Findings include: Resident #2Review of the admission Record dated 07/16/26 revealed Resident #2 was admitted on [DATE].Review of the History & Physical dated 04/15/26 for Resident #2 revealed an [AGE] year-old male with past medical history of dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, language, problem-solving, judgement, and orientation) and Cognitive Communication Deficit (Difficulty with speech, reading, writing, or listening caused by underline brain based thinking skills).Review of Quarterly MDS dated [DATE] for Resident #2 revealed, unclear speech, rarely makes self-understood and rarely understands others. Short-term and Long-term Memory problems. Frequently incontinent of urine. Incontinent of bowel. Active Diagnoses: Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life).Review of Care Plan revised 06/26/26 for Resident #2 revealed: -Resident has impaired thought process r/t Dementia. Interventions: Keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion.-Resident has a communication problem due to language barriers. Interventions: Anticipate and meet needs. The resident can communicate by using a communication board.-Resident is incontinent of bowel & bladder. Interventions: Incontinent care at least every two hours.During an observation and interview on 07/15/26 at 2:30 p.m. with LVN ADON A and CNA B revealed Resident #2 was lying in his bed, was awake. The ADON said that the resident was Vietnamese and did not speak English. She said the resident and staff communicate with him by pointing to things. There was strong body odor and urine odor in the room. CNA B said that the resident was showered on Monday-Wednesday- Friday on the evening shift. CAN B said, I have not given him a shower today. It was observed that the resident's bed sheet had a dried urine ring measuring approximately 24 inches and the resident's sweatpants had dried urine on the legs down to the knees. The CNA said that she could not remember the last time that she had checked the resident for incontinence. She said they had been trained to check the incontinent residents at the start of the shift, every two hours and as needed. The CNA assisted the resident to pull the sweatpants down and it was observed that the resident did not have any skin irritation or breakdown. The CNA assisted the resident to a standing position and was in the process of telling the surveyor that she would be taking the Resident to room [ROOM NUMBER] to give him a shower and the ADON was standing to the right side by the CNA shaking her head from side to side. The ADON instructed CNAB to take the resident to the shower room in the 300 Hall to give him a shower because they should not be showering residents in other resident rooms.During an observation on 07/15/26 at 2:39 p.m. with LVN ADON A revealed there was a sign posted on Resident #2's closet door that said the resident's family washed the resident's clothes. When the ADON opened the closet door, there was a soiled pair of sweatpants and a shirt lying on the floor. There was strong urine odor in the closet. She said that they had asked the family to bring a container to place the soiled clothing until they came to pick it up to take home to wash and the family never brought a container. She said the staff had been trained not to place soiled personal clothing on the floor in the closets and had been trained to place the soiled clothing in plastic bags to prevent cross contamination.During an observation on 07/16/26 at 8:48 a.m. with LVN ADON C of Resident #2's closet revealed there was one pair of sweatpants on the floor that was wet with urine, and there were two plastic bags that contained soiled clothing stored on the floor in the resident's closet. The ADON said the staff had been trained not to place soiled clothing on the floor in the closets for those residents whose families do the laundry for the residents to prevent urine odor in the room and prevent cross contamination.During an interview on 07/16/26 at 1:28 p.m. with CNA F on the 2-10 shift revealed the family of Resident #2 took his soiled personal clothing home to wash. She said that they placed the soiled clothing in plastic bags and stored them on the floor because the resident did not have a container to place the bags of dirty clothes. She said they had been trained not to store anything on the floors to prevent cross contamination. She said that yesterday 07/15/26 she had found resident with dried urine ring on the sheets and his sweatpants and there was strong body and urine odor in the room. She said that she also frequently found soiled disposable briefs in the trash can in the resident's room. She said that they had been trained not to leave the soiled disposable briefs in the trash cans in the resident rooms.During an interview on 07/16/26 at 1:34 p.m. with CNA G on the 2-10 shift revealed that Resident #2 was confused, required total assistance with ADLs, and was incontinent of bowel & bladder. She said that the resident occasionally urinated or had a bowel movement on the floor. She said that they had been trained to check incontinent residents at the start of the shift, every two hours and as needed. She said that they placed the resident's soiled clothing in plastic bags and placed them on the floor in the resident's closet for the family to pick up when they came to see the resident. She said that they did not have a container in the resident's closet to place the plastic bags that contained soiled personal clothing. She said they had been trained not to place anything on the floor to prevent cross contamination.During an interview on 07/16/26 at 1:45 p.m. with CNA D she said she was assigned to Resident #2 on 07/15/26 on the 6-2 shift and said that the last time she had checked if the resident was wet was at 1:00 p.m. on that day. She said they had been trained to check the incontinent residents at least every two hours. She said that she tried to do rounds every two hours, but it depended on the number of CNAs that were working. She said that when there were only 4 CNAs working on the unit, then each CNA was assigned 14 residents and sometimes they did not have the time to check the incontinent residents every two hours. She said that Resident #2 was showered on the 2-10 shift and that was the reason there was a strong urine smell in the room. She said that the resident's mattress also had a strong urine odor and sometimes the CNAs threw soiled briefs in the trash can in the resident's room. She said they had been trained not to leave soiled briefs in the room to keep the rooms from smelling bad.During an interview on 07/16/26 at 2:53 p.m. with Social Worker E revealed that she heard that Resident #2's responsible party had voiced a concern regarding the cleanliness of the room, found soiled briefs in the trash can when she came to visit and found the soiled personal clothing stored in the closet on the floor causing strong urine odor in the resident's room. She said that she was not aware of what the nursing staff had done to address these concerns because she did not know if a Grievance form had been completed by whoever received the family's concern. She said that the Administrator was the Grievance Official and she assigned the Grievances to the appropriate department head based on the allegations that had been reported.

Based on observation, interviews and record review, the facility failed to ensure efforts were made to resolve resident grievances, for 1 (Resident #5) of 5 residents reviewed for grievance resolution.The facility failed to ensure that the grievance filed by Resident #5 on 05/27/26 was resolved when she had complained that the CNAs were showering other residents in her room without her permission.These failures could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness. Findings include: Resident #5Review of the admission Record dated 07/16/26 revealed Resident #5 was admitted on [DATE].Review of the History & Physical dated 12/01/25 for Resident #5 revealed an [AGE] year-old female with past medical history of Mild Cognitive Impairment (A condition causing a noticeable decline in memory or thinking skills that is worse than typical age-related changes but not severe enough to interfere with daily life or independent living) and Depression (a serious mood disorder causing persistent sadness, loss of interest, and lack of motivation, affecting how the person feels, think, and act, differing from normal sadness by lasting long periods and interfering with daily life).Review of Physician Progress Note dated 06/01/26 revealed Resident #5 was alert, oriented to person, place, and time.Review of the Annual MDS dated [DATE] for Resident #5 revealed, BIMS Summary Score 9 (cognition moderately impaired). Active Diagnoses: Depression, and Mild Cognitive Impairment.Review of Care Plan revised 06/26/26 for Resident #5 revealed: -Resident has mild impaired cognitive function. Interventions: Identify yourself at each interaction. Keep the resident's routine consistent and try to provide consistent caregivers as much as possible to decrease confusion. Monitor and report to physician any changes in cognitive function, especially changes in decision making ability, memory recall and general awareness.-Resident has a history of making false accusations. Interventions: Notify Supervisor and Physician of any false allegations.Review of Resident Grievance for dated 05/25/26 revealed Resident #5 reported grievance about her previous roommate using the shower without her permission. Resolved 05/27/26. A summary of the pertinent findings and conclusions: Resident used shower in a room that was no longer assigned to her. What corrective action will be taken to prevent recurrence. Social Worker provided education to resident on boundaries and respecting others space. Social Worker reminded Resident that the room where she showered was no longer assigned to her and therefore could no longer use that specific shower. Resident displayed clear understanding. Date of notification: 05/27/26. During an interview on 07/16/26 at 5:12 p.m. with Resident #5 revealed that she was alert, oriented to person, place, time and situation. She said that the CNAs would bring other residents to shower in her room without her permission and it made her very upset because it was her room. She said, It is my right for me to refuse to allow them to shower other residents in my room, but they pay no attention to me, and they keep bringing patients to shower in my room every day. She said that she had complained about her previous roommate coming to shower in her room. Whoever handled my concern only addressed the concern about my former roommate coming to shower in my room, but nothing has been done about the CNAs still bringing other residents to shower in my room daily, so my concern has been ignored. She said, The people in charge here at the facility are just bull shitters and do not do anything to address my concerns.During an interview and record review on 07/16/26 at 5:39 p.m. with Administrator of the Grievance Binder revealed a Grievance Form dated 05/27/26 for Resident #5 that was completed by the Social Worker. The Grievance form documented Resident #5 had reported a grievance about her previous roommate using her shower without her permission. She said the Grievance had been resolved 05/27/26 by educating the resident's former roommate on respecting other resident's space. The former resident's roommate was reminded that she could not be showering in room [ROOM NUMBER], and the resident had voiced clear understanding. The Administrator said she had talked to Resident #5 several times after the Grievance had been resolved and she had not voiced any concerns about staff showering other residents in her room. She said, I was not aware that the CNAs were showering residents in other residents' rooms including [Resident #5's] room in 508. She said that she was not aware that it took a long time to get hot water in the community shower room in the 500 Hall and that was why the CNAs were showering residents in other resident rooms. There is another community shower in the 300 Hall where the CNAs can shower residents so they should not be showering residents in other residents' rooms. She said that she did not recall if Resident #2's family had voiced any concerns about having a strong smell of urine in the resident's room, finding soiled briefs in the trash can, or staff placing soiled linen on the floor in the resident's room. She said she was responsible for checking that the facility staff were completing a Grievance Form for all concerns reported so that the concerns could be assigned to the appropriate department head to resolve the concerns as soon as possible.Review of the facility's Grievance Policy and Procedure revised on 11/02/2016 provided by the Administrator revealed, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; And other concerns regarding their Long-Term Care facility stay. The resident has the right to, and the family must make prompt efforts by the facility to resolve grievances the resident may have. Procedure: The facility will notify residents on how to file a grievance orally, in writing or anonymously with postings in prominent locations. The grievance official of this facility is the administrator or their designee. The grievance official will: oversee the grievance process; Receive and track grievances to their conclusion; Lead any necessary investigation by the facility; Issue written grievance decisions to the resident. As needed, the facility will take immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated. All written grievance decisions will include: The date the grievance was received. A summary statement of resident's grievance. The steps taken to investigate the grievance. A summary of the pertinent findings or conclusions regarding the resident's concern(s). A statement as to whether the grievance was confirmed or not confirmed. Any corrective action taken or to be taken by the facility staff as a result of the grievance. The date the written decision was issued.

Based on observation, interview and record review the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming and personal hygiene for 1 (Resident #2) of 5 residents reviewed for quality care.-The facility failed to provide incontinent care to Resident #2 according to the comprehensive person-centered care plan.This failure could place residents at risk of not receiving the necessary personal care to maintain the resident's dignity and prevent skin irritation and skin breakdown. Findings include: Review of the admission Record dated 07/16/26 revealed Resident #2 was admitted on [DATE].Review of the History & Physical dated 04/15/26 for Resident #2 revealed an [AGE] year-old male with past medical history of dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, language, problem-solving, judgement, and orientation) and Cognitive Communication Deficit (Difficulty with speech, reading, writing, or listening caused by underline brain based thinking skills).Review of Quarterly MDS dated [DATE] for Resident #2 revealed, unclear speech, rarely makes self-understood and rarely understood others. Short-term and Long-term Memory problems. Frequently incontinent of urine. Incontinent of bowel. Active Diagnoses: Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life).Review of Care Plan revised 06/26/26 for Resident #2 revealed: -Resident has impaired thought process r/t Dementia. Interventions: Keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion.-Resident has a communication problem due to language barriers. Interventions: Anticipate and meet needs. The resident can communicate by using a communication board.-Resident is incontinent of bowel & bladder. Interventions: Incontinent care at least every two hours.During an observation and interview on 07/15/26 at 2:30 p.m. with LVN ADON A and CNA B revealed Resident #2 was lying in his bed, awake. There was strong urine odor in the room. It was observed that the resident's bed sheet had a dried urine ring measuring approximately 24 inches and the resident's sweatpants had dried urine on the legs down to the knees. The CNA said that she could not remember when the last time was that she had checked the resident. She said they had been trained to check the residents at the start of the shift, every two hours and as needed. The CNA assisted the resident to pull the sweatpants down and it was observed that the resident did not have any skin irritation or breakdown.During an interview and record review on 07/16/26 at 10:23 a.m. with the DON and MDS Nurse K revealed that the CNAs were expected to provide incontinent care every two hours according to the resident's care plan. The DON said that the CNAs had been trained to check the incontinent residents every two hours and as needed to prevent skin irritation and breakdown.During an interview on 07/16/26 at 1:28 p.m. with CNA F on the 2-10 shift revealed they had been trained to check the incontinent residents at the start of the shift and every two hours and as needed. She said that yesterday on 07/15/26 she had found Resident #2 with dried urine ring on the sheets and his sweatpants. She said there was strong body and urine odor in the room. She said that she had reported to the ADONs that residents are frequently found with dried urine rings at the start of shift and nothing had been done to address the problem.During an interview on 07/16/26 with LVN I at 1:32 p.m. revealed that he only worked PRN He said the CNAs had been trained to check the incontinent residents at the start of shift, every two hours and as needed. He said that he did not know which residents were incontinent of bowel & bladder.During an interview on 07/16/26 at 1:34 p.m. with CNA G on the 2-10 shift revealed that Resident #2 was confused, required total assistance with ADLs, was incontinent of bowel & bladder. She said that they had been trained to check incontinent residents at the start of the shift, every two hours and as needed.During an interview on 07/16/26 at 1:40 p.m. with CNA J the 2-10 shift assigned to work on the 300/500 Halls revealed they had been trained to check the incontinent residents at the start of the shift, every two hours and as needed. She said that she checked the incontinent residents prior to the end of the shift.During an interview on 07/16/26 at 1:45 p.m. with CNA D said she was assigned to Resident #2 on 07/15/26 on the 6-2 shift and said that the last time she had checked if the resident was wet was at 1:00 p.m. She said they had been trained to check the incontinent residents at least every two hours. She said that she tried check the incontinent residents every two hours, but it depends on the number of CNAs that were working on the unit. She said that when they did not have 5 CNAs, each CNA would be assigned 14 residents and sometimes they did not have the time to check the incontinent residents every two hours.The facility's policy on incontinent care was requested but was not provided prior to exit.

Based on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 2 (Resident #1 and Resident #2) of 11 residents observed for oxygen management.The facility failed on 06/05/2026 to ensure oxygen warning signs were posted outside the rooms of Resident #1 and Resident #2 while the residents were receiving oxygen therapy. The facility failed on 06/05/2026 to ensure oxygen cylinders not actively in use were stored in the designated oxygen storage room and instead left them inside Resident's #1 and Resident #2's room.These failures had the potential to expose residents receiving oxygen therapy to delayed identification of oxygen-related needs, increase the risk of fire hazards associated with oxygen use, and create unsafe environmental conditions by leaving oxygen cylinders stored in resident rooms when not in useFindings included:Record review of Resident #1's face sheet dated 06/05/2026 revealed a [AGE] year-old female with an admission date of 06/27/2024.Record review of the History and Physical dated 08/27/2024 revealed Resident #1 had diagnoses of ischemic stroke (a stroke caused by a blockage of blood flow to a portion of the brain) and hypertension (high blood pressure, a condition that places additional strain on the heart and blood vessels and increases the risk of future strokes and heart disease). Resident #1 required supplemental oxygen therapy (the use of oxygen to help maintain adequate oxygen levels in the blood when the lungs or body require additional respiratory support).Record review of the Annual MDS dated [DATE] revealed Resident #1 had a BIMS score of 15 out of 15, indicating Resident #1 was cognitively intact. Under Section I (Active Diagnoses), the MDS revealed a thyroid disorder (a condition affecting the thyroid gland, including hypothyroidism or Hashimoto's disease), cerebrovascular accident (CVA)/stroke (damage to the brain caused by interrupted blood flow), and hemiparesis (weakness affecting one side of the body). Section J (Health Conditions) revealed Resident #1 had shortness of breath or trouble breathing with exertion. Review of Section O (Special Treatments, Procedures, and Programs) revealed oxygen-related respiratory treatments. Section O revealed the resident had received respiratory therapy seven days a week for at least 15 minutes a day.Record review of Resident #1's care plan with a last care plan review date of 04/28/2026 revealed the resident had a care plan focus for Oxygen Therapy. The care plan revealed the oxygen therapy care plan was initiated on 06/28/2024 and revised on 08/12/2024. The care plan revealed Resident #1 was to remain free from signs and symptoms of poor oxygen absorption (a condition in which the body is not receiving enough oxygen to meet its needs) through the review date. Interventions revealed staff were to continue oxygen administration during meals by changing the oxygen delivery method, such as changing from a mask to a nasal cannula and returning the resident to the usual oxygen delivery method after meals. The care plan revealed staff were to monitor for signs and symptoms of respiratory distress (difficulty breathing or not getting enough oxygen), including changes in respirations, pulse oximetry (measurement of oxygen levels in the blood), tachycardia (an abnormally fast heart rate), restlessness (inability to remain calm or still), diaphoresis (excessive sweating), headaches, lethargy (unusual tiredness or lack of energy), confusion, cough, and changes in skin color, and report concerns to the physician as needed. The care plan further revealed CNAs were to notify the nurse if the resident's oxygen was off. The care plan revealed the resident received oxygen at 5 liters per minute via nasal cannula (a device that delivers oxygen through the nostrils).Record review of Resident #2's face sheet dated 06/05/2026, revealed a [AGE] year-old female with an original admission date of 11/13/2024, and a readmission date of 01/19/2026.Record review Resident #2's history and physical dated 03/23/2026 revealed Resident #2 had pneumonia (an infection of the lungs that can cause coughing, fever, and difficulty breathing), and Influenza A infection (a viral respiratory illness commonly known as the flu). The record review revealed end-stage renal disease requiring dialysis (advanced kidney failure in which the kidneys can no longer adequately remove waste products and excess fluid from the body, requiring routine dialysis treatments), as well as anemia related to chronic kidney disease (a condition in which there are not enough healthy red blood cells to effectively carry oxygen throughout the body, often causing fatigue and weakness). The record review also revealed oral mucositis (painful inflammation and sores inside the mouth), anxiety disorder (persistent feelings of worry, fear, or nervousness), depression (a mood disorder characterized by persistent sadness and loss of interest in daily activities), bipolar disorder (a mental health condition characterized by significant changes in mood, energy, and activity levels), history of thyroid cancer (a previous diagnosis of cancer affecting the thyroid gland) and a prior laryngectomy (surgical removal of the voice box).Record review of Resident #2's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15 out of 15, indicating Resident #2 was cognitively intact. Under Section I (Active Diagnoses), the MDS revealed diagnoses consistent with the resident's documented history of heart failure (a condition in which the heart does not pump blood effectively), end-stage renal disease requiring dialysis (advanced kidney failure requiring dialysis treatments), and other chronic medical conditions. Section J (Health Conditions) revealed Resident #2 had shortness of breath or trouble breathing with exertion. Review of Section O (Special Treatments, Procedures, and Programs) revealed oxygen therapy as a respiratory treatment provided while the resident resided in the facility.Record review of Resident #2's care plan with a last care plan review date of 04/28/2026 revealed the resident had a care plan focus for Oxygen Therapy. The care plan revealed the oxygen therapy care plan was initiated on 09/23/2025 and revised on 12/31/2025. The care plan revealed Resident #2 was to remain free from signs and symptoms of poor oxygen absorption through the review date. Interventions revealed staff were to change the resident's position to facilitate lung secretion movement and drainage, administer medications as ordered, and continue oxygen administration during meals by changing the oxygen delivery method, such as changing from a mask to a nasal cannula, and returning the resident to the usual oxygen delivery method after meals. The care plan revealed staff were to monitor for signs and symptoms of respiratory distress, including respirations, pulse oximetry, tachycardia, restlessness, diaphoresis, headaches, lethargy, confusion, cough, hemoptysis (meaning coughing up blood or blood-stained mucus from the lungs or airways), and changes in skin color, and report concerns to the physician as needed. The care plan revealed CNAs were to notify the nurse if the oxygen was off the resident. The care plan revealed the resident received oxygen at 3 liters per minute via nasal cannula.During an observation on 06/05/2026 at 11:00 a.m. outside of Residents #1 and #2, no oxygen-in-use warning signs were observed posted outside the room. At the time of the observation, oxygen concentrators were observed inside the residents' room. During an observation and interview conducted on 06/05/2026 at 11:02 a.m. inside the room of Resident #1 and Resident #2, two oxygen concentrators and two oxygen cylinders were observed stored inside the residents' room. Resident #1 stated she attended a physician appointment on 06/01/2026 and upon returning to the facility staff assisted her back to bed and left the oxygen cylinder in her room. Resident #1 stated the oxygen cylinder had remained in the room from 06/01/2026 until the observation on 06/05/2026. Resident #2 was not interviewed during this visit; the resident was out of the facility in a dialysis appointment for the day.During an interview and observation on 06/05/2026, at 11:15 a.m. with RN A inside Resident #1 and Resident #2's room, stated that residents receiving oxygen therapy were required to have oxygen warning signs posted outside their rooms and that it was not acceptable for those signs to be missing. RN A stated CNAs, LVNs, RNs, and the DON shared responsibility for ensuring the signs remained posted and visible. RN A stated oxygen cylinders not in use were required to be stored in the designated oxygen storage room. RN A stated missing oxygen signs could increase the risk of fire hazards and delay staff awareness that a resident required oxygen therapy, while improperly stored oxygen tanks could create safety hazards within resident rooms. During an interview on 06/05/2026, at 11:20 a.m. with Charge Nurse B, stated that oxygen signage was required outside the rooms of all residents receiving oxygen therapy and that staff were expected to address missing signs immediately. Charge Nurse B stated CNAs, LVNs, RNs, and the DON were responsible for ensuring oxygen signs were posted and oxygen cylinders were stored appropriately when not in use. Charge Nurse B stated failure to post oxygen signs could expose residents and staff to fire hazards and prevent caregivers from readily identifying residents requiring oxygen monitoring. Charge Nurse B stated oxygen tanks left in resident rooms unnecessarily could present environmental and safety hazards such as tripping hazards for staff and residents and fire hazards. During an interview on 06/05/2026, at 11:34 a.m. with LVN C, she stated that oxygen warning signs were required for residents receiving oxygen therapy and that the absence of such signage was not acceptable. She stated CNAs, LVNs, RNs, and the DON were responsible for monitoring compliance with oxygen safety practices, including ensuring cylinders not in use were secured in the oxygen storage room. LVN C stated missing signs could increase the risk of accidental ignition and make it more difficult for staff to recognize residents who required oxygen-related monitoring. LVN C stated unsecured oxygen cylinders in resident rooms could create tripping and fire hazards for residents, staff, and visitors. During an interview on 06/05/2026, at 12:00 p.m. with CNA D, stated that residents receiving oxygen therapy were expected to have oxygen signs always posted outside their rooms. CNA D stated CNAs, LVNs, RNs, and the DON were responsible for ensuring oxygen safety measures were followed, including proper storage of oxygen cylinders when not in use. CNA D stated oxygen signs helped alert staff and visitors to potential fire risks and identified residents who required oxygen therapy and monitoring. CNA D stated leaving oxygen cylinders in resident rooms when not being used could create avoidable safety risks and was not considered acceptable practice. During an interview on 06/05/2026, at 2:18 p.m. with the DON, stated it was not acceptable for oxygen signs to be missing from outside the rooms of residents receiving oxygen therapy or utilizing oxygen concentrators. The DON stated the signs were necessary to alert staff and visitors that oxygen was in use and to reduce fire and safety risks. The DON stated oxygen cylinders were not to be left in resident rooms when not in use and were required to be stored in the designated oxygen storage room. The DON stated all staff including CNAs, LVNs, RNs and DON, were responsible for reporting missing oxygen signs and improperly stored oxygen cylinders. During an interview on 06/05/2026, at 2:55 p.m. with the Administrator, stated it was not acceptable for oxygen signs to not be posted outside rooms where oxygen therapy or oxygen concentrators were in use. The Administrator stated the signs promoted resident safety and alerted staff to oxygen-related precautions. The Administrator stated oxygen cylinders should be stored in the designated oxygen storage area when not in use and should not remain in resident rooms. The Administrator stated all staff were expected to identify and report missing oxygen signs and oxygen cylinders left in resident rooms including CNAs, LVNs, RNs and DON, or any staff who worked directly with the residents from the facility. -Record review of the facility's policies and procedures titled Respiratory Policies and Procedures revised on 06/01/2006 revealed in part: POLICYHigh pressure cylinders are set up by a respiratory therapist or a licensed nurse with a physician's order. PURPOSE To deliver a high liter flow when required. To provide a means of portable oxygen when a liquid system is not available.PROCESS1. Follow precautions for safe handling of high pressure oxygen cylinders.1.1 Fire hazard is increased in the presence of oxygen. No smoking or open flame within five feet of oxygen.1.2 Cylinders must be properly secured to prevent accidental tipping of the tank and possible rupture causing high pressure release of gases. 1.3 To prevent fire, storage areas for medical gases must be dry, fire resistant, vented to the outside, and protected from heat. A No Smoking - Oxygen in Use sign must be posted in any area where high pressure cylinders are stored.1.4 Empty cylinders must be stored in separate rows from full cylinders. Full cylinders should have caps in place on large cylinders to minimize the risk of confusion. 3.2 No Smoking - Oxygen in Use sign;6. Explain safety rules. Post No Smoking - Oxygen in Use sign on patient's door.-Record review of the facility's policies and procedures titled Oxygen Administration, not dated, read in part: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The nasal cannula delivers 22-40% oxygen and is the most common, inexpensive, and easiest device to use. Common oxygen sources for long-term administration include cylinder (portable or stationary) or wall system near the resident's bed or concentrator. Goals1. The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. Procedure 11. Place NO SMOKING signs in areas where oxygen is administered and stored. Store oxygen canisters in an area free of flammable substances. Avoid the use of electrical appliances in the area where oxygen is administered.

Based on observations, interviews, and record reviews the facility failed to ensure that the residents environment remains as free of accidents hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 24 residents observed.The facility failed to dispose of an empty syringe and left it on top of Resident #1's dresser located in the room. This failure could place residents at risk of accidents, and potential harm.Findings include:Record review of Resident #1's face sheet dated 04/22/2026 revealed the resident was an [AGE] year-old female with an original admission date of 02/13/2025 with a readmission date of 09/15/2025.Record review of Resident #1's History and Physical revealed diagnoses including type 2 diabetes mellitus (a chronic condition where the body cannot properly regulate blood sugar levels), congestive heart failure (a condition where the heart cannot pump blood effectively), chronic obstructive pulmonary disease (a chronic lung disease causing difficulty breathing), hypertension (high blood pressure), and hyperlipidemia (high levels of fat in the blood).Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 14, indicating the resident was cognitively intact (able to understand and respond appropriately with minimal impairment). The MDS revealed under Section I (Active Diagnoses) that the resident had a diagnosis of Diabetes Mellitus. The MDS revealed under section N0350, medications, insulin; Resident #1 received insulin injections five days per week since the admission or reentry day.Record review of Resident #1's care plan revealed the resident had a diagnosis of Diabetes Mellitus with interventions including administering diabetes medications as ordered, monitoring side effects and effectiveness, and conducting blood glucose monitoring. The care plan reflected the need for ongoing management of the resident's condition, including medication administration and monitoring signs and symptoms of hypo/hyperglycemia (low/high blood sugar).During an observation and interview on 04/20/26 at 10:42 a.m., in Resident #1's room, an empty syringe was observed on top of Resident #1's dresser. The syringe was left unattended and within reach of any residents, staff or visitors who went into the room. Resident #1 was in bed with her tracheostomy tube (a curved tube inserted into an opening surgically made in the neck and trachea (windpipe) to help a person breathe) on and could not speak. Resident #1 slightly nodded when she was asked if she received insulin medications. During an interview on 04/20/2026 at 11:59 a.m., ADON A stated that sharps, including needles, razors, and syringes, were required to be disposed of in designated sharps containers immediately after medications had been administered to residents. He explained that unattended needles placed residents, staff, and visitors at risk for accidental injuries and infection control concerns. He stated that improperly discarded needles could expose individuals to bloodborne pathogens and create a hazardous environment within the facility.During an interview on 04/20/2026 at 3:15 p.m., CNA C stated that sharps and syringes were required to be discarded immediately after medications had been administered to residents to prevent accidents or injuries. She explained that leaving syringes unattended created a safety concern for both residents and staff members.During an interview on 04/20/2026 at 3:17 p.m., CNA D stated that syringes and sharps were expected to be disposed of promptly after medication administration. She stated that failure to properly dispose of sharps could result in another resident obtaining the syringe and accidentally injuring themselves, potentially causing allergic reactions or exposure risks. She also stated that staff members and visitors could be placed in danger if sharps were left exposed.During an interview on 04/21/2026 at 1:30 p.m., LVN F stated that anything containing a needle was considered a sharp and was required to be disposed of in a sharps container immediately following medication administration. He explained that safety syringes were to be secured before disposal. He stated that leaving syringes unattended in resident rooms created a significant safety risk for residents and staff due to possible needle-stick injuries and exposure to bloodborne pathogens, including HIV and Hepatitis C. He stated the incident would have been reported to his immediate supervisor after proper disposal.During an interview on 04/20/2026 at 1:48 p.m., CNA E stated that syringes and sharps were required to be discarded immediately after use and that the floor nurse should have been notified if one was found unattended. She explained that used syringes left in resident rooms created contamination and infection control concerns and increased the risk of residents being accidentally poked.During an interview on 04/22/2026 at 9:48 a.m., LVN G stated that syringes were to be placed in a red biohazard bag and then properly disposed of in a sharps container immediately after medications had been administered. He explained that sharps included any object that entered a person's body and was exposed to bodily fluids. He stated that concerns regarding improperly discarded sharps would have been reported to the ADON who was responsible for the hall. He stated that leaving syringes in resident rooms created a major safety hazard, particularly due to residents wandering into other rooms and potentially injuring themselves. He stated staff members could also sustain injuries and become exposed to infections.During an interview on 04/22/2026 at 10:22 a.m., LVN H stated that sharps and needles were considered biohazardous items and were required to be disposed of in designated sharps containers immediately after use. She explained that if a syringe had been found in a resident room, she would have donned gloves (put on gloves), disposed of the syringe appropriately, assessed the resident, and questioned the nurse responsible for leaving the syringe unattended. She stated that exposed syringes placed residents and staff at risk for needle-stick injuries and possible exposure to infections such as HIV and Hepatitis C.During an interview on 04/22/2026 at 12:03 p.m., ADON B stated that insulin needles should not have been left in resident rooms due to infection control concerns and the potential for injury or allergic reactions. She stated that the nurse administering the medication was responsible for disposing of needles immediately after medication administration. She explained that medication carts contained designated sharps containers to ensure proper disposal practices were followed.Record review of the facility's policy titled Fundamentals of Infection Control Precautions, not dated, read in part: 6. Resident care equipment and articles.1. Used sharps are never recapped and always placed in puncture-resistant containers. 2. Puncture-resistant containers, or sharps, will be maintained at designated areas where needles and sharps are used for resident care. Sharps containers will be locked and changed out when they are 2/3 full. Sharps containers will not be filled to more than 2/3 full. Sharp containers that have been locked will be placed in a bio-hazard container designated for medical waste removal.Record review of the facility's policy titled Standard Precautions, not dated, read in part: 15. Needles will not be purposely bent or broken by hand. 16. Contaminated sharps will not be recapped unless required by a specific medical procedure. Such recapping cannot employ a two-handed manual technique. 17. Sharps containers must be readily and easily accessible, closable, and puncture resistant and leak proof on the sides and bottom. Sharps containers must not be more than 2/3 full. The charge nurse or designee will be responsible for changing out sharps containers that are 2/3 full each shift. Sharps containers must be labeled with a biohazard sticker or color-coded (red). 18. Contaminated equipment must be closed immediately prior to removal or replacement and placed in the designated central collection area in preparation for waste removal. 25. Contaminated sharps will be discarded immediately in puncture-resistant, leak proof and closable containers. The containers will be easily accessible and labeled with the biohazard legend. 26. Sharps containers will be located as close as possible to the immediate area where sharps are used. Sharps containers will maintain in an upright position and replaced routinely. 27. When moving containers of contaminated sharps from the area of use, the containers will be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. 28. Full sharps containers may be placed in a secondary container if leakage is possible. Secondary containers will be closable, constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping. The secondary container will be labeled with the biohazard legend.

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 1 of 24 residents (Resident #2) reviewed for infection control in that:PPE (Protective equipment such as gowns and gloves) was not used properly by LVN H when performing an IV insertion and properly handling sharps for Resident #2.The deficient practice could place residents at risk for infection due to improper care practices.Findings include:Resident # 2 Record review of Resident # 2's face sheet dated 4/22/26 revealed [AGE] year-old female that was originally admitted on [DATE] and then re-admitted on [DATE]. Record review of Resident # 2's History and Physical dated revealed diagnosis including, Diabetes Mellitus, Hyperkalemia, malnutrition, displaced Introchanter Fixation (broken leg) of left femur, unspecified constipation, muscle weakness, overactive bladder, Dysphagia (trouble swallowing), hypothyroidism, cognitive communication deficit, Vitamin D, Myocardial infarction (heart attack) Record review of Resident # 2 's Quarterly MDS dated [DATE], revealed a BIMS score of 3 indicating poor cognitive level. Record review of Resident # 2's care plan dated 1/30/26 revealed focus plan on DRIPT IV Therapy infusion program, (IV fluid administration) with interventions that included. Record review of Resident # 2's physician order dated 04/22/26 revealed orders for IV administration of sodium chloride (IV fluids for hydration) every shift for 2liters . During an observation on 4/22/26 at 10:22 am, LVN H was observed initiating an intravenous (IV) insertion on Resident #2 with ADON B present. Aseptic technique was not consistently maintained during the procedure. The IV tubing was observed lying on the resident's sheets and blanket prior to administration, exposing it to potential contamination. Resident #2's linens were noted to be soiled, with visible stains present. During the procedure, after inserting the IV catheter into the resident's left wrist, LVN H was inserting an IV needle while wearing gloves that had a visible opening. The IV needle was placed on the resident's bed, resulting in blood staining the linens, and was subsequently picked up and placed on the resident's bedside table. LVN H then removed both gloves and disposed of them in the trash. The nurse proceeded to connect the IV tubing to the catheter without gloves and later identified that proper placement had not been achieved. The IV catheter was then removed without the use of gloves. At that time, LVN H stated that the IV was not successfully placed. ADON B stated that another nurse would be contacted to attempt IV insertion for the resident. Following this, LVN H was observed handling the IV needle with bare hands and disposing of additional items into the resident's trash receptacle. When questioned regarding the handling of the IV needle without gloves, LVN B stated, I only had one pair of gloves, and shrugged her shoulders. The IV needle was then placed into the sharps container. Hand hygiene was performed by LVN B after completion of the procedure .Interview on 4/22/2016 at 12:45 PM, ADON B stated that the standard IV initiation process included obtaining a physician's order, completing the appropriate assessment, gathering necessary supplies, and notifying the resident and/or responsible party. When asked whether gloves were consistently used, ADON B stated that gloves should be used. Regarding sharps handling, ADON B stated that sharps should be handled safely to avoid injury and disposed of properly in designated sharps containers. When asked about supply availability, ADON B stated that a central supply room was accessible to staff and stocked regularly. ADON B further stated that gloves were expected to be available in resident rooms and that additional supplies were maintained in central supply. ADON B stated that she had observed areas requiring improvement and that facility policies were not consistently followed. Regarding staff competency validation, ADON B stated that staff were expected to complete IV certification training and that skills validation tools were available. ADON B stated that most recent infection control training was conducted on October 29, 2025. ADON B stated that contaminated linens were expected to be changed immediately and that staff would be re-educated if proper procedures were not followed. In an interview on 04/22/2026 at 1:05 p.m., the Director of Nursing (DON) stated that for IV administration, the nurse receiving a physician order was expected to enter the order into the system, complete an IV assessment, initiate therapy, monitor the resident, and complete post-infusion follow-up. The DON stated that gloves were to be consistently used and that sharps were required to be disposed of immediately in designated sharps containers. The DON acknowledged that failure to properly dispose of sharps increased the risk of needle stick injuries and transmission of infection. The DON stated that residents were expected to be assessed prior to IV initiation, providers notified as appropriate, and documentation completed prior to initiating therapy. The DON further stated that staff were expected to have all necessary supplies available prior to beginning the procedure. When asked if policies were followed, the DON stated that based on the information received, policies were not followed. Regarding staff competency, the DON stated that staff were expected to complete IV certification training, including new hires, and that competency validation tools such as practice arms were available. When asked about the most recent infection control training, the DON stated she was unsure, as she was currently serving in an interim role.In an interview on 4/22/2016 at 1:15 PM, the Administrator stated that she was unsure of the standard practice for IV catheter initiation The Administrator stated that sharps should be capped and placed in a sharps container after use and that gloves were typically available in resident rooms and that sharps containers were located on medication carts. The Administrator stated that she was aware policies existed but could not recall them specifically. The Administrator stated that she did not have information on infection control training for staff. The Administrator stated that ongoing education and training courses were used to ensure staff remained up to date.During an interview on 04/22/2026 at 1:26 p.m., the Administrator stated that it was not appropriate to leave a syringe in a resident room and that all syringes should have been disposed of in designated sharps containers immediately after use. The administrator stated that exposed syringes created risks for infections and accidental injuries to residents, staff members, and visitors.During an interview with the LVN H on 04/22/26 at 1:15pm , the LVN stated that contamination of IV tubing is prevented by cleaning the resident with alcohol and ensuring that sterile supplies did not come into contact with linens or the resident's belongings. LVN H described the IV insertion process, stating that she gathered all necessary supplies, assessed the resident for appropriate vein placement, inserted the catheter, verified proper placement, and connected the tubing to the IV bag to initiate fluid administration. LVN H, stated if there was blood contaminated linens or surfaces, then LVN H stated that she would clean the area using disinfectant wipes and replace the soiled linens. LVN H, stated that all sharps were to be disposed of immediately in a sharps container and handled with gloves at all times. In an Interview with LVN H when asked about training related to infection control and IV procedures, LVN H stated that sharps such as needles and razors were to be placed in sharps containers. She further stated that she had not received in-person IV insertion training at the facility and had only completed IV training online.Record review of the facility's policy titled Standard Precautions, not dated, read in part: Procedure1. Hand washing is necessary after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Hands should be washed immediately after removing gloves, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. 3. Gloves should be worn when touching blood, body fluids, secretions, excretions, and contaminated items. Clean gloves should be used before touching mucous membranes and non-intact skin. 4. Gloves should be promptly removed after use, before touching noncontaminated items and environmental surfaces, and before going to another resident. 5. Gloves should be worn when performing other invasive procedures. 7. Change gloves before moving to a new body site that requires use of sterile or clean gloves. 13. Nonsterile gowns will protect skin and prevent the soiling of clothing during procedures and resident-care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Soiled gowns should be promptly removed. 14. Resident care equipment that has been used should be handled in a manner that prevents skin and mucous membrane exposures and contamination of clothing. 15. Needles will not be purposely bent or broken by hand. 16. Contaminated sharps will not be recapped unless required by a specific medical procedure. Such recapping cannot employ a two-handed manual technique. 17. Sharps containers must be readily and easily accessible, closable, and puncture resistant and leak proof on the sides and bottom. Sharps containers must not be more than 2/3 full. 21. Contaminated work surfaces will be disinfected with an approved disinfectant. Contaminated surfaces will be cleaned immediately when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials. 30. Soiled linen will be bagged at the site of use. handled as little as possible. 32. All linens will be recognized as potentially infectious and handled utilizing Standard Precautions. Contaminated sharps will be discarded immediately in puncture-resistant, leak proof and closable containers. The containers will be easily accessible and labeled with the biohazard legend.Record review of the facility's policy titled Fundamentals of infection Control Precautions, not dated, read in part: 1. Hand Hygiene- Hand hygiene continues to be the primary means of preventing the transmission of infection.Before and after performing any invasive procedure. After contact with a resident's mucous membranes and body fluids or excretions. After removing gloves or aprons; GlovingGloves are worn for three important reasons:1.To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. The wearing of gloves in specified circumstances reduce the risk of exposures to blood-borne pathogens and is mandatory for all employees. Gloves must be changed between resident contacts, and hands washed after gloves are removed. Wearing gloves does not replace the need for hand washing. Failure to change gloves between resident contacts is an infection control hazard.6. Resident care equipment and articles.1. Used sharps are never recapped and always placed in puncture-resistant containers.2. Puncture-resistant containers, or sharps, will be maintained at designated areas where needles and sharps are used for resident care. Sharps containers will be locked and changed out when they are 2/3 full. Sharps containers will not be filled to more than 2/3 full. Any resident care equipment/article that is visibly contaminated with blood or body fluids will be immediately cleaned with an approved disinfectant. 7. Linen and laundryAlthough soiled linen may be contaminated with pathogenic microorganisms. All soiled linen will be double bagged at the site that it was generated. All personnel will utilize appropriate personal protective equipment. 11. Preventing infections related to the use of specific devices. Consistent use of appropriate infection control measures when caring for residents with vascular access catheters reduces the risk for catheter-related infections use of appropriate PPE and hand hygiene during the care and treatment of residents with venous catheters.

Based on observation, interview, and record review the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated to prevent further potential while the investigation is in progress for 1 of 9 residents (Residents #3) reviewed for misappropriation. The facility failed to ensure the Administrator followed the facility's policy, by not completing an investigation, and reporting an allegation of misappropriation involving Resident #3. These failures could place residents at risk of not being provided services to meet their needs.Findings include:Record review of Resident #3's face sheet dated 04/22/2026, revealed the resident was an [AGE] year-old female with an original admission date of 01/18/2019 and a readmission date of 10/14/2020.Record review of Resident #3's History and Physical dated 01/22/2026 revealed the resident had diagnoses including dementia in other diseases classified elsewhere without behavioral disturbance (decline in memory and thinking abilities), schizophrenia, unspecified (mental disorder affecting perception, thoughts, and behavior), history of a brain hemangioma (abnormal collection of blood vessels in the brain) and seizure disorder (condition causing recurrent seizures).Record review of Resident #3's quarterly MDS dated [DATE] revealed under Section C (Cognitive Patterns) Resident #3 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of Section C revealed the resident was able to complete the BIMS, demonstrating intact memory recall and orientation. Review of Section B (Hearing, Speech, and Vision) revealed that the resident had clear speech, was understood by others, and demonstrated the ability to understand verbal communication. MDS section I for active diagnoses revealed Resident #3 had Non-Alzheimer's Dementia (type of dementia that are not caused by Alzheimer's disease, meaning a person has problems with memory, thinking, reasoning, or behavior severe enough to affect daily life), anxiety disorder (a mental health condition where a person experiences excessive worry, fear, nervousness, or panic that is stronger or lasts longer than normal everyday stress) and schizophrenia (a mental health disorder that affects how a person thinks, feels, behaves, and understands reality). Record review of Resident #3's care plan, last reviewed on 01/02/2026, revealed Resident #3 was diagnosed with major repression and called for staff intervention by monitoring the resident for signs of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints and tearfulness. Interventions included monitoring Resident #3 due to taking anti-anxiety medications which were associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looked like dementia.During an observation and interview on 04/20/2026 at 11:15 a.m., Resident #3 stated that money had been stolen from her purse but could not recall the exact amount or date the incident occurred. Resident #3 stated she routinely placed her handbag on top of the lamp located beside her bed. During the observation, Resident #3's handbag was observed on top of the lamp at the head of her bed. Resident #3 stated she had informed ADON B that money had been stolen from her purse and, sometime later, she was informed by an unidentified staff member from the front office that the facility would reimburse the missing money by depositing it into her resident account. Resident #3 stated she felt anxious and upset after discovering the money was missing.During an interview on 04/20/2026 at 11:57 a.m., ADON A stated that when allegations of misappropriation were reported, the resident was interviewed, the room was checked to verify the belongings were missing, and family members were contacted to determine whether they had removed any of the items or to ask if they knew the resident had spent money recently. ADON A stated the investigation process involved the nurse, ADON, DON, Administrator, and that allegations of this nature were believed to require documentation, investigation and reporting to the state. During an interview on 04/20/2026 at 11:59 a.m., CNA I stated that if a resident reported missing belongings or alleged misappropriation, she immediately reported the concern to the ADON and nursing staff. CNA I stated there had been an in-service regarding not touching resident belongings or searching through resident items. CNA I stated allegations involving missing money or belongings were believed to require investigation by the facility by asking residents if they knew anything about a missing item or money and that it was done by the abuse coordinator and upper management. During an interview on 04/21/2026 at 11:45 a.m., Resident #3's family member stated that during a visit with the resident, she informed him that money had been stolen from her purse. The family member stated he reported the allegation to the Administrator and was informed the resident would be reimbursed for the missing $60 through her resident account. The family member stated Resident #3 remained anxious during the period it took the facility to reimburse the missing money. During an interview on 04/21/2026 at 1:05 p.m., LVN J stated she informed ADON B regarding Resident #3's allegation that money had been stolen from her purse and that staff had searched for the money but were unable to locate it. LVN J stated ADON B informed her she would notify additional staff, possibly the social worker, although she was unsure. LVN J stated she was later informed the resident had been reimbursed for the missing money. LVN J stated allegations such as this were required to be investigated by the facility by asking residents if they had witnessed anything out of the ordinary and reporting to the state, although she did not know whether those steps had occurred. During an interview on 04/21/2026 at 1:51 p.m., the SW stated the allegation had been voiced directly to the BOM and an investigation had been initiated. The SW stated she spoke with the RP who reportedly was not concerned because Resident #3 occasionally became confused. The SW stated she discussed the missing money with Resident #3, who reportedly stated she was unsure whether she had misplaced or lost the $60. The SW stated she opened a grievance to ensure documentation of the concern and that the Administrator later took over the investigation. SW stated that based on the circumstances, she did not believe the resident had been exploited; however, she acknowledged allegations involving missing money were generally believed to require investigation and potential reporting to the state. During an interview on 04/21/2026 at 2:05 p.m., LVN F stated that in cases involving missing belongings or allegations of misappropriation, he would request assistance from another staff member or CNA to help search for the missing items. LVN F stated he would then notify the ADON and abuse coordinator regarding the allegation. LVN F stated upper management, including the Administrator, ADON, and DON, were responsible for following up on missing belongings, conducting the appropriate investigation, and ensuring the allegation was reported to the state when necessary. LVN F stated allegations of missing money or belongings were believed to require investigation and state reporting. During an interview on 04/22/2026 at 9:57 a.m., LVN G stated that if a resident approached him stating money had been stolen or was missing, he would immediately notify his supervisor to obtain direction regarding the next steps. LVN G stated he would assist the resident in attempting to locate the missing money and determine whether the resident had possessed the money. LVN G stated he would document the incident through an incident report and nurse's notes and understood the abuse coordinator and Administrator would need to conduct a full investigation. LVN G stated allegations involving missing money or belongings were believed to require investigation and possible reporting to the state if the money or item was not recovered. During an interview on 04/22/2026 at 10:00 a.m. with, the BOM stated Resident #3 informed her that $60 in cash had been stolen from her purse. The BOM stated she reported the allegation to the Administrator and was informed the social worker would initiate a grievance on behalf of Resident #3. The BOM stated she contacted a family member and learned other family members occasionally mailed cash to the resident. The BOM stated she reviewed the resident trust account and found no indication of being deposited or withdrawn funds related to the allegation. The BOM stated allegations involving missing money required investigation by the abuse coordinator and possible reporting to the state. During an interview on 04/22/2026 at 11:25 a.m., ADON B stated LVN J informed her that Resident #3 alleged someone had stolen $60 in cash from her purse. ADON B stated that she informed the Administrator regarding the allegation. ADON B stated she spoke with Resident #3's representative and explained the resident would be reimbursed using fundraising money from the facility. ADON B stated that the Administrator served as the abuse coordinator and assumed responsibility for the investigation after receiving the allegation. ADON B stated allegations involving stolen money should have been investigated through interviews with residents and staff and should have been reported to the state. During an interview on 04/22/2026 at 12:31 p.m., the Administrator stated she received the report regarding the missing money and spoke with Resident #3, who reportedly tended to forget locations, details, and amounts. The Administrator stated Resident #3 provided varying information regarding the amount of missing money and changed portions of her account of the incident. The Administrator stated Resident #3 did not inform her that someone had stolen the money and instead reported she had misplaced it. The Administrator stated she would have conducted a full investigation and reported the allegation to the state if Resident #3 had specifically alleged theft by another individual. The Administrator stated she did not document an investigation and did not ask residents or staff whether they had found any money. The Administrator stated the matter had only been treated as a grievance, and she did not believe it required investigation or reporting to the state.Record review of the facility's policy titled Nursing Policy and Procedure Manual, Abuse/Neglect, revised on 03/29/2018 read in part: The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.9.Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.E. Reporting:1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19.F. Investigation Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated.1. The administrator in consultation with Risk Management Department will be responsible for investigating and reporting cases to the HHSC. 2. After receipt of the allegation the Abuse Preventionist and administrator in conjunction with Risk Management will immediately evaluate the resident's situation using the criteria as stated in this policy. Determination will be made for required reporting to HHSC per reporting guidelines found in Provider letter 19-17. 6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s). A copy of the written report will accompany any personnel action deemed necessary. If a personnel action occurs, a copy of all pertinent documents will be placed in the employee's personnel file.7. The facility will report and cooperate with any and all investigations concerning reports of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source by the company's employees as set forth in state law (including to the state survey and certification agency).

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 2 of 2 residents (Residents #1 and #2) reviewed for records.The facility failed to provide an accurate report to HHSC on self-reportable incidents.This deficient practice could place residents at risk of not having accurate documentation and put residents at risk for further incidents of abuse or neglect.Findings include:Record review of Resident #1's face sheet, dated 02/03/2026, revealed an [AGE] year-old female with initial admission date of 11/14/25 and re-admission date of 12/20/25.Record review of Resident #1's health and physical, dated 12/30/25, revealed a medical history of: Hypertension (high blood pressure) and Dementia (a term used to describe a group of systems affecting memory, thinking, and social abilities).Record review of Resident #1's Prospective Payment System MDS, dated [DATE], revealed a BIMS of 7, which indicated severe cognitive impairment.Record review of Resident #1's Event note dated 12/25/25 noted Resident #1 was observed with swelling to her ankle, and Resident #1 denied pain. Physician and Responsible Party were notified per Event note.Record review of Resident #1's Trauma Informed PRN assessment dated [DATE] noted no negative findings.Record review of Resident #2 face sheet dated 02/03/26 revealed an [AGE] year-old female resident with initial admission date 05/08/25 and re-admission date 09/10/25.Record review of Resident #2's health and physical, dated 02/03/26, revealed a medical history of: Type 2 Diabetes Mellitus (a chronic condition that is characterized by high levels of sugar in the blood), Cerebrovascular Disease (a term used for conditions that disrupt blood flow to the brain, such as a stroke, which can cause brain damage), Anoxic Brain Damage (occurs when the brain is deprived from oxygen leading to potential permanent brain injury), and Sarcopenia (age-related loss of muscle mass and strength).Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #2 was unable to participate in BIMS.Record review of Provider Investigation Report for incident intakes did not include detailed information such as interviews conducted, what documentation was reviewed, or what interventions the facility took to correct or prevent further incidents. This included the following separate intakes involving Residents #1 and #2.In an interview on 02/04/26 at 10:48 AM with the DON, he stated Resident #1 had interventions implemented and included in the care plan after Resident #1's fall on 12/25/25, which included pain medication management, therapy evaluation, and compression to Resident #1's ankle. He stated the Physician and family were notified after Resident's #1's fall, and then again on 01/22/26 after swelling was observed and reported to nursing staff. He stated the nursing staff, which included CNA's and Nurses, the resident, and Therapy staff were interviewed as part of the facility's investigation. He stated the Administrator was to speak immediately with the resident during an incident, and the Social Worker completed the Trauma Informed Assessment on the resident. He stated the Social Worker would also did random audit checks for ANE with the residents, especially in the hall where the incident or allegation took place. He stated as the DON he also interviewed and trained staff on ANE. The DON stated staff were to complete an incident report after being made aware of an incident or allegation, which would be supporting documentation for the extent of the incident and cause. He stated it also included the Event Note and the progress notes in the resident's chart. He stated himself as the DON, and the Administrator were responsible for completing the Provider Investigation Report, and the Administrator reviewed it before finalizing and sending it to HHSC. The DON stated the Provider Investigation Report was vague and not detailed. He stated the documentation did not show the interventions discussed.In an interview on 02/05/26 at 4:04 PM with the Administrator, she stated Resident #1 did not complain of pain when the ankle fracture was discovered on 01/22/26, and it was the CNA's who reported an observation of swelling to the nurses. She stated the CNAs were showering Resident #1 when the observation was made. She stated Resident #1 was bed bound, so the day the ankle fracture was most likely in bed that day. She stated there were no changes in behavior before the fracture was discovered. The Administrator stated she had a history of falls and had a fall during her stay in the facility. She stated she was unable to recall what interventions Resident #1 had in place for the fall prevention. She stated the Physician and Responsible Party were notified for both incidents via phone. She stated the Physician ordered an X-ray on 01/22/26, which showed the fracture and Resident #1 was referred to her Orthopedist. She stated the residents and staff were interviewed as part of the investigation conducted by the facility. She stated the facility investigations also included identifying the time frame of the incident, changes in behaviors, and staff that worked the shift the incident took place. She stated ANE was determined by interviewing the resident, getting witness statements, and other interviews, taking pictures if applicable, and reviewing documentation such as progress notes. The Administrator stated Resident #1 was unable to answer questions due to her Dementia. She stated the DON was responsible for interviewing staff. The Administrator stated supporting documentation would include lab results, patient history, and progress notes. The Administrator stated she did not document her investigation into the residents' charts or in the report; she stated she had a personal notebook where she documented her investigations and findings. She stated she understood that documentation not included in residents' charts would cause the possible risk for stopping continuity of care to the residents, and staff would not be aware of what occurred. She stated the documentation provided to HHSC, which included the Provider Investigation report, was not complete or detailed. She stated it didn't include the interventions the facility took noted in the documentation. She stated she was responsible for completing the Provider Investigation report as the Administrator. She stated self as the Administrator and the DON reviewed documentation before finalizing and sending documentation to HHSC.Record review of the facility's, undated, policy Abuse, Neglect, Exploitation, read in part: F. Investigation- Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. and continued to read, 3. A report to the appropriate agency will include the following: E. The nature and extent of any injuries resulting from the suspected abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injury of unknown source. F. The nursing facility will make an addendum to any reportable incident in its report to HHSC if the resident subsequently experiences a negative outcome. G. Other pertinent information is available. The written report must be sent to HHSC . Lastly, it read, 6. The Abuse Preventionist and/or administrator will conduct a thorough investigation of the incident(s). A copy of the written report will accompany any personal action deemed necessary. Record review of the Texas Health and Human Services Commission document, Long-Term Care Regulation Provider Letter, undated, read in part under 2.0 Policy Details & Provider Responsibilties: A provider must: ensure a thorough investigation is conducted and documented in the PIR .

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Residents #1) reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #1 to address the fall that occurred in the facility on 12/25/25.This failure could place residents at risk for not receiving care and services to meet their needs.Findings Include:Record review of Resident #1's face-sheet, dated 02/03/2026, revealed an [AGE] year-old female with initial admission date of 11/14/25 and re-admission date 12/20/25.Record review of Resident #1's health and physical, dated 12/30/25, revealed a medical history of: Hypertension (high blood pressure) and Dementia (a term used to describe a group of systems affecting memory, thinking, and social abilities).Record review of Resident #1's Prospective Payment System MDS, dated [DATE], revealed a BIMS of 7, which indicated severe cognitive impairment.Record review of Resident #1's care plan, with revision date 01/30/26, revealed Resident #1's fall was not included. Resident #1's care plan noted she was a risk for falls related to impaired mobility included interventions for staff: anticipate and meet resident's needs; be sure the call light within reach and encourage resident to use it for assistance needed; and educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. In an observation on 02/03/26 at 09:05 AM, Resident #1 was in her bed with the bed in the lowest position with call light within reach. Resident #1 did not answer this State Surveyor when asked if she would answer questions regarding the Nursing Facility's care or services.In an interview on 02/04/26 at 09:54 AM with the MDS nurse, she stated Resident #1's fall that occurred in the facility should have been included in the care plan. She stated a fall would be considered a change of condition and would need to be updated and added to the resident's care plan. She stated care plans were individualized to the resident and were to make staff aware of the resident's history and how to provide care for that resident. She stated the ADON's were responsible for making acute changes to the resident's care plan. She stated MDS monitored residents' care plans quarterly, or as needed for significant changes which she would be responsible for updating the care plan at that time. The MDS nurse stated the possible risk to Resident #1 not having their fall included in the care plan could increase risks for future falls.In an interview on 02/04/26 at 10:55 AM with the DON, he stated Resident #1's fall was considered a change of condition that should have been included in the resident's care plan. He stated the nursing department, nurses, were responsible for monitoring the care plan and were to update it for acute changes such as Resident #1's fall. The DON stated MDS nursing were to review resident care plans quarterly, but they monitored daily. He stated the possible risk for Resident #1's fall not being on the care plan included risk for future falls and injuries to the resident. The DON stated Resident #1's fall was to be updated to the resident's care plan to address the fall that Resident #1 had on 12/25/25. He stated it was to prevent the risk for future falls and have staff aware of Resident #1's history.In an interview on 02/05/26 at 4:10 PM with the Administrator, she stated the care plan painted a picture of the residents' needs. She stated it provided information to all facility staff regarding the residents' care. She stated MDS nursing monitored care plans overall, which were reviewed quarterly. She stated if there was a change of condition, the care plan was to be updated immediately by the nursing staff. The Administrator stated the risk of not including Resident #1's fall included the resident having additional falls.Record review of the facility's, undated, policy Comprehensive Care Planning, read in part: The facility will develop and implement a comprehensive care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. It also read, The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #2) reviewed for transmission-based precautions.The facility failed to ensure the Wound Care RN provided wound care per facility policy on 02/04/26.This deficient practice could place residents at risk of exposing them to care that could lead to the spread of infections.Findings include:Record review of Resident #2 face sheet, dated 02/03/26, revealed an [AGE] year-old female with an initial admission date of 05/08/25 and re-admission date 09/10/25.Record review of Resident #2's health and physical, dated 02/03/26, revealed a medical history of: Type 2 Diabetes Mellitus (a chronic condition that is characterized by high levels of sugar in the blood), Cerebrovascular Disease (a term used for conditions that disrupt blood flow to the brain, such as a stroke, which can cause brain damage), Anoxic Brain Damage (occurs when the brain is deprived from oxygen leading to potential permanent brain injury), and Sarcopenia (age-related loss of muscle mass and strength).Record review of Resident #2's MDS revealed Resident #2 was unable to participate in the BIMS. Section M- Skin Conditions notated Resident #2 had pressure ulcers and Skin Treatments included Wound Care.Record review of Resident #2'sphysician order, dated 02/03/26, notated: Stage 4 Pressure Wound of the Left Buttock required Daily and PRN wound care; Stage 4 Pressure Wound of the Right Buttock required Daily and PRN wound care; and Stage 4 Pressure Wound of the Sacrum required Daily and PRN wound care.Record review of Resident #2's Wound Care progress note, dated 02/03/26, revealed all wound sites were observed and noted to be healing as evidenced by decreased depth of wounds, with no signs of infection noted.Record review of Resident #2's care plan, with revision date 02/04/26, revealed Resident #2 had pressure ulcers or potential for pressure ulcer: Stage 4 pressure wound to Right Buttock; Stage 4 pressure wound to Left Buttock; and Stage 4 pressure wound to Sacrum. Interventions for facility staff included Administering Arginaid as ordered.In an observation on 02/04/26 at 09:44 AM of Resident #2 revealed he was in his bed. Resident #2 was unable to answer questions due to his medical condition.In an observation and interview on 02/04/26 at 09:46 AM revealed Wound Care RN provided Resident #2 with wound care. Resident #2's left buttock and right buttock were observed. Resident #2's Left and Right Buttock's wound was observed; each wound was approximately 0.5 inch in length and width. No redness or swelling observed on either wound. The Wound Care RN stated wound care was ordered daily and as needed for Resident #2 and she observed an improvement in his healing on all sites. The Wound Care RN was observed applying powder medication, Arginaid which was a powder-form nutritional supplement designed to support wound healing, on Resident #2's Right and Left Buttock. The Arginaid powder applied onto Resident #2's Right and Left Buttock wound, and then the powder medication was observed to spill from the wound during wound care, onto Resident #2's brief. The Wound Care RN then secured the brief on Resident #2, with the medication opened and spill still on the brief.In an interview on 02/05/26 at 3:15 PM with the DON, he stated Wound Care nurses were responsible for ensuring to provide wound care per facility policy. He stated as the DON, he was responsible for monitoring wound progress notes, which was done weekly. He stated it was not acceptable for the Wound Care RN to not change the brief with contaminated powder medication. He stated the possible risks of leaving a brief on Resident #2 with the contaminated spilled medication on the brief could include possible infection or illness to the resident, as it could also infect the other wounds Resident #2 had.Record review of facility's, undated, policy Wound Treatment Management, read in part: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. It continued 1. Wound treatments will be provided in accordance with physician orders . 3. Dressing changes may be provided outside the frequency paramaters in certain sitiuations: a. Feces has seeped underneath the dressing. B. the dressing dislodged. C. the dressing is soiled or otherwise is wet.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent with bowel and bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #1 and Resident #2) of 4 residents reviewed for incontinence care. - The facility failed to ensure Resident #1's and Resident #2's foley catheter drainage tubes were secured with Catheter Holder prior to turning & repositioning the residents in bed. - The facility failed to ensure CNA B provided perineal care according to facility policy and procedure for Resident #1 when she failed to clean the perineal area from front to back when providing perineal care on 12/18/25. These failures placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter. Findings included:Resident #1Record review of Resident #1's admission Record revealed Original admission Date 05/28/25 and re-admission Date 09/10/25. Record review of Resident #1's History & Physical dated 11/17/25 revealed [AGE] year-old female with past medical history of CKD 3 (kidneys have moderate damage and are not filtering waste and extra fluid as well as they should) change position every two hours, keep area dry with foley (a device that drains urine from the bladder into a collection bag outside of the body when a person cannot urinate on their own or for various medical reasons).Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed reentry date 09/10/25. Section B - B0100. Persistent vegetative state/no discernible consciousness. Section: GG0115 - Functional Limitation in Range of Motion impairment on both sides of upper and lower extremities. Section GG - GG0130. Dependent with toileting hygiene. Indwelling catheter and incontinent of bowel. Review of Resident #1's Care Plan dated 12/15/25 revealed resident was incontinent of bowel. Goal: The resident will not have any complications r/t bowel incontinence. Interventions: Provide perineal care after each incontinent episode. Resident #1 has an ADL Self-Care performance deficit: Toilet use: requires staff x 2 for assistance. The Care plan did not address Resident#1 had a foley catheter. Review of Physician's Order Summary for Resident #1 revealed, Order Date: 10/17/25 Urinary Catheter using 16 FR (the size of the tube)/10 ml bulb to gravity drainage every shift related to neuromuscular dysfunction of bladder (a nerve damage from injury or disease that the signals between your brain and bladder muscles to be interrupted, making it hard to hold or release urine, causing incontinence, sudden urges, or inability to empty fully), Provide catheter care every shift. During an observation and interview on 12/18/25 at 1:07 PM with RN A Treatment Nurse and CNA B, revealed Resident #1 had an EBP sign posted on the wall by the entrance to the resident's room. Upon entering the room, the nurse and CNA washed their hands and put on a gown and gloves. The resident was asleep in bed, lying on her back. Resident's indwelling catheter was draining light yellow urine, and the drainage bag was hanging from the bed frame and was stored in a dignity bag. It was observed that the Catheter Holder was loose and hanging on the catheter tubing. The tube feeding was turned off and the CNA lowered the HOB. When CNA B released the tabs on the side of the disposable brief, it was observed that the wound dressing on the sacral area was intact and had loose fecal matter on the edges of the dressing. It was observed that the brief was saturated with loose brown stool covering the pubis area (the rounded, fatty mound above the genital that gets pubic hair) and buttocks. The RN and CNA placed a disposable pad under the resident. The brief was rolled down towards the rectal area and the CNA started to clean the resident with pre-moistened cleaning wipes from back to front with the cleaning wipes that were full of loose stool. She again cleaned the resident's pubis area using clean wipes and again cleaned the resident from back to front. The RN assisted the CNA to turn the resident to the left side and continued to clean the buttocks, rectal area and inner thighs with cleaning wipes. The CNA used multiple clean wipes after each stroke to clean the resident, until the resident was clean for the treatment nurse to proceed with wound care. The CNA said, The Catheter Holder comes off when the residents are showered or when cream is applied. I will let the nurse know that the Catheter Holder needs to be replaced.During An interview on 12/18/25 at 1:36 PM CNA B revealed she had been trained in providing Perineal Care to incontinent residents. She said she was trained to wipe the female residents working from front to back, using pre-moistened cleansing wipes to protect the small opening at the tip of the urethra and the vaginal opening from fecal matter to prevent cross contamination and infection; clean the inner thigh with cleaning wipes, and if a resident has a foley catheter to clean the catheter tubing with clean pre-moistened wipes. She said they had been trained to make sure the foley catheter tubing was placed in the Catheter Holder located on the top part of the inner thigh to prevent injury to the urethra when moving the resident in bed. She said they had been trained to immediately report to the nurses when the Catheter Holder fell off, so the nurses can reapply the Catheter Holder as soon as possible to prevent injury to the residents.During an interview on 12/18/25 at 1:45 PM CNA C revealed CNAs had been trained to immediately report to the nurses when the Catheter Holder fell off the inner thigh, so the nurses could reapply the Catheter Holder as soon as possible to prevent injury to the residents. She said they had been trained on perineal care and should wipe a female resident from front to back to prevent cross contamination of the urethra and vaginal area to prevent urinary tract infections. During an interview on 12/18/25 at 1:49 PM LVN Charge Nurse D on the 400 Hall assigned to Resident #1 revealed, she was in a vegetative state, did not respond to verbal or painful stimuli, required total assistance of two persons with Activities of Daily Living, had an indwelling catheter, and was incontinent of bowel. He said CNAs had been trained on how to provide incontinent care and should always clean the female residents from front to back to prevent fecal matter from getting on the urethra and vagina to prevent cross contamination that could result in urinary tract infections. He said that residents that had an indwelling catheter must always have a Catheter Holder on the inner thigh to prevent pulling and putting pressure on their urethra when the residents are turned and repositioned in bed. He said the Catheter Holders frequently fall off and do not stay in place when the residents are showered or when lotion is applied and should be replaced right away to prevent injury to the residents. He said the CNAs had been trained to immediately report to the nurses when the Catheter Holder falls off the inner thigh. He said that failure to place the catheter in the Catheter Holder could result in trauma to the urethra and cause injury and bleeding. During an interview and observation on 12/19/25 at 9:06 AM, CNA R, in the presence of RN G Regional Compliance Nurse, had repositioned Resident #1 on her back at 8:30 AM, after she showered the resident. It was observed that the resident's Catheter Holder had come loose and was hanging from the catheter drainage tube. CNA R said the Catheter Holders come off when the residents are showered or when lotion is applied. She said they had been trained to immediately report to the nurses if the Catheter Holder falls off the resident's inner thigh. She said that failure to keep the catheter tubing in the Catheter Holder, placed the resident at risk of trauma to the urethra when the resident was moved in bed. She said, I will notify the nurse right away. During an interview on 12/19/25 at 9:51 AM DON revealed the CNAs had been trained on perineal care and were trained to clean the female resident from front to back to prevent contamination of the urethral area that could result in urinary tract infections. He said licensed staff and CNAs had been trained on using Catheter Holders on all residents that had foley catheters to prevent trauma to the urethra and bleeding. He said the Catheter Holder should immediately be replaced by the licensed staff when the Catheter Holder becomes detached. During an interview on 12/19/25 at 2:06 PM RN N revealed the CNAs had been trained on perineal care and were trained to clean the female resident from front to back to prevent contamination of the urethral area that could result in urinary tract infections. She said CNAs had been trained in using Catheter Holders on all residents that had foley catheters to prevent trauma to the urethra and bleeding. She said the Catheter Holder should immediately be replaced by the licensed staff when the Catheter Holder becomes detached. Resident #2 Record review of Resident #2's admission Record revealed Original admission Date 05/10/25 and re-admission Date 12/11/25. Record review of Resident #2's History & Physical dated 12/15/25 revealed [AGE] year-old male with past medical history of chronic indwelling catheter and history of ESBL in urine (urinary tract infection caused by a bacteria that produce an enzyme resistant to many common antibiotics). Record review of Resident #2's admission MDS assessment dated [DATE] revealed reentry date 11/10/25. No speech. Indwelling catheter. Always incontinent of bowel. Stage 3 pressure ulcer present on admission. Review of Resident #2's Care Plan dated 11/30/25 revealed Resident was incontinent of bowel. Intervention: Provide perineal care after each incontinent episode. Resident has neuromuscular dysfunction of and has an indwelling foley catheter. Interventions: Ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra. Monitor/document pain/discomfort due to catheter. Review of Physician's Order Summary for Resident #2 revealed, Order Date: 10/17/25 Urinary Catheter using 16 FR/5 ml bulb to gravity drainage every shift related to neuromuscular dysfunction of bladder. Provide catheter care every shift. Ensure catheter strap in place and holding, every shift. Change as needed. During an observation and interview on 12/19/25 at 6:54 AM - 7:13 AM, with RN A Treatment Nurse and CNA B, an EBP sign was posted on the wall in the hallway by the entrance to Resident #2's room. Upon entering the room, the Treatment Nurse and CNA washed hands and put on an isolation gown and gloves. Resident #2 was lying in bed awake, turned to his left side, and he was on an air pressure mattress. It was observed that resident had a disposable brief soiled with loose feces, and there was a wound dressing on the sacral area that was intact and was clean. The resident had an indwelling catheter, draining light yellow urine. It was observed that the Catheter Holder was not attached to the skin on the inner thigh and was hanging from the catheter drainage tube. The CNA said the Catheter Holder detached easily when they move the residents in bed, or when they bathe and apply lotion.During an observation and interview on 12/19/25 at 9:14 AM with CNA B, Resident #2 had a bowel movement and she needed to change the brief and needed to get another CNA to help her turn the resident. Upon entering the room, both CNAs washed their hands, put on isolation gowns and gloves. The resident was turned towards the window on his left side, using the bed sheets to move the resident. It was observed that the brief had loose stool, and the resident was cleaned with pre-moistened cleaning wipes. It was observed that the resident's Catheter Holder on the right thigh was not attached to the thigh. CNA B stated she would tell the nurse that the Catheter Strap was detached and needed to be replaced as soon as they finished changing the resident. During an observation and interview on 12/19/25 at 9:19 AM with LVN D Charge Nurse assigned to Resident #2, the resident had been showered that morning and the Catheter Holder had been replaced after the shower. He said the CNAs had been trained to notify the nurse when the Catheter Holder comes off, so a new one can be reapplied, right away to prevent trauma to the urethra by pulling on the catheter and causing bleeding. He said, the CNA had not reported to him that the Catheter Holder had become loose after the resident was placed in bed. He said he would go and re-apply another Catheter Holder. Review of facility's undated Catheter Insertion Policy & Procedure provided by DON on 12/19/25 revealed, Female and male catheterization is the insertion of a catheter into the urinary bladder via the urethra to drain the bladder of urine. Procedure documented in part: Gently tug on the catheter to ensure a proper and secure placement in the urinary bladder. Connect the catheter end to closed drainage system. Place the catheter over the leg and position to not put pressure on urethra. The surveyor requested a policy and procedure on catheter care on 12/19/25 at 9:43 AM. The DON did not provide the policy prior to exit. Review of facility's on Perineal Care effective 05/11/25 provided by DON on 12/19/25 revealed, Purpose: This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. Procedure: Wipe across the pubis area. Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area-CLEAN to DIRTY! Female resident: Working from front to back, wipe one side of the labia majora, the outside folds of perineal skin that protects the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. If applicable, gently wash the juncture of the Foley catheter tubing from the urethra down the catheter about 3 inches. Then wipe the other side. Use a clean area of the washcloth or pre-moistened wipes for each stroke. Reposition the resident to their side. Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area.

Based on interview and record review, the facility failed to ensure the discharge needs of each resident are identified and the discharge planning process results in the development of a discharge plan for each resident for 1 (Resident #1) of 4 residents reviewed for discharge planning. The facility failed to develop a discharge plan when Resident #1 was issued a 30-Day Discharge Notice on 11/26/25 due to non-payment. This failure could result in residents experiencing psychosocial harm due to inappropriate discharges and placed residents at risk of being discharged without alternate placement and not having access to available advocacy services, discharge/transfer options, and denying them their rights in the appeal process. Findings included:Record review of Resident #1's admission Record revealed Original admission Date 05/28/25 and re-admission Date 09/10/25. Record review of Resident #1's History & Physical dated 11/17/25 revealed [AGE] year-old female with past medical history of CAD (heart's arteries get clogged with plaque, making them narrow and stiff, so they cannot deliver enough oxygen-rich blood to your heart muscle), DM (a condition where the body has too much sugar in the blood because it does not make enough insulin or cannot use it well), heart failure (the heart muscle becomes weak, stiff, or enlarged, causing blood to back up and fluid to build in the lungs and limbs), COPD (progressive lung disease that makes breathing difficult due to damaged airways and air sacs, causing inflammation, extra mucus, and air flow obstruction), PVD (circulation problem where narrowed or blocked blood vessels outside your heart and brain reduce blood flow to your limbs and organs due to plaque buildup), HTN (when the force of blood pushing against the artery wall is consistently too high, making the heart work harder and straining blood vessels, which increases the risk of heart attack and stroke), prior CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), CKD 3 (kidneys have moderate damage and are not filtering waste and extra fluid as well as they should) , anoxic encephalopathy (is a severe brain injury from a complete lack of oxygen, causing brain cells to die rapidly), who underwent cardiac arrest. Unable to be extubated (removal of breathing tube from the throat and windpipe after being on a ventilator to help with breathing and remains ventilator dependent), tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to bypass a blocked airway, to help with breathing, or remove secretions, providing a direct path for oxygen to the lungs), dysphagia (difficulty swallowing), and peg placement (feeding tube placed directly through the stomach to deliver food, liquids, and medicine). Pt. is bedbound. Stage IV sacral wound, stage IV to left buttocks and right buttocks. Air mattress, change position every two hours, keep area dry with foley (a device that drains urine from the bladder into a collection bag outside of the body when a person cannot urinate on their own or for various medical reasons), Provide heel protectors while in bed. Wound care to evaluate and treat. Interface with nutritional/dietary services. Resident does not follow commands, does not blink to threat, no purposeful movements seen. Social Services for discharge. The resident's family members desire the use of all life-sustaining measures, including, but not limited to cardiopulmonary resuscitation, intubation (a flexible breathing tube placed through the mouth or nose, down into the windpipe to keep the airway open, allowing a machine to help the person breath, deliver oxygen, or remove blockages), use of mechanical ventilation, and use of pressors (are powerful medicines used in emergencies to rapidly raise dangerously low blood pressure by squeezing blood vessels and making the heart beat stronger), We will therefore monitor progress and adjust treatment plan as clinical conditions change. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed reentry date 09/10/25. Section B - B0100. Persistent vegetative state/no discernible consciousness. Section: GG0115 - Functional Limitation in Range of Motion impairment on both sides of upper and lower extremities. Section GG - GG0130. Dependent with toileting hygiene. Indwelling catheter and incontinent of bowel. Active Diagnoses: CAD, heart failure, hypertension, PVD, DM, CVA, COPD, persistent vegetative state (person is awake, eyes opened, sleep-wake cycles, but has lost the ability to think, be aware of themselves or their surroundings, or respond to commands, even though the basic life functions work due to an intact brainstem) , anoxic brain damage (the brain is completely deprived of oxygen, resulting in significant cognitive, physical, and emotional deficits, potentially causing coma or death). Section Q: Family participated in assessment and goal setting. Q0310. Resident's Overall Goal was left blank. Q0400. Discharge Plan. Is active discharge planning already occurring for the resident to return to the community? No. Q0610, Referral. Has a referral been made to the Local Contact Agency? No. Q0620. Reason Referral to Local Contact Agency (LCA) not made code 3 Referral not wanted. Review of Resident #1's admission Agreement dated 05/28/25 revealed family member was designated as resident's responsible party. Authority: Resident authorizes Responsible Party to make: Financial decisions. Admission, care and discharge decisions. Other decisions related to Resident's personal property and well-being. Primary contact for this Resident. Obligations of Resident/Responsible Party. Responsible Party means a person who: has legal access to the resident's income or resources available to pay for nursing facility care; and has signed an admission agreement or other contract with the facility in which the person agrees to provide payment for the resident's facility care from the resident's income or resources. Financial Agreement: If Resident will not be managing her own financial resources, she may designate a Responsible Party with authority to manage Resident's financial resources and pay for goods and services provided by Health Care Center from Resident's funds. Resident and/or Responsible Party agree to pay for all charges for goods and services provided to Resident pursuant to Health Care Center admission and Financial Agreement, including basic charges and all additional charges for ancillary goods and services requested by Resident and/or Responsible Party. The admission Agreement was signed by responsible party on 05/28/2025. Review of Resident #1's email sent to resident's responsible party on 11/26/25 revealed, Resident #1 would be discharged from the facility on 12/26/25. This discharge is based on your failure, after reasonable and appropriate notice, to pay for provided services and your stay at this facility. The facility staff will work with you to make preparations needed to ensure a safe and orderly transition. An orientation for discharge planning will be held on 12/05/2025. If there is a conflict with this date, we will be happy to reschedule to a mutually agreeable time prior to the date of discharge. Resident #1 will be discharged to the following address: TO BE DETERMINED DURING DISCHARGE PLANNING. You have the right to appeal this decision as outlined in the Health & Human Services Commission's Fair Hearing, Fraud and Civil Rights Handbook. Requests must be made within 90 days. A copy of this letter was sent to the local Ombudsman. Review of Resident #1's Care Plan dated 12/15/25 revealed Discharge Care Plan had not been initiated when Discharge Notice was issued on 11/26/25 due to non-payment of applied income. Review of Report Summary sent to APS on 12/19/25 to report an allegation of exploitation for Resident #1 revealed the resident's daughter was refusing to pay the applied income and using her money for possible financial exploitation. The resident's responsible party is using resident's resources to pay for utilities in the community, home insurance, car payments and loans.Telephone call was placed to resident's responsible party on 12/18/25, no answer. Left message to call the surveyor back. Responsible Party did not return call prior to exit. During an interview on 12/18/25 at 12:28 PM DON reported they have not had a Social Worker since December 11, 2025. He said the Social Worker was responsible for initiating Discharge Plans as soon as possible once they knew that the resident was going to be discharged . He said he and the ADONs were helping with handling Discharge Planning until they hired a social worker. During an interview on 12/18/25 at 3:45 PM Administrator revealed Social Worker S's last day was 11/14/25. She said they had hired new Social Worker T, on 11/24/25 and Social Worker T was terminated on 12/11/25. She said she was in the process of interviewing to hire a new social worker. She said the DON and ADONs were helping with handling Discharge Planning. She said the discharge notice was issued due to non-payment of applied income. She said they were waiting for the 30 days from the date that the discharge notice was issued, to file a complaint with APS for exploitation by resident's responsible party who was not paying the applied income for several months. The Administrator stated they had not started a Discharge Plan when the Discharge Notice was issued to the resident's responsible party on 11/26/25. She said the resident's family had made no attempts to contact the family regarding discharge notice. She said she did not know why the facility had not conducted the orientation for discharge planning as scheduled for 12/05/25. She said, since the responsible party has not made plans for discharge. The resident will have to stay at the facility until the family makes plan for a safe discharge, since the resident is on mechanical ventilation and tracheostomy.During an interview on 12/19/25 at 10:15 AM, RN J MDS Nurse and LVN L MDS Nurse revealed Resident #1 was in a permanent vegetative state, did not respond to verbal and/or painful stimuli, was on mechanical ventilation/tracheostomy, enteral feeding via G-tube, had multiple stage VI pressure ulcers that were present upon admission to the facility and a DTI on left heel. LVN L MDS Nurse said the Social Worker was responsible for initiating the interdisciplinary discharge plan to ensure resident's needs would be met after discharge from the facility. She said the facility had not initiated a Discharge Plan for Resident #1 when the facility had issued the Notice of discharge on [DATE]. During an interview on 12/19/25 at 2:33 PM, Business Office Manager Q revealed Resident #1's family member who was the responsible party had been assigned Representative Payee a few months ago and she was not paying the facility the applied income amount of $2,191.17 a month and currently owed the facility $7257.35. She said the responsible party had only made an $800.00 payment. She said that was why they had issued 30 day Discharge Notice on 11/26/25. She said she had been calling the resident's responsible party, and she did not answer the telephone calls. She said she had emailed the resident's responsible party the online payment link on 10/01/2025 and she still had not made any payments to the facility. During an interview on 12/19/25 at 2:40 PM the Administrator revealed she did not know if Social Worker T had developed a Discharge Plan for Resident #1 when the facility issued a Notice of discharge on [DATE] to the resident's responsible party. She said the BOM, and the DON had been dealing with the family because they did not have a Social Worker. She said multiple attempts had been made by the BOM to reach the responsible party by telephone and she had not returned any of the calls. She said they had not attempted using any other type of means to contact the responsible party to assist her in developing a Discharge Plan. During an interview on 12/19/25 at 3:54 PM, the Administrator, DON, and Business Manager Q revealed that a Discharge Plan had not been completed for Resident #1 when they issued a Discharge Notice on 11/26/25 to the Resident's responsible party. The BOM said she had placed several telephone calls and had not been able to contact the resident's responsible party by telephone, and they had not attempted any other means to reach the responsible party to see what type of arrangements they were making to transfer the resident who was on mechanical ventilation/tracheostomy and was in a permanent vegetative state. The BOM said they were planning on calling in a complaint to APS for exploitation but were waiting until the last day of the 30-day discharge notice to file the report.During an interview and record review of Care Plan Conference Notes on 12/19/25 at 4:03 PM, LVN L MDS Nurse revealed Social Worker T had not written Care Plan Conference notes for 12/10/25, because she had quit without notice on 12/11/25. LVN L MDS Nurse said the care plan did not have a Discharge Plan. She said she did not know why the facility had not conducted the orientation for discharge planning as scheduled for 12/05/25. Review of facility's undated policy and procedure on Discharge Planning Process Policy provided by the Administrator on 12/19/25 at 4:41 PM, revealed Nursing Facility must complete discharge planning when you anticipate discharging a resident to a private residence, another Nursing Facility or Skilled Nursing Facility, or another type of residential facility. Discharge Planning includes: Assessing the resident's continuing care needs, including: Consideration of the resident's and family/caregiver's preferences for care; How services will be accessed; and How care should be coordinated among multiple caregivers, as applicable; Include regular re-evaluations of the resident to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed to reflect these changes. Assisting the resident and family/caregivers in locating and coordinating post-discharge services. Refer to Section Q of the RAI manual.

Based on interviews and record review the facility failed to ensure a facility with more than 120 beds employed a qualified social worker on a full-time basis. The facility failed to have a full-time social worker since 12/11/25, to address Grievances and complete Discharge Plans. This failure put facility residents at risk of not having their psychosocial or discharge planning needs met. Findings included:Record review of Resident #1's admission Record revealed Original admission Date 05/28/25 and re-admission Date 09/10/25. Record review of Resident #1's History & Physical dated 11/17/25 revealed [AGE] year-old female with past medical history of CAD (heart's arteries get clogged with plaque, making them narrow and stiff, so they cannot deliver enough oxygen-rich blood to your heart muscle), DM (a condition where the body has too much sugar in the blood because it does not make enough insulin or cannot use it well), heart failure (the heart muscle becomes weak, stiff, or enlarged, causing blood to back up and fluid to build in the lungs and limbs), COPD (progressive lung disease that makes breathing difficult due to damaged airways and air sacs, causing inflammation, extra mucus, and air flow obstruction), PVD (circulation problem where narrowed or blocked blood vessels outside your heart and brain reduce blood flow to your limbs and organs due to plaque buildup), HTN (when the force of blood pushing against the artery wall is consistently too high, making the heart work harder and straining blood vessels, which increases the risk of heart attack and stroke), prior CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die), CKD 3 (kidneys have moderate damage and are not filtering waste and extra fluid as well as they should) , anoxic encephalopathy (is a severe brain injury from a complete lack of oxygen, causing brain cells to die rapidly), who underwent cardiac arrest. Unable to be extubated (removal of breathing tube from the throat and windpipe after being on a ventilator to help with breathing and remains ventilator dependent) and remains ventilator dependent, tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to bypass a blocked airway, to help with breathing, or remove secretions, providing a direct path for oxygen to the lungs), dysphagia (difficulty swallowing), and peg placement (feeding tube placed directly through the stomach to deliver food, liquids, and medicine). Pt. is bedbound. Stage IV sacral wound, stage IV to left buttocks and right buttocks. Air mattress, change position every two hours, keep area dry with foley (a device that drains urine from the bladder into a collection bag outside of the body when a person cannot urinate on their own or for various medical reasons), Provide heel protectors while in bed. Wound care to evaluate and treat. Interface with nutritional/dietary services. Resident does not follow commands, does not blink to threat, no purposeful movements seen. Social Services for discharge. The resident's family members desire the use of all life-sustaining measures, including, but not limited to cardiopulmonary resuscitation, intubation (putting a breathing tube through the mouth down into the windpipe to help breath), and use of pressors (powerful drugs used to raise dangerously low blood pressure, to ensure vital organs get enough oxygen and blood flow) we will therefore monitor progress and adjust treatment plan as clinical conditions change. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed reentry date 09/10/25. Section B - B0100. Persistent vegetative state/no discernible consciousness. Section: GG0115 - Functional Limitation in Range of Motion impairment on both sides of upper and lower extremities. Section GG - GG0130. Dependent with toileting hygiene. Indwelling catheter and incontinent of bowel. Active Diagnoses: CAD, heart failure, hypertension, PVD, DM, CVA, COPD, persistent vegetative state (person is awake, eyes opened, sleep-wake cycles, but has lost the ability to think, be aware of themselves or their surroundings, or respond to commands, even though the basic life functions work due to an intact brainstem) , anoxic brain damage (the brain is completely deprived of oxygen, resulting in significant cognitive, physical, and emotional deficits, potentially causing coma or death). Section Q: Family participated in assessment and goal setting. Q0310. Resident's Overall Goal was left blank. Q0400. Discharge Plan. Is active discharge planning already occurring for the resident to return to the community? No. Q0610, Referral. Has a referral been made to the Local Contact Agency? No. Q0620. Reason Referral to Local Contact Agency (LCA) not made code 3 Referral not wanted. Review of Resident #1's Care Plan dated 12/15/25 revealed the resident did not have a Discharge Plan. Review of Discharge Notice dated 11/26/25 for Resident #1 revealed, written notification that resident will be discharged from the nursing facility effective thirty-one days from the receipt of this letter. The effective date of discharge is 12/26/2025. This discharge is based on your failure, after reasonable and appropriate notice, to pay for provided services and your stay at this facility. The facility staff will work with you to make preparations needed to ensure a safe and orderly transition. An orientation for discharge planning will be held on 12/05/25. If there is a conflict with this date, we will be happy to reschedule to a mutually time prior to the date of discharge. During an interview on 12/18/25 at 12:28 PM DON reported they have not had a Social Worker since December 11, 2025. He said the Social Worker was responsible for addressing Grievances and initiating Discharge Plans as soon as possible once they knew that the resident was going to be discharged . He said he and the ADONs were helping with handling Grievances and Discharge Planning until they hired a social worker. During an interview on 12/18/25 at 3:45 PM Administrator revealed Social Worker S's last day was 11/14/25. She said they had hired new Social Worker T, on 11/24/25 and Social Worker T was terminated on 12/11/25. She said she was in the process of interviewing to hire a new social worker. She said she was a social worker and she and the DON and ADONs were helping with handling Grievances and Discharge Planning. She said Grievances were discussed in the daily morning meeting, and staff had been trained to immediately write concerns/grievances on the Grievance Forms to assign to the appropriate Department Head. She said she was responsible for checking that Grievances were resolved and the Social Worker was responsible for notifying the families of the Grievance resolutions. She said she was not aware that Resident #1's family had voiced concerns on Tuesday 12/16/25 until today 12/18/25 when the DON informed her that he had not completed the Grievance Form on 12/16/25 according to facility policy. However, he had immediately addressed the family's concerns and requested a Neurologist consultation, MRI (a magnetic test that uses magnets and radio waves to make detailed pictures of the body organs, muscles, soft tissues, and structures) and a different mattress. She said they had issued a Discharge Notice on 11/26/25 to resident's responsible party and had sent an email to the local ombudsman. She said the discharge notice was issued to Resident #1 due to non-payment of applied income. She said they were waiting for the 30 days from the date that the discharge notice was issued, to file a complaint with APS for exploitation by resident's responsible party who had not paid the applied income to the facility for several months. The Administrator stated they had not started a Discharge Plan when the Discharge Notice was issued to the resident's responsible party on 11/26/25. She said the resident's family had made no attempts to contact the facility regarding discharge notice. She said she did not know why the facility had not conducted the orientation for discharge planning as scheduled for 12/05/25. She said so the family has not made plans for discharge. She said, So the resident will stay at the facility until the family makes plan for a safe discharge, since the resident is on mechanical ventilation and tracheostomy. During an interview on 12/19/25 at 10:15 AM, RN J MDS Nurse and LVN L MDS Nurse revealed Resident #1 was in a permanent vegetative state, did not respond to verbal and/or painful stimuli, was on mechanical ventilation/tracheostomy, enteral feeding via G-tube, had multiple stage VI pressure ulcers that were present upon admission to the facility and a DTI on left heel. LVN L MDS Nurse said the Social Worker would initiate interdisciplinary discharge plan to ensure resident's needs would be met after discharge from the facility. She said the facility had not initiated a Discharge Plan for Resident #1 when the facility had issued the Notice of discharge on [DATE]. During an interview and record review of Resident #1's Care Plan Conference Notes on 12/19/25 at 4:03 PM, LVN L MDS Nurse revealed the new Social Worker T had not written Care Plan Conference notes for 12/10/25 in Resident #1's clinical record, because she had quit without notice on 12/11/25. LVN L MDS Nurse said SW T had not initiated a Discharge Plan for Resident #1 when the facility had issued the Discharge Notice on 11/26/25. She said she did not know why the facility had not conducted the orientation for discharge planning as scheduled for 12/05/25. Review of advertisement dated 12/11/25 provided by the Administrator revealed they were hiring a Social Worker. The state surveyor requested a copy of the Social Worker Job Description on 12/18/25 at 12:45 PM, and it was not provided by the facility Administrator prior to exit.

Based on observation, interview and record review, the facility failed to ensure the right to be free from abuse was provided for 2 (Resident #1 and Resident #2) of 8 residents reviewed for abuse, in that: The facility failed to protect Resident #1 from abuse on 3/20/25 when Resident #1 hit Resident #2 on the face. As a result, there was bruising immediately starting to form on Resident #1's right side of face close to the right [NAME], bruising notes to right hand on knuckles, and bruise noted to right shin. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/20/2025 and ended on 03/25/2025. The facility had corrected the noncompliance before the investigation began. These failures could place residents at risk of abuse, injury, intimidation, fear, agitation, and psychological harm. Findings included: Resident #1: Record review of Resident #1's admission Record dated 05/15/2025, revealed the resident was a [AGE] year-old female with an original admission date of 02/21/2024. Resident #1's diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), anxiety disorder (feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and impulse disorder (mental health condition that makes it difficult to control actions or reactions). Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 99 indicating that the resident was unable to complete the interview. Resident #1 with short-term and long-term memory problems. Section E - Behavior revealed Resident #1 did not exhibit any physical, or verbal symptoms directed toward others. Section GG - revealed Resident #1 uses a manual wheelchair and able to wheel herself independently. Record review of Resident #1's care plan, dated 04/28/2025, reflected Focus (initiated 03/21/2025): Resident #1 had a behavior problem related to alert/oriented of zero; needs redirection enters other resident rooms. Goal: Resident will have fewer episodes. Interventions: administer medications as ordered; anticipate and meet resident's needs; care givers to provide opportunity for positive interaction, attention; intervene as necessary to protect the rights and safety of others; minimize potential for resident's disruptive behaviors; monitor behavior episodes and attempt to determine underlying cause; praise any indication of resident's progress/improvement in behavior; and provide a program of activities that is of interest and accommodates residents status. Resident #2: Record review of Resident #2's admission Record dated 05/15/2025, revealed the resident was an [AGE] year-old male with an admission date of 08/26/2022. Resident #2's diagnoses included vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to cognitive and behavioral changes) without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 02 indicating severe cognitive impairment. Section E - Behaviors reflected Resident #2 did not exhibit any physical or verbal behaviors towards others. Record review of Resident #2's care plan, dated 04/18/2025, reflected Focus (initiated 03/21/2025): Resident #2 had potential to demonstrate verbally and physical abusive behaviors, aggressive towards other residents. Goal: Resident #2 will demonstrate effective coping skills. Interventions: assess and anticipate resident's needs; assess resident's coping skills and support system; assess resident's understanding of the situation; notify the charge nurse of any abusive behaviors. Record review of the Provider Investigation Report dated 03/25/25 reflected, facility staff CMA F heard Resident #2 say to get out of his room. CMA F heard and walked into the room where she discovered Resident #2's belongings that were on his bedside table were thrown. Resident #1 was at edge/bottom of bed (not in arms reach of Resident #1). CMA F immediate removed Resident #2 from the room. CMA F informed charge nurse. Resident assessed for safety. Administrator, DON and Medical Director notified. Abuse neglect policy initiated. Record review of a witness statement from CMA F dated 03/20/2025, reflected CMA F found Resident #1 in Resident #2's room in her wheelchair with her back turned away from the door and next to Resident #2's bed. There was water all over the floor with the water pitcher, the sandals of (Resident #2), and a fork on the floor. Resident #1 told CMA F that Resident #2 had hit her. CMA F took Resident #1 out of the bedroom and reported the incident to LVN C. Interview on 05/15/2025 at 2:23 p.m., Resident #1 stated she did not recall any incidents involving any other residents. Resident #1 said she did not remember any incidents of going to another resident's bedroom and being hit with anything. Resident #1 said she felt safe at the facility and was not afraid of anyone. Interview on 05/15/2025 at 2:51 p.m., Resident #2 stated he did not remember any incident involving another female resident coming into his bedroom. Resident #2 said he did not remember any incident where he had to tell another resident to get out of his room, or any incident where he threw anything hitting the other resident. Resident #2 stated he did not have any issues with any other residents at the facility. Resident #2 stated he felt very safe at the facility. Interview on 05/15/2025 at 4:32 p.m., CMA F stated on the afternoon of 03/20/2025, she was passing out medications to other residents in the hall and heard someone yelling out. CMA F said started walked into the hall and turned into Resident #2's bedroom and saw Resident #1 seated on her wheelchair inside the room at the foot end of Resident #2's bed. CMA F stated she saw Resident #2's shoes next to Resident #1 on the floor and water bottle tipped over with spilled water. CMA F said she did not see Resident #2 hit Resident #1. CMA F said Resident #1 told her that Resident #2 had hit her. CMA F said she assisted Resident #2 out of the room on her wheelchair. CMA F said she reported it to LVN C. CMA F said Resident #1 self-propels and had history of wandering around the facility. CMA F said there had been no prior incidents between the Resident #1 and Resident #2 before 03/20/2025 nor any incidents since. Interview on 05/16/2025 at 8:38 AM, the DON revealed LVN C was no longer working a regular schedule at the facility and moved to a PRN role. On 05/16/2025 at 9:16 a.m., surveyor called LVN C with no answer. Voicemail message with call back information was left. On 05/16/2025 at 9:34 a.m., surveyor asked DON to assist in contacting LVN C. Call back information provided to DON. DON called and left voicemail message. DON texted contact information to LVN C. On 05/16/2025 at 10:25 a.m., surveyor called LVN C with no answer. Voicemail message with call back information was left. Record review of Resident #1's progress notes dated 03/20/2025 and written by LVN C, reads At around 1800 (6:00 p.m.) Resident #2 was heard by CMA F yelling from a room. Resident #1 was found in Resident #2's room. CMA F witnessed Resident #2 sitting up in bed hitting Resident #1 in face and throwing water pitcher and shoes at her telling her to go away. CMA F then removed Resident #1 from the room and notified LVN C about the incident. LVN C initiated head to toe assessment where bruising immediately started forming to Resident #1's right side of face close to right eye, bruising noted to right hand on knuckles and bruise noted to right shin. Resident #1 was not complaining of any pain. LVN C applied ice to help with swelling resident cooperating well. LVN C called Resident #1 family member (FM) to notify about incident. RM verbally understood and asked to be called and notified of any changes. DON, MD and Administrator notified. Record review of Resident #2's Event Nurses' Note - Behavior, dated 03/20/2025, completed by LVN C, reads LVN C was notified that resident was noted hitting and throwing things to another resident that was wandering in his room. CMA F was able to remove other resident from room but did witness resident throwing things to other resident. Resident #2 said that lady came into my room and started grabbing my stuff. Physician and RP notified. Interview on 05/16/2025 at 11:20 a.m., Administrator said Resident #2 had never had any altercation with any other residents prior to the incident reported on 03/20/2025. The Administrator said CMA F witnessed the incident and reported the incident. The Administrator said that Resident #1 has dementia and had history of wandering around the facility and had to be redirected from entering other resident's rooms in the past. The Administrator said on the day of the incident, Resident #1 wandered into Resident #2 room and Resident #2 threw items off the bedside table and hit Resident #1 on the face. The Administrator said there had been no other incidents between these two prior to 03/20/2025 or since the incident. The Administrator said Resident #2 had not exhibited any physical aggression towards any other resident before. The Administrator said Resident #1 was assessed for injury and he immediately initiated an investigation, verified Resident #2 was not exhibiting any further aggression and placed Resident #1 on one-to-one supervision for initiating the incident. The Administrator said Trauma Informed PRN Assessments were completed for Resident #1 and Resident #2. Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Resident to Resident - The above policy will apply to potential resident-to-resident abuse. Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance: Record review of Resident #1's Trauma Informed PRN Assessment completed 03/25/2025 with no concerns. Record review of Resident #2's Trauma Informed PRN Assessment completed 03/21/2025 with no concerns. Review of Resident #1's care plan updated on 03/21/2025, revealed focus on resident wandering in other resident's rooms, which included interventions of monitoring, record, and report to MD new onset signs and symptoms of delirium, changes in behavior, altered mental status, communication decline, disorientation, lethargy, restlessness and agitation. Reorient the resident to person, place, time, situation as required. Review of Resident #2's care plan updated on 04/01/2025, revealed focus: the resident had a behavior problem related to hitting and throwing things to another resident. Goal: The resident will have no evidence of behavior problems. Interventions: administer medications as ordered; anticipate and meet the resident's needs; intervene as necessary to protect the rights and safety of others; minimize potential for resident's disruptive behaviors; praise any indication of resident's progress/improvement in behavior; provide a program or activities that is of interest and accommodates resident's status. Record review of Safe surveys were completed with 8 residents with no issues noted. Record review of facility In Service Training dated 03/20/25, provided by Administrator reflected staff were In Serviced on the Abuse and Neglect to include responding to resident-to-resident incidents. Interviews on 05/15/2025 from 2:26 p.m. to 4:32 p.m., with ADON B, CNA D, CNA E, CMA F, HR, DON, and LVN I revealed the facility staff were able to verify education was provided to them. The staff stated they were educated on different types of abuse/neglect and responding to resident-to-resident incidents. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or suspected any issues with resident-to-resident abuse.

Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #10) of 10 residents reviewed for assistance with ADL's. CNA G failed to ask for assistance on 3/7/24 when providing perineal care to Resident #10, who required 2-person assistance, that resulted in fall with injury. This failure resulted in actual harm to Resident #10 on 03/07/24. It was determined to be past non-compliance due to the facility having implemented action that corrected it before the investigation began. This failure could place residents at risk of accidents and potential harm. Findings include: Record review of Resident #10's face sheet dated 4/24/24 revealed a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of muscle weakness and tracheostomy status. Record review of Resident #10's annual MDS assessment dated [DATE] revealed her cognitive status was severely impaired and was dependent on staff for toileting. Record review of Resident #10's care plan dated 4/1/24 revealed she required ADL assistance with 2-person assistance for incontinent care. Record review of Resident #10's kardex dated 4/24/24 revealed incontinent care requires 2 staff participation for incontinent care. Record review of Resident #10's progress note dated 3/7/24 written by LVN F revealed at approximately 1636 (4:36 pm) this nurse was called into room by CNA. [Resident #10] was on floor on her right side. CNA stated that during incontinent care resident started coughing and rolled off the side of the bed. Head to toe was performed on patient, laceration noted to right eyebrow 0.5 x 3.7 x 0.4 cm. Pressure was applied to site. Call placed to 911. EMS arrived at facility at approximately 1650 (4:50 pm). MD notified of fall. RP notified. Record review of Resident #10's progress note dated 3/7/24 written by ADON D revealed approximately 1636 (4:36 pm), made aware by CNA that during peri-care patient was being turned to her left-hand side when she started to cough and jerk. Patient rolled off her side of the bed and landed next to her bed on her right-hand side. CNA immediately called nurse. Patient was assessed while on the floor. Prom to x4 extremities with no verbal or non-verbal ques of pain. Pressure applied to right orbital laceration, 0.5 x 3.7 x 0.4 c to control bleeding . Record review of Resident #10's local hospital record dated 3/7/24 revealed patient is a [AGE] year-old female with previous stroke who was in bed with trach collar and PEG tube from nursing facility presenting to the emergency room after patient was dropped as they were transferring the patient, positive head strike, negative LOC, no blood thinner use. Patient at baseline is nonverbal, contracted in all extremities but does track with her eyes. This was a 3centimeter linear laceration. The laceration was above her right eyebrow. The wound was closed with 3-0 proline in an interrupted fashion with 6 Suters. This was a single layer closure. The patient tolerated this procedure well and there were no complications. Patient is to follow up for suture removal or sooner for concerns of infection. Wound care instructions were given. During an interview on 4/24/24 at 3:05 pm, Resident #10's RP stated she had been notified of the fall on 3/7/24 and was advised Resident #10 was taken to the hospital for further evaluation. Resident #10's RP stated Resident #10 had not had a fall or similar incidents prior to the accident on 3/7/24. During an interview on 4/24/24 at 3:45 pm, LVN F stated he worked on 3/7/24 and was the charge nurse for Resident #10. LVN F stated he was called over to Resident #10's room by CNA G. LVN F stated when he entered Resident #10's room, he saw her on the floor on her right side. LVN F stated CNA G reported she was providing perineal care and when she was on her left side, Resident #10 coughed and leaned forward that resulted in her rolling off the bed. LVN F stated he conducted head to toe assessment and noticed laceration to her right eyebrow. LVN F stated he cleansed and applied pressure and the bleeding would not stop. LVN F stated he called 911 to have her admitted to hospital for further evaluation. LVN F stated Resident #10 required 2-person assistance for perineal care and was not sure why CNA G had not asked for assistance. During an interview on 4/24/24 at 3:55 pm, CNA G stated she worked on 3/7/24 and was the CNA assigned to Resident #10. CNA G stated she had provided perineal care to Resident #10 and had rolled her to her left side. CNA G stated when Resident #10 was on her left side, she coughed and leaned forward which caused her to roll over and fell on the floor. CNA G stated she called LVN F for assistance and to assess. CNA G stated she was familiar with Resident #10's care and knew she required 2-person assistance with incontinent care. CNA G stated she had access to Kardex and knew Resident #10 required 2-person assistance with incontinent care. CNA G stated she failed to ask for assistance because she felt it was easier for her to provide perineal care alone. CNA G stated her failure to ask for assistance resulted in a fall with injury to Resident #10. CNA G stated she was suspended and received in-service on checking Kardex before providing ADL care and asking for assistance to meet resident level of care requirement. During an interview on 4/25/24 at 3:22 pm, ADON H stated she was responsible for conducting random observations for all 3-shift staff on various ADL task to include bathing, bed mobility, incontinent care, and transferring. ADON H stated this monitoring was initiated post Resident #10 fall on 3/7/24. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering: QAPI- perform ADL task/ ADL dated 3/7/24 revealed: how to use Kardex; ensure you follow all care planned interventions including how much staff is required to perform an ADL; if unable to have proper number of staff to assist, do not perform the task until the proper amount of staff is present, do not rush; if for any reason the amount of staff assistance needed is not listed for bathing, bed mobility, transferring, walking, incontinent care, then you should contact the charge nurse, ADON, and or DON. Initiate the following for monitoring: asl 10 nursing staff members per week, how to locate how much assistance is needed for a resident task and what they would do if the proper amount of staff is not present. Document date/time staff members name, if they responded correctly, and any corrective action if needed. Reviewed monitoring tool utilized for bathing, bed mobility, transferring, incontinent care monitoring for the following dates: starting March 8, 2024- April 23, 2024. A total of 80 observations were completed with different ADL, covering all 3 shifts, various and CNAs. No concerns were identified. In-services dated 3/7/24: In-service on: while providing peri care on pts that are total dependent ensure 2 person aid at all times. In-service on: If unable to have the proper number of staff to assist a resident, do not perform task until the proper amount of staff is present. do not rush. In-service on: if more assistance is required than what is on Kardex, report to ADON, DON, or MDS case manager immediately so the Kardex can be adjusted. In-service on: Ensure that you follow all care planned interventions including how much staff is required to perform an ADL In-service on: If for any reason the amount of staff assistance needed is not listed for bathing, bed mobility, transferring, walking, incontinent care; then you should contact Charge nurse, ADON, DON. In-service on: how to use kardex. Observation of peri-care on 04/24/24 at 1:24 PM, revealed, nursing staff provided appropriate care. CNA A and CNA B both confirmed in-service training related to checking Kardex before care was provided and asking for help if needed CNA A and CNA B stated the facility was conducting random observations with ADL care. No concerns identified.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 6 (Resident #2, Resident #5 and Resident #6) residents reviewed for Hoyer lift transfer. The facility failed to ensure Resident #2 had a safe Hoyer lift transfer which resulted in nose bone fracture. The facility failed to ensure Hoyer lift brakes were in place when transferring Resident's #5 and #6. These failures could place residents at risk of injuries due to not placing breaks in Hoyer lift as suggested from manufacturer. Findings included: Resident #2 Record review of Resident #2's face sheet dated 6/9/23 revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident #2's history and physical dated 5/8/23 revealed diagnoses of dementia. Record review of Resident #2's MDS admission assessment dated [DATE] revealed a BIMS score of 14, he was cognitive intact. Section G revealed he required total dependance with two-person physical assist for transfer. Record review of Resident #2's care plan dated 5/8/23 revealed focus area for ADL self-care with interventions of resident requires a (Hoyer) lift for all transfers. Record review of Resident #2's incident report dated 5/27/23 revealed incident description resident sustained a wound to the bridge of the nose; 4cm x2cm while been transferred from bed to chair by Hoyer lift. The CNA reported a faulty lift that swung resident to hit the face on the bar of the lift. There was bleeding to the wound. Immediate action taken section revealed called 911 and transfer resident to the ER. Predisposing situation factor section revealed during transfer, transfer with Hoyer lift from bed to chair.' Record review of Resident #2's local hospital record dated 5/27/23 revealed the patient is [AGE] years old ; fall, injury. Nasal cavity/ septum revealed multiple fracture through the nasal bones with mild displacement. Interview on 6/9/23 at 8:30 AM DON stated he received report from charge nurse that Resident #2 had sustained injury during a transfer from bed to chair using the Hoyer lift. DON stated charge nurse reported to him when staff was lowering Resident #2 to chair the swivel bar hit him (Resident #2) on the nose causing a laceration. DON stated Resident #2 had reported pain to charge nurse and was sent to the ER for further evaluation on what 5/27/23. DON stated staff were trained on Hoyer lift transfer upon hire. He did not know why the Hoyer lift tilted to the side when transfer Resident #2. Interview on 6/9/23 at 2:53 PM via phone call, CNA C stated she was one of the CNA's who assisted with Resident #2 Hoyer lift transfer on 5/27/23 when the incident happened. CNA C stated when her and Student CNA were lowering Resident #2 to wheelchair using Hoyer lift the Hoyer lift tilted sideways once Resident #2 was already siting in wheelchair. CNA C stated when the Hoyer lift tilted the bar hit Resident #2 in the face and almost hit her. CNA C stated Resident #2 started bleeding from the bridge of the nose and nurse was called for further assistance. CNA C stated her, and Student CNA inspected the Hoyer lift before using it for the transfer and stated locks were in place when lowering Resident #2 down to chair. CNA C stated she received training from PT on how to use Hoyer lift last week and upon hire. CNA C did not answer further questions due to being busy. CNA C stated she did not know why Hoyer lift Interview on 6/9/23 at 2:58 PM via phone call, Student CNA stated they were present during incident for Resident #2 on 5/27/23. Student CNA stated during Hoyer lift transfer from bed to wheelchair, Resident #2 sustained injury to nose. Student CNA stated everything happened so fast and does not recall details from incident. Student CNA stated she received training on use of Hoyer lift when she started working at the facility. Student CNA did not answer further questions due to being busy. Resident #4 Record review of Resident #4's face sheet dated 6/9/23 revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident #4's local hospital history and physical dated 4/28/23 revealed diagnoses of seizure disorder and multiple sclerosis. Record review of Resident #4's MDS admission assessment dated [DATE] Section G revealed transfer activity only occurred once and required two-person physical assist. Record review of Resident #4's care plan dated 5/18/23 revealed a focus area for ADL self-care with interventions that included Resident #4 requires a lift for all transfers. Observation on 6/9/23 at 11:27 AM CNA D, CNA E, and CNA F were in the room assisting with Hoyer lift transfer from bed to shower bed. Hoyer lift was already in place under bed and over Resident #4. CNA F was responsible for handling the Hoyer lift. CNA F did not place breaks when lifting Resident #4 from bed. When Resident #4 was moved to shower gurney, CNA F placed breaks on before lowering Resident #4. Interview on 6/9/23 at 11:30 AM CNA F stated she had recently received training regarding Hoyer lift transfer last week from PT. CNA F stated she was trained to inspect Hoyer lift before using to ensure it was working properly and to place breaks on when lifting and lowering residents. CNA F stated it was important to put breaks on Hoyer lift when lifting and lowering resident to decrease potential accidents. CNA F stated she had placed breaks before lifting and lowering Resident #4. Resident #5 Record review of Resident #5's face sheet dated 6/9/23 revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident #5's history and physical dated 12/19/22 revealed diagnoses of generalized anxiety, muscle weakness, age related osteoporosis without pathological fracture. Record review of Resident #5's MDS quarterly assessment dated [DATE] section G revealed resident required total assistance with two-person physical assist for transfers. Record review of Resident #5's care plan dated 2/10/21 revealed focus care for ADL self-care with interventions of Resident #5 required two staff for transfers with use of (Hoyer) lift. Observation on 6/9/23 at 11:32 AM CNA G and CNA H assisted Resident #5 from bed to wheelchair using Hoyer lift. CNA G was responsible for handling Hoyer lift. CNA G did not place breaks on before lifting Resident #5 from bed and did not place breaks before lowering Resident #5 to wheelchair. Interview on 6/9/23 at 11:51 AM CNA G stated she had recently received training regarding Hoyer lift transfer last week by PT. CNA G stated she was trained to place breaks before lifting and lowering residents to reduce any accidents. CNA G stated she forgot to place breaks and the failure could have caused the Hoyer to tilt and possible cause an injury to Resident #5. Interview on 6/9/23 at COTA stated he recently gave training to CNAs on use of Hoyer lift. COTA stated he trained staff the place breaks on Hoyer lift before lifting and lowering resident to the desired location. COTA stated Hoyer lift breaks were required to be in place to reduce potentially accidents like Hoyer tilting due to a resident's weight or center of gravity shifting resulting in an injury to either resident or staff. COTA stated he did not have answer for staff not putting breaks on Hoyer lift when lifting and lowering residents to desired location. Interview on 6/9/23 at Administrator directed Hoyer transfer questions to DON. Record review of Hydraulic Lift policy not dated revealed The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by manufacturer recommendations. 8: Lock or unlock the base wheels according to the lift manufacturer's recommendations. Record review of Manual/ Electric Portable Lift and Slings Owners Installation and Operating Instructions not dated, revealed on page 20, Only operate this lift with the legs in maximum open position and locked in place. The base legs must be always locked in the open position for stability and patient safety when lifting and transferring a patient. If the shifter handle is not positioned completely into its mounting slot, do not use the patient lift until shifter is properly seated and the legs of the patient lift locked in place or injury and/or damage may occur.

Based on interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent an accident for 1 of 5 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to ensure SNA B and SNA C used the shower gurney which required lock pins to secure and hold side rails to the gurney. This resulted in Resident #1 falling from the shower gurney and sustaining a non-displace nasal fracture. This failure resulted in actual harm to Resident #1 on 9/29/2022. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. The findings were: Record review of Resident #1's face sheet, dated 10/07/2022, revealed he was originally admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] (body's extreme response to an infection), [CONDITION(S)] (lack of red blood cells), fracture of the nasal bone, seizures, slow heart rate, chronic respiratory failure, type 2 diabetes, [CONDITION(S)] (lack of oxygen) brain damage, and dependence on respirator. Record review of Resident #1's quarterly MDS, dated [DATE], revealed resident is rarely/never understood. Resident #1 required total dependence for bed mobility, dressing, dating, toilet use, personal hygiene, and bathing. Record review of Resident #1's care plan for risk of falls related to balance issues during transition with date initiated 3/14/2021 and revised 09/30/2022. Interventions include in part, anticipate and meet the resident's needs; keep furniture in locked position. Another focus area includes alteration in musculoskeletal status related non-displaced right nasal bone fracture mildly angulated to the right, with intervention steps to include in part, anticipate and meet needs; monitor/document for risk of falls. Educate resident, family /caregivers on safety measures that need to be taken in order to reduce risk of falls. Another focus area includes Resident #1 has an ADL Self Care Performance Deficit, with intervention steps to include in part, Incontinent care: Resident is totally dependent on x2 staff for incontinent care; the resident is bedfast all or most of the time; BATHING: the resident is totally dependent on x2 staff to provide a bath; BED MOBILITY: The resident is totally dependent on x2 staff for repositioning and turning in bed. Record review of Resident #1's progress notes, dated 9/29/2022, reads in part, nurse was notified by another nurse that resident was on the floor. This nurse went in with other nurses and saw resident on the floor bleeding with 2 CNAs with resident in the shower room. 911 was called, resident was taken off the floor back to the shower bed. Upon assessment, resident had a laceration on mid nose, abrasion to right head, swelling to bilateral eyes, bleeding to right eye. Physician on call notified, DON notified, family is aware. Resident was sent to the hospital. Record review of Resident #1's progress notes, dated 9/30/2022, reads in part, Resident arrived to facility at 0312 via stretcher, 2 EMT's at bedside required full assistance in transfer to bed. Noted to have kerlix and ACE bandage to head saturated with blood. Assessed resident, provided PRN Tylenol for pain. Cleaned wounds to top and back of scalp with NS pat dry, applied dressing and wrapped ensuring circulation. Resident noted to have bruising and abrasion to left eye. Report includes the following: no acute pulmonary findings, non-displaced right nasal bone fracture mildly angulated to the right, mild to moderate left periorbital [CONDITION(S)], partially visualized right frontal scalp [CONDITION(S)], no acute cervical spine fracture, no acute [CONDITION(S)] scalp injury. During an observation and interview on 10/7/2022 at 2:48 p.m., Resident #1 was asleep in his room at the time. A was bandage was observed to the right side of Resident #1's head, sutures to bridge of nose and discoloration under left eye. Resident #1 woke up during the visit. Resident #1 did not provide any responses to any questions asked. During an interview on 10/7/2022 at 3:00 p.m., SNA-D said that Resident #1 was non-verbal CNA-D said that when any resident is assisted to shower using the shower gurney, they use locking pins to put the side rails in place. SNA-D said that sometimes the locking pins are usually available on the shower gurney but if needed staff will ask nursing for a locking pin which they have in the medication carts. SNA-D said that he has been trained by other CNA's on how to use the shower gurney when he first started working at the facility months ago and knows that locking pins are available when needed by asking nursing. During an interview on 10/10/2022 at 9:28 a.m., FA-E said the incident occurred in the shower room. FA-E said that the two staff members with Resident #1 used an unauthorized lock for the gurney bed rails. He said they used a toothbrush as a lock pin. He said the resident had a BM and when the two SNAs tried to clean him, they turned him, and he fell because the gurney rail that was locked with the toothbrush failed. He said that this had never happened before since he had been appointed FA about a year ago. He said the resident was assessed. He said following the incident the shower gurney was removed from the floor. He said that the gurney was inspected and there were no defects noted by maintenance staff. He said that he suspended the two SNA's pending investigation. He said that the two SNAs took it upon themselves to use the unauthorized lock. He said that gurney lock pins are available in the medications carts when needed and staff only need to ask nursing for the lock pins. He said the SNAs did not request for a shower bed lock from the Charge Nurse. He said that both SNAs were terminated. He said that all staff at the facility were educated on abuse/neglect policy, safe patient handling, lockout/tagout policy and reporting malfunctioning equipment. During an interview on 10/10/2022 at 9:54 a.m., SNA-I said she has been working at the facility since August of 2022. SNA-I said that when using a shower gurney, lock pins must be used to secure the side rails of the bed. SNA-I said that pins are usually on the beds but if they are not available then staff ask the nurse for a locking pin which they have in the medication carts. SNA-I said she received five days of training when she first started and part of the training included that shower beds could not be used without the locking pins for side rails, and not to turn residents for safety reasons. During an interview on 10/10/2022 at 10:07 a.m., CNA-J said she has been working at the facility for two years. CNA-J said there are holes that we insert a lock to keep the rails up when using a shower gurney. CNA-J said no one has ever fallen from the gurney. CNA-J said she has been working at the facility for over 8 to 9 months and knows that the locking pins have always been available when needed by asking nursing for a pin. CNA-J said that she was trained by two other CNA's and safe showering was included in the training. During an interview on 10/10/2022 at 10:20 a.m., SNA-K said she has been working at the facility for about two months. SNA-K said staff have to use locks on the sides of the shower gurney. SNA-K said she was informed during her initial training. SNA-K said she was trained by the CNA's. SNA-K said the locks should be on the shower gurney beds and if not, they can ask the nurses for the locks. SNA-K said she had not seen any defective equipment or seen anyone fall from use of the shower gurney. SNA-K said that additional locking pins are available in nursing carts. During an interview on 10/10/2022 at 10:32 a.m., CNA-L said she had been working at the facility for nine months. CNA-L said when she received training, she learned that the locks go on the shower gurney bed and the locks are usually found on the bed. CNA-L said if staff don't have a lock, they will call the nurse to get one. During an interview on 10/10/2022 at 10:50 a.m., LVN-M said she has bene working at the facility for about two months. LVN-M said I have been trained on how to use the shower gurneys although for the most part CNAs are usually the staff members who conduct the showers. LVN-M said additional locking pins are available in the medication carts upon request if the CNA's do not have them available on the gurney. LVN-M said that staff were supposed to check that everything works before using any equipment including ensuring that lock pins are available. During an interview on 10/10/2022 at 1:33 p.m., SNA-C said he was present in the shower room when Resident #1 fell from the shower gurney. He said that he no longer works at the facility as he was terminated on 10/7/2022. He said his usual shift is evening shift from 2:00 p.m. to 10:00 p.m. He said on 9/29/2022 he was pulled from the 300-hall assignment to go assist in the 400-hall. He said that he assisted SNA-B with patient baths. He said that some of the shower beds were missing the locks available on the gurney so he [NAME]-rigged (organized or constructed in a crude or improvised manner) the rail lock using items such as a piece of wood or a toothbrush. He said that he does not remember if he or SNA-B asked for a lock pin for the gurney that was carrying Resident #1. He said that they used a toothbrush in place of the lock pin. He said that when he started working at the facility, there was one other CNA who told him it was okay to use something else if the metal lock pin was not available. He said that he does not remember the name or description of the CNA who said it was okay to use another item if the lock pins were not readily available. He said he does not think that person works at the facility anymore. He said that on 9/29/22 he did not ask anyone for a lock pin for the gurney. He said that he believes there are lock pins in the nursing carts but did not ask any nurse for a lock pin. He said he used a toothbrush that they supply for the nursing homes. He said that he and SNA-B bathed the Resident #1. He said that Resident #1 had a BM right after bathing. He said he asked SNA-B to turn Resident #1 so he could clean him, and as he was cleaning him the rail snapped. He said the toothbrush snapped and rail gave way. He said that Resident #1 fell towards SNA-B, and she tried to catch the patient as he reached out and tried to stop the patient from falling but the Resident's body slipped from being wet. He said that he knows they should not have done the shower. He said that the locks should have been available on the shower gurney bed. He said they immediately called the nurse and were able to shimmy the transfer net under the patient and picked up the patient and put him back on the shower bed. He said the resident was bleeding from his face. He said the nurse assessed the resident. Ambulance was contacted and arrived within minutes. Multiple interview attempts were made to contact SNA-B by phone on 10/10/22 at 1:10 p.m. and 1:24 p.m. Voicemail messages requesting a call back were left. During an interview and observation on 10/10/2022 at 1:50 p.m., LVN-F said she has been working at the facility for three months. LVN-F said that shower gurney lock pins are in the medication carts at the facility. LVN-F opened the medication cart located in the 400-hall. Lock pins were observed in the top drawer of the medication cart. LVN-F said that the extra lock pins for the shower gurney have been available in the medication carts since she started working at the facility three months ago. LVN-F said that staff are aware to ask nursing if they need locking pins. During an interview on 10/10/22 at 2:20 p.m., LVN-G said on 9/29/2022 one staff from Westside of building was sent to the 400-hall to help with showering patients. LVN-G said that the SNA's started showering residents at 6:00 p.m. and showered three patients. LVN-G said that Resident #1's family were visiting at the time and Resident #1's wife wanted him to be showered because he had been receiving bed-baths. LVN-G said the two SNAs transferred Resident #1 from his bed to shower bed. LVN-G said he was not present in the room during the transfer. LVN-G said the SNAs took Resident #1 to the shower room. LVN-G said 15-20 minutes later SNA-B called LVN-G to the shower room. LVN-G said it SNA-B appeared to be scared. LVN-G said he found Resident #1 on the floor bleeding profusely to the head. LVN-G said that the Resident #1 was still connected to the ventilator. LVN-G said he secured the breathing and called Respiratory Therapist and another nurse to assist. LVN-G said they put Resident #1 back on the gurney to secure his breathing. LVN-G said he instructed one nurse to call 911 right away. LVN-G said they applied pressure to control the bleeding. LVN-G said that EMS arrived and took Resident #1. LVN-G said he told the two SNAs to get ready to write statements about what happened. LVN-G said that no one told him or asked him anything about the shower gurney that was used by the two SNAs. LVN-G said there are metal lock pins in the med carts and if staff need any pins, they ask the nurse, and the nurse gives them the lock pins. LVN-G said the lock pins were available in the medication cart. LVN-G said the SNAs did not say anything about needing any lock pins. LVN-G said he was not aware of any issues with the shower gurney and did not go into the shower room to see what staff were doing prior to the fall. The surveyor determined the facility was in non-compliance from 09/29/2022 to 10/06/2022. The facility took the following actions to correct the non-compliance: During observations on 10/10/2022 at 2:45 p.m., all shower gurneys were inspected and found to have locking pins. Facility medication carts had additional locking pins available. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering: Suspension of SNA-B and SNA-C during course of facility investigation. Termination of SNA-B and SNA-C on 10/6/2022. Record review of in-service dated 9/30/2022 revealed the following: Abuse/Neglect Purpose of the Abuse/Neglect policy is to provide and ensure the promotion and protection of residents' rights. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends o other individuals. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. Record review of in-service dated 9/30/2022 revealed the following: Lockout/tag out policy for staff: Purpose of the lockout/tag out policy is to ensure that all employees that are assigned to operate or work on mechanical equipment follow accepted safety practices and principles when performing task involving the maintenance and repair of mechanical equipment. Record review of in-service dated 9/30/2022 revealed the following: Safe Patient Handling: Purpose of Safe Patient Handling policy is to promote and assure safe patient handling for both the resident and employee. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose the resident or nurse to an unacceptable risk of injury; facility staff will report to supervisor the inability to complete resident lifting, transfer, or repositioning if they feel it will either endanger the resident or cause injury to staff. Separate interviews were conducted with staff regarding the content of the in-services they had received. The following staff were interviewed: SNA-D on 10/7/22, FA-E on 10/10/22 at 9:28 a.m., LVN-F on 10/10/22 at 1:50 p.m., SNA-I on 10/10/22 at 9:54 a.m., CNA-J on 10/10/22 at 10:07 a.m., SNA-K on 10/10/22 at 10:20 a.m., CNA-L on 10/10/22 at 10:32 a.m., and LVN-M on 10/10/22 at 10:50 a.m. Each staff member was able to correctly identify the process for safe use of the shower gurneys to include proper use of locking pins and where additional pins are located. Observations throughout this investigation from 10/7/22 to 10/10/22 on the 100, 200, 300, 400 and 500 halls revealed no broken or defective shower gurneys and locking pins available on the gurneys and additional pins in medication carts.

Based on observations, interviews and record review the facility failed to ensure the resident environment remains free of accident hazards and each resident received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for bed mobility and incontinent care in that: CNA's provided bed mobility and incontinent care without following Resident's #1 care plan resulting in fracture to the left femur (leg). This failure placed residents at risk for accident/hazard which could cause injuries. The findings were: Record review of Resident #1's face sheet, undated, revealed an admitted [DATE] with an initial admitted [DATE] with diagnoses that included displaced spiral fracture of shaft of left femur, [CONDITION(S)], dependence on respirator (ventilator) and [CONDITION(S)]. Record review of Resident #1's clinical care plan, dated 11/4/2021, revealed Resident #1 had an Activities of Daily Living (ADL) self-care performance deficit. She requires staff x2 assistance for bathing, dressing, bed mobility, and incontinent care/foley care. Record review of Resident #1's physical therapy evaluation, dated 8/16/2021, revealed that Resident #1 with weakness to both lower extremities, poor joint mobility, both ankles positioned in plantar flexion (foot in downward motion away from the body), low activity tolerance, poor trunk control and impaired gross motor execution which has affected the ability to perform all functional mobility tasks. Resident #1 is total dependence on bed mobility. Record review of Resident #1's physician orders summary, dated 12/14/2021 , revealed Focus: Resident #1 has an ADL Self Care Performance Deficit Date Initiated: 07/30/2021 and Revised on: 08/19/2021. Order revealed in part: date 7/30/21, bed mobility requires staff x2 for assistance by Certified Nursing Assistants (CNA); and incontinent care/foley care requires staff x2 for assistance by CNA. Record review of Resident #1's nurses notes, dated 12/10/2021 revealed resident was found with fracture at left lower extremity. Other information: nobody knows when and how the incident happened. Post assessment done by Nurse Practitioner (NP) who ordered X-rays of the affected area. Resident #1 mobility at time of event revealed in part: bed mobility and toileting x 2 or more staff assist. In an interview of 12/17/21 at 4:25 a.m., LVN C said that staff can reposition Resident #1 with one person, but it might cause her to be uncomfortable and Resident #1 is very contracted. He said that for incontinent care it would take two staff to perform the task as one assist in gently opening Resident #1's legs while the other staff performs the task of wiping. He said it could be difficult for one person to do that. He said that staff have been trained when working with certain people on how to be gentle and how to perform tasks safely along with the preference for two-person assist for specific residents including Resident #1. He said that he will update staff on any changes with the care plan. He said that staff access care plan information in the computer and it is their responsibility to review the information. He said that two staff are required to reposition Resident #1 and they have to go slowly by gently touching and not stretching Resident #1 legs. He said that on the night of 12/9/21 to 12/10/21 he believes that there were two staff there but he was not present during repositioning or incontent care done by CNA's so he does not know how gently the tasks occurred. He said that he knows that CNA C was in the unit but was not sure who the other CNA was and if the other CNA was present for every bed mobility task or incontinent care task during the shift. In an interview on 12/17/21 at 4:45 a.m., CNA D said that Resident #1 is contracted and has a tiny body. She said that Resident #1 does not move and requires total care. She said that Resident #1 is fragile. She said that prior to the injury one staff person could reposition Resident #1, but if staff are not as experienced then it should be two staff assisting to reposition. She said that she has conducted bed mobility alone before with Resident #1 as she is experienced. Observation on 12/17/21 at 4:53 a.m. of CNA C and CNA D providing bed mobility and incontinent care. CNA D provided assistance of holding Resident's #1 leg while CNA C provided care of wiping down resident and removing brief. Both staff were observed working together to reposition Resident #1 and CNA D said that the tasks being performed would be difficult for only one person to complete. In an interview on 12/17/21 at 4:53 a.m., CNA C said that she worked in the unit on 12/9/21 from 10:00 p.m. to 12/10/21 at 6:00 a.m. She said that she repositioned and changed Resident #1 adult brief alone, which she has routinely done before. She said that other staff were busy in other areas of the facility and not available in the unit. She said that she believes that Resident #1's care plan said it was okay for one person to reposition Resident #1. She said that on the night of 12/9/21 to 12/10/21 they were short-staffed and there was no other available staff to help her with bed mobility and incontinent care tasks during her last round which was at about 5:00 a.m. In an interview on 12/17/21 at 9:58 a.m., MDS Nurse said that when changing Resident #1's adult brief, she needed two people to help her as it would have been difficult for one person to clean and toilet her. She said that quarterly MDS revealed that toilet use for Resident #1 requires two-person physical assist. The MDS nurse said that quarterly MDS revealed that bed mobility for Resident #1 requires extensive assistance by one CNA to reposition. The MDS nurse said that ADL assistance for bed mobility is not consistent with Resident #1's care plan which revealed that bed mobility assistance required by two staff. The MDS nurse said that the MDS dated [DATE] is not accurate. In an interview on 12/17/21 at 10:45 a.m., DON said that CNA staff had access to kiosk where they can see the resident's needs. She said that care plan information including positioning and incontinent care instructions would have been available to the staff. She said that Charge Nurse trains CNA's when there are updates on care plans. She said that based on the care plan for Resident #1 prior to the injury reported on 12/10/21 , two persons should have provided incontinent care for Resident #1. She said that two-persons should have provided bed mobility assistance for Resident #1. She said that if there are any changes to the care plan, the Charge Nurse should have notified and updated the CNA's. In an interview on 12/17 at 11:10 a.m., LVN A said that she is the Charge Nurse during the shift that the injury to Resident #1 was discovered. She said that before Resident #1 was injured, one-person could have repositioned her. She said that Care Plans come from MDS so they should be in sync. She said that staffing during the day shift is good and there are enough CNA to help out with bed mobility and incontinent care. She said that she cannot speak about any of the other shifts. She said that care plan information is available in kiosk and is accessible for all CNA staff. She said that she has provided an in-service to staff about completion of documentation in the kiosk every shift. Record review of in-service training roster dated 9/29/21 revealed that LVN A provided training on completion of kiosk 100% every shift. Information includes in part that nurses are responsible for ensuring their CNA's complete their documentation. CNA's A and C names and signatures do not appear on the roster. In an interview on 12/17/21 at 11:27 a.m., CNA A said that on 12/10/21 between 7 to 8:00 a.m. she entered the bedroom of Resident #1 and was going to change Resident #1. She said that she was by herself at the time. She said that she would change Resident #1 and reposition her by herself and that Resident #1 did not need any more assistance. She said that it was not difficult to clean her alone and that she did not need help because Resident #1 was not difficult to clean or reposition because she is small. She said that she can access the information about repositioning and toileting on the computer that is located in the unit hallway kiosk computer

Based on observation, interview and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety in one kitchen for 4 (Residents #20, #84, #78, and #8) of 33 residents observed for dining services. A. On 05/21/18, Cook D prepared fried eggs using unpasteurized eggs. The egg yolks were runny. The eggs were served to Residents #20, #84, #78, and #8. These residents had [DIAGNOSES REDACTED]. An Immediate Jeopardy (IJ) was identified and the Administrator was notified on 05/21/2019. While the IJ was removed on 05/22/2019, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm at a pattern. This failure could place residents who request soft-cooked eggs at risk for Salmonella food poisoning which could include severe gastrointestinal illness, fever, diarrhea, and even death. B. The facility failed to properly label and store food items. Review of facility the facility's food storage revealed five food items that were not dated or stored correctly: 1. A metallic pan siting on the bottom shelf in a walk-in refrigerator filled with ground beef that was dated as being prepared on 5/20/19, but had no use by date. 2. One container with sliced tomatoes dated as being prepared on 5/20/19 with no use by date on the container. 3. An unopened box of cream cheese found under the walk-in refrigerator fan that was covered in mold on the top surface of the packaging and was not dated. This failure could place residents who eat food prepared in the kitchen at risk of food-borne illness. The findings include: A. Egg Preparation Observation on 05/21/2019 at 8:15 AM revealed an opened carton of eggs in the walk-in refrigerator. The carton did not specify anywhere on the packaging that the eggs were pasteurized. The packaging did carry the following statement, Safe Handling Instructions: To prevent illness from bacteria: keep eggs refrigerated. Cook eggs until yolks are firm, and cook foods containing eggs thoroughly. Review of the website https://www.fda.gov/food/buy-store-serve-safe-food/what-you-need-know-about-egg-safety, last reviewed on 05/21/2019, stated the following, in part: FDA requires all cartons of shell eggs that have not been treated to destroy Salmonella to carry this safe handling statement: Safe Handling Instructions To prevent illness from bacteria: keep eggs refrigerated, cook eggs until yolks are firm, and cook foods containing eggs thoroughly. 1) Resident #20 Review of Resident #20's Face Sheet dated 05/21/2019 documented in part that he was an [AGE] year-old male who was admitted to the facility on [DATE]. Review of Resident #20's [DIAGNOSES REDACTED]. Observation on 05/21/2019 at 8:37 AM revealed that he had consumed 25% of two eggs with liquid yolks. 2) Resident #84 Review Resident 84's of Face Sheet dated 05/21/2019 documented Resident #84 was an [AGE] year-old male admitted on [DATE]. Review of Resident #84's [DIAGNOSES REDACTED]. Observation on 05/21/19 at 8:40 AM revealed Resident #84 was served and ate over easy eggs with runny egg yolks. 3) Resident #78 Review of Resident #78's Face Sheet dated 05/21/2019 documented in part that he was a [AGE] year-old male and was admitted to the facility on [DATE]. Review of Resident #78's [DIAGNOSES REDACTED]. Observation and interview on 05/21/2019 at 08:46 AM, Resident #78 had liquid egg yolk on his plate. He stated he ate over easy eggs for breakfast. 4) Resident #8 Review of Resident 8's Face Sheet dated 05/21/2019 documented Resident #8 was a [AGE] year-old male admitted on [DATE]. Review of Resident #8's [DIAGNOSES REDACTED]. Observation on 05/21/2019 at 8:52 AM revealed Resident #8 had been served fried eggs with runny yolks. In an interview on 05/21/2019 at 9:35 AM the Facility Administrator stated that the Dietary Manager is overseen by the Registered Dietician. He further stated that the administrator also oversees the kitchen. He stated that the population served within the facility could get Salmonella from under cooked eggs. The Administrator said he did not think that it was possible to order eggs that were not pasteurized from the facility's food vendor. In an interview on 05/21/2019 at 8:20 AM the Dietary Manager stated that he was not aware that the eggs were not pasteurized. He further clarified that the eggs he purchased from the vendor were AA grade eggs and that the AA grade meant that the eggs had been pasteurized. He stated that the carton observed in the walk-in refrigerator were the only eggs available for fried eggs. Review of the United States Standards, Grades, and Weight Classes for Shell Eggs AMS 56 dated effective (MONTH) 20, 2000 by the United States Department of Agriculture (USDA) revealed the following definition of AA Quality eggs under §56.201: The shell must be clean, unbroken, and practically normal. The air cell must not exceed 1/8 inch in depth, may show unlimited movement, and may be free or bubbly. The white must be clear and firm so that the yolk is only slightly defined when the egg is twirled before the candling light. The yolk must be practically free from apparent defects. The definition of AA Quality eggs did not include any requirement for eggs to be pasteurized. In an interview on 05/21/2019 at 9:30 AM, the Dietary Manager said pasteurized eggs should be used for eggs that are underprepared such as over easy eggs with runny yolk. He stated that pasteurized eggs were necessary to protect residents from Salmonella outbreaks that can grow on eggs. He further stated that in vulnerable populations Salmonella can cause diarrhea, nausea, vomiting, and even death. In an interview on 05/21/19 at 9:51 AM the Registered Dietician stated that he meets with the Dietary Manager to make suggestions and recommendations. He stated that he looks at food textures, temperatures, and preferences. He reviews food labeling and storage. When the facility works with new staff he lets them know what is expected of employees. He watches meal preparation and goes over recipes with the cooks. As far as watching breakfast preparation he is in and out so he does not observe unless the Dietary Manager voices a concern. He stated that If the facility serves undercooked eggs, they must use pasteurized eggs. He said he has talked about the use of pasteurized eggs with the Dietary Manager but he has not checked the eggs himself. He stated that he would not want to serve undercooked eggs to the residents in the facility. He stated that some of the consequences of serving undercooked eggs to an elderly population included risk for getting sick from bacteria or food-based illness, and food poisoning. He stated that he had no concerns about the kitchen. Review of the facility food supplier order catalog revealed a product labeled as fresh, large, pasteurized eggs. The item code associated with the pasteurized eggs was 11. Review of a delivery invoice from the facility food supplier documented 15 dozen eggs not labeled as pasteurized were delivered on 05/14/2019 (Tuesday). The invoice included an item code associated with the eggs, 61, which indicated the facility had chosen unpasteurized eggs rather than pasteurized eggs. Review of the website https://www.cdc.gov/Features/SalmonellaEggs/, last reviewed on 05/21/2019, stated the following: Cook eggs until both the yolk and white are firm. Egg dishes should be cooked to an internal temperature of 160°F (71°C) or hotter. Make sure that foods that contain raw or lightly cooked eggs, such as hollandaise sauce, Caesar salad dressing, and tiramisu, are made only with pasteurized eggs. Adults older than [AGE] years, children younger than 5 years, and people with weakened immune systems, such as those with HIV/AIDS, diabetes, or an organ transplant, may get a more serious illness that can even be life threatening. The Administrator was notified of the Immediate Jeopardy on 05/21/2019 at 1:03 PM. The IJ Template was provided to the Adminsitrator at that time. The facility submitted a plan of removal that was accepted on 05/21/19 at 4:20 PM. The Plan of Removal documented the following: Immediate Actions: 1. 12 residents were identified for having consumed undercooked eggs and were assessed by licensed nursing staff for signs and symptoms of gastrointestinal distress on 05/21/2019. 2. All non-pasteurized eggs were removed and disposed of on 05/21/2019. 3. Pasteurized eggs were acquired from a sister location on 05/21/2019. 4. The vendor district sales manager has been notified by the Area Director on 05/21/2019 that the facility is only to acquire pasteurized eggs and non-pasteurized eggs were removed from the order guide. 5. Dietary Supervisor was in-serviced on ensuring only pasteurized eggs are purchased and served at all times in the facility. The in-service also contained information explaining how to identify pasteurized eggs from non-pasteurized eggs. This in-service was carried out on 05/21/2019. 6. All dietary staff were in-serviced on ensuring only pasteurized eggs are served and how to identify pasteurized eggs from non-pasteurized eggs on 05/21/2019. 7. The medical director and licensed dietician were notified that the facility will only use pasteurized eggs and of plan of removal on 05/21/2019. Oversight: 1. The Dietary Manager will review weekly orders with administrator to ensure only pasteurized eggs are ordered. 2. Administrator will check the food order with the vendor to ensure only pasteurized eggs are purchased. 3. The Dietary Manager, with the Administrator, will randomly check once a week to ensure only pasteurized eggs are being purchased. 4. The Registered Dietician on visits to the facility will check once a month to ensure only pasteurized eggs are being purchased. 5. Areas of concern identified on daily audits will be reviewed at the standards of care meeting to develop and modify plan of action. Observation on 05/22/2019 at 8:33 AM and at 9:51 AM revealed there were no unpasteurized eggs in the walk-in refrigerator. Pasteurized eggs were used for soft cooked eggs. In an interview and observation on 05/22/2019 at 9:52 AM Cook D stated that when preparing undercooked eggs, she had to use pasteurized. She further clarified by demonstrating how to determine that the egg was pasteurized by inspecting an egg in the walk-in refrigerator for a blue P stamped on the egg. Review of In-Service Training Report dated 05/21/2019 documented the dietary staff received training on the proper use and cooking methods of eggs and other potentially hazardous food items. The training was conducted by the facility Dietary Manager. The IJ was lifted on 05/22/2019 at 8:25 AM, at which time the facility Administrator was notified of the accepted plan of removal and the scope and severity was reduced to a level of no actual harm with potential for more than minimum harm at a pattern. B) Food labeling and storage Observation on 05/21/2019 at 8:15 AM during the initial observation of the kitchen revealed: 1. A metallic pan siting on the bottom shelf in a walk-in refrigerator filled with ground beef that was dated as being prepared on 5/20/19, but had no use by date. 2. One container with sliced tomatoes dated as being prepared on 5/20/19 with no use by date on the container. 3. An unopened box of cream cheese found under the walk-in refrigerator fan that was covered in mold on the top surface of the packaging and was not dated. In an interview on 05/21/2019 at 8:17 AM the Dietary Manager stated that the containers with beef and tomatoes had been dated the date they were pulled from the freezer and when they were prepared respectively. He stated that he did not know why the container of cream cheese was not dated. Review of the facility policy Food Storage dated 2008 stated, in part, that Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high-risk food.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards and residents received adequate supervision and assistance devices to prevent accidents for two (Resident #2 and #3) of five residents reviewed for accidents. The Wound Care Nurse failed to properly position Resident #2 when he went to his cart to retrieve forgotten supplies. When the Wound Care Nurse returned to the room, Resident #2 was on the floor face down. Resident #2, a resident with a [MEDICAL CONDITION], had multiple lacerations to his face and arms and required transport to the hospital for stitches. The staff failed to safely transport Resident #3, a ventilator resident, into the shower room which resulted in scrapes and bruises. This failure could affect the 14 residents treated by the wound care nurse and the 19 residents on the ventilator unit by placing them at risk for injuries. Findings included: Resident #2 Review of closed record for Resident #2's face sheet dated 2/27/2018 documented in part, Resident #2 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED].clevelandclinic.org/health/articles/wegeners-[DIAGNOSES REDACTED]tosis [DIAGNOSES REDACTED]tosis with polyangiitis (Wegener's) (GPA) is a rare disease of uncertain cause. It is the result of inflammation within the tissues called [DIAGNOSES REDACTED]tous inflammation and blood vessel inflammation (vasculitis), which can damage organ systems. The area's most commonly affected by GPA include the sinuses, lungs, and kidneys, but any site can be affected.), Pain, [MEDICAL CONDITION] status, gastrostomy, and acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented bed mobility required extensive assistance of two + persons physical assist. Review of Resident #2's Care Plan dated as last review/revised 11/27/2017 documented in part: At risk for falls due to decreased mobility,[MEDICAL CONDITION], Reisdent #2 will be free of falls with major injury, implement exercise program that targets resident's strength, gait and balance. Review of Admission Fall Risk assessment dated [DATE] documented in part; Resident #2 was a high risk of falls. Review of Physicial Therapy (PT) Plan of Care dated 11/19/2017 thru 1/19/2018 revealed the current level of bed mobility function required Maximum assistance (76 - 99% assist). Review of the facility generated event report dated 01/16/2018 at 8:24 AM documented on 01/16/2018 at 7:15 AM the nurse received a call from the Wound Care Nurse to Resident #2's room. Upon entering the room the resident was noted to be lying prone (face down) on the floor with blood noted to be oozing from a laceration to the forehead. Resident #2 was alert and oriented X 3 and able to answer questions appropriately. Resident #2 was in bed prior to the fall. He stated he started slipping and could not stop. Resident stated he may have lost consciousness for a couple of seconds. Resident complained of sharp pain to his forehead and no pain to his extremities. Resident denied any loss of sensation. Resident #2 was log rolled while maintaining his cervical spine to access his airway. Resident's [MEDICAL CONDITION] was midline and resident denied shortness of breath or dyspnea. Emergency Medical Services (EMS) arrived at 7:29 AM and resident was transported to the hospital. Review of the Complaint dated 01/19/2018 documented the emergency room Nurse was told by the resident that the Wound Care Nurse (WCN) left him on his side without rails on his bed. In an interview on 02/16/2018 at 2:40 PM the Wound Care Nurse said he went into Resident #2's room turned his tube feeding off, turned the resident over onto his side, removed his incontinent brief and wound patch on his left gluteal area. The Wound Care Nurse said he remembered he had forgotten something and went out to get it and when he came back the resident was on the floor on the right side of his bed and blood was on the floor he had cut his head. The Licensed Vocational Nurse (LVN) and the Certified Nursing Assistant (CNA) came to help. He said the resident had [MEDICAL CONDITION] was on an air mattress. The Wound Care Nurse said the Nurse Practitioner was at the facility and said send Resident #2 out to the hospital. The Wound Care Nurse said he turned Resident #2 back onto his back before he went out of the room. In an interview on 02/20/2018 at 10:00 AM LVN A said he went into Resident #2's room at 7 or 8 AM and checked his vital signs, at that time Resident #2 was positioned appropriately, while he was in the room Respiratory Therapist(RT) B came in. LVN A said about 20 minutes later WCN called him to go to Resident #2's room. LVN A said when he entered the room he saw the resident on the floor on his face. He said himself along with the WCN and the CNA did a log roll to not compromise the resident's cervical spine but he had to check his airway. LVN A said the resident had a laceration to his face. He said staff called 911 and EMS came. LVN A said Resident #2 didn't have movement, he could only move his arms, so he can't imagine how he fell to the floor. LVN A said when he first went in the room the resident told him he slid off the bed but he cannot imagine how the resident slipped off of the bed if he was positioned correctly in the bed. In an interview on 02/23/2018 at 2:50 PN LVN C said Resident #2 could move his arms a little, he could use the television remote, but he could not move from the waist down. LVN C said Resident #2 could not roll over or move on his own. In an interview on 02/23/2018 at 2:55 PM Respiratory Therapist (RT) B said Resident #2 could move his arms but not his body. Observation on 02/23/2018 at 3:00 PM with LVN C was made of the type of bed Resident #2 used when he was in the facility. Resident #2 was discharged on [DATE] and was no longer a resident in the facility. Resident #2 had a Derma Float low air loss Joerns Bed. The bed was an air bed with firm bolsters along each side. Review of the Derma Float low air loss Joerns Bed literature, undated, provided by the Director of Medical Records documented the bed had CairRails risk management side air bolsters. The bed also had a transport and power failure safety measure and stays inflated for up to 12 hours. In an interview on 02/26/2018 at 10:30 AM Physical Therapist (PT) F said Resident #2's arms were fine but not his lower muscles. PT F said Resident #2 required maximum assistance of 2 staff to reposition in bed. PT F said Resident #2 could not move on his own in bed, he could not turn over and he could not get out of bed by himself. In an interview on 02/26/2018 at 11:25 AM LVN G said Resident #2 required maximum assistance to turn but could move his arms. In an interview on 02/26/2018 at 11:32 AM CNA I said Resident #2 was extensive, maximum assistance to turn over. CNA I said Resident #2 could not turn over or move over by himself. In an interview on 02/26/2018 at 11:35 AM CNA H said Resident #2 required maximum assistance to turn or move. In an interview on 02/26/2018 at 11:50 AM RT B said she never saw Resident #2 move. RT B said Resident #2 could not move by himself, he had to have staff move him. In an interview on 02/26/2018 at 12:00 PM LVN A said Resident #2 did not have side rails on his bed because he had no movement from the waist down. LVN A said the resident could only move his hands and arms. LVN A said Resident #2 could not pull himself over or hold himself over using the side rail. LVN A said they did not want Resident #2 to get his arm stuck in a rail and break it. In an interview on 02/26/2018 at 2:15 PM LVN J said he only took care of Resident #2 for a short period of time. LVN J said on the Admission Fall Risk Assessment he completed it using the information from the hospital. In an interview on 02/27/2018 at 2:15 PM the daughter of Resident #2 said her father fell off of the bed and had laceration on his head and skin tears. She said 1 laceration required stitches. Resident #2's daughter said her father told the nurse at the hospital that the Wound Care Nurse left him turned on the side of the bed. Review of Wound Care Nurse personnel file revealed a Personnel Disciplinary Record dated 1/16/2018, a written warning. The reason for action documented: Employee was caring for Resident #2 and interrupted his care to retrieve something and left resident vulnerable and resident subsequently fell out of bed. Resident #3 Review of face sheet dated 2/27/2018 documented in part Resident #3 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3 resided on 400 hall. Review of comprehensive Minimum Data Set ((MDS) dated [DATE] documented Resident #3 required: Total dependence of two + staff for bed mobility Total dependence of two + staff for transfer Total dependence of two + staff for incontinent care Total dependence of one staff for personal hygiene such as shaving, brushing teeth, washing and drying hands and face Total dependence of one staff for bathing (bath, shower, and sponge bath). Total dependence of one staff for eating Review of Care Plan dated as reviewed/revised 2/13/2018 documented in part: Total dependence of 2 people for shower Turn and reposition every 2 hours and as needed Oral care every shift and as needed Provide range of motion exercises as needed Keep linens free from wrinkles Monitor resident every 2 hours and as needed Increased staff supervision with intensity based on resident needs Review of Fall Event Report documented Resident #3 had a fall on 2/5/2018 at 2:08 PM. The report documented the resident was being transported to the shower room by staff and he slid out of the shower chair. The report documented he obtained an abrasion to mid and lower back. Review of Progress Notes dated 2/5/2018 at 2:24 PM documented it was reported that Resident #3 As being transported to the shower room and upon entering the room that the resident slid out of the shower chair and was assisted to the floor by the CNA and resident was lifted back into the shower chair. Upon initial assessment it was noted that the resident had scratches noted to mid and lower back and buttock. At 2:52 PM new, orders were given to perform X-Ray of lumbar, [MEDICATION NAME] spine and bilateral hips. Apply antibiotic ointment to abrasions on back. Observation on 2/12/2018 at 4:46 PM Resident #3 was in bed lying on right side with ventilator and tube feeding. Resident #3 was clean and dry. In an interview on 2/12/2018 at 4:47 PM Resident #3's mother said her son had a fall from the shower chair the previous week. She said as a result of the fall he had burns, scrapes and bruises on his back, sides and hips. She said the Director of Nursing (DON) was putting CNA's to work on the ventilator unit without experience or training, they are always joking and playing around, they are not concerned for the residents and they don't know how to handle the residents with the tubes. In an interview on 2/13/2018 at 12:00 PM CNA H said last week CNA D was going to work a double so he asked him to help him get ahead and help with some evening showers so CNA H said yes. Resident #3's mother wanted him to use a specific shower chair, one that had a straight back so they put him in it via Hoyer lift and they were going over the shower room threshold CNA H was pulling the back of the shower chair backwards through the door and CNA D was rolling the VENT and the oxygen. CNA H said when he picked up the back of the chair Resident #3 shifted, because he is stiff, and he slid right out of the chair. It was shift change and everyone was there the nurses and RT came to look. CNA's H and D lifted the resident back into the chair using the Hoyer sling that was under him. In an interview on 2/16/2018 at 10:50 AM CNA D said he had worked at the facility as an aide about 1 year. He said he had special training before working on the ventilator unit. CNA D said Resident #3's mother doesn't want the CNA's to use the shower bed, she wants them to use the shower chair. He said on 2/5/2018 he was asked to stay over and work the next shift and agreed. CNA D said he asked the other day shift CNA to help him with some showers before he left and he agreed. He said the two of them were taking Resident #3 into the shower room CNA D had the vent and oxygen and CNA H had the resident. When CNA H went over the shower room threshold the resident slipped out of the chair. CNA D said it was shift change and the nurses came right away. He said they lifted Resident #3 back into the shower chair using the hoyer lift sling. CNA D said the shower chair does not have a seat belt or safety strap to secure a resident. In an interview on 02/20/2018 at 10:15 AM Licensed Vocation Nurse (LVN) said the incident with Resident #3 happened at shift change and everyone was in the hall. He said Resident #3 was on the floor and the CNA's reported to him as they went over the shower room threshold Resident #3 slipped out of the shower chair. Observation on 02/16/2018 at 4:00 PM revealed the shower chair was made out of PVC pipe, had a straight back and the seat and back were blue mesh. No straps were observed. Review of Policy and Procedure titled Safety and Supervision of Residents dated as revised (MONTH) 2007 documented in part: Our facility strives to make the environment as free from accident hazards as possible. Staff shall use various sources to identify risk factors Resident supervision is a core component of the systems approach to safety. Review of Facility Wound Summary Report dated 02/27/2018 provided by the Director of Nursing documented 14 residents receive wound care. Review on Facility Census dated 2/12/2018 documented 19 residents resides on ventilator unit 500 hall.

Based on interview and record review, the facility failed to implement measures to ensure residents received assistive decives to prevent accidents for 1 out of 4 (Resident #1) residents who were reviewed for accidents and supervision. Resident #1 who had been identified as a high risk for falls, fell from her bed on 2-4-17 around 4:10pm. Resident #1 sustained a fracture to her left tibia (one of the two bones in the lowere leg). Safety precautions were not in place at the time of the fall. This failure resulted in harm to Resident #1 and could have placed 63 residents identified at risk for falls at risk of not receiving the adequate supervision and/or measures to prevent accidents. Findings include: Record review of the Resident Admission Record revealed Resident #1 was a [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the most recent MDS ( Minimum Data Set) dated 2/1/17 documented Resident #1 required extensive assistance of one person to for bed mobility. Review of the most recent Fall Risk assessment dated [DATE] for Resident #1 documented an assessment score of 12. A score of 10 or higher represented a high risk for falls. Review of the Care Plan dated 12-16-16 documented Resident #1 was at risk for falling with the following interventions to prevent falls: -bed and chair alarm -low bed at all times -floor mats while resident is in bed There was no observation of Resident #1 as she was transferred out of the facility to the hospital. Review of the Provider Report documented Resident #1 was found on the floor on 2-4-17 around 4:10pm by housekeeping staff who reported this to LVN A. LVN A went to the room and assessed resident. Resident #1 was noted on the floor with her left lower leg deformed. 911 was called and the resident was sent out to the hospital. In an interview on 2-9-17 at 3:30 pm, LVN A he stated he was called to the room of Resident #1 on 2-4-17. When he arrived to the room he noted Resident #1 sitting on the floor next to her bed and her left leg was bent backwards. LVN A stated he began his assessment of Resident #1 and tried to move her left leg forward. At this time, LVN A noticed the leg was broken and stopped the assessment. LVN A stated he contacted 911. Resident #1 was unable to state how she fell but did inform LVN A that she was in pain. LVN A medicated resident #1 for pain prior to the ambulance arrival. LVN A stated resident #1 was a known risk for falls and was to have close supervision when up. LVN A stated the resident was in bed sleeping before she fell but after the fall he noticed her bed was not in the lowest position as it should have been. LVN A also stated when he found the resident on the floor she did not have any floor mats next to her bed or a bed alarm. In a telephone interview on 2-9-17 at 12:00pm with Housekeeping C, she stated on 2-4-17 she heard Resident #1 scream. When Housekeeper C got to the room the resident was already on the floor. Housekeeper C stated she informed the nurses. Housekeeper C stated the bed was not in the lowest position and there we no floor mats on the floor next to the bed. In an interview with RN B on 2-9-17 at 2:15pm, she stated the day Resident #1 fell (2-4-17) she was the weekend supervisor for the shift. RN B was notified that Resident #1 was found on the floor next to her bed close to the door. RN B stated when she entered the room of Resident #1 she noted the broken left leg. RN B stated the bed was not in the lowest position and the call bell was on the floor between the two beds. RN B stated she did not see any floor mats next to the bed on the floor. In an interview with the DON on 2-8-17 at 2:40pm, she stated the facility was still conducting the investigation but she was not sure why the safety measures for Resident #1 were not in place as outlined by her Care Plans. The DON stated everyone was aware of Resident #1 and her fall risk. The DON stated as a result of the fall the resident fractured her left tibia and the family did not wish to bring Resident #1 back to the facility. Record Review of the Fall Policy dated December 2007 stated in part: staff will identify interventions related to the resident;s specific risk and causes to prevent the resident from falling and try to minimize complications from falling. The 63 resident that were at risk for falls was obtained from an interview with the Administrator on 2-9-16 at 2:30pm.

Based on observation, interview and record review the facility failed to ensure 7 (ID #9, #17, #4, #16, #14, #8 and #5) of 13 residents reviewed for pressure ulcers received the necessary care and treatment to promote healing and/or to prevent infection of current pressure ulcers as evidenced by: A. Resident #9 had two Stage II Pressure Ulcers to the sacrum/coccyx on admission on 10/09/15. No treatment orders were obtained until 10/23/15 (14 days later). The wound progressed to an unstageable wound identified on 11/16/15 which became infected requiring opiate medications to treat the pain, antibiotics and surgery. B. Resident #8, around 10/15/15, developed facility-acquired unstageable pressure ulcers to both heels. Physician ordered weekly skin assessments were not completed and Prevalon boots were not worn as ordered. C. Resident #14 had a stage 2 pressure ulcer on his coccyx and an unstageable pressure ulcer on his left heel. Dressings, Prevalon boots, supplements and weekly skin assessments were not being done according to physician orders. D. Resident #15 was admitted on [DATE] and was a high risk for developing pressure ulcers. On 12/28/15 a deep tissue injury was identified. No subsequent Skin Assessments or Skin Integrity Condition reports were completed and the wound progressed to an unstageable pressure ulcer on 1/12/15. Resident #15 was not wearing the physician ordered Prevalon boots. E. Resident #4 developed a stage 2 pressure ulcer on his right buttock on 12/08/15. No orders for wound treatment were obtained until 12/28/15 (20 days later). F. Resident #16 had an unstageable pressure ulcer to her right heel identified on 12/16/15 and on her left heel on 12/18/15. There was no treatment for [REDACTED]. G. Resident #17 was identified with a facility-acquired deep tissue injury on his left heel on 12/16/15. Weekly Skin Assessments did not document the DTI as well as the Skin Integrity Condition Reports until 1/10/16. There was no treatment of [REDACTED]. This deficient practice resulted in an immediate jeopardy identified on 1/08/16. While the immediate jeopardy was removed on 1/14/16, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. The failure could affect the 15 residents identified with pressure ulcers by placing them at risk for delayed treatment and interventions to prevent pressure ulcer development, deterioration, infection, hospitalization , and death. The findings are: Resident #9 Closed record review of the Resident Admission Record revealed Resident #9 was a [AGE] year old female admitted on [DATE]. She was transferred to the hospital on [DATE]. Review of the History & Physical dated 10/21/15 documented Resident#9 had [DIAGNOSES REDACTED]. Review of the transferring Hospital Wound Care Progress Notes for Resident #9 dated 10/05/15 documented resident #9 had two stage II pressure ulcers on coccyx/sacrum, #1 measured 3 cm x 0.5 cm; pink/red/black, macerated, no drainage, wound bed-beefy red with granulation, slough, moist, no odor; #2 measured 2 cm x 1 cm. Treated with Calazine lotion daily and as needed. A Stage II is a partial thickness loss of skin layers that presents clinically as an abrasion, blister or shallow crater. The facility's Admission Nursing assessment dated [DATE] by License Vocational Nurse (LVN) O documented Resident #9 was admitted from acute care and required total assistance of two persons with Activities of Daily, was bed bound and was incontinent of bowel & bladder; Skin integrity-Stasis Ulcers. The assessment did not indicate resident #9 had two stage II pressure ulcers on the coccyx/sacrum upon admission to the facility. Review of Resident Progress Note (Nurses Note) dated 10/09/15 documented Resident #9 arrived at 6:56 PM via ambulance. The Note did not indicate resident had two stage II pressure ulcers on coccyx/sacrum present on arrival. In an interview on 01/07/16 at 10:34 AM, LVN F reported that Head to Toe assessments are done on the resident on admission. We (the nurses) will document if the resident has any type of skin breakdown, rashes etc. in the Admission Skin Assessment. Skin assessments are done ( by the floor nurse) on a weekly basis Monday - Friday on the day and evening shifts according to shower schedules. Licensed Staff are not allowed to stage wounds. Only the Certified Wound Care Nurse can stage the wounds. We are only allowed to document a description of what we found in the Resident Progress Notes. I do not know who will follow up on the skin assessments. LVN F reported that if the nurses identified skin problems they referred them to the Treatment Nurse. Review of Resident #9's Admission physician's orders [REDACTED]. There was an order for [REDACTED]. Review of the Braden assessment dated [DATE] scored Resident #9 at a 13 which is a moderate risk for pressure ulcers. Review of Care Plan initiated 10/09/15 did not indicate Resident #9 had stage II pressure ulcers upon admission to facility or that the resident was at risk of development of pressure ulcers. In an interview on 1/14/16 at 10:18 AM, the MDS (Minimum Data Set) nurse and the Director of Nurses (DON) confirmed that the Care Plan dated 10/09/15 did not document resident #9 had stage II pressure ulcers. Review of an undated hand written Preliminary Care Plan with the Director of Nurses (DON) and the MDS (Minimum Data Set) Nurse indicated Resident #9 had two wounds to the sacrum. Review of the medical record for Skin Assessment sheets revealed none were completed prior to 10/23/15. There were no further Skin Assessments completed prior to Resident #9's discharge on 11/23/15. Review of Resident #9's Physician order [REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] documented Resident #9 was at risk of developing pressure ulcers but did not have any pressure ulcers. Review of MDS PPS 14 day assessment dated [DATE] documented Resident #9 was at risk of developing pressure but did not document the existing pressure ulcers. In an interview on 1/14/16 at 10:57 AM, the DON and the MDS nurse confirmed that the Admission MDS dated [DATE] and 14 day PPD MDS did not document Resident #9 was admitted from the hospital with stage II pressure ulcers to the coccyx/sacral area. The MDS Nurse stated, I did not claim the pressure ulcers on the MDS dated [DATE] because I did not see any physician's orders [REDACTED]. The MDS Nurse stated that the Corporate Wound Care Nurse and the previous Treatment Nurse would write the care plans for the residents that had pressure ulcers. The MDS Nurse reported that the new Treatment Nurse was not writing the wound care plans because she did not know that she was responsible for writing the care plans for those residents that had pressure ulcers. So I just started writing care plans for those residents with pressure ulcers like a week ago. There used to be two MDS nurses at the facility and apparently they have not been able to find a replacement. I am trying to do the best I can. Review of the Skin Integrity Conditions Report for Resident #9 dated on 10/23/15 documented in part: Excoriation with an opened area on coccyx area measuring 6 x 3 with Slough, surrounding tissue intact. The Free Medical Dictionary (accessed on 1/26/16) defined Excoriation as an injury to a surface of the body caused by trauma, such as scratching, abrasion, or a chemical or thermal burn. Slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy (at times). Review of Physician Telephone Order for Resident #9 dated 10/23/15 documented Excoriated opened area to coccyx measuring 6 x 3 with yellow matter in the middle of the wound, cleaned with normal saline, pat dry and apply Santyl; Cover with 4 x 4 dressing daily. At Santyl.com (accessed on 1/26/16) it is described as an FDA-approved prescription medication that removes dead tissue from wounds so they can heal. Review of Resident Progress Note for Resident #9 dated 11/16/15 documented in part by the former Treatment Nurse: Unstageable wound to coccyx measuring at 4 x 4.5 cm; Depth less than 0.1 cm with presence of Slough and Serosanguinous drainage. No odor; No signs & symptoms of infection. Surrounding tissue is excoriated. There was no change in treatment. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will either a Category/Stage III or IV.) The National Pressure Ulcer Advisory Panel - NPUAP http://www.npuap.org>NPUAP Pressure Ulcer Stages/Categories (accessed 1/13/16) In review of the Weekly Pressure Ulcer Quality Improvement (QI) Log, prepared by the Wound Care Nurse on a weekly basis, dated 10/16/15 and 10/30/15 there was no documentation of Resident #9's pressure ulcers. In an interview on 1/07/16 at 4:38 PM, the DON said the previous Treatment Nurse was overwhelmed with the position and had difficulty with all the documentation that was required for the residents' pressure ulcers. Review of the Weekly Pressure Ulcer QI Log dated 11/10/15 and 11/16/15 documented Resident #9 had an unstageable wound on her coccyx with moderate drainage. Review of Dietitian Progress Note dated 11/13/15 documented significant wound to Coccyx. Review of Resident #9's Progress Note dated 11/23/15 documented in part: Resident (#9) lethargic and profuse oozing through [DEVICE], greenish exudate. Son and daughter at bed side requested to send to the ER. MD and DON notified. Review of Resident #9's Hospital Wound Care notes dated 11/24/15 documented in part: admitted [DATE]. Present on Arrival Pressure Ulcer Sacrum; Wound length 6.0 cm; Width 4.5 cm; Depth 2.0 cm; Unstageable; Wound description Red, Yellow, Slough; Drainage Description : Moderate, serosanguinous. Review of Resident #9's Hospital Consultation report dated 11/26/15 documented in part: Reason for Consultation: Infected stage III-IV sacrum and coccyx decubitus pressure ulcer wound. There is [MEDICAL CONDITION] and maceration over the overly infected wound. Review of Hospital Microbiology Report dated 11/24/15 for Resident #9 documented wound culture-Moderate growth of Escherichia coli (*bacteria found in the environment, foods, and intestines of people and animals) and Moderate growth of [MEDICAL CONDITION] (*a bacteria that is resistant to many antibiotics. In the community, [MEDICAL CONDITION] infections are skin infections. Can cause life-threatening bloodstream infections, pneumonia and surgical site infections) and Heavy growth of Corynebacterium species (*the bacteria that causes [MEDICATION NAME]). *Source: cdc.gov (accessed on 1/27/16). Review of Resident #9's Hospital Progress Note dated 11/29/15 documented in part: patient has a large decubitus ulcer that requires opiate medications to control the pain. Review of Resident #9's Hospital Operative Report dated 12/15/15 documented in part: Stage IV sacral decubitus, infected. Operative Procedure Performed: Incision, debridement, washout tissue. Debridement, skin, subcutaneous tissue, muscle, and fascia were debrided all the way to the bone. Resident #8 Record review of the Resident Admission Record revealed Resident #8 was a [AGE] year old male re-admitted to the facility on [DATE]. Review of the History & Physical dated 05/15/14 documented Resident #8 had [DIAGNOSES REDACTED]. In an interview on 01/05/16 at 11:08 AM, the Medical Record Clerk confirmed that the last History & Physical done on resident #8 was dated 05/15/14. Record review of Physician order [REDACTED].#8 dated 09/01/15 - 01/09/16 documented Prevalon Boots to be worn at all times. Monitor for placement; Skin assessment on Tuesdays - a head to toe assessment of the resident's skin condition. Look for any problems with the skin. Review of Physician order [REDACTED]. Record review of Physician order [REDACTED]. Review of Skin Assessments for Resident #8 revealed none were completed until 11/28/15 that documented Resident #8 had unstageable pressure ulcers on both heels. The next Skin Assessment was dated 12/07/15 and it only documented a skin tear on his right elbow. There were no further Skin Assessments. In an interview on 12/31/15 at 10:43 AM, the DON said around 12/08/15 she and the ADONs (Assistant Director of Nurses) had assessed all residents to make sure no pressure ulcers had been missed and they were in the midst of a second skin sweep. She did not know why Resident #8's pressure ulcers on his heels were not documented. In an interview on 1/05/16 at 10:13 AM, the DON, when asked for the facility policy and procedure for wound prevention and said she could not find any wound prevention policies at that time but she would continue to look for the polices by the current owners. The DON stated that the facility uses the Braden Scale which is the risk tool and drives the interventions for all skin care. In an interview on 1/07/16 at 4:28 PM, the DON said the nurses missed a lot of Skin Assessments in November, December and January. She did not know why. The DON said the nurses had received in-services, in October and December, concerning their responsibilities in doing the skin assessments. Observation on 01/05/16 at 2:19 PM, Resident #8 was lying in bed asleep and did not have Prevalon Boots on. Observation on 01/06/16 at 10:19 AM, Resident #8 was sitting in a wheelchair in the therapy room working on a jigsaw puzzle. It was observed that the resident did not have the Prevalon Boots on. Observation on 1/08/16 at 2:16 PM, accompanied by Licensed Vocational Nurse (LVN) C, Resident #8 was lying in bed on his back, and did not have Prevalon Boots on. The resident was complaining of pain to the heels. LVN C reported the resident had bilateral pressure ulcers on the heels. Bilateral heels were wrapped with Kerlix gauze. LVN C confirmed that Resident #8 had physician orders [REDACTED]. Prevalon Boots provide pressure relieving to prevent heel ulcers. LVN C looked for the Prevalon Boots in the closet and in the nightstand drawers and did not find the Prevalon Boots. LVN C told the resident, I am going to get you some new Prevalon Boots. Observation on 1/12/16 at 11:17 AM, with the Wound Care Nurse and the DON revealed Resident #8 had an unstageable pressure ulcer on the left heel measuring 1 cm x .7 cm; maceration, pale tissue. The right heel had an unstageable pressure ulcer measuring 3.7 cm x 2.6 cm; slough noted to middle of wound. The DON reported that the resident did not use the Prevalon Boots when sitting in wheelchair because he was going to therapy. Review of Dietitian Note dated 11/17/15 documented Resident #8 had a Stage II pressure on left heel; MVI (multivitamins) with minerals in place. Recommend Pro-Stat 30 ml by mouth twice a day x 30 days. Record review of Nursing Progress Notes dated 11/25/15 documented Resident #8 had an unstageable pressure ulcer on the right heel. Review of Resident #8's MAR (Medication Administration Record) dated November 2015 with the DON revealed the Pro-Stat was started 10 days later on 11/27/15. Review of the facility's Weekly Pressure Ulcer QI Log revealed the following entries for Resident #8: a. 10/16/15 - facility acquired right (1.2 cm X 1.3 cm) and left heel (1.3 X 1.5)unstageable pressure ulcers treated with Santyl b. 10/30/15 - 2 entries. 1) right (0.5 X 0.2) and left (1 X 1.2) heel unstageable pressure ulcers treated with Santyl. 2) right and left heels, no information except treated with [MEDICATION NAME]. c. 11/9/15 - left heel stage 2 no further information d. 11/10/15 - left heel stage 2 (1 X 1) treated with [MEDICATION NAME] e. 11/16/15 - left heel stage 3 (1 X 1) treated with [MEDICATION NAME] f. 11/17/15 - left heel stage 2 (1 X 1) depth undetermined. treated with [MEDICATION NAME] g. 11/27/15 - left heel unstageable (1 X 1) [MEDICATION NAME]; right heel unstageable, treated with skin prep and [MEDICATION NAME] h. 12/04/15 - left heel stage 3 (1 X 1) [MEDICATION NAME]; right heel unstageable skip prep (no measurements) i. 12/08/15 - left (1 X 1) and right (1 X 1.5) heel unstageable treated with Santyl j. 12//09/15 - left heel stage 3 (1 X 1) [MEDICATION NAME] and right (no measurement) heel unstageable treated with skin prep k. 12/21/15 - left (1 X 1) and right (1 X 1.5) heels unstageable treated with [MEDICATION NAME] l. 12/21/15 - left (1 X 1) and right (1 X 1.5) heels unstageable; left treated with [MEDICATION NAME] and right with skin prep and [MEDICATION NAME] m. 12/28/15 - admitted with left (1 X 1) and right (1 X 1.5) heels unstageable treated with [MEDICATION NAME] and skin prep (right) n. 1/04/16 - left (1 X 0.8) and right (1 X 1.2) heels unstageable treated with Santyl Review of Skin Integrity Condition Reports for this above time frame revealed there were none for Resident #8. (Document each wound's condition, measurement, treatments, stages). In an interview on 1/07/16 at 10:40 AM, the Wound Treatment Nurse said she usually fills out the Skin Integrity Condition reports once a week. She said the ADONs complete the Braden Scale but does not know the timing for the Bradens. The Wound Treatment Nurse did not have a reason for not filling out the Skin Integrity Condition reports for Resident #8. In an interview on 01/09/16 at 9:19 AM, the Medical Record Clerk reported that there was no documentation in the electronic record that indicated a Quarterly Braden Scale (used to assess the risk for pressure ulcers) had been completed for Resident #8. (should have had one completed quarterly and on readmission) In review of PPS 5 day MDS assessment dated [DATE] for Resident #8 there was no documentation he had an Unstageable - Suspected Deep Tissue ulcer. Review of PPS 14 day MDS assessment dated [DATE] for Resident #8 documented in part: Did not document resident had Unstageable - Suspected Deep Tissue. In an interview on 1/14/16 at 10:51 AM, the MDS Nurse and the DON confirmed that the PPS 5 day MDS and PPS 14 day MDS dated [DATE] did not document Resident #8 had bilateral unstageable pressure ulcers on the heels. The MDS Nurse confirmed that the most current Care Plan for Resident #8, dated 5/14/15, did not document Resident #8 had unstageable pressure ulcers to both heels and did not document the resident had Physician orders [REDACTED]. Review of In-Service Training Report dated 10/08/15 documented skin assessments should be performed on admission and then weekly by the charge nurses. Skin assessments should be no longer than 7 days apart. Document if no changes. On residents with identified wounds, the area should be documented and note that treatment is in progress. The skin assessment should be completed in Matrix (computer program) printed and placed in the binder at nurses station. Review of In-Service Training Report dated 12/30/15, nurses, CNAs and CMAs were in-serviced on see attached, pressure sores, applying barrier cream, repositioning Q 2 hours, report area of concern to nurse and wound care nurse, DON and ADON, keeping skin dry, report if Resident not hydrating or consuming of meals poorly. One of the attached pages titled Understanding CMS Interpretation of F314: page 3 stated under interventions: Pressure relief for heels. Resident #14 Record review of the Resident Admission Record revealed Resident #14 was a [AGE] year old male admitted on [DATE]. Review of physician progress notes [REDACTED].#14 had [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] revealed Resident #14 had 1 unhealed stage 2 pressure ulcer not present on admission/entry or reentry. Record review of the annual MDS dated [DATE] revealed Resident #9 had 2 unhealed stage 2 pressure ulcers. Record review of Resident #14's Care Plan for Pressure Ulcer with a start date of 11/18/15, stage 2 to coccyx and stage 2 to left heel. Interventions included to assess the skin weekly for changes and on admission/readmission; complete Braden on admission and quarterly; provide adequate hydration, nutrition and supplements as needed to promote and maintain wound healing. Page 2 of the Pressure Ulcer was dated 11/12/15 and documented a stage 2 pressure ulcer on the he left heel. Interventions included assess the pressure ulcer for location, state, size, presence/absence of granulation tissue and epithelization daily; conduct a systematic skin inspection weekly, give vitamins and minerals, use Prevalon for pressure reduction when Resident is in chair. Review of Resident #14's Physician order [REDACTED]. Weekly Skin assessments on Fridays as ordered. Record review of the Braden Scale for Prediction of Pressure Sore Risk dated 9/17/15 revealed a score of 17 - at risk. Record review of Skin Assessments from 11/13/15 to 1/08/16 for Resident #14 revealed 4 assessments were completed (11/13/15, 11/20/15, 12/14/15 and 1/08/16) leaving 5 weeks without a skin assessment (11/27/15, 12/04/15, 12/18/15, 12/25/15 and 1/01/16). Record review of (weekly) Skin Integrity Conditions for Resident #14 from 11/13/15 through 1/10/16 revealed 2 reports were needed for each week (2 wounds). Reports were completed on 11/26/15 and 1/10/16. Reports for 11/13/15, 11/20/15, 12/04/15, 12/11/15, 12/18/15, 12/25/15 and 1/01/15 (14 reports not completed on Resident #14's pressure ulcers). Record review of the Weekly Pressure Ulcer QI Log, completed by the Wound Care Nurse, revealed Resident #14 did not appear on the log until 11/10/15. The Logs revealed: a. 11/10/15 - left heel stage 2 (3.5 cm X 4 cm), treated with hydrogel b. 11/16/15 - left heel stage 2 (3.5 X 4), hydrogel c. 11/17/15 - left heel stage 2 (3.5 X 1), [MEDICATION NAME] d. 11/27/15 - left heel (2 X 0.5) state 2, hydrogel and sacrum stage 2 (0,5 X 0,5) [MEDICATION NAME] e. 12/04/15 - left heel stage 2 (2.5 X 0.5) [MEDICATION NAME] and sacrum stage 2 (1 X 0.5) [MEDICATION NAME] f. 12/08/15 - left heel stage 2 (2 X 0,5) hydrogel, sacrum stage 2 (0.5 X 0.5) [MEDICATION NAME] g. 12/09/15 - left heel stage 2 (2.5 X 0.5) [MEDICATION NAME], sacrum stage 2 (1 X 0.5) [MEDICATION NAME] h. 12/21/15 - left heel stage 2 (2 X 0.5) hydrogel, sacrum state 2 (0.5 X 0.5) [MEDICATION NAME] i. 12/28/15 - facility acquired left heel stage 2 (2 X 0.5), sacrum stage 2 (0.5 X 0.5) j. 1/04/16 - facility acquired left heel unstageable (2 X 0.5) skin prep, coccyx stage 2 (0.5 X 0.5) [MEDICATION NAME] Observation on 1/09/16 at 10:51 AM, revealed resident #14 was lying in bed asleep with slippers on his feet. Observation on 1/12/16 at 9:04 AM, with the Wound Care Nurse and the DON revealed Resident #14 was lying in bed without the Prevalon Boots. There was Kerlix gauze around the Left ankle. The Wound Care Nurse stated that the Kerlix should be on the left heel. It was observed that resident had a soiled disposable brief with feces and urine. There was no dressing on the wound on the coccyx. The wound was full of feces. The Wound Care Nurse stated, I have told the nurses on the evening and night shifts to make sure that they check that the dressing is in place and/or change the dressing to the wound as needed. The resident had a stage II pressure on the coccyx measuring .5 cm x .5 cm and a stage II (partial thickness loss of skin layers that presents clinically as an abrasion, blister or shallow crater) pressure ulcer on the sacrum measuring 1 cm x 1 cm. The DON stated, This is a chronic on the sacrum and is treated with [MEDICATION NAME]. The resident had bright red excoriation on the groin area and shearing on the scrotum measuring 0.4 cm x 0.8 cm. The DON demonstrated to the surveyor that the shearing was probably caused when the Certified Nurse Aides (CNA) pulled the disposable brief from under the resident towards the front to change it when soiled. It was observed that [MEDICATION NAME] ointment was applied to the coccyx, scrotum and groin area. The resident complained of pain as the [MEDICATION NAME] was applied to the scrotum. The DON stated that the shearing was just identified today and would be calling the Physician for orders to treat. Resident #14 had an Unstageable pressure ulcer to the Left Heel measuring 2 cm x 0.5 cm. Review of Physician Telephone Order for Resident #14 dated 12/29/15 documented Discontinue [MEDICATION NAME] to scrotum. Apply skin barrier after each incontinent episode. Review of Physician Telephone Order for Resident #14 dated 12/29/15 documented to clean the left heel with normal saline, apply hydrogel (woundcareadvisor.com on 1/27/16 defines hydrogel is 90% water in a gel base, which helps regulate fluid exchange from the wound surface), cover with [MEDICATION NAME], abdominal pad and wrap with Kerlix daily and as needed. Review of Physician Telephone Order For Resident #14 dated 1/04/16 documented Vitamin C 500 mg by mouth once a day x 14 days and Zinc Sulfate 220 mg by mouth once a day x 14 days to promote healing. Review of the Medication Administration Record [REDACTED]. In an interview on 1/13/16 at 9:56 AM, the DON reported that she was responsible for calling the Physician to get orders for the Dietitian Recommendations and for entering the new orders in the electronic clinical record. The DON stated, I remember entering both orders in the computer for resident #14. I probably just forgot to save the order after I entered the order in the computer for the Zinc Sulfate and that is why the MAR indicated [REDACTED]. Resident #15 Record review of the Resident Admission Record revealed Resident #15 was a [AGE] year old female admitted on [DATE]. Review of History & Physical dated 12/31/15 documented Resident #15 had [DIAGNOSES REDACTED]. The H & P did not document resident #15 had DTI (deep tissue injury) to her right heel. Review of the Initial Admission Nursing Assessment and Admission Nurses Note dated 12/18/15 for Resident #15 did not indicate the resident had any skin issues. The resident was oriented x 1, required total assistance of one person with Activities of Daily Living and was incontinent of bowel & bladder. Review of Braden Scale for Prediction of Pressure Sore Risk dated 12/18/15 for Resident #15 indicated a Score of 10 (10-12 High Risk for skin breakdown). Record review of Resident #15's Skin Assessments from 12/18/15 to 1/08/16 revealed only 1 of 5 weekly skin assessments was completed and that was the admission assessment on 12/18/15. This assessment documented there were no skin issues for Resident #15. Assessments due 12/25/15 and 1/01/16 and 1/08/16 were not completed. The Medical Record Clerk confirmed she had no other Skin Assessments. Review of Resident #15's Nurses Note dated 12/28/15 documented Certified Nurse Aide (CNA) alerted nurse resident had a darkened area on right heel will alert on-coming Wound Treatment Nurse. Record review of the (weekly) Skin Integrity Condition report revealed there were no reports completed until 1/10/16. This was confirmed by the Medical Records Clerk on 1/15/16. Review of Physician Telephone Order dated 12/30/15 (2 days after the deep tissue injury on the right heel was identified) for Resident #15 documented Prevalon boots in place at all times. There was no written order for treatment of [REDACTED]. Record review of Resident #15's MAR for December 2015 documented treatments were started for the right heel pressure ulcer on 12/30/15 - 2 days after it was identified. Record review of Resident #15's Care Plan dated a problem of Pressure Ulcer with a start date of 12/28/15 of a right heel deep tissue injury. The interventions included to assess the pressure ulcer for location, stage, size, presence or absence or granulation tissue and epithelization; conduct a systematic skin inspection weekly. Observation on 01/09/16 at 11:04 AM, with the Wound Care Nurse revealed Resident #15 was lying in bed without the Prevalon Boots. The Wound Care Nurse reported that the Prevalon Boots should be on at all times. Observation on 01/12/16 at 10:05 AM, with the Wound Care Nurse and the DON revealed a DTI to the right heel measuring 4.3 cm x 3 cm. The Wound Care Nurse stated that now the resident had area in the middle of the DTI measuring 2.9 cm x 1.9 cm of black eschar and was now going to stage the wound to the right heel as unstageable. I am going to get new orders to treat the unstageable. She did not have the eschar yesterday when I did the treatment. The area was cleaned with skin prep, covered with a 4 x 4 gauze and wrapped with Kerlix gauze. Prevalon Boots were put on both lower extremities. Review of the Care Plan dated 12/28/15 documented in part: DTI (Deep Tissue Injury) to right heel. Conduct a systematic skin weekly report and report any signs of further skin breakdown. The Care Plan had not been updated to reflect the physician order [REDACTED]. Resident #4 Record review of electronic records documented Resident #4 was a [AGE] year old man admitted on [DATE]. Record review of a physician progress notes [REDACTED]. Record review of the quarterly MDS dated [DATE], the Section M Skin Conditions documented no pressure ulcers. Record review of the Braden Scale for Prediction of Pressure Sore Risk dated 9/10/15 revealed a score of 16 (at risk). There were no subsequent Braden Scales in the medical record. Review of the weekly Skin Assessment for Resident #4 on the following dates documented skin issues: a. 12/02/15 - no skin issues b. 12/08/15 - right buttock. There was no description of the pressure ulcer. b. 12/23/15 - (2 weeks later) skin tear right buttock d.

Based on interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychological well-being, in accordance with the comprehensive assessment and plan of care, for 1 of 11 residents with tracheostomies (an artificial hole in the neck for the purpose of breathing) who were reviewed for quality of care. Resident #4 had a [MEDICAL CONDITION] (referred to as a trach) and was unable to speak. She called for assistance by either clapping her hands or banging her remote control on the side rails of her bed. Licensed Vocational Nurse (LVN) K discovered Resident #4 unresponsive in her bed with [MEDICAL CONDITION] off on [DATE] shortly after 6:00 PM. ([MEDICAL CONDITION] provides humidified air and oxygen to [MEDICAL CONDITION] openings but no breathing support). She was revived after she was re-attached to her ventilator (breathing machine). No interventions were taken to prevent or address a recurrence. On [DATE] at 5:00 AM, Resident #4 was taken off of her ventilator by Respiratory Therapist (RT) N and placed on [MEDICAL CONDITION]. Between 5:30 AM and 6:00 AM, LVN K heard Resident #4 clapping (her method of calling for assistance) but did not go to her room, despite having found her unresponsive on [DATE]. On [DATE] at 6:00 AM, Certified Nurse Aide (CNA) B discovered Resident #4 unresponsive and CPR (cardiopulmonary resuscitation) was started. Resident #4 was transferred to the hospital by paramedics where she died . This deficient practice resulted in an immediate jeopardy identified on [DATE]. While the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure to not follow resident plans of care could place 11 residents with tracheostomies at risk of not receiving necessary care and services which could lead to a decline in their health status or death. The findings included: Closed record review of the electronic face sheet on [DATE] documented Resident #4 was a [AGE] year old woman admitted to the facility on [DATE] and discharged on [DATE]. Closed record review of the facility History and Physical dated [DATE] for Resident #4 included [DIAGNOSES REDACTED]. Closed record review of Current Orders for [DATE] for Resident #4 documented [MEDICAL CONDITION] +5 PS 10 during night time, transition [MEDICAL CONDITION] during day time, keep sats > 92% (ventilator orders - continuous positive airway pressure of 5 with pressure support of 10 at night and put [MEDICAL CONDITION] during the day keeping oxygen saturations greater than 92%. The [MEDICAL CONDITION] keeps a measured amount of airway pressure at all times to make taking a breath easier.) Closed record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 could not talk but could understand others and make herself understood, had moderately impaired cognitive skills for decision making, had no behaviors, required total dependence of 1 person for all of her ADLs (activities of daily living), was on oxygen, was on a ventilator, and received suctioning [MEDICAL CONDITION]. Closed record review of Resident #4's Care Plan dated [DATE] revealed Problem: Resident has difficulty making self understood R/T (related to) claps and uses hand gestures to communicate, unable to speak clearly due [MEDICAL CONDITION] vent. Goal: Resident will establish a reliable means of communication as evidenced by resident claps and uses hand gestures to get attention and answer questions. Interview on [DATE] at 5:48 AM, LVN L (works on 400 hall Monday -Friday 10 PM - 6 A) said Resident #4 would either remove her ventilator so it would alarm or clap her hands if she needed something - like having her brief changed or be suctioned. LVN L said Resident #4 could go about 10 minutes off of her oxygen before her oxygen levels would drop and affect her. Closed record review of Resident Progress Notes dated [DATE], 4:02 AM, LVN K documented " at the start of the shift (shift began at 6:00 PM [DATE]) patient (Resident #4) was noted to not be responsive to verbal or physical stimuli. " Resident #4 was placed on the ventilator and within a few minutes she aroused easily. LVN K wrote, " Will continue to monitor for changes in conditions. " This incident occurred 36 hours prior to Resident #4 ' s death. Interview on [DATE] at 10:19 AM, LVN M, nurse on the 400 hall from 6 AM - 2 PM, said on [DATE] on the 6 PM to 6 AM shift Resident #4 removed [MEDICAL CONDITION] and became unresponsive. LVN M said if Resident #4 takes off [MEDICAL CONDITION] she desaturates (drops her oxygen level). LVN M said that was why Resident #4 was on a ventilator at night because if she removed the ventilator it would alarm. Closed record review on [DATE] of Resident #4's Care Plan revealed there was no care plan to address the concern that Resident #4 would remove [MEDICAL CONDITION] or that she required increased supervision because of this. Closed record review of Resident Progress Notes dated [DATE] documented the following: a. Respiratory Therapist (RT) N wrote at 5:00 AM, he placed Resident #4 on [MEDICAL CONDITION] with oxygen at 5 liters per minute (orders were to place on [MEDICAL CONDITION] during the day to keep oxygen saturations above 92%), b. LVN K documented he saw Resident #4 at 5:30 AM to give her medication which she tolerated well and 10 minutes later he heard her clapping her hands. Resident #4 was found unresponsive at 6:00 AM and CPR was started. Telephone interview on [DATE] at 12:57 PM, CNA P said Resident #4 would not use a call light but would clap her hands when she needed something. CNA P said she was the only CNA scheduled on the 400 hallway on the 10 PM - 6 AM shift on [DATE]. CNA P was in another room with a resident who was vomiting around 5:30 AM and did not hear Resident #4 clapping her hands. Interview on [DATE] at 6:02 PM, LVN K, who worked Saturdays and Sundays 6 PM - 6 AM, said he saw Resident #4 at 5:10 or 5:15 AM on [DATE] when he woke her up to take medicine. About 5:30 AM, a resident down the hallway 5 doors down and across the hall from Resident #4 started vomiting and LVN K went into the room to help CNA P. LVN K said he could hear Resident #4 clapping her hands but neither he nor CNA P could leave the resident they were assisting. LVN K said Resident #4 would clap her hands when she needed something because she did not use her call light. After he had completed assisting the resident, LVN K said he went to the nurse ' s station. He said he did not check on Resident #4. At 6:00 AM, Resident #4 was found unresponsive by CNA B, 911 was called and CPR was started by LVN M. Interview on [DATE] at 10:19 AM, LVN M said Resident #4 was alert, had [MEDICAL CONDITION] was on the ventilator at night. LVN M said when Resident #4 wanted something she would bang her remote on the bed or clap her hands. On [DATE] at almost 6:00 AM, CNA B yelled for help and LVN M said she ran into Resident #4's room. Resident #4 was unresponsive and cold to touch, had no pulse and no blood pressure. Interview on [DATE] at 8:19 AM, RT N said Resident #4 was an active woman and would clap her hands for attention or when she needed suctioning, etc. If she was attached to the ventilator she would take it off to get it to alarm to get staff attention. On [DATE] at 5 AM, Resident #4 was stable, awake, oxygen sats were 96% and she did not have abnormal secretions. Since she was awake and pulling off her ventilator, RT N placed Resident #4 on [MEDICAL CONDITION]. RT N said he continued stocking resident rooms with respiratory therapy supplies and could not hear Resident #4 clapping her hands. In an interview on [DATE] at 6:37 AM, the Respiratory Therapy (RT) Director said there was no consistency in how the different RTs operated during their shifts and there was no specific time nor protocols in place regarding times to put [MEDICAL CONDITION] back on residents. She said it should be done after the day shift arrives as there was not enough staff on the night shift to be able to monitor the residents. Interview on [DATE] at 3:51 PM, Nurse Practitioner (NP) U said he had cared for Resident #4 for several years and Resident #4 always clapped her hands. She used it as a mode of communication. She also would remove [MEDICAL CONDITION] (which would remove the flow of oxygen), but she could put it back on. She had no reserve (an example would be if someone required additional oxygen, their body would not be able to function if it was removed) and if she removed [MEDICAL CONDITION] and could not get it back or lost her source of oxygen she would have just gone out (become unresponsive) because she had no reserve. An immediate jeopardy was identified on [DATE] and the Nursing Facility Administrator (NFA) was informed at 10:20 AM on [DATE]. On [DATE] the facility submitted their 4th corrective action plan of removal: A. What did the facility do for the residents identified? a. Resident #4 is no longer in the he facility. Nonverbal residents and residents utilizing alternate means of communication have the potential to be affected by this alleged deficient practice. B. What is the facility doing to prevent recurrence? a. Nurse Managers will ensure there are always sufficient staff to meet the needs of the residents assigned to the 400 hall during the 10 - 6 shift. Along with a nurse and a Respiratory Therapist. DON/Nurse Managers completed an inservice for the scheduled 10 - 6 nurses on this topic on [DATE]. Additional nursing and respiratory staff will be inserviced by DON's/Nurse Managers before being allowed to work the floor. b. MDS Nurses completed a 100% audit on [DATE] to identify residents that are nonverbal and/or using alternative methods of communication to make needs known. These residents will be identified on the Nurse Aide pocket worksheet which will be kept at the nurse's station and in nursing staff pockets. They will be updated five times a week by Nurse Managers. Nurse Managers in-serviced scheduled nursing staff [DATE] and [DATE] regarding identified residents modes of expression being identified on these worksheets in red font, where the worksheets are located, where they should be kept during employee's shift and who should be notified if they detect a change in condition (Charge Nurse/Nurse Manager). Additional staff will be inserviced by DON/Nurse Managers before being allowed to work the floor. Understanding has been verified by Nurse Managers questioning staff on subject matter, written post test, and checking to ensure that pocket worksheets are in their pockets and at the nurse's station. These worksheets include important information that identifies the needs of the resident. Included are: Room number, name, bath schedule, location of meal service, if the resident is turned Q2h (every 2 hours), any enablers used, if half rails are used, continent, incontinent or Foley catheter, thickened liquids or fluid restriction, number of staff to transfer, code status and other needs as identified such as fall risk, splints, etc. c. Care plans for all residents identified as having special needs for communication have been reviewed and updated as needed by IDT Team as of [DATE]. d. Ventilator residents and resident with special assistance needs on 400 hall will be observed through rounds and interaction per physician order [REDACTED]. C. What systemic changes will the facility make to prevent recurrence? a. Nurse aide pocket worksheets were updated by Nurse Managers on [DATE] to identify residents with special needs for assistance and communications. b. Facility has added three direct cares staff members and will continue to add staff based on the needs/acuity of the residents on the night shift to assist in meeting the needs of the residents when needed. One staff member is floating and assisting with the entire facility, two other staff members are assigned one each to East ([DATE] halls) and West (200 and 400 halls) wing. c. In the event a staff member is unable to arrive for a shift they will call the on call phone. The Nurse Manager on call will call the facility and tell the nurse present to ensure that staff will stay over until the opening is filled and the covering employee is in the building. The on call nurse manager will then attempt to fill the opening. If unable, the Nurse Manager on call will be expected to work the opening herself. Nurses Managers were inserviced on the on call responsibilities and the above information on [DATE] by VP of Clinical Services. Additional staff will be inserviced as they report to work. Staff will not be allowed to work the floor until they have been inserviced on above information. d. As an additional resource for coverage, the facility has a contract with two staffing agencies. The administrator will provide agency contact information to the DON and Nurse Managers as needed. Agency staff will complete a new hire packet containing all orientation and inservice material before being allowed to work the floor. Maintaining sufficient staff to meet the needs of the resident on the night shift by notifying DON/Nurse Managers to call agency or by keeping the previous shift present has been inserviced to the DON/Nurse Managers and night shift staff on [DATE]. Additional staff will be inserviced before being allowed to work the floor. e. Interdisciplinary Team, IDT, was in-serviced in Individualized Care Plans by Vice President of Clinical Services on [DATE]. Inservice attendees were all facility MDS nurses, Social Services, Food Service Manager and Activity Director. Information included definition of interdisciplinary care plans and concept of individualization. Gave handouts from State Agency or individualized care plans specific to each discipline. Explained that once care plan is written, it should be discussed in the care plan meeting among all disciplines and "brainstormed" for further individualization. Participants were also shown how to initiate, individualize and update care plans on the computer using facility's software. f. Inservice information for Nurse Aide pocket worksheets, maintaining two aides on hall 400 on the night shift and individualized care plans will be added to employee orientation/new hire packet in order to maintain compliance. D. What is the facility doing to monitor for compliance? a. DON and Nurse Managers will ensure sufficient staff is scheduled for the facility. b. The facility will have sufficient staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychological well-being of each resident, as determined by resident assessments and individual plans of care. c. In addition, facility has added three direct cares staff members on the night shift to assist in meeting the needs/acuity of the residents. One staff member is floating and assisting with the entire facility, two other staff members are assigned one each to East and West wing. The facility has purchased [MEDICATION NAME] for all direct care staff members on the night shift in order to facilitate communication in an emergency. Facility staff is being inserviced on proper use of the [MEDICATION NAME] in an emergency to call for assist. d. Administrator, DON/Nurse Managers and/or designees will monitor staffing patterns and schedules on a daily basis to ensure the facility and 400 hall are staffed accordingly. DON, Nurse Managers and RT director will make rounds 3 times a week for 30 days on the ,[DATE] shift to confirm Quality of Care and staffing compliance. Thereafter, routine Quality of Care and staffing compliance rounds will be on-going and adjusted as needed by the administrator. e. Administrator will provide oversight through the QA (Quality Assurance) committee, morning meetings and as needed. f. Pocket worksheets will be monitored weekly by DON to ensure they are reflective of current status of residents. Interviews on [DATE] and [DATE] with 5 LVNs, 7 CNAs and 1 CMA (medication aide) confirmed they were aware of the increased need for staffing, who to contact if additional staffing is required, communication methods for non-verbal residents, review of the nurse aide pocket worksheets and review of resident care plans. The nurse aide pocket worksheets were reviewed for resident information. Those with altered communication methods were highlighted in red print. Other resident care needs were listed on the worksheets. Review of the staffing sign-in sheets for [DATE] and the schedule for [DATE] confirmed there was additional staff present on the night shift. After the surveyors verified the plan of removal was implemented, the administrator was informed the immediate jeopardy was removed effective [DATE] at 2:17 PM. The facility remained out of compliance at a scope and severity at a pattern of actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. The list of 11 residents with tracheostomies was obtained by interview with LVN M during initial rounds on [DATE].

Based on interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychological well-being, in accordance with the comprehensive assessment and plan of care, for 1 of 11 residents with tracheostomies (an artificial hole in the neck for the purpose of breathing) who were reviewed for quality of care. Resident #4 had a [MEDICAL CONDITION] (referred to as a trach) and was unable to speak. She called for assistance by either clapping her hands or banging her remote control on the side rails of her bed. Licensed Vocational Nurse (LVN) K discovered Resident #4 unresponsive in her bed with [MEDICAL CONDITION] off on [DATE] shortly after 6:00 PM. ([MEDICAL CONDITION] provides humidified air and oxygen to [MEDICAL CONDITION] openings but no breathing support). She was revived after she was re-attached to her ventilator (breathing machine). No interventions were taken to prevent or address a recurrence. On [DATE] at 5:00 AM, Resident #4 was taken off of her ventilator by Respiratory Therapist (RT) N and placed on [MEDICAL CONDITION]. Between 5:30 AM and 6:00 AM, LVN K heard Resident #4 clapping (her method of calling for assistance) but did not go to her room, despite having found her unresponsive on [DATE]. On [DATE] at 6:00 AM, Certified Nurse Aide (CNA) B discovered Resident #4 unresponsive and CPR (cardiopulmonary resuscitation) was started. Resident #4 was transferred to the hospital by paramedics where she died . This deficient practice resulted in an immediate jeopardy identified on [DATE]. While the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure to not follow resident plans of care could place 11 residents with tracheostomies at risk of not receiving necessary care and services which could lead to a decline in their health status or death. The findings included: Closed record review of the electronic face sheet on [DATE] documented Resident #4 was a [AGE] year old woman admitted to the facility on [DATE] and discharged on [DATE]. Closed record review of the facility History and Physical dated [DATE] for Resident #4 included [DIAGNOSES REDACTED]. Closed record review of Current Orders for [DATE] for Resident #4 documented [MEDICAL CONDITION] +5 PS 10 during night time, transition [MEDICAL CONDITION] during day time, keep sats > 92% (ventilator orders - continuous positive airway pressure of 5 with pressure support of 10 at night and put [MEDICAL CONDITION] during the day keeping oxygen saturations greater than 92%. The [MEDICAL CONDITION] keeps a measured amount of airway pressure at all times to make taking a breath easier.) Closed record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 could not talk but could understand others and make herself understood, had moderately impaired cognitive skills for decision making, had no behaviors, required total dependence of 1 person for all of her ADLs (activities of daily living), was on oxygen, was on a ventilator, and received suctioning [MEDICAL CONDITION]. Closed record review of Resident #4's Care Plan dated [DATE] revealed Problem: Resident has difficulty making self understood R/T (related to) claps and uses hand gestures to communicate, unable to speak clearly due [MEDICAL CONDITION] vent. Goal: Resident will establish a reliable means of communication as evidenced by resident claps and uses hand gestures to get attention and answer questions. Interview on [DATE] at 5:48 AM, LVN L (works on 400 hall Monday -Friday 10 PM - 6 A) said Resident #4 would either remove her ventilator so it would alarm or clap her hands if she needed something - like having her brief changed or be suctioned. LVN L said Resident #4 could go about 10 minutes off of her oxygen before her oxygen levels would drop and affect her. Closed record review of Resident Progress Notes dated [DATE], 4:02 AM, LVN K documented " at the start of the shift (shift began at 6:00 PM [DATE]) patient (Resident #4) was noted to not be responsive to verbal or physical stimuli. " Resident #4 was placed on the ventilator and within a few minutes she aroused easily. LVN K wrote, " Will continue to monitor for changes in conditions. " This incident occurred 36 hours prior to Resident #4 ' s death. Interview on [DATE] at 10:19 AM, LVN M, nurse on the 400 hall from 6 AM - 2 PM, said on [DATE] on the 6 PM to 6 AM shift Resident #4 removed [MEDICAL CONDITION] and became unresponsive. LVN M said if Resident #4 takes off [MEDICAL CONDITION] she desaturates (drops her oxygen level). LVN M said that was why Resident #4 was on a ventilator at night because if she removed the ventilator it would alarm. Closed record review on [DATE] of Resident #4's Care Plan revealed there was no care plan to address the concern that Resident #4 would remove [MEDICAL CONDITION] or that she required increased supervision because of this. Closed record review of Resident Progress Notes dated [DATE] documented the following: a. Respiratory Therapist (RT) N wrote at 5:00 AM, he placed Resident #4 on [MEDICAL CONDITION] with oxygen at 5 liters per minute (orders were to place on [MEDICAL CONDITION] during the day to keep oxygen saturations above 92%), b. LVN K documented he saw Resident #4 at 5:30 AM to give her medication which she tolerated well and 10 minutes later he heard her clapping her hands. Resident #4 was found unresponsive at 6:00 AM and CPR was started. Telephone interview on [DATE] at 12:57 PM, CNA P said Resident #4 would not use a call light but would clap her hands when she needed something. CNA P said she was the only CNA scheduled on the 400 hallway on the 10 PM - 6 AM shift on [DATE]. CNA P was in another room with a resident who was vomiting around 5:30 AM and did not hear Resident #4 clapping her hands. Interview on [DATE] at 6:02 PM, LVN K, who worked Saturdays and Sundays 6 PM - 6 AM, said he saw Resident #4 at 5:10 or 5:15 AM on [DATE] when he woke her up to take medicine. About 5:30 AM, a resident down the hallway 5 doors down and across the hall from Resident #4 started vomiting and LVN K went into the room to help CNA P. LVN K said he could hear Resident #4 clapping her hands but neither he nor CNA P could leave the resident they were assisting. LVN K said Resident #4 would clap her hands when she needed something because she did not use her call light. After he had completed assisting the resident, LVN K said he went to the nurse ' s station. He said he did not check on Resident #4. At 6:00 AM, Resident #4 was found unresponsive by CNA B, 911 was called and CPR was started by LVN M. Interview on [DATE] at 10:19 AM, LVN M said Resident #4 was alert, had [MEDICAL CONDITION] was on the ventilator at night. LVN M said when Resident #4 wanted something she would bang her remote on the bed or clap her hands. On [DATE] at almost 6:00 AM, CNA B yelled for help and LVN M said she ran into Resident #4's room. Resident #4 was unresponsive and cold to touch, had no pulse and no blood pressure. Interview on [DATE] at 8:19 AM, RT N said Resident #4 was an active woman and would clap her hands for attention or when she needed suctioning, etc. If she was attached to the ventilator she would take it off to get it to alarm to get staff attention. On [DATE] at 5 AM, Resident #4 was stable, awake, oxygen sats were 96% and she did not have abnormal secretions. Since she was awake and pulling off her ventilator, RT N placed Resident #4 on [MEDICAL CONDITION]. RT N said he continued stocking resident rooms with respiratory therapy supplies and could not hear Resident #4 clapping her hands. In an interview on [DATE] at 6:37 AM, the Respiratory Therapy (RT) Director said there was no consistency in how the different RTs operated during their shifts and there was no specific time nor protocols in place regarding times to put [MEDICAL CONDITION] back on residents. She said it should be done after the day shift arrives as there was not enough staff on the night shift to be able to monitor the residents. Interview on [DATE] at 3:51 PM, Nurse Practitioner (NP) U said he had cared for Resident #4 for several years and Resident #4 always clapped her hands. She used it as a mode of communication. She also would remove [MEDICAL CONDITION] (which would remove the flow of oxygen), but she could put it back on. She had no reserve (an example would be if someone required additional oxygen, their body would not be able to function if it was removed) and if she removed [MEDICAL CONDITION] and could not get it back or lost her source of oxygen she would have just gone out (become unresponsive) because she had no reserve. An immediate jeopardy was identified on [DATE] and the Nursing Facility Administrator (NFA) was informed at 10:20 AM on [DATE]. On [DATE] the facility submitted their 4th corrective action plan of removal: A. What did the facility do for the residents identified? a. Resident #4 is no longer in the he facility. Nonverbal residents and residents utilizing alternate means of communication have the potential to be affected by this alleged deficient practice. B. What is the facility doing to prevent recurrence? a. Nurse Managers will ensure there are always sufficient staff to meet the needs of the residents assigned to the 400 hall during the 10 - 6 shift. Along with a nurse and a Respiratory Therapist. DON/Nurse Managers completed an inservice for the scheduled 10 - 6 nurses on this topic on [DATE]. Additional nursing and respiratory staff will be inserviced by DON's/Nurse Managers before being allowed to work the floor. b. MDS Nurses completed a 100% audit on [DATE] to identify residents that are nonverbal and/or using alternative methods of communication to make needs known. These residents will be identified on the Nurse Aide pocket worksheet which will be kept at the nurse's station and in nursing staff pockets. They will be updated five times a week by Nurse Managers. Nurse Managers in-serviced scheduled nursing staff [DATE] and [DATE] regarding identified residents modes of expression being identified on these worksheets in red font, where the worksheets are located, where they should be kept during employee's shift and who should be notified if they detect a change in condition (Charge Nurse/Nurse Manager). Additional staff will be inserviced by DON/Nurse Managers before being allowed to work the floor. Understanding has been verified by Nurse Managers questioning staff on subject matter, written post test, and checking to ensure that pocket worksheets are in their pockets and at the nurse's station. These worksheets include important information that identifies the needs of the resident. Included are: Room number, name, bath schedule, location of meal service, if the resident is turned Q2h (every 2 hours), any enablers used, if half rails are used, continent, incontinent or Foley catheter, thickened liquids or fluid restriction, number of staff to transfer, code status and other needs as identified such as fall risk, splints, etc. c. Care plans for all residents identified as having special needs for communication have been reviewed and updated as needed by IDT Team as of [DATE]. d. Ventilator residents and resident with special assistance needs on 400 hall will be observed through rounds and interaction per physician order [REDACTED]. C. What systemic changes will the facility make to prevent recurrence? a. Nurse aide pocket worksheets were updated by Nurse Managers on [DATE] to identify residents with special needs for assistance and communications. b. Facility has added three direct cares staff members and will continue to add staff based on the needs/acuity of the residents on the night shift to assist in meeting the needs of the residents when needed. One staff member is floating and assisting with the entire facility, two other staff members are assigned one each to East ([DATE] halls) and West (200 and 400 halls) wing. c. In the event a staff member is unable to arrive for a shift they will call the on call phone. The Nurse Manager on call will call the facility and tell the nurse present to ensure that staff will stay over until the opening is filled and the covering employee is in the building. The on call nurse manager will then attempt to fill the opening. If unable, the Nurse Manager on call will be expected to work the opening herself. Nurses Managers were inserviced on the on call responsibilities and the above information on [DATE] by VP of Clinical Services. Additional staff will be inserviced as they report to work. Staff will not be allowed to work the floor until they have been inserviced on above information. d. As an additional resource for coverage, the facility has a contract with two staffing agencies. The administrator will provide agency contact information to the DON and Nurse Managers as needed. Agency staff will complete a new hire packet containing all orientation and inservice material before being allowed to work the floor. Maintaining sufficient staff to meet the needs of the resident on the night shift by notifying DON/Nurse Managers to call agency or by keeping the previous shift present has been inserviced to the DON/Nurse Managers and night shift staff on [DATE]. Additional staff will be inserviced before being allowed to work the floor. e. Interdisciplinary Team, IDT, was in-serviced in Individualized Care Plans by Vice President of Clinical Services on [DATE]. Inservice attendees were all facility MDS nurses, Social Services, Food Service Manager and Activity Director. Information included definition of interdisciplinary care plans and concept of individualization. Gave handouts from State Agency or individualized care plans specific to each discipline. Explained that once care plan is written, it should be discussed in the care plan meeting among all disciplines and "brainstormed" for further individualization. Participants were also shown how to initiate, individualize and update care plans on the computer using facility's software. f. Inservice information for Nurse Aide pocket worksheets, maintaining two aides on hall 400 on the night shift and individualized care plans will be added to employee orientation/new hire packet in order to maintain compliance. D. What is the facility doing to monitor for compliance? a. DON and Nurse Managers will ensure sufficient staff is scheduled for the facility. b. The facility will have sufficient staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychological well-being of each resident, as determined by resident assessments and individual plans of care. c. In addition, facility has added three direct cares staff members on the night shift to assist in meeting the needs/acuity of the residents. One staff member is floating and assisting with the entire facility, two other staff members are assigned one each to East and West wing. The facility has purchased [MEDICATION NAME] for all direct care staff members on the night shift in order to facilitate communication in an emergency. Facility staff is being inserviced on proper use of the [MEDICATION NAME] in an emergency to call for assist. d. Administrator, DON/Nurse Managers and/or designees will monitor staffing patterns and schedules on a daily basis to ensure the facility and 400 hall are staffed accordingly. DON, Nurse Managers and RT director will make rounds 3 times a week for 30 days on the ,[DATE] shift to confirm Quality of Care and staffing compliance. Thereafter, routine Quality of Care and staffing compliance rounds will be on-going and adjusted as needed by the administrator. e. Administrator will provide oversight through the QA (Quality Assurance) committee, morning meetings and as needed. f. Pocket worksheets will be monitored weekly by DON to ensure they are reflective of current status of residents. Interviews on [DATE] and [DATE] with 5 LVNs, 7 CNAs and 1 CMA (medication aide) confirmed they were aware of the increased need for staffing, who to contact if additional staffing is required, communication methods for non-verbal residents, review of the nurse aide pocket worksheets and review of resident care plans. The nurse aide pocket worksheets were reviewed for resident information. Those with altered communication methods were highlighted in red print. Other resident care needs were listed on the worksheets. Review of the staffing sign-in sheets for [DATE] and the schedule for [DATE] confirmed there was additional staff present on the night shift. After the surveyors verified the plan of removal was implemented, the administrator was informed the immediate jeopardy was removed effective [DATE] at 2:17 PM. The facility remained out of compliance at a scope and severity at a pattern of actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. The list of 11 residents with tracheostomies was obtained by interview with LVN M during initial rounds on [DATE].

Based on observation, interview and record review, the facility failed to have sufficient staffing to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #4) of 24 residents on the 400 hallway. Resident #4 had a [MEDICAL CONDITION] (referred to as a trach) and was unable to speak. She called for assistance by either clapping her hands or banging her remote control on the side rails of her bed. Licensed Vocational Nurse (LVN) K discovered Resident #4 unresponsive in her bed with [MEDICAL CONDITION] off on [DATE] shortly after 6:00 PM. ([MEDICAL CONDITION] provides humidified air and oxygen to [MEDICAL CONDITION] openings but no breathing support). She was revived after she was re-attached to her ventilator (breathing machine). No interventions were taken to prevent or address a recurrence. On [DATE] at 5:00 AM, Resident #4 was taken off of her ventilator by Respiratory Therapist (RT) N and placed on [MEDICAL CONDITION]. Between 5:30 AM and 6:00 AM, the only two nursing staff members on duty (LVN K and CNA P) were busy in another resident's room. LVN K heard Resident #4 clapping (her method of calling for assistance) but did not go to her room, despite having found her unresponsive on [DATE]. On [DATE] at 6:00 AM, Certified Nurse Aide (CNA) B discovered Resident #4 unresponsive and CPR (cardiopulmonary resuscitation) was started. Resident #4 was transferred to the hospital by paramedics where she died . This deficient practice resulted in an immediate jeopardy identified on [DATE]. While the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure to not have sufficient staff to provide care according to resident plans of care could place 11 residents with tracheostomies and/or on ventilators at risk of not receiving necessary care and services, injury or death. The findings included: Interview on [DATE] during initial rounds on the 400 hall from 8:15 AM to 10:18 AM, Licensed Vocational Nurse (LVN) M said there were 24 residents on the hallway - 11 residents with trachs, 7 of them on ventilators with an additional 4 residents that are bed-bound with total dependence on staff for all care. Closed record review of the electronic face sheet on [DATE] documented Resident #4 was a [AGE] year old woman admitted to the facility on [DATE] and discharged on [DATE]. Closed record review of the facility History and Physical dated [DATE] for Resident #4 included [DIAGNOSES REDACTED]. Closed record review of Current Orders for [DATE] for Resident #4 documented [MEDICAL CONDITION] +5 PS 10 during night time, transition [MEDICAL CONDITION] during day time, keep sats > 92% (ventilator orders - continuous positive airway pressure of 5 with pressure support of 10 at night and put [MEDICAL CONDITION] during the day keeping oxygen saturations greater than 92%. The [MEDICAL CONDITION] keeps a measured amount of airway pressure at all times to make taking a breath easier.) Closed record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 could not talk but could understand others and make herself understood, had moderately impaired cognitive skills for decision making, had no behaviors, required total dependence of 1 person for all of her ADLs (activities of daily living), was on oxygen, was on a ventilator, and received suctioning [MEDICAL CONDITION]. Closed record review of Resident #4's Care Plan dated [DATE] revealed Problem: Resident has difficulty making self understood R/T (related to) claps and uses hand gestures to communicate, unable to speak clearly due [MEDICAL CONDITION] vent. Goal: Resident will establish a reliable means of communication as evidenced by resident claps and uses hand gestures to get attention and answer questions. Interview on [DATE] at 5:48 AM, LVN L (works on 400 hall Monday -Friday 10 PM - 6 A) said Resident #4 would either remove her ventilator so it would alarm or clap her hands if she needed something - like having her brief changed or be suctioned. LVN L said Resident #4 could go about 10 minutes off of her oxygen before her oxygen levels would drop and affect her. Closed record review of Resident Progress Notes dated [DATE], 4:02 AM, LVN K documented " at the start of the shift (shift began at 6:00 PM [DATE]) patient (Resident #4) was noted to not be responsive to verbal or physical stimuli. " Resident #4 was placed on the ventilator and within a few minutes she aroused easily. LVN K wrote, " Will continue to monitor for changes in conditions. " This incident occurred 36 hours prior to Resident #4 ' s death. Interview on [DATE] at 10:19 AM, LVN M, nurse on the 400 hall from 6 AM - 2 PM, said on [DATE] on the 6 PM to 6 AM shift Resident #4 removed [MEDICAL CONDITION] and became unresponsive. LVN M said if Resident #4 takes off [MEDICAL CONDITION] she desaturates (drops her oxygen level). LVN M said that was why Resident #4 was on a ventilator at night because if she removed the ventilator it would alarm. Closed record review on [DATE] of Resident #4's Care Plan revealed there was no care plan to address the concern that Resident #4 would remove [MEDICAL CONDITION] or that she required increased supervision because of this. Closed record review of Resident Progress Notes dated [DATE] documented the following: a. Respiratory Therapist (RT) N wrote at 5:00 AM, he placed Resident #4 on [MEDICAL CONDITION] with oxygen at 5 liters per minute (orders were to place on [MEDICAL CONDITION] during the day to keep oxygen saturations above 92%), b. LVN K documented he saw Resident #4 at 5:30 AM to give her medication which she tolerated well and 10 minutes later he heard her clapping her hands. Resident #4 was found unresponsive at 6:00 AM and CPR was started. Telephone interview on [DATE] at 12:57 PM, CNA P said Resident #4 would not use a call light but would clap her hands when she needed something. CNA P said she was the only CNA scheduled on the 400 hallway on the 10 PM - 6 AM shift on [DATE]. CNA P was in another room with a resident who was vomiting around 5:30 AM and did not hear Resident #4 clapping her hands. CNA P said there were supposed to be 2 CNAs on the 400 hall "because there were a lot of trachs and feeding tubes." Interview on [DATE] at 6:02 PM, LVN K, who worked Saturdays and Sundays 6 PM - 6 AM, said he saw Resident #4 at 5:10 or 5:15 AM on [DATE] when he woke her up to take medicine. About 5:30 AM, a resident down the hallway 5 doors down and across the hall from Resident #4 started vomiting and LVN K went into the room to help CNA P. LVN K said he could hear Resident #4 clapping her hands but neither he nor CNA P could leave the resident they were assisting. LVN K said Resident #4 would clap her hands when she needed something because she did not use her call light. After he had completed assisting the resident, LVN K said he went to the nurse ' s station. He said he did not check on Resident #4. At 6:00 AM, Resident #4 was found unresponsive by CNA B, 911 was called and CPR was started by LVN M. LVN K said when the census was down there was 1 CNA. When he first started working at the facility there were 2 CNAs on the 400 hall. Two weeks before Resident #4 died there was only 1 CNA scheduled. Since she died there have been 2 CNAs on the hallway. Interview on [DATE] at 10:19 AM, LVN M said Resident #4 was alert and had a trach. Her pulmonologist (lung doctor) and the family wanted her to get off of the vent so she was on [MEDICAL CONDITION] during the day. ([MEDICAL CONDITION] is a device that is placed over [MEDICAL CONDITION] delivers humidified oxygen or air). She will remove [MEDICAL CONDITION] and there is enough staff on during the day to keep an eye on her to put it back on. If she takes off [MEDICAL CONDITION] she desaturates (drops her oxygen level). That was why she was on a ventilator at night because if she removed the ventilator it would alarm to let someone know she was off of her oxygen. Interview on [DATE] at 8:19 AM, RT N said Resident #4 was an active woman and would clap her hands for attention or when she needed suctioning, etc. If she was attached to the ventilator she would take it off to get it to alarm to get staff attention. On [DATE] at 5 AM, Resident #4 was stable, awake, oxygen sats were 96% and she did not have abnormal secretions. Since she was awake and pulling off her ventilator, RT N placed Resident #4 on [MEDICAL CONDITION]. RT N said he continued stocking resident rooms with respiratory therapy supplies and could not hear Resident #4 clapping her hands. In an interview on [DATE] at 6:37 AM, the Respiratory Therapy (RT) Director said there was no consistency in how the different RTs operated during their shifts and there was no specific time nor protocols in place regarding times to put [MEDICAL CONDITION] back on residents. She said it should be done after the day shift arrives as there was not enough staff on the night shift to be able to monitor the residents. Interview on [DATE] at 3:51 PM, Nurse Practitioner (NP) U said he had cared for Resident #4 for several years and Resident #4 always clapped her hands. She used it as a mode of communication. She also would remove [MEDICAL CONDITION] (which would remove the flow of oxygen), but she could put it back on. She had no reserve (an example would be if someone required additional oxygen, their body would not be able to function if it was removed) and if she removed [MEDICAL CONDITION] and could not get it back or lost her source of oxygen she would have just gone out (become unresponsive) because she had no reserve. Record review of the Schedule Sheet for [DATE] revealed the following staffing for the month: a. 1 CNA was scheduled for the 400 Hall on [DATE], [DATE], [DATE] (2 were scheduled but 1 called in), [DATE], [DATE] (2 scheduled 1 called in), [DATE], [DATE], [DATE], [DATE] and [DATE]. b. 2 CNAs were scheduled for the other nights. Record review of the facility census for March revealed the following: a. [DATE] through [DATE] - 9 vents, 3 trachs b. [DATE] through [DATE] - 7 vents, 3 trachs c. [DATE] - 9 vents, [MEDICAL CONDITION](no information available for [DATE] and [DATE]) d. [DATE] - 7 vents, 3 trachs e. [DATE] through [DATE], [DATE] through [DATE] and [DATE] 9 vents, 2 trachs Interview on [DATE] at 3:21 PM, the Director of Nurses (DON) said she would staff according to the staffing requirement set by the corporation and if the census was down she would send CNAs home or send to another unit if someone called in. When asked why, given the same number of residents and the same number of vents and trachs, one night would have 2 CNAs and the next night only 1 CNA she said that was the number of hours she had to work with. An immediate jeopardy was identified on [DATE] and the Nursing Facility Administrator (NFA) was informed at 10:20 AM on [DATE]. On [DATE] the facility submitted their 4th corrective action plan of removal: A. What did the facility do for the residents identified? a. Resident #4 is no longer in the he facility. Nonverbal residents and residents utilizing alternate means of communication have the potential to be affected by this alleged deficient practice. B. What is the facility doing to prevent recurrence? a. Nurse Managers will ensure there are always sufficient staff to meet the needs of the residents assigned to the 400 hall during the 10 - 6 shift. Along with a nurse and a Respiratory Therapist. DON/Nurse Managers completed an inservice for the scheduled 10 - 6 nurses on this topic on [DATE]. Additional nursing and respiratory staff will be inserviced by DON's/Nurse Managers before being allowed to work the floor. b. MDS Nurses completed a 100% audit on [DATE] to identify residents that are nonverbal and/or using alternative methods of communication to make needs known. These residents will be identified on the Nurse Aide pocket worksheet which will be kept at the nurse's station and in nursing staff pockets. They will be updated five times a week by Nurse Managers. Nurse Managers in-serviced scheduled nursing staff [DATE] and [DATE] regarding identified residents modes of expression being identified on these worksheets in red font, where the worksheets are located, where they should be kept during employee's shift and who should be notified if they detect a change in condition (Charge Nurse/Nurse Manager). Additional staff will be inserviced by DON/Nurse Managers before being allowed to work the floor. Understanding has been verified by Nurse Managers questioning staff on subject matter, written post test, and checking to ensure that pocket worksheets are in their pockets and at the nurse's station. These worksheets include important information that identifies the needs of the resident. Included are: Room number, name, bath schedule, location of meal service, if the resident is turned Q2h (every 2 hours), any enablers used, if half rails are used, continent, incontinent or Foley catheter, thickened liquids or fluid restriction, number of staff to transfer, code status and other needs as identified such as fall risk, splints, etc. c. Care plans for all residents identified as having special needs for communication have been reviewed and updated as needed by IDT Team as of [DATE]. d. Ventilator residents and resident with special assistance needs on 400 hall will be observed through rounds and interaction per physician order [REDACTED]. C. What systemic changes will the facility make to prevent recurrence? a. Nurse aide pocket worksheets were updated by Nurse Managers on [DATE] to identify residents with special needs for assistance and communications. b. Facility has added three direct cares staff members and will continue to add staff based on the needs/acuity of the residents on the night shift to assist in meeting the needs of the residents when needed. One staff member is floating and assisting with the entire facility, two other staff members are assigned one each to East ([DATE] halls) and West (200 and 400 halls) wing. c. In the event a staff member is unable to arrive for a shift they will call the on call phone. The Nurse Manager on call will call the facility and tell the nurse present to ensure that staff will stay over until the opening is filled and the covering employee is in the building. The on call nurse manager will then attempt to fill the opening. If unable, the Nurse Manager on call will be expected to work the opening herself. Nurses Managers were inserviced on the on call responsibilities and the above information on [DATE] by VP of Clinical Services. Additional staff will be inserviced as they report to work. Staff will not be allowed to work the floor until they have been inserviced on above information. d. As an additional resource for coverage, the facility has a contract with two staffing agencies. The administrator will provide agency contact information to the DON and Nurse Managers as needed. Agency staff will complete a new hire packet containing all orientation and inservice material before being allowed to work the floor. Maintaining sufficient staff to meet the needs of the resident on the night shift by notifying DON/Nurse Managers to call agency or by keeping the previous shift present has been inserviced to the DON/Nurse Managers and night shift staff on [DATE]. Additional staff will be inserviced before being allowed to work the floor. e. Interdisciplinary Team, IDT, was in-serviced in Individualized Care Plans by Vice President of Clinical Services on [DATE]. Inservice attendees were all facility MDS nurses, Social Services, Food Service Manager and Activity Director. Information included definition of interdisciplinary care plans and concept of individualization. Gave handouts from State Agency or individualized care plans specific to each discipline. Explained that once care plan is written, it should be discussed in the care plan meeting among all disciplines and "brainstormed" for further individualization. Participants were also shown how to initiate, individualize and update care plans on the computer using facility's software. f. Inservice information for Nurse Aide pocket worksheets, maintaining two aides on hall 400 on the night shift and individualized care plans will be added to employee orientation/new hire packet in order to maintain compliance. D. What is the facility doing to monitor for compliance? a. DON and Nurse Managers will ensure sufficient staff is scheduled for the facility. b. The facility will have sufficient staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychological well-being of each resident, as determined by resident assessments and individual plans of care. c. In addition, facility has added three direct cares staff members on the night shift to assist in meeting the needs/acuity of the residents. One staff member is floating and assisting with the entire facility, two other staff members are assigned one each to East and West wing. The facility has purchased [MEDICATION NAME] for all direct care staff members on the night shift in order to facilitate communication in an emergency. Facility staff is being inserviced on proper use of the [MEDICATION NAME] in an emergency to call for assist. d. Administrator, DON/Nurse Managers and/or designees will monitor staffing patterns and schedules on a daily basis to ensure the facility and 400 hall are staffed accordingly. DON, Nurse Managers and RT director will make rounds 3 times a week for 30 days on the ,[DATE] shift to confirm Quality of Care and staffing compliance. Thereafter, routine Quality of Care and staffing compliance rounds will be on-going and adjusted as needed by the administrator. e. Administrator will provide oversight through the QA (Quality Assurance) committee, morning meetings and as needed. f. Pocket worksheets will be monitored weekly by DON to ensure they are reflective of current status of residents. Interviews on [DATE] and [DATE] with 5 LVNs, 7 CNAs and 1 CMA (medication aide) confirmed they were aware of the increased need for staffing, who to contact if additional staffing is required, communication methods for non-verbal residents, review of the nurse aide pocket worksheets and review of resident care plans. The nurse aide pocket worksheets were reviewed for resident information. Those with altered communication methods were highlighted in red print. Other resident care needs were listed on the worksheets. Review of the staffing sign-in sheets for [DATE] and the schedule for [DATE] confirmed there was additional staff present on the night shift. After the surveyors verified the plan of removal was implemented, the administrator was informed the immediate jeopardy was removed effective [DATE] at 2:17 PM. The facility remained out of compliance at a scope and severity at a pattern of actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. The list of 11 residents with tracheostomies was obtained by interview with LVN M during initial rounds on [DATE].

Based on observation, interview and record review, the facility failed to have sufficient staffing to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #4) of 24 residents on the 400 hallway. Resident #4 had a [MEDICAL CONDITION] (referred to as a trach) and was unable to speak. She called for assistance by either clapping her hands or banging her remote control on the side rails of her bed. Licensed Vocational Nurse (LVN) K discovered Resident #4 unresponsive in her bed with [MEDICAL CONDITION] off on [DATE] shortly after 6:00 PM. ([MEDICAL CONDITION] provides humidified air and oxygen to [MEDICAL CONDITION] openings but no breathing support). She was revived after she was re-attached to her ventilator (breathing machine). No interventions were taken to prevent or address a recurrence. On [DATE] at 5:00 AM, Resident #4 was taken off of her ventilator by Respiratory Therapist (RT) N and placed on [MEDICAL CONDITION]. Between 5:30 AM and 6:00 AM, the only two nursing staff members on duty (LVN K and CNA P) were busy in another resident's room. LVN K heard Resident #4 clapping (her method of calling for assistance) but did not go to her room, despite having found her unresponsive on [DATE]. On [DATE] at 6:00 AM, Certified Nurse Aide (CNA) B discovered Resident #4 unresponsive and CPR (cardiopulmonary resuscitation) was started. Resident #4 was transferred to the hospital by paramedics where she died . This deficient practice resulted in an immediate jeopardy identified on [DATE]. While the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure to not have sufficient staff to provide care according to resident plans of care could place 11 residents with tracheostomies and/or on ventilators at risk of not receiving necessary care and services, injury or death. The findings included: Interview on [DATE] during initial rounds on the 400 hall from 8:15 AM to 10:18 AM, Licensed Vocational Nurse (LVN) M said there were 24 residents on the hallway - 11 residents with trachs, 7 of them on ventilators with an additional 4 residents that are bed-bound with total dependence on staff for all care. Closed record review of the electronic face sheet on [DATE] documented Resident #4 was a [AGE] year old woman admitted to the facility on [DATE] and discharged on [DATE]. Closed record review of the facility History and Physical dated [DATE] for Resident #4 included [DIAGNOSES REDACTED]. Closed record review of Current Orders for [DATE] for Resident #4 documented [MEDICAL CONDITION] +5 PS 10 during night time, transition [MEDICAL CONDITION] during day time, keep sats > 92% (ventilator orders - continuous positive airway pressure of 5 with pressure support of 10 at night and put [MEDICAL CONDITION] during the day keeping oxygen saturations greater than 92%. The [MEDICAL CONDITION] keeps a measured amount of airway pressure at all times to make taking a breath easier.) Closed record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 could not talk but could understand others and make herself understood, had moderately impaired cognitive skills for decision making, had no behaviors, required total dependence of 1 person for all of her ADLs (activities of daily living), was on oxygen, was on a ventilator, and received suctioning [MEDICAL CONDITION]. Closed record review of Resident #4's Care Plan dated [DATE] revealed Problem: Resident has difficulty making self understood R/T (related to) claps and uses hand gestures to communicate, unable to speak clearly due [MEDICAL CONDITION] vent. Goal: Resident will establish a reliable means of communication as evidenced by resident claps and uses hand gestures to get attention and answer questions. Interview on [DATE] at 5:48 AM, LVN L (works on 400 hall Monday -Friday 10 PM - 6 A) said Resident #4 would either remove her ventilator so it would alarm or clap her hands if she needed something - like having her brief changed or be suctioned. LVN L said Resident #4 could go about 10 minutes off of her oxygen before her oxygen levels would drop and affect her. Closed record review of Resident Progress Notes dated [DATE], 4:02 AM, LVN K documented " at the start of the shift (shift began at 6:00 PM [DATE]) patient (Resident #4) was noted to not be responsive to verbal or physical stimuli. " Resident #4 was placed on the ventilator and within a few minutes she aroused easily. LVN K wrote, " Will continue to monitor for changes in conditions. " This incident occurred 36 hours prior to Resident #4 ' s death. Interview on [DATE] at 10:19 AM, LVN M, nurse on the 400 hall from 6 AM - 2 PM, said on [DATE] on the 6 PM to 6 AM shift Resident #4 removed [MEDICAL CONDITION] and became unresponsive. LVN M said if Resident #4 takes off [MEDICAL CONDITION] she desaturates (drops her oxygen level). LVN M said that was why Resident #4 was on a ventilator at night because if she removed the ventilator it would alarm. Closed record review on [DATE] of Resident #4's Care Plan revealed there was no care plan to address the concern that Resident #4 would remove [MEDICAL CONDITION] or that she required increased supervision because of this. Closed record review of Resident Progress Notes dated [DATE] documented the following: a. Respiratory Therapist (RT) N wrote at 5:00 AM, he placed Resident #4 on [MEDICAL CONDITION] with oxygen at 5 liters per minute (orders were to place on [MEDICAL CONDITION] during the day to keep oxygen saturations above 92%), b. LVN K documented he saw Resident #4 at 5:30 AM to give her medication which she tolerated well and 10 minutes later he heard her clapping her hands. Resident #4 was found unresponsive at 6:00 AM and CPR was started. Telephone interview on [DATE] at 12:57 PM, CNA P said Resident #4 would not use a call light but would clap her hands when she needed something. CNA P said she was the only CNA scheduled on the 400 hallway on the 10 PM - 6 AM shift on [DATE]. CNA P was in another room with a resident who was vomiting around 5:30 AM and did not hear Resident #4 clapping her hands. CNA P said there were supposed to be 2 CNAs on the 400 hall "because there were a lot of trachs and feeding tubes." Interview on [DATE] at 6:02 PM, LVN K, who worked Saturdays and Sundays 6 PM - 6 AM, said he saw Resident #4 at 5:10 or 5:15 AM on [DATE] when he woke her up to take medicine. About 5:30 AM, a resident down the hallway 5 doors down and across the hall from Resident #4 started vomiting and LVN K went into the room to help CNA P. LVN K said he could hear Resident #4 clapping her hands but neither he nor CNA P could leave the resident they were assisting. LVN K said Resident #4 would clap her hands when she needed something because she did not use her call light. After he had completed assisting the resident, LVN K said he went to the nurse ' s station. He said he did not check on Resident #4. At 6:00 AM, Resident #4 was found unresponsive by CNA B, 911 was called and CPR was started by LVN M. LVN K said when the census was down there was 1 CNA. When he first started working at the facility there were 2 CNAs on the 400 hall. Two weeks before Resident #4 died there was only 1 CNA scheduled. Since she died there have been 2 CNAs on the hallway. Interview on [DATE] at 10:19 AM, LVN M said Resident #4 was alert and had a trach. Her pulmonologist (lung doctor) and the family wanted her to get off of the vent so she was on [MEDICAL CONDITION] during the day. ([MEDICAL CONDITION] is a device that is placed over [MEDICAL CONDITION] delivers humidified oxygen or air). She will remove [MEDICAL CONDITION] and there is enough staff on during the day to keep an eye on her to put it back on. If she takes off [MEDICAL CONDITION] she desaturates (drops her oxygen level). That was why she was on a ventilator at night because if she removed the ventilator it would alarm to let someone know she was off of her oxygen. Interview on [DATE] at 8:19 AM, RT N said Resident #4 was an active woman and would clap her hands for attention or when she needed suctioning, etc. If she was attached to the ventilator she would take it off to get it to alarm to get staff attention. On [DATE] at 5 AM, Resident #4 was stable, awake, oxygen sats were 96% and she did not have abnormal secretions. Since she was awake and pulling off her ventilator, RT N placed Resident #4 on [MEDICAL CONDITION]. RT N said he continued stocking resident rooms with respiratory therapy supplies and could not hear Resident #4 clapping her hands. In an interview on [DATE] at 6:37 AM, the Respiratory Therapy (RT) Director said there was no consistency in how the different RTs operated during their shifts and there was no specific time nor protocols in place regarding times to put [MEDICAL CONDITION] back on residents. She said it should be done after the day shift arrives as there was not enough staff on the night shift to be able to monitor the residents. Interview on [DATE] at 3:51 PM, Nurse Practitioner (NP) U said he had cared for Resident #4 for several years and Resident #4 always clapped her hands. She used it as a mode of communication. She also would remove [MEDICAL CONDITION] (which would remove the flow of oxygen), but she could put it back on. She had no reserve (an example would be if someone required additional oxygen, their body would not be able to function if it was removed) and if she removed [MEDICAL CONDITION] and could not get it back or lost her source of oxygen she would have just gone out (become unresponsive) because she had no reserve. Record review of the Schedule Sheet for [DATE] revealed the following staffing for the month: a. 1 CNA was scheduled for the 400 Hall on [DATE], [DATE], [DATE] (2 were scheduled but 1 called in), [DATE], [DATE] (2 scheduled 1 called in), [DATE], [DATE], [DATE], [DATE] and [DATE]. b. 2 CNAs were scheduled for the other nights. Record review of the facility census for March revealed the following: a. [DATE] through [DATE] - 9 vents, 3 trachs b. [DATE] through [DATE] - 7 vents, 3 trachs c. [DATE] - 9 vents, [MEDICAL CONDITION](no information available for [DATE] and [DATE]) d. [DATE] - 7 vents, 3 trachs e. [DATE] through [DATE], [DATE] through [DATE] and [DATE] 9 vents, 2 trachs Interview on [DATE] at 3:21 PM, the Director of Nurses (DON) said she would staff according to the staffing requirement set by the corporation and if the census was down she would send CNAs home or send to another unit if someone called in. When asked why, given the same number of residents and the same number of vents and trachs, one night would have 2 CNAs and the next night only 1 CNA she said that was the number of hours she had to work with. An immediate jeopardy was identified on [DATE] and the Nursing Facility Administrator (NFA) was informed at 10:20 AM on [DATE]. On [DATE] the facility submitted their 4th corrective action plan of removal: A. What did the facility do for the residents identified? a. Resident #4 is no longer in the he facility. Nonverbal residents and residents utilizing alternate means of communication have the potential to be affected by this alleged deficient practice. B. What is the facility doing to prevent recurrence? a. Nurse Managers will ensure there are always sufficient staff to meet the needs of the residents assigned to the 400 hall during the 10 - 6 shift. Along with a nurse and a Respiratory Therapist. DON/Nurse Managers completed an inservice for the scheduled 10 - 6 nurses on this topic on [DATE]. Additional nursing and respiratory staff will be inserviced by DON's/Nurse Managers before being allowed to work the floor. b. MDS Nurses completed a 100% audit on [DATE] to identify residents that are nonverbal and/or using alternative methods of communication to make needs known. These residents will be identified on the Nurse Aide pocket worksheet which will be kept at the nurse's station and in nursing staff pockets. They will be updated five times a week by Nurse Managers. Nurse Managers in-serviced scheduled nursing staff [DATE] and [DATE] regarding identified residents modes of expression being identified on these worksheets in red font, where the worksheets are located, where they should be kept during employee's shift and who should be notified if they detect a change in condition (Charge Nurse/Nurse Manager). Additional staff will be inserviced by DON/Nurse Managers before being allowed to work the floor. Understanding has been verified by Nurse Managers questioning staff on subject matter, written post test, and checking to ensure that pocket worksheets are in their pockets and at the nurse's station. These worksheets include important information that identifies the needs of the resident. Included are: Room number, name, bath schedule, location of meal service, if the resident is turned Q2h (every 2 hours), any enablers used, if half rails are used, continent, incontinent or Foley catheter, thickened liquids or fluid restriction, number of staff to transfer, code status and other needs as identified such as fall risk, splints, etc. c. Care plans for all residents identified as having special needs for communication have been reviewed and updated as needed by IDT Team as of [DATE]. d. Ventilator residents and resident with special assistance needs on 400 hall will be observed through rounds and interaction per physician order [REDACTED]. C. What systemic changes will the facility make to prevent recurrence? a. Nurse aide pocket worksheets were updated by Nurse Managers on [DATE] to identify residents with special needs for assistance and communications. b. Facility has added three direct cares staff members and will continue to add staff based on the needs/acuity of the residents on the night shift to assist in meeting the needs of the residents when needed. One staff member is floating and assisting with the entire facility, two other staff members are assigned one each to East ([DATE] halls) and West (200 and 400 halls) wing. c. In the event a staff member is unable to arrive for a shift they will call the on call phone. The Nurse Manager on call will call the facility and tell the nurse present to ensure that staff will stay over until the opening is filled and the covering employee is in the building. The on call nurse manager will then attempt to fill the opening. If unable, the Nurse Manager on call will be expected to work the opening herself. Nurses Managers were inserviced on the on call responsibilities and the above information on [DATE] by VP of Clinical Services. Additional staff will be inserviced as they report to work. Staff will not be allowed to work the floor until they have been inserviced on above information. d. As an additional resource for coverage, the facility has a contract with two staffing agencies. The administrator will provide agency contact information to the DON and Nurse Managers as needed. Agency staff will complete a new hire packet containing all orientation and inservice material before being allowed to work the floor. Maintaining sufficient staff to meet the needs of the resident on the night shift by notifying DON/Nurse Managers to call agency or by keeping the previous shift present has been inserviced to the DON/Nurse Managers and night shift staff on [DATE]. Additional staff will be inserviced before being allowed to work the floor. e. Interdisciplinary Team, IDT, was in-serviced in Individualized Care Plans by Vice President of Clinical Services on [DATE]. Inservice attendees were all facility MDS nurses, Social Services, Food Service Manager and Activity Director. Information included definition of interdisciplinary care plans and concept of individualization. Gave handouts from State Agency or individualized care plans specific to each discipline. Explained that once care plan is written, it should be discussed in the care plan meeting among all disciplines and "brainstormed" for further individualization. Participants were also shown how to initiate, individualize and update care plans on the computer using facility's software. f. Inservice information for Nurse Aide pocket worksheets, maintaining two aides on hall 400 on the night shift and individualized care plans will be added to employee orientation/new hire packet in order to maintain compliance. D. What is the facility doing to monitor for compliance? a. DON and Nurse Managers will ensure sufficient staff is scheduled for the facility. b. The facility will have sufficient staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychological well-being of each resident, as determined by resident assessments and individual plans of care. c. In addition, facility has added three direct cares staff members on the night shift to assist in meeting the needs/acuity of the residents. One staff member is floating and assisting with the entire facility, two other staff members are assigned one each to East and West wing. The facility has purchased [MEDICATION NAME] for all direct care staff members on the night shift in order to facilitate communication in an emergency. Facility staff is being inserviced on proper use of the [MEDICATION NAME] in an emergency to call for assist. d. Administrator, DON/Nurse Managers and/or designees will monitor staffing patterns and schedules on a daily basis to ensure the facility and 400 hall are staffed accordingly. DON, Nurse Managers and RT director will make rounds 3 times a week for 30 days on the ,[DATE] shift to confirm Quality of Care and staffing compliance. Thereafter, routine Quality of Care and staffing compliance rounds will be on-going and adjusted as needed by the administrator. e. Administrator will provide oversight through the QA (Quality Assurance) committee, morning meetings and as needed. f. Pocket worksheets will be monitored weekly by DON to ensure they are reflective of current status of residents. Interviews on [DATE] and [DATE] with 5 LVNs, 7 CNAs and 1 CMA (medication aide) confirmed they were aware of the increased need for staffing, who to contact if additional staffing is required, communication methods for non-verbal residents, review of the nurse aide pocket worksheets and review of resident care plans. The nurse aide pocket worksheets were reviewed for resident information. Those with altered communication methods were highlighted in red print. Other resident care needs were listed on the worksheets. Review of the staffing sign-in sheets for [DATE] and the schedule for [DATE] confirmed there was additional staff present on the night shift. After the surveyors verified the plan of removal was implemented, the administrator was informed the immediate jeopardy was removed effective [DATE] at 2:17 PM. The facility remained out of compliance at a scope and severity at a pattern of actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. The list of 11 residents with tracheostomies was obtained by interview with LVN M during initial rounds on [DATE].

Based on interview and record review the facility failed to ensure residents were free from significant medication errors as evidenced by: A. Four (Residents # 9, #34, #35 and #36) of 5 residents with separate day/night sliding scale insulin orders (insulin administered according to finger stick blood glucose parameters) were not administered insulin according to the physician ordered sliding scale. There were 105 doses of insulin that were not administered according to the sliding scale orders in an 11 week period (April to June 2014). B. One (Residents #9) of 65 residents with physician ordered parameters for the administration of blood pressure medications was not administered blood pressure medication according to those physician orders. A total of 35 doses over a 6 week period (May and June 2014) were administered with blood pressure and heart rate readings below physician ordered parameters. This deficient practice resulted in an immediate jeopardy identified on 6/13/14. While the immediate jeopardy was removed on 6/16/14, the facility remained out of compliance at a scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 33 residents with physician orders [REDACTED]. The findings included: A. Resident #9 Record review of face sheet dated 12/27/13 documented Resident #9 was a [AGE] year old woman admitted on [DATE] (re-admitted on [DATE]) with [DIAGNOSES REDACTED]. Record review of Resident #9's Physician order [REDACTED]. a. [MEDICATION NAME] (blood pressure, B/P, medication) 40 mg (milligrams) 1 tablet, gastric tube, Special instructions: hold medication if systolic blood pressure (top number in a blood pressure, SBP) is less than 120 and/or if pulse is less than 60 beats per minute; BID - Twice a Day. b. [MEDICATION NAME] immediate release (B/P medication) 50 mg 1 tablet gastric tube. Special instructions: HOLD for SBP <120 or HR heart rate, pulse) <60 ((<) less than) BID - Twice a day c. [MEDICATION NAME] (insulin) subcutaneous 5 times per day per sliding scale. As per sliding scale: BS (blood sugar) 131-160 - 4 units (u); BS 161-200 - 8u; BS 201-250 - 12u; BS 251-300 - 16u; BS 301-350 - 20u; BS 350-400 - 24u; BS > 400 call MD. Bedtime and 2 AM sliding scale: BS 201-250 - 2u; BS 251-300 - 3u; BS 301-350 - 4u; BS 351 - 400 - 5u. 5 times per day 7 AM, 11 AM, 5 PM, 8 PM, 2 AM. d. [MEDICATION NAME] (formula) at 65 ml (milliliters) per hour with 30 ml of water per hour via [DEVICE] (a tube placed through the skin into the stomach for the purpose of providing nutrition and medications) for 23 hours a day. May remove for shower and personal care. In record review of Resident #9's Medication Administration Record (MAR) for April 2014 the physician orders [REDACTED]. a. 2 AM BS on 4/01/14, 4/03/14, 4/06/14, 4/08/14, 4/10/14, 4/12/14, 4/14/14, 4/17/14, 4/18/14, 4/20/14, 4/21/14, 4/22/14, 4/24/14 - 4/28/14 and 4/30/14 ranged from 137 to 198. Four to 8u of insulin were given for the BS. The night time sliding scale ordered no insulin for BS less than 201. b. 2 AM BS on 4/15/14 and 4/16/14 were 205 and 216. Twelve units of insulin were administered for each. According to the sliding scale 2u of insulin should have been administered c. 2 AM BS on 4/02/14 was 261 and 16u of insulin were documented as administered. The sliding scale ordered 3u of insulin. d. 8 PM BS on 4/01-4/02/14, 4/05 - 4/07/14, 4/11-4/12/14 and 4/14/14 documented BS less than 201 with 4u to 8u of insulin administered. According to the bedtime sliding scale no insulin should have been administered. e. 8 PM BS on 4/10/14 was 202 and 8u of insulin was documented as administered. The sliding scale ordered 2 u of insulin. In record review of Resident #9's MAR for May 2014 the physician orders [REDACTED]. a. 2 AM BS on 5/01/14, 5/04 - 5/06/14, 5/08/14, 5/11 - 5/12/14, 5/18 - 5/19/14 and 5/24 - 5/26/14 were less than 201 and 4u to 8u of insulin were administered. According to the sliding scale no insulin was to be administered. b. 2 AM BS on 5/31/14 was 301 and 20u of insulin was administered. According to the sliding scale 4u should have been administered. c. 8 PM BS on 5/01/14 and 5/04/14 were less than 201 and 4u to 8u of insulin were administered. According to the sliding scale no insulin was to be administered. d. 8 PM BS on 5/03/14 was 208 and 12u of insulin was administered. According to the sliding scale 2u should have been administered. e. 8 PM BS on 5/21 - 5/22/14 were 209 and 210. 8 units of insulin were administered each. According to the sliding scale 2u should have been administered on each. In record review of Resident #9's MAR for June 2014 the physician orders [REDACTED]. a. 2 AM BS on 6/01 - 6/03/14 and 6/09/14 were less than 201 and 4u to 8u of insulin were administered. According to the sliding scale no insulin was to be administered. b. 2 AM BS on 6/08/14 was 216 and 12u of insulin was administered. According to the sliding scale 2u should have been administered. c. 8 PM BS on 6/01 - 6/03/14, and 6/05/14 were less than 201 and 4u of insulin were administered each. According to the sliding scale no insulin should have been administered. d. 8 PM BS on 6/07/14 was 218 and 12u of insulin was administered. According to the sliding scale 2u should have been administered. e. 8 PM BS on 6/04/14 was 254 and 12u of insulin was administered. According to the sliding scale 3u should have been administered. f. 3 PM BS on 6/10/14 was 240 and no insulin was administered. According to the sliding scale 12u should have been administered. In an interview on 6/13/14 at 2:57 PM, Licensed Vocational Nurse (LVN) R said, when asked why the incorrect doses of sliding scale insulin were administered, the computer was at fault for documenting incorrect times of administration. He pointed to the evening finger stick blood glucose results for Resident #9 and said they were within parameters for the daytime sliding scale. The evening/night time sliding scale orders were printed just below the day time orders, but he kept saying the 9 PM finger stick results were within the day time parameters. Observation on 6/13/14 at 3:00 PM, with LVN D, revealed the electronic MAR entry for the sliding scale insulin for Resident #36. The day time insulin sliding scale and instructions (the heading was written in capital letters - AS PER SLIDING SCALE) were printed in a bolder font than the night time insulin sliding scale also with the header written in capital letters - NIGHT SLIDING SCALE. In an interview on 6/13/14 at 3:00 PM, LVN D said the night time sliding scale parameters were to be used during the night. The electronic MAR will highlight the correct parameters to be used at the appropriate time. LVN D showed on the MAR that the daytime sliding scale insulin was in a darker print than the night time sliding scale. LVN D said when she gave the bedtime sliding scale insulin the daytime sliding scale was highlighted. The night time sliding scale will highlight when the night time sliding scale was to be used. In an interview on 6/13/14 at 3:16 PM, Assistant Director of Nurses (ADON) K said the evening and night time sliding scale parameters were very clear. The bedtime parameter for Residents #9 and #36 was for the last finger stick blood glucose obtained for the day. The electronic MAR does not highlight the parameters that are to be used at a specific time. Record review of Resident #9's MAR for May 2014 documented the following blood pressure medication administration. The blood pressure medication was not administered according to the physician ordered parameters on the following 25 opportunities: 1) [MEDICATION NAME] 50 mg by gastric tube twice a day. Hold for SBP <120 or HR <60. a. The 7 AM doses were not held per physician order [REDACTED]. SBP were between 98 and 111 and heart rates of 53 and 57. b. The 7 PM doses were not held per physician order [REDACTED]. SBP were between 90 and 116 and heart rates of 54 - 58. 2) [MEDICATION NAME] 40 mg 1 tablet be gastric tube twice a day. Hold medication if systolic blood pressure is less than 120 and/or if pulse is less than 60 beats per minute. a. 9 AM doses were not held according to physician order [REDACTED]. SBP were 118 and 110. b. 7 PM doses were not held according to physician order [REDACTED]. SBP ranged between 90 and 116 and HR of 56. Record review of Resident #9's MAR for June 2014 documented the following blood pressure medication administration. The blood pressure medication was not administered according to the physician ordered parameters on the following 12 opportunities: 1) [MEDICATION NAME] 50 mg by gastric tube twice a day. Hold for SBP <120 or HR <60. a. 7 AM doses were not given according to physician order [REDACTED]. SBP were 104 on 6/01/14 and HR was 59 on 6/03/14. b. 7 PM doses were not given according to physician order [REDACTED]. SBP ranged from 100 to 119 with HR 59. 2) [MEDICATION NAME] 40 mg 1 tablet be gastric tube twice a day. Hold medication if systolic blood pressure is less than 120 and/or if pulse is less than 60 beats per minute. a. 7 PM doses were not administered according to physician order [REDACTED]. SBP ranged from 100 to 119 and HR 51 to 59. In an interview on 6/13/14 at 2:57 PM, LVN R said [MEDICATION NAME] had no parameters and the blood pressure documented on the MAR was the blood pressure that was used for the administration of the blood pressure medications. LVN R said he did not know why the [MEDICATION NAME] he documented for Resident #9 as administered outside of the physician parameters was administered. In an interview on 6/13/14 at 3:16 PM, ADON K said the parameters, ordered by the physician, for the administration of blood pressure medication was clearly stated with the medications that required parameters. B. Resident #35 Record review of face sheet dated 6/05/14 documented Resident #35 was an [AGE] year old man admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #35's Physician order [REDACTED]. If BS is 130-160 - give 3 u; BS 161-200 - 6u; BS 201-250 - 9u; BS 251-300 - 12u; BS 301-350 - 15u; BS 351-400 - 18u; BS > 400 call MD. Special instructions: Night Sliding Scale: BS 201-250 - 2u; BS 251-300 - 3u; BS 301-350 - 4u; BS 351 - 400 - 5u. Before meals and at bedtime; 7 AM, 11:30 AM, 5 PM, 9 PM. In record review of Resident #25's MAR for June 2014 (6/01/14 to 6/13/14) the physician orders [REDACTED]. a. 9 PM BS 6/05/14 and 6/07/14 were less than 201 and 3u to 6u of insulin were administered. According to the sliding scale no insulin should have been administered. b. 9 PM BS 6/11/14 was 243 and 9u of insulin was administered. According to the sliding scale 2u should have been administered. c. 9 PM BS 6/10/14 was 352 and 18 u of insulin was administered. According to the sliding scale 5u should have been administered. C. Resident #36 Record review of face sheet dated 5/20/14 documented Resident #36 was an [AGE] year old man admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #36's Physician order [REDACTED]. If BS is 130-160 - give 3 u; BS 161-200 - 6u; BS 201-250 - 9u; BS 251-300 - 12u; BS 301-350 - 15u; BS 351-400 - 18u; BS > 400 call MD. Special instructions: Night Sliding Scale: BS 201-250 - 2u; BS 251-300 - 3u; BS 301-350 - 4u; BS 351 - 400 - 5u. Before meals and at bedtime; 7 AM, 11:30 AM, 5 PM, 9 PM. In record review of Resident #36's MAR for May 2014 the physician orders [REDACTED]. a. 9 PM BS 5/22 - 24/14, 5/26/14, and 5/30 - 5/31/14 were less than 201 and 3u to 6u of insulin were administered. According to the sliding scale no insulin should have been administered. b. 9 PM BS on 3/28/14 was 315 and 15u of insulin was administered. According to the sliding scale 4u should have been administered. In record review of Resident #36's MAR for June 2014 (6/01/14 to 6/13/14) the physician orders [REDACTED]. a. 9 PM BS on 6/02/14 and 6/06 - 6/12/14 were less than 201 and 3u to 6u of insulin were administered. According to the sliding scale no insulin should have been administered. D. Resident #34 Record review of face sheet dated 1/14/14 documented Resident #34 was a [AGE] year old man admitted on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #34's Physician order [REDACTED]. Special Instructions: Day Sliding Scale 161-200 - 2u; 201-250 - 4u; 251-300 - 6u; 301-350 - 8u; 351-400 - 10u; > 400 call MD. Night Insulin 201-250 - 2u; 251-300 - 3u; 301-350 - 4u; 351 - 400 - 5u. AC & HS - Before meals and at bedtime 7 AM, 11:30 AM, 5 PM, 9 PM. In record review of Resident #34's MAR for May 2014 the physician orders [REDACTED]. a. 9 PM BS on 5/06/14 was 166 and 2u of insulin were administered. According to the sliding scale no insulin should have been administered. b. 9 PM BS on 5/12/14 and 5/17/14 were 210 and 227 and 4u of insulin were administered. According to the sliding scale 2u each should have been administered. c. 9 PM BS on 5/03/14 and 5/11/14 were 274 and 263 and 6u of insulin were administered. According to the sliding scale 3u should have been administered. Record review of Resident #34's MAR for June 2014 (6/01/14 to 6/13/14) the physician orders [REDACTED]. a. 9 PM BS on 6/03/14, 6/04/14 and 6/12/14 were less than 201 and 2u of insulin were administered. According to the sliding scale no insulin should have been administered. b. 9 PM BS on 6/07/14, 6/08/14 and 6/10/14 were 203 to 216 and 4u of insulin were administered. According to the sliding scale 2u should have been administered. c. 9 PM BS on 6/02/14 and 6/09/14 were 270 and 266 and 6u of insulin were administered. According to the sliding scale 3u should have been administered. d. 9 PM BS on 6/05/14 was 301 and 8u of insulin was administered. According to the sliding scale 4u should have been administered. In an interview on 6/13/14 at 4:51 PM, Corporate Director Operations (CDO) said an E MAR (electronic MAR) compliance report is run every morning. It shows any medication that was missed and the facility looks at the reasons for it. CDO said sliding scale insulin administration is not reported on the report because it is not a compliance issue with missed medication. The same with blood pressure medications. If the dose was given, even if given outside of the parameters, it will not show up on the report. CDO said they would have to print a daily E MAR compliance report on each resident in order to see if medications were administered correctly and that would be about 500 pages. In an interview on 6/13/14 at 4:59 PM, the Nursing Facility Administrator (NFA) said the facility holds lengthy discussion of nursing issues and review 24 hour reports. If issues are found, they are follow-upped on. The NFA said he can look at progress notes and if he sees something there he will refer to the CDO or DON. There has always been a Corporate Nurse in the building if there was "no one in the DON slot". NFA said he does not look at medications as he does not have enough background to know if the medications are administered incorrectly. In a telephone interview on 6/17/14 at 1:45 PM, Consultant Pharmacist said he looks at resident medications to see if they are given according to orders. He can look at the MARs which show the ordered parameters for administration of some medications. Consultant Pharmacist said he had not noticed any problems with sliding scale insulin or blood pressure medication not being administered according to physician ordered parameters. Record review of the policy Insulin, Administration Of , undated and provided by Corporate Director Operations on 6/13/14 stated Procedure: Check physician's orders [REDACTED]. An immediate jeopardy was identified on 6/13/14 and the Nursing Facility Administrator and Corporate Director Operations were informed at 5:30 PM on 6/13/14. The Plan of Action was accepted at 2:11 PM on 6/16/14. A. What did the facility do for the identified residents? 1. Residents with identified sliding scale insulin issues were assessed on 6/13/14 for complications and signs/symptoms of hypo/[MEDICAL CONDITION] and found to have no changes in condition. 2. Sliding scale insulin orders for identified residents were clarified on 6/13/14. 3. Medication error reports were completed on 6/13/14 for residents found to have sliding scale insulin errors with MD, family notifications and corrective actions taken. 4. Lab orders received and executed for identified residents as per MD directives. 5. Interdisciplinary care plans were updated to reflect the current status of the identified residents (started on 6/13/14 and completed 6/15/14). 6. Audit performed by Corporate Nurse and Nursing Administration (completed on 6/15/14) of all Physician orders [REDACTED]. 7. All Current Medication Administration Records (MARS) for Residents identified with medication parameters were reviewed by Corporate Nurse and Nursing Administration (completed on 6/15/14) to identify compliance issues. 8. Medication error reports were completed for those residents found to have compliance issues related to medication parameters with MD, family notifications and corrective actions taken. 9. Resident identified with medication parameter compliance issues were assessed on 6/15/14 for complications, adverse consequences and found to have no changes in condition. B. All residents that have Physician orders [REDACTED]. C. What did the facility do to ensure alleged deficient practice does not happen again? 1. All insulin orders were checked and verified for accuracy completed on 6/15/14. 2. Employees responsible for any identified medication errors reviewed written disciplinary action and/or subsequent terminations as warranted completed on 6/16/14. 3. All Nursing staff in-serviced regarding medication administration, insulin administration, causes of medication errors and adherence to parameters for medication administration (started on 6/13/14, will be completed 6/16/14). 4. Administrator, DON and/or Designee printing, reviewing and investigation discrepancies identified on E Mar Compliance report daily (started 6/13/14, ongoing). The E Mar Compliance reports indicate proof of medications administered over the last 24 hours and were administered within parameters ordered. 5. QA meeting scheduled for Monday, June 16, 2014 to review all areas of facility compliance. 6. Proficiency check offs for medication administration conducted for all nurses and CMA's (started on 6/15/14, to be completed on 6/16/14). 7. Nursing Audit performed daily by DON and/or Designee to ensure all telephone orders are entered accurately in the computer (ongoing and discussed daily during facility morning meeting). 8. Re-in-serviced all nurses by Corporate Nurse and Nursing Administration on how to properly enter orders into the computer (started on 6/14/14 to be completed 6/16/14). 9. Re-in-serviced all nurses and CMA's by Corporate Nurse and Nursing Administration on specific medication tasks to remember, review of the 5 rights of medicating delivery and the 3 checks of medication administration (started on 6/15/14 to be completed 6/16/14). 10. Staffing/In-service Coordinator will be responsible for ensuring Nurses and CMA's will have medication administration proficiency check offs conducted annually and as needed. D. How will the facility monitor for compliance? 1. Administrator, DON and/or Designee will review E Mar Compliance reports for all Residents during daily facility morning meeting. The E Mar Compliance reports indicate proof of medications administered over the last 24 hours and were administered within parameters ordered. The E Mar Compliance reports will be reviewed for compliance daily X 30 days, if no further issues identified, then E Mar Compliance reports will be reviewed 2 x week x 30 days, then if no further issues at the end of 30 days, this will be considered resolved. 1. Review medication administration compliance reports during scheduled QA meetings. 2. Ensure Pharmacy Consultant reviewed medication administration compliance as part of scheduled visits. Through observations, interviews, and record reviews the surveyors determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective 6/16/14 at 3:09 PM. The facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. The 33 residents with orders for insulin and the 65 residents with blood pressure administration parameters were provided by Director Clinical Operations on 6/16/14.

Based on observation, interview and record review the facility failed to provide pharmaceutical services that ensured the accurate administration of medications to 6 of 38 residents whose medications were reviewed. A. Four (Residents # 9, #34, #35 and #36) of 5 residents with separate day/night sliding scale insulin orders (insulin administered according to finger stick blood glucose parameters) were not administered insulin according to the physician ordered sliding scale. There were 105 doses of insulin that were not administered according to the sliding scale orders in an 11 week period (April to June 2014). B. One (Residents #9) of 65 residents with physician ordered parameters for the administration of blood pressure medications was not administered blood pressure medication according to those physician orders. A total of 35 doses over a 6 week period (May and June 2014) were administered with blood pressure and heart rate readings below physician ordered parameters. This deficient practice resulted in an immediate jeopardy identified on 6/13/14. While the immediate jeopardy was removed on 6/16/14, the facility remained out of compliance at a scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. The following were not immediate jeopardy: C. During observation of the medication pass on 6/11/14, resident # 46 received medication at the wrong time. D. One of 2 medication refrigerators contained outdated insulin and IV medication for a discharged resident. E. One of 2 medication rooms contained open undated medications. F. Two of 3 medication carts reviewed contained open undated and improperly stored medications. This failure could have placed 33 residents with physician orders [REDACTED]. The findings included: IMMEDIATE JEOPARDY A. Resident #9 Record review of face sheet dated 12/27/13 documented Resident #9 was a [AGE] year old woman admitted on [DATE] (re-admitted on [DATE]) with [DIAGNOSES REDACTED]. Record review of Resident #9's Physician order [REDACTED]. a. Sotalol (blood pressure, B/P, medication) 40 mg (milligrams) 1 tablet, gastric tube, Special instructions: hold medication if systolic blood pressure (top number in a blood pressure, SBP) is less than 120 and/or if pulse is less than 60 beats per minute; BID - Twice a Day. b. Metoprolol tartrate immediate release (B/P medication) 50 mg 1 tablet gastric tube. Special instructions: HOLD for SBP <120 or HR heart rate, pulse) <60 ((<) less than) BID - Twice a day c. Novolog (insulin) subcutaneous 5 times per day per sliding scale. As per sliding scale: BS (blood sugar) 131-160 - 4 units (u); BS 161-200 - 8u; BS 201-250 - 12u; BS 251-300 - 16u; BS 301-350 - 20u; BS 350-400 - 24u; BS > 400 call MD. Bedtime and 2 AM sliding scale: BS 201-250 - 2u; BS 251-300 - 3u; BS 301-350 - 4u; BS 351 - 400 - 5u. 5 times per day 7 AM, 11 AM, 5 PM, 8 PM, 2 AM. d. Diabetasource (formula) at 65 ml (milliliters) per hour with 30 ml of water per hour via [DEVICE] (a tube placed through the skin into the stomach for the purpose of providing nutrition and medications) for 23 hours a day. May remove for shower and personal care. In record review of Resident #9's Medication Administration Record (MAR) for April 2014 the physician orders [REDACTED]. The insulin was not administered according to the physician ordered sliding scale on the following 30 opportunities: a. 2 AM BS on 4/01/14, 4/03/14, 4/06/14, 4/08/14, 4/10/14, 4/12/14, 4/14/14, 4/17/14, 4/18/14, 4/20/14, 4/21/14, 4/22/14, 4/24/14 - 4/28/14 and 4/30/14 ranged from 137 to 198. Four to 8u of insulin were given for the BS. The night time sliding scale ordered no insulin for BS less than 201. b. 2 AM BS on 4/15/14 and 4/16/14 were 205 and 216. Twelve units of insulin were administered for each. According to the sliding scale 2u of insulin should have been administered c. 2 AM BS on 4/02/14 was 261 and 16u of insulin were documented as administered. The sliding scale ordered 3u of insulin. d. 8 PM BS on 4/01-4/02/14, 4/05 - 4/07/14, 4/11-4/12/14 and 4/14/14 documented BS less than 201 with 4u to 8u of insulin administered. According to the bedtime sliding scale no insulin should have been administered. e. 8 PM BS on 4/10/14 was 202 and 8u of insulin was documented as administered. The sliding scale ordered 2 u of insulin. In record review of Resident #9's MAR for May 2014 the physician orders [REDACTED]. The insulin was not administered according to the physician ordered sliding scale on the following 29 opportunities: a. 2 AM BS on 5/01/14, 5/04 - 5/06/14, 5/08/14, 5/11 - 5/12/14, 5/18 - 5/19/14 and 5/24 - 5/26/14 were less than 201 and 4u to 8u of insulin were administered. According to the sliding scale no insulin was to be administered. b. 2 AM BS on 5/31/14 was 301 and 20u of insulin was administered. According to the sliding scale 4u should have been administered. c. 8 PM BS on 5/01/14 and 5/04/14 were less than 201 and 4u to 8u of insulin were administered. According to the sliding scale no insulin was to be administered. d. 8 PM BS on 5/03/14 was 208 and 12u of insulin was administered. According to the sliding scale 2u should have been administered. e. 8 PM BS on 5/21 - 5/22/14 were 209 and 210. 8 units of insulin were administered each. According to the sliding scale 2u should have been administered on each. In record review of Resident #9's MAR for June 2014 the physician orders [REDACTED]. The insulin was not administered according to the physician ordered sliding scale on the following 12 opportunities: a. 2 AM BS on 6/01 - 6/03/14 and 6/09/14 were less than 201 and 4u to 8u of insulin were administered. According to the sliding scale no insulin was to be administered. b. 2 AM BS on 6/08/14 was 216 and 12u of insulin was administered. According to the sliding scale 2u should have been administered. c. 8 PM BS on 6/01 - 6/03/14, and 6/05/14 were less than 201 and 4u of insulin were administered each. According to the sliding scale no insulin should have been administered. d. 8 PM BS on 6/07/14 was 218 and 12u of insulin was administered. According to the sliding scale 2u should have been administered. e. 8 PM BS on 6/04/14 was 254 and 12u of insulin was administered. According to the sliding scale 3u should have been administered. f. 3 PM BS on 6/10/14 was 240 and no insulin was administered. According to the sliding scale 12u should have been administered. In an interview on 6/13/14 at 2:57 PM, Licensed Vocational Nurse (LVN) R said, when asked why the incorrect doses of sliding scale insulin were administered, the computer was at fault for documenting incorrect times of administration. He pointed to the evening finger stick blood glucose results for Resident #9 and said they were within parameters for the daytime sliding scale. The evening/night time sliding scale orders were printed just below the day time orders, but he kept saying the 9 PM finger stick results were within the day time parameters. Observation on 6/13/14 at 3:00 PM, with LVN D, revealed the electronic MAR entry for the sliding scale insulin for Resident #36. The day time insulin sliding scale and instructions (the heading was written in capital letters - AS PER SLIDING SCALE) were printed in a bolder font than the night time insulin sliding scale also with the header written in capital letters - NIGHT SLIDING SCALE. In an interview on 6/13/14 at 3:00 PM, LVN D said the night time sliding scale parameters were to be used during the night. The electronic MAR will highlight the correct parameters to be used at the appropriate time. LVN D showed on the MAR that the daytime sliding scale insulin was in a darker print than the night time sliding scale. LVN D said when she gave the bedtime sliding scale insulin the daytime sliding scale was highlighted. The night time sliding scale will highlight when the night time sliding scale was to be used. In an interview on 6/13/14 at 3:16 PM, Assistant Director of Nurses (ADON) K said the evening and night time sliding scale parameters were very clear. The bedtime parameter for Residents #9 and #36 was for the last finger stick blood glucose obtained for the day. The electronic MAR does not highlight the parameters that are to be used at a specific time. Record review of Resident #9's MAR for May 2014 documented the following blood pressure medication administration. The blood pressure medication was not administered according to the physician ordered parameters on the following 25 opportunities: 1) Metoprolol tartrate 50 mg by gastric tube twice a day. Hold for SBP <120 or HR <60. a. The 7 AM doses were not held per physician order [REDACTED]. SBP were between 98 and 111 and heart rates of 53 and 57. b. The 7 PM doses were not held per physician order [REDACTED]. SBP were between 90 and 116 and heart rates of 54 - 58. 2) Sotalol 40 mg 1 tablet be gastric tube twice a day. Hold medication if systolic blood pressure is less than 120 and/or if pulse is less than 60 beats per minute. a. 9 AM doses were not held according to physician order [REDACTED]. SBP were 118 and 110. b. 7 PM doses were not held according to physician order [REDACTED]. SBP ranged between 90 and 116 and HR of 56. Record review of Resident #9's MAR for June 2014 documented the following blood pressure medication administration. The blood pressure medication was not administered according to the physician ordered parameters on the following 12 opportunities: 1) Metoprolol tartrate 50 mg by gastric tube twice a day. Hold for SBP <120 or HR <60. a. 7 AM doses were not given according to physician order [REDACTED]. SBP were 104 on 6/01/14 and HR was 59 on 6/03/14. b. 7 PM doses were not given according to physician order [REDACTED]. SBP ranged from 100 to 119 with HR 59. 2) Sotalol 40 mg 1 tablet be gastric tube twice a day. Hold medication if systolic blood pressure is less than 120 and/or if pulse is less than 60 beats per minute. a. 7 PM doses were not administered according to physician order [REDACTED]. SBP ranged from 100 to 119 and HR 51 to 59. In an interview on 6/13/14 at 2:57 PM, LVN R said Metoprolol had no parameters and the blood pressure documented on the MAR was the blood pressure that was used for the administration of the blood pressure medications. LVN R said he did not know why the Sotalol he documented for Resident #9 as administered outside of the physician parameters was administered. In an interview on 6/13/14 at 3:16 PM, ADON K said the parameters, ordered by the physician, for the administration of blood pressure medication was clearly stated with the medications that required parameters. B. Resident #35 Record review of face sheet dated 6/05/14 documented Resident #35 was an [AGE] year old man admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #35's Physician order [REDACTED]. If BS is 130-160 - give 3 u; BS 161-200 - 6u; BS 201-250 - 9u; BS 251-300 - 12u; BS 301-350 - 15u; BS 351-400 - 18u; BS > 400 call MD. Special instructions: Night Sliding Scale: BS 201-250 - 2u; BS 251-300 - 3u; BS 301-350 - 4u; BS 351 - 400 - 5u. Before meals and at bedtime; 7 AM, 11:30 AM, 5 PM, 9 PM. In record review of Resident #25's MAR for June 2014 (6/01/14 to 6/13/14) the physician orders [REDACTED]. a. 9 PM BS 6/05/14 and 6/07/14 were less than 201 and 3u to 6u of insulin were administered. According to the sliding scale no insulin should have been administered. b. 9 PM BS 6/11/14 was 243 and 9u of insulin was administered. According to the sliding scale 2u should have been administered. c. 9 PM BS 6/10/14 was 352 and 18 u of insulin was administered. According to the sliding scale 5u should have been administered. C. Resident #36 Record review of face sheet dated 5/20/14 documented Resident #36 was an [AGE] year old man admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #36's Physician order [REDACTED]. If BS is 130-160 - give 3 u; BS 161-200 - 6u; BS 201-250 - 9u; BS 251-300 - 12u; BS 301-350 - 15u; BS 351-400 - 18u; BS > 400 call MD. Special instructions: Night Sliding Scale: BS 201-250 - 2u; BS 251-300 - 3u; BS 301-350 - 4u; BS 351 - 400 - 5u. Before meals and at bedtime; 7 AM, 11:30 AM, 5 PM, 9 PM. In record review of Resident #36's MAR for May 2014 the physician orders [REDACTED]. a. 9 PM BS 5/22 - 24/14, 5/26/14, and 5/30 - 5/31/14 were less than 201 and 3u to 6u of insulin were administered. According to the sliding scale no insulin should have been administered. b. 9 PM BS on 3/28/14 was 315 and 15u of insulin was administered. According to the sliding scale 4u should have been administered. In record review of Resident #36's MAR for June 2014 (6/01/14 to 6/13/14) the physician orders [REDACTED]. a. 9 PM BS on 6/02/14 and 6/06 - 6/12/14 were less than 201 and 3u to 6u of insulin were administered. According to the sliding scale no insulin should have been administered. D. Resident #34 Record review of face sheet dated 1/14/14 documented Resident #34 was a [AGE] year old man admitted on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #34's Physician order [REDACTED]. Special Instructions: Day Sliding Scale 161-200 - 2u; 201-250 - 4u; 251-300 - 6u; 301-350 - 8u; 351-400 - 10u; > 400 call MD. Night Insulin 201-250 - 2u; 251-300 - 3u; 301-350 - 4u; 351 - 400 - 5u. AC & HS - Before meals and at bedtime 7 AM, 11:30 AM, 5 PM, 9 PM. In record review of Resident #34's MAR for May 2014 the physician orders [REDACTED]. a. 9 PM BS on 5/06/14 was 166 and 2u of insulin were administered. According to the sliding scale no insulin should have been administered. b. 9 PM BS on 5/12/14 and 5/17/14 were 210 and 227 and 4u of insulin were administered. According to the sliding scale 2u each should have been administered. c. 9 PM BS on 5/03/14 and 5/11/14 were 274 and 263 and 6u of insulin were administered. According to the sliding scale 3u should have been administered. Record review of Resident #34's MAR for June 2014 (6/01/14 to 6/13/14) the physician orders [REDACTED]. a. 9 PM BS on 6/03/14, 6/04/14 and 6/12/14 were less than 201 and 2u of insulin were administered. According to the sliding scale no insulin should have been administered. b. 9 PM BS on 6/07/14, 6/08/14 and 6/10/14 were 203 to 216 and 4u of insulin were administered. According to the sliding scale 2u should have been administered. c. 9 PM BS on 6/02/14 and 6/09/14 were 270 and 266 and 6u of insulin were administered. According to the sliding scale 3u should have been administered. d. 9 PM BS on 6/05/14 was 301 and 8u of insulin was administered. According to the sliding scale 4u should have been administered. In an interview on 6/13/14 at 4:51 PM, Corporate Director Operations (CDO) was shown the medication errors for the sliding scale insulin and the blood pressure medication and said, "It is what it is." CDO said an E MAR (electronic MAR) compliance report is run every morning. It shows any medication that was missed and the facility looks at the reasons for it. CDO said sliding scale insulin administration is not reported on the report because it is not a compliance issue with missed medication. The same with blood pressure medications. If the dose was given, even if given outside of the parameters, it will not show up on the report. CDO said the pharmacist has the same access to the medication information as the facility has. In a telephone interview on 6/17/14 at 1:45 PM, Consultant Pharmacist said he looks at resident medications to see if they are given according to orders. He can look at the MARs which show the ordered parameters for administration of some medications. Consultant Pharmacist said he had not noticed any problems with sliding scale insulin or blood pressure medication not being administered according to physician ordered parameters. An immediate jeopardy was identified and the Nursing Facility Administrator and Corporate Director Operations were informed at 5:30 PM on 6/13/14. The Plan of Action was accepted at 2:11 PM on 6/16/14. A. What did the facility do for the identified residents? 1. Residents with identified sliding scale insulin issues were assessed on 6/13/14 for complications and signs/symptoms of hypo/hyperglycemia and found to have no changes in condition. 2. Sliding scale insulin orders for identified residents were clarified on 6/13/14. 3. Medication error reports were completed on 6/13/14 for residents found to have sliding scale insulin errors with MD, family notifications and corrective actions taken. 4. Lab orders received and executed for identified residents as per MD directives. 5. Interdisciplinary care plans were updated to reflect the current status of the identified residents (started on 6/13/14 and completed 6/15/14). 6. Audit performed by Corporate Nurse and Nursing Administration (completed on 6/15/14) of all Physician orders [REDACTED]. 7. All Current Medication Administration Records (MARS) for Residents identified with medication parameters were reviewed by Corporate Nurse and Nursing Administration (completed on 6/15/14) to identify compliance issues. 8. Medication error reports were completed for those residents found to have compliance issues related to medication parameters with MD, family notifications and corrective actions taken. 9. Resident identified with medication parameter compliance issues were assessed on 6/15/14 for complications, adverse consequences and found to have no changes in condition. B. All residents that have Physician orders [REDACTED]. C. What did the facility do to ensure alleged deficient practice does not happen again? 1. All insulin orders were checked and verified for accuracy completed on 6/15/14. 2. Employees responsible for any identified medication errors reviewed written disciplinary action and/or subsequent terminations as warranted completed on 6/16/14. 3. All Nursing staff in-serviced regarding medication administration, insulin administration, causes of medication errors and adherence to parameters for medication administration (started on 6/13/14, will be completed 6/16/14). 4. Administrator, DON and/or Designee printing, reviewing and investigation discrepancies identified on E Mar Compliance report daily (started 6/13/14, ongoing). The E Mar Compliance reports indicate proof of medications administered over the last 24 hours and were administered within parameters ordered. 5. QA meeting scheduled for Monday, June 16, 2014 to review all areas of facility compliance. 6. Proficiency check offs for medication administration conducted for all nurses and CMA's (started on 6/15/14, to be completed on 6/16/14). 7. Nursing Audit performed daily by DON and/or Designee to ensure all telephone orders are entered accurately in the computer (ongoing and discussed daily during facility morning meeting). 8. Re-in-serviced all nurses by Corporate Nurse and Nursing Administration on how to properly enter orders into the computer (started on 6/14/14 to be completed 6/16/14). 9. Re-in-serviced all nurses and CMA's by Corporate Nurse and Nursing Administration on specific medication tasks to remember, review of the 5 rights of medicating delivery and the 3 checks of medication administration (started on 6/15/14 to be completed 6/16/14). 10. Staffing/In-service Coordinator will be responsible for ensuring Nurses and CMA's will have medication administration proficiency check offs conducted annually and as needed. D. How will the facility monitor for compliance? 1. Administrator, DON and/or Designee will review E Mar Compliance reports for all Residents during daily facility morning meeting. The E Mar Compliance reports indicate proof of medications administered over the last 24 hours and were administered within parameters ordered. The E Mar Compliance reports will be reviewed for compliance daily X 30 days, if no further issues identified, then E Mar Compliance reports will be reviewed 2 x week x 30 days, then if no further issues at the end of 30 days, this will be considered resolved. 1. Review medication administration compliance reports during scheduled QA meetings. 2. Ensure Pharmacy Consultant reviewed medication administration compliance as part of scheduled visits. Through observations, interviews, and record reviews the surveyors determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective 6/16/14 at 3:09 PM. The facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. NON-IMMEDIATE JEOPARDY FINDINGS C. Medication Pass Observation on 6/11/14 at 8:10 AM, Certified Medication Aide X administered Simethicone 80mg to Resident #46. In an interview on 6/11/14 at 8:14 AM, Resident #46 said she had already eaten breakfast and was extremely full. Review of admission record for Resident #46 revealed an [AGE] year old female admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Physician order [REDACTED].#46 revealed in part; Simethicone tablet, chewable; 80mg Three Times A Day Before Meals. D. Medication Refrigerator Observation on 6/13/14 at 7:35 AM of the east hallway medication refrigerator with Director of Nursing (DON) revealed: 1. One bag of intravenous (IV) Vancomycin for Resident #17, who was discharged 2. Resident # 47's Novolog insulin open date 5/7/14 Resident # 49's Novolog insulin open date 5/7/14 Review of Novolog.com revealed in part; vials that are in use may be kept at room temperature or in the refrigerator for up to 28 days 3. Resident # 4' s Levemir insulin did not have an open date on the vial Review of facility Nursing Policy and Procedures dated 7/25/13 and 5/21/14 documented in part; Vials and Ampules of Injectable Medications, The date opened and the initials of the first person to use the vial are recorded on multidose vials. E. Medication Rooms Observation on 6/13/14 at 7:45 AM of the east hallway medication room with Director of Nursing (DON) revealed: 1. Budesonide inhalation suspension did not have an open date Review of the professional monograph by the Food and Drug Administration (FDA) revealed in part; Budesonide inhalation suspension should be stored protected from light. When an envelope has been opened, the shelf life of the unused ampules is 2 weeks when protected. When the foil envelope is opened, the unused ampules should be used within 2 weeks. Remember to record the date you open the foil on the envelope in the space provided. F. Medication Carts Observation on 6/13/14 at 7:00 AM of the respiratory therapist medication cart with Respiratory Therapist Y revealed: 1. Xopenex inhalation solution did not have an open date Review of the professional monograph by the FDA revealed in part; Store Xopenex inhalation solution in the protective foil pouch, protect from light, once the foil pack is opened the vials should be used within 2 weeks. Store solution at 68 degrees F to 77 degrees F. 2. Three boxes of Duoneb inhalation solution had opened vials not in a foil pack. Review of the professional monograph by the FDA revealed in part; Vials should be protected from light before use, therefore, keep unused vials in the foil pouch. Store solution between 36 degrees F and 77 degrees F Record review of Pharmacy Services Policy, Pharmacy Services, undated, provided by Corporate Director of Operations on 6/17/14 stated pharmaceutical services are provided to residents, including procedures that assure accurate acquiring, receiving, dispensing and administering of all drugs and biological to meet the needs of each resident. Record review of the policy Medication Monitoring, Monitoring of Medication Administration, undated and provided by Corporate Director Operations stated the following: Policy: The consultant pharmacist evaluates medication administration to verify that the resident has received medications in accordance with the prescriber's orders and facility policy. Procedures: The consultant pharmacist reviews written records to determine that medications are administered at the frequency and times indicated in the prescriber orders. The consultant pharmacist observes the medication administration techniques of staff. The medication pass may include, but not be limited to reconciliation of observation with prescriber's orders including verification of current orders for drug given. On 6/13/14 at 8:47 AM the Corporate Director of Operations provided documentation of 33 residents receiving insulin, 65 residents receiving blood pressure medications and 8 residents receiving inhalation solution from the respiratory therapist.

Based on interview and record review, the facility Administrator and DON (Director of Nurses) failed to ensure the facility was administered in a manner which enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The Administrator failed to supervise the DON to ensure the DON was monitoring nursing staff to ensure medications were administered according to physician orders. The Corporate Nurse (Corporate Director Operations), DON and Assistant Director of Nurses failed to supervise the nursing staff to insure medications were administered according to physician orders. A. Four (Residents # 9, #34, #35 and #36) of 5 residents with separate day/night sliding scale insulin orders (insulin administered according to finger stick blood glucose parameters) were not administered insulin according to the physician ordered sliding scale. There were 105 doses of insulin that were not administered according to the sliding scale orders in an 11 week period (April to June 2014). B. One (Residents #9) of 65 residents with physician ordered parameters for the administration of blood pressure medications was not administered blood pressure medication according to those physician orders. A total of 35 doses over a 6 week period (May and June 2014) were administered with blood pressure and heart rate readings below physician ordered parameters. This deficient practice resulted in an immediate jeopardy identified on 6/13/14. While the immediate jeopardy was removed on 6/16/14, the facility remained out of compliance at a scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 33 residents with physician orders [REDACTED]. The findings included: In an interview on 6/13/14 at 4:37 PM, ADON K said the Director of Nurses (DON) runs an E MAR indicated [REDACTED]. When there has not been a DON in the facility, the Corporate Nurse runs the report. In an interview on 6/13/14 at 4:43 PM, the DON said he has only been in the facility since 6/02/14 and is still on orientation and is not familiar with electronic charting. In an interview on 6/13/14 at 4:51 PM, Corporate Director Operations (CDO) was shown the medication errors for the sliding scale insulin and the blood pressure medication and said, "It is what it is." CDO said an E MAR (electronic MAR) compliance report is run every morning. It shows any medication that was missed and the facility looks at the reasons for it. CDO said sliding scale insulin administration is not reported on the report because it is not a compliance issue with missed medication. The same with blood pressure medications. If the dose was given, even if given outside of the parameters, it will not show up on the report. CDO said they would have to print a daily E MAR indicated [REDACTED]. CDO said the pharmacist has the same access to the medication information as the facility has. In an interview on 6/13/14 at 4:59 PM, the Nursing Facility Administrator (NFA) said the facility holds lengthy discussion of nursing issues and review 24 hour reports. If issues are found, they are follow-upped on. The NFA said he can look at progress notes and if he sees something there he will refer to the CDO or DON. There has always been a Corporate Nurse in the building if there was "no one in the DON slot". NFA said he does not look at medications as he does not have enough background to know if the medications are administered incorrectly. A. Resident #9 Record review of clinical records documented Resident #9 was a [AGE] year old woman admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #9's Physician order [REDACTED]. a. [MEDICATION NAME] (blood pressure, B/P, medication) 40 mg (milligrams) 1 tablet, gastric tube, Special instructions: hold medication if systolic blood pressure (top number in a blood pressure, SBP) is less than 120 and/or if pulse is less than 60 beats per minute; BID - Twice a Day. b. [MEDICATION NAME] immediate release (B/P medication) 50 mg 1 tablet gastric tube. Special instructions: HOLD for SBP <120 or HR heart rate, pulse) <60 ((<) less than) BID - Twice a day c. [MEDICATION NAME] (insulin) subcutaneous 5 times per day per sliding scale. As per sliding scale: BS (blood sugar) 131-160 - 4 units (u); BS 161-200 - 8u; BS 201-250 - 12u; BS 251-300 - 16u; BS 301-350 - 20u; BS 350-400 - 24u; BS > 400 call MD. Bedtime and 2 am sliding scale: BS 201-250 - 2u; BS 251-300 - 3u; BS 301-350 - 4u; BS 351 - 400 - 5u. d. [MEDICATION NAME] (formula) at 65 ml (milliliters) per hour with 30 ml of water per hour via [DEVICE] (a tube placed through the skin into the stomach for the purpose of providing nutrition and medications) for 23 hours a day. May remove for shower and personal care. In record review of Resident #9's Medication Administration Record [REDACTED]. In record review of Resident #9's MAR for May 2014 the physician orders [REDACTED].#9 that exceeded the physician ordered dosage. In record review of Resident #9's MAR for June 2014 the physician orders [REDACTED].#9 that exceeded the physician ordered dosage. Record review of Resident #9's MAR for May 2014 documented the following: a. [MEDICATION NAME] 50 mg by gastric tube twice a day. Hold for SBP <120 or HR <60. There were 16 doses of [MEDICATION NAME] administered to Resident #9 that should have been held because her blood pressure and/or heart rate was below the physician ordered parameters. b. [MEDICATION NAME] 40 mg 1 tablet be gastric tube twice a day. Hold medication if systolic blood pressure is less than 120 and/or if pulse is less than 60 beats per minute. There were 9 doses of [MEDICATION NAME] administered to Resident #9 that should have been held because her blood pressure and/or heart rate was below the physician ordered parameters. Record review of Resident #9's MAR for June 2014 documented the following: a. [MEDICATION NAME] 50 mg by gastric tube twice a day. Hold for SBP <120 or HR <60. There were 5 doses of [MEDICATION NAME] administered to Resident #9 that should have been held because her blood pressure and/or heart rate was below the physician ordered parameters. b. [MEDICATION NAME] 40 mg 1 tablet be gastric tube twice a day. Hold medication if systolic blood pressure is less than 120 and/or if pulse is less than 60 beats per minute. There were 5 doses of [MEDICATION NAME] administered to Resident #9 that should have been held because her blood pressure and/or heart rate was below the physician ordered parameters. An immediate jeopardy was identified on 6/13/14 and the Nursing Facility Administrator and Corporate Director Operations were informed at 5:30 PM on 6/13/14. The Plan of Action was accepted at 2:11 PM on 6/16/14. A. What did the facility do for the identified residents? 1. Residents with identified sliding scale insulin issues were assessed on 6/13/14 for complications and signs/symptoms of hypo/[MEDICAL CONDITION] and found to have no changes in condition. 2. Sliding scale insulin orders for identified residents were clarified on 6/13/14. 3. Medication error reports were completed on 6/13/14 for residents found to have sliding scale insulin errors with MD, family notifications and corrective actions taken. 4. Lab orders received and executed for identified residents as per MD directives. 5. Interdisciplinary care plans were updated to reflect the current status of the identified residents (started on 6/13/14 and completed 6/15/14). 6. Audit performed by Corporate Nurse and Nursing Administration (completed on 6/15/14) of all Physician orders [REDACTED]. 7. All Current Medication Administration Records (MARS) for Residents identified with medication parameters were reviewed by Corporate Nurse and Nursing Administration (completed on 6/15/14) to identify compliance issues. 8. Medication error reports were completed for those residents found to have compliance issues related to medication parameters with MD, family notifications and corrective actions taken. 9. Resident identified with medication parameter compliance issues were assessed on 6/15/14 for complications, adverse consequences and found to have no changes in condition. B. All residents that have Physician orders [REDACTED]. C. What did the facility do to ensure alleged deficient practice does not happen again? 1. All insulin orders were checked and verified for accuracy completed on 6/15/14. 2. Employees responsible for any identified medication errors reviewed written disciplinary action and/or subsequent terminations as warranted completed on 6/16/14. 3. All Nursing staff in-serviced regarding medication administration, insulin administration, causes of medication errors and adherence to parameters for medication administration (started on 6/13/14, will be completed 6/16/14). 4. Administrator, DON and/or Designee printing, reviewing and investigation discrepancies identified on E MAR indicated [REDACTED]. The E MAR indicated [REDACTED]. 5. QA meeting scheduled for Monday, June 16, 2014 to review all areas of facility compliance. 6. Proficiency check offs for medication administration conducted for all nurses and CMA's (started on 6/15/14, to be completed on 6/16/14). 7. Nursing Audit performed daily by DON and/or Designee to ensure all telephone orders are entered accurately in the computer (ongoing and discussed daily during facility morning meeting). 8. Re-in-serviced all nurses by Corporate Nurse and Nursing Administration on how to properly enter orders into the computer (started on 6/14/14 to be completed 6/16/14). 9. Re-in-serviced all nurses and CMA's by Corporate Nurse and Nursing Administration on specific medication tasks to remember, review of the 5 rights of medicating delivery and the 3 checks of medication administration (started on 6/15/14 to be completed 6/16/14). 10. Staffing/In-service Coordinator will be responsible for ensuring Nurses and CMA's will have medication administration proficiency check offs conducted annually and as needed. D. How will the facility monitor for compliance? 1. Administrator, DON and/or Designee will review E MAR indicated [REDACTED]. The E MAR indicated [REDACTED]. The E MAR indicated [REDACTED]. 1. Review medication administration compliance reports during scheduled QA meetings. 2. Ensure Pharmacy Consultant reviewed medication administration compliance as part of scheduled visits. Through observations, interviews, and record reviews the surveyors determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective 6/16/14 at 3:09 PM. The facility remained out of compliance at a scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. The 33 residents with orders for insulin and the 65 residents with blood pressure administration parameters were provided by Director Clinical Operations on 6/16/14.

Based on interview and record review the facility failed to ensure 2 of 11 residents (Resident #1 & #2) reviewed for elopement risk received adequate supervision to prevent elopement and accidents. Resident #1, who was at high risk for elopement, left the faciity on [DATE] through the front door and was returned by facility staff. Resident #1 left the facility again on 10/12/13 and again on 10/20/13 without staff being aware. On 10/20/13 resident was last seen by staff at 4:45 PM. At 6:30 PM resident #1 called his daughter and said he was at a shopping center, 3 miles away from the facility. Resident #2, who was at high risk for elopement, left the faciity on [DATE] without staff being aware. A motorist passing by notified the facility there was a man outside on the ground. An IJ was identified on 12/4/13. While the IJ was removed on 12/9/13 the facility remained out of compliance at a pattern of potential harm for more than minimal harm due to the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. This failure could affect 9 current residents identified as wanderers at risk of leaving the facility without being seen by staff in situations that might lead to serious injury or death. Findings include: Resident #1 Review of History and Physical dated 9/16/13 revealed a [AGE] year-old resident with [DIAGNOSES REDACTED]. Review of face sheet documented 9/11/13 as resident #1's initial admitted , 10/3/13 as the latest return and 11/4/13 as date of discharge. Review of Minimum Data Set (MDS) revealed the results of the Brief Interview for Mental Status (BIMS); On 9/18/13 11 out of 15, Moderately Impaired On 10/17/13 11 out of 15, Moderately Impaired On 10/29/13 11 out of 15, Moderately Impaired Review of Care Plan dated 9/20/13 identified resident at risk for injury related to identified elopement risk factors and or exit seeking behavior as evidenced by: [DIAGNOSES REDACTED].> = high risk). Approach Wanderguard/Code Alert device in place per order, SW consult PRN, review resident's elopement risk status weekly @ commitee meeting, inform MD, responsible party (RP), resident risk factors and any changes noted, assess for possible placement in secured unit. No changes or updates were made to the Care Plan until 10/22/13 two days after the resident had left the building for the third time. Review of Resident Progress Note dated 10/10/13 documented in part, resident attempted to exit through the front door. He was observed by staff and escorted back into the building. Review of Event Report dated 10/12/13 revealed, resident exited facility without staff being aware, staff noted resident in back parking lot. Five minutes prior wanderguard was on and functioning, resident alarmend door and was re-directed back, resident stated, I want to see my crew. Resident exhibits anxiety, confusion, restlessness and anxiety disorder. Immediate measures taken after elopement was to place alarm band on. In an interview on 12/3/13 at 11:00 AM CNA A said she was working the evening shift on 10/12/13 and went out to her truck in the back parking lot for her break at about 8:00PM. While on break she noticed a man walking along and thought she recognized the walk. As he got closer she recognized him as Resident #1. Resident #1 said he was looking for the bus stop. Resident #1 was walking west in the parking lot towards Montana Ave. (a six lane road with a speed limit of 55 MPH and no sidewalks). CNA A could not convince him to go back to the building and no one else was out in the back parking lot. The door alarms were not going off, resident did not have a wanderguard on, so she finally called the facility with her cell phone and asked for help. Review of Event Report dated 10/12/13 revealed, resident exited facility without staff being aware, staff noted resident in back parking lot. Five minutes prior wanderguard was on and functioning, resident was re-directed back away from an exit, resident stated, I want to see my crew. Resident exhibits anxiety, confusion, restlessness and anxiety disorder. Immediate measures taken after elopement was to place alarm band on. Review of Event Report dated 10/20/13 revealed; at 5:20 PM resident #1 ' s daughter came into the facility requesting to take resident for an outing. The daughter said she did not see him in his room or the dining room. Resident#1 was last seen by staff at 4:45 PM walking toward the dining room. At 6:30 PM resident #1 called his daughter and said he was at George Deiter and Edgemere, 3 miles away from the facility. The daughter picked up Resident #1 from his location, took him home for dinner and then took him back to the facility. The Event Report documented, Resident #1 exhibited the following behavior prior to elopement, the resident had both successful elopements and unsuccessful elopement attempts in the past, was packing his belongings, was repeatedly opening doors/setting off alarms of secured doors, resisting redirection from staff, and was wandering with no rational purpose and attempting to open doors. Resident #1 exhibited agitation, confusion, resistiveness and restlessness. In an interview on 12/4/13 at 11:15 AM Resident #1 ' s daughter said on 10/20/13 she came to the facility at about 5:30 PM and she couldn ' t find her father. When she told staff she couldn ' t find him they thought he was in the dining room or his room. At about 6:30 PM resident #1 called from a shopping center 3 miles away from the facility and asked her to pick him up, which she did. Resident #1 had been pacing back and forth in front of a strip mall and people noticed him and asked if he wanted to use their cell phone to call someone. Resident #1 always had his Bible and written inside was her phone number. When they arrived back at the facility at 8:00 PM the NHA and SW were waiting and they were upset. They asked Resident #1 where he was going and he told them he wanted to go to work. The SW told her that the owners didn ' t want him to stay at the facility anymore. The NHA said resident #1 would need 1:1 and that would cost the facility lots of money. The daughter told them the family could not safely take care of him at home. The SW told her she could send him to a foster home. She felt a lot of pressure from the facility and didn ' t know what to do. The daughter said her brother went to the facility to ask why they were pressuring his sister to get resident #1 out and was told it is the law in Texas the facility had to discharge him if he wanted to go. In an interview on 12/3/13 at 4:45 PM LVN B said Resident #1 came to the nurses station and LVN B helped him call his daughter, then Resident #1 went walking down the hallway toward the dining room at 4:45 PM. Resident did not have Wanderguard on at time of arrival back at the facility, the torn wanderguard was found in the residents room. A visual check of the resident's wanderguard was done that morning and he had it on at that time. Review of Resident Progress Notes revealed: 9/11/13 Resident admitted from another nursing facility 9/12/13 3:15 AM Resident came out of his room wanted to know where the cafeteria is to go eat. Nurse told him it was 3 AM the cafeteria was closed. 9/12/13 4:45 PM Elopement Risk Assessment complete = High Risk. Wander guard placed on right ankle. 9/13/13 1:37 AM Resident awake stated he needs to get his medications from home. Nurse told resident medications are already at the facility. 9/15/13 Resident continues to wander throughout the facility, has been found sleeping in empty rooms, resident re-directed, continue to monitor. 9/18/13 Resident found in the wrong room hanging his clothes in the closet, resident requires redirection. 9/20/13 12:01 AM Resident did not want to go to bed, up walking around facility 9/23/13 10:35 PM Resident walking around facility stated he is not sleepy. 9/28/13 Out to hospital High Blood Sugar 10/7/13 Returned from hospital (wanderguard placed on resident, standard order continue to have visual check every shift and functional check weekly) 10/11/13 Social Worker (SW) met with resident ' s son and daughter. They explained the family is unable to care for the resident and they wish for him to remain long term. The family requested that staff stop telling the resident that he is able to leave the facility for visits home or going out to dinner with family. SW explained that staff cannot lie to the resident and must tell him the truth. 10/13/13 SW informed by NHA and Director of Nursing (DON) resident continueselopement attempts. Administrator requested SW contact family members and discuss the possibility of discharging to a foster home. 10/14/13 SW met with daughter and discussed discharge plans. Daughter reiterated that neither she nor anyone in her family can take the resident home and care for him. In an interview on 11/26/13 at 10:15 AM the Nursing Facility Administrator (NHA) said he didn't consider the building exit on 10/10/13 as an elopement because resident #1 exited out the front door and only got three feet outside into the parking lot before the receptionist caught up to him and brought him back into the building. Nothing was changed after the 10/10/13 or the 10/12/13 events, no systems or policies and procedures, we have wander guards and we redirect and that is what we continued to do. After the 10/20/13 elopement he was put on 1:1. In an interview on 11/27/13 at 11:00 AM the Director of Nursing (DON) said after the 10/20/13 elopement Resident #1 was put on 1:1. Nothing was changed after the first two events, 10/10/13 and 10/12/13. Resident #1 got out of the building; we did what we always did. Wanderers have wander guards on and we redirect and that is what we continued to do. Record review of staffing daily assignment sheets revealed: 10/21/13 - no 1:1 assigned 10/22/13 - no 1:1 assigned 10/23/13 - no 1:1 assigned for 2PM-10PM and 10PM-6AM 10/25/13 - no 1:1 assigned 10PM-6AM 10/28/13 - no 1:1 assigned 2PM-10PM 10/30/13 - no 1:1 assigned 2PM-10PM In an interview on 12/3/13 at 4:30 PM with the NHA and SW. The SW said a 30 day notice was not given. SW said after the elopement on 10/20/13 the Vice President of Operations (VPO) told us to get rid of Resident #1, get him out of the building, discharge him, so that was what we were doing. In an interview on 12/4/13 at 4:20 PM NHA said the last Quality Assurance meeting was 10/29/13 where the SW said Resident #1 was a threat to self-due to elopements and legally could have a 5 day discharge. No plan was discussed or developed to prevent future elopements. Resident #2 Review of Resident face sheet revealed a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Elopement Risk assessment dated [DATE] revealed a score of 33 (20 or above equals High Risk), wander guard place on resident. Review of Care Plan dated 8/7/13 revealed problems of, Behavioral Symptoms - Wanders throughout facility, update 8/16/13 at risk for falling related to dementia and unsteady gait at times. Review of Incident Report dated 9/8/13 revealed LVN C observed resident at the door behind the East nursing station, redirected the resident back to the front of the nursing station. LVN C went to assist a family to the front door and did not reset the alarm on the door behind the East nursing station. When LVN C returned to the nursing station she did not see Resident #2. LVN C asked other staff at the East Nursing Station if they had seen him, no one had seen him. LVN C and a second LVN looked up and down 200 hallway and did not find Resident #2, went to 600 hallway, went to 500 hallway to the West Nursing Station and asked if anyone had seen Resident #2. LVN C was returning to East Nursing Station when she noticed a man outside the East Nursing Station emergency exit. A motorist passing by knocked on the East Nursing Station emergency exit door and notified them there was a man outside on the ground. LVN C looked outside of the door over to the left and Resident #2 was on his hands and knees on the ground. Resident #2 had a skin tear to the right outer elbow measuring 2cm X 2cm with fresh blood and a bruise to the right outer upper extremity measuring 4cm X 5cm. Resident #2 was assisted back into the building. In an interview on 12/3/13 at 9:30 AM DON said Resident #2 exited through the 200 hall nursing station door, he always stood at the nursing station. On 9/8/13, Resident #2 pushed the emergency exit bar, the nurse redirected him. The nurse LVN C put the code in one keypad but not both of the keypads, the door did not reset, so the door just opened when he pushed on it again and it wasn ' t alarmed. LVN C went down the hallway to direct family members to the front door, when she came back Resident #2 wasn ' t there. In a while a motorist passing by knocked on the east nursing station door and told the staff a man was on the ground outside around to the left of the door. The motorist did not leave his name or contact information, he was probably driving by and saw Resident #2 on the ground and pulled over to report it. Review of Wunderground.com, past weather report for El Paso, TX, 9/8/13 at 1:51 PM the temperature was recorded as 90 degrees. In an interview on 11/26/13 at 10:15 AM the Nursing Facility Administrator (NHA) said they put wander guards on residents that wander and they redirect them when they go to the door. That is their system and nothing changed after the resident eloped from the building. They did place a velcro banner that has a stop sign on it across the door. Observation on 12/3/13 at 9:29 AM Resident #13 pushed the emergency exit door, the door had the Stop banner across it. Staff responded to the door alarm at 9:31 AM, 2 minutes after it began to alarm. Observation on 12/3/13 at 10:57 AM Resident #13 pushed the emergency exit door, the door had the Stop banner across it. Staff responded to the door alarm at 11:01 AM, 4 minutes after it began to alarm. Observation on 12/3/13 at 11:04 AM Resident #13 pushed the emergency exit door, the door had the Stop banner across it. Observation on 11/26/13 at 8:45 AM Resident #11 pushed the emergency exit door, the door had the Stop banner across it Observation on 12/9/13 at 10:00 AM Resident #11 pushed the emergency exit door, the door had the Stop banner across it. Observations throughout survey Residents #11 and #13 attempted to exit the facility through emergency exits which displayed the velcro Stop banner. In an interview on 11/27/13 at 11:00 AM the Director of Nursing (DON) said we continued to do what we always did, wanderers have wander guards on and we redirect. Nurses check wanderguards visually every shift and a functional check is done once a week by taking the residents with wanderguards to the front door, if the front door alarms then we know the wanderguard is working.. Review of Event Report Elopement dated 9/8/13 revealed at 1:58 PM Resident #2 was found outside the East middle exit door. The Event Report documented, Resident #2 exhibited the following behaviors prior to elopement, the resident had unsuccessful elopement attempts, repeatedly opening doors/setting off alarms of secured doors and wandering with no rational purpose and attempting to open doors. The resident exhibits confusion, restlessness,unclear speech and dementia. Resident #2 was unable to state his name and location, disoriented X4. Review of Resident Progress Notes dated 8/3/13 at 1:47 PM SW documented Plan is for the resident to continue long term care at this facility. In an interview on 12/6/13 at 4:00 PM Corporate Clinical Nurse (CCN) said if our wander guard system isn ' t good enough they should all be put into a locked unit. In an interview on 12/6/13 at 4:10 PM VPO said I'll just discharge them if the wander guard system that we have is not good enough I will discharge all of them. Review of facility policy Wandering and/or missing residents(undated) provided by the DON stated in part: At times the facility admits and retains residents that are confused and have the tendency to wander about the facility. It becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their confusion. The facility must ensure the resident ' s safety To meet this need the facility will obtain information during pre-admission or admission conferences regarding any history of wandering or the potential. All instances of wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implemented with specific approaches and goals An IJ was identified on 12/4/13 and the facility Administrator was informed at 6:19 PM. Plan of Removal #4 submitted by the facility and accepted on 12/7/13 at 6:58 PM.: A.Resident #1 and #2 no longer reside at the facility. B. What is the facility doing to prevent recurrence: 1.Equipment related items a.Code alert system at the front door has been updated to lock down and sound alarm when a resident approaches and will not open until reset code entered by staff. Facility staff in-serviced by Administration beginning on 12/7/13 with projected completion date 12/9/13 b. Front door will have automatic timer that will lock the front door at specific times (when there is not assigned staff at front desk projected completion date 12/9/13) Facility staff in-serviced by Administration beginning on 12/7/13 with projected completion date 12/9/13 c.LED visual light added to all exit doors that will indicate doors are armed and activated. Projected completion date 12/9/13. Facility staff in-serviced by Administration beginning 12/7/13 with projected completion date 12/9/13 d.Installed a blue flashing light, at each nurse station that is connected to the code system at the front door. We increased the audio alert that is associated to the flashing blue light. Completed installation on 12/5/13 Facility staff in-serviced by DON beginning 12/4/13 with projected completion date of 12/9/13 e.All facility exits have been checked and will continue to be checked by facility Maintenance Supervisor. All safety features were found to be operating correctly. Code alert system checked out correctly 12/4/13. f. A portable device to perform functional checks of the code alert devices has been ordered on [DATE] and delivered on 12/7/13. This is in addition to what is currently our practice of escorting the resident to the front door to check code alert device function. Facility staff in-serviced by Administration beginning 12/7/13 with projected completion date 12/9/13. g.A functional check of each code alert device in use was done on 12/5/13 with no malfunctions noted. The expiration date of the code alert transmitter was added to the Nurse MAR on 12/6/13 to ensure transmitter stays within manufacturer ' s functional limits. 2.Bright orange elopement risk alert bracelets placed on all residents with code alerts. Nursing staff will document visual check of bracelet q shift. Facility staff in-serviced by Administration beginning 12/7/13 with projected completion date 12/9/13. 3.Framed instructions have been mounted at each exit door to alert staff and visitors not to allow residents with bright orange wrist bands to exit building without checking with nursing.Facility staff in-serviced by Administration beginning 12/7/13 with projected completion date 12/9/13. 4. A duplicate copy of the elopement book with resident photos was placed at the Front Desk of the facility on 12/6/13 and will be updated as needed. 5. Weekend nursing staff in-serviced by Nursing Administration beginning 12/6/13 with projected completion date 12/8/13 regarding the importance of the visual check of the Code Alert device at a minimum 3 c ' s / day 6. Facility staff was re-in serviced by DON beginning on 12/5/13 with projected completion date 12/9/13 regarding residents that are wandering, exit seeking and these are behaviors that must be documented. 7. Activity stations were put in place on 12/5/13 to provide arts and crafts and games 24 hours a day, 7 days a week to keep residents occupied.Facility staff was in-serviced by Administration beginning on 12/5/13 with projected completion date of 12/9/138. 8. Addendum to elopement policy was prepared and signed on 12/5/13 by Medical Director, Administrator and Director if Nurses. Facility staff was in-serviced on Addendum by DON beginning 12/5/13 with projected completion date of 12/9/13.9. 9. Revised Resident Behavior Flow sheets were put in place for those residents with Code Alert devices. Documentation will be reviewed by interdisciplinary Team at morning stand-up meeting. Nursing staff in-serviced by Nursing Administration beginning 12/5/13 with projected completion date of 12/9/13. 10.Nurse Aide pocket worksheets were updated on 12/5/13 and will continue to be updated with resident-specific items as identified. 11. Interdisciplinary care plans for residents with elopement risk and code alert use were updated on 12/5/13 and will continue to be updated with resident-specific items as identified. 12. Safety Committee weekly. Conducted 12/7/13. C.What is the facility doing to monitor for compliance: 1.Continue to provide employee training related to wandering/ elopement policy and procedures. All new/updated policies will be included in the " new employee " orientation. 2. Continue to review all Incidents/Accidents by Interdisciplinary Team with follow-up as needed. 3. Random observations of facility staff to determine compliance with monitoring residents with code alerts and wandering, exit seeking behavior(s). 4. Activity Director and Social Worker will perform random interviews with elopement risk residents to determine issues, concerns, care plan adjustments as needed. 5 Review at scheduled QA meeting(s) to determine compliance with Action plans developed as needed. 6 Nursing Administration to perform random checks to confirm the presence of code alert devices and orange wrist bands 7. Safety Committee meeting weekly 8. Scheduled Safety equipment checks by Maintenance Supervisor. Through observations, interviews, and record reviews on 12/9/13 the surveyor determined that the interventions documented in the facility's action plan were implemented and the NHA, VPO and Corporate Clinical Nurse were notified the immediate jeopardy was removed effective 12/9/13 at 3:51PM. The facility remained out of compliance at a scope and severity of pattern of potential for more than minimal harm. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. There were 9 current residents identified as wanderers in an interview with the DON on 12/5/13 at 5:00 PM.