Every finding on record at The Chateau Waco

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. The facility failed to properly discard dented/damaged cans and take them out of use for resident consumption. This failure could place residents at risk of foodborne contamination.Findings included: In an interview and observation on 03/17/2026 at 9:19 AM, with [NAME] A, she stated that she had just returned to work on 03/16/2026 from extended leave. She stated the previous DM was no longer employed at the facility upon her return. When the surveyor asked where the dented cans were kept, [NAME] A pointed to a large array of cans, sitting on a lower shelf under the food preparation table, some with visible dents. She stated that the previous DM had instructed the cooks to use the dented cans first, and the cans were not sent back with the supplier or discarded.In an interview on 03/17/2026 at 12:45 PM, with [NAME] B, she stated she had not been working at the facility for long. She stated that the dented cans kept on the lower shelf beneath the preparation table, were what the previous DM told the cooks to separate from regular cans, and to use those dented cans first for cooking. [NAME] B stated she had finished her computer-based training recently and that training also told her to use dented cans first. She stated that she did not, however, use the dented cans because she knew she was supposed to use undamaged cans to cook with. In an interview on 03/17/2026 at 12:48 PM with the SFDM, she stated that the facility practice should be to put dented/damaged cans in the DM's office, and/or dump them out, and they were not to be used for resident meals. She stated that dented cans should not be used because metal shavings could get in resident's food. She stated she was not sure how long the previous DM was working at the facility or how long the practice of using the dented cans was in place for. She also stated that she was positive the computer-based training did not instruct cooks to use dented cans at all. The SFDM stated that the kitchen followed guidance from the TFER and FDA food code.In an interview on 03/19/2026 at 12:39 PM with the ADM and DON revealed that they were not aware the previous DM had told the cooks to use dented cans. They stated the process for dented cans was that the staff were supposed to check for dents before the delivery truck unloaded to ensure dent-free cans, and to give damaged cans back or to refuse them. The ADM stated that if the damaged cans made their way into the kitchen, the cans need not be placed on the shelf and not used or given to DM. The ADM stated that there could be holes in the cans, food could be contaminated, or infection could be passed onto the residents. The DON stated that there were 3 residents in the facility who required tube feedings and did not eat from the kitchen. The ADM stated that the kitchen followed the guidance from the TFER and FDA food code.Review of the 2022 FDA food code revealed on page 147, Products that are held by the permit holder for credit, redemption, or return to the distributor, such as damaged, spoiled, or recalled products, shall be segregated and held in designated areas that are separated from food, equipment, utensils, linens, and single-service and single-use articles. On page 346 under 'Compliance with Food Law' revealed, Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard. On Page 359 revealed, Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. Suspect cans must be returned .Review of the August 2021 TFER revealed, Food shall be obtained from approved sources in accordance with Food Code, Subpart 3-201, 228.61 of this chapter, and 228.62 of this chapter and shall be in sound condition and be safe for human consumption.

Based on interviews, observations, and record reviews, the facility failed to ensure residents had the right to a dignified existence for 1 of 16 (Resident #39) residents reviewed.The facility failed to treat Resident #39 with dignity and respect when MA F had called her little girl and asked, what is wrong with you?.This failure could place residents at risk for psychosocial harm and isolation.Findings Included:Record review of Resident #39's face sheet revealed a [AGE] year-old woman who admitted to the facility on [DATE], who had diagnoses of chronic obstructive pulmonary disease (a progressive, incurable lung disease), hyperlipidemia (common condition characterized by high levels of lipids), cerebral infarction (a serious medical emergency where blood flow to part of the brain is blocked, causing tissue death due to lack of oxygen) and major depressive disorder (serious, common mood disorder characterized by persistent sadness, loss of interest and low energy lasting at least two weeks).RR of Resident #39's quarterly MDS assessment dated [DATE] revealed that Resident #39 had a BIMS score of 14, which indicated no cognitive impairment. The MDS also revealed that Resident #39 had refused care 1-3 times during the review period.RR of Resident #39's Care Plan dated 01/27/2026 revealed Resident #39 had a diagnosis of depression. The goal indicated Resident #39 will not exhibit signs of isolation. The interventions listed on the care plan indicated staff should convey an attitude of acceptance toward the residents, establish a trusting relationship with the residents, and support the resident's appropriate mood and behaviors.An observation conducted on 03/18/2026 at 10:19AM revealed MA F had entered Resident #39's bedroom and was heard saying Why are you walking around with scissors? What is wrong with you? During the observation, MA F then told Resident #39 to come over here and sit-down little girl in a demeaning way.An interview was attempted on 03/18/2026 at 3:15PM with Resident #39 but was unsuccessful because she was asleep and did not want to talk.An interview was conducted on 03/18/2026 at 3:15PM with Resident #39's husband. Resident #39's RP stated that he and his wife had always had issues with MA F. He stated the issues they had involved in the way MA F communicated with him and Resident #39. He stated that when MA F talked to Resident #39 in the manner she did listed above, it made him feel angry and hurt for his wife.An interview was conducted on 03/19/2026 at 1:56pm with LVN E who stated she had been employed at the facility for a little less than a year. LVN E stated she had received training on resident rights which included the residents had the right to dignity. LVN E also stated she had received training on dignity which included how staff should talk to residents with respect. LVN E stated staff should never call residents by another name, like little girl. She stated that it could affect the residents by the development of depression and isolation. LVN E stated she had not witnessed MA F talk to residents without dignity and respect, but would report it to the AC who was also the ADM.An interview was conducted on 03/19/2026 at 2:53PM with MA G who stated he had been employed at the facility for 4 months. MA G stated he had received training in dignity which included how staff should make residents feel welcome and to ensure that their dignity is upheld. MA G stated that staff should talk to residents with respect at all times and never should be called a nickname, like little girl. MA G stated that residents could refuse to eat and develop depression as a result of not being treated with dignity and respect. MA G stated that if he had suspicions of these concerns, he would report it to the AC who was also the ADM.An interview was conducted on 03/19/2026 at 3:14PM with CNA C who stated she had been employed at the facility for 2 months. CNA C stated she had received training on dignity which included training on how staff are to treat residents and talk to residents with respect. CNA C stated it would never be okay to call a resident by a nickname such as little girl. CNA C stated it could affect the residents to feel sad if they were not treated with dignity and respect. CNA C stated if she had witnessed any concerns of the nature, she would report it to the AC, who was also the ADM.An interview was attempted on 03/19/2026 at 3:27PM with MA F but was unsuccessful due to not answering the phone.An interview was conducted on 03/19/2026 at 03:29PM with the DON who stated she had been employed at the facility for a little under a year. The DON stated she had received training on dignity which included residents should received the care they need with autonomy and respect. The DON stated her expectation for floor staff was to be respectful and provide dignified care to all residents. She stated she expected her staff to use respectful verbiage and tone when engaged with residents. The DON stated should staff members call residents by nicknames such as little girl, it would affect the residents' psychosocial wellbeing. She stated she had not been made aware of staff treating residents poorly.An interview was conducted on 03/19/2026 at 03:56PM with the ADM who stated she had been employed at the facility for a little over 1.5 months. The ADM stated she had received training on dignity at the facility. She stated her policy for dignity included that the residents have the right to be dignified and treated with respect. The ADM stated it could negatively affect the residents if staff had talked down on them, by causing residents to not feel safe, upset, and worthless even. She stated she had not had any complaints about staff treating residents poorly.RR of the in-services conducted on 03/19/2026 indicated the facility had not conducted in-service training on dignity for the staff in the last 3 months.RR of the facility provided policy titled Resident Rights Dignity and Respect dated 05/06/2021 revealed the following:It is the policy for this facility that all residents be treated with kindness, dignity and respect.The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.Violations of the Residents' right to dignity and respect should be promptly reported to the DON and/or the ADM.

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 diseases and infections for 1 of 3 residents (Resident #69) observed for infection prevention.The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed when CNA C and CNA D performed catheter and peri care for Resident #69.This deficient practice could place residents at risk for the spread of infection.Findings Included: Record review of Resident #69's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included: Type II Diabetes, Vascular dementia (decreased blood flow to areas of your brain), Respiratory disorders and diseases, Hypertension (high blood pressure), Sleep Apnea (common condition where breathing stops and starts again), Uninhibited Neuropathic Bladder (frequent urination, reoccurring urinary tract infections, unable to hold urine often following a stroke in Parkinson's patients, or dementia), transient cerebral ischemic attack (Stroke), Congestive heart failure (long term condition that affects your hearts ability to pump blood well).Record review of Resident#69's physician orders revealed that an order with the start date of 02/23/2026, Enhanced Barrier precautions: PPE required for high resident contact care activities. Indication: Indwelling catheter each shift. This was documented and acknowledged each shift on the Treatment Administration Record by the covering nurses.Record review of care plan initiated on 02/23/2026 revealed that Resident #69 was on EBP and interventions included: Direct care staff to utilize gowns and gloves for all personal care.In observations during the duration of the survey between 3/17/2026 9AM-4:30PM, 03/18/2026 9AM-4:30PM and 3/19/2026 9AM-4:00PM, signs were observed on several resident doors stating, Enhanced Barrier Precautions Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and gown for the following High-Contact Resident Care Activities. Dressing, Bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use central line, urinary catheters, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. Also noted on resident nameplates next to specific residents the initials EBP designating which resident in the room had an order for EBP.In an observation on 03/18/2026 at 10:08 AM of peri and catheter care for Resident #69 performed by CNA C and CNA D revealed staff performed care following aseptic technique cleansing hands and changing gloves at appropriate intervals to prevent the spread of infection. Staff failed to wear gowns in providing this care. No sign on Resident #69's door or name plate was noted indicating she was on EBP. Observed that there was also not a supply of PPE outside the door as noted at most resident doors indicating they were on EBP.In an interview on 03/18/2026 at 10:23AM with CNA C she stated she was frequently in-serviced on infection control, and it included EBP. She stated that she would know a resident was on EBP by the sign on the door and the name plate indication. She stated the nurse would also inform a CNA if a resident was on EBP and it can be seen in the plan of care. She stated if a resident is on EBP they would need to wear a gown and gloves when providing care to a resident to prevent the spread of germs. She stated the IP was responsible for placing the EBP signs on the door and name plate. She stated that she did not wear a gown when providing the care as there was not a sign on the door and she did not think fully about the fact that she had a catheter. She stated that typically residents with catheters and wounds are on EBP. She stated she should have realized the resident should be on EBP.In an interview on 03/18/2026 at 10:25 AM with CNA D she stated she was frequently in-serviced on infection control which included EBP. She stated she would know a resident was on EBP by the sign indicating on the door and the EBP sticker by their name on the name plate. She stated she can also see in PCC. She stated that she was unsure why there was not a sign on Resident #69's door and does not know why it did not dawn on her that catheter care typically means the resident is on EBP. She stated that she did not get a chance to check PCC prior to performing the care that was observed. She stated that residents with wounds and catheters are typically on EBP. She stated the IP is responsible for placing the signs on the door and the stickers next to the name plate indicating a resident is on EBP. She stated if a resident is on EBP they should wear gowns and gloves when performing care to prevent them from carrying bacteria from their clothing to the resident.In an interview on 03/18/2026 at 1:00PM with LVN E she stated she has been a nurse for over 25 years, and she is frequently in-serviced on infection control which covers enhanced barrier precautions. She stated that residents that have wounds, catheters, peg tubes or any device that enters the body would be placed on enhanced barrier precautions. She stated that when a resident is on enhanced barrier precautions the staff providing care should wear a gown and gloves. She stated if the staff do not wear PPE while performing care, they can spread bacteria causing the residents to become sick. She stated, the staff knows a resident is on EBP when there is a sign on the door and a small sticker next to their name plate that states, EBP. She stated that EBP direction can be found in the care plan and in orders. She stated the nurse would also tell the CNA if there was an order for EBP. She stated that the infection preventionist typically places the signs on the door and the sticker on the name plate.In an interview on 03/18/2026 at 1:38 PM with WCN she stated she is frequently in-serviced on infection control to include EBP. She stated that residents with catheters, feeding tubes, wounds are the residents that would be placed on EBP. She stated that IP is the person responsible for placing the EBP signs on the door to indicate EBP. She stated that if a resident is on EBP they must wear gowns and gloves when providing close contact care and a mask if necessary. She stated she wears a mask when performing the wound care dressing changes. She stated if the proper PPE is not worn when providing care to residents on EBP they can potentially spread germs and cause infection to the residents.In an interview on 3/19/2026 at 3:23 PM with IP, she stated she has worked in the facility for 2 years and she is currently the Infection control nurse. She stated she and the staff are frequently in-serviced on infection control including EBP. She stated residents with wounds, catheters, colostomies, infections, dialysis, IVs, and PICC lines would all be placed on EBP. She stated if a resident is on EBP the staff must wear a gown, gloves and occasionally a mask when providing care to a resident. She stated that a CNA would know a resident had an order for EBP because there is a sign on the door and an EBP symbol next to the name plate. She stated she is responsible for putting the signs on the door but if she is not working when the order is input the nurse covering at the time should place the signs on the door. She stated they do huddles and in-services weekly to review the list of EBP residents with the staff including the CNAs. She stated she has made a cheat sheet for the CNAs. She stated that if the staff do not wear the proper PPE, they could get germs on their clothing and spread germs causing infections or the residents to get sick. She stated that she was sure that she had placed a sign on Resident #69's door, but they had a disgruntled staff that had been in the building the night before and they believe they may have pulled it down.In an interview on 3/19/2026 at 3:34PM with the DON she stated she has been working in the facility for a little over a year. She stated the staff are frequently in-serviced on infection control including enhanced barrier precautions. She stated that residents with indwelling devices, foley, IVs, Ports, and wounds are placed on EBP. She stated that a CNA would know a resident was on enhanced barrier precautions by PCC posted signs on doors and by the name plate and when they come on each shift the nurse will discuss in report to indicate who is on EBP. She stated if a resident is on EBP she expects staff to wear gowns and gloves when providing high touch care such as peri care, catheter care, or wound care. She stated that if staff do not wear the proper PPE, they can transmit germs and get the resident sick. She stated that they believe there was a sign on Resident #69's door the previous day, but they had a disgruntled employee in the building that they assume pulled them down and they have begun to re-inservice their employees where to find the needed information and not rely solely on the signs.In an interview on 3/19/2026 at 3:50 PM with ADM she stated she started in the facility on 02/01/2026. She stated that staff are frequently in-serviced on infection control to include EBP. She stated that a resident would be placed on EBP if they had c-diff (infection in the intestines), MRSA (drug resistant infection). She stated that a CNA would know a resident was on EBP by the sign on the door she stated it should be identified in the charting system, but she was unsure where as she was new to PCC. She stated that if a resident is on enhanced barrier precautions she expects staff to abide by the check-off sheet. She stated the IP and nurses are responsible for putting the sign on the door to indicate that a resident is on EBP. She stated that if staff do not wear the expected PPE, they can spread infection and germs and contamination from the staff to the residents.Record review of facility policy titled IPCP standard and Transmission-Based Precautions-Infection Control Original written date June 2023 with revision dates July 2022; October 2022 revealed that Enhanced barrier Protection (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for direct transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (Residents with wounds and indwelling medical devices are at especially high risk of both acquisition of colonization with MDROs.) Examples of high contact resident care activities requiring gown and glove used for EBP include Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use: central vascular line, indwelling urinary catheter, feeding tube, tracheostomy/ventilator, wound care.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) for complete and accurate records. The facility failed to ensure Resident #1's wound treatment for sacrum(base of spine that forms the posterior wall of the pelvis), coccyx(tailbone), left hip, left distial(further from the center of the body) medial(closer to the midline of the body) foot ,and left lateral(away from midline of the body) foot was documented in Matrix on January 10th and January 12th. This failure could place residents at risk for the possibility of not verifying the needed care and services to meet their needs.Findings include:A record review of Resident #1's face sheet, dated 01/23/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's had diagnoses which included essential (primary) hypertension (high blood pressure), dysphagia (difficult swallowing), and edema (swelling of body tissue caused by trapped, excess fluid, commonly affecting the feet, ankles, legs, hands, or abdomen)A record review of Resident #1's Quarterly MDS assessment, dated 01/07/2026, reflected Resident #1 had BIMS score of 3, indicated severe cognitive impairment with pressure ulcers.A record review of Resident #1's care plan, dated 01/23/2026, reflected Resident #1 had an actual pressure ulcer(skin and tissue damage cause by prolonged pressure) on the left distal medial foot, left lateral foot, right hip, left hip, coccyx(tail bone), sacrum(triangular shaped bone located at the base of the spine) related to reduced mobility.A record review of Resident #1's physician's order dated 01/07/2026 reflected wound treatment coccyx (tail bone) (unstageable) apply zinc oxide (skin protectant) to wound three times every shift start date 01/07/2026.A record review of Resident #1's MAR dated 01/10/2026 reflected wound treatment coccyx (tail bone) (unstageable) apply zinc oxide (skin protectant) to wound three times every shift was not signed off by RN A at 7:00 PM and 11:00 PM.A record review of Resident #1's MAR dated 01/12/2026 reflected wound treatment coccyx (tail bone) (unstageable) apply zinc oxide (skin protectant) to wound three times every shift was not signed off by RN B at 7:00 PM.A record review of Resident #1's physician's order dated 01/07/2026 reflected wound treatment sacrum (triangular shaped bone located at the base of the spine) (stage 3) apply zinc oxide (skin protectant) three times every shift.A record review of Resident #1's MAR dated 01/10/2026 reflected wound treatment sacrum (triangular shaped bone located at the base of the spine) (stage 3) apply zinc oxide (skin protectant) three times every shift was not signed off by RN A at 7:00 PM and 11:00 PM.A record review of Resident #1's MAR dated 01/12/2026 reflected wound treatment sacrum (triangular shaped bone located at the base of the spine) (stage 3) apply zinc oxide (skin protectant) three times every shift was not signed off by RN B at 7:00 PM.A record review of Resident #1's physician's order dated 12/26/2025 reflected wound treatment left, distal medial foot cleanse wound with Dakins, blot dry, apply gauze sponge sterile moisten with Dakins to wound, cover with a dry dressing, and wrap with Kerlix/Secure with tape daily.A record review of Resident #1's MAR dated 01/10/2026 reflected wound treatment left, distal medial foot cleanse wound with Dakins(antiseptic wound cleanser), blot dry, apply gauze sponge sterile moisten with Dakins (antiseptic wound cleanser), to wound, cover with a dry dressing, and wrap with Kerlix(sterile gauze)Secure with tape daily was not signed off by RN A between 7:00 AM-7:00 PM.A record review of Resident #1's physician's order dated 12/26/2025 reflected wound treatment left lateral foot, cleanse wound with Dakins (antiseptic wound cleanser), blot dry, apply gauze sponge sterile moisten with Dakins (antiseptic wound cleanser), to wound, cover with a dry dressing, and wrap with Kerlix (sterile gauze) Secure with tape daily.A record review of Resident #1's MAR dated 01/10/2026 reflected wound treatment left lateral foot, cleanse wound with Dakins(antiseptic wound cleanser), blot dry, apply gauze sponge sterile moisten with Dakins(antiseptic wound cleanser), to wound, cover with a dry dressing, and wrap with Kerlix(sterile gauze)Secure with tape daily was not signed off by RN A between 7:00 AM-7:00 PM.A record review of Resident #1's physician's order dated 01/07/2026 reflected wound treatment left hip (stage 3) cleanse with normal saline (sterile solution), blot dry, cover with Alginate Calcium (non-adhesive gel) size to fit, cover with dry dressing, and apply house barrier cream to surrounding area daily.A record review of Resident #1's MAR dated 01/10/2026 reflected wound treatment left hip(stage 3) cleanse with normal saline, blot dry, cover with Alginate Calcium (size to fit), cover with dry dressing , and apply house barrier cream (protectant)to surrounding area daily was not signed off on by RN A between 7:00 AM-7:00 PM.Unable to interview Resident # 1 on 01/23/2026, he was sent out to the hospital on [DATE] for change of condition.During an interview with Resident #1's RP on 01/23/2026 at 11:04 AM stated that Resident # 1 was very sick and have been in and out of the hospital for some time now. Resident #1's RP stated Resident # 1 was sent out to the hospital on [DATE] for a change in condition. Resident # 1's RP stated Resident #1 was very sick and she cannot blame anyone on Resident #1's health decline.During an interview with the WCD on 01/23/2026 at 3:00 PM, the WCD stated he come to the facility weekly to see Resident # 1. The WCD stated he debrided Resident # 1 foot on 01/17/2026 and Resident#1's bone was exposed. The WCD had Resident #1 sent out to the hospital for higher level of care as the facility was not going to be able to handle. The WCD stated Resident # 1 had daily wound care treatments and if there were treatments that were not signed off on would not make things any worse for Resident #1. The WCD stated that 01/10/2026 and 01/12/2026 wound treatment not documented would not have any effects of the wounds getting worse if the treatment was not completed or signed off on. The WCD stated wound care in some cases would not have to change out dressings every day and he was not aware of any missed wound care treatments for Resident#1.During an interview with RN A on 01/23/2026 at 3:45 PM stated on 01/10/2026 he provided all wound treatments to Resident #1. RN A stated he did not sign off being completed as he was assisting with other nursing duties after. RN A stated it was expected for him to sign off on treatments when they were completed. RN A stated if the treatments was not signed off on would indicate the treatments was not completed.During an interview with the DON on 01/23/2026 at 3:54 PM, the DON stated it was expected for RN A and RN B to have signed off on the MAR on 01/10/2026 and 01/12/2026. The DON stated it was expected for RN A and RN B to have clear accurate documentation and signed off in Matrix once treatment was completed. The DON stated when the MAR was not signed off would indicate the treatment was not completed.During an interview with the ADM on 01/23/2026 at 4:11 PM, the ADM stated it was expected for RN A and RN B to have signed off on Resident # 1's MAR in Matrix on 01/10/2026 and 01/12/2026 to ensure documentation was completed. The ADM stated if the MAR was not signed off on would have indicated that it was not completed.During an interview with RN B on 01/23/2026 at 5:50 PM stated on 01/12/2026 she provided all the wound care treatments for Resident #1 but just did not sign off on being completed. RN B stated she was busy with other job duties and failed to complete documents. RN B stated it was expected to sign off when the treatment was completed. RN B stated when the treatment was not signed off on would show that the wound treatment was not completed.Record review of the facility's, dated 2023, policy titled Nursing Policies and Procedures Documentation reflected Documentation pretraining to the patient/resident will be recorded in accordance with regulatory requirements. The nursing staff will be responsible for recording care and treatment, observations and assessments and other appropriate entries in the patient/resident clinical record.4. Medications and Treatments The quailed nursing staff notes the time, date and dosage of all medications and treatments at the time they are administered and initials the note on the medication and/or treatment record. The nurse's full name and title must be written at least once on each page of the Medication/Treatment Record or on an individual resident specific signature sheet.

Based on interview and record review the facility failed to ensure that residents are free of any significant medication errors for 1 of 6 residents (Resident #1) reviewed for significant medication errors in that Resident #1 's hospital Discharge summary dated [DATE] stated Stop taking Valacyclovir 1000mg. Resident #1 received 5 doses of Valacyclovir 1000mg after the medication had been discontinued, resulting in readmission to the hospital for altered mental status and metabolic encephalopathy due to Valacyclovir toxicity. The resident had been prescribed Valacyclovir for HSV Opthalmicus (infection of the eye by Herpes Simplex Virus). The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 09/20/2025 and ended on 09/22/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of serious outcomes such as overdose or death.Findings include: Record review of Resident #1's Face Sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Acute and Subacute Infective Endocarditis (an infection of the inner lining of the heart (endocardium) and its valves.) Record review of Resident #1's Quarterly MDS, dated [DATE] reflected a BIMS of 15 meaning there is no or very little cognitive impairment. Record review of Resident #1's Care Plan, last updated 08/13/2025 reflected that Resident #1 required Hemodialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so.Record review of the hospital Discharge Instructions dated 09/20/2025 stated stop taking: Valacyclovir 1000mg tablet.Record review of the MAR for September 2025 indicated Resident #1 was administered 3 doses of Valacyclovir on 9/21/25 and 1 dose on 9/22/25. During an interview on 09/26/2025 at 10:47AM, the DON stated Resident #1 was originally admitted to the hospital for Metabolic Encephalopathy (a condition where the brain does not function properly due to an imbalance in the chemicals and nutrients that the brain needs to function normally) then returned to the facility on 9/20/2025. When Resident #1 returned the agency nurse admitted her to the facility and entered the medications per the discharge instructions from the Hospital. There was an order to discontinue the Valacyclovir, but the agency nurse failed to discontinue this medication. Upon learning of Resident 1's rehospitalization, the DON completed an audit of Resident #1's chart and discovered the error. The DON stated she contacted the agency nurse; however, the agency nurse merely stated she was unfamiliar with the version of the electronic medical record and offered no other explanation for the error. The DON stated they have a nurse reference book that describes how to manage orders. It also contained information for contacting members of the nursing management team if there were any questions regarding the management of medication orders. The DON stated they notified the agency of the need to discontinue services of this nurse. The DON stated that upon discovery of the error, a medication error report was completed, and the physician and responsible party were notified. The DON stated they held an Ad Hoc QAPI on 09/22/2025. During an interview with ADON D on 09/26/2025 at 11:25AM, the ADON stated she contacted the agency representative on 09/22/2025 at 2:43PM and reported the error and notified the representative that the agency nurse was not to return to the facility.Record review of the hospital admission records dated 09/22/2025 was due to Metabolic Encephalopathy (a condition in which the brain does not receive enough oxygen or nutrients leading to changes in brain function) due to Valacyclovir toxicity. During an interview on 09/26/2025 at 11:32AM, LVN A stated after breakfast on 09/21/2025, Resident #1's family member stated that Resident #1 was very confused and was not answering questions appropriately. Resident #1 was Spanish speaking only and LVN Awas bilingual. LVN A stated she assessed Resident #1, and she had slurred speech and could not follow commands. LVN A stated she then notified the nurse practitioner who assessed Resident #1 and gave orders for transport to the hospital. Record review of the Facility Investigation Report dated 09/22/2025 indicated actions taken prior to entrance were: Medication error report completed with appropriate physician and responsible party notified. The nurse responsible for medication error suspended pending further investigation. Resident report roster was completed for the 30 days of facility admissions August 23, 2025, to September 22, 2025. These resident's hospital discharge orders were reviewed in comparison to the admitting orders entered into the electronic medical record and the Medication Reconciliation Report. There were no other errors found during the audit. Re-education of Administrative Nurses by Clinical Services Director on process of medication reconciliation with admission orders and confirmation of admission orders with physician. DON/Designee will re-educate staff nurses, before nurse completes new admission or re-admission. Ad Hoc QAPI was held on 09/22/2025. Record Review of the Inservice Sign in sheets dated 09/22/2025 revealed staff were educated on the medication reconciliation process.During interviews on 09/26/2025 with staff, the following was stated:*At 2:43PM ADON D stated she was in-serviced by the Clinical Services Director regarding the process for medication reconciliation as documented on the in-service sign in sheet of 09/22/2025.*At 5:13PM The DON stated she was in-serviced by the Clinical Services Director regarding the process for medication reconciliation as documented on the in-service sign in sheet of 09/22/2025. She stated weekend staffing was amended to include a member of the nursing leadership team to ensure a second nurse reviews medication reconciliation during non-business hours. She stated she, the 2 ADONs, and the MDS nurse will now work one weekend per month to provide this coverage. *At 5:14PM RN F stated she received training of second nurse review of medication reconciliation.*At 5:50PM LVN I stated she received training of second nurse review of medication reconciliation. LVN I stated she was in-serviced by the Clinical Services Director regarding the process for medication reconciliation as documented on the in-service sign in sheet of 09/22/2025. Record Review of the Ad Hoc QAPI agenda and sign in sheet revealed the meeting was held. Record Review was conducted of the audit of resident hospital discharge orders as compared to admitting orders and outcomes were confirmed on 09/26/2025 by conducting a Record Review of the medical records of 5 Residents selected for the random sample. Record Review of the undated policy Medication Reconciliation was conducted on 09/26/2025. Policy statement #2 read: Residents who are being readmitted to our facility after an acute care stay will have review of the most current SNF discharge medication profile with the readmission medication orders to validate that the resident has a comprehensive and accurate medication profile.The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 09/20/2025 and ended on 09/22/2025. The facility had corrected the noncompliance before the investigation began.

Based on observation, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #4) reviewed for accidents, hazards, and supervision, in that: The facility failed to provide adequate supervision to prevent injury for an incident that occurred on on 08/09/2025 at 4:30PM in the Dining Room, Resident #4 was attempting to get a cup of coffee. The cup overflowed and spilled coffee in Resident #4's lap and resulted in urns with 3 blisters to the left upper thigh. The facility failed to take the temperature of the coffee and keep temperature logs of the coffee. The facility failed to assess other residents for hot liquids An (IJ) Immediate Jeopardy was identified on 08/26/2025. The IJ template was provided to the ADM on 08/26/2025 at 7:28PM. While the IJ was removed on 8/28/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #4's undated Face Sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, unspecified (brain tissue death caused by a blocked artery supplying blood to the brain, leading to a lack of oxygen and nutrients) and Hemiplegia (the total or severe loss of motor function on one side of the body, resulting in paralysis) and Hemiparesis (weakness on one side of the body, affecting the arm, leg, or face) following cerebral infarction affecting right dominant side, diabetes, Hypertension, Burn of unspecified degree of left thigh Record review of Resident #4's quarterly MDS, dated [DATE] reflected a BIMS score of 12 (moderate cognitive impairment) Section G of the MDS reflected for eating and drinking resident# 4 required the need for supervision, oversight, encouragement and cueing. Record review of Resident #4's Care Plan, last updated 08/18/2025 reflected that Resident #4 required some minimal assistance with ADLs. History of CVA with right hemiparesis, Current. Care Planned interventions include the following: Approach: Eating: Assist of 1 staff member.During an interview with DA C conducted on 08/20/2025 at 2:38PM, she stated she saw Resident #4 trying to get coffee and she tried to help. DA C stated there was a lid on the cup, but it spilled anyway, and DA C reported the event immediately to the nurse. During the verbal assessment performed by the nurse, Resident #4 denied any injury. DA C stated she was in-serviced on removing the coffee servers from the Dining Room and placing them in the locked Nutrition Room after each meal service and the dietary staff are not to bring the coffee into the Dining Room unless nursing staff are present. On 08/20/2025 at 2:42PM, conducted a phone interview with the Dietary Manager. The Dietary Manager confirmed the coffee available for self-service to the residents prior to Resident #4 receiving the burn injury was not temperature tested. On 08/20/2025 at 3:13PM conducted an interview with LVN E. She stated Resident #4 informed her about the burns to his legs on the day following the event. LVN E stated she assessed the leg on 08/10/2025 at 7:27AM and obtained orders for care of the wounds and notified the DON. She stated she did find 3 open areas that appeared to be blisters that had burst. Record review of Resident #4's progress note dated 08/09/25 at 6:30 PM Recorded as Late Entry on 08/12/2025 at 08:53 AM- reflected Resident found in dining room with pants wet with coffee. Resident assessed for pain and burn. Resident reported not feeling pain or burn. Resident reported I'm fine I don't feel burn right now. Resident continued with process of getting coffee and returned to room. Record Review on 8/20/2025 of the progress note dated 08/09/2025 at 6:30PM written by LVN D regarding the coffee spill. LVN D documented that she asked the resident if he was injured, and Resident #4 denied being injured. Record review of Resident #4's incident report dated 08/10/25 reflected incident date 08/09/2025 resident was observed in the dining room with pants wet with coffee. Resident reported trying to get coffee with kitchen staff assistance. Resident assessed immediately for pain and burn. Resident reported not feeling pain or burn stating I'm fine I don't feel any pain. Resident proceeded with getting another cup of coffee and returning to his room.Record review of Resident #4's progress note dated 08/10/25 at 6:00 PM [Recorded as Late Entry on 08/12/2025 at 08:51 AM] reflected Resident reported dressing came off. Assessed skin and affected area. Skin appears pink and moist. Changed dressing. Resident reported feeling pain during procedure. Resident was given PRN acetaminophen. Cleaned skin with normal saline and gauze. Xeroform Petrolatum dressing placed on affected area. Covered dressing with Non adhesive super absorbent wound dressing and secured with skin tape. Assessed resident for discomfort. Resident tolerated procedure with no further discomfort after receiving PRN pain medication. Record review of Resident #4's prescription orders dated 08/10/25 reflected order description: for Silvadene (silver sulfadiazine) cream; 1%; amt: small amount cover wounds; topical, frequency: twice a day 1: 06:00 AM- 06:00 PM 2: 06:00 AM- 06:00 PM. Special instructions: apply cream to 3 open wounds on left thigh.Record review of Resident #4's progress note dated 08/10/25 at 11:30 AM -- INVALID -- On 8/9/25, at 6:30PM, reflected resident was found in dining room with pants wet with coffee spilled on himself. Resident assessed for pain and burn. Resident reported not feeling pain or burn. resident returned to room with coffee. Record review of Resident #4's progress note dated 08/10/25 at 11:25 AM -- INVALID-- reflected Resident found in dining room with pants wet with coffee. Resident assessed for pain and burn. Resident reported not feeling pain or burn. Resident reported I'm fine I don't feel burn right now. Resident continued with process of getting coffee and returned to room. Record review of Resident #4's progress note dated 08/10/25 at 9:45 AM reflected Call made to resident's family member to inform about coffee spilling on resident's left thigh. Discussed treatment plan ordered by provider. Advised that will continue to monitor resident for any signs of infection. Answered all questions and listened to concerns had. Family member stated that she will be at facility later today to see resident. Record review of Resident #4's progress note dated 08/10/25 at 9:32 AM reflected Call to on-call provider to notify that resident had coffee spilled onto left thigh. Rec'd order for Silvadene cream to be applied to areas 2x per day. Wound care order to cleanse area with normal saline, apply thick layer of Silvadene cream and to cover with non-stick dressing and monitor for sign/symptoms of infection. Record review of Resident #4's progress note dated 08/10/25 at 8:23 AM reflected Spoke with resident about coffee spill incident that occurred on Saturday evening. Resident stated that after dinner the dietary aide helped him get coffee while in the dining room. Resident was using the cup with the lid, but it must have been overfilled. Stated that the coffee spilled onto his leg. He stated the dietary aide put towels on the area and took him to his room. Resident reports that it was not painful. Assessed left thigh and observed approximately dollar size open area, quarter sized open area, and dime size area open area. No signs/symptoms of infection noted. Will continue to monitor for changes. Record review of Resident #4's progress note dated 08/10/25 at 7:27 AM reflected Resident came up to this nurse and stated he was in the dining room getting coffee with another resident yesterday and they spilled coffee on his lap. Resident L thigh has 3 open areas where it appears to have bubbled then burst. Area cleaned and dressing placed. Weekend supervisor and DON notified. Record review of a therapy screening form dated 08/11/25 for Resident #4 reflected nursing referral for difficulty performing ADLs: feeding. Resident with coffee burn, assessment of AE referral, occupational therapy is recommended. Record review of Resident #4's progress note dated 08/11/25 at 1:22 PM reflected Resident seen by provider due to recent burns to left thigh. New orders received to start Doxycycline 100mg BID x10 days to prevent infection. Orders updated on MAR; family member aware. No other concerns at this time. Care ongoing.Record review of Resident #4's progress note dated 08/13/25 at 1:21 PM reflected Resident seen for initial visit by Dr. for Burn Wound of Left, Anterior Thigh w/Partial Thickness and Burn Wound of Left Medial Thigh w/Partial Thickness. Burn wound #1 is located on left anterior thigh caused by hot beverage; wound measures 6.1 x 4.5 x 0.1 cm/surface area 27.45 cm2. Light serous drainage (clear, watery fluid) noted. 100% dermis observed. Edges attached to wound base. Redness noted to peri-wound. Temperature is warm to touch. Burn wound #2 is located on the left medial thigh; measuring 2.3 x 13 x 0.21 cm/surface area 29.90 cm2. Light serous drainage noted. Erythema (superficial reddening of the skin)and fluid filled blisters noted to peri wound. Edges attached to base. 100% Dermis observed. New orders apply Silver Sulfadiazine to wounds, cover with Xeroform Gauze dressing, and wrap wounds with Gauze Roll Kerlix 4'5, and secure Kerlix with Ace Bandage or Coban 3(three) times daily. Emergency contact updated on wound visit with WCD. No concerns verbalized at this time.On 8/20/2025 at 11:15am attempted observation and interview with resident# 4, not available not in room. Attempted to locate resident # 4 throughout the day. On 08/20/2025 at 4:45PM conducted an in-person interview with the DON. The DON stated she was not notified that the resident sustained burns to his upper leg on the evening it occurred. She was notified on 8/10/2025 by the Nursing Supervisor, LVN E, after Resident #4 had complained to her that morning about having the burns on his leg. The DON stated she notified her corporate supervisor as soon as she was notified of the event. The DON then described the follow up actions of both nurses to include they received instructions for wound care. The DON also verbally confirmed the documented in-service training received by herself, the Administrator, and the Dietary Director. The DON further stated she initiated in-service training with the staff immediately. The DON stated she was not notified of the event in a timely manner; therefore, she implemented corrective action with the responsible nurse. In an interview on 8/26/2025 with the DON at 4:00pm revealed they completed an observation assessment on 8/10/2025 and 8/18/2025. The DON stated each resident who had access and drank coffee was observed this included 19 other residents. The DON stated they did not have a formal assessment for the observation that was completed. The DON was not able to state what the observation included in order to determine if a referral to PT (physical therapy) was needed. The DON stated the results of the observations completed was not documented. Record Review of the policy Guidelines to Reduce Risk of Burns from Hot Beverages. Dated 08/01/2020. The policy statement stated, Precautions shall be implemented to limit the risk of burns from hot beverages (coffee, tea, etc.). he policy described the recommended coffee brewing temperatures as between 195- and 205-degrees Fahrenheit. The actual serving temperatures should range from 155 degrees to 175 degrees based on individual preference. An (IJ) Immediate Jeopardy was identified on 08/26/2025 at 7:15PM due to the above failures. The Census was 64. The ADM was notified on 08/26/2025 at 7:28PM. The ADM was provided with the (IJ) Immediate Jeopardy template on 08/26/2025 at 7:28PM, and a Plan of Removal (POR) was requested. A Plan of Removal was first submitted by the ADM on 08/26/2025 at 9:20PM. The Plan of Removal was accepted on 08/28/2025 at 3:43PM. The facility failed to ensure that the resident environment remained free from accidents and was appropriately supervised. Performed Record Review of facility investigation and follow up of the incident on 08/20/2025. Charge Nurse verbally questioned resident on 8/9/25 regarding burn and pain, resident denied both. Identified resident had skin assessment completed on 8/10/25 by charge nurse and on call nurse practitioner notified. Treatment orders were received and implemented on 8/10/25. Nurses note entered on 8/10/25 by charge nurse of notification and orders received. The Electric urn used for self-service coffee was disconnected on 8/10/25 by the Dietary Manager. The Dietary manger was reeducated by the Clinical Consultant on 8/10/25 on coffee service for residents including: temperature checks for hot beverages to include recording the start temperature and the serving temperature, between 155 degrees F and 175 degrees F on a temperature log. Coffee will be served into carafes from the commercial coffee maker in the kitchen and placed in the nourishment room for nursing staff to dispense as requested by residents.Kitchen staff were reeducated by the Dietary manger by 8/27/25 on coffee service for residents including: temperature checks for hot beverages to include recording the start temperature and the serving temperature, between 155 degrees F and 175 degrees F on a temperature log. Coffee will be served into carafes from the commercial coffee maker in the kitchen and placed in the nourishment room for nursing staff to dispense as requested by residents. An audit was completed by Nursing Leadership, Dietary Department and Administrator to identify residents in house who drink coffee. 20 were identified. Head to toe skin audits on the 20 identified residents were completed by the Licensed Nurses on 8/10/25 on paper and uploaded to the resident's medical record. No additional concerns were identified. An Evaluation will be completed on Residents who consume coffee to identify their ability to manage hot beverages independently by the Director of Nursing/Designee by 8/27/25. Those identified as needing assistance will have care plans updated by the Director of Nursing/Designee with needed safeguards individualized by resident needs to reduce the risk of burns from hot beverages. Clinical Consultant reeducated Administrator, Director of Nursing and Dietary Manager on appropriate notification and assessment if a coffee burn is identified on 8/10/25. Nursing staff and dietary staff were reeducated by the Director of Nursing/Designee on guidelines to reduce the risk of burns from hot beverages on 8/26/25 including: Pot or urns containing hot liquids will not be left unattended Facility staff will pour hot beverages Use of resident specific additional safeguards if indicated If a resident sustains an injury, an assessment from the licensed nurse will be completed immediately. Director of Nursing and physician will be notified for further direction This re-education will be completed by 8/26/25. Nursing staff or dietary staff not receiving this re-education by this date will receive prior to next scheduled shift. This will be provided for agency staff and new hire orientation through verbal education by the Director of Nursing/Designee. The Dietary Manager/Designee will assess newly admitted residents thorough the diet history observation in the electronic medical record Monday - Friday to identify those residents that request and/or consume coffee and communicate to the Director of Nursing/Designee to validate any needing assistance with hot beverages have care plans in place with needed safeguards. The Director of Nursing/Designee will review new admissions in clinical morning meeting Monday - Friday to validate residents identified as needing assistance with hot beverages have care plans updated with needed safeguards, recording on the clinical morning meeting form. The medical director was notified of the immediate jeopardy on 8/26/2025 by the administrator.An Ad Hoc Quality Assurance Performance Improvement meeting was held on 8/26/2025 regarding the contents of this plan. Monitoring on 08/27/2025 and 08/28/2025 included the following:Record review of Resident #4's care plan dated 07/16/25 reflected: Problem Start Date: 08/27/2025 Resident should have a lid on all hot liquids and should be sitting at a table while drinking or eating them. Goal Target Date: 12/27/2025 Resident will not get a burn Approach Start Date: 08/27/2025Resident to use cup with lid, temp will not exceed 175 degrees, resident should be sitting at table while eating or drinking hot fluids, staff to assist. 08/27/25 Regarding hot liquid safety, resident has some weakness in upper extremities and reduced movement in upper extremities, suggested interventions include that the resident will use a cup with a lid, hot liquids do not exceed 175 degrees, and that the resident should be drinking all hot fluids while sitting at a table while using a sippy cup and has been seeing therapy. Record review of Resident #4's progress note dated 08/27/25 @ 10:00pm written by LVN S, regarding hot liquid safety, reflected resident has some weakness in upper extremities and reduced movement in upper extremities, suggested interventions include that the resident will use a cup with a lid, hot liquids do not exceed 175 degrees, and that the resident should be drinking all hot fluids while sitting at a table while using a sippy cup and has been seeing therapy. On 08/27/25 at 4:00 PM Observation of the dining room revealed the electric urn was removed. On 8/27/25 at 5:13 PM observation of the coffee urn in the locked nutrition room by the nurse's station revealed the item name, date, temperature reading, and employee initial. Dietary Staff R. On 8/27/25 at 5:15 PM Interview with the Dietary Manager who stated she worked at the facility for 10 months. She stated she was re-educated on abuse, neglect, rights, and coffee service for residents. She stated re-education on coffee services for residents included temperatures for hot beverages and had to be documented on a daily log. She stated the temperature had to be between 155 degrees- 175 degrees; not to exceed 175 degrees. She stated dietary staff use a stainless-steel thermometer. She stated the coffee urn is not to be left unattended. She stated facility staff would pour and serve hot beverages. She stated the facility ordered new coffee cups with lids. She stated they are using Styrofoam cups with tear back lids until the new cups arrive. She stated some of the residents use a specialized cup with lid. She stated coffee would be placed in the locked nutrition room for nursing staff to serve if residents request. She stated she was re-educated on reporting guidelines for hot beverage burns and proper procedure for handling and monitoring hot liquids. She stated she would report to the DON immediately. She stated she was re-educated on assessing newly admitted residents. She stated she would assess newly admitted residents the day after admission. She stated she goes over the resident's preferences and identifies residents that request coffee. She stated she documents in the resident profile under meal tracker, care plan, meal ticket and communicates with the DON alerting her of hot beverages the residents are getting and how often. She stated she would update preferences upon request by residents. She stated she re-educated all dietary staff on the hot beverage procedure, and daily coffee temperature log. She stated she put a sticker on the in-service sheet which showed the item, date, time, temperature, and staff initial. Coffee temperatures are checked before the urn is put on the food cart or brought to the nurse station which also include sticker. The urn for the dining room stays in the kitchen until nursing or CNA staff are in the dining room feeding and serving residents. Dietary staff are monitoring drinks during all meals in the dining room. She stated after meal services hot beverages will be put in the nutrition room for as needed services. On 08/27/25 at 5:45 PM Observed several staff in the dining room assisting residents with meal and drinks. Observed a Sign posted on the wall that said, Coffee available upon request located in the nutrition room between meals. Observed a coffee urn in the dining room on the counter which included a sticker with item, date, temperature reading 159 degrees, and staff initial. Observed staff pouring and serving coffee in a Styrofoam cup with lid and specialized cups to residents. On 08/27/25 at 5:56 PM Interview with Med Aide N who stated she had worked at the facility for 5 months. She stated she had been trained on abuse, neglect, rights, notification of resident change, and hot beverages. She stated staff are in-serviced every other week. She stated they went over the proper way of handling and serving the coffee. She stated coffee is served from an urn. She stated staff had to pour and serve all hot beverages. She stated staff serve coffee in Styrofoam cups with lids. She stated dietary staff check the temperature and put a sticker on the urn with the temperature before bringing it to the dining room. She stated the coffee cannot be brought out until the charge nurse is in the dining room. The coffee urn will never be left unattended.She stated if a resident asked for coffee, she would tell the resident she would have to get with the charge nurse or offer a different type of beverage. She stated the temperatures should be around 155 degrees. She stated if a resident sustained an injury, she would immediately notify the nurse. On 08/27/25 at 6:10 PM Interview with CNA J. She stated she had worked at the facility 3 years. She stated she had been in-serviced on abuse, neglect, rights, notification of resident change and hot beverages. She stated staff are in-serviced every week. She stated staff had to pour and serve coffee for the residents. She stated coffee is served in styrofoam cup with a lid or specialized cup with lid. She stated the coffee is not to be left unattended, and when finished serving staff would take the coffee urn to the kitchen. She stated a coffee urn is kept locked in the nutrition room by the nurses' station. She stated the electric coffee urn was taken out of the dining room. She stated if a resident wanted coffee she would tell the resident to go to the dining room and she would bring coffee to them in a Styrofoam cup with a lid. She stated dietary staff check the coffee temperature and put a sticker on the coffee urn. She stated the coffee temperature ranges between 155degrees -175 degrees. She stated if a resident sustained an injury, she would immediately notify the nurse in charge. On 08/27/25 at 6:20 PM Interview with [NAME] F who stated she had worked at the facility for one year. She stated she had been in-serviced on abuse, neglect, rights, and checking the temperature for hot beverages and hot beverage policy. She stated staff are in-serviced monthly. She stated the big coffee pot had been taken out of the dining room. She stated nursing staff had to request coffee from the kitchen. She stated staff had to pour coffee for the residents and the coffee is now being served out of an insulated coffee pitcher. She stated temperatures are checked before coffee is brought to the dining room with a stainless-steel thermometer. She stated temperature checks for hot beverages include the start and serve temperatures. She stated temperatures should be between 155 degrees and 175 degrees and logged on a temperature log. She stated a label is put on the coffee pitcher which includes the item, date, time, temperature, and employee initial. She stated the coffee pitcher will not be left unattended. She stated coffee is kept locked in the nutrition room by the nurse station and staff had to serve the resident coffee. Record Review of in-service dated 08/10/25 reflected 3 administrative staff had been in-serviced on reporting guidelines for hot beverage burns and proper procedure for handling and monitoring hot liquids. Record Review of facility nutrition policies and procedures revision date 08/01/2020 reflected Precautions shall be implemented to limit the risk of burns from hot beverages (coffee, tea, etc.). 1. Hot beverages should be consumed at temperatures between 155 F and 175 F. Palatability is affected by temperature and varies from person to person, based on individual preference. 2. Commercial coffee brewing equipment is designed to heat water and hold coffee at desirable temperatures.A. Coffee should be brewed at temperatures between 195 F and 205 F to extract the full flavor. Storing coffee at temperatures between 175 F and 190 F will maintain the fresh brewed flavor for a limited period.B. Hot water dispensed from commercial coffee urns will be in the 185 F to 200 F range. 3. Pots or urns containing hot liquids should not be left unattended. 4. Facility staff should pour all hot beverages. 5. Locations where hot beverages may be prepared and/or re-heated such as employee break rooms or nourishment rooms should be safeguarded. 6. Patients or residents should not carry hot beverages without a lid while walking or moving in a wheelchair. 7. Beverages should not be re-heated by patients or residents or visitors. 8. The Facility may consider using china or ceramic cups, in lieu of plastic mugs, or foam cups, which do not provide for rapid cooling. 9. When serving hot beverages to patients or residents:A. Transfer the beverage from its brewing urn to a serving container. Beverages served directly from the brewing urn will be hotter.B. Do not overfill cups.C. Explain to patient/resident that a hot beverage is being served.D. Place cup away from the edge of the table and within patient's/resident's field of vision and reach of dominant hand.E. Remove lids to allow beverage to cool faster.10. When hot beverages are available for self-service: (e.g. dining room, lobby, beverage cart on unit)A. Coordinate beverage set-up in supervised areas only.B. Transfer the beverage from its brewing urn to a serving container.C. Do not overfill serving containers.D. Use only containers with safety or screw top lids rather than loose lids.E. Pre-pour beverages whenever possible into cups with lids. Record Review of in-service dated 08/10/2025 reflected that 5 staff had been in-serviced on hot beverage procedures regarding start and serving temperature and check of the beverage until it has reached a temperature range of 155 degrees-175 degrees per company policy. Once the proper temperature is reached staff will write out a ticket of type of beverage, date, time, and temperature. No hot beverage will be put out for serving until nursing staff is there to start. After all meal services hot beverages will be put in the nutrition room for as needed service. Record Review of skin monitoring: comprehensive CNA shower review dated 08/11/2025 reflected head to toe audits for 19 residents who drink coffee. No concerns were noted. Record Review of hot beverage temperature log sheet for August 2025 reflected start and serve temperatures. No concerns were noted. On 08/28/25 at 12:42 PM Interview with LVN E who stated she had worked at the facility for 2 years.She stated she had been in-serviced on abuse, neglect, rights, notification of resident change, and hot beverages and hot cereal. She stated staff are in-serviced every two weeks. She stated the coffee is served in an urn with a handle. She stated they went over serving temperature which is 155 degrees. She stated dietary staff check coffee temperature in the kitchen and put a label on the urn which includes the item, date, temperature, and staff initial. She stated the coffee is brought to the dining room when nursing staff is in the dining room and urns containing hot liquids will not be left unattended.She stated staff had to pour and serve hot beverages to the residents. She stated staff use Styrofoam cups with lids. She stated some of the residents have a specialized cup with lid. She stated the Administrator had ordered new cups with lids; they are using Styrofoam cups with lids until the new cups arrive. She stated coffee is kept in the nutrition room for nursing staff to dispense if residents request. She stated most of the residents that drink coffee are independent.She stated if a resident sustained an injury she would immediately assess the resident, notify the family, DON, and PCP. On 08/28/25 at 12:57 PM Interview with [NAME] O who stated she had worked at the facility for 1 year. She stated she had been in-serviced on abuse, neglect, rights, and hot beverages and cereal. She stated staff are in-serviced once a month. She stated dietary aides are supposed to check the temperature when coffee is freshly brewed and served. She stated the serving temperature should be between 155 degrees -175 degrees. She stated dietary staff had to wait until nursing staff asked for the coffee to be brought to dining room. She stated the coffee is served in an urn with a label which included item, temperature, date and staff initials. She stated the nursing staff had to pour the coffee and serve to residents. She stated coffee is poured in Styrofoam cups with a lid until the new cups and lids arrive. She stated coffee will not be left unattended. She stated a coffee urn is placed in the nutrition room for staff to dispense if residents request. She stated dietary staff also have to check the temperature and label the hot cereal. She stated a temperature log is kept daily for hot beverages. Temperatures are checked with a stainless-steel thermometer. She stated if a resident asked for coffee she would tell the resident to go ask the nurse. She stated if a resident sustained an injury, she would immediately notify nursing staff. On 08/28/25 at 1:15 PM conducted Interview with CNA P who stated he had worked at the facility for about 4 months. He stated he had been in-serviced on abuse, neglect, rights, hot beverages, and notification of resident change. He stated staff are in-serviced monthly. He stated coffee is served from an urn and only when nursing staff is in the dining room. He stated coffee is not to be left unattended in the dining room. He stated after meals the coffee is brought to the nutrition room which is kept locked. He stated the temperature should be between 155 degrees -175 degrees. He stated the coffee is served in an urn which had a sticker that shows the item, temperature, and staff initial. He stated staff pour and served the coffee for residents. He stated if a resident asked for coffee, he would go get the coffee and bring it to the resident. He stated most of the coffee drinkers are independent. He stated coffee is served in a Styrofoam cup with lid. He stated some of the residents had a specialized cup with lid. He stated if a resident sustained an injury he would immediately report to the nurse in charge. Record Review of in-service dated 08/10/2025 reflected 13 staff from different shifts had been in-serviced on abuse, neglect, and resident rights. Record Review of in-service dated 08/10/2025 reflected 18 staff had been in-serviced on the hot beverage policy. Record Review of evaluations completed for all residents. Their criteria were all the same for the evaluations. Residents were screened for cognition, mobility, dexterity, and behaviors to see if they were safe with hot beverages. Record Review of facility daily monitor log for appropriate hot beverage cup/lids reflected 08/11/25 through 08/15/25 no concerns. On 08/28/25 at 3:00 PM conducted Interview the DON stated she had worked at the facility for four months.She stated she had been trained on abuse, neglect, resident rights, and hot beverages. She stated the electric urn was discontinued immediately. She stated coffee is being served from an urn. She stated the dietary manager, DON, and Administrator were reeducated on coffee service for the r[TRUNCATED]

Based on interview and record review, the facility failed to immediately notify the resident's physician following an incident that occurred on 08/09/2025 at 4:30PM in the Dining Room, when Resident #4 was attempting to get a cup of coffee. The cup overflowed and spilled coffee in Resident #4s lap, resulting in Resident #4 sustaining 3 blisters to the left upper thigh. The facility failed to notify Resident #4's physician when he sustained burns from hot coffee, he spilled in his lap. This deficient practice could place residents at risk of not receiving adequate and timely intervention. The findings include: Record review of Resident #4's undated Face Sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, unspecified (brain tissue death caused by a blocked artery supplying blood to the brain, leading to a lack of oxygen and nutrients) and Hemiplegia (the total or severe loss of motor function on one side of the body, resulting in paralysis) and Hemiparesis (weakness on one side of the body, affecting the arm, leg, or face) following cerebral infarction affecting right dominant side. Record review of Resident #4's quarterly MDS, dated [DATE] reflected a BIMS score of 12 (moderate cognitive impairment) and in Section G, the need for a low level of supervision in the form of staff oversight, with encouragement or cueing with eating or drinking. Record review of Resident #4's Care Plan, last updated 08/18/2025 reflected that Resident #4 requires some minimal assistance with ADLs, and he does not ask for help and often time refuses to allow staff to help him, History of CVA with right hemiparesis, Current. Care Planned interventions include the following:Approach: Eating: Assist of 1 staff member. Record Review was conducted of Resident #4's medical record. A progress note entered by LVN D on 08/09/2025 at 6:30PM, described how Resident #4 spilled coffee in his lap and LVN Ds assessment of Resident #4 who denied any injury. There was no documentation of notification of the physician or the DON in the progress note. During an interview with DA C conducted on 08/20/2025 at 2:38PM, she stated she saw Resident #4 trying to get coffee and she tried to help. DA C stated there was a lid on the cup, but it spilled anyway, and DA C reported the event immediately to the nurse. During an interview with the DON on 08/20/2025 at 4:45PM, the DON stated she was not notified of the event until the following day. She stated had she been notified; she would have ensured Resident #4's physician was notified. The DON stated she implemented corrective action with LVN D for not notifying the physician and the DON. Record review of the facility investigation report dated 08/15/2025 was performed on 08/20/2025. The report indicated the facility investigation findings as unconfirmed. There is also documentation of the following: Nursing Staff in services on Abuse, Neglect/Misappropriation, Hot Beverage Policy, Burn Policy and Proper Notification to the DON and Administrator, The Administrator, DON, and Dietary Manager were in serviced on Guidelines to Reduce the Risk of Burns from Hot Beverages, Dietary staff were in serviced on measuring the temperature of coffee and placing a sticker on the coffee pots with the date and temperature of the coffee, and One on one Inservice with LVN D regarding reporting incident/change of condition to the DON/Designee. Documentation of the Personnel action was present and reflected the signature of LVN D. Record Review of in-service dated 08/11/2025 reflected 20 staff had been in-serviced on notification of resident change. Our ability to ensure trust is paramount in what we do daily, and by keeping lines of communication open and involving the resident and their responsible party/emergency contact in the care we are providing; we build that foundation. It is REQUIRED to notify residents, responsible parties, or an emergency contact of any changes that occur with our residents. Responsible Party (RP) or an emergency contact if resident is their own RP will be notified of any changes at the time of occurrence and be DOCUMENTED in the progress notes.Record Review of in-service dated 08/11/2025 reflected 14 staff had been in-serviced on notification to the director of nursing but there was no mention of notification of the physician. Communication is crucial for proper management of nursing facilities and notification of the Director of nursing is imperative. You are required to notify the Director of Nursing and or designee for the following immediately: Incidents and Accidents with C/O Pain or Observed Injury BurnsSafety Hazards / Equipment Malfunction Record Review of in-service dated 08/12/2025 reflected 22 staff had been in-serviced on burns. Burns are a major incident in nursing homes and can cause serious negative out comes. Any burn injuries are required to have the provider assigned, DON, RP, and administrator notified immediately no matter the severity of the burn. Record Review of facility wound care policies and procedures revision date 06/01/2015 reflected all burns and scalds will be seen by a physician or a nurse as soon as possible for appropriate treatment. The purpose is to provide immediate first aid when injury occurs in the facility. Record review of the policy entitled: Care of a Burn Injury dated 06/01/2025 states Notify the physician and supervisor as soon as possible.

Based on interview and record review, the facility failed to permit Resident #1 to remain in the facility and failed to document the reason or notice of the discharge in the resident's medical record or implement policies to allow the resident to return to the facility upon discharge from the hospital for 1 of 1 resident reviewed for discharges (Resident #1).The facility failed to allow Resident #1 to return to the facility after his hospitalization. The facility failed to appropriately notify the resident, his representative, and the Long-term Care Ombudsman in writing of the discharge. This failure placed residents at risk of an extended, unnecessary hospitalization and a traumatic psychosocial adjustment to a new facility. Record review of Resident #1's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] and discharged [DATE] at 04:15 PM. The face sheet revealed his diagnoses were Metabolic Encephalopathy (brain function disrupted due to chemical imbalances), Gastric Reflux (acid from stomach backs up into the esophagus), prostate disease ( range of medical conditions affecting the prostate gland), Parkinson's disease (a movement disorder of the nervous system), and Cognitive Communication Deficit (a group of disorders that affect the ability to communicate effectively). Record review of Resident #1's Initial MDS assessment dated [DATE] revealed a BIMS score of 10, which indicated the resident's cognitive ability was moderately impaired and he required assistance with his activities of daily living. Record review of Resident #1's Care Plan, reflected a Focus area was initiated for Cognitive Loss / Dementia on 7/18/25 with a goal to meet the residents needs and maintain his dignity. Resident #1's interventions included to provide a quiet non-hurried environment free of distractions. In an interview on 7/30/25 at 9:30 AM, the ADM stated Resident #1 was sent to the ER on [DATE] for evaluation after he assaulted a staff member by blocking her in a chair and forcefully touching her in a sexual manner which was not his normal behavior. He stated neither the staff member or the resident was injured and neither required medical attention. ADM stated the police were not notified. He stated the hospital could not find any medical changes with the resident and they wanted to return the resident to the facility, but the facility refused on 7/25/25 to accept Resident #1 back. ADM stated the family, Ombudsman, and the Medical Director were notified but discharge paperwork was still being worked on. A record review on 7/30/25 at 2:00 PM of Resident #1's facility chart did not reflect a discharge noticeIn an interview on 7/30/25 at 5:00 PM, the BOM stated the normal discharge process was to issue a 30-day discharge notice. She stated this is important as it gives families time to find safe or alternate placement for the resident. If notices are not given, then something could happen to the resident to cause them harm. She stated she did not handle Resident #1's discharge. She stated she handled financial discharges, and the ADM handles the other types of discharges. In an interview on 7/30/25 at 5:25 PM, the DON stated the normal process for discharge was to follow the policy for safe discharge planning if the resident did not initiate the discharge. She stated they give a 30-day notice and help find an alternate place. She stated a discharge notice is the residents right and it is important to ensure resident is safe to go home and to prevent injury to the resident. She stated Resident #1 was not provided a discharge notice prior to his discharge on [DATE].In an interview on 7/30/25 at 5:44 PM, the ADM stated the normal policy for discharge is to give a 30-day discharge notice. He stated Resident #1's discharge paperwork was still in process and the resident was discharged without planning. He stated the purpose of the 30-day notice is to allow time for families to find placement needed to prevent an unsafe discharge which could lead to harm to a resident. A record review of the hospital Discharge summary dated [DATE] for Resident #1, reflected the resident was sent to the ER for out of character behavior on 7/25/25 and remained in the hospital until 7/29/25. The records reflected on 7/29/25 the resident was discharged to an alternate local nursing home with clinical notes reflecting he was stable with an unremarkable exam except for known Dementia Parkinson Disease with other behavioral disturbances. The discharge summary also reflected, the facility (nursing home) had declined to take him back and Patient would need placement at a different facility, as he could not live on his own.A record review of the facility policy titled, Social Services Policies and Programs-Discharge Notification dated 6/9/2023 reflected the following: Before a facility discharges a resident, the facility must notify the resident of the discharge and the reasons for the move in writing and in a language and manner they understand. The notice of discharge must be made by the facility at least 30 days before the resident is discharged . A copy of the discharge notice must be included in the resident's record.

Based on interview and record review, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for one (Resident #2) of 3 residents reviewed for PASARR services. The facility failed to submit a NFSS request within 20 days of the IDT meeting that was held on 2/4/2025 and failed to resubmit a NFSS request when it was initially denied ensuring the request was approved for specialized services for PASARR for Resident #1. This failure could place residents at risk of not receiving the needed care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings included:Resident #2 face sheet dated 6/30/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Schizoaffective disorder, depressive type (mental health condition), Major Depressive Disorder with psychotic features (mental health disorder characterized by depressed mood or loss of interest in activities), Unspecified lack of expected normal physiological development in childhood, reduced mobility, Spina Bifida (birth defect affecting the development of a developing baby's spinal cord), Paraplegia (loss of motor and sensory functions in the lower limbs, and generalized anxiety. Review of Resident #2's quarterly MDS dated [DATE] reflected he had a BIMS of 15 suggesting resident had no cognitive impairments. Review of Resident #2's care plan dated 6/30/2025 reflected Resident #2 has been identified as having a positive PASSAR evaluation related to [diagnosis] of Schizoaffective D/O Bipolar type and MDD with an intervention of coordinating services with a representative from the MHMR. Review of Resident #2's PCSP dated 2/12/2025 reflected an IDT meeting was held on 2/4/2025 for PASSAR services with nursing facility staff and local mental health authority staff in attendance with Resident #2. During an interview on 7/1/2025 at 9:45 am, Resident #2 stated he had attended his PASARR meeting back in February and was getting the services he needed. He stated he was unaware of the documentation required by the nursing facility of deadlines. He stated he was aware of the PASARR he was entitled to and had no concerns. During an interview on 6/30/2025 at 12:02 pm, the MDS Nurse stated Resident #2 was still on PASARR services and an IDT meeting was held with the local mental health authority on 2/4/2025. She stated she was on vacation at the time and was not aware the IDT meeting had taken place. She stated she found about the IDT meeting sometime later - she was not sure of the date - and she contacted corporate, and they sat down and completed the NFSS. She stated it was already late at that point - past the 20 business days. She stated the NFSS is normally done by therapy, but the Director of Rehabilitation (DOR) didn't know how to do the NFSS so she and corporate completed it and submitted the form. She stated they did not know about the IDT meeting until they received an email from HHS (PASARR) on 4/21/2025. During an interview on 6/30/2025 at 1:50 pm, the DOR stated therapy did an evaluation on Resident #2 on 4/24/2025 and the first NFSS was submitted on 4/24/2025 and was denied on 5/8/2025. They submitted a new application on 5/16/2025 and it was accepted on 5/24/2025. She stated she was unaware of the IDT meeting that was held on 2/4/2025 and was not in the building at the time. She stated she was responsible for completing and sending in PASARR forms and not getting them in on time could cause the resident to not receive the services they required. During an interview on 7/1/2025 at 2:00 pm, the ADM stated he was aware of the PASARR issue with Resident #2, but this had happened under the previous administration. He stated to his knowledge there were no other issues with PASARR services in the facility, and it was just not meeting a deadline for documentation. Review of Facility Policy PASARR Documentation Policy dated 11/1/2017, reflected This policy is intended as a general guide for the PASARR process. Each facility develops a process for completion of the PASARR requirements as indicated by state specific policy and procedures.4. Any individual seeking admission to a Medicaid Certified nursing facility (NF) receives a PASARR Level I screening for any intellectual disability or (ID) or developmental disability (DD) or mental illness (MD) before or upon admission.5. If the PASARR Level I screening indicates the individual may have an ID, DD, or MI diagnosis, follow the state-specific process for completion of the Level II evaluation.6. If the Level II evaluation confirms an ID, DD or MD diagnosis the Facility collaborates with local resources when special services are necessary or required.7. If special services are required, the Facility will coordinate services per state policy and develop a care plan that addresses the specific needs.8. Care plan will be reviewed and updated as needed, quarterly and with significant change to evaluate and validate the effectiveness of interventions and make adjustments as necessary.

Based on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of ten residents reviewed for changes in condition. The facility failed to notify the CHF clinic or the MD of Resident #1's weight gain per providers orders. On 3/7/25 Resident #1 exhibited signs of shortness of breath and required IV Lasix a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure) to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. An Immediate Jeopardy (IJ) was identified on 03/19/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 03/19/25 at 05:36 PM. While the Administrator and DON were notified that the IJ was removed on 03/20/25 at 06:10 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk of a delay in medical evaluation and treatment contributing to avoidable harm such as fluid overload, respiratory distress, swelling, and increased blood pressure. Findings included: Review of Resident #1's face sheet dated 03/19/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included acute on chronic (congestive) heart failure (primary, admission)(long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), post-traumatic stress disorder-chronic (mental and behavioral disorder that develops from experiencing a traumatic event), generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), and Alzheimer's disease with early onset (condition that affects memory, thinking, and behavior). Residents face sheet also reflected she discharged to another SNF on 03/11/25. Review of Resident #1's Discharge MDS dated [DATE] reflected a BIMS score of 15 indicating cognition intact. The Discharge MDS also identified unspecified combined systolic (congestive) and diastolic (congestive) heart failure as an active diagnosis. Other health conditions, shortness of breath was checked for shortness of breath or trouble breathing with exertion (walking, bathing, transferring), shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Medications also indicated Resident #1 was on a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure). Review of Resident #1's care plan last revised 02/26/25 reflected [Resident #1] is at risk for respiratory distress/SOB due to dx of CHF with goal of [Resident #1] will not exhibit or develop respiratory distress as evidence by no SOB or O2 sat (oxygen saturation, amount of oxygen in the blood) at 90% and interventions that included administer medications as ordered, monitor adverse reaction. Contact MD if noted. Review of Resident #1's physician orders reflected an order for daily weights with a start date of 02/25/25 with special instructions that revealed, CHF/Check daily weight each morning and contact CHF clinic for weight gain of 2+ lbs overnight or 3-5 lbs in 1 week. Review of Resident #1's documented weights by LVN A and LVN B included: 03/08/25: 244.20 lbs 03/07/25: 250.00 lbs 03/06/25: 251.00 lbs 03/05/25: 250.00 lbs 03/04/25: 248.20 lbs 03/03/24: 246.00 lbs 03/02/25: 242.00 lbs 03/01/25: 241:00 lbs 02/28/25: 236.80 lbs Weight on 02/28/25 was 236.8 pounds and weight on 03/07/25 was 250 pounds which was a 13.2-pound weight gain in a week. Daily weights also reflected Resident #1 had multiple days (03/01/25, 03/03/25, 03/04/25, and 03/05/25) with a 2-pound overnight weight gain. Record review of Resident #1's O2 Saturation levels reflected: 03/06/25 O2 Saturation at 90% at 12:11 PM 03/06/25 O2 Saturation at 90% at 01:31 PM Review of Resident #1's nursing progress notes between 02/28/25 and 03/07/25 reflected no notes on notification of weight gain to the CHF facility per orders. Review of Resident #1's nursing progress notes dated 03/06/25 reflected resident called NP and stated to have SOB. 90% O2 NC. Review of Resident #1's MAR/TAR 02/27/25-03/10/25 revealed , observe for s/s of SOB or trouble breathing and reflected multiple days SOB with exertion. Included lying flat was avoided 7 of 12 days. Review of CHF clinic documents dated 03/07/25 revealed nursing note Lasix 100mg IV per mini infuser, patient up 10.7 pounds from 02/26/25. In an interview on 03/19/25 at 10:40 AM with Resident #1's family, she stated she was concerned that the facility was not managing Resident #1's weights or adjusting her Lasix as needed. She stated Resident #1 appeared like she could not breathe very well and then later she found out from the CHF clinic after her visit on 03/07/26 that Resident #1 had a lot of fluid built up. Resident #1's family stated that when she asked the CHF clinic why this was not caught earlier and if they were notified by the SNF, the CHF clinic told her they were not notified of the weight changes by the SNF which resulted in delay of care and built up of fluid in Resident #1's body. In an interview on 03/19/25 at 12:10PM with the DON, after reviewing the nursing progress notes for 02/28/25 through 03/07/25), she stated she was only able to identify a notification to the resident's physician regarding weight gain on 03/01/25 but did not see notification was made to the CHF clinic between 02/27/25-03/07/25 regarding the weight gain. She stated it was her expectation that the notification was made per the order. She stated there should have been a call by the charge nurse on duty. She stated it was important because of the possibility of fluid overload (fluid overloading the heart) and a negative outcome of not following the order could be respiratory distress (difficulty breathing). In an interview on 03/19/25 at 01:04 PM with the CHF Facility RN Supervisor (RNS), she stated that Resident #1 was seen at the facility on 02/27/25 and again on 03/07/25. She stated based on their weight records they documented the resident gained 10.7 pounds on 03/07/25 since her last visit 02/27/25. RNS stated the CHF Facility was not notified in between visit days of an increase in weight. She stated it was the expectation that they were notified by the facility of changes because they were trying to keep the resident out of the hospital and the emergency room . She stated noticing changes in weight gain was how they monitored fluids and by catching it early they were able to make changes to diuretic medications. She stated, We want to catch the problem before it becomes serious. She stated that the resident had to be administered IV Lasix as a result of the large amount of weight gain/fluids and was SOB from the large amount of fluid in her body (including around heart and lungs). In an interview on 03/19/25 at 01:36 PM with the MD, he stated it was his expectation was that nursing staff followed the orders and notify the CHF facility of weight gain. He stated the reason was the CHF clinics had the ability to track subtle changes like weight gain or breathing before they became bigger problems and would allow them to adjust diuretics. He stated a negative outcome of not following the orders had the potential to result in the resident having difficulty breathing and would end up in the hospital. In an interview on 03/19/25 at 02:15 PM with LVN A she stated the CHF facility should have been notified of Resident #1's weight gain and said she took weights for Resident #1 on the weekend and let the oncoming nurse know through report of the weight gain and not the CHF facility . She stated no follow up was made to ensure the CHF facility was made aware. She stated a negative outcome of not notifying the CHF clinic would be cardiac issues with the resident, and CHF clinic should have been notified. In an interview on 03/19/25 at 2:22 PM with LVN B she stated she took weights for Resident #1 on weekdays as well as weekends. She stated she was aware of the order to notify the CHF facility if there was an increase in weight of 2 pounds per day but did not recall making the notifications to CHF center. LVN B stated the CHF facility should have been notified by the nurse on shift and did not recall why she did not make the notification. She stated a negative outcome of not notifying would be a delay in care for the resident or the required use of IV Lasix to manage the increase in fluids. She also stated the increase in weight was also a significant change in condition which also resulted in the IV administration of Lasix which was a change in Resident #1's care. Review of facility policy Physician and Other Communication/ Change in Condition last revised 05/05/23 reflected: To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. Changes and new approaches will be reflected in the individualized care plan. All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. The ADM, DON, and CC were notified on 03/19/25 at 06:09 PM that an IJ was identified due to the above failures and the facility's need to take immediate action to ensure facility staff act timely to prevent a delay in treatment for residents while following providers orders. The Plan of Removal was accepted on 03/20/25 and included: Plan of Removal Problem: F684 Quality of Care On 3/19/25 an abbreviated survey was initiated at the facility. The surveyor provided an immediate jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy stating: The facility failed to notify the CHF clinic of Resident #1's weight gain per provider's orders. Resident #1 was exhibiting signs of shortness of breath and required IV Lasix to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. Resident #1 no longer resides in the facility. The facility activity report and the 24hour report for the past 72hours will be audited by the Director of Nursing/Designee on 3/19/25 to identify any documentation that indicates changes in resident's condition and notification to provider as ordered. None were identified. The Director of Nursing will be reeducated by the Clinical Consultant on 3/19/25 on following providers orders to prevent a delay in treatment and change in condition including: Prompt notifications documented in residents medical record to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. Shortness of breath Weight gain in residents with Congestive Heart Failure causing shortness of breath Licensed nurses, including PRN nurses, will be reeducated by 3/20/25 by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: Prompt notifications to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Shortness of breath Weight gain in Congestive Heart Failure residents causing shortness of breath Licensed Nurses, including PRN nurses not receiving this education by 3/20/25 will receive prior to their next scheduled shift and this will be completed in New Hire orientation. Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting Monday - Friday beginning 3/20/25 to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months. The Administrator will oversee the continuation of this plan. Ad Hoc QAPI will be held on 3/19/25 The Medical Director was notified of the Immediate Jeopardy and contents of this plan on 3/19/25. Monitoring began 03/20/25 and included the following: Record review completed of the facility 24-hour report for previous 72 hours as of 03/20/25 . Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up. Record review of an in-service dated 03/19/25 titled: Change of Condition monitoring, reviewing clinical documentation and signs & symptoms of CHF exacerbation with proper notification to providers of changes. revealed staff were educated on: - Prompt notifications documented in residents medical record to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. - Shortness of breath - Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed as completed by the DON and presented by the CC. Record review of an additional in-service dated 03/19/25 revealed: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Validating any clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. - Shortness of breath. - Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed by the DON and presented by the CC. Record review of in-service dated 03/20/25 titled Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Reflected signed by the DON and presented by the CC. Record review of a staff in-service dated 03/20/25 revealed staff were educated on Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Presented by the DON and signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of a staff in-service dated 03/20/25 revealed staff were educated on: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Shortness of breath - Weight gain in Congestive Heart Failure residents causing shortness of breath. Signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record Review of training dated 03/19/25 titled: Change of Condition revealed staff were trained on: - Licensed nurses must notify providers of change of condition for orders if necessary to prevent a delay in treatment including: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of the Adhoc QAPI dated 03/19/25 for F684 revealed the meeting included the ADM, DON, CC, and MD. Record Review of a signed statement by the DON on 03/19/25 revealed notification to the MD regarding Immediate Jeopardy. Record review of the undated new hire orientation packet which included an added section revealed the following: - Respiratory care all nurses validate resident is receiving oxygen per MD orders. - Change of condition recognition and notification to providers. - Prompt notification to providers, all attempts to notify medical staff and RP will be documented in residents medical record. - Notifications to require medical staff of weight changes as ordered. SOB, weight gain in CHF resident causing SOB. - Policy on physician and other communication /change in condition policy added and packet on the Management of heart failure preventing and managing exacerbations & comorbidities. Record review of education provided to the only 2 agency nurse (LVN F and LVN G) staff working on 03/19/25-03/20/25 revealed education included change of condition and CHF education. Record review of an email from the DON to RN C dated 03/20/25 at 11:29 AM revealed communication with RN C on change of conditions and early warning signs of CHF exacerbation and the need to notify. RN C stated she read the in-services and understood the material being presented. RN C was not on shift that day per the schedule and so was provided the material and in-service virtually per the DON, which was reviewed. Record review of an email from the DON to LVN B dated 03/20/24 at 11:34 AM revealed communication with LVN B on change of conditions and early warning signs of CHF exacerbation and the need to notify/ Management of Heart Failure. LVN B responded that she reviewed the material and understood the topics presented. LVN B was not on shift per the schedule and the material was provided virtually per the DON , which was reviewed. Record review of text messages from the DON to LVN A from 03/20/25 at 12:53 PM, revealed LVN A was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN A stated she acknowledged the in-services and understood the material being provided. Record review of text messages from DON to LVN D from 03/20/25 at 02:40 PM, revealed LVN D was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN D stated she acknowledged the in-services and understood the material being provided. In an interview on 03/20/25 at 04:27 PM with LVN E, she stated she was provided the in-service training which covered changes of condition and the need to notify providers. She stated it was presented to her by the DON prior to her shift. LVN E stated there was a verbal assessment to confirm understanding of the material presented and that she also reviewed a PowerPoint on CHF management. LVN E stated she would observe for changes in behavior, weight gain, or changes in oxygen saturation and make sure she was notifying the providers and the CHF clinic as needed if identified in the orders. LVN E stated that all interventions and notifications should be documented in the resident's progress notes. LVN E also stated she understood weights should be taken in the morning after the resident's first bathroom break to accurately assess. She stated any weights over a 2-3 pound change overnight or a 5 pound change in a week was reportable to the providers. In an interview on 03/20/25 at 04:40 PM with LVN F, she stated she received in-services prior to starting her shift which included changes of condition and who she would notify, weight gain, CHF management including s/s and concerns to look for. She stated the material was presented to her by the DON and was given a verbal quiz to confirm understanding on the material. LVN F provided examples of what to look for and information on what was considered outside of normal parameters for oxygen and weight to confirm understanding. LVN F stated all interventions and notification of change should be documented in the resident's progress notes. In an interview on 03/20/25 at 04:57 PM with the DON, she stated training was provided to her by the CC and then she provided training to floor staff (other nurses) on changes of condition and CHF management. She stated education was provided before shift to those working 03/20/25, and virtual training was provided to those not on shift. She stated training would also be ongoing to any oncoming agency, PRN, or new staff. She stated a review was also completed on all current CHF residents and there were no concerns with the orders and none required to be seen by a CHF clinic at the time of review. In an interview on 03/20/25 at 05:49 PM with the ADM, he stated that 03/19/25 was the first time he was made aware of Resident #1s weight fluctuations. He stated it was his expectations that providers were notified per orders. He stated he was interim Administrator but that all documentation for the IJ would be available to the incoming Administrator and that the DON would also be at the facility to continue to provide education to new staff to ensure orders are being followed to prevent potential negative outcomes. Review of the staff training indicated above reflected that out of the 10 staff of RNs/LVNs, 8 of them were confirmed to have received the in-service for change of condition, notification of change, and CHF management meeting 80% overall compliance. Training was provided to RN's and LVN's only across all shifts as this is who was in charge of weights and notifying of changes of condition. The Administrator was notified the IJ was removed on 03/20/25 at 06:10 PM, however the facility remained out of compliance, at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

Based on interview and record review, the facility failed to ensure the residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 residents (Resident #1) reviewed for quality of care. The facility failed to notify the CHF clinic of Resident #1's weight gain per providers orders. On 3/7/25 Resident #1 exhibited signs of shortness of breath and required IV Lasix a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure) to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. An Immediate Jeopardy (IJ) was identified on 03/19/25. The Administrator was notified of the Immediate Jeopardy and provided with the IJ Template on 03/19/25 at 05:36 PM. While the Administrator and DON were notified that the IJ was removed on 03/20/25 at 06:10 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at risk of a delay in medical evaluation and treatment contributing to avoidable harm such as fluid overload, respiratory distress, swelling, and increased blood pressure. Findings included: Review of Resident #1's face sheet dated 03/19/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included acute on chronic (congestive) heart failure (primary, admission)(long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), post-traumatic stress disorder-chronic (mental and behavioral disorder that develops from experiencing a traumatic event), generalized anxiety disorder (condition with exaggerated tension, worrying, and nervousness about daily life), unspecified combined systolic (congestive) and diastolic (congestive) heart failure (long term condition that happens when your heart cant pump blood well enough to give your body a normal supply), and Alzheimer's disease with early onset (condition that affects memory, thinking, and behavior). Residents face sheet also reflected she discharged to another SNF on 03/11/25. Review of Resident #1's Discharge MDS dated [DATE] reflected a BIMS score of 15 indicating cognition intact. The Discharge MDS also identified unspecified combined systolic (congestive) and diastolic (congestive) heart failure as an active diagnosis. Other health conditions, shortness of breath was checked for shortness of breath or trouble breathing with exertion (walking, bathing, transferring), shortness of breath or trouble breathing when sitting at rest, and shortness of breath or trouble breathing when lying flat. Medications also indicated Resident #1 was on a diuretic (medication used to reduce extra fluid in the body, also known as edema, caused by heart failure). Review of Resident #1's care plan last revised 02/26/25 reflected [Resident #1] is at risk for respiratory distress/SOB due to dx of CHF with goal of [Resident #1] will not exhibit or develop respiratory distress as evidence by no SOB or O2 sat (oxygen saturation, amount of oxygen in the blood) at 90% and interventions that included administer medications as ordered, monitor adverse reaction. Contact MD if noted. Review of Resident #1's physician orders reflected an order for daily weights with a start date of 02/25/25 with special instructions that revealed, CHF/Check daily weight each morning and contact CHF clinic for weight gain of 2+ lbs overnight or 3-5 lbs in 1 week. Review of Resident #1's documented weights by LVN A and LVN B included: 03/08/25: 244.20 lbs 03/07/25: 250.00 lbs 03/06/25: 251.00 lbs 03/05/25: 250.00 lbs 03/04/25: 248.20 lbs 03/03/24: 246.00 lbs 03/02/25: 242.00 lbs 03/01/25: 241:00 lbs 02/28/25: 236.80 lbs Weight on 02/28/25 was 236.8 pounds and weight on 03/07/25 was 250 pounds which was a 13.2-pound weight gain in a week. Daily weights also reflected Resident #1 had multiple days (03/01/25, 03/03/25, 03/04/25, and 03/05/25) with a 2-pound overnight weight gain. Record review of Resident #1's O2 Saturation levels reflected: 03/06/25 O2 Saturation at 90% at 12:11 PM 03/06/25 O2 Saturation at 90% at 01:31 PM Review of Resident #1's nursing progress notes between 02/28/25 and 03/07/25 reflected no notes on notification of weight gain to the CHF facility per orders. Review of Resident #1's nursing progress notes dated 03/06/25 reflected resident called NP and stated to have SOB. 90% O2 NC. Review of Resident #1's MAR/TAR 02/27/25-03/10/25 revealed , observe for s/s of SOB or trouble breathing and reflected multiple days SOB with exertion. Included lying flat was avoided 7 of 12 days. Review of CHF clinic documents dated 03/07/25 revealed nursing note Lasix 100mg IV per mini infuser, patient up 10.7 pounds from 02/26/25. In an interview on 03/19/25 at 10:40 AM with Resident #1's family, she stated she was concerned that the facility was not managing Resident #1's weights or adjusting her Lasix as needed. She stated Resident #1 appeared like she could not breathe very well and then later she found out from the CHF clinic after her visit on 03/07/26 that Resident #1 had a lot of fluid built up. Resident #1's family stated that when she asked the CHF clinic why this was not caught earlier and if they were notified by the SNF, the CHF clinic told her they were not notified of the weight changes by the SNF which resulted in delay of care and built up of fluid in Resident #1's body. In an interview on 03/19/25 at 12:10PM with the DON, after reviewing the nursing progress notes for 02/28/25 through 03/07/25), she stated she was only able to identify a notification to the resident's physician regarding weight gain on 03/01/25 but did not see notification was made to the CHF clinic between 02/27/25-03/07/25 regarding the weight gain. She stated it was her expectation that the notification was made per the order. She stated there should have been a call by the charge nurse on duty. She stated it was important because of the possibility of fluid overload (fluid overloading the heart) and a negative outcome of not following the order could be respiratory distress (difficulty breathing). In an interview on 03/19/25 at 01:04 PM with the CHF Facility RN Supervisor (RNS), she stated that Resident #1 was seen at the facility on 02/27/25 and again on 03/07/25. She stated based on their weight records they documented the resident gained 10.7 pounds on 03/07/25 since her last visit 02/27/25. RNS stated the CHF Facility was not notified in between visit days of an increase in weight. She stated it was the expectation that they were notified by the facility of changes because they were trying to keep the resident out of the hospital and the emergency room . She stated noticing changes in weight gain was how they monitored fluids and by catching it early they were able to make changes to diuretic medications. She stated, We want to catch the problem before it becomes serious. She stated that the resident had to be administered IV Lasix as a result of the large amount of weight gain/fluids and was SOB from the large amount of fluid in her body (including around heart and lungs). In an interview on 03/19/25 at 01:36 PM with the MD, he stated it was his expectation was that nursing staff followed the orders and notify the CHF facility of weight gain. He stated the reason was the CHF clinics had the ability to track subtle changes like weight gain or breathing before they became bigger problems and would allow them to adjust diuretics. He stated a negative outcome of not following the orders had the potential to result in the resident having difficulty breathing and would end up in the hospital. In an interview on 03/19/25 at 02:15 PM with LVN A she stated the CHF facility should have been notified of Resident #1's weight gain and said she took weights for Resident #1 on the weekend and let the oncoming nurse know through report of the weight gain and not the CHF facility . She stated no follow up was made to ensure the CHF facility was made aware. She stated a negative outcome of not notifying the CHF clinic would be cardiac issues with the resident, and CHF clinic should have been notified. In an interview on 03/19/25 at 2:22 PM with LVN B she stated she took weights for Resident #1 on weekdays as well as weekends. She stated she was aware of the order to notify the CHF facility if there was an increase in weight of 2 pounds per day but did not recall making the notifications to CHF center. LVN B stated the CHF facility should have been notified by the nurse on shift and did not recall why she did not make the notification. She stated a negative outcome of not notifying would be a delay in care for the resident or the required use of IV Lasix to manage the increase in fluids. She also stated the increase in weight was also a significant change in condition which also resulted in the IV administration of Lasix which was a change in Resident #1's care. Review of facility policy Physician and Other Communication/ Change in Condition last revised 05/05/23 reflected: To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. Changes and new approaches will be reflected in the individualized care plan. All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. The ADM, DON, and CC were notified on 03/19/25 at 06:09 PM that an IJ was identified due to the above failures and the facility's need to take immediate action to ensure facility staff act timely to prevent a delay in treatment for residents while following providers orders. The Plan of Removal was accepted on 03/20/25 and included: Plan of Removal Problem: F684 Quality of Care On 3/19/25 an abbreviated survey was initiated at the facility. The surveyor provided an immediate jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy stating: The facility failed to notify the CHF clinic of Resident #1's weight gain per provider's orders. Resident #1 was exhibiting signs of shortness of breath and required IV Lasix to be administered on her visit to the CHF clinic 03/07/25 for a greater than 10-pound weight gain in a week from 02/27/25 to 03/07/25. Resident #1 no longer resides in the facility. The facility activity report and the 24hour report for the past 72hours will be audited by the Director of Nursing/Designee on 3/19/25 to identify any documentation that indicates changes in resident's condition and notification to provider as ordered. None were identified. The Director of Nursing will be reeducated by the Clinical Consultant on 3/19/25 on following providers orders to prevent a delay in treatment and change in condition including: Prompt notifications documented in residents medical record to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. Shortness of breath Weight gain in residents with Congestive Heart Failure causing shortness of breath Licensed nurses, including PRN nurses, will be reeducated by 3/20/25 by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: Prompt notifications to providers as designated in provider orders All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record Notifications to required medical staff of weight changes as ordered Shortness of breath Weight gain in Congestive Heart Failure residents causing shortness of breath Licensed Nurses, including PRN nurses not receiving this education by 3/20/25 will receive prior to their next scheduled shift and this will be completed in New Hire orientation. Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting Monday - Friday beginning 3/20/25 to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months. The Administrator will oversee the continuation of this plan. Ad Hoc QAPI will be held on 3/19/25 The Medical Director was notified of the Immediate Jeopardy and contents of this plan on 3/19/25. Monitoring began 03/20/25 and included the following: Record review completed of the facility 24-hour report for previous 72 hours as of 03/20/25 . Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up. Record review of an in-service dated 03/19/25 titled: Change of Condition monitoring, reviewing clinical documentation and signs & symptoms of CHF exacerbation with proper notification to providers of changes. revealed staff were educated on: - Prompt notifications documented in residents medical record to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Nursing Leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda Monday - Friday during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor. - Shortness of breath - Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed as completed by the DON and presented by the CC. Record review of an additional in-service dated 03/19/25 revealed: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Validating any clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. - Shortness of breath. - Weight gain in residents with Congestive Heart Failure causing shortness of breath. Signed by the DON and presented by the CC. Record review of in-service dated 03/20/25 titled Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Reflected signed by the DON and presented by the CC. Record review of a staff in-service dated 03/20/25 revealed staff were educated on Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms. Presented by the DON and signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of a staff in-service dated 03/20/25 revealed staff were educated on: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. - Shortness of breath - Weight gain in Congestive Heart Failure residents causing shortness of breath. Signed by the nursing staff. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record Review of training dated 03/19/25 titled: Change of Condition revealed staff were trained on: - Licensed nurses must notify providers of change of condition for orders if necessary to prevent a delay in treatment including: - Prompt notifications to providers as designated in provider orders. - All attempts to notify medical staff and responsible parties will be documented in resident's medical record. - Notifications to required medical staff of weight changes as ordered. (80% of compliance met, 8 of 10 nursing staff, LVNs and RN's employed) Record review of the Adhoc QAPI dated 03/19/25 for F684 revealed the meeting included the ADM, DON, CC, and MD. Record Review of a signed statement by the DON on 03/19/25 revealed notification to the MD regarding Immediate Jeopardy. Record review of the undated new hire orientation packet which included an added section revealed the following: - Respiratory care all nurses validate resident is receiving oxygen per MD orders. - Change of condition recognition and notification to providers. - Prompt notification to providers, all attempts to notify medical staff and RP will be documented in residents medical record. - Notifications to require medical staff of weight changes as ordered. SOB, weight gain in CHF resident causing SOB. - Policy on physician and other communication /change in condition policy added and packet on the Management of heart failure preventing and managing exacerbations & comorbidities. Record review of education provided to the only 2 agency nurse (LVN F and LVN G) staff working on 03/19/25-03/20/25 revealed education included change of condition and CHF education. Record review of an email from the DON to RN C dated 03/20/25 at 11:29 AM revealed communication with RN C on change of conditions and early warning signs of CHF exacerbation and the need to notify. RN C stated she read the in-services and understood the material being presented. RN C was not on shift that day per the schedule and so was provided the material and in-service virtually per the DON, which was reviewed. Record review of an email from the DON to LVN B dated 03/20/24 at 11:34 AM revealed communication with LVN B on change of conditions and early warning signs of CHF exacerbation and the need to notify/ Management of Heart Failure. LVN B responded that she reviewed the material and understood the topics presented. LVN B was not on shift per the schedule and the material was provided virtually per the DON , which was reviewed. Record review of text messages from the DON to LVN A from 03/20/25 at 12:53 PM, revealed LVN A was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN A stated she acknowledged the in-services and understood the material being provided. Record review of text messages from DON to LVN D from 03/20/25 at 02:40 PM, revealed LVN D was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify. LVN D stated she acknowledged the in-services and understood the material being provided. In an interview on 03/20/25 at 04:27 PM with LVN E, she stated she was provided the in-service training which covered changes of condition and the need to notify providers. She stated it was presented to her by the DON prior to her shift. LVN E stated there was a verbal assessment to confirm understanding of the material presented and that she also reviewed a PowerPoint on CHF management. LVN E stated she would observe for changes in behavior, weight gain, or changes in oxygen saturation and make sure she was notifying the providers and the CHF clinic as needed if identified in the orders. LVN E stated that all interventions and notifications should be documented in the resident's progress notes. LVN E also stated she understood weights should be taken in the morning after the resident's first bathroom break to accurately assess. She stated any weights over a 2-3 pound change overnight or a 5 pound change in a week was reportable to the providers. In an interview on 03/20/25 at 04:40 PM with LVN F, she stated she received in-services prior to starting her shift which included changes of condition and who she would notify, weight gain, CHF management including s/s and concerns to look for. She stated the material was presented to her by the DON and was given a verbal quiz to confirm understanding on the material. LVN F provided examples of what to look for and information on what was considered outside of normal parameters for oxygen and weight to confirm understanding. LVN F stated all interventions and notification of change should be documented in the resident's progress notes. In an interview on 03/20/25 at 04:57 PM with the DON, she stated training was provided to her by the CC and then she provided training to floor staff (other nurses) on changes of condition and CHF management. She stated education was provided before shift to those working 03/20/25, and virtual training was provided to those not on shift. She stated training would also be ongoing to any oncoming agency, PRN, or new staff. She stated a review was also completed on all current CHF residents and there were no concerns with the orders and none required to be seen by a CHF clinic at the time of review. In an interview on 03/20/25 at 05:49 PM with the ADM, he stated that 03/19/25 was the first time he was made aware of Resident #1s weight fluctuations. He stated it was his expectations that providers were notified per orders. He stated he was interim Administrator but that all documentation for the IJ would be available to the incoming Administrator and that the DON would also be at the facility to continue to provide education to new staff to ensure orders are being followed to prevent potential negative outcomes. Review of the staff training indicated above reflected that out of the 10 staff of RNs/LVNs, 8 of them were confirmed to have received the in-service for change of condition, notification of change, and CHF management meeting 80% overall compliance. Training was provided to RN's and LVN's only across all shifts as this is who was in charge of weights and notifying of changes of condition. The Administrator was notified the IJ was removed on 03/20/25 at 06:10 PM, however the facility remained out of compliance, at a scope of isolated and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.

Based on observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice and the resident's goals and preferences for 1 of 6 residents (Resident#1) reviewed for respiratory care. The facility failed to supply oxygen to Resident #1 while she was out on pass to a medical clinic appointment on 02/13/2025 and 02/21/25 resulting in increased shortness of breath, anxiety, and an inability to breath. An Immediate Jeopardy (IJ) was identified on 2/25/25 at 6:07 p.m. The IJ template was provided on 02/25/2027 at 6:07PM. While the IJ was removed on 2/27/25, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents on continuous oxygen at risk of experiencing desaturation, unconsciousness, and death. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of acute on chronic systolic heart failure (a condition in which the heart is too weak to pump the blood around the body to meet its needs), chronic obstructive pulmonary disease (a group of lung conditions making it difficult to breath), personal history of COVID-19, and wheezing. Record review of Resident #1's care plan dated 01/08/2025 reflected there were no care plans to reflect Resident#1's need for oxygen, disease process of COPD (Chronic Obstructive Pulmonary Disease), disease process of CHF (Congestive Heart Failure), or her ADL (Activities of Daily Living) needs. Record review of Resident #1's Quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. Resident #1 required substantial/maximal assistance indicating the helper did more than half the effort or the helper lifted or held trunk or limbs and provided more than half the effort for ADL care showering, upper and lower body dressing, and toileting hygiene. The MDS reflected Resident #1 received oxygen therapy while a resident continuously. Record review of Resident #1s' Physician orders for February 2025 reflected an order for Oxygen at 2 liters per minute via nasal cannula every shift dated 02/17/2025. Record review of Resident #1s' Physician orders history report for dated of 01/01/2025 through 02/25/25 reflected an order for Oxygen at 2 liters per minute via nasal cannula every shift dated 12/20/2024. The order history report also reflected an order to check Resident #1 every hour to ensure the oxygen delivery is functioning properly. Report any complications to the DON or Administrator. This order was started on 01/10/2025 and then discontinued on 01/26/2025. Record review of the facility's grievance log for January and February 2025 reflected Resident #1's RP had filed a grievance on 01/10/2025 stating when Resident #1 was at an appointment the oxygen tank was not turned on after being transported from the facility. The RP turned the oxygen on. Then later within the same day the RP was dropping off laundry and noticed the residents' eyes looking glassy so she checked her oxygen tank and found the tank was full but not turned on and she had to turn it on again. The internal investigation revealed there were new oxygen regulators at the facility and had not been attached to the oxygen tank appropriately. Staff were in serviced on 1/17/25 on oxygen regulators and the grievance was closed as resolved. Record review of Oxygen saturation Vital sign report reflected on 02/13/25 Resident #1 had her oxygen level checked at 1:18pm and it was 97% with oxygen in place at 2 pm. Record review reflected on 02/21/25 at 2:39am the facility staff checked Resident #1's oxygen level, and it was 98% with oxygen in place at 2 lpm. Record review of a Medical Clinic visit reflected that on 2/13/25 at 9:35 Resident #1 arrived at the medical clinic and she had an oxygen saturation level on room air (without oxygen flowing) of 84% but recovered up to 100% after being placed on oxygen at 2 liters per minute in the clinic. In an interview on 02/25/25 at 10:15 The Private Caregiver for Resident #1 stated there have been many times that Resident #1 was sent out to a medical appointment with an empty oxygen tank causing her shortness of breath, changes in mental status, and severe anxiety. She stated she meets the resident at the medical clinic to relay to the family if there were any changes in residents' condition or care. She stated that the resident's RP had filed a complaint with the facility back in January 2025 and had an emergency care-plan meeting with the facility staff related to the residents need for working oxygen tanks. She stated they thought the issues were resolved but this month the resident had been sent to the specialty medical clinic twice with empty portable oxygen tanks. On 2/13/25 and on 2/21/25 the resident was sent with a portable oxygen tank to the medical clinic that was reading red indicating the oxygen tank was empty. This caused the resident to have low oxygen level while at the medical clinic causing Resident #1 confusion, shortness of breath, and anxiety. The Private Caregiver stated that the medical clinic staff were able to intervene and place Resident #1 on their in-house oxygen unit and brought her oxygen levels back up. She stated the facility staff did not check the tanks prior to the resident leaving and never monitored if the tanks were full or empty. In an interview on 02/25/25 at 10:25 Resident #1 stated she had a constant problem with the facility not ensuring there was oxygen in the portable oxygen tanks. She stated she had a diagnosis of CHF and COPD (both disease process will cause shortness of breath) and has difficulty breathing. She stated she always used oxygen continuously. Resident #1 stated she must see a medical specialist weekly for management of her CHF and COPD disease processes. She stated she was sent to the medical clinic the last 2 visits on 2/13/25 and on 2/21/25 with empty oxygen tanks. The specialty clinic staff changed her from her empty potable tanks (sent by the facility) to the wall oxygen unit in the medical clinic. Resident #1 stated she became confused, belligerent, and has severe crippling anxiety due to feeling as if she must struggle to breathe without adequate oxygen supply. Resident #1 stated she was transported to the medical clinic by ride safe a transport company. She stated the nurses do not check the oxygen tank to see if it's empty or full prior to leaving to her medical appointments. Resident #1 stated she was told to use the oxygen concentrator in her room. She stated that limits her mobility to freely move around the building and she did not like being grounded to her room, it was like a punishment. Resident #1 stated she could not take her oxygen concentrator with her to the appointments as it required electricity to function. She stated the oxygen tank problem had been reported to the administrator previously in a grievance form in January 2025. She stated she attended an emergency care-plan meeting with her RP regarding the issue, and the facility staff began to check the oxygen more frequently. Then the staff stopped checking the oxygen. So, it did not last long them checking the tanks. In an interview on 02/25/25 at 10:25 the RP of Resident #1 stated she has found Resident #1 with either her oxygen off, attached wrong, with an empty oxygen tank, or the liter flow set to the wrong amount multiple times. She stated she did meet with the facility ADM in January and drafted an emergency plan for the facility to increase the frequency of checking Resident #1's oxygen and then they stopped. The RP stated Resident #1 has shown up for two appointments in the last 2 weeks with empty oxygen tanks at the specialty medical clinic. At one of those appointments her oxygen saturation was 84%, normal range is above 90%. She said Resident #1 was belligerent, confused, short of breath, and having anxiety. The RP said the nurses at the clinic were able to transfer Resident #1 to their in-house oxygen unit on the wall and brought her level up to 100% but she still suffered from anxiety and not being able to breathe. She stated Resident #1 wears her oxygen continuously. She was never without it unless the facility failed to ensure she has oxygen on. In an interview on 02/25/25 at 11:15 am the RN Specialty Clinic Director stated it was their expectation that all residents coming from a facility should have a working portable oxygen tank with them If they were oxygen dependent. She stated Resident #1 had been to the clinic 2 times with an empty portable oxygen tank on 02/13/25 and 02/21/25. She stated when a Resident #1 arrived at the clinic the staff checked her vital signs and, on the 02/13/25, when Resident #1 came into the facility, she had a saturation level of 84% indicating a critically low oxygen level and Resident #1 was not receiving enough oxygen in her blood to function. The RN Specialty Clinic Director stated a normal oxygen level is above 90%. She stated the staff immediately hooked Resident #1 to their in-house oxygen unit on the wall and within 3 minutes Resident #1s oxygen saturation went up to 100%. She stated it was a very similar situation on 2/21/25 when the resident arrived again with an empty tank. She stated clinical staff did call the facility and addressed it with the charge nurse of Resident #1. She stated the lack of oxygen caused Resident #1 to feel like she was unable to breath, causing shortness of breath, anxiety, and confusion from hypoxia (low oxygen level). She stated Resident #1 did have anxiety, confusion, and shortness of breath at both clinical visits on 02/13/25 and 02/21/25. In an interview on 02/25/25 at 1:15 pm the Interim DON stated she has been at the facility for 2 weeks. She stated the nurses were instructed to check oxygen tanks and should check portable oxygen tanks prior to the residents leaving the facility. She stated staff should always make sure the portable oxygen tank was on and full for mobile residents. She stated the staff were educated on monitoring the tanks verbally and with written in-services. She stated the DON was responsible for providing education to the staff. She stated she was aware of a recent in-service given in January on oxygen concentrator/regulator monitoring. The Interim DON stated she was not aware of an emergency plan for Resident #1 to have increased monitoring. She stated the negative outcomes for having empty oxygen tanks in use for a resident that required oxygen while out to medical appointments could be confusion and respiratory distress due to inadequate oxygen delivery. In an interview on 02/25/25 at 1:35 pm the Interim ADM stated he was not aware of the Emergency Plan for Resident #1. He stated that Resident #1 was hardly in her room and sometimes would leave on ride safe without checking with the nurses prior to leaving. He stated he was aware of a recent complaint related to the oxygen regulators. He stated the facility had bought new regulators and the nursing staff had to be educated on them. The Interim ADM stated all residents should be sent out on pass to medical appointments or anywhere with adequate amount of oxygen if they require continuous oxygen to prevent shortness of breath. On 02/25/25 at 2:15 pm a call was placed to The Medical Director and a message was left for a return call. In a record review of facility policy titled Oxygen Therapy dated 02/12/2024 reflected: Oxygen administration helps relieve hypoxemia and maintain adequate oxygenation of tissues and vital organs. Oxygen administration increases blood oxygen content so that the heart doesn't have to pump as much blood per minute to meet tissue demands. PRECAUTIONS: The administration of oxygen to patients/residents with Chronic Obstructive Pulmonary Disease (COPD), especially a carbon dioxide retainer, must be carefully monitored as too much oxygen can cause a decrease in respirations due to Carbon dioxide narcosis. Special Considerations: Maintain the patient's/resident's target oxygen saturation level within the provider's recommended range. If the patient/resident has COPD or another risk factor for hypercapnic respiratory failure, a saturation of 88%-92% may be necessary. DOSAGE: Oxygen therapy will be used to administer a FI02 (Fraction of Inspired Oxygen) (the amount of air a person is breathing in) greater than 21 % by means of various administration devices. Oxygen therapy will be used to raise the patient's/resident's Pa02 (Partial Pressure of Oxygen in the arterial blood flow) to an acceptable baseline using the lowest FI02. Preparation of Equipment: The licensed nurse is to check the oxygen outlet port to verify flow in accordance with provider's order. An Immediate Jeopardy was identified on 2/25/25 at 6:07 p.m. and an IJ template was provided to the Interim ADM and Interim DON. The following Plan of Removal submitted by the facility was accepted on 02/27/2025 at 7:48 a.m. Plan of Removal for F695 Head to toe comprehensive assessment, including assessing the respiratory system for abnormalities, signs of distress or change in condition completed on Resident #1 by Director of Nursing/Designee on 2/25/25 with no negative effects and physician notified. Resident #1's responsible party notified on 2/25/25. An observation of the 6 residents currently in the facility with orders for continuous Oxygen was completed on 2/25/25 by the Director of Nursing/Designee to validate oxygen is being delivered per physician orders. No issues identified. Administrative Nurses were reeducated on Oxygen Administration on 2/25/25 by the Clinical Consultant including: Validate residents are receiving oxygen per physician's orders. Validating residents with orders for continuous oxygen have a full portable oxygen tank prior to going out of the facility and document on the resident's leave of absence form. Licensed nurses were reeducated on Oxygen Administration on 2/25/25 by the Director of Nursing/Designee including: Validate residents are receiving oxygen per physician's orders. Validating residents with orders for continuous oxygen have a full portable oxygen tank prior to going out of the facility and document on the resident's leave of absence form. Licensed Nurses working on 2/25/25 received this education. All nurses that have not worked will receive education by the Director of Nursing/Designee prior to their next scheduled shift. This education will also be completed in New Hire and agency orientation by the Director of Nursing/Designee. Member of Nursing Management will interview 2 staff members per week for 4 weeks to validate comprehension of provided reeducation. Members of Nursing Management will round daily and document on the validation tool for 5 days to validate that oxygen is being delivered per physician's orders, then 3x per week for 2 weeks. Director of Nursing/designee will validate and document on the validation tool that the leave of absence form is completed for residents who leave the facility and have orders for continuous oxygen, including documentation that the resident was sent with a full portable cylinder. This will be validated daily for 5 days, then 3x per week for 2 weeks. QAPI was held on 2/25/25. The Medical Director was notified of the Immediate Jeopardy on 2/25/25. Monitoring of the plan of removal included the following: 2/27/25 10:28am- Record Review reflected a head-to-toe comprehensive assessment including respiratory system was completed on Resident #1 on 2/25/25 by the DON with no negative finding. Record review reflected that 6/6 residents who wore oxygen continuously were evaluated to ensure physicians orders were being followed and residents were receiving oxygen. Record review reflected on 2/25/25 the DON and the ADON were reeducated by the Clinical Services Director on verifying oxygen was on and tank had enough for residents when going out on pass and during activities in the building. Record review reflected that licensed nurses (10/12) have been reeducated on oxygen administration on 2/25/25 by the DON including validating residents were receiving oxygen per physicians' orders, validating residents with orders for continuous oxygen had a full tank prior to going out of the facility, and documenting on the residents leave of absence form adequate supply of oxygen. Record review reflected that 1 random staff member had been audited by the DON for comprehension on education provided related to oxygen dated 2/26/25 and passed. Record Review reflected that the DON rounded daily, and documented oxygen was being delivered as ordered for those residents requiring oxygen dated 2/25/25, 2/26/25, and 2/27/25. Record review reflected that Resident #1 was provided a leave of absence form on 2/26/25 and the oxygen tank was verified by the DON to be full prior to the resident's exit from the facility for a medical appointment. Record review reflected that on 2/25/25 at 7:00PM a QAPI was held attended by the Medical Director, Interim Administrator, Interim DON, and the Clinical Services Director. During the meeting the IJ was discussed along with the writing of the POC. Observation on 2/27/25 at 11:38 am rounds were completed and reflected 6/6 residents requiring continuous oxygen had oxygen in place as ordered by their physician. Their portable tanks were secured and full or almost full. Interviewed 10 nursing staff (2-night shift LVN A and LVN B, 1 agency staff nurse LVN C, 1 PRN LVN D, a Weekend Supervisor RN E, and 5-day shift nurses LVN F, LVN G, LVN H, LVN I, LVN J ) they stated they had been educated on receiving oxygen orders, oxygen administration, oxygen order verification, and validating residents who required oxygen had it in place as ordered by the physician. They stated they were aware of the leave of absence form and to verify in writing on the form, that residents who were going out on pass and required oxygen, that their tanks were full. The Nurses stated the pass forms were printed from their matrix (an electronic medical record) system and in writing the nurse validated the amount of oxygen in the tank onto the form to ensure the resident was safe for transportation. In an interview on 2/27/25 at 2:35 pm the Interim DON stated she was educated by the clinical services director on oxygen administration, checking oxygen, and ensuring residents were adequately equipped with oxygen prior to leaving the facility. She stated she educated the nursing staff on the above in person and by phone. There were 2 nurses that work night shift that have not worked since the IJ was called and they would be educated prior to their next shift. She stated she did do a head-to-toe full comprehensive assessment on Resident #1 with no negative findings. The DON stated an audit was completed on residents with oxygen and all residents receiving oxygen had adequate supply within their portable tanks. She stated she has questioned 1 nurse this week so far to ensure comprehension of new oxygen plan and plans to continue audits x 4 weeks. The DON stated since Resident #1 frequently leaves for appointments and was out of her room the facility was planning on obtaining her a portable concentrator for her to take with her that will be battery operated with a backup battery in case it was needed. The portable concentrator had already been ordered at that time. The plan was for all residents to have adequate oxygen supply if needed and no negative outcomes. In an interview on 2/27/25 at 2:50PM the Interim ADM stated the POR had been implemented as written, the nursing mangers were educated and in turn the nurses were educated by the managers. He stated that an audit was completed on residents receiving oxygen and all residents were receiving it per physicians' orders. He stated Resident #1 had a full body assessment and there were no negative findings. He stated a QAPI meeting was help with The Medical Director for the development of the POR and all residents would receive an out on leave form printed from their EMR. The nurses were to sign the form ensuring residents leave the facility with a full bottle of oxygen. He stated that today the facility had ordered a portable concentrator for Resident #1 to ensure she always had adequate supply of oxygen because she was out of her room often and the portable concentrator would not restrict her freedom to roam the building as she desired. The Interim ADM and Interim DON were informed the Immediate Jeopardy was removed on 02/27/2025 at 3:45 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of Isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record review, the facility failed to implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #1) of 6 residents reviewed for care plans. The facility failed to complete an accurate comprehensive care plan for Resident #1, by not care planning her required need for oxygen, monitoring her for shortness of breath related to her disease process of Chronic Obstructive Pulmonary. The facility failed to complete an accurate comprehensive care plan for Resident #1, by not care planning her required need for specialty medical appointment related to her disease process of Congestive Heart Failure. The facility failed to complete an accurate comprehensive care plan for Resident #1, by not care planning her need for substantial/maximal assistance with her Activities of Daily Living including showering, upper and lower body dressing, and toileting hygiene. This failure could place residents at risk of not having their care and treatment needs met to ensure necessary care and services were provided for specific disease processes and activities of daily living. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] wit diagnosis of acute on chronic systolic heart failure (a condition in which the heart is too weak to pump the blood around the body to meet its needs), chronic obstructive pulmonary disease (a group of lung conditions making it difficult to breath), personal history of COVID-19, and wheezing. Record review of Resident #1's care plan dated 01/08/2025 reflected there were no care plans to reflect Resident#1's need for oxygen, disease process of COPD (Chronic Obstructive Pulmonary Disease), disease process of CHF (Congestive Heart Failure), or her ADL (activities of Daily Living) needs. Record review of Resident #1's Quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. Resident #1 required substantial/maximal assistance indicating the helper did more than half the effort or the helper lifted or held trunk or limbs and provided more than half the effort for ADL care showering, upper and lower body dressing, and toileting hygiene. The MDS reflected Resident #1 received oxygen therapy while a resident continuously and received a diuretic medication. Record review of Resident #1s' Physician orders for February 2025 reflected an order for oxygen at 2 liters per minute via nasal cannula every shift dated 02/17/2025. The Physician orders reflected an order to assist times 2 persons with bed mobility dated 12/20/24, and for Resident #1 to have daily weights with special instructions: CHF/check daily weight each morning and contact CHF clinic for weight gain of 2+ lbs. overnight or 3-5+ lbs. in 1 week Once A Day at 07:00 AM dated 2/25/25. Record review of Resident #1s' Physician orders history report for dated of 01/01/2025 through 02/25/25 reflected an order for oxygen at 2 liters per minute via nasal cannula every shift dated 12/20/2024. The order history report also reflected an order to check Resident #1 every hour to ensure the oxygen delivery is functioning properly. Report any complications to the DON or Administrator. This order was started on 01/10/2025 and then discontinued on 01/26/2025. Record review of facility's grievance log for January and February 2025 reflected Resident #1s RP had filed a grievance on 01/10/2025 stating when Resident #1 was at an appointment the oxygen tank was not turned on after being transported from the facility. The RP turned the oxygen on. Then later within the same day the RP was dropping off laundry and noticed the residents' eyes looking glassy and checked her oxygen tank and found the tank was full but not turned on and she had to turn it on again. The internal investigation revealed there were new oxygen regulators at the facility and had not been attached to the oxygen tank appropriately. Staff were in serviced on 1/17/25 on oxygen regulators and the grievance was closed as resolved. In an interview on 02/25/25 at 10:25 Resident #1s stated she has a constant problem with the facility not ensuring there was oxygen in the portable oxygen tanks. She stated she had a diagnosis of CHF and COPD (both disease process will cause shortness of breath) and has difficulty breathing. She stated she always uses oxygen continuously. Resident #1 stated she must see a medical specialist weekly for management of her CHF and COPD disease processes. She stated she was sent to the medical clinic the last 2 visits on 2/13/25 and on 2/21/25 with empty oxygen tanks. The specialty clinic staff changed her from her empty potable tanks (sent by the facility) to the wall oxygen unit in the medical clinic. Resident #1 stated she becomes confused, belligerent, and has severe crippling anxiety due to feeling as if she must struggle to breathe without adequate oxygen supply. Resident #1 stated she was transported to the medical clinic by ride safe a transport company. She stated the nurses do not check the oxygen tank to see if it's empty or full prior to leaving to her medical appointments. Resident #1 stated she was told to use the oxygen concentrator in her room. She stated that limits her mobility to freely move around the building and she does not like being grounded to her room it was like a punishment. Resident #1 stated she could not take her oxygen concentrator with her to the appointments as it requires electricity to function. She stated the oxygen tank problem had been reported to the administrator previously in a grievance form in January 2025. She stated she attended an emergency care-plan meeting with her RP regarding the issue, and the facility staff began to check the oxygen more frequently. Then the staff stopped checking the oxygen. So, it did not last long them checking the tanks. In an interview on 02/25/25 at 10:25 The RP of Resident #1 stated she has found Resident #1 with either her oxygen off, attached wrong, with an empty oxygen tank, or the liter flow set to the wrong amount multiple times. She stated she did meet with the facility ADM in January and drafted an emergency plan for the facility to increase the frequency of checking Resident #1s oxygen and then they stopped. The RP stated Resident #1 has shown up for two appointments in the last 2 weeks with empty oxygen tanks at the specialty medical clinic. At one of those appointments her oxygen saturation was 84%, Normal range is above 90%, she said Resident #1 was belligerent and confused short of breath and having anxiety. The RP said the nurses at the clinic were able to transfer Resident #1 to their in-house oxygen unit on the wall and bring her level up to 100% but she still suffered from anxiety and not being able to breathe. She stated Resident #1 wears her oxygen continuously she is never without it unless the facility fails to ensure she has oxygen on. In an interview on 2/26/25 at 1:30pm with the MDS Coordinator she stated she has worked for the facility for 8 years. She stated she did the basic comprehensive care plan for Resident #1, and the emergency care plans were completed by the DON or the ADON. She stated she was responsible for holding the care plan meetings. She stated she did not update the comprehensive care plan at the care plan meetings. The MDS Coordinator stated she should have done a care plan for the COPD, CHF, and oxygen use. She stated It would be nice if she were able to update the care plans at the meetings, but she would have to borrow a computer and there was no way to update the care plan while in the meeting. She stated she did not think there were any negative effects for not having a care plan, in place for COPD, CHF disease processes, and ADL care for Resident #1. She stated Resident #1 was alert and oriented and she could verbalize her needs. In an interview on 2/26/25 at 1:45pm the Interim DON stated that the MDS coordinator was responsible for completing the comprehensive care plan. She stated the DON and the ADON updated the care plan with acute changes. She stated the MDS coordinator should update comprehensive care plans after each meeting. Those care plan meeting were held quarterly and as needed. The Interim DON stated the disease processes of CHF, COPD, interventions, monitoring, and use of oxygen should have been care planned. The care plan should have been updated with residents' changes in condition including the need to increase the monitoring of the oxygen, daily weights, and assistance with needs within the ADL care plan. The negative effects could be that the resident would not receive appropriate care. Record review of facility policy titled Care Plan Process Person -Centered Care dated 05/05/2023 reflected: PROCEDURES Following RAI Guidelines (a tool used by Nursing Homes to assess a resident needs and strengths) develop and implement a comprehensive person-centered care plan 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. The Interdisciplinary Team (IDT) will review for effectiveness and revise the person-centered care plan after each assessment. This includes both the comprehensive and quarterly assessments. For the comprehensive assessment the review will be completed with seven (7) days and no more than 21 days after admission. Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls and pressure ulcer development. Residents will remain actively engaged in the person-centered care planning process and has the right to participate in the development of and be informed in advance any changes to the person-centered care plan; see the person-centered care plan and choose to sign the care plan after significant changes. The person-centered care plan includes: Date Problem Resident goals for admission and desired outcomes Time frames for achievement Interventions, discipline specific services, and frequency

Based on interviews and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Resident #1, Resident #2, and Resident #3) of six residents reviewed for quality of care. The facility failed to weigh Residents #1, #2, and #3 according to physician orders. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including congestive heart failure, edema (swelling), hypertension (high blood pressure), and type II diabetes. Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 14, indicating no cognitive impairment. Review of Resident #1's admission care plan, dated 12/30/24, reflected she was at risk of nutrition and/or dehydration with an intervention of monitoring weights, skin report, and labs per policy. Review of Resident #1's physician order, dated 12/26/24, reflected daily weights. Review of Resident #1's weights in her EMR, from 12/26/24 - 01/08/25, reflected she was weighed on 12/26/24, 12/29/24, 01/01/25, 01/07/25, and 01/08/25. Review of Resident #2's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acute kidney failure, congestive heart failure, generalized edema, and hypertension. Review of Resident #2's admission MDS, dated [DATE], reflected a BIMS score of 3, indicating a severe cognitive impairment. Review of Resident #2's admission care plan, dated 12/18/24, reflected he was at risk of nutrition and/or dehydration risk with an intervention of monitoring weights, skin report, and labs per policy. Review of Resident #2's physician order, 01/03/25, reflected daily weights. Review of Resident #2's weights in his EMR, from 12/18/24 - 01/08/25, reflected she was weighed on 01/04/25. Review of Resident #3's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, congestive heart failure, morbid obesity, and pressure ulcers. Review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS score of 14, indicating no cognitive impairment. Review of Resident #3's quarterly care plan, dated 12/16/24, reflected she was at risk of nutrition and/or dehydration with an intervention of monitoring weights, skin report, and labs per policy. Review of Resident #3's physician order, dated 08/13/24, reflected daily weights. Review of Resident #3's weights in her EMR, from 11/01/24 - 01/08/25, reflected she was weighed on 11/01/24, 12/04/24, 12/10/24, and 01/01/25. During an interview on 01/08/25 at 2:57 PM, the DON stated physician orders should always be followed. She stated it was her expectation for the admitting nurses were expected to weigh a resident upon admission and then nurses were to weigh weekly or daily - whichever was ordered. She stated it was important for a resident with a diagnosis of CHF to be diagnosed as ordered so weight gain could be monitored (to ensure no excess fluid was on the heart). She stated a negative outcome of not weighing residents regularly could be exacerbation of health conditions. Review of an in-service entitled Weights, dated 11/11/24 and conducted by the DON, reflected the following: Nursing and Aides: We have several residents on daily and weekly weights. The weights must be collected in order to track our residents' weights. This is IMPORTANT to collect the weight on the day it is due. Review of the facility's Physician Orders Policy, revised May 5, 2023, reflected it did not address the importance of following physician orders.

Based on observations, interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for three (Resident #2, Resident #4, and Resident #6) of six residents reviewed for respiratory care. The facility failed to: - Ensure Resident #2 had an order for oxygen therapy or had an Oxygen in Use sign on the door to his room. - Ensure Residents #4's oxygen tubing not in use was bagged and off the floor of their room. - Ensure Resident #4 was not eating lunch in the dining room utilizing oxygen with an empty oxygen tank. - Ensure Resident #6's nasal cannula tubing was connected to the concentrator and water was in the cannister. These deficient practices could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Review of Resident #2's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acute kidney failure, congestive heart failure, generalized edema (swelling), and hypertension (high blood pressure). Review of Resident #2's admission MDS, dated [DATE], reflected a BIMS score of 3, indicating a severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected he did not required any respiratory treatments. Review of Resident #2's admission care plan, dated 12/18/24, reflected no problems or interventions for oxygen therapy. Review of Resident #2's physician orders, on 01/08/25, reflected no orders for continuous oxygen. Observation on 01/08/25 at 11:05 AM revealed Resident #2 asleep in his room utilizing an oxygen concentrator with the cannula in his nose. There was no Oxygen in Use sign on the door to his room. Review of Resident #4's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a disease that was characterized by persistent respiratory symptoms), presence of cardiac pacemaker, hypertension, and dysphagia (difficulty swallowing). Review of Resident #4's quarterly MDS assessment, dated 12/06/24, reflected a BIMS score of 15, indicating no cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected he did not required any respiratory treatments. Review of Resident #4's quarterly care plan, dated 10/28/24, reflected he required oxygen by nasal cannula at 2-4 L per minute continuous with an intervention of O2 equipment turned on accurately, connected properly, and set to the correct setting (flow rate). Review of Resident #4's physician order, dated 10/18/24, reflected O2 at 2-4 liters per minute via nasal cannula to keep sats >90%. Review of Resident #4's physician order, dated 10/18/24, reflected keeping O2 cannula/mask/tubing and/or nebulizer mask/tubing bagged when not in use. Observation on 01/08/25 at 10:22 AM revealed Resident #4 asleep in his room utilizing his oxygen concentrator. He had an oxygen tank on the back of his wheelchair that was empty with the tubing not bagged and on the floor. He had a nebulizer mask on his bedside table that was not bagged. During and observation and interview on 01/08/25 on12:56 PM revealed Resident #4 eating lunch in the dining room. He had his oxygen nasal cannula in his nose and the oxygen tank on the back of his wheelchair was empty. He stated his oxygen was working okay. During an interview on 01/08/25 at 1:02 PM, LVN A stated she noticed Resident #4's oxygen tank was empty when she took him to the dining room, but she had taken his oxygen saturations and they were at 93% and he did not require oxygen unless his saturations were under 93%. During an observation and interview on 01/08/25 at 1:04 PM, CNA B stated Resident #4 always needed to be receiving oxygen. When she noticed his tank was empty, her eyes went wide, and she called for LVN C for assistance. LVN C took Resident #4's oxygen saturations which was at 91%. She left to go get him a full oxygen tank after stating he needed to always have oxygen on. Review of Resident #6's undated face sheet printed 01/08/24, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), vascular dementia with anxiety, neuromuscular dysfunction of bladder (nerve damage impairing bladder control), and coronary artery disease (narrowing of the vessels that carry blood to the heart). Review of Resident #6's quarterly MDS assessment dated [DATE], reflected a BIMS score of 7 indicating severely impaired cognition. Section O (Special Treatments, Procedures, and Programs) reflected she required oxygen therapy. Review of Resident #6's comprehensive care plan, revised 01/08/24 reflected, Problem: Resident is on 2-4 liters of oxygen per minute via NC . She likes to take it off often times during the day. Goal: Have improved lung sounds, maintaining healthy diet, have a target O2 SAT level between 94% and 98%. Approach: Encourage Resident #6 to leave her oxygen tubing in place. Explain that it helps her to breathe. O2 equipment should be turned on, connected properly, and set to the correct flow rate and to monitor O2 levels. [sic] Review of Resident #6's physician order dated 11/25/24 reflected, O2 at 2-4 liters per minute via nasal cannula prn to keep sats greater than 90% every shift prn. During an observation on 01/08/25 at 10:15 AM, Resident #6 was lying in bed with the head of the bed elevated. She was wearing a nasal cannula. The oxygen concentrator next to her bed had a water cannister attached. The cannister did not contain any water. The cannula tubing was dated with a piece of tape. The tape was stuck to a baggie that was hanging from the concentrator. The end of the nasal cannula tubing was not attached to the oxygen concentrator. An observation and interview on 01/08/25 at 10:23 AM revealed LVN C, donned PPE and entered Resident #6's room. She informed the resident that she was going to check her oxygen saturation. She checked and reported a result of 92%. LVN C took the water canister and filled it with tap water from the bathroom. She returned the cannister and attached it to the concentrator. LVN prepared to leave the room. When asked if she had any other concerns with oxygen set up other than the empty water canister, she returned to the concentrator and found the nasal cannula tubing was not connected to the concentrator. LVN C stated she had made rounds earlier and the oxygen had been connected. She stated she did not know how the tubing became disconnected but though maybe the resident had pulled on the tubing. She stated not having the tubing connected could have resulted in the resident's oxygen level dropping. During an interview on 01/08/25 at 2:57 PM, the DON stated she believed the rule to have an oxygen in use sign outside the room of a resident who utilized oxygen had gone away years ago because it was a dignity issue. She stated residents on continuous oxygen that leave the room more often had tanks in their rooms. She stated she would hope the aides would check the tanks to ensure they were not empty before a resident left the room. She stated it was everyone's responsibility of making sure tanks were full. She stated if tubing was not in use in a resident's room it should be bagged. She stated it was to prevent a resident from walking over it and prevent infection control issues. She stated if a resident was on continuous oxygen they should probably have a physician's order for it. She stated Resident #4 did not necessarily need oxygen on when not in his room. She stated it was her expectation that oxygen would be administered as ordered by the physician, the tubing be correctly attached, and the resident be monitored. She stated water was not necessary for the concentrators because it did not mess with the delivery of the oxygen. Review of the facility's Oxygen Therapy Policy, revised 02/12/24, reflected the following: Oxygen administration increases blood oxygen content so that the heart doesn't have to pump as much blood per minute to meet tissue demands. . Verify the provider's order for the oxygen therapy; all orders for oxygen therapy will include administration modality, liter flow, continuous or as needed (PRN). PRN orders will include the specific guidelines as to when the patient/resident is to use oxygen. . Check the patient's/resident's room to make sure it's safe for oxygen administration, place oxygen precautions sign on the door of the patient's/resident's room.

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two of five residents (Resident #3 and Resident #6) reviewed for infection control. CNA D failed to wear PPE while providing care to resident #3 who was on Enhanced Barrier Precautions. LVN C used a pulse oximeter (a device that measures the amount of oxygen in the blood) on Resident #6, who was on Enhanced Barrier Precautions, then failed to clean or sanitize the oximeter before placing it back in her pocket. These failures could place residents at risk for spread of infection. Findings included: Review of Resident #3's face sheet printed 01/08/24, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included coronary artery disease (narrowing of the vessels that carry blood to the heart), heart failure, and diabetes mellitus type 2 (a condition that affects the way the body processes blood sugar). Review of Resident #3's quarterly MDS assessment dated [DATE], reflected a BIMS score of 14 indicating intact cognition. Review of Resident #3's physician order dated 11/11/24 reflected, Resident is on EBP precautions for wound to buttock. Review of Resident #3's comprehensive care plan, last reviewed/revised 01/08/24 reflected the problem, Resident is on EBP precautions for wound to buttocks. The goal reflected, Resident remain infection free. The approach reflected, Staff wears PPE during direct patient care. Review of Resident #6's face sheet printed 01/08/24, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (stroke), vascular dementia with anxiety, neuromuscular dysfunction of bladder (nerve damage impairing bladder control), and coronary artery disease (narrowing of the vessels that carry blood to the heart). Review of Resident #6's quarterly MDS assessment dated [DATE], reflected a BIMS score of 7 indicating severely impaired cognition. Review of Resident #6's physician order dated 11/11/24 reflected, Resident is on EBP for catheter use. Review of Resident #6's comprehensive care plan, last reviewed/revised 01/08/25 reflected the problem, Resident is on EBP precautions for catheter use. The goal reflected, Resident stays infection free. The approach reflected, Staff wears PPE during direct patient care. An observation on 01/08/25 at 10:01 AM revealed Resident #3's room door was open, but the privacy curtain closed. Below the level of the curtain, two sets of lower legs and feet, very close together, were visible. A staff member stepped from behind the curtain. She was wearing gloves and had a bag of trash in one hand. She verified she was providing care to Resident #3. A sign on the door indicated Enhanced Barrier Precautions were in effect. The sign had pictures of the PPE required when providing care. To the left of the doorway there was a cart that contained PPE supplies. During an interview on 01/08/25 at 10:09 AM, CNA D came out of Resident #3's room. She stated she had been helping the resident and assisted her to the bedside commode. She confirmed that she had received training on EBP and infection control. She stated when the resident was on EBP, you had to wear a gown, mask, and gloves when providing care. CNA D stated she did not wear a gown or mask when providing care to Resident #3. She stated she did not see the sign on the door, so she did not know to wear the PPE. She stated not following infection control protocols could spread infections. An observation and interview on 01/08/25 at 10:23 AM revealed LVN C, without first performing hand hygiene, donned a mask, gown, then gloves and entered Resident #6's room. She informed the resident that she was going to check her oxygen saturation. LVN C put her gloved hand under the isolation gown and checked multiple pockets until she found the pulse oximeter. She checked and reported a result of 92%. She then reached under the isolation gown again and placed the oximeter back in her pocket. She completed a couple other tasks, doffed the PPE, and exited the room. LVN C stated they had frequent trainings regarding infection control, and she had been trained on EBP. When asked about the procedure for cleaning equipment used on more than one resident, such as a blood pressure cuff or an oximeter, she stated she had to go back to her cart at the nurses' station to get a wipe because they don't keep wipes near the rooms. She stated she would clean the oximeter then. When asked how she cleaned her pockets, she stated she used a wipe for the pocket too. During an interview on 01/08/25 at 2:07 PM, the ADON stated it was her expectation, that when providing care to a resident on EBP, staff would wear PPE including a mask, gown, and gloves. She stated anyone with things such as a catheter, a dialysis port, a colostomy, or a g-tube should be on EBP. She stated not wearing PPE or not following infection control practices could get people sick or spread infection. She stated as the Infection Preventionist, she was responsible for monitoring infections. She stated both her and the DON were responsible for training the staff about infection control. She stated CNA D had been trained on EBP recently, but she was unable to find the document at the time of the interview. She stated she had told staff not to put equipment in their pockets. The wipes were used for sanitizing, and you had to be aware of the dry time listed on the label. During an interview on 01/08/25 at 2:57 PM, the DON stated it was her expectation that infection control practices were followed. She stated anyone with a wound or a line such as a catheter, gastric tube, or intravenous catheter, should be on EBP. When staff provided care to those residents, she expected a mask, gown, and gloves to be worn. She stated purple top wipes were available and nurses had them on their carts. She expected those wipes to be used to clean the equipment. She stated it was not acceptable to put equipment in pockets and it was not okay to use a sanitizing wipe to clean a pocket. She stated the ADON did most of the infection control training and monitoring. Review of the policy, Isolation/Precautions Including Standard/Universal Precautions, and Enhanced Barrier Precautions, revised 08/25/22, reflected in part, . 1. A. EBP will be implemented for all residents with the following: .2) Wounds and/or indwelling medical devices (central lines, urinary catheter .) regardless of MDRO colonization status. B. EBP will be implemented during the following high-contact resident care activities: 1) Dressing 2) Bathing/showering 3) Transferring 4) Providing hygiene 5) Changing linens 6) Changing briefs or assisting with toilet 7) Device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator. C. EBP requires the following PPE: 1) Gloves 2) Gown 3) Face protection if performing activity with risk of splash or spray 4) All PPE is donned and doffed with appropriate hand hygiene and disposable after individual use or when visibly soiled .F. The facility will post clear signage on the door or wall outside of the room indicating the type of precaution and required PPE (gowns and gloves) G. The facility will post signage that clearly indicates the high-contact resident care activities that require the use of gown and gloves . Review of the CDC website https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, accessed on 01/08/25, reflected in part, Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.

Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 4 of 6 residents (Residents #10, #12, #39, and #57) reviewed for care plans. The facility failed to include anticoagulant medication in Resident #10 and #39's comprehensive care plan. The facility failed to include opioid medication in Resident #12's comprehensive care plan. The facility failed to include antiplatelet medication in Resident #57's comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included: Record review of Resident #10's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included: cerebral infarction (a pathologic process that results in an area of dead tissue in the brain), dysphagia (difficulty in swallowing), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), and hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated). Record review of Resident #10's Quarterly MDS assessment dated [DATE], reflected that Resident #10 had a BIMS score of 00 which reflected the resident was severely cognitively impaired. Resident #10's Quarterly MDS assessment reflected that the resident was receiving anticoagulant medication. Record review of Resident #10's Physician's Orders, dated 12/18/24, reflected the resident had an order for: Eliquis (apixaban) tablet; 5 mg; amt: 1 tablet (5MG) BID; oral Twice A Day on 12/16/24. Eliquis is an anticoagulant medication. Record review of care plan dated 11/13/2024 reflected Resident #10 was not care planned for taking an anticoagulant medication. In an observation on 12/16/24 at 09:35 AM, Resident #10 was laying in her bed. She did not respond when her named was called or when eye contact was given. She continued to be look at the TV with a blank stare. No visible bruising was seen on Resident #10. Record review of Resident #12's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #12 had diagnoses which included: diffuse traumatic brain injury with loss of consciousness (when a sudden external physical assault damages the brain and involves a loss of consciousness that lasts more than 6 hours), dysphagia (difficulty in swallowing), dysuria (difficult or painful urination), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), respiratory failure (results from inadequate gas exchange by the respiratory system meaning that the arterial oxygen, carbon dioxide, or both cannot be kept at normal levels), and pain in leg (pain). Record review of Resident #12's Quarterly MDS assessment dated [DATE], reflected that Resident #12 had a BIMS score of 15 which reflected the resident was cognitively intact. Resident #12's Quarterly MDS assessment reflected that the resident was receiving an opioid medication. Record review of Resident #12's Physician's Orders, dated 12/18/24, reflected the resident had an order for: acetaminophen-codeine - Schedule III tablet; 300-30 mg; amt: 1; oral. Special Instructions: 1 tablet PO every 6 hours as needed for pain ordered on 01/26/24 and Tylenol (acetaminophen) [OTC] tablet; 325 mg; amt: 2 tabs; oral Special Instructions: Give 2 tabs PO PRN every 4hrs for mild pain ordered on 11/16/23. Acetaminophen-Codeine is an opioid medication. Record review of Resident #12's care plan which was last revised 10/31/24 reflected Resident #12 was not care planned for taking an opioid medication. In an interview on 12/16/24 at 10:53 AM, Resident #12 stated he was fine, and everything was ok. He stated he had no concerns. Record review of Resident #39's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included: cerebral infarction (a pathologic process that results in an area of dead tissue in the brain), anxiety (intense, excessive, and persistent worry and fear about everyday situations), hyperlipidemia (abnormally high levels of any or all fat cells in the blood), and dysphagia (difficulty in swallowing). Record review of Resident #39's Quarterly MDS assessment dated [DATE], reflected that Resident #39 had a BIMS score of 07 which reflected the resident was severely cognitively impaired. Resident #39's Quarterly MDS assessment reflected that the resident was receiving an anticoagulant medication. Record review of Resident #39's Physician's Orders, dated 12/18/24, reflected the resident had an order for: Eliquis (apixaban) tablet; 5 mg; amt: 1 tab; oral Twice A Day on 08/06/24. Eliquis is an anticoagulant medication. Record review of Resident #39's care plan which was last reviewed 11/18/24 reflected Resident #39 was not care planned for taking an anticoagulant medication. In an interview on 12/16/24 at 10:14 AM, Resident #39 stated things were ok, and she had no concerns. Record review of Resident #57's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included: anxiety (intense, excessive, and persistent worry and fear about everyday situations), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), atrial fibrillation (a common heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often rapidly), and hyperlipidemia (abnormally high levels of any or all fat cells in the blood). Record review of Resident #57's Admission MDS assessment dated [DATE], reflected that Resident #57 had a BIMS score of 04 which reflected the resident was severely cognitively impaired. Record review of Resident #57's Physician's Orders, dated 12/17/24, reflected the resident had an order for aspirin [OTC] tablet, chewable; 81 mg; amt: 81mg; oral Once A Day. Aspirin in an anticoagulant medication. Record review of Resident #57's care plan dated 12/16/24 reflected Resident #57 was not care planned for taking an antiplatelet medication. In an interview on 12/16/24 at 10:10 AM, Resident #57 stated he was fine, and he had no concerns. In an interview on 12/17/24 at 2:04 PM LVN C stated she was an agency nurse and she had worked at the facility for only three days. She stated she was given a 206-page document to read when she started. She stated the MAs passed the medication on the 300 hall, and they should have monitored and documented on the MAR that they monitored for signs and symptoms from anticoagulants. She stated some of the symptoms could have been bruising or bleeding. She stated, she was not sure how the facility monitored anticoagulants on care plans or why Resident #10's care plan did not show anticoagulants. She stated anticoagulant medications should have been included on the care plan and that was a question management should have answered. In an interview on 12/18/24 at 9:11 AM, the DON, stated she had noticed Resident #10's anticoagulant, Eliquis, was not on her care plan but was in her physician's order and being monitored. She stated some nurses knew how to update care plans and some do not. She further stated the MDS coordinator was responsible for ensuring care plans were completed; however, DON, ADON, and LVNs can make changes if a resident received a new order or if there was a change of condition, the care plan would need to be updated. She stated she was responsible for training the LVNs on care plans and if they had any issues with an update, she was available for them to ask for help. She stated she believed they had a care plan policy, and she would have to look for it. She stated negative effects of not monitoring Resident #10's anticoagulant in her care plan would be potential bruising and bleeding, and because she cannot verbally tell staff if she fell or bumped her elbow, which could lead to a bruise, staff would not know to monitor for bruising. In an interview on 12/18/24 at 9:20 AM, the MDS stated depending on the department, such as social services were responsible for care planning and monitoring behaviors, anti -psychotic drugs, and anticoagulant medications, would determine who was responsible for documenting on the care plan, but she was responsible for the initial care plan unless there was a change and/ or medication started after the comprehensive assessment was done. She stated the DON was good at keeping up with the care plans however she could not believe Resident #10 had been at the facility for 3 years and no one had noticed her anticoagulant was not on her care plan. She stated as of 12/18/24 she was starting a care plan audit. She stated she did not look at a care plans when most important was a residents lab work and the Nurse Practitioner's concerns. A care plan was not going to decide on a resident care like the labs and the Doctor who would provide information such as blood in the stool, vomiting, and falls. In an interview on 12/18/24 at 11:39 AM, the MDS stated she was responsible for completing the MDS assessments. She stated it was a group of staff, such as the DON, Dietary Manager, Social Services, and Charge Nurses who were responsible for completing care plans. She stated it was the responsibility of the group to check for accuracy of the care plans. She stated she had been trained on completion of care plans and she had been doing this a long time. She stated resident information such as aspirin/antiplatelets, anticoagulants, and pain should have all been reflected correctly on the care plans. She stated if a resident's care plan was completed inaccurately, it could have caused confusion towards staff regarding the resident's care. In an interview on 12/18/24 at 01:27 PM, the DON stated there are multiple staff members, such as herself, activities, nurse leadership, charge nurses, social services, and dietary manager that were responsible for completing care plans. She stated it was the responsibility of the MDS nurse and corporate to check for accuracy of the care plans. She stated the staff responsible for the care plans had been trained on completion of care plans. She stated resident information such as aspirin/antiplatelets, anticoagulants, and pain should have all been reflected correctly on the care plans. She stated if a resident's care plan was completed inaccurately, she does not really know how it would affect the resident because there are orders in place to monitor for pain and for any bleeding due to the anticoagulants/antiplatelets and as long as the staff were following physicians orders, the resident should not have been affected. Review of facility policy dated 2023 (complete revision May 5, 2023) titled Care Plan Process, Person-Centered Care revealed Policy: The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes trying to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and understanding the resident's life before coming to reside in the nursing home . The services provided or arranged by the facility, as outlined by the comprehensive person-centered care plan, will meet professional standards of quality. Procedures: 2.The baseline person-centered care plan will include the minimum healthcare information necessary to properly care for the resident including, but not limited to initial goals based on admission orders, resident goals, physician orders, dietary orders, therapy services, social services, and PASRR recommendation, if applicable. 3.Following RAI Guidelines develop and implement a comprehensive person-centered care plan 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. 4. A. The Baseline Person-centered care plan Summary includes immediate resident needs. B. Physician Orders or CCD (Continuity of Care Document). 9. Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as but not limited to falls and pressure ulcer development. 11. The person-centered care plan includes: A. Date B. Problem C. Resident goals for admission and desired outcomes D. Time frames for achievement E. Interventions, discipline specific services, and frequency F. Refusal of services and/or treatments 1) Evaluation of resident's decision-making capacity 2) Educational attempts 3) Attempts to find alternative means to address the identified risk/need. G. Discharge plans 1) Resident's preference and potential for future discharge 2) Resident's desire to return to the community and any referrals to local contact agencies and/or other appropriate entities, for this purpose. H. Resolution/Goal Analysis

Based on observations, interview, and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 4 of 6 residents (Resident #3, Resident #37, Resident #41, and Resident #52) reviewed for hygiene. The facility failed to ensure Resident #3 Resident #37, Resident #41, Resident #52 received a shower or bath as scheduled. This deficient practice could place residents who were dependent on staff for ADL care at risk for loss of dignity, and/or a diminished quality of life. The findings were: Resident #3 Record review of Resident #3's undated face sheet reflected she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Paraplegia (the inability to move the lower half of the body), unspecified, Cerebral infarction (a condition in which part of the brain dies from lack of oxygen), unspecified, Neuromuscular dysfunction of bladder (when the nerves and muscles that control your bladder are not working), unspecified, and Muscle wasting and atrophy. Record review of Resident #3's care plan dated 08/20/2024 reflected Resident #3 required assistance with ADLs. The care plan's goal was that Resident #3 would maintain a sense of dignity by being clean, dry, odor free and well-groomed over the next 90 days. Interventions included: Bathing- Assist of 1 or 2 staff members- If showering, use 2 staff and the mechanical lift. Encourage resident to take a shower, she often refuses and only wants a bed bath. Sometimes she refuses the bed bath. Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. The MDS reflected she was Dependent for bathing indicating the helper does all the effort and the resident does none of the effort to complete the activity. The MDS reflected the resident did not reject care. Record review of an undated facility shower assignment sheet reflected Resident #3 was to receive a shower or bed bath every Monday, Wednesday, and Friday on the day shift. The schedule indicated resident should have received a shower or bed bath on 12/2, 12/4, 12/6, 12/9, 12/11, 12/13, 12/16, 12/18. Record review of the resident shower assignment sheet for 12/02/24 reflected that Resident #3 had received a bed bath on 12/2/24, the Resident left early for an appointment and was not bathed. Date of 12/4/24 and was not showered with no indication resident had refused care. On dates of 12/9/24, 12/11/24, and 12/13/24 the shower assignment sheet was signed by a CNA but was not marked for bed bath or shower. Record review of Point of care history report for the month of December 2024 reflected Resident #3 received Physical help with bathing on 12/02/24, Bathing activity did not occur on 12/4/24, total dependence (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for 12/6/24, supervision (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) on 12/9/24 , activity did not occur on 12/11/24, activity did not occur on 12/13/24, activity did not occur on 12/16/24. In an interview and observation on 12/16/24 at 10:10 AM Resident #3 stated she was to have surgery on her right eye today and would like a bath prior to surgery. She stated the staff said they would come but have not. Resident #3 was worried about being on time and stated she had to leave at 11:30 am. Resident #3 had a urine odor to her clothing and her sheets had food spills on them from her breakfast . In an interview on 12/17/24 at 1:53 PM, Resident #3 stated she did not get a shower yesterday prior to her appointment. Resident #3 stated she just did not want to stink prior to her appointment. She stated she was unsure the day of her last shower. Resident #37 Record review of Resident #37's undated face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Chronic obstructive pulmonary disease (a condition of the lungs affecting the ability to breathe), unspecified, Type 2 diabetes mellitus without complications (elevated blood sugars), Rash and other nonspecific skin eruption, and Muscle weakness. Record review of Resident #37's care plan dated 08/20/2024 reflected Resident #37 required assistance with ADLs. The care plan's goal was that Resident #37 would maintain a sense of dignity by being clean, dry, odor free and well-groomed over the next 90 days. Interventions included: Bathing Assist of 1- often refuses related to his breathing. Resident #37 preferred to shower only 1 time weekly, and staff will honor his wishes. Record review of Resident #37's Quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 11 indicating he had moderate cognitive impairment. The MDS reflected he required substantial/maximal assistance with bathing indicating the helper does more than half the effort to complete the task. The MDS reflected the resident did not reject care. Record review of an undated facility shower assignment sheet reflected Resident #37 was to receive a shower every Tuesday, Thursday, and Saturday on the day shift. The schedule indicated resident should have received a shower or bed bath on 12/3/24, 12/5/24, 12/7/24, 12/10/24, 12/12/24, 12/14/24, 12/17/24. Record review of Point of care history report for the month of December 2024 reflected shower activity did not occur from December 03/2024 to December 17/2024 indicating Resident #37 missed 7 opportunities for showering equaling 14 days without a shower. Record review of facility progress notes for 12/1/2024 to 12/17/2024 did not indicated Resident #37 had refused his showers. In an interview and observation on 12/16/24 at 9:54 AM Resident #37 stated he hasn't had a shower in a while, sometime last week. He has musty body odor, and his clothes are disheveled and appear dirty . Resident #37 stated he used to have a schedule for his showers on his wall and he can't remember what days. Resident #37 said he would like to have a shower consistently. Resident #41 Record review of Resident #41's undated face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Cerebral infarction, unspecified (a condition in which part of the brain dies from lack of oxygen), Type 2 diabetes mellitus (elevated blood sugars), Iron deficiency anemia, and Major depressive disorder, recurrent. Record review of care plan dated 12/28/2022 reflected Resident #41 required assistance with ADLs. He will refuse to take shower and will. refuse to get out of bed. The care plan's goal was that Resident #41 would maintain a sense of dignity by being clean, dry, odor free and well-groomed over the next 90 days. Interventions included: BATHING: Assist of 1 if giving a bed bath, requires 2 staff members when giving a shower. Record review of Resident #41's Annual MDS assessment dated [DATE] reflected he had a BIMS score of 13 indicating he was cognitively intact. The MDS reflected he was Dependent for bathing indicating the helper does all the effort and the resident does none of the effort to complete the activity. The MDS reflected the resident did not reject care. Record review of Progress notes dated 12/1/24 to 12/17/24 reflected no episodes of Resident #41 refusing his showers. Record review of an undated facility shower assignment sheet reflected Resident #41 was to receive a shower every Tuesday Thursday and Saturday on the day shift. The schedule indicated resident should have received a shower or bed bath on 12/3, 12/5, 12/7, 12/10, 12/12, 12/14, 12/17. Record review of Point of care history report for the month of December 2024 reflected shower activity occurred on 12/10/24 and a bed bath was given on 12/17/24. This indicated that Resident #41 was bathed 2 times within the last 17 days. In an interview on 12/16/24 at 10:01 AM Resident #41 stated he hasn't had a shower in many days. He stated he would like to, but the staff must use a mechanical lift and that is just too difficult. Resident #41 stated he would like to feel clean, Resident #52 Record review of Resident #52's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Unspecified fracture of left femur, initial encounter for closed fracture, Polyosteoarthritis (arthritis in multiple joints), Pediatric feeding disorder, Muscle weakness, Dysphagia (difficulty swallowing), seizures, and Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side (paralysis after a stroke). Record review of Resident #52's care plan dated 11/06/2024 reflected Resident #52 required assistance with ADLs. The care plan's goal was that Resident #52 would maintain a sense of dignity by being clean, dry, odor free and well-groomed over the next 90 days. Interventions included: BATHING: Assist of 1 if giving a bed bath, requires 2 staff members when giving a shower. Record review of Resident #52's Quarterly MDS assessment dated [DATE] reflected she had severely impaired cognition and was unable to complete the BIMS. The MDS reflected she was Dependent for bathing indicating the helper does all the effort and the resident does none of the effort to complete the activity. The MDS reflected the resident did not reject care. Record review of an undated facility shower assignment sheet reflected Resident #52 was to receive a shower every Monday, Wednesday, and Friday on the day shift. The schedule indicated Resident #52 should have received a shower or bed bath on 12/2/24, 12/4/24, 12/6/24, 12/9/24, 12/11/24, 12/13/24, and 12/16/24. Record review of Point of care history report for the month of December 2024 reflected shower activity occurred on 12/02/24 and a bed bath was given on 12/04/24 and 12/11/24. This indicated that Resident #52 was only bathed 3 times within the last 17 days. In an interview on 12/16/24 at 11:42 AM with Resident #52's family member and guardian stated it had been 1 week since Resident #52 had been showered, the staff just do not shower her unless I'm on them . The Family Member stated Resident #52 does not have the capability to refuse care as she is nonverbal. In an interview on 12/17/24 at 2:10 PM CNA H stated she was not at the facility all the time and works for an agency. She stated she feels like the facility is adequately staffed to meet resident's needs. She stated documentation of showers is completed in the residents plan of care She stated the facility also has a handout that the nurse aides acquire at the start of their shifts with resident room numbers and beds assigned to shower days. She stated if a resident were to refuse their shower the staff report that to the charge nurse and the charge nurse then reports to the DON. CNA H was not aware of Residents #3, #37, #41, and #52's showers had been missed or refused. She stated negative effects for not giving showers could include body odors and depression. In an interview on 12/17/24 at 2:17 PM with MA G she stated she works for an agency and floats the building depending on where they need her to work. She stated she had been trained on ADL policy and care required to provide. She stated shower documentation was completed within the POC under bathing. She stated there was a shower sheet completed also that was handed in to the nurse. She stated the facility was not always adequately staffed to give the showers. She stated occasionally residents refuse their showers and at that time she would leave the resident and attempt again later in the day. MA G stated if a resident were to refuse a second time, she would notify the charge nurse and mark the shower as refused. MA G stated some of the negative effects for not giving showers would be body odors, depression, and skin irritation. In an interview on 12/18/24 at 9:25am LVN B stated the CNAs should report to the nurses and then the nurse will attempt to convince the resident to take a shower. She stated there was a shower sheet and if the resident refused the shower the nurse will fill out a sheet and sign it and send the sheet to the DON informing her of the refusal. LVN B stated there were some residents who do refuse showers often and some of the residents only like certain staff. LVN B stated she had suggested getting a shower aide to the DON because It's hard to keep up with the call lights sometimes when the CNAs are in the rooms giving showers. She stated negative effects for not giving showers could include poor hygiene and depression. She stated residents feel better when they are showered. In an interview on 12/18/24 at 01:27 PM The DON stated her expectations are that the shower is due the day it is due. She stated staff need to find out why the resident is not taking their shower. The DON stated all staff were trained when they enter the facility on ADL care. She stated the facility will also pair agency staff with another CNA who will train them. She stated the charge nurse was responsible for charting interventions and communication with the management when residents refuse showers. She stated staff needed to alert families and DON of problems, so families are not shocked when they discover their loved one is refusing showers. The DON stated negative effects on the resident really depends on the person. She said some of these residents did not bathe 3 times a week at home and we must honor their rights when they refuse the shower. Record review of facility policy titled Activities of Daily Living, Optimal Function dated May 05, 2023, reflected The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene.

Based on interview, and record review, the facility failed to ensure residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and a resident with pressure ulcers receives the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 3 (Resident #3, Resident #41, and Resident #52) of 6 residents reviewed for quality of care. The facility failed to complete weekly skin assessments according to their orders and for Residents # 3, # 41, and # 52. These failures could place residents at risk for developing pressure ulcers or wounds. Findings included: Resident #3 Record review of Resident #3's undated face sheet reflected she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Paraplegia (the inability to move the lower half of the body), unspecified, Cerebral infarction (a condition in which part of the brain dies from lack of oxygen), unspecified, Neuromuscular dysfunction of bladder (when the nerves and muscles that control your bladder are not working), unspecified, and Muscle wasting and atrophy. Record review of Resident #3's Quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. The MDS reflected Resident #3 was at risk for pressure ulcer /injuries The MDS reflected she was admitted with a stage 3 pressure ulcer. Record review of Resident #3's care plan dated 08/20/2024 reflected Resident #3 has a Stage 3 Pressure ulcer to Coccyx (buttocks). Resident goal was that Resident's skin will remain intact. Interventions included to Report any signs of skin breakdown (sore, tender, red, or broken areas). Record review of an undated physicians order report reflected Resident #3 was ordered to have a skin inspection completed weekly on Fridays with a start dated on 03/27/2024. Record review of observation history report for the month of December 2024 reflected Resident #3 had no weekly skin observation from 12/01/2024 to 12/17/2024. Resident #41 Record review of Resident #41's undated face sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Cerebral infarction, unspecified (a condition in which part of the brain dies from lack of oxygen), Type 2 diabetes mellitus (elevated blood sugars), Iron deficiency anemia, and Major depressive disorder, recurrent. Record review of Resident #41's Annual MDS assessment dated [DATE] reflected he had a BIMS score of 13 indicating he was cognitively intact. The MDS reflected Resident #41 was at risk for pressure ulcer /injuries. The MDS reflected Resident #41 had a venous and arterial ulcer present. Record review of care plan dated 12/28/2022 reflected Resident #41 is at risk for pressure ulcers related to debility, moisture, current and HX of pressure ulcers. Resident #41's goal was for skin to remain intact. Interventions on the care plan included to conduct a systematic skin inspection weekly, pay particular attention to the bony prominences. Record review of undated physicians order report reflected Resident #41 was ordered to have a skin inspection completed weekly on Fridays with a start dated on 03/27/2024. Record review of observation history report for the month of December 2024 reflected Resident #41 had no weekly skin observation from 12/01/2024 to 12/17/2024. Resident #52 Record review of Resident #52's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Unspecified fracture of left femur, initial encounter for closed fracture, Polyosteoarthritis (arthritis in multiple joints), Pediatric feeding disorder, Muscle weakness, Dysphagia (difficulty swallowing) seizures, and Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side (paralysis after a stroke). Record review of Resident #52's Quarterly MDS assessment dated [DATE] reflected she had severely impaired cognition and was unable to complete the BIMS. The MDS reflected she was Dependent for bathing indicating the helper does all the effort and the resident does none of the effort to complete the activity. The MDS reflected Resident #52 was at risk for pressure ulcer /injuries. The MDS reflected Resident #52 had no current pressure ulcers or skin injuries. Record review of Resident #52's care plan dated 03/20/2024 reflected Resident #52 was at risk for pressure ulcers related to moisture, debility, decreased sensory perception. The residents' goal was for the skin to remain intact. Interventions included Report any signs of skin breakdown (sore, tender, red, or broken areas). Record review of an undated physicians order report reflected Resident #52 was ordered to have a skin inspection completed weekly on Wednesday with a start date on 10/18/2024. Record review of observation history report for the month of December 2024 reflected Resident #52 had one weekly skin inspection dated 12/04/2024 from 12/01/2024 to 12/17/2024. In an interview on 12/18/24 at 9:25am LVN B stated the nurses were responsible for completing the skin assessments for the residents. She stated skin assessments were ordered for A bed on the morning shift and B bed were on the night shift once weekly. She stated skin assessments were documented under observations within the medical record. She stated she was not sure why Residents #3, #41, or #52's skin assessments were not completed. LVN B stated failure to complete weekly skin assessments could lead to pressure sores or skin issues. In an interview on 12/18/24 at 1:27 PM The DON stated she has to hold the nurses accountable, and her expectations were that skin assessments were to be completed on the day they are due. She stated there was an order in the computer for them to be completed that alerts the nurse on treatment record to complete the skin assessments. She stated the nurses were trained on the skin assessment and skin system as needed, quarterly, and monthly at the all-staff meeting. She stated the wound care nurse, and The DON were responsible for ensuring skin assessments were completed. She stated she was not sure why Residents #3, #41, or #52's skin assessments were not completed. She stated the facility has been relying on agency nurses to staff their building and its difficult to follow up with them to ensure their work was completed. The DON stated negative effects for residents when not completing skin assessments included not catching skin issues early that can lead to worsening outcomes for residents. In an interview on 12/18/24 at 2:01 PM LVN D stated she has worked at the facility for 1 month. She stated, skin assessments were the responsibility of the nurses. She stated she and The DON oversee the system to make sure the skin assessments were completed. She stated the facility had had a lot of agency nurses in the building and that is the reason why the skin assessments were not completed. She stated she was not sure why Residents #3, #41, or #52's skin assessments has not been completed. She stated negative effects for not completing skin assessments included skin breakdown and worsening skin issues. Record review of facility policy titled Documentation -Licensed Nursing dated May 5, 2023, reflected Documentation pertaining to the patient/resident will be recorded in accordance with regulatory guidelines. The nursing staff will be responsible for recording care and treatment observations and assessments and other appropriate entries in the patient /resident clinical record. Surveyor requested skin assessment policy on 12/18/24 and it was not provided by facility.

Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 5 residents (Residents #39, #42, and #57) reviewed for comprehensive assessments. The facility failed to complete an accurate quarterly comprehensive assessment dated [DATE] for Resident #39 by not including hospice services. The facility failed to complete an accurate annual comprehensive assessment dated [DATE] for Resident #42 and failed to complete an accurate admission comprehensive assessment dated [DATE] for Resident #57 by not including an antiplatelet medication and incorrectly including an anticoagulant medication. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided. The findings included: Record review of Resident #39's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included: cerebral infarction (a pathologic process that results in an area of dead tissue in the brain), anxiety (intense, excessive, and persistent worry and fear about everyday situations), hyperlipidemia (abnormally high levels of any or all fat cells in the blood), and dysphagia (difficulty in swallowing). Record review of Resident #39's Quarterly MDS assessment dated [DATE], reflected that Resident #39 had a BIMS score of 07 which reflected the resident was severely cognitively impaired. Resident #39's Quarterly MDS assessment reflected that the resident was not receiving hospice services. Record review of Resident #39's Physician's Orders, dated 12/18/24, reflected the resident had an order to admit to hospice on 08/08/24. Record review of Resident #39's care plan dated 08/20/24 reflected Resident #39 was on end of life hospice services. Goal: Resident will experience death with dignity and physical comfort. Advanced directive wishes will be honored. Interventions included: Communicate with hospice when any changes are indicated to the plan of care. Notify hospice when there is any change in the resident's condition. Record review of Resident #42's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #42 had diagnoses which included: atherosclerotic heart disease of native coronary artery (coronary artery disease) (heart disease involving the reduction of blood flow to the cardiac muscle due to a build up of atheromatous plaque in the arteries of the heart), dysphagia (difficulty in swallowing), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), and congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs). Record review of Resident #42's Annual MDS assessment dated [DATE], reflected that Resident #42 had a BIMS score of 10 which reflected the resident was moderately cognitively impaired. Resident #42's Annual MDS assessment reflected that the resident was not receiving antiplatelet medication but was receiving anticoagulant medication. Record review of Resident #42's Physician's Orders, dated 12/17/24, reflected the resident had an order for aspirin [OTC] tablet, chewable; 81 mg; amt: 1 tablet (81MG) daily; oral Once A Day. The Physician orders did not reflect an order for an anticoagulant medication. Aspirin is an antiplatelet drug. Record review of Resident #42's care plan dated 10/31/24 reflected Resident #42 was currently taking antiplatelet medication. Goal: resident will receive therapeutic treatment from medication with no complications. Interventions included: Antiplatelet Drug - Monitor for Extreme tiredness, (fatigue), Heartburn, Headache, Upset stomach and nausea, Stomach pain, Diarrhea, Nosebleed. Licensed Nurse will obtain and monitor lab results and report to physician. Record review of Resident #57's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #57 had diagnoses which included: anxiety (intense, excessive, and persistent worry and fear about everyday situations), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), atrial fibrillation (a common heart arrhythmia that causes the upper chambers of the heart to beat irregularly and often rapidly), and hyperlipidemia (abnormally high levels of any or all fat cells in the blood). Record review of Resident #57's Admission MDS assessment dated [DATE], reflected that Resident #57 had a BIMS score of 04 which reflected the resident was severely cognitively impaired. Resident #57's Admission MDS assessment reflected that the resident was not receiving antiplatelet medication but was receiving anticoagulant medication. Record review of Resident #57's Physician's Orders, dated 12/17/24, reflected the resident had an order for aspirin [OTC] tablet, chewable; 81 mg; amt: 81mg; oral Once A Day. The Physician orders did not reflect an order for an anticoagulant medication. Aspirin is an antiplatelet drug. Record review of Resident #57's care plan dated 12/16/24 reflected Resident #57's antiplatelet medication was not care planned. In an interview on 12/18/24 at 11:39 AM, the MDS stated she was responsible for completing the MDS assessments. She stated it was the responsibility of the group to check for accuracy of the MDS assessments. She stated she had been trained on completion of MDS assessments and she had been doing this a long time. She stated resident information such as aspirin/antiplatelets, anticoagulants, and hospice should all be reflected correctly on the residents' MDS assessments. She stated if an MDS assessment was not completed correctly, she would have done a modification of the assessment, and it could have caused financial interruption or discretion for the facility. In an interview on 12/18/24 at 01:27 PM, the DON stated the MDS nurse was responsible for completing the MDS assessments. She stated it was the responsibility of the MDS nurse and corporate to check for accuracy of the MDS assessments. She stated the staff responsible for the MDS's had been trained on completion of MDS assessments. She stated resident information such as aspirin/antiplatelets, anticoagulants, and hospice should all be reflected correctly on the residents' MDS assessments. She stated if an MDS assessment was not completed correctly, it would require a modification and could cause the facility to lose money. Record review of RAI Manual MDS 3;0 Section N reflected N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). N0415I2. Antiplatelet: Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). Record review of the facility's policy dated 2023 with a completed revision date of 05/05/23 and an e-mail revision date of 09/28/23 titled Minimum Data Set reflected Policy: A licensed nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. Procedures: 1. Review the resident's medical record. This review may include pre-admission activities. Identify resident's status, care and services rendered during the Observation Period for the current assessment. Review is to include, but not be limited to pre-admission, admission, and transfer notes; current plan of care, physicians' orders, progress notes, history and physical; nursing, dietary, activity, social service, and therapy notes and assessments; monthly summaries, lab and x ray reports, consultations, medication administration records, treatment administration records, and resident, staff and family interviews. 2. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Supplemental information must be gathered and analyzed by the facility based on the triggered CAAs prior to developing the comprehensive care plan. Documentation of the facility's rationale for deciding whether or not to proceed with care planning for each area triggered is recorded in the medical record. The Facility addresses all risks identified within the context of the MOS assessment, even if they do not cause a CAA to trigger. 7. Interview the resident's physician. Ask about the discharge plan, goals of care, medication, and treatment orders. Discuss any negative outcomes identified during assessment.

Based on interviews and record reviews the facility failed to ensure each resident receives adequate supervision with assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. The facility failed to ensure Resident #1 received assistance, in an appropriately sized space, while being lifted out of her wheelchair using a mechanical lift, as specified in the care plan. CNA B did not ensure Resident #1 was positioned in the center of the lift sling and CNA D failed to stay by Resident #1's side with hand on assistance. The noncompliance was identified as PNC. The IJ began on 11/4/24 and ended on 11/23/24 The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injuries, falls, and a decline in quality of life. Findings included: Record review of Resident #1's face sheet dated undated reflected; Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included fracture of the left femur (broken thigh bone), poly osteoarthritis (painful inflammation in five or more joints), cerebral infarction (blocked blood flow to the brain causing brain tissue to die), muscle weakness, hemiplegia (paralysis on one side of the body), hemiparesis (one sided muscle weakness) following unspecified cerebrovascular disease (conditions that affect blood flow to the brain) affecting left dominant side. Record review of Resident #1's annual MDS assessment, dated 1/18/24, section C (Cognitive Patterns) reflected no BIMS score as resident was rarely or never understood. Section GG (Functional Abilities) reflected she was dependent for bed mobility and bed to chair transfers. Record review of Resident #1's comprehensive care plan, revised 11/15/24, reflected in part, Resident has side rails on bed for repositioning. She is at risk for falls. She also has a full torso harness attached to her wheelchair as she has zero trunk control. She will thrust herself forward at times. She is a mechanical (lift brand name) for transfers. Intervention added 11/07/24, Rearrange furniture and bed in (Resident #1's) room to ensure smooth transition for the (lift brand name). Record review of a progress note dated 11/4/24 reflected, Witnessed Fall RP present. Res being transferred to bed via (mechanical lift brand name) 2 CNAs and grandmother present CNA (CNA B and D's names) stated while positioning (Lift) alongside bed res raised up leaned forward slide out of the sling onto the floor. Standing outside the door I immediately went into the room observed res laying on the floor. Head to toe assessment completed VS: 104/70 90 20 97.0 97% RA res is nonverbal assisted onto bed off the floor. Dr notified transported to (Local) Hospital for further evaluation. Record review of Resident #1's Local Hospital Emergency Department Discharge Instructions dated 11/5/24 revealed no new orders. X-ray results were noted to be negative. Record review of Resident #1's progress note dated 11/5/24 reflected, Resident #1 returned from the hospital with no injuries having been found. The nurse documented This nurse was made aware of a hematoma (a collection of blood that pools outside the blood vessels) on the left hip. Residents [family member] requested the area be re-x rayed as it may be a delayed injury related to a fall the week prior. Record review of Resident #1's radiology reports from a mobile x-ray provider (performed at the facility), dated 11/14/24 reflected in part, HIP UNI W OR W/O PELVIS 2-3 V, LEFT Results: The left hip joint is in alignment, but there is narrowing of the joint space due to mild degenerative changes. There is mild degenerative spurring involving acetabular border and femoral head and neck junction. No fracture or dislocation is seen. Pubic rami are intact. Conclusion: Mild osteoarthritis of the left hip. Record review of Resident #1's progress note dated 11/20/24 included additional x-rays were ordered. The nurse documented the x-ray results in her progress note as follows: Acute fracture distal femur with some displacement and impaction noted. Orders received from provider to send resident to ED for further evaluation. Record review of Resident #1's radiology reports from a mobile x-ray provider (performed at the facility), dated 11/20/24 reflected in part, Femur 1 View, Left. Results: Acute fracture distal femur with some displacement and impaction. No acute findings elsewhere. Conclusion: Distal femoral fracture. Record review of Resident #1's Local Hospital Emergency Department Discharge Instructions dated 11/20/24 revealed a diagnosis of a closed femur fracture. A referral to a local surgeon for scheduling of surgery, and an immobilizer for left knee. During an observation, and an interview on 11/24/24 at 3:04pm in Resident #1's room revealed Resident #1 was in bed and a FM was sitting in a chair next to the bed. When asked if she was aware of Resident #1's fall, FM replied that she had been visiting when the drop, not a fall from the lift occurred. FM stated she feels responsible because she was not paying attention to the lift, she was trying to move Resident #1's wheelchair out of the way since it was a tight fit to use the lift in the small space available. FM stated she had since watched the video of the lift and pointed out a camera in the room pointing toward Resident #1's side of the room. FM opened the video on her phone. The video dated 11/4/24 showed CNA B in the room entranceway, which had an opening between the adjoining room wall and the wall/door to the bathroom. Resident #1 was sitting in her wheelchair with a lift sling under her. CNA D came into the area, walking sideways between the wall and the wheelchair, Resident #1 was lifted into the air by the mechanical lift. Resident #1 was observed tilting to the left with her head and upper body on the edge of the sling as she became visible to the camera prior to the fall. CNA B was standing at the foot of Resident #1, controlling the lift and CNA D, was standing on Resident #1's left side, she begins to turn Resident #1 suspended in the air, towards the bed. Resident #1 position while suspended is at the foot of the bed to the right side of the bed and between the bathrooms outer wall. Resident #1 is not over the bed. There was a pause and CNA D moved herself towards Resident #1's feet away from Resident #1's left upper body side, there did not appear to be room beside the resident and the edge of the bed. Resident #1 slid to the left and off the sling, upper body first, landing on the floor and the metal mechanical lift leg extensions. At time stamp 14:34:17 on the video Resident #1 can be seen on the floor laying towards her left side with her thigh area on top of the mechanical leg extension. During an interview on 11/24/24 at 12:20pm LVN A stated had been working on 11/20/24 when Resident #1's FM pointed out to her that Resident #1 had a new area of swelling on her left leg. LVN A stated Resident #1 had been indicating via grimacing that she was in pain and was being provided pain medications since the fall from the lift. She stated multiple x-rays had been taken, that they and the hospital had not seen an injury. On 11/20/24 she called the doctor and was given orders for Resident #1's entire left leg; those x-rays showed the fracture. During an interview on 11/24/24 at 2:36pm CNA B stated when she first arrived on 11/4/24 Resident #1's FM asked for Resident #1 to be put into bed. She stated CNA D assisted her since Resident #1 required the use of a mechanical lift. CNA D stated she started having trouble moving the left because of the positioning of the bed, CNA D came toward her to help with the lift positioning. Resident #1 unexpectedly leaned forward at the same time CNA D moved and Resident #1 fell out of the sling. CNA B stated there was not enough room to maneuver the lift. The room had been arranged the same way for a while and she knew the room had limited space. CNA B stated Resident #1's room had since been rearranged so we do not have that problem any longer. CNA B stated LVN C had been in the hallway outside Resident #1's room, she had immediately entered the room to check on Resident #1. CNA B stated she did not understand how Resident #1's fracture could be from that fall as the resident hit her head not her leg. CNA B stated Resident #1 was positioned correctly on the sling it happened because Resident #1 unexpectedly leaned forward. During an interview on 11/24/24 at 3:58pm LVN C stated she had been in the hallway outside Resident #1's room preparing medications. She heard screaming and ran into Resident #1's room. She stated Resident #1 was on the floor, CNA B and CNA D were standing back on the other side of the lift and Resident #1's FM was behind all of them. LVN C stated the CNA's told her the resident had hit her head in the fall she did an assessment of Resident #1 and did not see any injuries, including on the resident's legs. She called emergency services right away because the resident had hit her head. LVN C stated she did not see the actual lift for Resident #1, but the FM had shown her a video and Resident #1 was leaning to the left and not positioned correctly in the center of the sling. During an interview on 11/24/24 at 4:47pm CNA D stated she had started working at the facility a week before the incident. CNA D stated by the time she got to the room to assist, Resident #1's sling was already hooked up. CNA D stated the fall happened because Resident #1 had leaned forward and to the left. When asked about the positioning of Resident #1 in the sling prior to the fall, CNA D stated everybody keeps talking about this video like it shows something and discontinued the call/interview. During an interview on 11/24/24 at 4:29pm the DON stated all staff receive training on using a mechanical lift upon hire and while shadowing a staff the first three days on the floor. She stated after the fall occurred all staff had been provided an in-service on appropriate use of the lift, including positioning. DON stated prior to Resident #1's fall they had to use the lift between the wall and the bed, making it difficult to maneuver. She stated they rearrange the room so it would not be as difficult to put mechanical lift legs under the bed. DON stated she had seen sections of the video that Resident #1's FM had but not the entire video. She was not aware of Resident #1 leaning to the left but stated they had included in the in-service the correct positioning and sling to be used. DON stated CNA B and CNA D should have positioned Resident #1 better in the sling and kept someone at Resident #1's side. DON stated the outcome of not using lift correctly could be harm to the resident. During an interview on 11/24/24 at 5:31pm the Adm stated she was made aware of Resident #1's having fallen out of the lift at the time it happened. She stated although Resident #1 returned from the hospital without injuries, they did in-services with all staff and rearranged the furniture in Resident #1's room. She stated they had done an additional set of x-rays at the facility after continued expressions of pain. On 11/20 swelling was noted and x-rays were again performed and that set of x-rays showed a fracture. The Administrator stated she wondered if the injury was because of the fall. She stated she had not seen the video of the fall, but the DON had seen parts of the video and planned to look at the entire video. Adm stated they have been and will continue to do monitoring of mechanical lifts. Record review of CNA B's Infection Prevention and Control Boot Camp Class evaluation, dated 2/4/24, includes mechanical lift training and transfer techniques. Record review of CNA D Check off sheet evaluation, dated 10/25/24 includes mechanical lift training and transfer techniques. Record review of the facility Record of Inservice, dated 11/7/24, given to CNAs Band D reflected the following was included, one staff always have a hand on the resident and position patient/resident for maximum comfort. Record review of the facility Record of Inservice, dated 11/23/24, given to all staff reflected the following was included, one staff always have a hand on the resident and position patient/resident for maximum comfort. The inservice includes review of policy which includes need for full back support, head support and the residents medically appropriate position. Review of the facility policy dated 3/27/2017 Mechanical Lifts: General Guidelines reflected in part, H. 3) Clear path for the lift device. a) Ensure adequate space for lift to pivot and move freely to receiving area. b) Ensure lift can fit under or around receiving surface and through doorways, as needed.

Based on observation, interview and record review, the facility failed to ensure that residents received appropriate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #8) reviewed for accident hazards and supervision. The facility failed to supervise Resident # 8 while using the restroom which resulted in a fall on 4/20/2022. These failures placed the residents at risk for falls, injuries, hospitalization s, and decreased quality of life. Findings include: Resident #8 Review of Resident #8's face sheet revealed an [AGE] year old female admitted to the facility on [DATE] with diagnosis: Cerebral Infarction (Stroke), Cognitive communication deficit (difficulty communicating), Abnormalities of gait and mobility, Type 2 Diabetes Mellitus (problems regulating blood sugars), [CONDITION(S)] (brittle or fragile bones), Dysphagia (Difficulty swallowing), [CONDITION(S)] and [CONDITION(S)] affecting right dominant side ([CONDITION(S)] on one side of the body, and muscle weakness. Review of Resident #8's MDS revealed a BIMS of 8, indicating moderate impairment. Review of Resident #8's Care Plan revealed the problem 'falls, resident has a history of falling' with interventions that include: keep bed in lowest position with brakes locked, keep call light in reach at all times and keep personal items within reach. The care plan also revealed the problem 'resident requires assistance with ADL's' with interventions that include: TRANSFER - assist of 1, TOILETING - assist of 1. A record review of Resident #8's progress notes dated 4/7/22 at 10:46 AM, written by the ADON revealed This nurse spoke to husband *related to* concerns with resident transfers for toileting. Resident sound asleep on rounds. Discussed with therapy director, who stated that resident is not safe to leave alone on toilet. Staff education provided at this time. A record review of Resident #8's progress notes dated 4/20/22 at 8:00 A, written by LVN A stated, Husband insisted the Resident be sent to Hospital. I did not receive a call from the on-call NP. Resident sent out via 911 per husbands' insistence. ADON notified. A record review of Resident #8's progress notes dated 4/20/22 at 10:24 AM, written by the ADON stated, Call placed to *hospital* ER for follow up resident fall. Being admitted at this time for*Right* Hip FX. Notified Admin. A record review of Resident #8's fall incident report dated 4/27/2022 revealed the fall occurred on 4/20/2022 at 7:30 am. The incident report stated, The CNA that found resident was interviewed and she stated that she had helped resident to the restroom, instructed her to use the call light when finished and she went back into the room to gather some clothes to change the resident for the day. CNA stated that she heard the resident yell, when she re-entered the restroom the resident was on the floor by the commode During an interview on 5/4/22 at 1120 am CNA A stated she was supposed to stay inside the rest room with her referring to Resident #8. She further stated, she (Resident #8) asked for privacy, so I left the room to go get her clothes together and I heard her fall and yell. CNA A stated she had received the in-service training for Resident #8 that stated, 'do not leave alone on toilet' and stated this means not to leave her inside the bathroom alone. I was outside the bathroom when she fell getting some clothes and the resident had asked for privacy to have a BM. CNA A looked at the training in-service sheet dated 4/7/22 for Resident # 8 and stated that was her name and signature on the back of the training sheet for attending the training. During an interview on 5/4/22 at 12:24 PM, LVN A stated regarding Resident #8's fall the aide came and got me, and I went down there, and the resident was on the floor of the bathroom. I completed an assessment and the resident stated she was hurting a little on her arm and head. We got her into a sitting position on the floor in the bathroom. We let her sit there and get her bearings a little bit and I asked her again about pain - she stated only her hand and head. We put a gait belt around her and assisted her up and into her wheelchair, then we wheeled her out to her room. When she first stood up, she was fine but then she let out a yelp and started yelling. We immediately got her into bed, then I went and called the NP. She stated a few minutes later while at the nurse's station her husband came in the building and she stopped him and told him what happened. A little while later, she still hadn't heard back from the on-call NP services, so she went to check on Resident #8 and the husband insisted on sending her to the hospital now due to her yelling, so I went out and called 911. During an interview on 5/4/22 at 10:15 AM, the ADON stated she had done specific in-service training for Resident #8 with staff on 4/7/22 per her progress note because the husband was worried about resident falling and getting hurt. She stated the in-service covered assisting the resident with toileting and to not leave the resident alone on the toilet. She stated this lady's normal was confused. This means do not leave her alone - be there with them while they are in the bathroom. She stated it was her expectation that staff will stay with the resident at all times as resident was confused at baseline and a fall risk. The ADON further stated the CNA assisting the resident she should have stayed there with her. During an interview on 5/4/22 at 10:56 AM the Director of Therapy stated she was the one the ADON spoke to regarding not leaving Resident #8 alone on the toilet. She stated it means you literally need to be right next to them. She needed moderate assistance for toileting. If the staff walks away, then they have left her alone, so that would not meet the definition of 'do not leave alone on the toilet' She further stated it would not meet her expectations if a CNA put a resident on the commode and turned their back or walked away out of the bathroom. A record review of in-service training date 4/7/22 given by the ADON stated the objectives of the interview: Please assist resident with toileting. (then highlighted text) Do not leave alone on toilet. Further review of training sheet revealed CNA A's written name and signature on the back of the training sheet. A record review of the facility's policy Fall Management dated revision 7/1/2006 revealed POLICY: 1. The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls. 2. Qualified staff will complete the Fall Risk Evaluation to determine if patient/resident is a fall risk. 3. A patient/resident fall management program will be implemented that educates staff in creative, functional strategies while recognizing patient/resident's rights and their need to maintain the highest practical level of function.

Based on interview and record review, the facility failed to ensure each resident's drug regimen did not have an excessive dose, for an excessive duration, with inadequate monitoring for 1 of 32 residents (Resident #4) reviewed for unnecessary medications. The facility failed to take appropriate action in response to a critical [MEDICATION(S)] Serum level for Resident #4 who was receiving [MEDICATION(S)], had a recent increase in [MEDICATION(S)] dose, had a critical [MEDICATION(S)] Serum level, had a change in condition, and had an order that was not completed to repeat the [MEDICATION(S)] Serum level to validate the critical result prior to resuming the [CONDITION(S)] medication. This led to Resident #4 being admitted to acute care hospital on 11/3/21 and was diagnosed with acute [CONDITION(S)], altered mental state, hypercalcemia, and [MEDICATION(S)] toxicity. Lab records revealed Resident #4's [MEDICATION(S)] level was 2.0 mmol/L (critical level) when she arrived at the hospital. These failures resulted in an Immediate Jeopardy (IJ) situation on 11/04/2021 at 3:55 pm. While the IJ was removed on 11/06/21, the facility remained out of compliance at a severity level of actual harm but with potential for more than minimal harm with a scope identified as isolated due to the facility requiring more time to monitor and assess the plan of removal for effectiveness to ensure the safety of the residents. These failures could place residents taking [CONDITION(S)] medications at risk for serious adverse outcomes including drug toxicity, need for hospitalization , and/or death. The Findings Included: Record review of the Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #4 was a [AGE] year-old female who admitted to the nursing facility on 10/18/2021 from acute care Hospital A. Review of Resident #4's admission MDS assessment dated , 10/25/2021 reflected active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected, Resident #4 had a Brief Interview for Mental Status (BI MS) score of 11 which indicated Resident #4 was moderately cognitively impaired in daily decision-making skills and was severely depressed with a Patient Health Questionnaire-9 (PHQ-9) score of 20 which included nearly daily thoughts she would be better off dead, or of hurting herself in some way. Resident #4 had potential indicators of [CONDITION(S)] which included hallucinations (perceptual experiences in the absence of real external sensory stimuli), delusions (misconceptions or beliefs that are firmly held, contrary to reality). Review of Resident #4's care plan with admitted [DATE] only reflected a problem with category of Social Services (advance directives-full code) with problem start date of 10/19/2021. Review of Resident #4's hospital records from acute care hospital A revealed in the Summary of Care record dated 10/18/2021, Resident #4 (who normally lived at home alone, cared for herself and drove her own car) was brought to the emergency room (ER) on 10/10/2021 by her family member due to increased confusion, expressive [CONDITION(S)] (a communication disorder characterized by partial loss of the ability to speak), and decreased ability to care for herself at home that started about one week prior to the ER visit. The record reflected that the admitting physician suspected Resident #4's altered mental status with increased confusion and expressive [CONDITION(S)] to be secondary to metabolic [CONDITION(S)] (a condition in which the function of the brain is altered due to illness, infection, electrolyte imbalance and presents most often as [CONDITION(S)]). Resident #4 admitted to the acute care hospital from 10/11/2021 to 10/18/2021 and received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . A stroke is an emergency condition in which blood flow or bleeding into the brain can cause loss of strength or sensation on one side of the body, problems with speech or language and/or changes in vision or balance). On 10/16/2021 during the acute care hospital admission, Resident #4 received a telepsychiatry consult appointment because she had increased paranoia (a condition characterized by delusions and/or excessive suspicion of others).The psychiatry consult determined Resident #4's symptoms were related to waxing and waning [CONDITION(S)] (short term confusion and changes in cognition that fluctuates in intensity). During the acute care hospital admission period, Resident #4's medication record revealed she received medications including [MEDICATION(S)] ([MEDICATION(S)]) 2.5 mg-take 0.5 tablets at bedtime ([CONDITION(S)] Disorder), [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg-take1 tablet every 12 hours as needed (Anxiety), [MEDICATION(S)] CR (Eskalith ER) 450 mg-take 450 mg at bedtime ([CONDITION(S)] Disorder) and [MEDICATION(S)] ([MEDICATION(S)]) 1 G by IV every 24 hours ([CONDITION(S)]). The discharge progress note dated 10/17/2021 revealed Resident #4 did not have paranoid thoughts at discharge, she was alert and disoriented but could follow simple instructions. The acute care hospital A records reflected Resident #4 experienced cognition changes described as altered mental status, increased confusion, and expressive [CONDITION(S)] secondary to metabolic [CONDITION(S)], paranoia, and waxing and waning [CONDITION(S)]. The records did not reflect Resident #4 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The records revealed Resident #4 was treated at acute care hospital A for Elevated Troponin (elevated blood levels which could indicate heart attack). She received cardiac monitoring at acute care hospital A which reflected no continued increase in Troponin levels and/or cardiac monitor events occurred (indicated Resident #4 did not have a heart attack or heart condition). Review of Resident #4's EMR nursing progress note dated 10/18/2021 at 1:15 pm reflected, Resident #4 was alert and oriented x4 (oriented to person, place, time, and situation) at arrival to the facility. She assisted with transfer from the wheelchair to the bed. The record did not reflect that Resident #4 had thoughts of harming herself or was experiencing hallucinations or paranoia at the time of admission. Review of Resident #4's consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #4's EMR physician admission progress note written by DR E dated 10/18/2021 reflected Resident #4 was diagnosed with urinary tract infection, cystocele (weakened ligaments that support the bladder), [CONDITION(S)] disorder, and hypertension. The progress notes reflected Resident #4's medication list included [MEDICATION(S)] 450 mg once per day. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR (medication administration record) reflected Resident #4 did not receive scheduled dose on 10/18/21 because the medication was not available. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Pt lying in bed on arrival. When asked how she was doing she said she was 'hollering about dying, her legs aren't working, her nerves are too close together.' She wants someone to come into the room and sit and talk with her. Stated that she is very afraid. According to the psychologic assessment section of the progress note, Resident #4 exhibited an anxious and agitated behavior, labile mood (emotions that are unstable and tend to change quickly), poor judgment, disordered thinking, and confusion. Resident #4's general assessment in the same physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The record revealed Resident #4 now had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note reflected continued plan for current [MEDICATION(S)] dose, planned weekly [MEDICATION(S)] lab analysis and planned referral to psych services. Review of undated laboratory report provided by laboratory provider for the nursing facility reflected a serum [MEDICATION(S)] sample was collected on 10/19/21 at 7:35 pm. The record reflected Resident #4 had a low serum [MEDICATION(S)] level of 0.4 mmol/L (reference range 0.6-1.2 mmol/L). The report did not reflect Resident #4's missed [MEDICATION(S)] dose on 10/18/21 and/or dose due on 10/19/21 that had not been administered at the time the specimen was collected. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The report did not reflect Resident #4's missed [MEDICATION(S)] dose on 10/18/21 and/or the dose on 10/19/21 administered after the serum [MEDICATION(S)] level had been collected. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Noted [MEDICATION(S)] serum levels low, pt continues to have hallucinations. Dosing retrieved from Epocrates. Further review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . General assessment of Resident #4 on the progress note reflected her awake, alert, no acute distress, calm, cooperative, appeared comfortable, frail, and appeared chronically ill. The psychologic assessment section reflected Resident #4 had normal mood/affect, clear and lucid speech (easy to understand) and oriented to self only. The progress note revealed Resident #4 had a [MEDICATION(S)] level of 0.4 mmol/L (low) and planned orders for weekly [MEDICATION(S)] levels. The progress note continued to reflect planned request for referral to psych services. Record request was sent to the facility's laboratory service provider on 11/4/21 at 3:02 pm. Record review of undated laboratory audit report provided by laboratory provider on 11/12/21 in response to request for records prior to exit reflected a serum [MEDICATION(S)] level was ordered by LVN A on 10/27/21 at 6:03 pm but was cancelled by the DON on 10/28/21 at 11:54. Interview with management representative from the laboratory's quality analysis department on 11/15/21 at 9:52 am revealed orders were cancelled electronically by the DON. She stated the DON cancelled the wrong lab order/requisition if she intended to cancel the weekly lab order. She stated ordered and cancelled requests were tracked electronically. Record review of the laboratory report/audit provided by the laboratory quality analysis department revealed the DON placed a note to cancel weekly labs in a requisition that was a one-time order for [MEDICATION(S)] serum level ordered on 10/27/21 and scheduled for 10/28/21. Record review of untimed handwritten physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This same handwritten physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of laboratory order history document provided by the DON and dated 11/2/21 at 4:49 pm did not include the 10/28/21 order for a one-time [MEDICATION(S)] level. The laboratory order history document provided by the DON reflected the last order entered in the record to be collected from Resident #4 prior to the discharge date was on 10/27/21 at 6:03 pm for a one-time [MEDICATION(S)] level which was cancelled on 10/28/21 at 11:53 am. Despite Resident #4's discharge date of [DATE], the laboratory order history document provided by the DON reflected an order was entered on 11/2/21 at 3:00 pm for a [MEDICATION(S)] level. Review of Resident #4's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #4 did not receive dose due on 10/30/21 at 9:00 pm due to Resident #4 was not available. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note revealed Resident #4 denied any complaints and seemed calmer. General assessment of Resident #4 on the progress note reflected her awake, alert, no acute distress, calm, cooperative, appeared comfortable, frail, and appeared chronically ill. Psychologic assessment per the progress note reflected Resident #4 was oriented only to self, clear and lucid, normal mood/affect. The cognitive status assessment in the progress note reflected Resident #4 was confused. Per the progress note of 10/25/21, Resident #4's [MEDICATION(S)] level was low at 0.4 mmol/L (low), plan for weekly [MEDICATION(S)] levels, referral to psych services, and continued on [MEDICATION(S)] 450 mg twice per day. Review of psychiatric progress notes dated 10/26/21 at 2:30 pm reflected, Resident #4, LVN A, and SW D attended an appointment with Dr. C to discuss circumstances leading to her (Resident #4) stay at their facility and observations thus far. The record reflected Resident #4's medication list to include [MEDICATION(S)] 450 mg tablet with instructions to take 1 tablet by mouth at bedtime which was prescribed by Dr. C and two additional medications that were noted in the record to have been prescribed to Resident #4 in the hospital ([MEDICATION(S)] 0.5 mg as needed twice per day and [MEDICATION(S)] 2.5 mg at night). It was not reflected in the appointment record that Resident #4's medication had been increased to twice per day on 10/23/21 by NP B and/or that Dr. C was aware of the changed dosage. The appointment record reflected Resident #4's chief complaint was my life has fallen apart. I had a sudden stroke and [CONDITION(S)]. The record reflected that it was reported to Dr. C that Resident #4 has not had any incidents of aggressive behavior. She has been compliant with [MEDICATION(S)]. She is eating well and staying hydrated. Staff reports she falls asleep at night but experiences multiple nighttime awakenings as well as early morning awakenings. She appears to be anxious at night and has had 'screaming fits.' Staff has also observed depressed mood. Dr. C determined and noted in the appointment record that Resident #4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Current or most recent episode depressed. In full remission. Specificity: In remission on medication and [CONDITION(S)] due to another medical condition. The record reflected, upon exam today, patient's thought process and behaviors appear to be most consistent with [CONDITION(S)]. She reports visual hallucinations, fluctuating awareness, alertness, attention, and orientation as well as disorganized thought processes. Current presentation is not consistent with hypomania or [CONDITION(S)] though she does appear depressed. The appointment record reflected plan which included: 1. Safety: Patient at low imminent risk of hurting self or others at this time. Appropriate for continued outpatient management. 2. Psychiatric: a. Continue [MEDICATION(S)] ER 450 mg q HS for mood b. Recommend discontinuation of [MEDICATION(S)]. Thus far it has not been administered. Concern for worsening cognitive functioning should she be administered a benzodiazepine. c. Awaiting clarification regarding whether patient is receiving [MEDICATION(S)]. Will provide further recommendations after it is confirmed whether or not it is being administered. d. Start [MEDICATION(S)] 20 mg daily to target depressive symptoms. e. Start [MEDICATION(S)] 25 mg q HS for sleep. Dose can be increased to 50 mg q HS if lower dose is not effective 3. Medical. [MEDICATION(S)] level reported to be low by SW, awaiting confirmation of lab value. 4. Substances. No concerns for medication misuse or abuse. 5. Psychosocial. Not currently engaged in psychotherapy. The progress notes for the appointment reflected next appointment no appointment scheduled and PRN (as needed). Review of Speech Therapy notes dated 10/27/21 reflected Resident #4 demonstrated confabulatory(false)/irrelevant speech and required increased redirection from previous sessions. Review of physician progress written by NP B note dated 10/27/21 at 9:52 am reflected, Resident #4 was very confused. Pt sitting up to wc on arrival. Very confused still. Pt is worried about losing her kids. The progress note reflected Resident #4 weighed 184 pounds (9.5 pounds since admission). General assessment of Resident #4 on the progress note reflected her awake, alert, no acute distress, calm, cooperative, appeared comfortable, frail, and appeared chronically ill. Psychologic assessment per the progress note reflected, Resident #4 was oriented only to self, clear and lucid, normal mood/affect, insight impaired, poor judgment, disordered thinking, confused. The cognitive status assessment in the progress note reflected Resident #4 was forgetful, confused. Per the progress note of 10/27/21, Resident #4's [MEDICATION(S)] level was low at 0.4 mmol/L (low), plan for weekly [MEDICATION(S)] levels, referral to psych services, and continued on [MEDICATION(S)] 450 mg twice per day. Review of Speech Therapy notes dated 10/28/21 reflected Resident #4 exhibited increased confusion during the session. Review of Physical Therapy notes dated 10/28/21 reflected Resident #4 demonstrated increased confusion and had a recent decline from previous sessions. Review of Speech Therapy notes dated 10/29/21 reflected Resident #4 demonstrated severe apparent anxiety, crying, and expressing fear that she was going to die or that someone was going to kill her. SLP reported this to nurse, who stated patient's [MEDICATION(S)] is critically high at this time. Nursing will assess patient. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note reveals Resident #4's [MEDICATION(S)] medication was changed from twice per day back to once daily. General assessment of Resident #4 on the progress note reflected her to have no acute distress, calm, cooperative, and appeared comfortable. The progress note continued to reflect Resident #4 with a [MEDICATION(S)] level of 0.4 mmol/L (low). The progress note did not contain a psychologic assessment and/or cognitive status assessment of Resident #4. The assessment/plan section of the progress note reflected to continue [MEDICATION(S)] 450 mg tablet once daily. The progress note reflected Resident #4 to be followed by Dr. C of psych services. Review of Electronic Medical Record's untimed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Electronic Medical Record's medication administration documentation dated 11/2/21 for Resident #1 reflected: 1. 10/18/21 [MEDICATION(S)] 450 mg dose due at 9:00 pm/not administered with note Not Administered: Drug/Item unavailable (admitted to NF) 2. 10/19/21-[MEDICATION(S)] 450 mg due and administered at 9:00 pm 3. 10/20/21-[MEDICATION(S)] 450 mg due at 9:00 pm and administered at 7:31 pm with note Early Administration: Resident request 4. 10/21/21-[MEDICATION(S)] 450 mg due at 9:00 pm and administered at 10:35 pm with note Late Administration: Administered late 5. 10/22/21-[MEDICATION(S)] 450 mg administered at 9:00 pm Review of Electronic Medical Record's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. 10/23/21-[MEDICATION(S)] 450 mg due at 9:00 pm and administered at 11:35 pm with note Late Administration: Charted late 2. 10/24/21-[MEDICATION(S)] 450 mg due and administered at 9:00 am 3. 10/24/21-[MEDICATION(S)] 450 mg due and administered at 9:00 pm 4. 10/25/21-[MEDICATION(S)] 450 mg due at 9:00 am and administered at 10:09 am with note Late administration: Charted late: given on time 5. 10/25/21-[MEDICATION(S)] 450 mg due and administered at 9:00 pm 6. 10/26/21-[MEDICATION(S)] 450 mg due and administered at 9:00 am 7. 10/26/21-[MEDICATION(S)] 450 mg due at 9:00 pm and administered at 11:47 pm with note Late administration: Administered late 8. 10/27/21-[MEDICATION(S)] 450 mg due and administered at 9:00 am 9. 10/27/21-[MEDICATION(S)] 450 mg due at 9:00 pm/Not Administered with note Not Administered: On Hold 10. 10/28/21-[MEDICATION(S)] 450 mg due at 9:00 am and administered at 10:13 am with note Late Administration: Charted late Review of Electronic Medical Record's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. 10/28/21-[MEDICATION(S)] 450 mg dose due and administered at 9:00 pm 2. 10/29/21-[MEDICATION(S)] 450 mg dose due and administered at 9:00 pm 3. 10/30/21-[MEDICATION(S)] 450 mg dose due/Not Administered with note Not Administered: Resident Unavailable (Resident at hospital) Review of laboratory audit provided by facility's laboratory service provider reflected the following [MEDICATION(S)] level orders for Resident #4: 1. Order ID 5-82- [NAME] ([MEDICATION(S)] one-time order) 10/18/21 at 1:36 pm-order placed 10/19/21 at 7:35 pm-sample drawn 10/20/21 at 11:52 am-results released/faxed ([MEDICATION(S)] level 0.4 mmol/L) 2. Order ID 9-82- (S) [NAME] ([MEDICATION(S)] series order) 10/18/21 at 12:41 pm-standing order for weekly [MEDICATION(S)] test to start 10/26/21 10/26/21 at 10:25 pm-sample drawn 10/27/21 at 1:24 pm-results released/faxed ([MEDICATION(S)] level 2.0 mmol/L)(critical) 10/27/21 at 1:38 pm-critical call attempt 10/27/21 at 2:31 pm-critical call attempt 10/27/21 at 3:14 pm-critical call attempt 10/28/21 at 5:58 am-critical call attempt 10/28/21 at 5:59 am-unable to reach facility upon numerous attempts 3. Order ID 4-82- [NAME] ([MEDICATION(S)] one-time order) 10/27/21 at 6:03 pm-order placed by LVN A 10/28/21 at 11:54 am-order cancelled by DON with note Dr wrote an order to DC weekly [MEDICATION(S)] levels 4. Order ID 5-82- (S) [NAME] ([MEDICATION(S)] series order) 11/2/21 11/3/21 at 4:20 pm -order cancelled by DON Telephone interview with DR C on 11/3/21 at 8:54 am revealed she was contacted by SW D on 10/22/21 because she had been the psychiatrist for Resident #4 on an outpatient basis prior to the resident entering the nursing facility. She stated she made it very clear to SW D that she did not follow residents in nursing facilities because she had a small at home practice that she dedicated approximately 10 hours per week to scheduled appointments for her current clients only. She stated she drastically limited her clinic practice after having her children so that she could dedicate time to her family. She stated that because of this decision to have more time at home with her small children, she did not accept new clients and only met with current clients for scheduled/follow-up appointments which meant that she did not follow clients if they required a higher level of care than scheduled appointments. She stated she informed SW D that it appeared Resident #4 required placement in the nursing facility because she needed a higher level of care. She stated in addition to informing SW D that she did not follow clients while they were in higher level of care facilities that she had never worked in a nursing home, so she was not familiar with the processes involved with these types of facilities and/or she did not have access to clinical records, etc. that would be required to follow a resident in the facility. She stated SW D informed her that the facility only needed her assistance to determine if Resident #4's presentation in the facility was the resident's normal presentation and to provide suggestions for the facility through outpatient appointments only. She stated that SW D informed her that an appointment could be arranged through telehealth, so she scheduled an appointment for Resident #4 for the following Monday (10/25/21). She stated, she would expect the facility to follow their normal process for a resident that required psychiatric care while at their facility like consulting with in-house providers or contractors but she felt the appointment was the right thing to do since I knew her, and I thought I would help them out until they implemented whatever process they used to help people who require psychiatry assistance while in their facility. She stated the nursing facility had technology issues and SW D had to leave early on 10/25/21 so the appointment was rescheduled for Tuesday 10/26/21. She stated during the appointment on 10/26/21 which included Resident #4, SW D and LVN A, she provided feedback to the current problem which included that she felt Resident #4 appeared to be depressed. She stated she was informed by the facility (SW D or LVN A) that Resident #4 had been eating and drinking well but had difficulty sleeping at nighttime with outbursts. She stated she informed SW D and LVN A that Resident #4's presentation was consistent with [CONDITION(S)] that usually occurred suddenly with change in orientation that frequently included hallucinations. She stated LVN A reported to her that Resident #4 had been compliant with her [MEDICATION(S)] medication and had been prescribed [MEDICATION(S)] and [MEDICATION(S)] while in the hospital. She stated she was not informed that Resident #4's [MEDICATION(S)] dose had been doubled by NP B. She stated she was informed of Resident #4's low [MEDICATION(S)] level but was not provided the low-level [MEDICATION(S)] value. She stated based on the presentation of Resident #4 and complaints voiced in the appointment regarding Resident #4 being depressed with sleep pattern disruption, she agreed to call in prescriptions for the current problems related to depression and sleep disturbance. She stated she informed LVN A that she would call in [MEDICATION(S)] for depression and [MEDICATION(S)] to assist with sleep. She stated she informed LVN A to continue the prescribed [MEDICATION(S)] dose (at night) and she provided recommendation to discontinue [MEDICATION(S)] that had been prescribed for Resident #4 while she was in the hospital because it had not been administered to her yet. She stated it was not clear whether Resident #4 had received [MEDICATION(S)] that was prescribed to her in the hospital so she informed LVN A that she would not provide recommendations for [MEDICATION(S)] without an accurate account and current status of this medication. She stated the appointment and recommendations provided by her was not an agreement to follow Resident #4 while at the nursing facility. She stated she did not have access to the clinical record, so she depended on staff or the resident to provide an accurate account of concerns. She stated she was not informed that Resident #4 had lost 9.5 pounds in the 8 days that she had been at the facility. She stated to the contrary, she was told Resident #4 had been eating and drinking well. Telephone interview with DR C on 11/3/21 at 8:54 am revealed DR C was contacted on 10/27/21 (Wednesday) around 5:00 pm by LVN A because a critical/toxic [MEDICATION(S)] level had been received at the facility. DR C stated although she was not aware of who ordered the [MEDICATION(S)] level, she informed LVN A to hold the [MEDICATION(S)] dose until the [MEDICATION(S)] level could be verified as an accurate level. She stated although LVN A reported the critical/toxic [MEDICATION(S)] level to her, LVN A did not inform her that NP B had doubled the [MEDICATION(S)] dose for Resident #4. She stated when she questioned LVN A about the last [MEDICATION(S)] dose administered for Resident #4, LVN A reported Resident #4 received [MEDICATION(S)] on 10/26/21 at 9:00 pm and lab collected the specimen for the sample on 10/26/21 at 9:30 pm. She stated she informed LVN A that the critical/toxic level [MEDICATION(S)] result would probably be an inaccurate result since the specimen was collected 30 minutes after Resident #4 received her last [MEDICATION(S)] dose. She asked LVN A about Resident #4's status and LVN A reported Resident #4 did not exhibit a change in status from the previous day's tele appointment. She stated she provided LVN A with education related to assessment specific to [MEDICATION(S)] toxicity which included monitor for diarrhea, tremors, slurred speech, lethargic state/change in presentation and/or decreased oral intake. She stated she informed LVN A that she would need to hold Resident #4's dose that night and repeat the [MEDICATION(S)] level in the morning to determine if the toxic level was an accurate level. DR C stated that after LVN A informed her that lab collected all specimens at night, she advised LVN that because Resident #4 was not demonstrating a change in condition, the specimen could wait until the next night but she told LVN A to hold the [MEDICATION(S)] until the serum level could be verified. She stated LVN A again did not inform her that NP B had increased Resident #4's [MEDICATION(S)] dose to twice per day. She stated she did not have access to any clinical records to view changed medication regimen and/or administration times or verify what information was reported to her. DR C was informed during the telephone interview with investigator the lab specimen was collected on 10/26/21 at 9:25 pm prior to [MEDICATION(S)] administration which occurred at 11:47 pm on the night of 10/26/21. She stated if this had been reported to her on the night of 10/27/21, she would have advised LVN A to repeat the [MEDICATION(S)] level immediately

Based on interview and record review, the facility failed to ensure the resident's right to be free from abuse for two (Resident #1 and #2) of eighteen residents reviewed for abuse and neglect. A. LVN A failed to ensure Resident #2 was transferred from oxygen cylinder to oxygen concentrator for four hours for a resident on continuous oxygen. B. LVN B failed to respond and assess Resident #2 after being notified by family the resident was in respiratory distress which contributed to Resident #2 death. These failures resulted in an Immediate Jeopardy situation on 01/17/2020. While the IJ was removed on 01/21/2020, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions C. Resident #1 was physically and verbally abused by CNA M, CNA O, and CNA Q which was recorded by the resident's electronic monitoring device. An Immediate Jeopardy situation was determined on [DATE]20. While the IJ was removed on 02/11/2020 at 1:52 pm, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective actions. These failures placed all residents who use oxygen at risk and could place all residents at risk for abuse. Findings include: Review of Resident #2's face sheet revealed a [AGE] year-old female DOB 11/13/1927 with admission date of [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #2's minimum data set (MDS) assessment revealed no brief interview for mental status (BI[CONDITION]) score because Resident #2 was only in the facility for six hours before she passed away. Review of Resident #2's clinical records reflected no care plan. Review of Resident #2's transfer communication from the local hospital dated 12/11/2019 reflected an order for [REDACTED]. Oxygen Cylinders have a finite amount of oxygen compressed within them and inhaled by the user until it runs out. Oxygen Concentrators filter and generate medical grade oxygen, at an infinite supply so long as the battery that powers this mechanism has life. Review of Resident #2's progress notes dated 12/12/2019 reflected Resident #2 was pronounced dead on 12/12/2019 at 2:10 a.m. by the hospice nurse. Review of Resident #2's physician orders [REDACTED]. In a phone interview on 01/13/2020 at 10:31 am, Resident #2's Responsible Party (RP) stated Resident #2 has always been on oxygen continuously and was discharged to the facility with an order for [REDACTED]. He stated on 12/11/2019 at about 9:30 p.m., he walked into the facility and found Resident #2 gasping for air. Resident #2's nasal cannula (N/C) was at her nostrils but no oxygen was flowing through the tube. He stated there was an oxygen cylinder present, calibrated at 4, and the tank indicated it was empty. In an interview on [DATE]20 at 10:42 a.m., the ADON stated prior to residents being admitted to the facility, the nurses get report and set up the room based on what the resident's needs are. She stated she makes follow up checks to make sure the room is ready, and all equipment are available. She stated she did not check the room for readiness prior to Resident #2 being admitted . In an interview on 01/16/2020 on 1:07 p.m., LVN A stated she worked on 12/11/2019 6am-6pm shift. She stated prior to residents being admitted to the facility, she gets a report to find out about the resident's needs, if they are requiring oxygen or not. She stated Resident #2 was on oxygen upon admission and hospice was supposed to supply an oxygen concentrator. She stated if the resident is being admitted on hospice, the hospice is responsible to set up the oxygen delivery. She stated Resident #2 admitted just before the end of her shift. LVN A got the report from the hospital regarding Resident #2 and she thought Resident #2 was on oxygen. She stated she put Resident #2 on oxygen at 2 liters from the oxygen concentrator and documented on the 24 hours report. She stated, I could have sworn I put her on oxygen, it could have been an oversight. I am not 100% sure I put oxygen on her, it was change of shift and everything was going on. Review of facility's 24 hours report dated 12/11/2019 and 12/12/2019 did not reflect Resident #2's name, if she was admitted to the facility and/or was requiring oxygen usage. In an interview on 01/16/2020 at 11:48 a.m., LVN B stated he worked on 12/11/2019 to 12/12/2019 from 6pm to 6am (night shift). He stated Resident #2 was admitted before he started his shift. He stated he made rounds with LVN A prior to starting his shift and Resident #2 was not on oxygen. He stated he found out Resident #2 needed to be on oxygen when the hospice nurse got into the building later that evening and orders were written for Resident #2. He stated Resident #2's RP asked him why Resident #2 was not on oxygen. He stated he did not document about Resident #2 being out of oxygen. In an interview 01/16/2020 at 2:04 p.m., the DON stated she participates in the admission process and she reviews the clinical portions. She stated, clinically, she looks to see if the facility can meet resident's needs. She stated all nursing staff make sure the room is equipped prior to admission. She stated oxygen concentrators should be available in the facility. She stated Resident #2 was on hospice at her home prior to going to the hospital and was being readmitted to hospice upon admission to the nursing facility. The DON stated Resident #2's room is one of the rooms in the facility with direct oxygen flow in the room so, there shouldn't have been issues with hooking the resident to continuous oxygen. Observations made on 01/16/2020 at 4:00 p.m. revealed rooms on the 300 hall where Resident #2 was placed had oxygen flow built in the walls. In an interview on 01/16/2020 at 3:20 p.m., the Hospice Nurse stated Resident #2 was admitted to the facility on [DATE] at about 5:30 p.m. She stated she assessed Resident #2 and she was in good spirits and was worried about her crocs, cell phone and her Baylor blanket. She stated Resident #2 was connected to oxygen at 4 liters via nasal cannula from a portable oxygen cylinder. She stated there was no oxygen concentrator in Resident #2's room when she left the facility at about 9:00 p.m. She stated, It is the hospice policy for facilities to provide equipment while our equipment is being delivered. She stated, LVN B was making rounds and she gave him a breakdown of Resident #2's needs including oxygen use. In a phone interview on 01/17/2020 at 11:40 a.m., Resident #2's RP stated he asked about Resident #2's oxygen and was told by LVN B Resident #2 was on hospice and hospice had not yet delivered the oxygen concentrator. He (RP) stated the oxygen cylinder Resident #2 was transferred from the local hospital was in Resident #2's wheelchair, nasal cannula attached, and the tank was empty. He (RP) stated he started looking for an oxygen concentrator himself and then LVN B joined him to look. He stated there was no oxygen concentrator in the room and that if one had been present he would have connected Resident #2 to it. He stated when they (RP and LVN B) found an oxygen concentrator, he (RP) hooked up the canula and attached to Resident #2, put on 4 liters. He stated LVN B did not check Resident #2's vitals or assess her after she had been out of oxygen for so long. He stated, he left the facility at about 10:30-10:45 p.m. on 12/11/2019, Resident #2 was still gasping for air, but she was relaxed a little. In a phone interview on 01/17/2020 at 12:32 p.m., LVN B stated he took the oxygen concentrator to the room and he believed CNA F connected Resident #2 to the oxygen concentrator. He stated Resident #2's RP was concerned as to why her oxygen was not turned on or connected to her. He stated, I did not connect Resident #2 to the oxygen concentrator. LVN B stated Resident #2 was not very responsive, but her vital signs were okay upon admission. He stated he can't remember what Resident #2's oxygen level was upon admission. LVN B stated he did not ask the RP what Resident #2's baseline was. He stated after he rolled the oxygen concentrator into the room he did not check on Resident #2 until CNA F brought to his attention that Resident #2 had passed around 2:00 a.m. In an interview on 01/17/2020 at 2:35 p.m., the DON stated she was not aware of any issues with Resident #2's care and would never have thought the nurses didn't hook up the oxygen. She stated the EMT that transported Resident #2 should have changed from cylinder to concentrator. She stated she didn't expect Resident #2 to pass so quickly. She stated she was told Resident #2 was on hospice prior to going to the hospital and she was going to continue with hospice care. Review of facility policy titled Respiratory Policies and Procedures with a revision date 04/01/17 reflect the subject as: Oxygen Therapy General Policy. The description is: -The facility provides oxygen therapy at a FiO2 greater than 21% by means of various administration devices -The procedures reflect to review physician's orders [REDACTED]. -frequency or duration -physician signature and date. -Gather necessary equipment - Assess the patient/resident -establish baseline respiratory rate and heart rate - start O2 flow rate at the prescribed liter flow or appropriate flow for administration device, -place administration device on the patient/resident -monitor respiratory rate and heart rate. Post oxygen safety sign on the patient/resident's room door -Document initiation of therapy in the medical record -per documentation standards to include date/time of setup, type of administration devices used, instructions given to the patient/resident for no smoking or flammable substances while oxygen is in the room, evaluation of the effectiveness of therapy, signature and credentials of personnel administering oxygen. An Immediate Jeopardy was identified on 01/17/2020 at 2:59 pm. The Administrator and DON were notified of the Immediate Jeopardy on 01/17/2020 at 3:15 p.m. The Administrator and DON expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 01/17/2020 at 6:30 PM. The Plan of Removal reflected: 1. Resident identified is no longer in the facility. The nurses identified have been suspended. 2. Residents who have a physician's orders [REDACTED]. An audit was completed of the 24-hour report and progress notes for the past [AGE] hours to validate that there is no documentation of changes in respiratory status requiring a physician notification. An audit was done on residents who have physician orders [REDACTED]. 3. The Director of Nursing and nursing managers were re-educated by the Clinical Consultant regarding the expectation of reviewing the admission information prior to the resident's admission to the facility to anticipate the need for an oxygen concentrator in the room for availability upon admission. This was completed on January 17, 2020. The Admissions Director will be re-educated by the Administrator regarding informing members of nursing management and providing the admission information for review in order to identify and provide the oxygen concentrator to be available on admission. This will be completed prior to return to work. Licensed Nurses were re-educated on the following regarding the continuity of care for residents admitted from the hospital on oxygen: Validating that oxygen concentrator is in the room prior to the resident's admission Upon admission a resident receiving oxygen per a portable cylinder is to be transferred to oxygen concentrators or piped in oxygen from wall Identifying a change of condition related to respiratory status by auscultating breath sounds, obtaining vital signs and notification of physician for further direction and notify responsible party. Following physician orders [REDACTED]. Communication to on-coming shift and to nursing management is per the 24-hour report and progress notes. Abuse, Neglect and Misappropriation and Exploitation This re-education began immediately and will be completed by January 18, 2020. Any licensed nurse not receiving this information prior to this date will receive prior to next scheduled shift. This re-education is being performed by the Director of Nursing/designee. The re-education is being performed by giving direct verbal education to each licensed nurse. 4. Members of Nursing management will review prospective admissions prior to admission each day to identify the need for oxygen concentrator upon admission. Residents who are admitted to the facility and require oxygen will be observed by Director of Nursing/designee to validate that the admitted resident was provided with oxygen concentrator or have wall oxygen in use. This will be done with each admission requiring oxygen for 3 months. Members of Nursing Management will round daily for one week, then weekly for three months to validate that oxygen is being delivered per physician's orders [REDACTED]. Director of Nursing/designee will interview a minimum of 5 nurses weekly for 2 weeks then monthly for 2 additional months regarding the process for oxygen delivery to validate understanding of the education provided. Director of Nursing/designee will monitor the appropriate measures taken by the nurse for a change of condition related to respiratory status by reviewing 24hr reports in morning meeting, reviewing progress notes via the facility activity report and reviewing medical records of residents discharged to an acute care setting. Ad Hoc QAPI was held on January 17, 2020 The Medical Director was notified of the Immediate Jeopardy on January 17, 2020 The Survey Team monitored the current plan of removal as follows: Monitoring done on 01/18/2020 reflected the following: Record review on 01/18/2020 reflected facility completed an audit on resident physician orders [REDACTED]. The Medical Director verified all orders were correct and the MAR and TAR were updated. 100% facility chart audit completed. The only finding is on 1/5/2020 Resident #7 returned from the hospital at 9:55 p.m. and her O2 use was not initialed on the MAR. Record review of in-services completed on 01/17/2020 reflected the Regional Nurse trained the DON, NAC, RN G, ADON 2 and ADON 1 on reviewing admission paperwork prior to resident's admission to ensure the residents needs will be met upon admission. This includes verifying if oxygen is required for the resident and having a concentrator available prior to admission. In an interview 1/19/2020 at 3:15 p.m. the DON stated she has been talking with staff about checking equipment, reviewing admission paper work to see if they have any equipment and that they have it ordered. Normally the medical director orders the equipment needed for a resident who is admitting. In an interview 1/19/2020 at 3:45 p.m. ADON 2 stated when they get the admission packet up front she usually has [DIAGNOSES REDACTED]. O2 dependent 300 and 400 hall because the oxygen is pipped in. If they are not they will go in and will put the appropriate equipment. ADON gets admission packet just like the nurses do. Most of the new admission come on the skilled side. ADON 2 stated when the packet comes in she will double check the nurse's work, medicine and the equipment required for the incoming resident. She stated she will talk with the families as well and check the room. If additional equipment is needed, she would request it immediately. ADON 2 stated when there is a change of condition, the CNAs should notify the nurses immediately and the nurses would notify management immediately. Review of In-services dated 1/17/2020 reflected titled of change in condition and oxygen use. Inservice reflected when there is a change in resident condition, the charge nurse must be notified immediately. The charge nurse must go assess the resident immediately initiate an SBAR and following the direction of the SBAR. The physician must be notified immediately so further orders can be obtained. SBAR must be completed one the resident condition has improved/resolved, or the resident is transferred out of the facility. The charge nurse needs to print a completed SBAR and put under the ADONs office door for review. Oxygen orders must be verified, and the charge nurse must make sure all orders are being followed correctly. All new orders change in resident condition, and or any relevant resident information needs to be placed on the 24-hour report and discussed with the oncoming nurse at shift change. Both nurses to sign report. When a change of condition for respiratory status occurs make sure that during your nursing assessment, breath sounds are auscultated, and vital signs obtained. These assessment findings must be documented, and the physician must be notified for further orders. The ADON and DON must be notified for all resident change in conditions orders received and status of resident upon completion of event. Family must also be notified. Review of Inservice dated 1/17/2020 reflected Equipment at admission. When a resident is admitting to the facility all equipment needs to be ordered and put in room prior to admission for example if a resident is on continuous o2 a concentrator need to be in the room and immediately switch the resident form cylinder to concentrator. Another example if a resident has a wound and needs special equipment (mattress wound vac etc) that equipment needs to be ordered upon accepting the resident and in the resident's room when resident arrives and then equipment switched to resident use immediately. All rooms need to be checked for equipment's and notify DON and or ADON if equipments are not available and ready. Review of Inservice dated 1/19/2020 reflected Abuse and Neglect Inservice completed. During an interview on 1/19/2020 at 2:40 p.m. LVN H stated an in-service was done yesterday (1/18/2020) and today (1/19/2020). LVN H stated residents requiring oxygen therapy had their orders verified to ensure they were correct. LVN H stated they are to verify orders where they are coming from once at the facility they are to have a head to toe and make sure the oxygen is on and hooked up correctly. LVN stated that they are to take a concentrator into the room if they do not have the hook up to the wall. During an interview on 1/19/2020 at 2:43 p.m., LVN I stated she received training prior to shift: make sure residents are equipped with everything necessary. Document equipment needed for the patient. Put on 24 report. If there is a change in condition place on the progress report and put in 24-hour report. Equipment needed would be oxygen tank and cylinder, tubing mask and cannula. Concentrator and already placed oxygen in rooms. Abuse and neglect - physical sexual AND verbal. Report to Administrator and file an incident report. During an interview on 1/19/2020 at 2:58 p.m., LVN J stated when you get report verify they are on oxygen canister and a concentrator if not on a hall with oxygen access on the walls. Verify orders. Make sure they are in matrix correctly 24hr repot and signing the 24 hours report. During an interview on 1/19/2020 at 4:03 p.m., LVN K stated that she had training when she was hired, yesterday, and today prior to her shift. LVN K stated that they are to ensure that the resident has the needed equipment prior to the resident coming to the facility and ensure that it is set up. LVN K stated that there are two halls that have oxygen pipped through the walls and the other halls would need an oxygen concentrator. LVN K stated that they are to communicate any changes to the next shift and communicate to their supervisor, also should be documented on the SBAR, progress notes, and on the 24-hour report. Nurses should be signing off on the 24-hour report. Also, verifying orders. She stated that she will go from room to room and see if the resident has any concerns on the short term and long-term side. Record review of in-services on 1/19/2020 reflected nurses on duty had been in attendance prior to their shifts. Record review on 1/19/2020 of the Review of Admission Validation of O2 equipment reflected the facility had two admission on 1/18/2020: Resident # 9 did not need equipment (DON signed). Second admission on 1/18/2020 reflected Resident #10 and that equipment was needed and in place (y - was circled to reflect a yes). Record review on 1/19/2020 of January Calendar 2020 reflected Nurse Rounds Members of nursing management will round daily for one week, then weekly for three months to validate that oxygen is being delivered per physician orders. Unit 1 reflected RN signatures on the 18th and 19th. Unit 2 reflected signature on 1/18/2020 and 1/19/2020. Observation and interview on 1/21/2020 at 1:05 p.m., revealed Resident #7 in hallway between nursing station and activities room. Resident was observed with nasal cannula appropriately placed. Resident stated that she had not run out of oxygen anytime during her stay at the facility since admission. Observation of oxygen tank with oxygen released at 2 liters per minute tank was at the half point on gauge and Resident #7 confirmed she was receiving oxygen. Observation on 1/21/2020 at 1:10 p.m., revealed residents throughout the facility were appropriately dressed, well-groomed with no foul odors. Residents were engaged in activities and in small clusters chatting with each other. Staff was present throughout the facility with no concerns noted. In an Interview on 1/21/2020 at 1:15 p.m. the Admission Director stated she had been in-serviced over abuse and neglect and how to get rooms ready prior to admission. She demonstrated a previously used bright pink piece of paper that is used to communicate with nurses prior to admission, if a resident needs DME such as oxygen. She stated she was not aware of any new processes implemented. She stated that she tries to give the admitting nurse a couple of hours to get the room ready but there are times when they only have 30 minutes due to driver availability. She stated that she would go to the facility on a Saturday if she was able. She stated that she tries to communicate to nursing verbally but understands that at times nursing is busy with medications and such. She stated when that occurs she will just let them know she left admission paperwork at the nurse's station for them. In an Interview on 1/21/2020 at 1:30 p.m., the DON stated she realized the charting that was being completed prior to entrance of surveyors was not clear on what was going on with residents. She stated she had in-serviced all nursing staff on charting, room readiness, notifying DON and ADON if equipment is needed for an admission but is not readily available. She stated that most rooms are equipped with wall oxygen and can easily have a tank (cylinder) conversion after admission. She stated that the facility nursing managers are currently doing daily checks on all residents who receive PRN Oxygen and Continuous Oxygen. She stated currently she is verifying that all new admissions who receive oxygen, have oxygen readily available in their room prior to admission. She stated she understood this was not sustainable and her goal was to train her managers and nurses. She stated it starts with the nurses and then the managers to verify and follow up. She stated that she looks over all new referrals and is aware of any admissions that may have oxygen needs (or DME) and notifies not only the nurse but the nurse manager as well. She stated that this Saturday they had an admission that was on continuous oxygen and it went smoothly. She stated she was in the room with the admitting nurse when resident arrived and ensured resident was safely admitted . DON demonstrated a new checklist that the Administrator implemented but she has tweaked to fit her needs. This checklist ensures that oxygen is appropriately ordered, administered and available. On 01/21/2020 at 2:02 p.m., the Administrator and DON were informed that the IJ was lifted. C. Review of Resident #1's face sheet revealed a [AGE] year-old female, DOB 6/09/1921 with original admission date of [DATE] and readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's progress notes dated 08/20/2019 reflected, Resident #1 complained of her eye bothering her and per CNA staff it wasn't there the day before. Swelling under eye and bruising noted on both sides, along of bridge of Resident#1's nose. Noted Bilateral bruising and discoloration to upper extremities. Complained pain in left shoulder and Resident #1 was able to move arm to 30 degrees without discomfort. This was made aware to the Nurse Practitioner (NP). Per staff this is baseline pain. Skin check completed. No other bruising noted. Administrator, ADON, and RP notified. This nurse was instructed that when family came to visit, to see if they had any further concerns and would like for any x-ray's ordered. Family denies that x-ray is needed. Per RP, her mother seemed to be ok. Family does visit frequently. Review of Resident #1's consolidated physician orders [REDACTED]. Review of facility's provider investigation report dated 08/21/2019 reflected, Resident # 1 had some bruising on her left arm and small bruise on her nose. RP said they suspect Abuse. Review of the remainder of the provider report did not show evidence that e local law enforcement was notified, witness statements were taken, skin assessments on vulnerable residents or that the family was not notified of the outcome. In an interview on [DATE]20 at 10:31pm the Administrator, he stated he did not notify the law enforcement regarding the 08/20/2019 bruising incident with Resident #1. When asked about witness statements from staff for for both incident (08/20/2019 and 11/15/2019) , he said he could not provide them due to legalities Review of Resident #1's restorative nursing assistant (RNA) progress notes dated 09/03/2019 reflected, Resident #1 was unable to perform any assignments on her own. She tried to help with blouse complain of left shoulder hurting reported to nurse. restorative performed all duties dressing and grooming. Passive range of motion (PROM) performed as much as tolerated resident would not perform active range of motion (AROM). Review of Resident #1's restorative nursing assistant (RNA) progress notes dated 09/04/2019 reflected, Resident #1 was unable to perform duties. restorative aide assisted in all dressing and grooming. attempted AROM resident would not comply kept grabbing left arm no complaint of pain perceive to PROM. Review of Resident #1's restorative nursing assistant (RNA) progress notes dated 10/01/2019 reflected, Resident #1 complained of left shoulder pain. Review of Resident #1's restorative nursing assistant (RNA) progress notes dated 10/02/2019, 10/04/2019, 10/05/2019, 10/07/2019, [DATE], 10/24/2019, 10/26/2019, [DATE], 11/01/2019, 11/02/2019, 11/5/2019, 1[DATE]19, [DATE] reflected, Resident #1 complained of left shoulder pain and it was reported to the nurse. Review of Resident #1's nursing progress notes reflected no evidence of nurses addressing Resident #1's left shoulder pain after being told by the RNA until after the video footage on 11/25/2019. Review of Resident #1's minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BI[CONDITION]) score of 00 indicating the resident did not participate in the assessment. Review of Resident #1's Care Plan 01/02/2020 revealed Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to (r/t) dementia; has mood and behavior needs related to her [DIAGNOSES REDACTED]. Review of Resident #1's physician order [REDACTED]. Review of Resident #1's physician order [REDACTED]. Review of Resident #1's physician order [REDACTED]. Review of Resident #1's physician order [REDACTED]. Review of Resident #1's physician order [REDACTED].= 1000mg by mouth every 8 hours for pain. On [DATE]20 at 12:27pm surveyors reviewed the video evidence provided by Resident #1's family to the facility for surveyors review revealed the following: On 10/28/2019, CNA M and CNA O transferred Resident #1 by using the waist of her pants and threw her onto the bed. Resident #1 became combative after the transfer. CNA M restrained the Resident's left hand by placing it between her legs/knees. CNA M was laughing while she restrained Resident #1. On 11/06/2019, CNA N threw Resident #1 from the wheelchair to the bed without using a gait belt to properly transfer the Resident #1. Resident #1 was crying and moaning and said leave me alone. CNA N said, I am sorry. On 11/07/2019, CNA M was talking on the cell phone (earbuds) while dressing/providing care for Resident #1. CNA M was laughing and telling the person on the other side of the phone how difficult Resident #1 was to take care of. CNA M realized she didn't have a brief and said[***]and went to get the brief. CNA M continued laughing at Resident #1. On 11/08/2019, CNA P and CNA Q while transferring Resident #1 from the bed to chair, Resident #1 was thrown into the chair. CNA P and CNA Q were both using explicit language (shit, [***] ) and having personal conversation (attending concert) while caring for Resident #1. Resident #1 was crying. On 11/13/2019, CNA R, CNA S, and CNA O were in Resident #1's room. Resident #1 was roughly transferred from wheelchair to bed by lifting her under both armpits and slinging her toward the bed. CNA O stood in front of the camera, blocking footage while the CNA R and CNA S were performing peri care on Resident #1. On 11/17/2019 CNA Q transferred Resident #1 from bed to wheelchair without a gait belt, using the Resident #1 pants. On [DATE] at 9:25 p.m., CNA M attempted to transfer Resident #1 from the wheelchair to the bed using the back of the Resident's pants. Resident #1's bed was not locked, the bed rolled, Resident #1 landed on the floor. CNA M stared at Resident #1 on the floor, then looked at her cell phone, CNA M walked out of the room leaving Resident #1 on the floor. At 9:32 p.m., CNA M came back to the room, looking at Resident #1 on the floor, Resident #1 is complaining of pain, while CNA M is talking to someone on the cell phone. At 9:33 p.m., Resident #1 was still on the floor crying, CNA O walked in the room. Resident #1 was roughly transferred from the floor to the bed by CNA M grabbing he

Based on interview and record review, the facility failed to have evidence that an alleged allegation of abuse was thoroughly investigated for one (Resident #1) of eighteen residents reviewed for abuse. The Administrator failed to thoroughly investigate an allegation of abuse with an injury of unknown origin for Resident #1 on 08/20/2019. Which placed Resident #1 at risk for continued physical and verbal abuse on 10/28/2019, 11/06/2019, 11/07/2019, 11/08/2019, 11/13/ 2019, 11/17/2019, and [DATE] An Immediate Jeopardy situation was determined on [DATE]20. While the IJ was removed on 02/11/2020 at 1:52 pm, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective actions. This failure placed all residents in the facility at risk for abuse Findings include: Review of Resident #1's face sheet revealed a [AGE] year-old female, DOB 6/09/1921 with original admission date of [DATE] and readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's progress notes dated 08/20/2019 reflected, Resident #1 complained of her eye bothering her and per ''CNA staff it wasn't there the day before.' Swelling under eye and bruising noted on both sides, along of bridge of Resident#1's nose. Noted Bilateral bruising and discoloration to upper extremities. Complained pain in left shoulder and Resident #1 was able to move arm to 30 degrees without discomfort. This was made aware to the Nurse Practitioner (NP). Per staff this is baseline pain. Skin check completed. No other bruising noted. Administrator, ADON, and RP notified. This nurse was instructed that when family came to visit, to see if they had any further concerns and would like for any x-ray's ordered. Family denies that x-ray is needed. Per RP, her mother seemed to be ok. Family does visit frequently Review of facility's provider investigation report dated 08/21/2019 reflected, Resident # 1 had some bruising on her left arm and small bruise on her nose. RP said they suspect Abuse. Review of the remainder of the provider report did not show evidence that e local law enforcement was notified, witness statements were taken, skin assessments on vulnerable residents or that the family was not notified of the outcome. In an interview on [DATE]20 at 10:31pm the Administrator, he stated he did not notify the law enforcement regarding the 08/20/2019 bruising incident with Resident #1. When asked about witness statements from staff for 08/20/2019 incident, he said he could not provide them due to legalities. Review of Resident #1's restorative nursing assistant (RNA) progress notes dated 09/03/2019 reflected, Resident #1 was unable to perform any assignments on her own. She tried to help with blouse resident complained of left shoulder hurting reported to nurse. Restorative performed all duties dressing and grooming. Passive range of motion (PROM) performed as much as tolerated resident would not perform active range of motion (AROM). Review of Resident #1's restorative nursing assistant (RNA) progress notes dated 09/04/2019 reflected, Resident #1 was unable to perform duties. restorative aide assisted in all dressing and grooming. attempted AROM resident would not comply kept grabbing left arm no complaint of pain perceive to PROM. Review of Resident #1's restorative nursing assistant (RNA) progress notes dated 10/01/2019 reflected, Resident #1 complained of left shoulder pain. Review of Resident #1's restorative nursing assistant (RNA) progress notes dated 10/02/2019, 10/04/2019, 10/05/2019, 10/07/2019, [DATE], 10/24/2019, 10/26/2019, [DATE], 11/01/2019, 11/02/2019, 11/5/2019, 1[DATE]19, [DATE] reflected, Resident #1 complained of left shoulder pain and it was reported to the nurse. Review of Resident #1's nursing progress notes reflected no evidence of nurses addressing Resident #1's left shoulder pain after being told by the RNA until after the video footage on 11/25/2019. Review of Resident #1's minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BI[CONDITION]) score of 00 indicating the Resident did not participate in the assessment. Review of Resident #1's Care Plan 01/02/2020 revealed Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to (r/t) dementia; has mood and behavior needs related to her [DIAGNOSES REDACTED]. On [DATE]20 at 12:27pm surveyors reviewed the video evidence provided by Resident #1's family to the facility for surveyors review revealed the following: On 10/28/2019, CNA M and CNA O transferred Resident #1 by using the waist of her pants and threw her onto the bed. Resident #1 became combative after the transfer. CNA M restrained the Resident's left hand by placing it between her legs/knees. CNA M was laughing while she restrained Resident #1. On 11/06/2019, CNA N threw Resident #1 from the wheelchair to the bed without using a gait belt to properly transfer the Resident #1. Resident #1 was crying and moaning and said leave me alone. CNA N said, I am sorry. On 11/07/2019, CNA M was talking on the cell phone (earbuds) while dressing/providing care for Resident #1. CNA M was laughing and telling the person on the other side of the phone how difficult Resident #1 was to take care of. CNA M realized she didn't have a brief and said[***]and went to get the brief. CNA M continued laughing at Resident #1. On 11/08/2019, CNA P and CNA Q, while transferring Resident #1 from the bed to chair, Resident #1 was thrown into the chair. CNA P and CNA Q were both using explicit language (shit, [***] ) and having personal conversation (attending concert) while caring for Resident #1. Resident #1 was crying. On 11/13/2019, CNA R, CNA S, and CNA O were in Resident #1's room. Resident #1 was roughly transferred from wheelchair to bed by lifting her under both armpits and slinging her toward the bed. CNA O stood in front of the camera, blocking footage while the CNA R and CNA S were performing peri care on Resident #1. On 11/17/2019 CNA Q transferred Resident #1 from bed to wheelchair without a gait belt, using the Resident #1 pants. On [DATE] at 9:25 p.m., CNA M attempted to transfer Resident #1 from the wheelchair to the bed using the back of the Resident's pants. Resident #1's bed was not locked, the bed rolled, Resident #1 landed on the floor. CNA M stared at Resident #1 on the floor, then looked at her cell phone, CNA M walked out of the room leaving Resident #1 on the floor. At 9:32 p.m., CNA M came back to the room, looking at Resident #1 on the floor, Resident #1 is complaining of pain, while CNA M is talking to someone on the cell phone. At 9:33 p.m., Resident #1 was still on the floor crying, CNA O walked in the room. Resident #1 was roughly transferred from the floor to the bed by CNA M grabbing her by the legs and CNA O grabbed under the arms and Resident #1 was airborne into the bed. CNA M stated have you seen her fight before? She fights like a [***] . (hitting her fist in her palm). CNA M went to perform peri-care, Resident #1 was being combative, and CNA M hit Resident #1 in the face with an open palm. Resident #1 continued to cry while CNA M was communicating on her cell phone and left the room. During an interview and review of the video on 1/15/2020 at 12:27 p.m., Regional Nurse and Administrator reviewed video evidence presented by Resident #1 family. The Regional Nurse stated it was hard to imagine this happened and couldn't believe it until she saw the video. The Administrator stated that the video just gets worse. In an interview on 1/16/2020 at 10:51 a.m. with Resident #1's family, the RP stated there were several incidents involving injuries that caused bruising on Resident #1's face around her nose area, both eyes, and pain to her left shoulder. No one explained the cause of the injuries. She has never had any pain problems with her left shoulder until after she was admitted to the facility. An X-ray was done which revealed a previous fracture. On 08/20/19, I took pictures of redness on her left shoulder, scratches on forehead, nose area was swollen and bruised, along with both her eyes, and left hand. We had a meeting with the administrator on 08/21/2019 after the bruises kept appearing and no one did anything. We followed up with the Administrator regarding the outcome of the bruises and he asked what I meant. The RP stated she was upset and told him that he hasn't given any answers since she has been at the facility and we keep going in circles because nursing will say they will address but nothing is ever done. The RP stated that her grandmother has never been combative, always easy going, and feels she is now being combative because of the care she is receiving. Prior to being admitted , she was seeing the pain doctor due to a dislocated disc to her back and the facility was made aware of this. When we installed the camera, it got unplugged and she came up with a bruise. The RP asked maintenance if there was a reason the camera was unplugged, and he said they had an internet problem; come to find out from the receptionist this wasn't true. We have looked into transferring Resident #1 to other facilities but because of the progress notes indicating combative behaviors they won't accept her. The RP further stated that she stayed with Resident #1 overnight from 8 P.M. to 5 A.M. and no one ever came to check on her during the night. The RP also stated the family felt horrible after seeing the videos. It is horrible to see and to know that there is no one in here to fix abuse or anything else. The Administrator refused to talk to me about the concerns because he said I was not listed as her contact and he is following policy; and now all he does is apologize because he knows he's not addressing anything. The DON apologized to us because she didn't take the allegation seriously. We don't feel they resolved everything. My grandmother has voiced on many occasions that she is afraid to go to her room and sleep at night because she fears being thrown in her bed or being pushed against the wall. We noticed her sleeping during meals, so her brother comes to feed her. Review of Facility Provider Investigation Report dated 11/25/19 reflected After further review of the videos in which CNA M can be seen mishandling Resident #1 during transfers, walking away from Resident #1 during mid-transfer, on her phone while providing care, and cursing in front of the resident. In two of the videos it can be seen that CNA O improperly transferred Resident #1 causing the resident to cry out in pain and subsequently become combative with the aide. Two videos indicated CNA Q improperly transferred Resident #1. Over the 8 total videos, it was revealed that in several different videos there were instances where several aides were present (CNA N, CNA P, CNA R, and CNA S). These aides never reported that any inappropriate transfer or abuse had occurred. Due to the overwhelming evidence presented in the videos all seven employees suspended pending investigation. Review of the remainder of the provider report did not show evidence witness statements were taken, assessments on vulnerable residents or that a psychosocial assessment was done on Resident #1. Review of documentations reflected CNAs were suspended on 11/26/2019. Review of Resident #1's progress notes dated 11/25/2019 reflected Late Entry: On 11/25/19 at 12:15 p.m. DON, ADON, and charge nurse assisted resident back to bed using a gait belt to complete head to toe assessment. Resident had 2 quarter size bruises noted: one on upper left extremity and one on right forearm. No other injuries noted. Review of Resident #1's progress notes dated 11/25/2019 reflected Received new orders from the NP for labs to be drawn on CBC, CMP, sedimentary rate and CRP on 11/26/19. Apply sling to left arm/shoulder, apply bio freeze to left shoulder every shift and take an x-ray of left shoulder on 11/26/19. Review of Resident #1's physician order [REDACTED]. In an interview on [DATE]20 at 4:40 p.m., CNA S stated she was hired in November of 2019. CNA S stated she had witnessed abuse but did not recognize it at the time (on 11/13/2019), she realized when she was told by the DON and Administrator. She stated she was standing there for one of the incidents (on 11/13/2019) regarding Resident #1. She further stated, she was called to help Resident #1 get in bed and didn't remember what exactly happened. She later stated, they had training after her suspension. CNA S stated, if a Resident says no, go and come back later with another staff, use gait belt. I will report as soon as possible, move the resident to safety, notify the charge nurse and the DON. In an interview on 1/16/2020 at 1:39 p.m., CNA P stated she was hired in September of 2019. She also stated Abuse is like talking ugly to a Resident, being rough with a Residents, and if she witnessed an abuse, she would intervene and report to the nurse. She stated the Abuse coordinator is the Administrator and she can report to anyone above and to the state. She further stated they were in-serviced on Abuse and Neglect after the video incident with Resident #1. She later stated, I knew there were cameras in Resident #1's the room, I knew she was dead weight (total assist), I don't think there was a gait belt. We are supposed to transfer with a gait belt for more support; We are not supposed to transfer using arms and clothing. I didn't feel like CNA Q was being abusive because she moves fast. When a resident cries in pain to stop then care should be stopped. An unsuccessful attempt was made to call CNA M on 01/17/20 at 1:20 PM due to a disconnected line. CNA Q did not answer the phone with no option to leave a message, CNA's N and O did not answer the phone and did not respond to the message left on their voicemail. In an interview on 01/16/2019 at 2:03 p.m., the DON stated she expects staff not to abuse the residents, to be nice and report any suspicion of abuse. She also stated bruises were discovered on Resident #1 and they couldn't figure out the origin of the bruises. She also stated it was reported to the State Survey Agency and after investigations, she did not have any answers for the family and believed the Administrator may have communicated with the family. She further stated the administrator noted a mandatory meeting after the video abuse was exposed to address Abuse and Neglect. She later stated they did in-services on bed safety, use of cell phones, re-educated staff, terminated four CNAs, frequent rounds and observed CNAs provide care, routine visits on the weekends and after business hours (night), popping in to see what staff are doing to make sure they are following the rules. In an interview on 1/16/2020 at 3:35 p.m., CNA R stated she was hired in October 2019. She also stated the Abuse and Neglect coordinator is the administrator, and suspected abuse or neglect should be reported to the DON, administrator or via the 1[AGE]0 number. She further stated abuse is hurting (hitting, pushing) a resident, neglect is not providing ADLs care. She stated, at the time she was not aware of Resident #1's situation was abuse, she was just moving so fast and called someone to help transfer Resident #1 from chair to bed. She stated, I will stop if a resident says stop. I don't remember what I heard Resident #1 say that night. She ended by saying they were in-serviced on Abuse, neglect and exploitation and safe transfers. In an interview on 1/16/2019 at 3:48 p.m., the Administrator stated his expectation is for staff to make sure the Residents are safe no matter what the situation is and report any suspicion of Abuse or Neglect to him (the abuse coordinator) immediately. He also stated, Resident #1 family first presented the allegation of Abuse, no staff was named. Later Resident #1 family presented video footage of Resident #1 being physically and verbally abused, the facility immediately suspended all 7 employees involved, initiated an in-service for all staff before working the floor, explained what abuse was, policy, zero tolerance for abuse in general, if you are aware and not report you are liable also. The family did not name any staff member. The family was notified of the outcome of the findings of the 1st bruising for. Terminated 4 staff member. I think the in-services are effective as of this point. You can report to the cooperate office and it is confidential (in-house) and the 1-[AGE]0 number is posted every, staff know that they can report to state as well. He ended by saying, we are doing our best and writing staff out and even terminated some. Progressive discipline, verbal, written and termination. The survey team re-entered the facility on [DATE]20 at 9:15 p.m. Observation made on [DATE]20 at 9:20 P.M. revealed Resident #1 in her bed asleep. The bed was at lowest position and the call light was within reach. Resident #1 appeared comfortable. Staff involved in the 11/26/2019 video footage is still working night shift on the 100 hall with Resident #1. In an interview on [DATE]20 at 9:25 P.M. CNA R stated that Resident #1 sleeps all day. She was up yesterday during the day and she gets her days and nights mixed up at times. CNA R stated she works the 2-10pm shift on the 100 hall with Resident #1. She later stated, she was suspended after the video footage (11/26/2019), she was in-serviced and talked to but was not asked for a written statement. In an interview on [DATE]20 at 9:40 P.M. LVN W stated she works the 6p-6a shift on the 100 hall with Resident #1. She also stated, she cannot record writing a statement after the video footage came out 11/26/2019 and no one approached her to inquired. In an interview on [DATE]20 at 9:50 P.M. CNA S stated she was floating on both halls and she normally does not work on hall one. She stated she has not worked with Resident #1 since the incident. She stated she has received training after she was suspended, and they told her what happened. She stated she had no recollection of the incident and cannot remember if she was asked to write a statement of the incident. In an interview on [DATE]20 at 10:33pm the Administrator and DON could not see how the 08/20/2019 incident of injury of unknown origin was connected to the 11/25/2019 incident of physical abuse for Resident #1. In an interview on [DATE]20 at 11:42 P.M. CNA F stated that she has worked with Resident #1 since she was admitted and that she lashed out at times and likes to talk about birds. She stated Resident #1 has not wanted to go to bed lately, has been refusing the past 2-3 weeks to go to sleep; however, when she does sleep it's usually for 1-2 days. She stated she was in-service on abuse and neglect last week. Review of facility policy titled Leadership Policy and Procedures with a revision date 11/01/2017 reflect the subject as: Abuse, Neglect, Exploitation, or Mistreatment. The policy description reads: The facility's leadership prohibits neglect, mental physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately. --Component VI: Investigation --The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. If the alleged abuse or neglect involves serious physical harm to the patient/resident, please contact the FCOS Clinical Services Director and/or Regional Vice President of Operations. You may be directed to contact the FAS Legal Department (Legal Department). --Investigations are prompt, comprehensive and responsive to the situations and contain founded conclusions --The investigation may include but is not limited to the following: A. Identification and removal of the alleged perpetrator (s). G. Measures taken to prevent future incidents. An Immediate Jeopardy was identified on [DATE]20 at 10:05 pm. The Administrator and DON were notified of the Immediate Jeopardy on [DATE]20 at 10:05 pm. The Administrator and DON expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 02/07/2020 at 1:27 am The Plan of Removal reflected: 1. Head to toe completed on identified resident. No identified issues noted. Psychosocial evaluation will be completed on resident by licensed social worker on [DATE]. Identified psychosocial needs will be addressed immediately and social worker will monitor residents needs for [AGE]hour and ongoing as needed. 2. Residents who have bruising of unknown origin have the potential to be affected by the alleged deficient practice. An audit was completed on progress notes, incident reports & grievances for last [AGE] hours to identify bruising of unknown origin and possible incidents of physical, emotional or psychological abuse. Skin assessments will be initiated on residents to identify bruising of unknown origin. 3. The administrator and Director of Nursing were re-educated by the Regional Vice President of Operations on abuse policy including: Reporting immediately allegations involving abuse to HHSC Immediate notification of allegations of abuse to Local Law Enforcement Completing prompt investigation of any allegation received of suspected abuse and implementing immediate actions to safeguard resident This reeducation was completed on [DATE]20. Facility staff were re-educated on the Abuse, Neglect and Misappropriation and Exploitation including identifying and assessing suspected or alleged reports of abuse such as suspicious bruising, witness reports and trends of potential abuse. This reeducation began immediately and will be completed by February 8, 2020. Any staff not receiving this information prior to this date will receive prior to next scheduled shift. This reeducation is being performed by the Director of Nursing/designees. The reeducation is being performed by giving direct verbal education to each staff member. 4. Administrator will review incident reports and grievance reports daily for identification of possible allegations of abuse. Members of nursing Management will round daily for one week, then weekly for three months validating skin assessments are completed as ordered and to identify potential risks. Ad Hoc QAPI will be held on [DATE]. The Medical Director was notified of the Immediate Jeopardy on February 7, 2020 The Survey team monitored the current plan of removal as follows: Review of Resident #1's clinical records reflected the Social worker went to visit Resident #1 on [DATE] at 8:52 am and noted Social worker visited with Resident #1. Resident #1 was sitting in the activity room. An activity was about to start. She appeared dressed neatly and clean. Review of Resident #1's clinical records reflected the Social worker went to visit resident on 2/8/20 at 10:45 am and noted I made a visit to Resident #1's home (room). She was resting comfortably and was asleep. I did speak with the nurse and she told me that Resident #1 did not eat breakfast today and she was tired and wished to sleep in today. The nurse states that sometimes she stays up late and then the next day she sleeps late. She assured me that she an aide had cleaned her and got her dressed earlier today. Interview with the Administrator on 2/09/20 at 10:41 am revealed he is aware the Social worker did not complete item 1 on the POC and he doesn't know what to do about it. It was also there were no other residents that had bruising of an unknown origin, so he could not complete item #2. Interview with the DON on 2/9/20 at 11:30 am revealed she performed a full head to toe skin assessment on [DATE] at 12:49 am and there were no skin issues identified. DON stated in-services were performed for 3 of the 6 grievances but she has no documentation to show who was in-serviced or what they in-serviced about. Stated she will start documenting better. Interview with Administrator on 2/9/20 at 11:50 am revealed the other grievances have not been addressed with family and staff but he will be following up this week. Record review of current grievances from 2/3/20 thru 2/5/20 revealed none of the grievances have been cleared. Record Review on 2/9/20 at 10:50 am revealed in-service documents on Abuse, Neglect and Exploitation. It appears all staff and Administration have been re-educated. Interview on 2/9/20 at 10:52 am with Administrator revealed the Medical Director is on vacation and cannot hold a QAPI meeting with the staff until next week. Observation on 02/11/2020 at 12:22pm, DON is noted feeding Resident #1 in the main dining hall. No distress noted from Resident #1. In an interview on 02/11/2020 at 12:24pm, the administrator stated he spoke with Medical Director on the phone because he was out on vacation. He also stated the Medical Director is back and he signed the QAPI meeting dated 02/07/2020. In an interview with the social worker on 2/11/2020 at 12:30pm, she stated she visited with Resident #1 for 5 days since the IJ was identified and she was well responsive and clean. She also stated, there were no distress (crying, depression) noted from Resident #1 and if sign and symptom was noted she would have recommended Psych services for the Resident. She stated she could not do a safe survey on Resident #1 because of her low BI[CONDITION] score and a [DIAGNOSES REDACTED]. There is no concerns of Abuse and Neglect at this time and all the residents she visited are comfortable. Observation on 02/11/2020 @ 12:46pm, Resident #1 was being transfer from wheelchair to bed by CNA T and LVN U, gait belt was used, wheelchair locked, process was explained to Resident #1, transfer was safe. There was no combativeness noted from Resident #1. Review of in-services documentations reflected the Administrator and DON were both trained by the Regional Vice President. - Abuse/Neglect Exploitation, Reporting and Investigating dated 02/07/2020 at 1:15am Review of in-services documentations reflected the administrator initiated an in-service on 02/07/2019 on Abuse and Neglect for all other staff Review of the documentations reflected the facility held a QAPI meeting on [DATE]20 which was signed by the Medical director, Administrator, DON, ADONs, Social Services, maintenance supervisor, Staff Development coordinator, Nurse Assessment Coordinator. Review of documentations reflected skin assessments were done on the following Residents: Resident #1, Resident #6, Resident #11, Resident #12, Resident #13 and Resident #14. The IJ was lifted on 02/11/2020 at 1:52pm Four (CNA's M, N, O, and Q) of the seven alleged perpetrators were terminated after investigation.

Based on observation, interview, and record review, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one resident (Resident #2) of eighteen residents reviewed for Quality of Care. A. LVN A failed to ensure Resident #2 was transferred from oxygen cylinder to oxygen concentrator for four hours for a resident on continuous oxygen. B. LVN B failed to respond and assess Resident #2 after being notified by family the Resident was in respiratory distress which contributed to Resident #2 death. These failures resulted in an Immediate Jeopardy situation on 01/17/2020. While the IJ was removed on 01/21/2020, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need for monitoring the implementation of their corrective actions. This failure placed all residents who use oxygen at risk . Findings include: Review of Resident #2's face sheet revealed a [AGE] year-old female DOB 11/13/1927 with admission date of [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #2's minimum data set (MDS) assessment revealed no brief interview for mental status (BI[CONDITION]) score because Resident #2 was only in the facility for six hours before she passed away. Review of Resident #2's clinical records reflected no care plan. Review of Resident #2's transfer communication from the local hospital dated 12/11/2019 reflected an order for [REDACTED]. Oxygen Cylinders have a finite amount of oxygen compressed within them and inhaled by the user until it runs out. Oxygen Concentrators filter and generate medical grade oxygen, at an infinite supply so long as the battery that powers this mechanism has life. Review of Resident #2's progress notes dated 12/12/2019 reflected Resident #2 was pronounced dead on 12/12/2019 at 2:10 a.m. by the hospice nurse. Review of Resident #2's physician orders [REDACTED]. In a phone interview on 01/13/2020 at 10:31 am, Resident #2's Responsible Party (RP) stated Resident #2 has always been on oxygen continuously and was discharged to the facility with an order for [REDACTED]. He stated on 12/11/2019 at about 9:30 p.m., he walked into the facility and found Resident #2 gasping for air. Resident #2's nasal cannula (N/C) was at her nostrils but no oxygen was flowing through the tube. He stated there was an oxygen cylinder present, calibrated at 4, and the tank indicated it was empty. In an interview on [DATE]20 at 10:42 a.m., the ADON stated prior to residents being admitted to the facility, the nurses get report and set up the room based on what the resident's needs are. She stated she makes follow up checks to make sure the room is ready, and all equipment are available. She stated she did not check the room for readiness prior to Resident #2 being admitted . In an interview on 01/16/2020 on 1:07 p.m., LVN A stated she worked on 12/11/2019 6am-6pm shift. She stated prior to residents being admitted to the facility, she gets a report to find out about the resident's needs, if they are requiring oxygen or not. She stated Resident #2 was on oxygen upon admission and hospice was supposed to supply an oxygen concentrator. She stated if the resident is being admitted on hospice, the hospice is responsible to set up the oxygen delivery. She stated Resident #2 admitted just before the end of her shift. LVN A got the report from the hospital regarding Resident #2 and she thought Resident #2 was on oxygen. She stated she put Resident #2 on oxygen at 2 liters from the oxygen concentrator and documented on the 24 hours report. She stated, I could have sworn I put her on oxygen, it could have been an oversight. I am not 100% sure I put oxygen on her, it was change of shift and everything was going on. Review of facility's 24 hours report dated 12/11/2019 and 12/12/2019 did not reflect Resident #2's name, if she was admitted to the facility and/or was requiring oxygen usage. In an interview on 01/16/2020 at 11:48 a.m., LVN B stated he worked on 12/11/2019 to 12/12/2019 from 6pm to 6am (night shift). He stated Resident #2 was admitted before he started his shift. He stated he made rounds with LVN A prior to starting his shift and Resident #2 was not on oxygen. He stated he found out Resident #2 needed to be on oxygen when the hospice nurse got into the building later that evening and orders were written for Resident #2. He stated Resident #2's RP asked him why Resident #2 was not on oxygen. He stated he did not document about Resident #2 being out of oxygen. In an interview 01/16/2020 at 2:04 p.m., the DON stated she participates in the admission process and she reviews the clinical portions. She stated, clinically, she looks to see if the facility can meet resident's needs. She stated all nursing staff make sure the room is equipped prior to admission. She stated oxygen concentrators should be available in the facility. She stated Resident #2 was on hospice at her home prior to going to the hospital and was being readmitted to hospice upon admission to the nursing facility. The DON stated Resident #2's room is one of the rooms in the facility with direct oxygen flow in the room so, there shouldn't have been issues with hooking the resident to continuous oxygen. Observations made on 01/16/2020 at 4:00 p.m. revealed rooms on the 300 hall where Resident #2 was placed had oxygen flow built in the walls. In an interview on 01/16/2020 at 3:20 p.m., the Hospice Nurse stated Resident #2 was admitted to the facility on [DATE] at about 5:30 p.m. She stated she assessed Resident #2 and she was in good spirits and was worried about her crocs, cell phone and her Baylor blanket. She stated Resident #2 was connected to oxygen at 4 liters via nasal cannula from a portable oxygen cylinder. She stated there was no oxygen concentrator in Resident #2's room when she left the facility at about 9:00 p.m. She stated, It is the hospice policy for facilities to provide equipment while our equipment is being delivered. She stated, LVN B was making rounds and she gave him a breakdown of Resident #2's needs including oxygen use. In another phone interview on 01/17/2020 at 11:40 a.m., Resident #2's RP stated he asked about Resident #2's oxygen and was told by LVN B Resident #2 was on hospice and hospice had not yet delivered the oxygen concentrator. He (RP) stated the oxygen cylinder Resident #2 was transferred from the local hospital was in Resident #2's wheelchair, nasal cannula attached, and the tank was empty. He (RP) stated he started looking for an oxygen concentrator himself and then LVN B joined him to look. He stated there was no oxygen concentrator in the room and that if one had been present he would have connected Resident #2 to it. He stated when they (RP and LVN B) found an oxygen concentrator, he (RP) hooked up the canula and attached to Resident #2, put on 4 liters. He stated LVN B did not check Resident #2's vitals or assess her after she had been out of oxygen for so long. He stated, he left the facility at about 10:30-10:45 p.m. on 12/11/2019, Resident #2 was still gasping for air, but she was relaxed a little. In a phone interview on 01/17/2020 at 12:32 p.m., LVN B stated he took the oxygen concentrator to the room and he believed CNA F connected Resident #2 to the oxygen concentrator. He stated Resident #2's RP was concerned as to why her oxygen was not turned on or connected to her. He stated, I did not connect Resident #2 to the oxygen concentrator. LVN B stated Resident #2 was not very responsive, but her vital signs were okay upon admission. He stated he can't remember what Resident #2's oxygen level was upon admission. LVN B stated he did not ask the RP what Resident #2's baseline was. He stated after he rolled the oxygen concentrator into the room he did not check on Resident #2 until CNA F brought to his attention that Resident #2 had passed around 2:00 a.m. In an interview on 01/17/2020 at 2:35 p.m., the DON stated she was not aware of any issues with Resident #2's care and would never have thought the nurses didn't hook up the oxygen. She stated the EMT that transported Resident #2 should have changed from cylinder to concentrator. She stated she didn't expect Resident #2 to pass so quickly. She stated she was told Resident #2 was on hospice prior to going to the hospital and she was going to continue with hospice care. Review of facility policy titled Respiratory Policies and Procedures with a revision date 04/01/17 reflect the subject as: Oxygen Therapy General Policy. The description is: -The facility provides oxygen therapy at a FiO2 greater than 21% by means of various administration devices -The procedures reflect to review physician's orders [REDACTED]. -frequency or duration -physician signature and date. -Gather necessary equipment - Assess the patient/resident -establish baseline respiratory rate and heart rate - start O2 flow rate at the prescribed liter flow or appropriate flow for administration device, -place administration device on the patient/resident -monitor respiratory rate and heart rate. Post oxygen safety sign on the patient/resident's room door -Document initiation of therapy in the medical record -per documentation standards to include date/time of setup, type of administration devices used, instructions given to the patient/resident for no smoking or flammable substances while oxygen is in the room, evaluation of the effectiveness of therapy, signature and credentials of personnel administering oxygen. An Immediate Jeopardy was identified on 01/17/2020 at 2:59 pm. The Administrator and DON were notified of the Immediate Jeopardy on 01/17/2020 at 3:15 p.m. The Administrator and DON expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 01/17/2020 at 6:30 PM. The Plan of Removal reflected: 1. Resident identified is no longer in the facility. The nurses identified have been suspended. 2. Residents who have a physician's orders [REDACTED]. An audit was completed of the 24-hour report and progress notes for the past [AGE] hours to validate that there is no documentation of changes in respiratory status requiring a physician notification. An audit was done on residents who have physician orders [REDACTED]. 3. The Director of Nursing and nursing managers were re-educated by the Clinical Consultant regarding the expectation of reviewing the admission information prior to the resident's admission to the facility to anticipate the need for an oxygen concentrator in the room for availability upon admission. This was completed on January 17, 2020. The Admissions Director will be re-educated by the Administrator regarding informing members of nursing management and providing the admission information for review in order to identify and provide the oxygen concentrator to be available on admission. This will be completed prior to return to work. Licensed Nurses were re-educated on the following regarding the continuity of care for residents admitted from the hospital on oxygen: Validating that oxygen concentrator is in the room prior to the resident's admission Upon admission a resident receiving oxygen per a portable cylinder is to be transferred to oxygen concentrators or piped in oxygen from wall Identifying a change of condition related to respiratory status by auscultating breath sounds, obtaining vital signs and notification of physician for further direction and notify responsible party. Following physician orders [REDACTED]. Communication to on-coming shift and to nursing management is per the 24-hour report and progress notes. Abuse, Neglect and Misappropriation and Exploitation This re-education began immediately and will be completed by January 18, 2020. Any licensed nurse not receiving this information prior to this date will receive prior to next scheduled shift. This re-education is being performed by the Director of Nursing/designee. The re-education is being performed by giving direct verbal education to each licensed nurse. 4. Members of Nursing management will review prospective admissions prior to admission each day to identify the need for oxygen concentrator upon admission. Residents who are admitted to the facility and require oxygen will be observed by Director of Nursing/designee to validate that the admitted resident was provided with oxygen concentrator or have wall oxygen in use. This will be done with each admission requiring oxygen for 3 months. Members of Nursing Management will round daily for one week, then weekly for three months to validate that oxygen is being delivered per physician's orders [REDACTED]. Director of Nursing/designee will interview a minimum of 5 nurses weekly for 2 weeks then monthly for 2 additional months regarding the process for oxygen delivery to validate understanding of the education provided. Director of Nursing/designee will monitor the appropriate measures taken by the nurse for a change of condition related to respiratory status by reviewing 24hr reports in morning meeting, reviewing progress notes via the facility activity report and reviewing medical records of residents discharged to an acute care setting. Ad Hoc QAPI was held on January 17, 2020 The Medical Director was notified of the Immediate Jeopardy on January 17, 2020 The Survey Team monitored the current plan of removal as follows: Monitoring done on 01/18/2020 reflected the following: Record review on 01/18/2020 reflected facility completed an audit on resident physician orders [REDACTED]. The Medical Director verified all orders were correct and the MAR and TAR were updated. 100% facility chart audit completed. The only finding is on 1/5/2020 Resident #7 returned from the hospital at 9:55 p.m. and her O2 use was not initialed on the MAR. Record review of in-services completed on 01/17/2020 reflected the Regional Nurse trained the DON, NAC, RN G, ADON 2 and ADON 1 on reviewing admission paperwork prior to resident's admission to ensure the residents needs will be met upon admission. This includes verifying if oxygen is required for the resident and having a concentrator available prior to admission. In an interview 1/19/2020 at 3:15 p.m. the DON stated she has been talking with staff about checking equipment, reviewing admission paper work to see if they have any equipment and that they have it ordered. Normally the medical director orders the equipment needed for a resident who is admitting. In an interview 1/19/2020 at 3:45 p.m. ADON 2 stated when they get the admission packet up front she usually has [DIAGNOSES REDACTED]. O2 dependent 300 and 400 hall because the oxygen is pipped in. If they are not they will go in and will put the appropriate equipment. ADON gets admission packet just like the nurses do. Most of the new admission come on the skilled side. ADON 2 stated when the packet comes in she will double check the nurse's work, medicine and the equipment required for the incoming resident. She stated she will talk with the families as well and check the room. If additional equipment is needed, she would request it immediately. ADON 2 stated when there is a change of condition, the CNAs should notify the nurses immediately and the nurses would notify management immediately. Review of In-services dated 1/17/2020 reflected titled of change in condition and oxygen use. Inservice reflected when there is a change in resident condition, the charge nurse must be notified immediately. The charge nurse must go assess the resident immediately initiate an SBAR and following the direction of the SBAR. The physician must be notified immediately so further orders can be obtained. SBAR must be completed one the resident condition has improved/resolved, or the resident is transferred out of the facility. The charge nurse needs to print a completed SBAR and put under the ADONs office door for review. Oxygen orders must be verified, and the charge nurse must make sure all orders are being followed correctly. All new orders change in resident condition, and or any relevant resident information needs to be placed on the 24-hour report and discussed with the oncoming nurse at shift change. Both nurses to sign report. When a change of condition for respiratory status occurs make sure that during your nursing assessment, breath sounds are auscultated, and vital signs obtained. These assessment findings must be documented, and the physician must be notified for further orders. The ADON and DON must be notified for all resident change in conditions orders received and status of resident upon completion of event. Family must also be notified. Review of Inservice dated 1/17/2020 reflected Equipment at admission. When a resident is admitting to the facility all equipment needs to be ordered and put in room prior to admission for example if a resident is on continuous o2 a concentrator need to be in the room and immediately switch the resident form cylinder to concentrator. Another example if a resident has a wound and needs special equipment (mattress wound vac etc) that equipment needs to be ordered upon accepting the resident and in the resident's room when resident arrives and then equipment switched to resident use immediately. All rooms need to be checked for equipment's and notify DON and or ADON if equipment are not available and ready. Review of Inservice dated 1/19/2020 reflected Abuse and Neglect Inservice completed. During an interview on 1/19/2020 at 2:40 p.m. LVN H stated an in-service was done yesterday (1/18/2020) and today (1/19/2020). LVN H stated residents requiring oxygen therapy had their orders verified to ensure they were correct. LVN H stated they are to verify orders where they are coming from once at the facility they are to have a head to toe and make sure the oxygen is on and hooked up correctly. LVN stated that they are to take a concentrator into the room if they do not have the hook up to the wall. During an interview on 1/19/2020 at 2:43 p.m., LVN I stated she received training prior to shift: make sure residents are equipped with everything necessary. Document equipment needed for the patient. Put on 24 report. If there is a change in condition place on the progress report and put in 24-hour report. Equipment needed would be oxygen tank and cylinder, tubing mask and cannula. Concentrator and already placed oxygen in rooms. Abuse and neglect - physical sexual AND verbal. Report to Administrator and file an incident report. During an interview on 1/19/2020 at 2:58 p.m., LVN J stated when you get report verify they are on oxygen canister and a concentrator if not on a hall with oxygen access on the walls. Verify orders. Make sure they are in matrix correctly 24hr repot and signing the 24 hours report. During an interview on 1/19/2020 at 4:03 p.m., LVN K stated that she had training when she was hired, yesterday, and today prior to her shift. LVN K stated that they are to ensure that the resident has the needed equipment prior to the resident coming to the facility and ensure that it is set up. LVN K stated that there are two halls that have oxygen pipped through the walls and the other halls would need an oxygen concentrator. LVN K stated that they are to communicate any changes to the next shift and communicate to their supervisor, also should be documented on the SBAR, progress notes, and on the 24-hour report. Nurses should be signing off on the 24-hour report. Also, verifying orders. She stated that she will go from room to room and see if the resident has any concerns on the short term and long-term side. Record review of in-services on 1/19/2020 reflected nurses on duty had been in attendance prior to their shifts. Record review on 1/19/2020 of the Review of Admission Validation of O2 equipment reflected the facility had two admission on 1/18/2020: Resident # 9 did not need equipment (DON signed). Second admission on 1/18/2020 reflected Resident #10 and that equipment was needed and in place (y - was circled to reflect a yes). Record review on 1/19/2020 of January Calendar 2020 reflected Nurse Rounds Members of nursing management will round daily for one week, then weekly for three months to validate that oxygen is being delivered per physician orders. Unit 1 reflected RN signatures on the 18th and 19th. Unit 2 reflected signature on 1/18/2020 and 1/19/2020. Observation and interview on 1/21/2020 at 1:05 p.m., revealed Resident #7 in hallway between nursing station and activities room. Resident was observed with nasal cannula appropriately placed. Resident stated that she had not run out of oxygen anytime during her stay at the facility since admission. Observation of oxygen tank with oxygen released at 2 liters per minute tank was at the half point on gauge and Resident #7 confirmed she was receiving oxygen. Observation on 1/21/2020 at 1:10 p.m., revealed residents throughout the facility were appropriately dressed, well-groomed with no foul odors. Residents were engaged in activities and in small clusters chatting with each other. Staff was present throughout the facility with no concerns noted. In an Interview on 1/21/2020 at 1:15 p.m. the Admission Director stated she had been in-serviced over abuse and neglect and how to get rooms ready prior to admission. She demonstrated a previously used bright pink piece of paper that is used to communicate with nurses prior to admission, if a resident needs DME such as oxygen. She stated she was not aware of any new processes implemented. She stated that she tries to give the admitting nurse a couple of hours to get the room ready but there are times when they only have 30 minutes due to driver availability. She stated that she would go to the facility on a Saturday if she was able. She stated that she tries to communicate to nursing verbally but understands that at times nursing is busy with medications and such. She stated when that occurs she will just let them know she left admission paperwork at the nurse's station for them. In an Interview on 1/21/2020 at 1:30 p.m., the DON stated she realized the charting that was being completed prior to entrance of surveyors was not clear on what was going on with residents. She stated she had in-serviced all nursing staff on charting, room readiness, notifying DON and ADON if equipment is needed for an admission but is not readily available. She stated that most rooms are equipped with wall oxygen and can easily have a tank (cylinder) conversion after admission. She stated that the facility nursing managers are currently doing daily checks on all residents who receive PRN Oxygen and Continuous Oxygen. She stated currently she is verifying that all new admissions who receive oxygen, have oxygen readily available in their room prior to admission. She stated she understood this was not sustainable and her goal was to train her managers and nurses. She stated it starts with the nurses and then the managers to verify and follow up. She stated that she looks over all new referrals and is aware of any admissions that may have oxygen needs (or DME) and notifies not only the nurse but the nurse manager as well. She stated that this Saturday they had an admission that was on continuous oxygen and it went smoothly. She stated she was in the room with the admitting nurse when resident arrived and ensured resident was safely admitted . DON demonstrated a new checklist that the Administrator implemented but she has tweaked to fit her needs. This checklist ensures that oxygen is appropriately ordered, administered and available. On 01/21/2020 at 2:02 p.m., the Administrator and DON were informed that the IJ was lifted.