Every finding on record at The Hillcrest of North Dallas

Based on observation, interview and record review the facility to ensure the resident environment remained as free of accident hazards as possible for one of one maintenance office reviewed for accident hazards. The facility failed to ensure the maintenance office was locked, which contained hazardous or unsafe chemicals, when there was no one present in the office.This failure could place residents at risk for being able to ingest hazardous chemicals.Findings include:In an observation on 10/14/2025 at 10:31 AM and at 12:05 PM, the maintenance office at the end of the 300 hall was propped open. There was a spray bottle sitting on the edge of the desk. It was half full of a pink liquid labeled ZEP, Professional Sprayer, Great for cleaners, Pesticides and other liquids. On the shelf to the left of the desk was a container labeled All Purpose Leak Detector. Both chemicals had labels that read, Keep out of reach of children due to potential hazard. In an interview on 10/14/2025 at 12:16 PM with the Maintenance Director revealed he had been working at the facility for 2 years. He stated his office should be locked when there was no one in there and today it was locked earlier, he must have forgotten to lock it and shut the door. He stated the risk of leaving it open was residents could come in and grab something they should not have access to. In an interview on 10/14/2025 at 2:45 PM, with the administrator revealed she expected the maintenance office door should be closed and always locked with the risk being that someone could wander into the room. A record review of the facility's policy Maintenance-Storge Areas, dated 08/2020, revised stated, flammable liquids are never stored in areas where intense heat or open flame could ignite .Cleaning supplies and similar substances must be stored in areas separate from food storage rooms and must be stored as instructed on the labels of such products.

Based on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who is unable to carry out activities of daily living for seven of seven residents (Resident #25, Resident #24, Resident #111, Resident # 12, Resident #85, Resident #67, and Resident #35) reviewed for ADL care. 1. The facility failed to provide Resident #25, who required extensive assistance, with timely incontinence care on 07/29/25 from 6:30 a.m. to 02:30 p.m. 2. The facility failed to ensure Resident #24, who required extensive assistance received consistent baths/ showers and failed to provide timely incontinence care on 07/30/25 when she called for assistance at 08:30 a.m. and was not changed until 09:55 a.m. 3. The facility failed to provide consistent showers and shaving to Resident #111, who required moderate assistance with personal hygiene. 4. The facility failed to provide consistent shaving and shampooing to Resident #12's hair, who was dependent on personal hygiene. 5. The facility failed to provide consistent showers and grooming to Resident #85, who required extensive assistance with bathing and personal hygiene. 6. The facility failed to provide consistent baths/showers and shampooing to Resident #67's hair, who was dependent on baths and personal hygiene. 7. The facility failed to ensure Resident #35 had her fingernails cleaned and trimmed on 07/29/2025. This failure could place residents at risk of skin breakdown, urinary tract infections, skin infections and loss of dignity.Findings included: 1. Record review of Resident #25's Face sheet dated 07/31/25 reflected an admission date of 10/27/23. Record Review of Resident #25's quarterly MDS assessment, dated 07/08/25 reflected a [AGE] year-old male who had a BIMS score of 1 which indicated he was severely cognitively impaired. He was dependent for all activities of daily living and required the assistance of 2 persons to complete most activities. He was always incontinent of bladder and bowel. Diagnoses included dementia, cerebral vascular accident (stroke) and aphasia (language disorder that affects a person's ability to communicate). Review of Resident #25's care plan revised on 07/29/25 reflected, . [Resident #25] has mixed bladder incontinence.Intervention.the resident uses disposable briefs. has a history of urinary tract infections.has potential for pressure ulcer development related to incontinence, decreased ADL's.Interventions.Follow facility policies/protocol for the prevention/treatment of skin breakdown. In an observation on 07/29/25 at 11:35 a.m. Resident #25 was observed sitting in the common/dining room area in a reclining wheelchair. Attempts to interview the resident were made, but he was unable to carry on a conversation. Resident #25 had an odor of urine. In an interview with CNA R on 07/29/25 at 11:50 a.m. he stated he was not assigned to Resident #25 today. He stated Resident #25 was on hospice service and they had gotten him up shortly after the beginning of the 06:00 a.m. shift. In an interview with CNA T on 07/29/25 at 11:55 a.m. she stated Resident #25 was bathed, changed and gotten up by hospice this morning around 6:30 a.m. She stated they had to leave him up for a while after he ate to give his food time to digest. She stated they would not put him to bed, since he would have to sit up after lunch so the 2-10 p.m. shift would be putting him back to bed. She stated she had not taken him back to his room this shift. Observation of Resident #25 on 07/29/25 at 12:20 p.m. revealed he remained up in the common/dining room area. Observation of Resident #25 on 07/29/25 at 01:20 p.m. revealed he was served his lunch tray and was provided feeding assistance by ADON A. Observation of Resident #25 on 07/29/25 at 02:10 p.m. revealed he remained up in the common/dining room area. On 07/29/25 at 02:20 p.m. ADON A was notified by this surveyor, Resident #25 had been up since 06:30 a.m. and had not been checked or changed the entire shift. ADON A then instructed CNA N to take Resident #25 to his room to be checked and changed. In an observation on 07/29/25 at 2:25 p.m. CNA N was observed taking Resident #25 to his room which was under electronic monitoring. CNA N stopped in the hallway in front of his room. She stated he was not her resident and was not sure who was coming to put him to bed. In an observation on 07/29/25 at 02:30 p.m. CNA U, CNA L and RN C came and pushed Resident #25 into his room and positioned his wheelchair next to the bed with him facing the head of the bed. CNA U and RN C transferred the resident to the bed revealing his pants were urine soaked as was the wheelchair cushion. RN C removed his gloves, performed hand hygiene and left the room to obtain sanitizer to clean the wheelchair cushion. CNA U and CNA L rolled the resident onto his back and removed his pants. CNA U unfastened the resident's brief and provided peri care. Both staff rolled the resident onto his side revealing the resident had a moderate size bowel movement. Skin was noted to be intact with some mild redness. CNA U completed the peri-care and both staff placed a clean brief and clean pants onto the resident. RN C and CNA U positioned the resident on the side of the bed and transferred the resident back to his wheelchair. In an interview with RN C on 07/29/25 at 03:00 p.m. he stated Resident #25 was saturated with urine. He stated staff were supposed to check and change residents who were incontinent of urine every 2 hours. He stated the resident's family had requested he be gotten up for all meals, but stated they had to take him to his room to check and change him between meals. He stated the resident was usually still up when he came on duty for the 02:00 p.m. to 10:00 p.m. shift. In an interview with CNA U on 07/29/25 at 03:05 p.m. she stated she worked the 02:00 p.m. to 10:00 p.m. shift. She stated when she was assigned to Resident #25, he was usually still up when they came on shift. She stated he was usually very wet when they checked and changed him on their first rounds. In an interview with Resident #25's responsible party on 07/30/2025 at 7:53 a.m. she stated she had noticed they keep him out of his room most of the day. She stated she had not looked at the camera footage from yesterday (07/29/25) but would check to see if he had been brought back to the room to be changed on the day shift and would let the Surveyor know. In a follow up interview with Resident #25's responsible party on 07/30/2025 at 9:41 a.m. she stated on 07/29/25 the hospice staff changed him around 6:30 a.m. and had gotten up. She stated he was not brought back to the room to be changed again until 2:40 p.m. 2. Record review of Resident #24's MDS assessment dated [DATE] reflected Resident #24 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), muscle weakness, and lack of coordination. Resident #24 had a BIMS score of 15 which indicated her cognition was intact. Further review revealed Resident #24 was always incontinent of bowel and bladder, and her functional status reflected she required extensive assistance for personal hygiene. Review of Resident #24's Comprehensive Care Plan, created date 06/06/25, reflected the following: Focus: [Resident #24] has an ADL Self Care Performance Deficit related to impaired mobility, weakness Goal: [Resident #24] will maintain current level of function through the review date. Intervention. TOILET USE: The resident requires. staff participation to use toilet. PERSONAL HYGIENE/ORAL CARE: the resident requires.staff participation with personal hygiene . The facility did not indicate if the resident required 1or 2-person assistance and ADL care. Review of Resident #24's orders reflected Order Summary: Torsemide Oral Tablet 100 MG (Torsemide) Give 1 tablet by mouth one time a day at 09:00 AM for Diuretic (causes the kidneys to make more urine) active MD order since 05/17/25. Record review of the facility's shower schedule with an effective date of 11/11/24, reflected Resident #24 was scheduled for showers on Tuesday, Thursday, Saturday on the 6:00 a.m. to 02:00 p.m. shift. Review of Resident #24's shower sheets for July 2025 reflected Resident#24 received a bed bath on July 4, 2025, and a documentation of refusal on July 8, 2025. There were no additional shower sheets for July 2025. Observation and interview on 07/29/25 at 11:01 a.m., revealed Resident #24 was lying in bed, and she stated she did not get showers, only bed baths. She stated she had only received 2 bed baths in two months. Resident #24 did not have an odor or appear unclean. Observation and interview on 07/30/25 at 09:42 a.m., revealed Resident #24 stated she did not get a bed bath yesterday (07/29/25) on her scheduled day. Resident #24 stated she was wet and had called for someone to change her at 08:30 a.m., and no one had come. Resident #24 stated she passed urine three times this morning. Resident #24 pushed the call light, and CNA X entered Resident #24's room at 09:55 a.m. to do her incontinent care. CNA X unfastened Resident #24's brief and cleaned her front area. CNA X assisted the resident onto her right side, revealing the brief was saturated with urine which had also soaked through to the draw sheet and fitted sheet of the bed. The sheet had a yellow ring at the edges of the soaked area. No skin issue was noted. In an interview with CNA X on 07/30/25 at 09:55 a.m. she stated she was a floater and was not assigned to Resident #24, and she was just helping where needed. In an interview on 07/30/2025 at 10:01 a.m. CNA Y stated she was assigned to Resident #24 for the morning shift on 07/30/25. She stated she did not change the resident this morning. CNA Y stated she came in to work at 05:55 a.m. She stated she checked Resident #24, and she was not wet. She stated Resident #24 liked to be changed after breakfast. Breakfast was served at 07:30 a.m. She stated the last time she checked on Resident #24 was at 7:30 a.m. and Resident #24 said she did not want to be changed. CNA Y stated Resident #24 called after breakfast at 8:30 a.m. and she was ready for incontinent care, but she stated she did not change her because they were busy picking up the trays after breakfast. CNA Y stated she was supposed to make rounds on the residents at least every 2 hours to check residents and change them if they were wet. CNA Y stated the risk of incontinent care not being provided on time would be skin break down, and infection. 3. Record review of Resident #111's face sheet dated 07/31/25 reflected a [AGE] year-old male with an admission date of 05/20/24. Record Review of Resident #111's quarterly MDS assessment, dated 06/23/25 reflected he had a BIMS score of 14 which indicated he was cognitively intact. He required moderate assistance with bathing and personal hygiene. Diagnoses included diabetes and seizure disorder (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain). Record review of Resident #111's care plan revised on 07/30/25 reflected, . [Resident #111] has an ADL self-care performance deficit related to seizures disorders, repeated falls, weakness, impaired mobility.bathing.Personal hygiene.assist x 1. Record review of the facility's shower schedule with an effective date of 11/11/24, reflected Resident #111 was scheduled for showers on Tuesday, Thursday, Saturday on the 6:00 a.m. to 02:00 p.m. shift. Record review of Resident #111's shower sheets for July 2025 reflected Resident #111 received a shower and was shaved on 07/08/25 and on 07/17/25 he received a shower but no shave by CNA S. There were no other shower sheets for Resident #111 for July 2025. In an observation and interview with Resident #111 on 07/29/25 at 11:15 a.m. the Resident was observed sitting on the side of his bed. Resident #111 was observed with a full mustache that was growing over his lip and a chin beard. Resident #111 stated he had not had shower in a week and a half. He stated he used to get a shower 3 x week, then it dropped down to 2 x week and now none. He stated the staff told him it was due to some kind of change, but he did not know what. He stated he hated having a mustache and beard and stated no one had offered to shave him. He stated he preferred to be clean shaven. In an interview with CNA V on 07/30/25 at 01:00 p.m. she stated she did not recall if she showered Resident #111 last Thursday (07/24/25). She stated they had a shower aide who provided most of the showers, so she was not sure if she showered him or if the shower aide showered him. She stated she usually did not work this hall. She stated she did not recall ever shaving Resident #111. In an interview with the Staffing Coordinator on 07/30/25 at 01:05 p.m. she stated CNA S was the assigned shower aide, but stated usually the CNA who was assigned to the resident would sign out if the shower had been given in the electronic record. She stated regardless, the staff were required to turn in a shower sheet on every resident who had a shower scheduled. She stated they were to indicate what type of bath was given, bed/or shower or if the resident had refused. She stated if the resident refused, then the nurse was supposed to talk with the resident to see if there were issues, or if they wanted it at another time. She stated if a resident continually refused, they were to reach out to the family for assistance and stated all of this should be documented in the record. She stated the nurse was responsible for signing off on the shower sheets and then turning them in to the Treatment Nurse. She stated obviously the CNAs were not doing their shower sheets as required. In an interview with CNA S on 07/30/25 at 01:10 p.m. she stated she was the assigned shower aide and worked Monday through Friday. She stated she had not been able to do all the showers in the last week because she had been pulled to do weights and assist with transportation. She stated when she was not available the CNA who was assigned to the resident was responsible for giving them their shower. She stated she was supposed to turn in a shower sheet for each resident she showered. She stated she did not shower Resident #111 any this week or last week. Attempted to reach CNA T on 07/30/25 at 01:30 p.m. who was the assigned CNA to Resident #111 on 07/29/25 (his assigned shower day). Message left, with no return call received. In an interview with ADON A on 07/30/25 at 01:45 p.m. she stated she had started at the facility 3 days ago. She stated she was still learning the facility's process and the residents. Informed ADON A of Resident #111's desire to be clean shaven and his lack of showers over the last week. She stated she would make sure he was showered and shaved today. In an observation and interview with Resident #111 on 07/31/25 at 09:00 a.m. the resident was observed to be clean shaven. Resident #111 stated he had gotten his shower and been shaved and he felt much better. 4. Record review of Resident #12's face sheet dated 07/31/25 reflected a [AGE] year-old-male with an admission date of 04/15/25. The resident's admission picture reflected he was clean shaven with short hair. Record Review of Resident #12's quarterly MDS assessment, dated 05/13/25 reflected he had a BIMS score of 9 which indicated he was moderately cognitively impaired. He was dependent on staff for all ADLS. Diagnoses included cerebral vascular accident (stroke), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body), and heart failure. Record review of Resident #12's care plan revised on 05/19/25 reflected, . [Resident #12] has an ADL self-care performance deficit related to hemiparesis (partial paralysis of one side of the body) following stroke .bathing.Personal hygiene.The resident is dependent on staff for personal hygiene and oral care. Record review of the facility's shower schedule with an effective date of 11/11/24, reflected Resident #12 was scheduled for showers on Tuesday, Thursday, Saturday on the 6:00 a.m. to 02:00 p.m. shift. Record review of Resident #12's shower sheets for July 2025 reflected he had received one shower and shave on 07/08/25 by CNA S. There were no other shower sheets for Resident #12 for July 2025. In an observation and interview on 07/29/25 at 10:16 a.m. Resident #12 was observed lying in bed with a hospital gown on. Resident stated he had a stroke which had affected his left side. Resident #12 was observed to have a full, unkept beard that was approximately an inch in length, mustache and long oily hair. Resident #12 stated he was getting bed baths but had not been shaved or had his hair washed. He stated he was not able to shave himself. In an interview with CNA R on 07/31/25 at 09:00 a.m. he stated he was assigned to Resident #12 on 07/29/25. He stated he had bathed Resident #12 but had not shaved him or washed his hair. He stated he might have shaved him about 2 weeks ago but could not be certain. He stated they were supposed to shave residents on their shower days or daily if they wanted it, but stated there were only 4 CNAs covering Hall 300 and 400 and they did not always have time to get the residents shaved. In an observation of Resident #12 on 07/31/25 at 09:10 a.m. he was observed in the common/dining room area, clean shaven and hair washed and cut. In an interview with LVN J on 07/31/25 at 10:45 a.m. she stated she had been there for 3 weeks. She stated the CNAs were supposed to turn in a shower sheet for all their assigned showers. She stated if a resident refused care the staff were supposed to let her know and she was required to follow up. She stated residents who wished to be shaved needed to be shaved daily. She stated the only way she would know if a resident had received their shower was by the shower sheets and through her observation of the residents. 5. Record review of Resident #85's quarterly MDS assessment dated [DATE] reflected Resident #85 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), cerebrovascular accident, and aphasia (a language disorder that affects a person's ability to communicate). Resident #85 had a BIMS score of 15 which indicated Resident #85's cognition was intact. Further review revealed Resident #85 functional status reflected he required extensive assistance for personal hygiene. Record review of Resident #85's Comprehensive Care Plan dated 05/08/25, reflected the following: . [Resident #85] has an ADL Self Care Performance Deficit related to Activity Intolerance, weakness and debility, decline in ADL's, Goal: [Resident #85] will maintain/improve current level of function in . Personal Hygiene.Intervention. BATHING: The resident requires (2) staff participation with bathing Record review of the facility's shower schedule with an effective date of 11/11/24, reflected Resident #85 was scheduled for showers on Tuesday, Thursday, Saturday on the 6:00 a.m. to 02:00 p.m. shift. Record review of Resident #85's shower sheets for July 2025, reflected Resident #85 received a bed bath on July 12, 2025. There were no additional shower sheets for the month of July 2025 for Resident #85. Record review of the facility grievances documentations reflected, Resident #85 had filed a grievance on 07/22/25 stating he was not getting his showers, and he needed his fingernails trimmed. Review of the grievance response by the assigned department on July 23, 2025, reflected, Resident #85 received shower and nails trimmed. Observation and interview on 07/29/25 at 1:40 p.m., Resident #85 was lying in bed. Resident #85 was noted to have a long beard about two inches in length. Resident's nails on both hands were trimmed and clean. He stated he got a bed bath once a week, but sometimes it would take a couple of weeks before he got another one. Resident #85 stated the beard did not bother him, but he would like it trimmed. He stated he was supposed to get bed baths on Tuesday, Thursday and Saturdays. Observation and interview on 07/30/25 at 09:40 a.m., revealed Resident #85 stated he did not get a bed bath yesterday (07/29/25), on his scheduled day. Resident#85 could not remember the last time he had a shower/bed bath. 6. Record review of Resident #67's MDS assessment dated [DATE] reflected Resident #67 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), cerebrovascular accident, aphasia (a language disorder that affects a person's ability to communicate), and Hemiplegia or Hemiparesis (paralysis of one side of the body/weakness on one side of the body). Resident #67 had a BIMS score of 99 which indicated she was severely cognitively impaired. Further review reflected Resident #67 was dependent on the staff for all ADLS. Record review of Resident #67's Comprehensive Care Plan, created date 06/30/25, reflected the following: .[Resident #67] has an ADL Self Care Performance Deficit related to Activity Intolerance, cerebral infarction hemiplegia/hemiparesis left side. Goal: [Resident #67] will maintain current level of function in (Total assist with Bed Mobility, Transfers.and Personal Hygiene total assist.) through the review date. Intervention. BATHING: Avoid scrubbing & pat dry sensitive skin. Provide the resident with a sponge bath when a full bath or shower cannot be tolerated.the resident is totally dependent on staff to provide a bath how often 3 x weekly and as necessary . Record review of the facility's shower schedule with an effective date of 11/11/24, reflected Resident #67was scheduled for showers on Tuesday, Thursday, Saturday on the 6:00 a.m. to 02:00 p.m. shift. Review of Resident #67's shower sheets for July 2025, reflected, Resident#67 did not receive bed bath on July 4, 2025, because not here and she received a bed bath on July 16, 2025. There were no other shower sheets for the month of July 2025. Observation on 07/29/2025 at 2:19 p.m. revealed Resident #67 was lying in bed wearing a hospital gown. Resident #67's face was sweaty, and her hair looked disheveled. She had a feeding a tube. Resident #67 was unable to participate in an interview. Observation on 07/30/2025 at 8:53 a.m. of Resident #67 during a medication pass with LVN I revealed her hair remained unkempt and disheveled. LVN I uncovered Resident#67 to access her feeding tube for medication administration. Upon removing the top sheet and raising the Resident's gown, Resident #67 was noted to have a strong body odor. In an interview on 07/30/2025 at 12:39 p.m. LVN I stated Resident #24 and Resident #85 refused showers most of the time. He stated it was documented on the shower sheets by the CNAs and they would let him know. He stated when the resident's refused he would talk to the residents to make sure they did not want their shower or bath. When asked when the last time he talked to Resident #24, and Resident #85 about their shower/bed bath refusals, he said he could not remember and would have to check the showers sheets. In an interview on 07/3025 at 12:45 p.m. LVN I stated Resident #67 LVN I got showers regularly, but did not remember if she got a shower this week. LVN I stated it was the responsibility of the assigned CNAs and the Charge Nurses to make sure residents got their showers. He stated the risk of not providing showers to the residents, they would be stinky, and he would not want that for himself. He stated it could lead to skin break down, and dignity issues.Interview on 07/31/25 at 10:09 a.m. CNA Q stated she was assigned as a shower Aide for the Residents on Hall 400 for today and had not given showers to any of the residents yet. In an interview with ADON A on 07/31/25 at 10:50 a.m. she stated they made sure everyone who needed a shower and shave received a shower and shave last night. She stated she would be educating and monitoring the CNAs on the procedure for showers, the correct documentation and turning in shower sheets. In an interview with the DON on 07/31/25 at 10:55 a.m. she stated staff were to check and change residents who were incontinent every 2 hours or more frequently if needed. She stated she expected the nurses to monitor the residents who were taken to the common area to make sure they were not left there for long periods of time without getting repositioned and checked for incontinence. She stated all resident needed to be checked before going to the dining room. She stated failing to do this placed the residents at risk of skin breakdown and a loss of dignity. The DON stated she had been working for the facility for a few weeks now, and her intervention to prevent the residents from not getting showers was to eliminate the shower aides and have the CNAs be responsible for their assigned residents according to their showers/bed bath schedule days and as needed. She stated the Charge nurses and the ADONs would be responsible for ensuring the residents were receiving their scheduled showers. 7. Record review of Resident #35's MDS dated [DATE], reflected she was a [AGE] year old female with an admission date of 05/20/2025. Diagnoses included Unspecified fracture of left femur (a fracture left thigh bone that cannot be classified into a specific category based on its appearance and location), Unspecified fracture of the lower end of right radius ( a break in the lower part of the radius bone on the right forearm), Major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities and a significant impact on daily life). Resident #35 had a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #35's care plan dated 06/06/2025 reflected she had impaired cognitive function/dementia or impaired thought process related to cirrhosis of the liver (a late-stage liver disease which impairs its ability to function properly), and Resident #35 had ADL self-care performance deficit. Observation and interview with Resident #35 on 07/29/2025 at 11:02 a.m. revealed she was sitting in her wheelchair in her room. Resident #35 had approximately 1/2 inch uneven, dirty long fingernails on both hands. Resident #35 stated none of the staff offered to trim her nails and she would like for them to be short. Interview with CNA S 07/31/2025 at 10:10 a.m. revealed she expected resident's fingernails to be trimmed and cleaned, and all the staff were responsible to make sure residents' fingernails were trimmed. She stated long fingernails increased the risk of bacterial infections and skin tears among residents. She stated she received had been in serviced on fingernail care a week ago. Interview with RN D on 07/31/2025 at 10:27 a.m. revealed she expected all resident's fingernails to be trimmed and cleaned unless the resident refused it. She stated she and all the staff were responsible to make sure the fingernails were trimmed and not trimming the fingernails increased the risk for the resident to have infections, illness and skin tear. She stated she received in service on fingernail care a week ago. Interview with LVN E on 07/31/2025 at 11:01 a.m. revealed all staff were responsible to ensure the resident's fingernails were trimmed and cleaned. She stated the nurses trimmed the fingernails if a resident had a diagnosis of diabetes, if not an aide could do it. She stated she provided care to Resident #35; she was not aware Resident #35 had long fingernails. She stated long fingernails increased the risk of bacterial infections and skin tear among residents. She stated she received in service on fingernails care that week. Interview with LVN G on 07/31/2025 at 11:14 AM revealed she expected all resident's fingernails to be trimmed and cleaned and all the staff were responsible to make sure residents' fingernails were trimmed. She stated long fingernails increased the risk of bacterial infections and skin tear among residents. She stated she received in service on fingernails care that week. Interview with CNA O on 07/31/2025 at 11:25 AM revealed all staff were responsible to ensure resident's fingernails were trimmed and cleaned. She stated she knew Resident #35 had long fingernails and long fingernails increased the risk for having skin tear and infections. She stated she received in service on fingernail care a month ago. Interview with the DON on 07/31/2025 at 12:19 PM revealed she expected all residents' fingernails to be trimmed and cleaned, and the entire nursing staff were responsible to make sure the fingernails were trimmed. She stated it was important to keep the fingernails trimmed and cleaned to ensure resident dignity, prevent infections and skin injury. She stated all the employees received in service on skin care every month and as needed. A record review of the facility's policy Perineal Care , revised June 2020, reflected Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown. Policy: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need . Record review of the facility's undated policy, Showering a Resident, reflected, Purpose: A shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors. Policy: Residents are offered a shower at a minimum of once weekly and given per resident request. Record review of undated facility policy titled, Care of the Fingernails and Toenails, Purpose: Nail care is given to clean and keep the nails trimmed. I. Fingernails are trimmed by Certified Nursing Assistants except for residents with the following conditions:A. Diabetes or circulatory impairment of the handsB. Ingrown, infected, or painful nailsC. Nails that are too hard, thick, or difficult to cut easily.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen.1. The facility failed to ensure food item in the facility walk-in refrigerator was dated, labelled and not expired.2. The facility failed to ensure food item in the facility refrigerator was dated and labelled.These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included:Observation of the facility walk in refrigerator on 07/29/2-25 at 09:14 AM revealed cabbages in a tray were not labelled or dated, butter in an open box was not dated or labelled, salad mix in two plastic bags were not labelled, an open box of dessert was not dated, shredded cabbage in a plastic bag had an expiration date of 07/23/2025. Garlic bread in a plastic bag in the refrigerator was not dated or labelled. An interview on 07/30/2025 at 02:46 PM with [NAME] Z revealed all the kitchen employees were responsible to ensure the food items were dated, labelled and not expired. She stated she expected all the food items to be dated the day she received it, put the date when the box was open, and throw any expired food item into trash. She stated dating, labelling was important to ensure the food was fresh and not expired. She stated not dating, labeling and expired food increased the risk for food poisoning and food borne illness among the residents. She stated she received training and in services on food handling every month and the most recent she received was that day. An interview with the Dietitian on 07/30/2025 at 03:06 PM revealed she expected all the food items to be dated, labelled and not expired. She stated the dietary manager was responsible to ensure all the food items were dated, labelled and not expired. She stated the staff did not have to put a date on the food item if it had the delivery date sticker by the food vendor. She stated not having a date, label, or use of expired food may cause food borne illness among the residents. She stated all the kitchen employees received in service training on dating labelling and handling food every month. She stated they did not use the expired food item and it was discarded. An interview with Dietary Aide AA on 07/30/2025 at 03:13 revealed all the kitchen employees were responsible to ensure the food items were dated, labelled and not used beyond the expiry date. He stated the cooks were responsible to ensure the food items in the refrigerator and freezer were dated, labelled and not expired. He stated dating, labeling and discarding expired food were important to ensure residents were not affected by food poisoning and illness. He stated he received in service that week on food handling, dating, labelling, discarding food items beyond the expiration date. An interview with Dietary Aide BB on 07/30/2025 at 03:20 PM revealed all the kitchen staff were responsible to ensure the food items were dated, labelled and not expired. He stated the staff were responsible to put the date the day they received the item, the date they opened a box. He stated not dating, labelling and using food beyond expiration date increased the risk of residents getting sick due to food borne illnesses. He stated he received in service training on food labeling and dating that week. An interview with the Dietary Manager on 07/30/2025 at 03:28 PM revealed all the kitchen staff were responsible to make sure the food items were dated, labelled and not expired. She stated she expected the staff to date when they received the food item, date it when they opened the box and to throw away the expired items. She stated not dating, labelling and discarding expired food could lead to food borne illness and death among the residents. Record review of the facility policy titled food labeling and dating, dated 1/25/25 reflected To establish guidelines for storing, thawing, and preparing food. Policy: Food items will be labelled, dated, stored, thawed in accordance with good sanitary practice. Procedure: I. Dietary employees will be trained regarding proper food storage procedures, labeling, and dating. II. The product name will be labelled on food items, including the original packaging, zip-lock bag, and storage bin. III. Label each package, box, can, etc., with the date of receipt. Items stored should be dated upon receipt, unless they contain a manufacture's use-by, or a date delivered. If the vendor pick stickers have the receive date or delivery date printed on the pick sticker, this can serve as a receiving date labelling. IV. The practice of First In, First Out (FIFO) will be utilized. Products that do not have an imprinted use-by or expiration date on the product will be dated when they are received and rotated as new inventory is purchased. V. Frozen bread products will be labelled with the product name, the storage box, rack or bin will be dated with the received date, the date item was pulled to thaw, and the date with the manufacture's recommended shelf-life. VI. Opening a food item can change the storage life of a product. Once a package or container is opened, the item must be labeled with an open by date and use-by date or dated with the use-by or expired on the manufacturer's recommended shelf-life. A. If the manufacturer does not include a recommended use by or expire date, the dietary staff must determine a use by date for the food item based on the Storage Period table or 7 days. Label the original packaging, Ziplock bag, bin, or container appropriate use by date. VIII. Prepackaged individual wrapped portion control items (aka PC items) will be stored in the original box, packing, container, or bin labeled with the date received on the container, and the manufacturer's recommended shelf-life date from the original container or best by date will be used for discard. If PC items are removed from the original packing and placed in a container or bin, the product name will be on the label on the bin or container. X. Expiration or use-by dates will be checked; any product that is found to be out of date will be discarded. Perishable foods and Dairy foods that have a date on them that is best if used by, Best by, or Use by will be used by or discarded on that manufacturer's date. XI. Discard foods that have exceeded their expiration date. If the product is delivered with an out-of-date expiration date, the vendor will be called, the product will be removed from usable stock

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 6 of 19 residents (Resident #25, Resident # 12, Resident #125, Resident #16, Resident # 94, Resident #102) observed for infection control. 1. The facility failed to ensure CNA U and CNA L performed hand hygiene while providing incontinence care to Resident #25 and failed to ensure CNA L placed soiled linens and clothing in a plastic bag and not the floor on 07/29/25. 2. The facility failed to ensure RN C, CNA Q, and CNAP used the required PPE for Resident #12, who was on enhanced barrier precautions due to his foley catheter during a transfer and incontinence care observation 07/30/25, and CNA Q failed to perform glove change and hand hygiene during the incontinence care. 3. The facility failed to ensure CNA N and LVN I used the required PPE for Resident#125 who was on enhanced barrier precautions due to his feeding tube and failed to ensure CNA N performed hand hygiene during the incontinence care. 4. The facility failed to ensure LVN K disinfected the blood pressure cuff in between blood pressure checks for Residents #16, Resident #94, and Resident#102 during a medication pass on 07/31/25. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of Resident #25's Face sheet dated 07/31/25 reflected a [AGE] year-old male with an admission date of 10/27/23. In an observation on 07/29/25 at 02:30 p.m. revealed CNA U, CNA L and RN C came and pushed Resident #25 into his room. All staff performed hand hygiene and put on gloves. RN C and CNA U positioned the resident's wheelchair next to the bed with him facing the head of the bed. CNA U and RN C transferred the resident to the bed. Resident #25's pants were observed to be urine soaked as was the wheelchair cushion. RN C removed his gloves, performed hand hygiene and left the room to obtain sanitizer to clean the wheelchair cushion. CNA U and CNA L rolled the resident onto his back and removed his pants. CNA L threw the urine-soaked pants onto the floor while CNA U unfastened the resident's brief and provided peri care, wiping from front to back. Both staff rolled the resident onto his side revealing the resident had a moderate size bowel movement. CNA U completed the peri-care, removed her gloves and re-gloved without performing hand hygiene. CNA L removed the soiled linen from under the resident and threw them onto the floor, on top of the resident's wet pants. CNA L did not change gloves or perform hand hygiene. Both staff placed a clean brief and clean pants onto the resident. RN C re-entered the room and wiped the wheelchair cushion with a germicidal wipe and placed a clean towel over the cushion. CNA L grabbed a plastic bag and placed the soiled linen from the floor into the bag and the wet pants into another bag in the resident's bathroom. CNA L then removed her gloves and performed hand hygiene and left the room with the bag and both CNA U and RN C and transferred the resident back to his wheelchair. Both staff then removed their gloves and performed hand hygiene. In an interview with CNA L on 07/29/25 at 02:45 p.m., she stated they were instructed to never throw dirty linens onto the floor. She stated they did not go in the room prepared with enough plastic bags. She stated she should have changed her gloves and performed hand hygiene after handling the soiled linen, but stated she did not have any hand sanitizer with her. She stated the risk for not changing gloves and throwing the dirty linen on the floor was the spread of germs. In an interview with CNA U on 07/29/25 at 03:05 p.m., she stated she was supposed to change her gloves and perform hand hygiene when going from dirty to clean. She stated she changed her gloves but forgot to perform hand hygiene. She stated she had hand sanitizer in her pocket and just forgot to use it. She stated they were never to throw dirty linens on the floor and stated she did not realize CNA L had thrown them on the floor. She stated the risk of not performing hand hygiene was cross contamination and throwing dirty linens on the floor would spread germs. 2. Record review of Resident #12's face sheet dated 07/31/25 reflected a [AGE] year-old-male with an admission date of 04/15/25. An observation on 07/30/25 at 01:55 p.m. revealed RN C, CNA P and CNA Q entered Resident #12's room to transfer him from his wheelchair to the bed. A posting outside of the resident's doorway and over the head of his bed reflected the resident was on enhanced barrier precautions. The staff had brought a mechanical lift sling (a fabric sling the resident is placed on and then hooked to a mechanical lift for transport) into the room. All three staff performed hand hygiene and put on gloves but did not put on a gown. All three staff positioned the mechanical lift sling under the resident while he was in his wheelchair. RN C unhooked the urinary drainage bag from under his wheelchair and held it below the resident's bladder while CNA P and CNA Q positioned the mechanical lift into place. After the mechanical lift was hooked to the sling, the Corporate DON who was present for the observation, prompted the staff to put on gowns. All three staff then put on a gown and transferred the resident to his bed. CNA P then removed his gown, performed hand hygiene and removed the mechanical lift from the room. RN C and CNA Q removed the resident's pants and CNA Q placed the urinary drainage bag onto the bedrail. CNA Q then opened the resident's brief and provided catheter care and then with assistance of RN C rolled the resident on his side, revealing the resident had a small soft bowel movement. CNA Q continued to provide peri-care, wiping from front to back. Once completed, CNA Q removed the soiled brief and with the same soiled gloves on, placed a clean brief under the resident. CNA P then re-entered the room and put on gloves without performing hand hygiene and did not put on a gown. He returned to the bedside and unhooked the urinary drainage bag and held it while CNA Q and RN C placed the brief under the resident. CNA Q then reached into the resident's bedside chest of drawers, still wearing the soiled gloves and retrieved a tube of barrier cream. CNA Q then applied barrier cream to Resident #12's buttocks and peri-area with the same soiled gloves. CNA Q and RN C then fastened the resident's brief, positioned him in the bed and covered him the sheets. CNA Q adjusted the head of his bed and placed his bedside table beside his bed, still wearing soiled gloves. CNA Q then gathered up the soiled linen in a bag and then all three of the staff removed their gloves and performed hand hygiene. In an interview with RN C, CNA Q and CNA P on 07/30/25 at 02:25 p.m. they all stated they had received training on enhanced barrier precautions and stated they should have had a gown on during all the care since the resident had a Foley catheter. RN C stated the risk of not following enhanced barrier precautions was the spread of MDROs. CNA Q stated she was supposed to perform glove changes and hand hygiene when she moved from one contaminated site to another. She stated she thought she had changed gloves and performed hand hygiene, but RN C stated, no you did not. He stated he was trying to signal her that she needed to change her gloves after she completed the incontinence care. Both CNA Q and RN C stated the risk to the resident was cross contamination and spread of germs and infections. 3. Record review of Resident #125's admission MDS assessment dated [DATE] reflected Resident #125 was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #125's Comprehensive Care Plan, created date 07/19/25, reflected the following, .Enhanced Barrier Precautions related to G-tube (tube inserted into the abdomen to provide nutrition) . Interventions.Staff members will wear a clean gown and gloves while performing high contact resident care activities to include Dressing, Bathing/Showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance . Observation on 07/29/25 at 12:11 p.m. revealed CNA N and LVN I entered Resident #125's room to provide incontinence care. Signage was posted at the left side of the room entrance for enhanced barrier precautions, and a PPE supply cart was inside the room at the left side of the entrance. A sign was also posted over the head of the Resident bed which indicated he was on enhanced barrier precautions. Both staff performed hand hygiene and put on gloves, but no gown. CNA N opened the residents brief which was saturated with urine. CNA N cleaned from front to back and rolled the resident on his side revealing he had a large soft bowel movement. CNA N was cleaning Resident #125 buttocks front to back, using couple of wipes at a time. CNA N's gloves became soiled with feces, and she reached into the nightstand drawer, still wearing soiled gloves, and got another box of wipes she then removed her gloves and reached into her pocket to retrieve clean gloves and put them on without performing hand hygiene. CNA N continued cleaning Resident #125, folded and removed the dirty brief, and put it in the plastic bag. CNA N removed her gloves and put on clean gloves from her pocket without performing hand hygiene. CNA N pushed the fitted sheet under Resident #125 and then got a clean fitted sheet put it on the bed and pushed it under Resident #125. CNA N got a clean draw sheet with the clean brief and placed them under Resident #125. CNA N with the help of LVN I turned Resident #125 to his left side. LVN, I removed the soiled sheet and put it in a plastic bag for linen. LVN I changed gloves and performed hand hygiene. CNA N finished putting the brief on Resident #125 LVN I pulled the fitted sheet over the bed. CNA N covered Resident#125 with clean sheet. Both staff put a clean gown on Resident #125. Both staff positioned the resident in the bed and CNA N lowered the bed down and put the fall mat back, close to the bed. LVN I removed his gloves and preformed hand hygiene, and CNA N removed her gloves and gathered the plastic bags and left the room without performing hands hygiene. In an interview with LVN I on 07/29/25 at 12:25 p.m. he acknowledged Resident #125 was on enhanced barrier precautions because of his feeding tube. He stated he was supposed to wear gloves and a gown when helping with incontinence care. LVN I stated adhering to proper hand hygiene, and wearing appropriate PPE was important to prevent the spread, and development of infection to residents. Interview on 07/29/25 at 12:28 PM CNA N acknowledged she was changing gloves without any form of hands hygiene during Resident #125's incontinence care. CNA N stated, she was supposed to wear gloves and a gown when providing incontinence care to Resident #125 because he had a feeding tube and was on enhanced barrier precautions. CNA N stated she was not supposed to carry gloves in her uniform pocket. CNA N stated she was supposed to follow proper hand hygiene and wash or sanitize his hands before putting on the clean gloves. CNA N stated she was supposed to follow facility policy related to EBP. She stated that adhering to proper hand hygiene, and wearing appropriate PPE was important to prevent the spread, and development of infection to residents. In an interview with ADON B on 07/31/2025 at 1:06 p.m. she stated she was the infection preventionist for the facility. She stated they did annual skills checks which included infection control, hand hygiene and glove use. She stated the staff had extensive training on EBP. She stated she thought because the previous DON had the gowns outside of the door, they would readily see it, but the new DON had requested the PPE be placed inside the room and she thought the staff were just overlooking it. She stated they posted signs outside of the door and in the resident's room that required EBP, so the staff should still be aware. She stated any direct contact with a resident with a Foley, feeding tube, etc. would require the use of gown and gloves to help prevent the spread of MDROs. In an interview with the DON on 05/20/25 at 4:35 p.m. she stated any resident who had any type of indwelling medical device was placed on enhanced barrier precautions to help reduce the spread of MDROs. She stated signage was posted outside to the door, which explained what PPE was to be worn and for what task the PPE was to be worn for. She stated any contact with a resident with a catheter or feeding tube required the use of gown and gloves. She stated the staff had received trainings on the use of enhanced barrier precautions. 4. Observations on 07/31/25 between 07:06 AM and 07:43 a.m. revealed LVN K coming out of Resident #94's room after checking the resident's blood pressure. LVN K placed the blood pressure cuff on top of the medication cart without sanitizing it. LVN K gave Resident #94 her morning medications. LVN K moved the medication cart to the front of Resident #102's room. LVN K retrieved the blood pressure cuff from the top of the medication cart and checked Resident #102's blood pressure. LVN K returned to the medication cart and placed the blood pressure cuff on top of the medication cart and again did not sanitize the cuff. LVN K gave Resident #102 her morning medications. LVN K moved the medication cart to the front of Resident #16's room. LVN K picked up the blood pressure cuff and checked Resident #16's blood pressure and again returned it to the top of the medication cart without sanitizing the cuff. LVN K gave Resident #16 her morning medications. In an interview with LVN K on 07/31/25 at 07:50 a.m. she stated she cleaned the blood pressure cuff at the start of her shift this morning. LVN K stated she forgot to clean the blood pressure cuff between resident's use. LVN K stated that she was supposed to use bleach wipes or sanitizing wipes to clean the equipment after each use and let it air dry between residents. LVN K stated the risk of not cleaning the cuff between each resident was cross-contamination, spread of germs, and it could harm residents who were immunocompromised [low immune system]. In an interview with the DON on 07/31/25 at 11:35 a.m. she stated all staff were expected to follow infection control policy when in the building. She stated all equipment should be cleaned between patient use according to the infection control policy. She stated there was an infection control policy specifically for equipment. The DON stated the risk to the residents was cross contamination Record review of the Facility's policy titled, Standard and Enhanced Precautions, revised January 2025, reflected, The facility will implement Standard Precautions for all residents and Enhanced Barrier Precautions (EBP) for residents at increased risk for the transmission of multidrug-resistant organisms (MDROs) or other identified pathogens. All staff must follow CDC and CMS guidelines to minimize infection risk.Enhanced Barrier Precautions.designed to reduce MDRO transmission during high-contact care activities for resident with indwelling medical devices (e.g, urinary catheters.), even when contact precautions are not otherwise indicated.Activities involving close physical contact, increasing the risk of pathogen transmission (e.g., dressing, bathing, transfers) . Record review of the facility's policy titled, Hand Hygiene, revised June 2020, reflected, .The facility considers hand hygiene the primary means to prevent the spread of infections.Facility staff.must perform hand hygiene procedures in the following circumstances.Wash hands with soap and water.when soiled with visible dirt or debris.After removing personal protective equipment PPE and before moving to another resident in the same room or exiting the room.Alcohol -based hand hygiene products can and should be used to decontaminate hands.immediately upon entering a resident occupied area .regardless of glove use.Immediately upon exiting a resident occupied area.regardless of glove use. Hand hygiene is always the final step after removing and disposing of personal protective equipment.The use of gloves does not replace hand hygiene procedures.Record review of the facility's policy titled, Cleaning and Disinfection of Environment Surfaces, revised October 2022, reflected, The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in the resident's environment.Non-critical items are those that come in contact with intact skin but no mucous membrane.Non-critical surfaces are disinfected with an EPA-registered intermediate or low-level disinfectant according to the labels safety precautions use directions.Low-level disinfection is generally appropriate for most non-critical equipment.

Based on observation, interview and record review the facility failed to ensure each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 10 of 28 residents (Resident#17, Resident#24, Resident#71, Resident#49, Resident#85, Resident#11, Resident#67 and Resident#61, Resident#125, and Resident#3, ) reviewed for residents' call system.1-The facility failed on 07/29/2025 to ensure the call light system was accessible if needed by a resident who was on the floor and that call lights were not missing the pull string, in the shared residents' toilets located inside the residents' room for the following residents: Resident#17, Resident#24, Resident#71, Resident#49, Resident#85, Resident#11, Resident#67, and Resident#612-The facility failed to provide a working communication system, that was easily at reach, that would allow Resident #3, Resident#85, and Resident#125 the ability to safely call for staff for assistance.1-Observation on 07/29/25 at 11:15 AM revealed the residents' toilet call light pull string was looped at the call light outlet and was two feet from the floor, for Resident #17 and Resident#24.2-Observation on 07/29/25 at 11:30 AM revealed the residents' toilet call light pull string was missing for Resident #71 and Resident #49.3-Observation on 07/29/25 at 1:41PM revealed the resident's toilet call light pull string was looped around the grab bar and was two feet from the floor for Resident#85, Resident #11, Resident #67 and Resident #61.Interview and observation on 07/30/25 at 2:38 PM the Maintenance Supervisor who stated he looked at the call light outlets and stated the strings needed to be within the reach of a resident who was on the floor. The Maintenance Supervisor stated he just started working with the facility for the last two weeks and he would fix them right away. The Maintenance Supervisor stated the risk to a residents was the residents could fall, not get help, and could cause someone to be lying there for hours . 4- Record review of Resident #85's quarterly MDS assessment dated [DATE] reflected Resident #85 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), cerebrovascular accident, and aphasia (a language disorder that affects a person's ability to communicate). Resident #85 had a BIMS score of 15/15 which indicated Resident #85's cognition was intact. Further review revealed Resident #85 functional status reflected extensive assistance for ADL's, including bed to wheelchair transfers.Review of Resident #85's Comprehensive Care Plan date 05/08/25, reflected the following: Focus: [Resident #85] has a communication problem r/t expressive language disorder, cerebral infraction. Goal: [Resident #85] will be able to make basic needs known on a daily basis through the review date. Intervention. Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation.An observation on 07/29/25 at 1:40 PM revealed Resident #85 was sitting up in bed, and the call light button was on the floor. Resident#85 stated he was unable to call for help. Resident #85 stated the staff put the call light cord across his chest without a cord clip, and it could fall anytime on the floor. He further stated he had been asking for a cord clip for the call light and was not provided one. He stated he could not call for help for anything. The surveyor pushed the call button for the resident. CNA M answered the call light, she gave Resident#85 his pillow and put the call light across his chest. Interview on 07/29/25 at 1:43 PM CNA M stated the call light was on the floor, and not next to Resident#85. She stated the problem was he would not be able to call for help, anything could happen to him. CNA M stated if he was incontinent, he could not call if he was having and emergency he could not call.Interview and observation on 07/30/25 at 2:38 PM the Maintenance Supervisor looked at the call light cord across Resident #85's chest and stated the cord needed to be always clipped to the resident's clothes or cover and be within the reach of the resident. The Maintenance Supervisor stated he would get a call light cord clip right away for Resident #85. The Maintenance Supervisor stated the risk to a resident was the resident could not call for help, and his needs not met. 5- Record review of Resident #125's admission MDS assessment dated [DATE] reflected Resident #125 was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hypertension (elevated blood pressure), cerebrovascular accident (a medical emergency that occurs when the blood supply to the brain is interrupted, causing brain tissue damage), and aphasia (a neurological condition that affects a person's ability to communicate). No BIMS score was documented for Resident #125. The Coding on C1000. Cognitive Skills for Daily Decision Making revealed 3. Severely impaired - never/rarely made decisions. Further review revealed Resident #125 functional status reflected extensive assistance for ADL's, including bed to wheelchair transfers.Review of Resident #125's Comprehensive Care Plan, created date 07/19/25, reflected the following: Focus: [Resident #125] is at risk for falls r/t restlessness, impaired mobility. Goal: [Resident #125] will be free of falls through the review date. Intervention. Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.Observation on 07/29/2025 at 2:09 PM revealed Resident#125 was lying in bed. The call light button was next to the side rail at the right side of the bed. Resident#125 was trying to use the call light. Resident #125 was unable to use to call light, because of shaking, and uncoordinated hands movement, and the call light ended up on the floor three feet away from the Resident #125.Interview/observation on 07/29/25 at 2:11 PM revealed ADON A entered Resident#125's room, she looked at the call light button on the floor and stated the call light button had to be close to Resident#125 where he could reach it. ADON A gave the call light button to Resident #125. Resident #125 was unable to push the button. ADON A stated, she would get him a call light device that accommodated his needs. She stated the issue was the resident would not be able to get assistance.6-Record review of Resident #3's admission record dated 7/29/25 reflected a [AGE] year-old female with an original admission date of 1/25/23 and readmission date of 10/2/24. Pertinent diagnoses included Acute or Chronic Heart failure, Acute Kidney Failure, End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), lack of coordination, need for assistance with personal care, and Morbid Obesity Record Review of Resident #3's Quarterly MDS dated [DATE] reflected a BIMS score of 13 indicating no cognitive impairment. Resident #3 used a wheelchair and had upper extremity impairment on one side and lower extremity impairment on both sides. Resident #3 was totally dependent for showering, toileting, dressing and transfers. Resident #3 was a fall risk. Record review of Resident #3's of care plan dated 7/12/25 reflected resident was a fall risk and should have her call light within reach and be encouraged to use it if needed. Observation and interview with Resident #3 in her room on 7/29/25 at 11:13am revealed the resident was yelling and stated she needed her call light and couldn't breathe. Staff entered the room immediately and put her oxygen on. The surveyor then entered the room and noted she had her oxygen on but Resident #3 asked for her call light. It was noted her call light was on her bed behind her and she was in her wheelchair and could not reach it. Interview and observation with the Staffing Coordinator in Resident #3's room on 7/29/25 at 11:13am revealed she was the staff that had turned on Resident #3's oxygen. She was asked where the call light was, and she found it on the resident's bed behind the resident's wheelchair. She stated Resident #3 should have her call light within arm's reach. She stated Resident #3 could not reach her call light where it was, and she placed it next to the resident in her wheelchair. She stated when the resident was asking for assistance with her oxygen, she made the oxygen a priority and overlooked the call light was not close to the resident. She stated the risk to the resident of not having her call light within reach were many things, she could have an emergency or needed something, and it would delay help. Interview with CNA Q on 7/30/25 at 2:41pm revealed Resident #3's call light should be pinned to her clothing when in her wheelchair. The risk to the resident for not having had the call light was she may have an emergency in which she couldn't breathe and the only thing that would help her notify staff would be the call light. Interview with LVN H on 7/30/25 at 3:09 pm revealed risk to residents not having had access to their call lights were infection related to delayed incontinent care, skin breakdowns, fluid loss, falls; there was a whole list of risks to residents. Interview with the LVN on 7/31/25 at 8:45am revealed call lights should be placed next to residents. If a resident was in their wheelchair in their room the call light should be on them. Interview with RN D on 7/31/25 at 8:53am revealed Resident #3's call light should be on her lap when in her wheelchair. RN D stated Resident #3 would yell and ask for her call light if she did not have it. The risk of Resident #3 not having had her call light would be she could be in distress or may have had an accident. Interview with the DON on 7/31/25 at 10:09 am revealed the expectation for call light placement was residents should always have the call light within reach and the call light should be placed on the resident's dominant side. She stated they in-serviced staff yesterday when she was made aware of Resident #3 not having had her call light within reach. The risk to residents of not having had their call lights within reach was delayed care. The DON stated call light string in the bathrooms supposed to be within the reach of the resident lying in the floor. Interview on 07/31/25 at 10:34 AM the Administrator stated the call light string should be within the resident's reach, so they could call for help when they need it. Interview with the Administrator on 7/31/25 at 10:57am revealed the expectation was all residents should be able to always reach their call light. She stated strings for the bathroom call lights of not been being up to standard regulation of four inches from the floor could be a safety issue. She stated the risks to the residents of not having had their call light in reach were falls or delayed care. Review of the facility policy titled Communication-Call System revised June 2020 revealed Purpose: To provide a mechanism for residents to promptly communicate with nursing staff. Policy: The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. Call bells located within resident bathrooms are considered emergency calls due to the potential for falls and injury and must be answered promptly.

Based on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his quality of life for 1 of 2 residents (Resident #61) observed for care in that: The facility failed to ensure Resident #61's urinary drainage bag (a bag at the end of an indwelling catheter that drains urine from the bladder) had a privacy cover in place on 07/29/25. This failure could affect residents in the facility who received care and could result in residents not being treated with dignity and respect.Finding included: Record review of Resident #61's MDS assessment dated [DATE] reflected Resident #61 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted [DATE]. His diagnoses included hypertension (elevated blood pressure), neurogenic bladder, type 2 diabetes (elevated blood sugar), quadriplegia (paralysis of all four limbs), and schizophrenia (a serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucination). Resident #61 had a BIMS score of 15/15 which indicated Resident #61's cognition was intact. Review of Resident #61's Comprehensive Care Plan, created date 06/16/25, reflected the following: Focus: [Resident #61] has indwelling Catheter r/t Neurogenic bladder (a condition where nerve damage affects the bladder's ability to store and release urine, leading to various urinary problems). Goal: [Resident #61] will show no signs/symptoms of Urinary infection through review date. Intervention. TOILET USE: [Resident #61] is totally dependent on staff for toilet use . Further review revealed Focus: Enhanced Barrier Precautions R/T G tube. Goal: Reduce transmission of pathogens. Interventions: Monitor for signs/symptoms of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter. [Resident#61] will have catheter change every month and as needed.Observation and interview on 07/29/25 at 2:31 PM revealed Resident #61 was observed up in a wheelchair in the lobby by the dining room entrance. He was observed with a urinary drainage bag on the right side of his chair with no privacy cover in place. Resident#61 stated he got up every day in his wheelchair between breakfast and dinner, and he stayed in the lobby, because he was a smoker, so he could go outside to smoke during the smoking time. Resident#61 did not say anything related to the drainage bag without privacy bag.In an interview on 07/29/2025 at 2:42 PM LVN G looked at Resident#61's foley catheter drainage bag and stated it needed a privacy bag. She stated not having drainage bag covered with privacy bag could affect Resident#61 dignity.In an interview on 07/31/25 at 10:34 AM the Administrator said privacy bags needed to be in place for resident's dignity. During an interview on 07/31/25 at 11:35 AM the DON said she expected her staff to ensure privacy bags were in place for residents with a urinary drainage bag. She said it was a dignity issue for the residents. She said she would be monitoring to ensure they were used going forward. Record review of a facility policy titled Notice of Resident Rights with revised date 08/2020, read To ensure that residents are fully informed of their rights during stay at the facility.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 8 residents (Residents #8, #31, & #54) reviewed for care plans.1. The facility failed to develop a comprehensive person-centered care plan that reflected Resident #8 had broken teeth and required dental follow up.2. The facility failed to develop a comprehensive person-centered care plan that reflected Resident #31's behavior of hiding cigarettes. 3. The facility failed to develop a comprehensive person-centered care plan that reflected Resident #54's diet order for large portions dated 07/10/25. These deficient practices could place residents at risk of not receiving the necessary care or services.Findings included:1. Record review of Resident #8's Quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old male, admitted to the facility on [DATE], with the diagnoses of heart failure, diabetes (high blood sugar), osteoarthritis (breakdown of cartilage) and a BIMS score of 13 (intact cognition). Record review of Resident #8's care plan, dated 07/28/25, revealed there were no care areas regarding Resident #8's teeth or dental services. Record review of Resident #8's dental assessment dated [DATE] reflected Resident #8 was seen for an assessment exam and there were 7 teeth that needed to be extracted due to broken root tips and abscessed. Record review of Resident #8's progress notes from 05/01/25-07/31/25 reflected the following physician follow up progress note, dated 05/13/25: .Diagnosis, Assessment, and Plan. Tooth decay.refer to dentist In an interview and observation on 07/29/25 at 2:09 PM with Resident #8, he stated he needed to see a dentist since March 2025 because he had broken teeth and an infection that needed to be addressed; observation revealed broken and missing teeth on the top and bottom of his mouth. He stated he thought he had been seen by the dentist twice and they looked at his teeth but he had not heard any information about a follow up exam or treatment. He stated he was not sure who was scheduling the follow up visits and the facility was aware because he mentioned it to the physician and the social worker.In an interview on 07/31/25 at 10:19 AM with the Regional Social Services Consultant revealed she was one of the social workers who covered the facility while a full-time social worker was being onboarded. She stated she was not familiar with Resident #8. She reviewed Resident #8's dental assessment dated [DATE] and stated she did not think his dental concerns were care planned because every resident needed to see the dentist. In an interview on 7/31/25 at 11:30 AM with the Administrator she stated the resident's dental issues should have been care planned. She stated care plans were important to guide the plan of care for a resident.An interview on 07/31/25 at 3:13 PM with the Regional MDS Coordinator revealed it was the responsibility of the clinical team to update acute needs. She reviewed Resident #8's care plan and noted he did not have any care areas related to dental. She stated Resident #8's dental issues, such as the ones noted in the dental visit on 3/13/25, should have been added to the care plan. She stated care plans ensured staff knew what residents' needs were and a new staff member should be able to look at a care plan and know exactly what the residents' needs were. She stated there was no risk to residents for not listing the dental concerns because the care should have been provided regardless if it was in the care plan or not. In an interview on 07/31/25 at 3:53 PM with the DON she stated she was not familiar with Resident #8 because she recently began working at the facility. 2. Record review of Resident #31's Quarterly MDS, dated [DATE], reflected she was a [AGE] year-old female, admitted to the facility on [DATE], with the diagnoses of sepsis (systemic infection), neuralgia (nerve pain), cellulitis (bacterial infection of the skin), and a BIMS score of 15 (intact cognition).Record review of Resident #31's care plan, dated 07/18/25, reflected she was a smoker and interventions included to provide assistance to the smoking area, monitor for unsafe smoking such as dropping cigarette or holding close to body and report to the nurse, and assess smoking ability quarterly. The care plan did not reflect Resident #31 had hidden cigarettes on 06/18/25 and 07/29/25.Record review of Resident #31's smoking violations dated 6/18/25 reflected cigarettes were found in Resident #31's room and were removed, Resident #31 refused to sign the smoking violation form. A smoking violation dated 07/30/25 reflected cigarettes were found in Resident #31's room and were removed with re-education provided, Resident #31 refused to sign the smoking violation form and physician and family were notified, signed by the Administrator. Record review of Resident #31's nurse's progress notes from 05/01/25 through 07/31/25 reflected a progress note dated 07/29/25, written by RN CC: Resident was observed with cigarettes in room. Resident's cigarettes are supposed to be in a box and given to resident during smoking scheduled times. Resident was reorientated with facility smoking policy. Resident 's cigarettes were taken from resident and to be given when it's a smoke scheduled time.Observation and interview on 07/29/25 at 11:56 AM with Resident #31 revealed she was in her room, seated in a chair with a bedside table in front of her with a pack of Lucky Strike cigarettes on the bedside table. Resident #31 stated she knew she was not supposed to have cigarettes in her room and was not going to put them in the smoking lock box because the last time she went to the hospital and returned to the facility her cigarettes were gone and believed they were stolen. In an interview on 07/29/25 at 12 PM with RN CC, she was informed Resident #31 had cigarettes in her room. She stated residents were not supposed to have smoking supplies in their rooms and was going to immediately speak with Resident #31. An interview on 07/30/25 at 1:03 PM with CNA DD revealed she was aware Resident #31 had hid cigarettes in her room in the past. She stated there had been a time that she searched the room for cigarettes, and she was not able to find them due to Resident #31 hiding the cigarettes. She stated Resident #31 told her she was not going to turn in the cigarettes because they had been stolen when they were in the lock box in the past. She stated the Administrator was aware. An interview on 07/31/25 at 10:19 AM with the Regional Social Services Consultant revealed she was not aware that Resident #31 had a behavior of hiding cigarettes and was not sure if it was care planned. She stated it would be important to care plan a behavior of hiding cigarettes, so all staff were aware of the behavior.An interview on 07/31/25 at 11:30 AM with the Administrator reflected they had spoken with Resident #31 regarding the cigarettes in her room and was provided a second smoking violation and educated her on the facility's smoking policy. She stated she expected residents to abide by the smoking rules and had educated residents in the past 3 resident council meetings of smoking rules she stated Resident #31's behavior of hiding cigarettes should be care planned so staff were aware of the behavior. She stated it was important for care plans to be specific and note any behaviors because it guided the resident's plan of care.In a follow up interview on 07/31/25 at 12:20 PM with RN CC she stated she was not aware Resident #31 had cigarettes or had hidden cigarettes before and she and the Administrator spoke with Resident #31 on 07/29/25 and obtained the cigarettes. She stated Resident #31 admitted to having the cigarettes when she spoke with her on 07/29/25. She stated Resident #31 told her that she hid them because she did not want to keep the cigarettes in the smoking supplies box because she thought they would be stolen. She stated it was important to care plan the behavior of hiding cigarettes to ensure staff were aware of the behavior. In an interview on 07/31/25 at 3:13 PM with the Regional MDS Coordinator she stated Resident #31 keeping cigarettes in her room should have been care planned because it was a behavioral issue. She stated that Resident #31's care plan had been updated to reflect hoarding cigarettes and was not updated until the surveyor brought it to staffs' attention. She stated care plans ensured staff knew what a residents' needs were and a new staff member should be able to look at a care plan and know exactly what the residents' needs were and their behaviors. She stated Resident #31's hoarding cigarettes in her room could pose a risk to her and other residents if she was hoarding cigarettes. 3. Record review of Resident #54's Comprehensive MDS, dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of kidney failure, fracture of right leg, and traumatic brain injury, and a BIMS score of 15 (intact cognition). Record review of Resident #54's care plan, dated 07/24/25 reflected he was at risk for malnourishment and interventions included .Provide and serve diet as ordered and did not reflect his diet order for large portions dated 07/10/25. Record review of Resident #54's physician orders reflected a large portions diet order dated 07/10/25. In an interview on 07/29/25 at 2:48 PM with Resident #54 he stated the only concern was there were times he did not receive large portions and had to ask an aide for seconds. He stated it frustrated him because it seemed to keep happening despite his meal ticket showing large portions. He stated he had spoken with the Dietary Supervisor about his concern and when the Dietary Supervisor worked, his meals were the correct portions and thought it was due to having different staff in the kitchen. An interview on 07/30/25 at 1:03 PM with CNA DD revealed Resident #54 had a double portions diet. She stated there were times as recently as last week where Resident #54 did not appear to receive large portions, and she let the kitchen know and offered an alternative meal. She stated that his meal ticket always said large portions and was not sure if it was care planned. She stated she was not sure why there were times he did not seem to receive meals as ordered. An interview on 07/30/25 at 2:08 PM with the Dietary Supervisor revealed Resident #54 had an order for large portions. She stated when Resident #54 had admitted to the facility he requested large portions, and it was reflected on his meal ticket. She stated she was not aware that he had not received large portions recently and it was important to ensure residents received their diet as ordered because the facility was their home, and it might be the way he was used to eating at home. She stated if the resident had an order for large portions, it should be care planned and was not aware that the resident's order was not care planned.An interview on 7/31/25 at 11:30 AM with the Administrator revealed she was not sure if a resident's diet for large portions was something that would be care planned. In an interview on 07/31/25 at 3:13 PM with the Regional MDS Coordinator she stated Resident #54's current care plan stated, serve diet as ordered and it should be more detailed to include the order for large portions. She stated care plans ensured staff knew what residents' needs were and a new staff member should be able to look at a care plan and know exactly what the residents' needs were. She stated there was no risk to the residents for not addressing the order for large portions because the large portions were provided regardless of if it was in the care plan or not.In an interview on 07/31/25 at 3:53 PM with the DON she stated Resident #54's diet order for large portions should be care planned because it ensured staff were aware that he was supposed to have large portions and it could negatively impact his weight. Record review of the facility's care plan policy, titled Care Planning, dated revised October 24, 2022, reflected: Purpose: To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.Procedure:I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines.II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.

Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of seven residents (Resident #25) reviewed for quality of care. 1. The Facility failed to ensure CNA N provided safe transport for Resident #25 when she walked forward pulling the resident's wheelchair backwards down the hallway and running the wheelchair footrest into the wall on 07/29/25. 2.The Facility failed to ensure CNA U and RN C used a gait belt and instead lifted Resident #25 under his arms when transferring him from his wheelchair to the bed on 07/29/25. 3. The Facility failed to ensure CNA U and RN C performed a correct gait belt transfer when they lifted the resident under his arm when transferring him from the bed to his wheelchair on 07/29/25. These failures could affect the residents by placing the residents at risk for falls, injuries, and skin tears. Findings included: Record review of Resident #25's Face sheet dated 07/31/25 reflected an admission date of 10/27/23. Record Review of Resident #25's quarterly MDS assessment, dated 07/08/25 reflected a [AGE] year-old male who had a BIMS score of 1 which indicated he was severely cognitively impaired. He was dependent for all activities of daily living and required the assistance of 2 persons to complete most activities. He was always incontinent of bladder and bowel. Diagnoses included dementia, cerebral vascular accident (stroke) and aphasia (language disorder that affects a person's ability to communicate). Review of Resident #25's care plan revised on 07/29/25 reflected, [Resident #25] had an ADL Self Care Performance Deficit related to dementia.Intervention.Transfer: The resident requires x 2 staff participation with transfers. In an observation on 07/29/25 at 11:35 a.m. Resident #25 was observed sitting in the common/dining room area in a reclining wheelchair. Attempts to interview the resident were made, but he was unable to carry on a conversation. In an observation on 07/29/25 at 2:25 p.m. CNA N was observed walking forward and pulling Resident #25 backwards in his wheelchair from the common/dining room area toward the nurses' station and down the hallway to his room. When CNA N rounded the corner at the nurse's station, the foot of the wheelchair bumped into the wall. RN C followed CNA N down the hallway and instructed CNA N to push the resident forward instead of pulling him down the hall backwards. CNA N then turned the resident around and stopped in the hallway in front of his room. She stated he was not her resident and was not sure who was coming to put him to bed. In an interview with CNA N on 07/29/25 at 02:28 p.m. she stated she was not supposed to pull the resident backward because it was a safety risk. She stated she was not aware she bumped the wall with his wheelchair. In an observation on 07/29/25 at 02:30 p.m. CNA U, CNA L and RN C came and pushed Resident #25 into his room and positioned his wheelchair next to the bed with the resident facing the head of the bed. CNA U and RN C placed their arms under the resident's arm pits and lifted him from the wheelchair to the bed without the use of a gait belt. Resident #25's legs were not extended, and his feet were not touching the ground. A gait belt was observed laying on top of the chest of drawers by the resident's bed. CNA U and CNA L rolled the resident onto his back and removed his pants. CNA U completed the peri-care and both staff placed a clean brief and clean pants onto the resident. RN C and CNA U then positioned the resident on the side of the bed and both CNA U and RN C placed the gait belt around the resident's waist. Both staff placed one of their hands on the gait belt and placed their other arm under the residents' armpits, lifting him from the bed to wheelchair. Again, his feet did not touch the ground. In an interview with RN C on 07/29/25 at 03:00 p.m. he stated Resident #25 was a 2-person transfer. He stated sometimes he can stand a little but other times he cannot. He stated he was not sure if he had been evaluated for a mechanical lift transfer but stated that would be better. He stated all two persons assist transfers which were not mechanical lift should have a gait belt. He stated they should not have lifted him by his arms because it could cause injury to the resident's shoulders. He stated he did not see the gait belt in the room and should have stopped and looked before they transferred the resident. In an interview with CNA U on 07/29/25 at 03:05 p.m. she stated they were supposed to use a gait belt anytime they assisted with a transfer. She stated a gait belt was used to help steady a resident and help prevent a fall and injury to the resident and to themselves. She stated she was not aware they could not place their arms under the residents' arm pits when using the gait belt. In an interview with PT W on 07/30/25 at 03:45 p.m. she stated she had done some new employee training with gait belts and mechanical lift transfers, but it was not something they did on a routine basis. She stated the facility's expectation for safe transfers was any resident who needed contact assistance with a transfer would need a gait belt to assist with fall recovery and or prevent falls. She stated it was never acceptable to lift a resident under the arm pits due to risk of shoulder injury. She stated both hands were to be placed on the gait belt, one in the front and one in the back. She stated Resident #25 could stand at times, but due to his poor cognition it was not consistent. In an interview with the DON on 07/31/25 at 10:55 a.m. she said it was the expectation for staff to use a gait belt when providing transfers to residents to prevent the risk of injury to the resident and the staff. She stated they had re-educated the staff last night (07/30/25) on correct transfers and were in the process of re-skills checks for the staff to ensure everyone was using the proper techniques. She stated at no time were staff to pull residents backwards, since it was a safety issue and a dignity issue. She stated she had been there for 3 weeks and was in the process of getting her systems in place. She stated going forward she and the ADONs would be responsible for ensuring staff were skills checked. Record review of the facility's policy, Transfer of Residents dated June 2020, reflected, .Mechanical lift procedures are used on any resident unable to independently pivot or transfer.Use a gait belt for transfers.Two-Person Assisted Transfer (resident who must be able to bear weight).May apply gait belt (unless contraindicated) around resident's waist securely enough to prevent sliding up over ribs.Each person will extend the arm closet to the resident forward between the resident's side and elbow. With fingers pointing downward, grasp the gait belt firmly. Instruct the resident to place their hand between your body and arm grasping the gait belt and holding on the back of your upper arm. There was no instruction on transporting residents in their wheelchair.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #3) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #3's oxygen was administered at the correct setting of 2 liters per minute on 7/29/25 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #3's admission record dated 7/29/25 reflected a [AGE] year-old female with an original admission date of 1/25/23 and readmission date of 10/2/24. Pertinent diagnoses included Acute or Chronic Heart failure, Acute Kidney Failure, End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), and Morbid Obesity. Record review of Resident #3's Order Summary Report dated 06/29/2025, and a physician order on 7/1/25 reflected O2 (oxygen) @ 2 liters per minute via Nasal Cannula every shift.Record review of Resident #3's person-centered care plan, initiated date 7/12/25 reflected .resident has Oxygen Therapy related to Ineffective gas exchange Date Initiated: 09/14/2023 Revision on: 09/08/2024.CHANGE respiratory tubing mask, bottle water q 7 days, and prn (as needed) -clean oxygen concentrator filter with soap and water, and air dry 7 days, and prn (as needed) -check o2 (oxygen) saturation qshift (every shift) and prn (as needed) ( may titrate oxygen flow rate 2-5 lpm (liters per minute) Date Initiated: 05/29/2024 Revision on: 11/01/2024 LVN O2 (oxygen) @ 2 liters per minute via Nasal Cannula as needed for To maintain 02>90 Date Initiated: 09/14/2023 Revision on: 11/07/2024 CNA LVN RN. Record review of Resident #3's Quarterly MDS assessment, dated 7/2/25 in section O-C1 reflected resident required oxygen while residing at the facility. Her BIMS score was 13 which indicated little to no impairment to cognition. In an interview and observation with Resident #3 on 07/29/2025 at 10:58 AM the resident was heard yelling from her room she needed her call light and oxygen because she couldn't breathe. The Staffing Coordinator entered the room immediately and left shortly after. The Surveyor entered the room to check on Resident #3 after the Staffing Coordinator had left. Resident #3 was observed with oxygen on via nasal cannula. The oxygen tank read 4.5 liters. Resident #3 reported she needed her oxygen on because she was having difficulty breathing and felt better now that it was on. Resident #3 stated she did not know the oxygen level her machine should have been at and had not adjusted it herself, as she could not reach it. During and interview and observation with the Staffing Coordinator on 7/29/25 at 11:13am revealed she responded to Resident #3 yelling and turned on the oxygen tank for the resident. She stated she was unsure of the oxygen orders, but the oxygen machine was usually set to where the resident needed it. She stated oxygen was typically ordered at 1 or 2 liters. She was asked to read the oxygen level on the tank and she stated it was at 4.5 liters, and she then stated oh I need to slow it down. She was observed adjusting the oxygen level and left the room to check Resident #3's orders. When she returned, she stated Resident #3's order was for 2 liters via nasal cannula and did not make any adjustments to the oxygen tank. She stated the risk to the resident of incorrect oxygen administration was administration of oxygen may not be as ordered by the physician. She stated the resident had too much oxygen going in before she adjusted it but did not know the risk for that resident of getting too much oxygen and would have to check. An observation of Resident #3 in her room on 7/29/25 at 11:15am revealed the oxygen tank was set at 3.5 liters and the resident continued to receive oxygen via nasal cannula. In an observation and interview with ADON A in Resident #3's room on 7/29/25 at 11:47am she confirmed the oxygen tank was set at 3.5 Liters. She stated she did not know what it should be at but would get a nurse from the floor and check the order. She stated she knew it was set incorrectly as she walked out of the room. ADON A returned and stated the physician order was 2 liters via nasal cannula. The Staffing Coordinator and ADON A entered the room again and corrected Resident #3's oxygen to 2 liters. The Surveyor observed the oxygen tank to be set at 2 liters. ADON A stated she was unsure of the risk to Resident #3 getting too much oxygen but stated if her oxygen had been administered 8 to 10 liters, she could become disoriented. She stated oxygen can usually be titrated between 2 and 4 liters; however, the physician order must be followed. An interview with LVN H on 7/30/25 at 3:09pm revealed if a resident was asking for their oxygen and had as needed oxygen, she would look at the physician order, verify how many liters the order stated and would place them on oxygen. She stated if the resident was on continuous oxygen, then the resident would already have been on oxygen and would verify the resident was receiving the right amount of oxygen. An interview with LVN F on 7/30/25 at 3:31pm revealed he was familiar with Resident #3 and stated she was prescribed oxygen. He stated when Resident #3 requested oxygen he would check her oxygen levels to ensure she needed it and would follow the physician orders for oxygen. He reported no risk to the resident of not giving the right amount of oxygen because he always checks the physician order before administering oxygen so it would not happen. An interview with LVN J on 7/31/25 at 8:45am revealed when a resident asked for oxygen, they checked the order and turned the oxygen on based on the physician order. She did not know the risk to residents if too much oxygen was given.An interview with RN D on 7/31/25 at 8:53am revealed Resident #3 used oxygen as needed. When Resident #3 requested her oxygen she would check the orders, check the resident's oxygen saturation and pulse and administer oxygen as ordered. She stated she knew Resident #3 was ordered to receive 2 liters of oxygen via nasal cannula. The risk of not giving Resident #3 the appropriate oxygen was she would have trouble breathing. In most cases Resident #3's oxygen levels were good. An interview with the DON on 7/31/25 at 10:09am revealed the expectation was if a resident requested oxygen, the nurses should assess oxygen saturation, and if they needed oxygen they would provide the oxygen per the doctor's order on file. The risk to the resident of not getting the appropriately ordered oxygen was the resident could become confused or hypoxic (low levels of oxygen). There was no risk for Resident #3 to have oxygen between 2 liters to 4.5 liters because it could be titrated, but they should have followed the doctor's order.An interview with the Administrator on 7/31/25 at 10:57am revealed the Staffing Coordinator was a nurse and could administer oxygen. The expectation when administering oxygen was to assess the resident, check their oxygen levels and determine if oxygen was needed. If it was ordered titrated, they adjusted the oxygen by following the physician orders. The risk to Resident #3 of giving her more oxygen than what was ordered was unknown because the care plan showed her to have titrated oxygen, but the order did not. She stated the order had been corrected since the incident occurred to match the care plan, which had titrated oxygen. Record review of the facility's policy titled Oxygen Administration revised 6/2020 reflected .I. Initiation of Oxygen A. A physician's order is required to initiate oxygen therapy. Procedure I. Explain the procedure to the resident. II. Check the physician's order. III. Wash hands IV. Assist resident to semi- or high Fowler's position (a semi-sitting body position where the head of the bed is elevated between 45 and 60 degrees), if tolerated. V. Attach oxygen tubing to nozzle on flowmeter. A. If using a high oxygen flow (> 4 liters), attach humidifier to the flowmeter. B. Attach oxygen tubing to humidifier. VI. Turn on the oxygen at the prescribed rate.

Based on observation, interview and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 8 residents (Residents #8) reviewed for dental services.The facility failed to provide and coordinate dental services for Resident #8 after a dental assessment on 03/13/25 indicated he needed 7 teeth extracted. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.Findings included:Record review of Resident #8's Quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old male, admitted to the facility on [DATE], with the diagnoses of heart failure, diabetes (high blood sugar), osteoarthritis (breakdown of cartilage) and a BIMS score of 13 (intact cognition). Record review of Resident #8's face sheet, dated 07/30/25, reflected his primary payor source was Medicaid.Record review of Resident #8's care plan, dated 07/28/25, did not reflect and care areas regarding Resident #8's teeth or dental services. Record review of Resident #8's dental assessment dated [DATE] reflected Resident #8 was seen for an assessment exam and there were 7 teeth that needed to be extracted due to broken root tips and having an abscessed. Record review of Resident #8's progress notes from 05/01/25-07/31/25 reflected the following physician follow up progress note, dated 05/13/25: .Diagnosis, Assessment, and Plan. Tooth decay.refer to dentist In an interview and observation on 07/29/25 at 2:09 PM with Resident #8, he stated he needed to see a dentist since March 2025 because he had broken teeth and an infection that needed to be addressed. Observation revealed broken and missing teeth on the top and bottom of his mouth. He stated he thought he had been seen by the dentist twice and they looked at his teeth and - he had not heard any information about a follow up exam or treatment. He stated he was not sure who was scheduling the follow up visits and the facility was aware because he mentioned it to the Physician and the Social Worker. He stated he was able to eat and experienced some discomfort at times, but it did not cause him pain.In an interview on 07/31/25 at 10:19 AM with the Regional Social Services Consultant revealed she was one of the social workers who covered the facility while a full-time social worker was being onboarded and they were responsible for coordinating dental follow up visits and referrals. She reviewed Resident #8's dental assessment dated [DATE] and stated she would have expected Resident #8 to be seen by dental services since March 2025 and would have to contact the company to determine if he was seen. She stated it was important to ensure residents had timely dental referrals and follow ups because dental issues could impact their day-to-day life. She stated residents who had broken teeth or abscesses could experience pain and difficulty eating. In an interview on 7/31/25 at 11:30 AM with the Administrator revealed she would have expected Resident #8 to have been seen by dental services since March 2025 for his root tips and dental concerns. She stated that the social worker was responsible for making referrals and follow up visits for residents. She stated the Regional Social Services Consultant and other social workers were responsible for resident social services referrals and the facility had recently hired a full-time social worker. She stated she expected dental follow ups and referrals to be timely because residents could experience pain or difficulty eating. In an interview on 07/31/25 at 3:53 PM with the DON she stated she was not familiar with Resident #8 because she recently began working at the facility. She stated dental follow ups and referrals were the responsibility of the social worker. She stated it was important to ensure residents had timely dental care follow ups to ensure they received the care they needed and did not experience discomfort, pain, or problems eating.Record review of the facility's referral policy, titled Referrals to Outside Services, dated August reflected: .Purpose: To provide residents with outside services as required by physician orders or the Care Plan.The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility. To facilitate this process, the Facility maintains service provider contracts with a variety of providers.

Based on interviews and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for 3 residents (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #1's Hydrocodone-Acetaminophen were ordered and administered according to physician's orders, causing the resident to miss 3 doses in May 2025. 2. The facility failed to ensure Resident #2's Hydrocodone-Acetaminophen were ordered and administered according to physician's orders, causing the resident to miss 2 doses in April 2025. 3. The facility failed to ensure Resident #3's Oxycodone HCL were ordered and administered according to physician's orders, causing the resident to miss 2 doses in May 2025. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status and decreased quality of life. Findings included: 1. Record review of Resident #1's face sheet, dated 6/03/25, reflected the resident was a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses that included: fibromyalgia (disease that causes widespread pain and fatigue in body), and chronic pain syndrome. Record review of Resident #1's Quarterly MDS assessment, dated 4/11/25, reflected her BIMS score was 15, which indicated the resident was cognitively intact. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most self-care ADLs and was independent with all mobility ADLs. Further review of this document under Section J-Health Conditions, reflected the resident received a scheduled pain medication regimen with pain being present rarely and mildly. Record review of Resident #1's care plan, dated 4/21/25, reflected the resident was on pain medication therapy r/t dx of pain. Interventions included: administering medication as order, asking physician to review medication if side effects persist, monitoring respirations, monitoring for altered mental status and adverse reactions, monitoring for increased risk for falls, and reviewing for pain medication efficacy (desired results). Further review of this document reflected Resident #1 required pain management (hydrocodone) d/t pain in right and left shoulder. Interventions included: honoring resident's wishes to d/c Lidocaine patches, administering analgesia (pain reliever), as ordered, anticipating the resident's need for pain relief and responding immediately, evaluating the effectiveness of pain interventions, and monitoring and documenting any side effects of pain medication. Review of Resident #1's active order summary, dated 6/03/25, reflected the resident was ordered the following medications for pain: -Biofreeze External Gel 4%-apply to left shoulder/neck topically every 12 hours as needed for acute pain. Start date: 4/15/24. -Hydrocodone-Acetaminophen oral tablet 5-325 mg-give 1 tablet by mouth five times a day (6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, 10:00 PM) related to fibromyalgia; pain in right shoulder; pain in left shoulder. Start date: 12/19/24. -Methocarbamol oral tablet 500 mg-give 1 tablet by mouth three times a day (7:00 AM, 1:00 PM, and 7:00 PM) for muscle spasms. Start date: 1/05/23. -Methocarbamol oral tablet 500 mg-give 1 tablet by mouth every 8 hours as needed. Start date: 1/05/23. Record review of Resident #1's Medication Administration Record for May 2025, reflected the following: -Hydrocodone-Acetaminophen oral tablet 5-325 mg was not administered on 5/31/25 at 10:00 AM, 2:00 PM, or 6:00 PM. Record review of Resident #1's-controlled drug administration record, dated 5/31/25, reflected the following: -Hydrocodone APAP 5-325 MG- 120 tablets were received at the facility on 5/31/25 (time not specified) and the first dose was signed out on 5/31/25 at 10:00 PM. Record review of Resident #1's progress notes, dated 5/31/25 at 1:42 PM by the ADON, reflected the following: Late Entry- [ADON] was notified by nurse that norco was unavailable. [ADON] notified [Pain Management NP] of situation N/O to hold norco give Tylenol 500mg for pain until norco arrives. In an observation and interview on 6/03/25 at 10:00 AM, Resident #1 was lying in bed in her room with no signs of distress or pain. Resident #1 stated she felt good and denied currently being in pain. She stated having no concerns at the facility except for this past weekend when they ran out of her pain medication (Hydrocodone). Resident #1 stated she could not recall the exact day, but she remembered receiving the first morning dose and the nurse telling her the MD was being called because they did not have any medication for her next dose. Resident #1 stated she received Tylenol instead of Hydrocodone for one of her doses but could not recall which dose. She stated the Tylenol helped some and she slept most of the day so she could not remember being in severe pain. Resident #1 stated by evening she was able to receive her Hydrocodone. In an interview on 6/03/25 at 12:46 PM, the ADON stated LVN C notified her that Resident #1 was out of her Hydrocodone and the Pain Management NP had been notified. The ADON stated LVN C was unable to get the medication from the emergency kit because the order at the pharmacy needed to be updated and they would not allow the Hydrocodone to be dispensed. The ADON stated the Pain Management NP gave a new order for Tylenol 3 while she worked on submitting a new order for the Hydrocodone, which arrived at the facility the same day. The ADON stated the facility had protocols in place to prevent the residents from running out of medications . She stated the nurses were able to get medication from the emergency kit, have an emergency prescription sent to a local pharmacy if there was an issue with their contracted pharmacy, or call the MD for an alternative order. In an interview on 6/03/25 at 2:27 PM, the Administrator stated she worked at the facility since 2/2025. The Administrator stated she was aware of the issue the facility was having with ensuring that medications were re-ordered on time. She stated the facility was going through a turn-over with new management and she was trying to get everyone trained. She stated she was notified about the recent incident when Resident #1 ran out of her Hydrocodone. She stated the nurses used a texting system to communicate with management, and LVN C texted on 5/31/15 at approximately 11:00 AM that Resident #1 did not have any Hydrocodone and she was unable to get a dose from the emergency kit because there was not an updated order on file. The Administrator stated the nurse notified the NP was able to get an order to administer Tylenol 3. An attempted interview on 6/03/25 at 2:45 PM with LVN C, who worked with Resident #1 when she ran out of her narcotic pain medication, was unsuccessful due to no response to call. 2. Record review of Resident #2's face sheet, dated 6/03/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had diagnosis of fractures of lower end of left radius. Record review of Resident #2's admission MDS assessment, dated 3/18/25, reflected her BIMS score was 15, which indicated the resident was cognitively intact. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required moderate assistance with most self-care ADLs and moderate assistance with most mobility ADLs. Further review of this document under Section J-Health Conditions, reflected the resident did not receive a scheduled pain medication regimen, but received PRN pain medications, with pain being present frequently with pain at a 7 on a scale from 0-10. Record review of Resident #2's care plan, dated 4/11/25, reflected the resident required pain management r/t femur and radius fracture. Interventions included: administering analgesia (pain reliever), monitoring and documenting for side effects of pain medication, and monitoring, documenting, and reporting the resident's complaints of pain and requests for pain treatment. Review of Resident #2's active order summary, dated 6/03/25, reflected the resident was ordered the following medications for pain: - Methocarbamol oral tablet 500 mg-give 1 tablet by mouth four times a day (7:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM) for pain. Start date: 3/14/25. -Oxycodone HCL oral tablet 5 mg-give 1 tablet by mouth every 4 hours (12:00 AM, 4:00 AM, 8:00 AM. 12:00 PM, 4:00 PM, and 8:00 PM) for pain. Start date: 4/15/25. Record review of Resident #2's Medication Administration Record for May 2025, reflected the following: -Oxycodone HCL oral tablet 5 mg-not administered on 5/27/25 at 12:00 AM or 4:00 AM. Resident #2 was away from the facility for doses at 8:00 AM, 12:00 PM, and 4:00 PM. Documented as administered at 8:00 PM on 5/27/25. -Pain assessment- pain level documented as 0 for day, 2 for evening, and 2 for night on 5/27/25. Record review of Resident #2's progress notes, dated 5/27/25 at 9:06 AM by LVN B, reflected the following: [LVN B] called [pharmacy] about oxycodone order reported would be on evening delivery [Resident #2] notified of above information. Record review of Resident #2's-controlled drug administration record, dated 5/27/25, reflected the following: - Oxycodone HCL oral tablet 5 mg - 120 tablets were received at the facility on 5/27/25 (time not specified) and the first dose was signed out on 5/27/25 at 8:00 PM. In an observation and interview on 6/03/25 at 10:13 AM, Resident #2 was lying in bed watching television. She did not appear to be in discomfort or pain and had her left arm propped on a pillow. Resident #2 denied being in pain and stated the staff were taking good care of her. Resident #2 stated the facility was a nice place. Resident #2 stated she did not want to get anyone in trouble but there was a time she was unable to get her pain medication (Oxycodone). Resident #2 stated she heard the nurse who forgot to reorder her pain medication had been terminated for making the same mistake with other residents, and there had been no issues since then. Resident #2 stated the day the facility was out of her Oxycodone, they gave her another pain medication, but she could not remember what it was, but it helped some. She stated she was still in a little pain, but it was tolerable. Resident #2 stated her Oxycodone was available later that day. An attempted interview on 6/03/25 at 4:28 PM with LVN B, who worked with Resident #2 when she ran out of her narcotic pain medication, was unsuccessful due to no response to call. 3. Record review of Resident #3's face sheet, dated 6/03/25, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had diagnoses that included: depression (mood disorder), multiple pressure ulcers/open wounds, chronic pain, hypotension (low blood pressure), complete traumatic amputation at level between left hip and knee and acquired absence of right leg above knee. Record review of Resident #3's Quarterly MDS assessment, dated 4/13/25, reflected her BIMS score was 15, which indicated the resident was cognitively intact. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #3 required moderate to maximal assistance with most self-care ADLs and maximal assistance with most mobility ADLs. Further review of this document under Section J-Health Conditions, reflected the resident received a scheduled pain medication regimen with pain being present frequently with pain at a 7 on a scale from 0-10. Record review of Resident #3's care plan, dated 5/15/25, reflected the resident had neuropathic pain. Interventions included: anticipating the resident's need for pain relief and responding immediately, monitoring and documenting side effects of pain medication, notifying the physician if interventions are unsuccessful or change in complaint of pain, observing and reporting any changes in usual routines. Review of Resident #3's active order summary, dated 6/03/25, reflected the resident was ordered the following medications for pain: - Hydrocodone-Acetaminophen oral tablet 10-325 mg-give 1 tablet by mouth every 4 hours (12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 8:00 PM) for pain related to neuralgia (nerve pain) and neuritis (inflammation of nerves). Start date: 3/12/25. Record review of Resident #3's Medication Administration Record for April 2025, reflected the following: -Hydrocodone-Acetaminophen oral tablet 10-325 mg- not administered on 4/13/25 at 12:00 AM or 4:00 AM. -No pain assessment monitoring scale (outside of pain scale for routine Hydrocodone-Acetaminophen administration) Record review of Resident #3's-controlled drug administration record, dated 4/13/25, reflected the following: -Hydrocodone APAP 10-325 MG- 120 tablets were received at the facility on 4/13/25 (time not specified) and the first dose was signed out on 4/14/25 at 12:00 AM. Record Review of emergency kit record for Resident #3, dated 4/13/25, reflected the following was dispensed: - Hydrocodone-Acetaminophen oral tablet 10-325 mg- dispensed on 4/13/25 at 9:59 AM , 1:27 PM, and 4:10 PM. In an observation and interview on 6/03/25 at 10:18 AM, Resident #3 did not appear to be in discomfort or pain. She stated she currently felt fine and had received all meds as ordered so far today. Resident #3 stated the facility had the potential to be great, but they kept losing their good nurses and were hiring people who were less experienced and would work for less money. Resident #3 stated because of this, the nurses were not always refilling the medication on time and would have to scramble to figure something out. Resident #3 stated the facility ran out of her Hydrocodone a few months ago. She stated they gave her Tylenol and some other alternative pain medication until they could get Hydrocodone reordered. She could not recall how much pain she was in but stated she was sure the Tylenol did something for the pain. She stated she was able to get her Hydrocodone at some point during that day. Resident #3 stated that was the only time she could recall not having her Hydrocodone available. In an interview on 6/03/25 at 4:37 PM, LVN D stated she worked at the facility since 4/05/25. She stated she worked with Resident #3 and remembered there being an issue with her insurance paying for her Hydrocodone, which was what delayed the order being refilled. LVN D stated she worked with Resident #3 on 4/13/25 when the facility ran out of her Hydrocodone. LVN D stated she called the pharmacy and NP and was able to get the Hydrocodone refilled. LVN D stated the medication came the same day and she was at the facility when it arrived. LVN D stated the nurses were responsible for administering and reordering all narcotic medications. She stated they had to reorder the medications when it got down to the blue area on the medication card that was marked for Reorder, and not wait until the last pill. LVN D stated any issues with the pharmacy or getting medications from the emergency kit would be immediately reported to the DON and MD. In an interview on 6/03/25 at 1:03 PM, the DON stated she started working at the facility on 5/14/25, so had only been there for about 3 weeks. The DON stated it was the nurses' responsibility to notify the MD and reorder narcotics as needed. The DON stated the nurses did a narcotic count with the oncoming nurse during shift change and knew when the medications were getting low and needed to be reordered. The DON stated the previous DON had a system in place for the nurses to know when to reorder the meds. She stated she was not sure how many pills had to be remaining before they could reorder. The DON stated she was still learning and working on getting her own system in place. The DON stated the facility had a Pyxis cabinet available at the facility to dispense emergency medications when needed. She stated the pharmacy did an electronic count to ensure that cabinet was always stocked with medication, and the ADON and DON were responsible for doing a manual check at least weekly. In an interview on 6/03/25 at 1:21 PM, the Pharmacy Representative, stated the pharmacy received an electronic report from the Pyxis of the available inventory and automatically sent a signal to the pharmacy when a medication was getting low and needed to be refilled. The Pharmacy Representative stated when a medication needed to be refilled, the pharmacy would send someone over to exchange the medication drawer to refill with a nurse at the facility. She stated if there was a discrepancy with a resident's medication for whatever reason and the nurse needed to get an emergency dose, they could notify the pharmacy to get a one-time access code to go into the Pyxis and get the medication. She stated this service was always available to the facility, even on the weekends. The Pharmacy Representative stated the only way the pharmacy would not allow a nurse to get a medication from the Pyxis was if there was not an active order on file for the resident. In an interview on 6/03/25 at 2:45 PM, the VP of Clinical Services stated the facility was going through a transition with new management and she was there to help with clinical issues. The VP of Clinical Services stated the previous DON left unexpectedly and the facility was without a DON for a few weeks, and that was when a lot of the issues with reordering medications came about. The VP of Clinical Services stated there were insurance issues with some of the medications and the pharmacy was sending the alerts to the previous DON's email, which the facility was not aware. She stated this caused a delay in getting some of the orders refilled on time. The VP of Clinical Services stated they have added more contacts for the pharmacy to resolve this issue. She stated she was also in-servicing the nurses on medication administration, documentation, and reordering medications in a timely manner. In an interview on 6/03/25 at 4:12 PM, the Pain Management NP stated her expectation was for the nurses to notify her 2-3 days ahead of time when an order needed a refill. She stated if the nurses did not notify her in time or if there were any other issues, they could either call the pharmacy and get a code to get the medication from the emergency kit or call her for an alternative. The Pain Management NP stated residents are sometimes on other medications for pain that would be enough to alleviate their pain until the narcotic was available. She stated Methocarbamol was used as a muscle relaxer and pain medication and was a medication that she would order as an alternative to be used for pain. She stated Resident #1 and Resident #2 were both ordered Methocarbamol to help with their pain. The Pain Management NP stated Gabapentin was another medication that was for pain, especially nerve pain, that would help alleviate pain until a narcotic was available. She stated Resident #3's pain was mostly nerve pain, and the Gabapentin would have helped alleviate her pain. The Pain Management NP stated the risk of residents not having narcotic pain medication available as ordered could be increased pain and withdrawal symptoms. Review of the facility policy titled Medication-Administration, undated, reflected in part the following: Purpose: To provide practice standards for safe administration of medications for residents in the Facility. Policy: I. Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner, or as consistent with state law. A policy regarding reordering narcotic medications was requested from the Administrator on 6/03/25 and was not received by exit.

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 2 residents reviewed for Pharmacy Services. 1. The facility failed to ensure LVN A administered medications per the Physician's Orders on 05/05/25 for Resident #1. 2. LVN A filled out a wasted form when the medication was not wasted. 3. MA B signed the wasted form even though she did not witness LVN A waste the medication. This failure could place residents at risk for worsening of their medical conditions by not receiving the therapeutic effects of medications prescribed for them, medication error, and drug diversion. Findings included: Record review of Resident #1's face sheet, dated 05/23/25, revealed Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included: transient cerebral ischemic attack (a temporary interruption of blood flow to the brain, causing symptoms similar to a stroke but with the symptoms resolving within 24 hours, usually within minutes or hours), osteoarthritis of knee (a degenerative joint disease where the protective cartilage in the knee joint breaks down, causing bones to rub together, resulting in pain, stiffness, and swelling), aftercare following joint replacement surgery, and spinal stenosis (a condition where the spaces within the spine narrow, putting pressure on the spinal cord and nerve roots), idiopathic peripheral autonomic neuropathy (nerve damage in the peripheral nervous system, specifically the autonomic nerves), and low back pain. Record review of Resident #1's MDS assessment, dated 05/04/25, revealed the resident had intact cognitive function with a BIMS score of 15. In Section J - Health Conditions for Pain Management, Resident #1 received a scheduled pain regimen, including PRN pain medications. Record review of Resident #1's Care Plan dated 05/15/25 revealed the following: Focus: [Resident #1] had diagnosis of narcotic dependence. [Resident #1] will say he did not receive pain med after it has been administered, and where corrected will say he'll watch it on video . Date Initiated: 04/29/2025 Revision on: 05/01/2025 Goal: [Resident #1] will verbalize awareness of the relationship between substance abuse and the current situation by next review date. Date Initiated: 04/29/2025 Target Date: 05/07/2025 Interventions/Tasks: Educate [Resident #1] on risks of narcotic abuse. Date Initiated: 04/29/2025 Pain management consult. Date Initiated: 04/29/2025 Psych consult. Date Initiated: 04/29/2025 Focus: [Resident #1] required pain management D/T osteoarthritis, joint replacement, spinal stenosis, lower back pain, and neuropathy. 4/5/25 - Resident readmitted to facility post-surgery. Date Initiated: 04/30/2025 Revision on: 05/15/2025 Goal: [Resident #1] will display a decrease in behaviors of inadequate pain control example irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying through the review date. Date Initiated: 04/30/2025 Revision on: 05/01/2025 Target Date: 05/07/2025 [Resident #1] will not have discomfort related to side effects of analgesia through the review date. Date Initiated: 05/01/2025 Revision on: 05/01/2025 Target Date: 05/07/2025 Interventions/Tasks: Administer analgesia (pain) medication as per orders. Give 1/2 hour before treatments or care. Date Initiated: 04/30/2025 Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 04/30/2025 Revision on: 05/01/2025 Evaluate the effectiveness of pain interventions (FREQ). Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Date Initiated: 04/30/2025 Revision on: 05/01/2025 . Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Date Initiated: 04/30/2025 Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. Date Initiated: 04/30/2025 . Record review of Resident #1' s Physician Order Summary Report, dated May 2025 reflected: 05/01/25 Pregabalin Oral Capsule 300 MG (Pregabalin) (generic for Lyrica), give 1 tablet by mouth three times a day for idiopathic peripheral autonomic neuropathy. Record review of Resident #1's Medication Administration Record (MAR) dated May 2025 reflected: 05/05/25 Pregabalin Oral Capsule 300 MG (Pregabalin) Give 1 capsule by mouth three times a day related to OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY . -Order Date- 05/01/2025 The MAR revealed: 1 Capsule on 05/05/25 at 7:00 AM administered by MA B. 1 Capsule on 05/05/25 at 1:00 PM administered by MA B. 1 Capsule on 05/05/25 at 7:00 PM administered by LVN D. Record review of Resident #1's Narcotic Record for Pregabalin 100 mg CAP (generic for Lyrica) reflected the resident was ordered to receive 1 Capsule by mouth three times a day. The resident received the following doses of Pregabalin 100 mg CAP: 1 Capsule on 05/05/25 at 7:00 AM administered by MA B. 1 Capsule on 05/05/25 at 1:00 PM administered by MA B. 1 Capsule on 05/05/25 at 7:00 PM, administered by LVN B. The total doses signed out as administered was 2 by MA B. The total doses signed out as administered was 1 by LVN D. The total doses signed out as Wasted was 1 by LVN A. Record Review of the HR File for LVN A revealed that she was employed at the facility from 03/07/25 to 05/05/25. LVN A was terminated from the facility on 05/05/25. Record review of the facility's form titled, Medication/Treatment Unusual Occurrence Report (Medication/Treatment Error) reflected on 05/05/25 during the Day Shift (6am-2pm), LVN A made a Medication Error for Resident #1 for the Lyrica. Resident #1 did not have any adverse reactions to receiving an extra dosage of Lyrica by LVN A. The Actions Taken to Correct the Error included staff In-Service/Reeducation on Medication Administration. Record review of the Correction Action Memo for LVN A and MA B revealed that on 05/05/25 both staff members received a violation for Unsatisfactory Performance and were placed on Suspension. LVN A and MA B were placed on Suspension, pending the facility's investigation regarding the dosages of medication that were given to Resident #1 on 05/05/2025. LVN A and MA B signed the Correction Action Memo on 05/05/25. Record Review of the In-Service Attendance Record for Medication Pass and Administration on 05/05/25. The subjects of the In-Service Training included Medication Pass Expectations, No Pre-Popping of Medications, Hand Hygiene, Resident Observation, Pre-Administration Protocols, MAR/Narcotic Sheet Documentation, and Privacy and Dignity. LVN A did not sign the In-Service Training due to being terminated from the facility. MA B signed the In-Service Training Attendance Sheet on 05/05/2025. An attempted telephone interview with LVN A on 05/21/25 at 11:20 AM was unsuccessful. An attempted telephone interview with LVN A on 05/21/25 at 11:42 AM was unsuccessful. An attempted telephone interview with LVN D on 05/21/25 at 11:45 AM was unsuccessful. In an interview with Resident #1 on 05/22/25 at 12:15 PM, he stated that he had been at the facility for a year. Resident #1 stated that last month (April 2025) he had surgery on his knee which post-surgery has caused him some considerable pain. Resident #1 stated that on 05/05/25, MA B gave him his routine prescriptions of Lyrica (Pregabalin 100 mg) and Oxycodone 10 mg for pain. Resident #1 stated that within an hour of receiving his pain medication from MA B, he put on his Call Light and LVN A came into his room, and he told her that he was in pain and needed some more pain medication. Resident #1 stated that LVN A told him that she would bring him some pain medication and exited him room, Resident #1 stated that some time had passed (unknown time) and LVN A returned to his room and provided him another dosage of his Lyrica (Pregabalin 100 mg) medication. Resident #1 stated that after he received his dosage of Lyrica (Pregabalin 100 mg) medication from LVN A, he realized that he received the same medication within an hour. Resident #1 stated that he then notified ADON C to inform her what occurred. Resident #1 stated that he had a camera in his room and provided the video footage to ADON C of the Medication Administration from LVN A and MA B on 05/05/25. Resident #1 stated that ADON C exited his room and notified the Administrator and both the Administrator and ADON C both returned to his room and viewed the video footage together. Resident #1 stated that after he received the double dosage of his Lyrica (Pregabalin 100 mg) medication, staff notified his PCP and then they were doing observation checks on him for 24 hours. Resident #1 stated that he felt safe at the facility, and he did not experience any harm to his body during his 24-hour Observation. Resident #1 stated that the Administrator apologized for the situation and assured that the situation will not occur again. Resident #1 stated that MA B is currently employed at the facility, but LVN A had not been at the facility since the incident occurred on 05/05/25. Resident #1 stated that the situation involving him receiving an extra dosage of medication was the first and only time since his admission that had occurred. Resident #1 stated that he has not had any issues with his Medication Administration by staff since the incident with LVN A and MA B or any other staff. Resident #1 denied that he abuses his pain medication, and he needs the pain medication to alleviate his pain due to post-surgery for his knee. In an interview with MA B on 05/22/25 at 1:04 PM, she said she had been employed at the facility as a Medication Aide for 3 months. MA B stated she worked the 6:00 AM - 2:00 PM shift with Resident #1 on 05/05/25. She said on 05/05/25, she administered 100 mg Pregabalin (Lyrica) dose to the resident 2 times. She said she documented in the medication administration record and the Narcotic Sheet that she administered the dose on 05/05/25. MA B stated that at 12:00 PM on 05/05/25, she gave Resident #1 his dosage of 100 mg Pregabalin (Lyrica). MA B stated that she gave her key to the Medication cart to LVN A prior to her lunch break. She stated that when she returned from her lunch break, LVN A gave her a Wasted Sign and she signed the Form. MA B stated that although she signed the Wasted Sign, for LVN A, she did not observe LVN A waste the 100 mg Pregabalin (Lyrica) dosage for Resident #1. MA B stated that she did not ask LVN A what she was signing, and she signed that LVN A wasted Resident #1's medication. MA B stated that she later learned that LVN A gave Resident #1 another dosage of Lyrica during her lunch break and wrote Wasted on the Narcotic Administration Record. MA B stated that she and LVN A were suspended while the facility investigated the incident involving Resident #1. MA B stated that the Administrator told her that she knowingly signed something that she did not observe, and she signed for medication that she did not observe LVN A discard. MA B stated that because she is a Certified Medication Aide, a Nurse is supposed to sign the Wasted Buster. MA B stated that she received an In-Service 1:1 Training (a meeting with two individuals, often a manager and employee, meet to discuss work, career development, and progress) for Medication Administration on 05/05/25. MA B stated that the In-Service Training gave directives not to sign anything such as Waste Busters, and there must be 2 Nurses anytime any medications were wasted. MA B stated that MA B stated that prior to 05/05/25, LVN A had never given her any document(s) to sign regarding wasting medication. MA B stated that she was told to return to work at the facility after the facility's investigation of the incident involving Resident #1 and his double dosage of Lyrica on 05/05/25. MA B stated that LVN A did not return to work at the facility after 05/05/25 and was terminated after the incident. In an interview with the Administrator on 05/22/25 at 2:57 PM, she stated that she had been employed at the facility for 3 months. She stated on 05/05/25, the ADON came to her and said that Resident #1 told her that he was administered the same pain medication by LVN A within a 45-minute timeframe of MA B administering the same medication. MA B administered Resident #1 his pain medication of Lyrica prior to going out of the facility for her scheduled lunch break. MA B said that she gave her key to the Medication Cart to LVN A prior to going on her scheduled lunch break. LVN A administered Resident #1 Lyrica during MA B's lunch break. The Administrator stated that Resident #1 received an extra dosage of the narcotic medication of Lyrica due to a verbal communication breakdown between LVN A and MA B. Resident #1 had already received his prescribed pain medication of Lyrica from MA B, who properly signed both the MAR and the Narcotic Count Sheet for Resident #1. The Administrator stated that the resident had a video camera in his room and the video footage revealed that LVN A entered Resident #1's room and Resident #1 requested more pain medication from LVN A due to having some pain issues. LVN A told the resident that she would return with some pain medication and exited Resident #1's room. LVN A did not verify the MAR and the Narcotic Count Sheet and administered Resident #1 an additional dosage of Lyrica, which resulted in Resident #1 receiving an extra dosage of Lyrica. The facility met with MA B and LVN A and both received a Corrective Action for Unsatisfactory Performance due to the medication administration error that occurred with Resident #1's Lyrica medication on 05/05/25. LVN A and MA B were both suspended pending the facility's investigation. Resident #1 was placed on 24-hour monitoring for symptoms of sedation, and/or adverse reactions. Resident #1 did not have any adverse reactions due to receiving 2 dosages of his pain medication of Lyrica that was administered by LVN A on 05/05/25. The facility notified Resident #1's PCP immediately after the incident. Resident #1 was his own RP. The Administrator stated that after the incident involving LVN A and MA B on 05/05/25, the facility did the following: 1. LVN A and MA B involved in the incident were placed on immediate suspension, pending the outcome of the facility's Investigation. MA B returned to work after the investigation was completed. LVN A was terminated after the facility's Investigation due to failure to adhere to the facility's policy of Medication Administration, and being dishonest regarding the medication waste of the medication. 2. The facility initiated a full audit on 05/05/25 of all Narcotic Count Sheets from 02/02/25 - 05/05/25 and there were not any concerns. 3. In-Service Training with all licensed Nurses and Medication Aides on The Six Rights of Medication Administration, which included: a. Right resident b. Right medication c. Right dose d. Right route e. Right time f. Right documentation 4. All staff (including Nurses and Medication Aides) completed a Clinical Competency Validation via a mock Oral Medication Administration demonstration. 5. Resident Council Meeting was held on 05/05/25 to inform and educate residents on medication safety, including the importance of notifying staff if they have already received a dosage of medication. The residents were also informed and educated on the facility's Medication Management Policy. 6. Safe Surveys were conducted with all residents to assess their perceptions of medication safety and confidence in reporting their concerns to staff. 7. A new system was implemented and required the DON to be notified prior to any medication(s) being wasted. This change was implemented due to LVN A's admission of providing false information of wasting Resident #1's medication of Lyrica during the facility's investigation. The Administrator stated that the risk of Resident #1 receiving an extra dosage of his Lyrica on 05/05/25 by LVN A was the resident could have an adverse reaction to receiving the extra dosage of medication, such as sedation. The Administrator stated that Resident #1 was under 24-hour observation after the incident, therefore there was no harm caused. In an interview with ADON C on 05/22/25 at 3:36 PM, she stated that she had been employed at the facility for 6 years. ADON C stated that she was the ADON upstairs where Resident #1 is located. ADON C stated that currently she is the ADON downstairs. ADON C stated that on 05/05/25, Resident #1 requested for her to come to speak with him in his room. ADON C stated that Resident #1 has a camera in his room and requested for her to view the Medication Administration for 05/05/25 with LVN A and MA B. ADON C stated that Resident #1's video footage did not have any sound, but they obtained a speaker to listen to the audio on the video footage. The video footage provided by Resident #1 revealed MA B gave Resident #1 his pain medication of Lyrica. ADON C stated that within almost 45 minutes (during MA B's lunch break), LVN A was observed entering his room and speaking to Resident #1. Resident #1 told ADON C that he requested some pain medication from LVN A. LVN A was observed reentering Resident #1's room and administered some medication, which was later discovered to be Lyrica to Resident #1. ADON C stated that she was able to identify LVN A and MA B on the video footage provided by Resident #1. ADON C stated that after reviewing the video footage provided by Resident #1, she notified the Administrator and told her about Resident #1 receiving the double dosage of Lyrica by LVN A and MA B on 05/05/25. ADON stated that LVN A denied that she administered the Lyrica medication to Resident #1 on the video footage provided by Resident #1. LVN A told the Administrator and ADON that she wasted the Lyrica medication for Resident #1 on 05/05/25. ADON C stated that she told LVN A that per the facility's procedures and guidelines, there were to be 2 Nurses present when medication was wasted. ADON C stated that MA B was not a Nurse, and she should have never signed the Wasted Buster. The ADON stated that LVN A and MA B were suspended pending the facility's investigation of the incident. ADON C stated that LVN A was terminated after the incident because she administered the Lyrica medication to Resident #1 but wrote on the log it was wasted and the medication was not wasted. MA B was given a 1:1 In-Service Training on Medication Administration, Guidelines and Procedures. The Nurses and MA's all received the In-Service Training and were quizzed on Medication Administration and all passed their quizzes. ADON said that the MA returned to the facility and is currently employed at the facility. ADON C stated that Resident #1 was his own RP and the staff notified his PCPs about the incident. ADON C stated that Resident #1 seeks pain medication and was only concerned about missing his next dosage of pain medication. ADON C stated that Resident #1 was placed on a 24-hour Observation, and he did not have any adverse s/s during his observation period. ADON C stated that Resident #1 stated that this was a one-time occurrence involving his Medication Administration. ADON C stated that after this incident management has implemented the procedure that required the DON to be notified prior to any medications being wasted. ADON C said that this was a one-time ordeal and the staff have not had any situations such as the one involving Resident #1 receiving an extra dosage of medication. ADON C stated that because Resident #1 was given the same dosage of his pain medication (Lyrica) within an hour, there was a risk of him becoming ill and having some adverse side effects from the medication. An attempted telephone interview with LVN A on 05/22/25 at 5:36 PM was unsuccessful. Record review of the facility's undated policy titled Medication - Administration, reflected: Purpose: To provide practice standards for safe administration of medications for residents in the Facility. Policy: I. Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner, or as consistent with state law. II. No medication will be used for any resident other than the resident for whom it was prescribed. III. Medications must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law. IV. The licensed nurse must know the following information about any medication they are administering: A. The drug's name (generic and trade) B. The drug's route of administration C. The drug's action D. The drug's indication for use and desired outcome E. The drug's usual dosage F. The drug's side effects and adverse effects G. Any precautions and special considerations V. Medications may be administered one hour before or after the scheduled medication administration time. VI. Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, may be performed as required by state law, and the results recorded. VII. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record (i.e., BP, pulse, finger stick blood glucose monitoring etc.). VIII. Medications will not be left at the bedside. IX. If the Attending Physician increases or changes a medication order, this is an automatic stop or discontinue order for the original order. X. Safe Handling of Oral Hazardous Drugs - A hazardous drug is any medication possessing at least one of the following characteristics: carcinogenicity, teratogenicity, reproductive toxicity, organ toxicity at low doses, or genotoxicity. A. Pharmacy will alert nursing to hazardous medications by placing a caution label on the medication. B. Hand hygiene and use of nitrile gloves during handling of medication will minimize exposure to hazardous drugs. XI. Administration by Unlicensed Personnel - Medications and treatments will be administered only by Licensed Medical or Licensed Nursing Staff . Procedure: . IV. Nursing Staff will keep in mind the seven rights of medication when administering medication: A. The right medication B. The right amount C. The right resident D. The right time E. The right route F. Right indication G. Right outcome V. Additional considerations include: . C. The Rule of 3 - The Licensed Nurse administering medications will perform 3 checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR). VI. Approach medication preparation task in a calm manner and do not allow for distractions during the process unless under emergent conditions. VII. The resident's MAR will be reviewed for allergies and/or special considerations for administration including: A. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the drug or biological. B. Accepted professional standards and principles. C. Vital sign parameters and lab results as appropriate. VIII. Compare the Licensed Practitioner's prescription/order with the MAR (first check). IX. Compare the Licensed Practitioner's order with the pharmacy label on the medication package (second check). X. Compare the pharmacy label and MAR (third check). XI. Any discrepancies identified during the first, second, and/or third check must be resolved prior to the administration of any medication. XII. Explain the procedure to the resident. XIII. Verify the resident's identity before administering the medication. XIV. Administer the medication to the resident. XV. The Licensed Nurse will remain with the resident until the medicine is actually swallowed. A. If resident is refusing to take medication, the Licensed Nurse who is passing the medications will initial and draw a circle around his/her initials in the designated area on the MAR. Documentation will be entered on the back of the MAR stating the reason for the refusal. B. The Licensed Nurse will re?approach the resident and attempt to give the medications at a later time, but if resident continues to refuse after one hour, the refused medications will be destroyed. Licensed Nurse will notify the Attending Physician and document in the medical record. C. If the resident repeatedly refuses medication, the Licensed Nurse will contact the physician to discuss alternative measures for medication administration. The plan of care will be updated as indicated. XVI. The Licensed Nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the MAR . XVII. Holding Medications A. Whenever a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initials. The Licensed Nurse will document the reason the medication was held on the back of the MAR. XVIII. PRN Medication Documentation A. When a PRN medication is given, it will be documented on the Medication Administration Record. The Nurse will document the date, time, and reason for giving the medication. B. The result or effectiveness of the PRN medication will be charted by the responsible Nurse on the back of the MAR or in the nursing notes. XIX. Documentation A. The time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment. B. Recording will include the date, the time and the dosage of the medication or type of the treatment. C. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record.

Based on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of two residents reviewed for medications. 1. The facility failed to ensure LVN A administered medications per the Physician's Orders on 05/05/25 for Resident #1. 2. LVN A filled out a wasted form when the medication was not wasted. 3. MA B signed the wasted form even though she did not witness LVN A waste the medication. This failure could place residents at risk for worsening of their medical conditions by not receiving the therapeutic effects of medications prescribed for them, medication error, and drug diversion. Findings included: Record review of Resident #1's face sheet, dated 05/23/25, revealed Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included: transient cerebral ischemic attack (a temporary interruption of blood flow to the brain, causing symptoms similar to a stroke but with the symptoms resolving within 24 hours, usually within minutes or hours), osteoarthritis of knee (a degenerative joint disease where the protective cartilage in the knee joint breaks down, causing bones to rub together, resulting in pain, stiffness, and swelling), aftercare following joint replacement surgery, and spinal stenosis (a condition where the spaces within the spine narrow, putting pressure on the spinal cord and nerve roots), idiopathic peripheral autonomic neuropathy (nerve damage in the peripheral nervous system, specifically the autonomic nerves), and low back pain. Record review of Resident #1's MDS assessment, dated 05/04/25, revealed the resident had intact cognitive function with a BIMS score of 15. In Section J - Health Conditions for Pain Management, Resident #1 received a scheduled pain regimen, including PRN pain medications. Record review of Resident #1's Care Plan dated 05/15/25 revealed the following: Focus: [Resident #1] had diagnosis of narcotic dependence. [Resident #1] will say he did not receive pain med after it has been administered, and where corrected will say he'll watch it on video . Date Initiated: 04/29/2025 Revision on: 05/01/2025 Goal: [Resident #1] will verbalize awareness of the relationship between substance abuse and the current situation by next review date. Date Initiated: 04/29/2025 Target Date: 05/07/2025 Interventions/Tasks: Educate [Resident #1] on risks of narcotic abuse. Date Initiated: 04/29/2025 Pain management consult. Date Initiated: 04/29/2025 Psych consult. Date Initiated: 04/29/2025 Focus: [Resident #1] required pain management D/T osteoarthritis, joint replacement, spinal stenosis, lower back pain, and neuropathy. 4/5/25 - Resident readmitted to facility post-surgery. Date Initiated: 04/30/2025 Revision on: 05/15/2025 Goal: [Resident #1] will display a decrease in behaviors of inadequate pain control example irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying through the review date. Date Initiated: 04/30/2025 Revision on: 05/01/2025 Target Date: 05/07/2025 [Resident #1] will not have discomfort related to side effects of analgesia through the review date. Date Initiated: 05/01/2025 Revision on: 05/01/2025 Target Date: 05/07/2025 Interventions/Tasks: Administer analgesia (pain) medication as per orders. Give 1/2 hour before treatments or care. Date Initiated: 04/30/2025 Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 04/30/2025 Revision on: 05/01/2025 Evaluate the effectiveness of pain interventions (FREQ). Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Date Initiated: 04/30/2025 Revision on: 05/01/2025 . Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Date Initiated: 04/30/2025 Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. Date Initiated: 04/30/2025 . Record review of Resident #1' s Physician Order Summary Report, dated May 2025 reflected: 05/01/25 Pregabalin Oral Capsule 300 MG (Pregabalin) (generic for Lyrica), give 1 tablet by mouth three times a day for idiopathic peripheral autonomic neuropathy. Record review of Resident #1's Medication Administration Record (MAR) dated May 2025 reflected: 05/05/25 Pregabalin Oral Capsule 300 MG (Pregabalin) Give 1 capsule by mouth three times a day related to OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY . -Order Date- 05/01/2025 The MAR revealed: 1 Capsule on 05/05/25 at 7:00 AM administered by MA B. 1 Capsule on 05/05/25 at 1:00 PM administered by MA B. 1 Capsule on 05/05/25 at 7:00 PM administered by LVN D. Record review of Resident #1's Narcotic Record for Pregabalin 100 mg CAP (generic for Lyrica) reflected the resident was ordered to receive 1 Capsule by mouth three times a day. The resident received the following doses of Pregabalin 100 mg CAP: 1 Capsule on 05/05/25 at 7:00 AM administered by MA B. 1 Capsule on 05/05/25 at 1:00 PM administered by MA B. 1 Capsule on 05/05/25 at 7:00 PM, administered by LVN B. The total doses signed out as administered was 2 by MA B. The total doses signed out as administered was 1 by LVN D. The total doses signed out as Wasted was 1 by LVN A. Record Review of the HR File for LVN A revealed that she was employed at the facility from 03/07/25 to 05/05/25. LVN A was terminated from the facility on 05/05/25. Record review of the facility's form titled, Medication/Treatment Unusual Occurrence Report (Medication/Treatment Error) reflected on 05/05/25 during the Day Shift (6am-2pm), LVN A made a Medication Error for Resident #1 for the Lyrica. Resident #1 did not have any adverse reactions to receiving an extra dosage of Lyrica by LVN A. The Actions Taken to Correct the Error included staff In-Service/Reeducation on Medication Administration. Record review of the Correction Action Memo for LVN A and MA B revealed that on 05/05/25 both staff members received a violation for Unsatisfactory Performance and were placed on Suspension. LVN A and MA B were placed on Suspension, pending the facility's investigation regarding the dosages of medication that were given to Resident #1 on 05/05/2025. LVN A and MA B signed the Correction Action Memo on 05/05/25. Record Review of the In-Service Attendance Record for Medication Pass and Administration on 05/05/25. The subjects of the In-Service Training included Medication Pass Expectations, No Pre-Popping of Medications, Hand Hygiene, Resident Observation, Pre-Administration Protocols, MAR/Narcotic Sheet Documentation, and Privacy and Dignity. LVN A did not sign the In-Service Training due to being terminated from the facility. MA B signed the In-Service Training Attendance Sheet on 05/05/2025. An attempted telephone interview with LVN A on 05/21/25 at 11:20 AM was unsuccessful. An attempted telephone interview with LVN A on 05/21/25 at 11:42 AM was unsuccessful. An attempted telephone interview with LVN D on 05/21/25 at 11:45 AM was unsuccessful. In an interview with Resident #1 on 05/22/25 at 12:15 PM, he stated that he had been at the facility for a year. Resident #1 stated that last month (April 2025) he had surgery on his knee which post-surgery has caused him some considerable pain. Resident #1 stated that on 05/05/25, MA B gave him his routine prescriptions of Lyrica (Pregabalin 100 mg) and Oxycodone 10 mg for pain. Resident #1 stated that within an hour of receiving his pain medication from MA B, he put on his Call Light and LVN A came into his room, and he told her that he was in pain and needed some more pain medication. Resident #1 stated that LVN A told him that she would bring him some pain medication and exited him room, Resident #1 stated that some time had passed (unknown time) and LVN A returned to his room and provided him another dosage of his Lyrica (Pregabalin 100 mg) medication. Resident #1 stated that after he received his dosage of Lyrica (Pregabalin 100 mg) medication from LVN A, he realized that he received the same medication within an hour. Resident #1 stated that he then notified ADON C to inform her what occurred. Resident #1 stated that he had a camera in his room and provided the video footage to ADON C of the Medication Administration from LVN A and MA B on 05/05/25. Resident #1 stated that ADON C exited his room and notified the Administrator and both the Administrator and ADON C both returned to his room and viewed the video footage together. Resident #1 stated that after he received the double dosage of his Lyrica (Pregabalin 100 mg) medication, staff notified his PCP and then they were doing observation checks on him for 24 hours. Resident #1 stated that he felt safe at the facility, and he did not experience any harm to his body during his 24-hour Observation. Resident #1 stated that the Administrator apologized for the situation and assured that the situation will not occur again. Resident #1 stated that MA B is currently employed at the facility, but LVN A had not been at the facility since the incident occurred on 05/05/25. Resident #1 stated that the situation involving him receiving an extra dosage of medication was the first and only time since his admission that had occurred. Resident #1 stated that he has not had any issues with his Medication Administration by staff since the incident with LVN A and MA B or any other staff. Resident #1 denied that he abuses his pain medication, and he needs the pain medication to alleviate his pain due to post-surgery for his knee. In an interview with MA B on 05/22/25 at 1:04 PM, she said she had been employed at the facility as a Medication Aide for 3 months. MA B stated she worked the 6:00 AM - 2:00 PM shift with Resident #1 on 05/05/25. She said on 05/05/25, she administered 100 mg Pregabalin (Lyrica) dose to the resident 2 times. She said she documented in the medication administration record and the Narcotic Sheet that she administered the dose on 05/05/25. MA B stated that at 12:00 PM on 05/05/25, she gave Resident #1 his dosage of 100 mg Pregabalin (Lyrica). MA B stated that she gave her key to the Medication cart to LVN A prior to her lunch break. She stated that when she returned from her lunch break, LVN A gave her a Wasted Sign and she signed the Form. MA B stated that although she signed the Wasted Sign, for LVN A, she did not observe LVN A waste the 100 mg Pregabalin (Lyrica) dosage for Resident #1. MA B stated that she did not ask LVN A what she was signing, and she signed that LVN A wasted Resident #1's medication. MA B stated that she later learned that LVN A gave Resident #1 another dosage of Lyrica during her lunch break and wrote Wasted on the Narcotic Administration Record. MA B stated that she and LVN A were suspended while the facility investigated the incident involving Resident #1. MA B stated that the Administrator told her that she knowingly signed something that she did not observe, and she signed for medication that she did not observe LVN A discard. MA B stated that because she is a Certified Medication Aide, a Nurse is supposed to sign the Wasted Buster. MA B stated that she received an In-Service 1:1 Training (a meeting with two individuals, often a manager and employee, meet to discuss work, career development, and progress) for Medication Administration on 05/05/25. MA B stated that the In-Service Training gave directives not to sign anything such as Waste Busters, and there must be 2 Nurses anytime any medications were wasted. MA B stated that MA B stated that prior to 05/05/25, LVN A had never given her any document(s) to sign regarding wasting medication. MA B stated that she was told to return to work at the facility after the facility's investigation of the incident involving Resident #1 and his double dosage of Lyrica on 05/05/25. MA B stated that LVN A did not return to work at the facility after 05/05/25 and was terminated after the incident. In an interview with the Administrator on 05/22/25 at 2:57 PM, she stated that she had been employed at the facility for 3 months. She stated on 05/05/25, the ADON came to her and said that Resident #1 told her that he was administered the same pain medication by LVN A within a 45-minute timeframe of MA B administering the same medication. MA B administered Resident #1 his pain medication of Lyrica prior to going out of the facility for her scheduled lunch break. MA B said that she gave her key to the Medication Cart to LVN A prior to going on her scheduled lunch break. LVN A administered Resident #1 Lyrica during MA B's lunch break. The Administrator stated that Resident #1 received an extra dosage of the narcotic medication of Lyrica due to a verbal communication breakdown between LVN A and MA B. Resident #1 had already received his prescribed pain medication of Lyrica from MA B, who properly signed both the MAR and the Narcotic Count Sheet for Resident #1. The Administrator stated that the resident had a video camera in his room and the video footage revealed that LVN A entered Resident #1's room and Resident #1 requested more pain medication from LVN A due to having some pain issues. LVN A told the resident that she would return with some pain medication and exited Resident #1's room. LVN A did not verify the MAR and the Narcotic Count Sheet and administered Resident #1 an additional dosage of Lyrica, which resulted in Resident #1 receiving an extra dosage of Lyrica. The facility met with MA B and LVN A and both received a Corrective Action for Unsatisfactory Performance due to the medication administration error that occurred with Resident #1's Lyrica medication on 05/05/25. LVN A and MA B were both suspended pending the facility's investigation. Resident #1 was placed on 24-hour monitoring for symptoms of sedation, and/or adverse reactions. Resident #1 did not have any adverse reactions due to receiving 2 dosages of his pain medication of Lyrica that was administered by LVN A on 05/05/25. The facility notified Resident #1's PCP immediately after the incident. Resident #1 was his own RP. The Administrator stated that after the incident involving LVN A and MA B on 05/05/25, the facility did the following: 1. LVN A and MA B involved in the incident were placed on immediate suspension, pending the outcome of the facility's Investigation. MA B returned to work after the investigation was completed. LVN A was terminated after the facility's Investigation due to failure to adhere to the facility's policy of Medication Administration, and being dishonest regarding the medication waste of the medication. 2. The facility initiated a full audit on 05/05/25 of all Narcotic Count Sheets from 02/02/25 - 05/05/25 and there were not any concerns. 3. In-Service Training with all licensed Nurses and Medication Aides on The Six Rights of Medication Administration, which included: a. Right resident b. Right medication c. Right dose d. Right route e. Right time f. Right documentation 4. All staff (including Nurses and Medication Aides) completed a Clinical Competency Validation via a mock Oral Medication Administration demonstration. 5. Resident Council Meeting was held on 05/05/25 to inform and educate residents on medication safety, including the importance of notifying staff if they have already received a dosage of medication. The residents were also informed and educated on the facility's Medication Management Policy. 6. Safe Surveys were conducted with all residents to assess their perceptions of medication safety and confidence in reporting their concerns to staff. 7. A new system was implemented and required the DON to be notified prior to any medication(s) being wasted. This change was implemented due to LVN A's admission of providing false information of wasting Resident #1's medication of Lyrica during the facility's investigation. The Administrator stated that the risk of Resident #1 receiving an extra dosage of his Lyrica on 05/05/25 by LVN A was the resident could have an adverse reaction to receiving the extra dosage of medication, such as sedation. The Administrator stated that Resident #1 was under 24-hour observation after the incident, therefore there was no harm caused. In an interview with ADON C on 05/22/25 at 3:36 PM, she stated that she had been employed at the facility for 6 years. ADON C stated that she was the ADON upstairs where Resident #1 is located. ADON C stated that currently she is the ADON downstairs. ADON C stated that on 05/05/25, Resident #1 requested for her to come to speak with him in his room. ADON C stated that Resident #1 has a camera in his room and requested for her to view the Medication Administration for 05/05/25 with LVN A and MA B. ADON C stated that Resident #1's video footage did not have any sound, but they obtained a speaker to listen to the audio on the video footage. The video footage provided by Resident #1 revealed MA B gave Resident #1 his pain medication of Lyrica. ADON C stated that within almost 45 minutes (during MA B's lunch break), LVN A was observed entering his room and speaking to Resident #1. Resident #1 told ADON C that he requested some pain medication from LVN A. LVN A was observed reentering Resident #1's room and administered some medication, which was later discovered to be Lyrica to Resident #1. ADON C stated that she was able to identify LVN A and MA B on the video footage provided by Resident #1. ADON C stated that after reviewing the video footage provided by Resident #1, she notified the Administrator and told her about Resident #1 receiving the double dosage of Lyrica by LVN A and MA B on 05/05/25. ADON stated that LVN A denied that she administered the Lyrica medication to Resident #1 on the video footage provided by Resident #1. LVN A told the Administrator and ADON that she wasted the Lyrica medication for Resident #1 on 05/05/25. ADON C stated that she told LVN A that per the facility's procedures and guidelines, there were to be 2 Nurses present when medication was wasted. ADON C stated that MA B was not a Nurse, and she should have never signed the Wasted Buster. The ADON stated that LVN A and MA B were suspended pending the facility's investigation of the incident. ADON C stated that LVN A was terminated after the incident because she administered the Lyrica medication to Resident #1 but wrote on the log it was wasted and the medication was not wasted. MA B was given a 1:1 In-Service Training on Medication Administration, Guidelines and Procedures. The Nurses and MA's all received the In-Service Training and were quizzed on Medication Administration and all passed their quizzes. ADON said that the MA returned to the facility and is currently employed at the facility. ADON C stated that Resident #1 was his own RP and the staff notified his PCPs about the incident. ADON C stated that Resident #1 seeks pain medication and was only concerned about missing his next dosage of pain medication. ADON C stated that Resident #1 was placed on a 24-hour Observation, and he did not have any adverse s/s during his observation period. ADON C stated that Resident #1 stated that this was a one-time occurrence involving his Medication Administration. ADON C stated that after this incident management has implemented the procedure that required the DON to be notified prior to any medications being wasted. ADON C said that this was a one-time ordeal and the staff have not had any situations such as the one involving Resident #1 receiving an extra dosage of medication. ADON C stated that because Resident #1 was given the same dosage of his pain medication (Lyrica) within an hour, there was a risk of him becoming ill and having some adverse side effects from the medication. An attempted telephone interview with LVN A on 05/22/25 at 5:36 PM was unsuccessful. Record review of the facility's undated policy titled Medication - Administration, reflected: Purpose: To provide practice standards for safe administration of medications for residents in the Facility. Policy: I. Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner, or as consistent with state law. II. No medication will be used for any resident other than the resident for whom it was prescribed. III. Medications must be given to the resident by the Licensed Nurse preparing the medication, or as consistent with state law. IV. The licensed nurse must know the following information about any medication they are administering: A. The drug's name (generic and trade) B. The drug's route of administration C. The drug's action D. The drug's indication for use and desired outcome E. The drug's usual dosage F. The drug's side effects and adverse effects G. Any precautions and special considerations V. Medications may be administered one hour before or after the scheduled medication administration time. VI. Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, may be performed as required by state law, and the results recorded. VII. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record (i.e., BP, pulse, finger stick blood glucose monitoring etc.). VIII. Medications will not be left at the bedside. IX. If the Attending Physician increases or changes a medication order, this is an automatic stop or discontinue order for the original order. X. Safe Handling of Oral Hazardous Drugs - A hazardous drug is any medication possessing at least one of the following characteristics: carcinogenicity, teratogenicity, reproductive toxicity, organ toxicity at low doses, or genotoxicity. A. Pharmacy will alert nursing to hazardous medications by placing a caution label on the medication. B. Hand hygiene and use of nitrile gloves during handling of medication will minimize exposure to hazardous drugs. XI. Administration by Unlicensed Personnel - Medications and treatments will be administered only by Licensed Medical or Licensed Nursing Staff . Procedure: . IV. Nursing Staff will keep in mind the seven rights of medication when administering medication: A. The right medication B. The right amount C. The right resident D. The right time E. The right route F. Right indication G. Right outcome V. Additional considerations include: . C. The Rule of 3 - The Licensed Nurse administering medications will perform 3 checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR). VI. Approach medication preparation task in a calm manner and do not allow for distractions during the process unless under emergent conditions. VII. The resident's MAR will be reviewed for allergies and/or special considerations for administration including: A. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the drug or biological. B. Accepted professional standards and principles. C. Vital sign parameters and lab results as appropriate. VIII. Compare the Licensed Practitioner's prescription/order with the MAR (first check). IX. Compare the Licensed Practitioner's order with the pharmacy label on the medication package (second check). X. Compare the pharmacy label and MAR (third check). XI. Any discrepancies identified during the first, second, and/or third check must be resolved prior to the administration of any medication. XII. Explain the procedure to the resident. XIII. Verify the resident's identity before administering the medication. XIV. Administer the medication to the resident. XV. The Licensed Nurse will remain with the resident until the medicine is actually swallowed. A. If resident is refusing to take medication, the Licensed Nurse who is passing the medications will initial and draw a circle around his/her initials in the designated area on the MAR. Documentation will be entered on the back of the MAR stating the reason for the refusal. B. The Licensed Nurse will re?approach the resident and attempt to give the medications at a later time, but if resident continues to refuse after one hour, the refused medications will be destroyed. Licensed Nurse will notify the Attending Physician and document in the medical record. C. If the resident repeatedly refuses medication, the Licensed Nurse will contact the physician to discuss alternative measures for medication administration. The plan of care will be updated as indicated. XVI. The Licensed Nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the MAR . XVII. Holding Medications A. Whenever a medication is held for any reason, the Licensed Nurse will initial the appropriate area on the MAR and circle his/her initials. The Licensed Nurse will document the reason the medication was held on the back of the MAR. XVIII. PRN Medication Documentation A. When a PRN medication is given, it will be documented on the Medication Administration Record. The Nurse will document the date, time, and reason for giving the medication. B. The result or effectiveness of the PRN medication will be charted by the responsible Nurse on the back of the MAR or in the nursing notes. XIX. Documentation A. The time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administers the drug or treatment. B. Recording will include the date, the time and the dosage of the medication or type of the treatment. C. Initials may be used, provided that the signature of the person administering the medication or treatment is also recorded on the medication or treatment record.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of six residents reviewed for care plan. The facility failed to ensure Resident #1's care plan was revised to reflect person centered interventions for pain and physical therapy. This failure could place the resident at risk of current needs not being met. Findings included: Record review of Resident #1's Admission Record dated 5/1/25 reflected a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15 indicating he was cognitively intact. He had been receiving scheduled pain medications including opiates. His diagnoses included Hypertension (high blood pressure); spinal stenosis (tight spaces between bones of the spine that can cause pressure on the spinal cord causing pain, tingling, or weakness in extremities); low back pain and other reduced mobility. Record review of Resident #1's Order Recap Report dated 5/1/25 reflected the following orders: PT clarification order: Patient to be seen 5x/period 30 days for presence of left artificial knee joint, and generalized muscle weakness. Order dated 4/5/25 and discontinued 4/10/25. PT Clarification: Patient to be seen 5x/week for 30 days for spinal stenosis and generalized muscle weakness. Order dated 4/10/25. Oxycodone Hcl 10 mg. Give two tablets every 4 hours for pain. Order dated 4/6/25. Pregabalin 300 mg three times a day for neuropathy (nerve pain). Order date 4/5/25. Record review of Resident #1's hospital records dated 4/22/25 reflected he had received a left total knee arthroplasty (knee replacement) and hardware removal on 3/26/25. His discharge recommendations included: multimodal pain management per attending [physician] .PT/OT/CM: Encourage OOB to chair and ambulate daily with nursing and/or therapy . Record review of Resident #1's Progress noted reflected the following: An entry dated 4/6/25 at 12:03 AM: Note Text: 4/5/25 @ 12:47 [PM], readmitted res to facility from [hospital name] via stretcher accompanied by three attendants, Dx; left knee replacement. a/ox4 [alert and oriented to person, place, time, and situation], vs; BP 109/95, HR 98, Resp 18, Temp 97.6, 02 sat 96%RA, c/o left knee pain, prn oxycodone given as ordered, resp even and unlabored. no s/s of distress noted at this time. surgical wound to left knee, r/t left knee replacement, wound dressing dry, clean and intact. no s/s of infection noted at this time. per hospital report received over the phone, cleanse wound to left knee with wound cleanser, and apply dry dressing daily until 4/8/25, then may left [sic] open to air. Medication list verified with HCP and updated in EMAR/ETAR for pharmacy delivery. Weekend RN supervisor aware of res arrival, DON, and MD notified. nursing staff will continue to monitor res for any changes. Record review of Resident #1's Care Plan Report retrieved 5/1/25 reflected the following entries: Entry initiated 4/14/25 and Revised 4/28/25, Focus: The resident is resistive to care r/t anxiety/pain. Interventions/Tasks included: Allow the resident to make decisions about treatment regime, to provide sense of control . Educate resident on risks of not obtaining weight as ordered .Explain the risks of refusing wound care . Give clear explanation of all care activities prior to and as they occur during each contact . Entry initiated 4/29/25, Focus: Patient has diagnosis of narcotic dependence. Interventions/Tasks included: Educate resident on risks of narcotic abuse .Pain Management consult .Psych consult . No entries were located with a focus on pain management or physical therapy. During an observation and interview on 4/29/25 at 11:18 AM, Resident #1 was observed lying in bed. He stated he was upset the facility had not increased his pain medication doses following his recent knee surgery. He stated he was unhappy with his pain management physician and Nurse Practitioner for refusing to increase his medication doses. He stated they had offered other medications, and he did not wish to take them. Resident #1 stated he was exploring his other options including moving to another facility or getting a new pain management physician. Resident #1 stated he had not received any physical therapy since returning to the facility after surgery. He stated he had returned to the hospital twice over the past month for other issues related to his knee but did not know why he had not received any therapy. During an interview on 4/29/25 at 11:36 AM, LVN C stated Resident #1 was unhappy with his pain medication regimen. She stated he received scheduled pain medications every 4 hours and had initially received a higher dose upon return from the hospital and he wanted to continue it. She stated the pain NP, (NP D) saw him regularly and had explained to him why they could not increase his dose. She stated he had also met with the Pain Management physician as well as the Medical Director about the issue and they were also giving him other medications such as muscle relaxers for his pain. LVN C stated she believed he had received physical therapy but could not say whether he was receiving any at that time. She stated she was unsure whether either issue had been care planned but knew the pain was addressed frequently. During an interview on 4/30/25 at 11:06 AM, the Director of Therapy reviewed Resident #1's notes and stated he had received physical therapy. She stated he had initially been declined by his insurance company but the Administrator approved therapy payment for him. She stated he had received a full evaluation and received services five times before leaving to go back to the hospital. She stated the facility continued to work with his insurance company to approve coverage, but the process had been stalled by repeated trips to the hospital and had to be restarted. She stated she was scheduled that day for another evaluation and re-initiation of therapy. During an interview on 5/1/25 at 4:00 PM, with the Administrator and Regional Nurse Consultant, the Administrator stated care plans were typically initiated within 48 hours of admission or readmission. The Administrator reviewed Resident #1's medical record during the interview. She stated she did not know why pain did not trigger as a focus area for his care plan and noted pain management was included as an intervention for a previous fall he had had. She stated she was unsure whether it was important for his therapy to be included in his nursing care plan as he was receiving therapy services. The Regional Nurse Consultant stated his assessments and care planning had been complicated a bit due to the fact he had returned to the hospital twice since his readmission. The Administrator stated she was responsible for ensuring Resident Care Plans were completed as well as the interdisciplinary team. She stated they met as a team to review all aspects of the resident's care. The Administrator stated the risk for insufficient care plan included the potential for insufficient care, but she felt Resident #1 was having his pain and therapy needs met as he was followed by a pain management group and was receiving physical therapy. Record review of the facility's policy titled, Care Planning, dated revised 6/2020 reflected the following: Purpose To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Policy: I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines. II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs . Procedure: The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission. The Baseline Care Plan will include at least the following information: A. Initial goals based on admission orders B. Physician orders C. Dietary orders D. Therapy services . IV. The Baseline Care Plan will be updated to reflect changes in the resident's condition or needs occurring prior to the development of the Comprehensive Care Plan .VIII. A comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. A. In the event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and provided to the resident and/or resident's representative. B. Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. These subsequent changes will not need to be reflected through updates to the Baseline Care Plan XI. The Comprehensive Care Plan must be prepared by the IDT team. The IDT team includes the following individuals: A. The Attending Physician; B. The Resident Assessment Coordinator; C. The Licensed Nurse who has responsibility for the resident; . G. Therapists as applicable; H. Consultants (as appropriate) .

Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one resident (Resident #1) of three residents reviewed for discharge planning. -The facility failed to provide or document sufficient preparation for an orderly discharge of Resident #1. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge, which could cause physical and emotional harm. Findings included: Record review of Resident #1's face sheet, dated 04/04/2025, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and discharged on 03/13/2024 with diagnoses that included: cerebral ischemia (a condition where the brain does not receive enough blood flow, resulting in a lack of oxygen and nutrients. This can lead to brain damage.), Generalized Anxiety Disorder (a mental health condition characterized by excessive, persistent, and often unrealistic worry about everyday things, which can significantly impact daily life and cause distress.), hypertensive urgency (is a condition where blood pressure is significantly elevated but there is no evidence of acute organ damage.) Lack of coordination, Cognitive communication deficit (difficulties in communication skills from cognitive impairments, attention, memory .). Record review of Resident #1's Quarterly MDS assessment, dated 03/12/2025, reflected in Section A0310 G was left blank for unplanned or planned discharge. Section A1010 was left blank for race. the resident had a BIMS score of 15 which indicated no cognitive impairment. The MDS assessment reflected Resident #1 was independent with most ADLs; however, the resident required moderate assistance and/or supervision with hygiene, and upper body dressing. Further review reflected Resident #1 had a mood of feeling down, depressed, or hopeless several days at a time. Resident #1 had a behavior of physical behavioral symptoms toward others and rejecting assessments care 1 to 3 days. Resident #1 was occasionally incontinent for urine and frequently incontinent with bowel. Section Q participation in assessment and goal setting .Q0610 referral to Local contact agency indicated no. Section I0620 Reason referral to local contact agency (LCA) not made reflected 5 (discharge date more than 3 months away. The MDS did not address resident returning to the community, due to this being his quarterly MDS. The quarterly MDS signature included LMSW signature for completion of Sections B, C, D, E, Q. However, section A was completed with entry discharge reporting (none of the above). The facility had not completed a discharge MDS for Resident #1. Record review of Resident #1's care plan, dated 03/12/2025, reflected Resident #1 wishes to return/ discharge to home. Encourage resident to discuss feelings, and concerns impeding discharge, monitor for and address episodes of anxiety, fear, distress, establish a pre-discharge plan with the resident/family/caregivers) and evaluate progress and revise plan, evaluate residents' motivation to return to the community. Resident has potential for an ADL Self Care Performance Deficit r/t Cerebral ischemia, Degenerative disease of the nervous system and diabetes Monitor/document/report to MD PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record review of Resident #1's MD orders reflected no discharge orders for the resident. Record review of Resident #1's electronic documents dated 02/27/2025 revealed a 30 day discharge notice that reflected this letter is written in notification to [Resident #1] will be discharged from [facility] effective 30 days from the date of this letter March 28, 2025, this discharge is based on failure to pay the facility staff will work with you to make the preparations needed to ensure a safe and orderly transition .should you prefer to be discharged to another facility we will assist with relocating an appropriate alternate placement .you have a right to appeal this decision . signed by the ADM Further review Resident #1's MD orders reflected that there was not a discharge order. Record review of the facility discharge report dated 04/04/2025, reflected [Resident #1] was discharged on 03/13/2025 at 5:15 PM . discharge status: discharged /transferred to SNF. Record review of Resident #1's progress note dated 3/13/2025 at 05:07 AM Communication with Resident/Family Late Entry: The ADON and Administrator met with the resident regarding his discharge. The resident stated he did not want to be transferred to a group home or another nursing facility; instead, he requested to be discharged to a motel of his choosing. The facility van driver transported him to his selected location. The resident has a BIMS score indicating decision-making capacity and was educated on the risks associated with discharging to a motel. While the facility is currently in the process of finding an alternative placement, the resident insisted on being discharged to the motel. The family and attending physician have been made aware. Record review of Resident #1's progress note dated 03/13/25 at 5:59 AM by RN P, indicated the resident was alert and oriented x 4 . can let all needs be known, no s/s of distress or discomfort noted, resident discharge to shelter. Record review of Resident #1's progress notes 03/13/25 at 9:18 AM by RN P reflected Resident discharge home. Record review of Resident # progress note on 03/13/2025 at 10:22 PM by RN P reflected the discharge GG evaluation was completed and indicated: *Reason for evaluation is discharge (stand-alone or combination). *Eating: Discharge Performance: Setup or clean-up assistance. *Oral hygiene: Discharge Performance: Partial/moderate assistance. *Toileting hygiene: Discharge Performance: Independent. *Shower/bathe self: Discharge Performance: Partial/moderate assistance. *Personal hygiene: Discharge Performance: Independent. *Upper body dressing: Discharge Performance: Independent. *Lower body dressing: Discharge Performance: Independent. *Putting on / taking off footwear: Discharge Performance: Independent. *Roll left and right: Discharge Performance: Independent. *Sit to lying: Discharge Performance: Independent. *Lying to sitting on side of bed: Discharge Performance: Independent. *Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed: Discharge Performance: Independent. *Chair / bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair): Discharge Performance: Independent. *Toilet transfer: The ability to get on and off a toilet or commode: Discharge Performance: Independent. *Tub/shower transfer Tub / shower transfer: The ability to get in and out of a tub/shower: Discharge Performance: Independent. *Car transfer: The ability to transfer in and out of a car or van on the passenger side: Discharge Performance: Independent. *Walk 10 feet: Discharge Performance: Independent. *Walk 50 feet with two turns: Discharge Performance: Independent. *Walk 150 feet: Discharge Performance: Independent. *Walking 10 feet on uneven surfaces: Discharge Performance: Independent. One step (curb): Discharge Performance: Independent. *Four steps: Discharge Performance: Independent. *Twelve steps: Discharge Performance: Independent. *Picking up object: Discharge Performance: Independent. *Indicate the type of wheelchair/scooter used. - Discharge Performance: Manual. The Resident uses a wheelchair and/or scooter. *Wheel 50 feet with two turns: Discharge Performance: Independent. Wheel 150 feet: Discharge Performance: Independent. This note was entered at 10:22 PM after the resident was discharged from the facility on 03/13/2025 at 5:15 PM. Record review of progress note dated 03/12/2025 at 3:17 PM, by the SW reflected [facility] AL discussed admitting the resident tomorrow under private pay. Record review of progress note dated 03/12/2025 at 2:45 PM, by the SW reflected onsite complete with [facility] pending. Record review of progress note dated 03/12/2025 at 2:40 PM, by the SW reflected met with [Resident #1] of notice to discharge. [Resident #1] was content with SW sending referrals to other SNF's in order to prevent him from losing his AL benefits. Referral sent to [facility] and [facility]. Record review of progress note dated 03/12/2025 at 2:28 PM, by the SW reflected relocation specialist). She reports she will send information for a group home. Note Text: [NAME] House pending accepting transfer. DC date and wait time pending. Record review of Resident #1's progress note dated 03/12/2025 at 1:58 PM by SW, reflected Referral sent to [facility]. Record review of Resident #1's psychological services progress note dated 03/13/2025 from 10:40 AM to 10:58 AM by Ph D reflected a DX of generalized anxiety disorder .top target symptoms: Somatic concerns Mild (excessive worrying .leading to significant distress/or functional impairment .not fully explained by a medical condition). Depression Moderate (clinical disorder characterized by a sustained feeling of sadness and loss of interest). Anxiety moderate (a mental health condition where excessive and persistent worry or fear about everyday situations interferes with daily life, causing distress and difficulty functioning). Patient's Response to Intervention: The therapist was informed by staff of patient being spotted engaging in inappropriate behavior with another resident. He explained the other patient is his friend and he sat on her bed, and they ate cinnamon rolls together. He feels he is being falsely accused and denied all wrongdoing. He feels the 1:1 is currently just as much to keep the other patient out of his room as she keeps going into his room so they can talk as they did prior to the incident. He is hopeful to transfer soon and spoke of going back to [city] as soon as he is able. Plan For Next Session: Continue individual psychotherapy to build rapport and improve interactions with others. During an interview with TPS D on 04/03/2025 at 11:00 AM he stated that he was asked by the Administrator on 03/13/2025 at approximately 5:00 PM to transport resident #1 to a shelter. TPS D stated he loaded resident personal property in the van and proceeded to transport Resident #1 to the homeless shelter. TPS D stated that Resident #1 wanted to be transported to a nearby hotel instead the homeless shelter. TPS D stated that he transported Resident #1 to the nearest hotel, and remained with the resident until a key and room was assigned. TPS D said he assisted the resident with moving all personal items to the room. He returned to the facility and notified the Administrator of the location. TPS D was unable to provide any information on the resident's current cognitive status. During an interview with the DON on 04/04/2025 at 2:15 PM, she said that Resident # 1 was discharged on 03/13/2025 to a homeless shelter after refusing three facility placement referrals. The DON said that once TPS D returned to the facility, he informed the DON and ADM that Resident #1 asked TPS D to take him to a nearby hotel, instead of the homeless shelter. The DON said that the facility did not attempt to contact Resident #1 after discharge to the hotel and check on his wellbeing or safety. During an interview with the ADM on 04/04/2025 at 2:40 PM, Resident #1's was discharged on 03/13/2025, after an incident with another resident on 03/12/25. Resident was placed on one-on-one staff supervision until discharge. The resident was his own RP and did not want to transfer to another nursing facility. She stated the SW contacted three other facilities and the resident refused placement. She stated he was discharged to a homeless shelter. However, upon being transported by facility staff TPS D, Resident #1 requested to be taken to a hotel nearby. Resident paid for his room with his own money. The ADM stated she nor her staff followed up with Resident #1 after discharge to confirm his whereabouts or safety. In an interview with the ombudsman on 04/11/2052 at 9:01 AM she stated that she would have to review facility notes to confirm that she was contacted about the discharge of Resident #1. This surveyor requested a return call upon reviewing the information. Record review of Resident #1's record did not reveal any contact information for Resident #1 to follow up on discharge or interview. Review of the facility's policy title Transfer and Discharge, operational manual - admission and Discharge, revised 06/2020, revealed in part the following: Nursing facility must complete discharge planning when you anticipate discharging a resident to a private residence, another nursing facility or skilled nursing facility, or another type of residential facility. Purpose: To ensure that residents are transferred and discharged from the Facility in compliance with state and federal laws and to provide complete, safe, and appropriate discharge planning and necessary information to the continuing care provider. Policy: The Facility may transfer or discharge a resident for the following reasons: residents are transferred/discharged based on physician order unless the sign themselves out against medical advice. See Policy Discharge Against Medical Advice. Discharge Planning begins with the pre-admission process by identifying and assessing the resident's living and social support network prior to admission. Discharge planning continues throughout the stay. includes: Assessing the resident's continuing care needs, including: Consideration of the resident's and family/caregiver's preferences for care; How services will be accessed; Developing an interdisciplinary team discharge plan designed to ensure that the resident's needs will be met after discharge from the facility, including resident and family/caregiver education needs To facilitate a smooth transition of care, the Facility will utilize Continuity of Care Checklist to provide the following information to the receiving entity: If the resident is transferred because his/her needs cannot be met, the Facility must document attempts to meet the resident's needs and the service available at the receiving facility to meet the need(s). The medical record will contain written documentation from a physician if the resident is transferred/ discharged because: The safety of individuals in the facility was endangered by the resident's presence.

Based observation, interview and record review the facility failed ensure that a resident that needed tracheostomy care was provided such care consistent with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for tracheostomy care. The facility failed to ensure Resident #1's tracheostomy tubing was changed out within a seven-day period upon observation on 11/07/2024 at 4:13 PM. These failures could place residents at risk of cross-contamination and the development of infection. Findings include: Record review of Resident #1's face sheet, dated 12/07/2024 at 5:41 PM, reflected a [AGE] year-old resident who was admitted to the facility on [DATE]. Resident #1 had relevant diagnoses which included Moyamoya disease (blood vessel disorder that reduces blood flow to the brain,) cerebral infarction (blood supply to the brain is blocked or reduced) and tracheostomy status (hole in front of the neck into the windpipe to keep open for breathing.) Record review of Resident #1's Comprehensive Care Plan, dated 12/07/2024 , reflected Resident #1 had a tracheostomy and required his oxygen tubing, humidification bottle and mask changed weekly or as needed when visibly soiled. Record review of Resident #1's quarterly MDS , dated 11/15/2024, reflected he was not able to complete a BIMS assessment but had short- and long-term memory problems and was severely impaired in his cognitive skills for daily decision making. He had impairments on both sides in both upper and lower extremities and required a wheelchair for mobility. Resident #1 was totally dependent upon staff for hygiene, toileting, dressing and transfers. Resident #1's appliances included indwelling catheter for urinary management and ostomy for bowel management. Resident #1 had a feeding tube and received 51% or more total calories from tube feeding. He required oxygen therapy and tracheostomy care. Record review of Resident #1's Physician Orders reflected: -Change respiratory tubing, mask, bottled water every 7 days with a start date of 12/03/2024 and timed for 10 PM each Sunday. -Tracheostomy: Change oxygen tubing, bottled water for humidification, and mask weekly and as needed with a start date of 12/05/2024. No time listed as this is an as needed order. -Oxygen at 4 liters per minute via tracheostomy with a start date of 12/03/2024 and timed each shift. -Tracheostomy care daily and as needed with a start date of 12/05/2024. Record review of Resident #1's Progress Notes, authored by LVN A on 12/07/2024 at 2:13 PM, reflected Resident #1's tracheostomy care was completed. In observation of Resident #1 on 12/07/2024 at 4:13 PM, he was resting in bed with family at his bedside. Resident #1 had a tracheostomy present with tracheostomy tubing, oxygen tubing, tracheostomy mask, bottled water for humidification, adapter and concentrator equipment present. Resident #1's tracheostomy tubing was dated 11/26/2024 both on the bag and on the tubing. Interview with Resident #1 on 12/07/2024 at 4:13 PM was not successful due to the resident's cognitive and verbal limitations. In interview with Resident #1's family member on 12/07/2024 at 4:13 PM, revealed they were not knowledgeable of Resident #1's tracheostomy care. In interview and observation with Resident #1's nurse, LVN A, on 12/07/2024 at 4:37 PM, she stated she performed tracheostomy care and changed out Resident #1's oxygen tubing, tracheostomy mask, and bottled water for humidification earlier that day. She stated she did not change out the tracheostomy tubing at that time and stated she did not notice the date, nor did she recognize it needed to be changed at that time. She stated all the tracheostomy equipment was ordered to be changed weekly on Sunday nights and it was the night shift nurse's responsibility to complete this task. She stated if that was not completed, it was the next nurse's responsibility to ensure this was completed. She stated it was important for the respiratory tubing to be changed out weekly for infection control purposes. In interview with the facility's ADON on 12/07/2024 at 5:00 PM, she stated tracheostomy tubing and equipment needed to be changed weekly by the weekend night shift nurse or as needed by any nurse when out of date (which was determined by assessing the date listed on the equipment) or if tubing was soiled or compromised. She stated she typically did an audit and visual inspection each Monday to ensure this was completed; but she recently came back from vacation and did not think it was delegated. She stated it was important for the respiratory tubing to be changed out weekly for infection control purposes. In interview with the facility's DON on 12/07/2024 at 5:15 PM, she stated tracheostomy tubing and equipment needed to be changed out weekly by the weekend night shift nurse. She stated her expectation was if this was not completed, then the next nurse the resident had in their care would complete this task. She stated the ADON typically completed an audit on Monday, but every nurse Resident #1 had should be assessing the date on the tubing equipment each shift to ensure the tubing was not out of date and needed to be changed for infection control purposes. Record review of the facility policy Tracheostomy - Care of rev. 06/2020 reflected tracheostomy care will be performed as ordered by the Physician. Record review of the facility policy, Oxygen Administration, rev. 06/2020 reflected a Physician's Order is required to initiate oxygen therapy. All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen will be changed weekly and when visibly soiled.

Based on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #01) of four residents reviewed for reasonable accommodations. The facility failed to provide a different mattress to help alleviate Resident#1 pain due to his diagnoses and physical condition. Resident #01 was admitted to the facility on [DATE] and was provided with a low air loss mattress. Resident transferred to Long-term care on 11/13/24 and transferred rooms on 11/22/24 and he was provided with a pressure relieving mattress instead. This failure could place residents at risk of not being able to have their needs met. Findings included: Record review of Resident#1 admission MDS assessment, dated 09/17/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included: malignant neoplasm of unspecified part of unspecified bronchus or lung (a type of lung cancer); adjustment disorder (a mental health conditions that occurs when someone has an extreme reaction to a stressful event or change in their life), other Malaise (general feeling of discomfort, weakness, illness, or lack of well-being), antineoplastic chemotherapy induced pancytopenia (A condition that occurs when blood- forming stem cells in the bone marrow are affected by chemotherapy), Neoplasm related pain (acute chronic)(pain caused by cancer), unspecified chord compression, Hypo-osmolality and Hyponatremia (low levels of electrolytes in the blood), depression unspecified, paraplegia (a chronic condition that involves the loss of movement and sensation in the lower body) unspecified other chronic pain and other long term (current) drug therapy. Record review of Resident#1 quarterly MDS assessment dated [DATE] reflected Resident# 01 determination of pressure ulcer/injury risk by clinical assessment. Resident#1 was at risk of developing pressure ulcers/injuries. For ulcer/injury treatment a pressure reducing device for bed to be used. his BIMS was 15 out of 15, which revealed he was cognitively intact. Record review of hospital records dated, 08/03/24 reflected Resident#1 was admitted to the hospital on 08/03/24 for thoracic spinal cord injury and lung cancer. Past medical history reflected: small cell carcinoma (port inn place), spinal cord compression with paraparesis (status T4-T5 and T10-T11 laminectomy on 06/04/24), mediastinal mass, stage 3 coccyx pressure injury. Record review of hospital Assessment and plan dated, 09/04/24: Diagnoses: Stage 3 pressure injury coccyx section reflected on 08/05/24: Patient seen and examined. Undetermined onset. Given the depth, we will begin to pack with hydrophore blue. Patient advised to reposition often if in bed to reduce the pressure at the wound. Will also benefit from a low air loss mattress. 1. Stage 3 pressure injury coccyx, - offloading: LAL mattress ordered, nursing staff to turn q2h Record review of Resident#1 care plan dated 11/05/24 reflected, focus: ulcer or potential for pressure ulcer. development r/t Disease process, paraplegia and lung cancer. Goal: skin, free of redness, blisters, or discoloration by/through review date. Interventions: Notify nurse immediately of any new areas of skin break down . Record review of weekly wound assessment dated [DATE] reflected, Resident#1 Stage 2 pressure wound sacrum Record review of weekly wound assessment dated [DATE] reflected, Resident#1 Stage 2 pressure wound sacrum (Resolved on 09/17/24) Record review of bed census from 09/05/24 to 11/22/24 reflected, Resident#1 transferred to long term care on 11/13/24 and transferred rooms again on 11/22/24. Record review of progress notes from 11/02/24 to 12/02/24 reflected, no documentation of Resident# 1's mattress change from LAL to a pressure relieving mattress. Record review of orders on 12/02/24 reflected, no orders for a LAL mattress. Interview on 12/02/24 at 3:30 PM Resident#1 stated he has not been able to sleep because his back hurts and he was not comfortable on the mattress he had now. Resident#1 stated he was moved to Long Term Care and was not able to stay in the room with his roommate and asked to be transferred to a different room. Resident#1 stated when he was moved, he was given a different mattress. Resident#1 stated he had multiple surgery on his back and had cancer. Resident#1 stated he used to have a wound on his bottom, but it was healed. Resident#1 stated he told the DON, ADON B and previous Administrator and new Administrator that he needed his old mattress back. Interview and observation on 12/02/14 at 4:00 PM the ADON A stated she was not familiar with Resident#1. ADON A stated ADON B worked the upstairs halls and was out on vacation. Observation of the mattress revealed Resident#1 mattress was a pressure relieving mattress and firm to the touch. Interview on 12/02/24 at 4:25 PM the DON stated all the residents were at risk for getting pressure sores and that interventions were on the resident's care plans. DON stated the mattress changed should have been documented on Resident#1 progress notes. DON stated the resident had a pressure relieving mattress and did not met criteria for the LAL mattress. Interview on 12/02/24 at 5:00 PM the Administrator stated he has been in the facility for two weeks. The Administrator stated Resident#1 was admitted with a pressure wound on the bottom and it had healed by the beginning to mid-September. Administrator stated Resident#1 had a LAL mattress since he was admitted to the facility. Administrator stated in mid-November, he was transferred to a pressure relieving mattress because another resident needed the mattress. Administrator stated Resident#1 did not meet the facility criteria for a LAL mattress. The Administrator stated he talked with Resident#1 and a spare LAL mattress was switched out with the resident's pressure relieving mattress. On 12/02/24 at 6:oo PM, attempted to call ADON B and phone went straight to voicemail. Record review of policy undated, titled: Support Surface Guidelines reflected, The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown . II. The Facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development . (b) Low?air?loss mattresses are giant air?permeable pillows that are continuously inflated with air; the air flow has a drying effect on tissues. (i) Indicated for residents with stage I pressure ulcers who develop hyperemia on static surfaces and for residents with stage III or IV pressure ulcers. Record review of policy revised 08/2020, titled: Resident Rights .B. Gather information about the resident's personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record; .

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one of six residents (Resident #1) reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #1's contracture to her left hand after discharge from occupational therapy on [DATE]. This failure could result in a decline in range of motion and worsening of contractures to the residents. Findings included: Record review of Resident #1's quarterly MDS assessment, dated [DATE], reflected a [AGE] year-old female with an admitted [DATE]. Resident #1 was unable to participate in the brief interview for mental status and staff had assessed her to be severely cognitively impaired. The Resident had upper and lower extremity impairment on one side. Resident #1 had not received OT or PT services in the seven days look back period. Resident #1 had not received restorative care, splints, or braces. Resident #1 was dependent for all ADLs and had no history of refusing care. Active diagnoses included cerebral vascular accident (stroke), hypertension, diabetes mellitus, and aphasia (language disorder). Record review of Resident #1 Orthotic Caregiver Training dated [DATE] reflected, Nursing staff to safely donn (sic) and doff (take on and off) R resting hand splint to R hand and L hand palmar guard (hand cushioned glove) daily or as tolerated. Record review of Resident #1 Focus on Function .Range of Motion/Contracture Tool, created by OT H dated [DATE] reflected . Resident #1 demonstrate decreased ROM in left and right wrists and fingers .patient has a splint for that specific joint .resident appear to be at risk for decreased joint mobility due to inactive or any other reasons .it has been 3 months since the current joint protection or contracture management program has been reviewed . Record Review of Resident #1 Occupational Therapy Discharge Summary created by OTA and OT H dated [DATE] reflected, .Dates of Services: [DATE]-[DATE] .Short-Term Goals .Patient will safety wear a resting splint R hand and a palmar guard on left hand for up to 2 hours w/minimal signs and symptoms of redness, swelling, discomfort or pain . Record review of Resident #1's Nursing Restorative Care Program created by OT H, undated reflected, Patient will tolerate resting hand R hand and palmar guard L hand daily or as tolerated. Nursing staff will safely donn and doff R hand resting hand and L hand palmar guard daily or as tolerated. Record review of Resident #1's Telephone physician order dated [DATE] reflected, Patient to wear R hand resting hand splint and L hand palmar guard daily or as tolerated. Record review of Resident #1's Treatment administration record for [DATE], [DATE] did not reveal any notation of splint application to right hand and palm guard application to left hand. Review of [DATE] treatment administration record reflected on [DATE] Place carrot sponge on the left palm to prevent resident's nails from digging into skin. Check for skin integrity every shift. Record review of Resident #1 Documentation Survey report for [DATE], [DATE] reflected no documentation for application of splints or palm guards to the resident's hand contractures. Review of the [DATE] report reflected, splint program: left hand was first documented on [DATE] on the evening shift (3:00 PM-11:00 PM). Record review of Weekly Skin Check V,d+[DATE] dated [DATE] reflected, The assessment was completed using direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members. Record review of Weekly Skin Check V,d+[DATE] created by LVN B dated [DATE] reflected, G-tube site/stoma with no signs of infection, unable to assess patient's contracted hands because pt was resistant to assessment/care. MD notified. Family member aware. Record review of Weekly Skin Check V,d+[DATE] created by LVN B dated [DATE] reflected, G-tube site/stoma with no signs of infection. Family member here, able to open her left hand, wound noted to the left palm. Wound cleansed with wound cleanser, dry dressing applied, and a rolled face towel put in place to keep the contracted hand open. An observation of Resident #1 on [DATE] at 1:22 p.m. revealed left hand drawn into a fist. Resident #'1 hand was wrapped in white bandage. Resident #1 was unable to open hand or move fingers. Resident #1 had a contracture to right hand and had no splints or hand rolls in place. An observation of Resident #1 with LVN A on [DATE] at 3:05 p.m. revealed a wound in the center of Resident #1 left hand. The wound was bright red and smaller than the size of a dime. The palm of Resident #1's hand was light brown in color. Record review of Nurses progress note dated [DATE] by LVN B reflected , Resident's Family Member 2 asked to see the nurse. This nurse went in the room and seen Family Member 2 repeatedly trying to ask the resident to allow her look at the contracted left hand as resident kept on resisting. Family Member 2 was able to see what appeared to be a wound on the contracted hand that the resident will historically not let the nurses assess. MD notified, new orders to clean the wound and apply triple antibiotic and keep a rolled face towel to keep the contracted hand open, Pain and skin assessment completed, pain medication administered as ordered, wound consult in progress and wound nurse to review on the next visit. Treatment immediately started. will continue to monitor. In an interview with LVN A on [DATE] at 3:52 p.m. she stated Resident #1's wound was odd looking. She stated it could be a pressure ulcer, but it looked weird. She stated the wound looked like a stoma (an opening in the body) and appeared perfectly round. She stated the edges weren't raised. She stated she is unsure how the resident got the wound. She stated if the wound was caused by a fingernail, it would have more of crescent moon shape. In progress notes dated [DATE], the MD was notified by LVN B. In an interview with Family Member #2 on [DATE] at 4:11 p.m. revealed she walked into Resident's #1 room on [DATE] and smelled a stench . Family Member #2 stated she opened Resident #1's left hand and smelled a decomposing smell, like someone had died . She stated she saw blood draining from Resident #1 left hand. She stated she opened Resident #1 left hand more and saw blood and a wound. She stated the wound was red and bleeding and looked like Resident #1's finger was digging into Resident #1 skin. She stated Resident #1 pinky and ring finger were stuck to Resident #1 palm. She stated she immediately called for LVN B. LVN B came to assess the resident. She stated she told LVN B that she got Resident #1's nail out of Resident #1's flesh. Family Member #2 stated she asked LVN B to cut Resident #1 nails. She stated LVN B cleaned Resident #1 wound and came back 25 minutes later and cut and filed Resident #1 nails. She stated she took pictures of Resident #1 wound and text the DON to report the wound and her concerns. Family Member #2 stated she had previously asked the facility to cut Resident #1 nails and the facility reported not having the instruments to cut Resident #1's nails. She stated the family purchased and provided the facility with the instruments to cut Resident #1 nails. She stated Resident #1 had a carrot to increase the range of motion to Resident #1's hand, but it was not being used. She stated she complained to the DON back in [DATE] about Resident #1's nails not being cut. Family Member #2 stated LVN B did respond to the complaint and cut resident nails. She stated LVN B could only cut three out of the five Resident #1's fingernails as LVN B told her that Resident #1 would not allow her to get to the other fingernails. In an interview on [DATE] at 1:21 p.m. she stated she was unsure if Resident #1 had a splint or a roll. She stated Resident #1 had received restorative nursing services and the CNAs were to assist Resident #1 with ROM. She stated Resident #1 had received therapy but did not know why it ended. She stated Resident #1 used a splint or handroll as tolerated. CNAs are responsible for applying handroll/splints to the resident. They are to document the information in the CNA Kardex. She stated it was the responsibility of the nurses to ensure the services were being provided to the residents. In an interview with DOR on [DATE] at 9:42 a.m. she stated Resident #1 received therapy from [DATE]-[DATE] for contracture management. She stated Resident #1 was discharged on [DATE]. She stated the CNAs were trained to apply the splint and palmar guard to Resident #1 hands. In an interview with CNA C on [DATE] at 10:16 a.m. she stated Resident #1 had a carrot and a blue splint. She stated she just started back working with Resident #1 last week. She stated the last time she put the splint on Resident #1 left hand was Thursday. She stated she did not notice a wound to Resident #1 left hand but did notice a smell. She stated she did not know where the smell came from . She stated she informed the nurse on duty about the smell. She stated the splint was to be applied to Resident #1's left hand when Resident #1 is out of bed. She stated the carrot, which is used to increase range of motion, is to be used when Resident #1 is in bed. She stated when she came on duty Friday, Resident #1 did not have the carrot in her left hand. She stated a couple of times during that week she did not see Resident #1 with anything on her hand. She stated she had not seen a palmar guard on Resident #1 since she started back working with Resident #1 last week. CNA C stated she received training on how to put on and take off splints and [NAME] guards. She stated there is list printed out daily of all residents with contractures. She stated it was the responsibility of both the CNA's and nurses to ensure the residents received services. In a telephone interview with LVN D on [DATE] at 10:36 a.m. she stated she was responsible for trimming Resident #1 nails. She stated she is supposed to check Resident #1 nails weekly. She stated Resident #1 sometimes resisted care and would not open her hand. She stated the splint is to be applied to Resident #1 when Resident #1 is out of bed. She stated it is the responsibility of the nurses to assess Resident #1 and to assure the splint and palmar guard are being applied. She stated Resident #1 was to wear the palmar for two hours daily if tolerated. In an interview with OT H on [DATE] at 10:55 a.m. he stated he worked with Resident #1 back in [DATE]. He stated he recommended a resting splint for Resident #1 right hand. He stated Resident #1 had good a good passive ROM in the right hand. He stated the issues were more of Resident #1 clinching her fist. He stated he recommended the palmar guard daily for Resident #1 left hand for two hours as tolerated. In the OTR H's observation of Resident #1 on [DATE] at 11:00 a.m. he stated Resident #1's wound had pressure and moisture to her left hand and the nail is the possible cause for the wound. He stated the palmar guard is less harsh on Resident #1's hand than the carrot. In the RN G's observation of Resident #1 on [DATE] at 11:00 a.m. she stated the cause of Resident #1's wound looked like a nail had dug in Resident #1's hand. In an interview with the MDS on [DATE] at 11:16 a.m. she stated restorative care is provided by the CNAs. She stated CNA C and E received training on how to apply the splint and [NAME] guard to Resident #1 hands. She stated the therapy department was responsible for the training. CNA C and CNA E received Orthotic Caregiver Training on [DATE]. Both CNA C and CNA E signed the training log where they acknowledged they received the training. In an interview with LVN B on [DATE] at 11:25 a.m. she stated the nurses are responsible for putting palmar guards on Resident #1. She stated sometimes Resident #1 would not have the splint on when she comes on duty. She stated Resident #1 does not use the splint. She stated when she would be on duty, Resident #1 would not have anything on her hands. She stated last Friday, Family Member #2 alerted her about Resident #1 wound. She stated she observed the wound. She stated the wound was bright red and bleeding. She stated Resident #1's fingernails were long on her left hand. She stated in the past she tried to assess Resident #1's left hand but Resident #1 would [NAME] her hand making it difficult for her to assess her hand and skin. She stated she would notify the DON weekly when she could not assess Resident #1 left hand. She stated she had not tried to soak or massage Resident #1's hand to gain access. She stated no other options were attempted to gain access to Resident #1's hand for assessment. She stated she had not cut Resident #1's nails on her left hand since the end of [DATE]. In an interview with the DON on [DATE] at 11:48 a.m. he stated the CNAs are responsible for providing restorative care to Resident #1. He stated it is the nurse's responsibility to ensure the CNAs are applying the splint and palmar guard. He stated Resident #1 should have had the palmar guard applied to Resident #1's left hand and right resting splint to her right hand as ordered. He stated it is the responsibility of the nurses on each shift to do a skin assessment of Resident #1 skin when using the splint or palmar guard. In a telephone interview with CNA E on [DATE] at 12:53 p.m. she stated she only put the blue splint on Resident #1 left hand when Resident is in her chair. She stated she was able to get Resident #1 hand opened twice. She stated she last worked with Resident #1 three weeks ago. She stated she did not put anything on Resident #1 right hand. She stated she was not aware that she was supposed to put the splint on Resident #1 right hand and the palmar guard on Resident #1 left hand . She stated there was a list printed out daily of residents with contractures. She stated Resident #1 never refused to have the splint apply to her hand. She stated if she could not get Resident #1 hand open to apply the splint, she would get the nurse. Record Review of Occupation Therapy assessment dated [DATE] reflected, #1 Short-Term Goals .Patient will demonstrate good tolerance with use of hand roll in L hand to facilitate extension of digits for contracture. (Target: [DATE]). #2 Provide PROM to L hand/digits into extension to facilitate decreased joint tightness and improved placement and fit of hand roll for contracture management. (Target: [DATE]). #3 Improve L hand hygiene and nail care to good to facilitate prevention of further skin breakdown. (Target: [DATE]). Record review of Resident #1's comprehensive care plan dated [DATE] revealed the facility initiated a care plan on [DATE] (after surveyor entered) and revised on [DATE] for . Alteration in musculoskeletal status r/t contracture left hand. Trial L hand palmar guard splint/roll with therapy only. Apply left hand splint/handroll. Trial L hand palmar guard splint/roll with therapy only. Ensure site is clean, nails are trimmed Record review of Resident #1 Kardex report dated as of [DATE] reflected, Therapy .Apply left hand splint/handroll. Trial L hand palmar guard splint/roll with therapy only. Ensure site is clean, nails are trimmed, and monitor how resident tolerates the procedure. Notify nursing for pain, redness and swelling to left hand. PT/OT evaluation and treatment as per MD orders. Review of the facility's policy titled, Restorative Nursing Program Guidelines dated [DATE], reflected, A resident may be started on a Restorative Nursing Program .When a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy .The Restorative Nurse's Aide (RNA) carries out the restorative program according to the care plan and document daily. In addition, the RNA completes a written weekly summary for residents on a Restorative Nursing Program .Licensed Nurses reflect participation in and progress of residents in the Restorative Nursing Program in their weekly/monthly summaries .General restorative nursing care is that which does not require the use of a qualified professional therapist to render such care. The basic restorative nursing categories include Splinting or bracing .

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for two (Residents #1 and Resident #2) of three residents reviewed for pharmacy services. 1. The facility failed to give Resident #1 Acidophilus Lactobacillus Oral Capsule every 12 hours as ordered. 2. The facility failed to give Resident #2 Gabapentin every 12 hours as ordered. This failure could affect residents by placing them at risk for a delay in medical treatment or worsening in condition. Findings included: Record review of Resident #1's face sheet, dated 08/29/24, reflected a [AGE] year-old female, with an initial admitted [DATE]. Resident #1 had a diagnosis of Acute Respiratory Failure (shortness of breath), Cellulitis of lower left limb (bacterial infection in the skin and underlying tissue), Type 2 Diabetes (high blood sugar), Neuromuscular Dysfunction of Bladder (nerves that control the bladder do not work properly), Morbid Obesity (body mass index of 40 or higher), Muscle Weakness, Hemiplegia and Hemiparesis following Cerebral Infarction (paralysis and weakness on one side of the body), and Need for Assistance with Personal Care. Record review of Resident #1's MDS, dated [DATE], reflected a BIMS score of 15 which indicated she was cognitively intact. Record review of Resident #1's physician's order dated, 03/23/23 reflected an order for Acidophilus Lactobacillus Oral Capsule, give one tablet by mouth every 12 hours for antidiarrheal. Record review of Review of Resident #1's Medication Admin Audit Report dated 08/30/24 reflected the following: Acidophilus Lactobacillus Oral Capsule (Lactobacillus) Give 1 capsule by mouth every 12 hours for Antidiarrheal Scheduled for 8:00 AM and 20:00 (8:00 PM) Acidophilus Lactobacillus was marked as given on 08/03/24 at 11:25 AM Acidophilus Lactobacillus was marked as given on 08/03/24 at 19:57 (7:57 PM) Acidophilus Lactobacillus was marked as given on 08/04/24 at 10:17 AM Acidophilus Lactobacillus was marked as given on 08/04/24 at 19:47 (7:47 PM) Acidophilus Lactobacillus was marked as given on 08/11/24 at 11:38 AM Acidophilus Lactobacillus was marked as given on 08/11/24 at 20:09 (8:09 PM) Acidophilus Lactobacillus was marked as given on 08/12/24 at 9:33 AM Acidophilus Lactobacillus was marked as given on 08/12/24 at 20:40 (8:40 PM) Record review of Resident #1's Progress Notes on the resident's electronic record revealed no documentation on 08/03/24, 08/04/24, 08/11/24, or 08/12/24, regarding the late medication pass. Record review of Resident #2's face sheet, dated 08/30/24, reflected a [AGE] year-old male, with an admitted [DATE]. Resident #2 had a diagnosis of Type 2 Diabetes (high blood sugar), Essential Hypertension (high blood pressure), Muscle Weakness, and Poly Neuropathy (damage affecting nerves). Record review of Resident #2's MDS, dated [DATE], reflected a BIMS score of 15 which indicated he was cognitively intact. Record review of Resident #2's physician order dated 11/03/22, reflected an order for Gabapentin, give 1 capsule by mouth every 12 hours for polyneuropathy. Record review of Resident #2's Medication Admin Audit Report dated 08/30/24 reflected the following: Order Summary Gabapentin Capsule 300 MG Give 1 capsule by mouth every 12 hours for Polyneuropathy Scheduled for 8:00 AM and 20:00 (8:00 PM) Gabapentin was marked as given on 08/01/24 at 8:10 AM Gabapentin was marked as given on 08/01/24 at 21:21 (9:21 PM) Gabapentin was marked as given on 08/03/24 at 9:34 AM Gabapentin was marked as given on 08/03/24 at 19:34 (7:34 PM) Gabapentin was marked as given on 08/04/24 at 9:35 AM Gabapentin was marked as given on 08/04/24 at 19:40 (7:40 PM) Gabapentin was marked as given on 08/05/24 at 9:19 AM Gabapentin was marked as given on 08/05/24 at 21:47 (9:47 PM) Gabapentin was marked as given on 08/06/24 at 9:15 AM Gabapentin was marked as given on 08/06/24 at 21:08 (9:08 PM) Gabapentin was marked as given on 08/07/24 at 7:19 AM Gabapentin was marked as given on 08/07/24 at 21:11 (9:11 PM) Record review of Resident #2's Progress Notes on the resident's electronic record revealed no documentation on 08/01/24, 08/03/24, 08/05/24, 08/06/24, or 08/07/24 regarding the late medication pass. In an interview on 08/29/24 at 10:20 AM, Resident #2 stated he was the lived in the facility for about two years and was an active member of the resident council. He stated some staff members were recently fired, and that did not make the facility any better. Resident #2 stated he did not receive his medication on time unless certain nurses were at work. He stated a lot of times the medication was given an hour to an hour and a half late. He stated now he has an agreement with the weekday morning staff member to give his medications before the other residents to ensure he gets his medication on time. Resident #2 stated the other shifts and on the weekends was a different story. He stated he did not get his medications on time during those times. He stated it's really slow on the weekends. In an interview on 08/29/24 at 3:35 PM, the ADON stated he had not received any complaints about late medications. He stated he would check into resident concerns. In the same interview, Corporate Nurse B stated the facility would complete an audit and safe surveys to ensure residents were receiving their medications. In an interview on 08/30/24 at 11:55 AM, Resident #1 stated sometimes the medication was given late. She stated the staff are busy, and sometimes the medication is given later in the day. She stated she did not have any side effects, but she would like to get her medication like the doctor ordered. In an interview on 08/30/24 at 3:20 PM, the DON stated he did not receive any complaints from residents regarding late medications. He stated the expectation is for a resident to receive their medications up to an hour before or an hour after the scheduled medication time. The DON stated any late medications passes should be documented in the electronic record. The stated the nurses and ADON was responsible for ensuring the documentation was completed. He stated the risks of late medication passes depends on the medication, but he was not made aware of any late medication passes or any adverse effects. In an interview on 08/30/24 at 3:37 PM, the Administrator stated he had not received any complaints about medications given passed the scheduled time. He stated late medications passes should be documented on the resident's electronic record and the medication administration record has an area to mark an exception. He stated the risk of not giving medications on schedule or according to the physician's order is a medication dosage could be given too close together. Record review of the facility's in-serviced titled, Medication Pass dated 08/29/24, reflected the following: All routine medications are to be given within one hour of scheduled time. Medication administration is to be documented at the time of med pass. Record review of the facility's undated policy titled, Medication Administration reflected the following: To provide practice standards for safe administration of medications for residents in the Facility. Medications may be administered one hour before or after the scheduled medication administration time. Nursing Staff will keep in mind the seven rights of medication when administering medication: A. The right medication B. The right amount C. The right resident D. The right time The Rule of 3 - The Licensed Nurse administering medications will perform 3 checks comparing the physician's order, pharmacy label, and Medication Administration Record (MAR). IV. Compare the Licensed Practitioner's prescription/order with the MAR (first check). V. Compare the Licensed Practitioner's order with the pharmacy label on the medication package (second check). VI. Compare the pharmacy label and MAR (third check). VII. Any discrepancies identified during the first, second, and/or third check must be resolved prior to the administration of any medication.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #1) observed for accuracy of medical records. The facility failed to document Resident #1's bed bath refusals on the same day for each refusal. This deficient practice could place residents at risk for errors in care and treatment. The findings were: Record review of Resident #1's face sheet, dated 08/29/24, reflected a [AGE] year-old female, with an initial admitted [DATE]. Resident #1 had a diagnosis of Acute Respiratory Failure (shortness of breath), Cellulitis of lower left limb (bacterial infection in the skin and underlying tissue), Type 2 Diabetes (high blood sugar), Neuromuscular Dysfunction of Bladder (nerves that control the bladder do not work properly), Morbid Obesity (body mass index of 40 or higher), Muscle Weakness, Hemiplegia and Hemiparesis following Cerebral Infarction (paralysis and weakness on one side of the body), and Need for Assistance with Personal Care. Record review of Resident #1's MDS, dated [DATE], reflected a BIMS score of 15 which indicated she was cognitively intact. Record review of Resident #1's Care Plan, dated 03/18/24 reflected Resident #1 was at risk of skin breakdown and has an ADL self-care performance deficit. Resident #1's care plan noted a two staff requirement for assistance with bathing. Record review of a shower schedule dated 08/17/24, reflected Resident #1 was scheduled to get baths on Monday, Wednesday, and Friday during the 6:00 AM to 2:00 PM shift. Record review of Resident #1's Progress Notes reflected the following late entries for shower/bed bath refusals documented by LVN C: All refusals were documented on 08/29/24 after the start of the investigation: Progress notes created on 08/29/24 noted: Resident #1 refused a bed bath on 08/05/24 Resident #1 refused a bed bath on 08/07/24 Resident #1 refused a bed bath on 08/12/24 Resident #1 refused a bed bath on 08/16/24 Resident #1 refused a bed bath on 08/19/24 Resident #1 refused a bed bath on 08/21/24 Resident #1 refused a bed bath on 08/26/24 In an interview on 08/29/24 at 3:04 PM, Caregiver A stated she provided care to Resident #1 and last gave her a bed bath about two weeks ago. She stated since then she was not sure if any other staff members provided bed baths or showers to Resident #1. Caregiver A stated Resident #1 was a larger woman and required a two person assist. Caregiver A stated she recalled Resident #1 refused a bed bath last week, and due to the short staff recently, Resident #1 might not have received the care she requested. She stated she would tell a nurse when a resident refused a shower or bed bath and then the nurse would be the one to document the refusal in the resident record. In an interview on 08/30/24 at 2:45 PM, LVN C stated he had helped Resident #1, and she did not complain about not getting bed baths. LVN C stated he tried to document on a resident immediately, but at the worst at the end of each shift. LVN C stated he did not know how he missed documenting the bed bath refusals from Resident #1. He stated he noticed this week, he did not document the refusals, so he started going back yesterday to document her refusals. LVN C stated the risk of late documentation was a resident not getting the appropriate care. He stated the next shift might not have been aware that a resident still needed a bed bath or shower. In an interview on 08/30/24 at 2:56 PM, the ADON stated he trained his staff to ask questions to see why a resident refused and to see if they could come back later to give the bed bath or shower. The ADON stated the shower and bed bath refusals were documented on paper and staff would tell a nurse about the refusal. He stated the nurse would be responsible for documenting on the resident's electronic record and notifying a family member. The ADON stated the nurse should document during that shift or within 24 hours at the latest. In an interview on 08/30/24 at 3:20 PM, the DON stated the staff were expected to document before their shift ended. He stated late documentation could intervene with a resident's care. He stated the facility had meetings every morning to review charts and to follow-up with any concerns. He stated he was not sure how the late documentation for Resident #1's refusals were missed. The DON stated the refusals should be documented immediately or by the end of the shift. He stated the refusals should have been documented in the progress notes and the family should be notified. He stated the ADON would check to ensure other nurses and caregivers were documenting the refusals either in the resident's electronic record or the shower sheets. In an interview on 08/30/24 at 3:37 PM, the Administrator stated the facility started in-services to ensure staff know the importance of documenting timely. He stated the expectation is for staff to document during their shift or within 24 hours at the latest. He stated all refusals should be documented on the resident's electronic record. He stated refusals could not be followed-up on if the refusal was not documented on time. Record review of the facility's policy titled, Documentation Nursing dated 06/2020, reflected the following: Purpose To provide documentation of resident status and care given by nursing staff. Policy Nursing documentation will be concise, clear, pertinent, accurate and evidence based. Narrative charting, as outlined in specific policies and procedures, will be used for initial treatments or procedures. Nursing staff will not falsify or improperly correct nursing documentation. Procedure ADL Documentation A. The CNA will document the care provided on the facility's method of documentation, manually or electronic. B. The CNA will sign each entry on the ADL Flow Sheet in the appropriate area of the record according to the date and shift that services were performed. Documentation will be completed by the end of the assigned shift.

Based on observations, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 2 (Residents #1 and Resident #2) of 6 residents reviewed for resident abuse. 1. The facility failed to ensure Resident #1 was free from verbal and physical abuse by the Assistant Dietary Manager. 2. The facility failed to ensure the Assistant Dietary Manager did not work in the facility even though Resident #1 was afraid of him. 3. The facility failed to protect Resident #2, who was unable to give consent for sexual activity, from sexual abuse after Resident #3 was discovered in her bed with Resident #2 on top of her by facility staff. 4. The facility failed to protect Resident #2 who was a prior victim of abuse and unable to give consent for sexual activity. 5. The facility failed to follow physician's orders for Resident #3 and ensure that Resident #3 had un-monitored access to Resident #2 from 07/06/2024 to 07/11/2024 to prevent possible repeated abuse. An Immediate Jeopardy (IJ) was identified on 08/08/24 at 5:00 PM and 08/09/24 at 5:00PM. The IJ template was provided to the facility on [DATE] at 5:44PM and 08/09/24 at 5:24PM and signed by the Administrator. While the IJ was removed on 08/12/2024 at 7:05PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk for serious injuries, abuse, and serious harm. Findings included: 1. Record Review of Resident #1's Admission MDS Assessment, dated 05/19/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. He was cognitively intact. He did not have any behaviors. His diagnoses included stroke, heart failure, and hemiplegia (paralysis of one side of the body.) Review of Resident #1's Care Plans , not dated, reflected: Resident had a history of making false allegations/inaccurate statements as evidenced by previously accusing/stating: Makes up stories of falling, explained the same fall with different version to other nurses Interventions: If statements were determined to be inaccurate, staff will reorient and redirect as needed with reassurance and reality orientation. Listen openly to allegations/inaccurate statements and offer clarification as needed. Resident had potential to demonstrate verbally abusive behaviors related to ineffective coping skills, and poor impulse control. Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Evaluate for side effects of medications. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. Psychiatric/Psychogeriatric consult as indicated. Record review of Resident #1's Progress Notes, dated 06/15/24 at 7:20 pm reflected: Resident came to the nursing station to complain that he requested a double portion, but he was served with one portion of meal at dinner. He was offered another tray of dinner, but he refused and said that he was going downstairs. 7:26 PM Nurse was notified by the weekend supervisor that the resident wanted to go into the kitchen, but he was prevented from going in and he started altercation with the kitchen personnel. It was reported that the resident called the police. The resident came upstairs and said get my meds ready because I'm going out. Nurse had his medication prepared but the resident never came back to take his scheduled night medication. 8:15 PM A CNA came and told this nurse that the resident just left with his [family member] to the hospital. Note documented by LVN H. Review of Resident #1's Facility Self-Report dated 06/15/24 reflected: It was reported to Administrator on 6/15/24 that Resident #1 and the Assistant Dietary Manager had a verbal altercation. It was then reported to that the resident said that the Assistant Dietary Manager hit him in the chest. When the Administrator interviewed Resident #1 , he said the Assistant Dietary Manager also threw his walker and grabbed him by the throat. The Assistant Dietary Manager was interviewed and he denied ever putting a hand on the resident. The Administrator interviewed staff and residents that were in the dining room and kitchen when the altercation happened. In all of the Administrator interviews, everyone stated that they never saw the Assistant Dietary Manager put his hands on Resident #1. They also all said that it was the resident who was the aggressor, yelling and cursing at the kitchen staff. Investigation findings were unconfirmed because there was no witnesses that ever saw the Assistant Dietary Manager touch or hit the resident. In all interviews the witnesses stated Resident #1 was the aggressor and the one that was yelling and cursing. The Assistant Dietary Manager was allowed to come back to work from suspension. 1. Staff was in-serviced on abuse, neglect and dealing with aggressive behavior. 2. The Assistant Dietary Manager was allowed to return to work. 3. Resident #1 was presented a Behavior contract. Staff Witness Statements from the incident reflected: Resident #1 - The resident went to the kitchen to get double portions and the kitchen told him that they would send him another tray. He left and went back upstairs, and they could not find the tray. He came back downstairs and told them again that his tray was not up there. They told him that they would get him another tray once they finish with the other residents. He was standing in the door to the kitchen when he said the Assistant Dietary Manager came at him saying we are not going to do this Resident #1. Resident #1 then said that the Assistant Dietary Manager grabbed his walker and threw it about 10 feet. He then said that the Assistant Dietary Manager grabbed his neck and hit him in the chest. Resident #1 then stated that he took his shirt off to point at his chest that he had a pacemaker and then put his arms to his side and started saying that he did not touch anyone. Assistant Dietary Manager - Resident #1 was cursing at the cook about getting double portions. The Assistant Dietary Manager came to the door and asked the resident to not cuss at the employees. He stepped back into the kitchen and the resident called him a bitch. The Assistant Dietary Manager stated that he asked the resident, what you just said to me? The Assistant Dietary manager then said that he never put a hand on him. The Assistant Dietary Manager then stated that the resident tried to hit him but did not hit him. The resident then took his shirt off and started yelling that people were touching him. Dietary Aide I - He was working in the kitchen when Resident #1 came to the kitchen and was asking for more food. He stated that the resident started yelling at the cook and stating that he did not get double portions. The Dietary Aide I got the resident another plate and the resident still kept yelling at the staff. Dietary Aide I went and got the Assistant Dietary Manager to help with the resident, so they could finish the trays for the other residents. Dietary Aide I then said the Assistant Dietary Manager asked the resident to step out of the doorway to the kitchen. Resident #1 continued to yell and cuss at the Assistant Dietary Manager. The resident was getting more aggressive, and they tried to calm him down. Dietary Aide I stated that he never saw the Assistant Dietary Manager touch or hit Resident #1. Dietary Aide J - He stated that he never saw the Assistant Dietary Manager hit or touch Resident #1. He then stated that Resident #1 was the aggressor during the altercation. CNA K - see attached statement. (No statement attached.) Review of Resident #1's Hospital Records, dated 06/15/24, reflected the resident was an assault victim with a right chest wall contusion (bruise), neck strain, back strain, and contusion on his left ankle. There was no police report for 06/15/24. There was no facility incident report for 06/15/24. There was no resident assessment for 06/15/24. There was no trauma assessment for 06/15/24. The Surveyor requested the police report on 08/09/24 at 3:45 PM from the police department. An observation and interview with Resident #1 on 08/08/24 at 1:25 PM revealed he said he was assaulted on 06/15/24 by the Assistant Dietary Manager. He said he was supposed to get extra food and went down to get it and the Assistant Dietary Manager got in his face and threw his walker. He said it took 4-5 people to get the Assistant Dietary Manager off of the resident. Resident #1 said he was scared of him and did not feel comfortable eating food from him. The resident said he had bruises on his neck and chest on 06/15/24 and went to the hospital. He said they took images of his chest and pacemaker. He said the right side of his chest was still sore. The resident said he currently was ordering take-out food and his RP complained because it was $100/day. The resident said his food was almost always messed up. Resident showed the Surveyor a piece of over-cooked, dry bacon and said all three of his meals were messed up. The resident said he thought his walker was messed up because the Assistant Dietary Manager threw it. The resident said when he would go to the kitchen and see him, they whispered about him. The resident said he did not feel safe getting his food from the Assistant Dietary Manager. The Administrator walked over during the conversation and the resident showed the Administrator the piece of bacon. The Administrator said, ok and walked away. An interview on 08/09/24 at 1:15 PM with the RP for Resident #1 revealed he arrived to the facility on [DATE] and he saw that the resident had a large red mark on his right chest and shoulder. He said the police did a scene report. The RP said following the incident the resident was afraid to eat the facility food. He said he took the resident to the hospital. An interview on 08/08/24 at 1:15 PM with the Assistant Dietary Manager revealed on 06/15/24 an incident occurred. He said on Resident #1's tickets he was supposed to get large portions. The resident would say he did not get them, but he did. He said on 06/15/24, Resident #1 came to the kitchen and had a tray with him. The resident also had a tray upstairs, and a 3rd one that the cook had. The Assistant Dietary Manager said when saw the resident he was arguing with the cook even though he had 3 trays. The resident was riled up, cussing, and the Assistant Dietary Manager took the tray from the resident. The resident told him he was, nothing but a bitch anyway. The Assistant Dietary Manager said he turned around, walked back to the resident and asked what he said. He repeated, you're nothing but a bitch. The Assistant Dietary Manager told Resident #1 that he was not going to call him a bitch. The Assistant Manager said he was angry and yelling back at the resident and the other staff was trying to keep both him and the resident calm. The resident ran up on the Assistant Dietary Manager and changed his mind and moved back. The Assistant Dietary Manager said he raised his voice at the resident and Resident #1 called the police. The Assistant Dietary Manager said he told the resident he was not going to be threatening his staff. The Assistant Dietary Manager said there was another incident when the resident came to the kitchen, but when he saw the Assistant Dietary Manager, the resident left. He is a headache, and he is one of a kind. The Assistant Dietary Manager said he had been trained to de-escalate behaviors and that is why he stepped into the situation. He said he did not receive any disciplinary action but was suspended pending investigation. He said [NAME] L no longer worked at the facility and the Dietary Manager was off on 06/15/24. An interview on 08/08/24 at 1:35 PM with Dietary Aide J revealed he had worked at the facility for 2 months. He said on 06/15/24, he was washing the dishes and heard Resident #1 yelling and being mean to the staff. He said he went to the front and the Assistant Dietary Manager and the resident were cursing at each other and were in each other's face. Dietary Aide J aid it got to a point where the argument was dying down and then the resident called the Assistant Dietary manager a bitch. The resident started cursing at all of the kitchen staff and the Assistant Dietary Manager responded and got louder. The Assistant Dietary Manager was upset. He was standing in the doorway and they were close to each other. Dietary Aide J went to grab the resident and was told not to put his hands on him. Dietary Aide J stood by the resident's right shoulder and was facing the Assistant Dietary Manager to separate them. He said the Assistant Dietary Manager did not calm the situation, and he did not see them touch each other. Dietary Aide J said the Assistant Dietary Manager should have calmed down and let the situation go because the resident was about to leave by himself. The resident had a history of lashing out and then walking away. The police showed up 15 minutes later and the Assistant Dietary Manager left for the day. Dietary Aide J said he had to sign a paper but did not receive any in-services following the incident. An interview on 08/08/24 at 3:00 PM with CNA K revealed she had worked at the facility since 2022. She said on 06/15/24 Resident #1 got his tray and he said he did not get double portions. [NAME] L looked at his tray and said that he did receive double portions. The Assistant Dietary Manager came in and told the resident to step out of the kitchen. Resident #1 called the Assistant Dietary Manager the N word and stupid. The Assistant Dietary Manager was standing in the door of the kitchen. Resident #1 said he would slap the fuck out of the Assistant Dietary Manager. CNA K said she told the resident to come to her and to wait for his tray. Resident #1 reached across CNA K and tried to punch the Assistant Dietary Manager. CNA K said she told the Assistant Dietary Manager to back off and to walk away. CNA K said she got the tray for Resident #1. CNA K said the Assistant Dietary Manager escalated the situation and that she had to step in between them and back up Resident #1 from the Assistant Dietary Manager. She said the Assistant Dietary Manager should have walked away. An interview on 08/12/24 at 2:30 PM with LVN H revealed she was the nurse for Resident #1 on 06/15/24. She said she was told there was an incident in the kitchen and dining room and that Resident #1 went in the kitchen and was insulting staff and calling them names. She said the LVN Weekend Supervisor was handling the situation. She said when the resident came back to her following the altercation he said he needed to get his medications. Resident told her that he went to the kitchen to get food and he was attacked and insulted by staff. LVN H said she did not know if anyone attacked him because he was always making up stories. She said the resident told her he went to the hospital, but she did not assess him before he left or when he got back. She said the resident was wearing a shirt. She said she did not believe that anyone attacked him and she did not know why he was a resident in the facility. She said she did not complete an incident report because she was not there when it happened. An interview on 08/12/24 at 4:15 PM with the LVN Weekend Supervisor revealed she did not work the weekend of 06/15/24. An interview on 08/08/24 at 3:20 PM with the Psychiatrist NP revealed she had been seeing Resident #1 for a couple of months. She said he spoke to her about the incident on 06/15/24 where he was confronted by the kitchen staff for wanting food. Resident #1 said that his friend had been providing him money so that he did not have to eat at the facility. He said he did not trust the food the kitchen gave him. An interview on 08/08/24 at 2:10 PM with the Administrator revealed on 06/15/24, he got a call the afternoon or evening that the Assistant Dietary Manager and the Resident #1 had the altercation. He said when he arrived, the police were wrapping up their investigation and gave him the police report number. The Administrator said he did not get the police report. He said Resident #1 left the facility with his friend. The Administrator said he interviewed the staff in the dining room and interviewed the resident when he came back. The Administrator called the Assistant Dietary Manager and suspended him. The Administrator said he found in his interviews with staff the common denominator was that Resident #1 was the aggressor. He was loud and arguing with the cook and he did not feel he got double portions. He kept trying to go in the kitchen with his walker. He said the staff got the Assistant Dietary Manager and asked him to please not go in the kitchen. Resident #1 yelled more and took his shirt off and thought he was ready to fight the Assistant Dietary Manager. The Administrator said staff did not see the Assistant Dietary Manager touch Resident #1. Resident #1 said he took his shirt off and said he had a pacemaker. The Assistant Dietary Manager denied throwing the walker and no one observed him throw the walker. Resident #1 said he was going to the hospital to have his pacemaker checked out, but he did not know if he actually went to the hospital. The Administrator said staff were supposed to de-escalate situations and re-direct residents and remove them form the situation. The Administrator said staff were not supposed to yell at residents and staff had to separate the Assistant Dietary Manager and Resident #1, because Resident #1 was being aggressive. He said he suspended the Assistant Dietary Manager but felt the Assistant Dietary Manager handled the situation appropriately. The Administrator said the resident said he was going to the hospital, but he did not think he went. An interview on 08/09/24 at 2:50 PM with the Medical Director revealed Resident #1 was his resident. He said he knew the resident had frequent altercations and was only aware of the resident's most recent hospitalization on [DATE]. He said he did not know what the hospital records for 06/15/24 said. He said he did not expect the facility to do an assessment on the resident following the incident on 06/15/24 if they did not know he went to the hospital. He said maybe the resident got the bruise if he went out earlier in the day. He said he did not find the facility was at fault and had no proof that a physical altercation occurred. He said he did not expect that the facility would have done a more thorough investigation if they did not know he went to the hospital. An interview was attempted on 08/12/24 at 6:19 PM with Dietary Aide I, but he did not return the call of the surveyor. Record review of the facility's policy, Abuse Prevention and Prohibition Program, revised 10/24/22, reflected: I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Administrator was notified of the Immediate Jeopardy on 08/09/24 at 5:24PM due to the above failures and provided the IJ template to Corporate DON. A Plan of Removal was requested. The facility's plan of removal was accepted on 08/08/24 at 5:40 PM and included the following: 1. The administrator submitted a self-report to HHSC regarding the incident on 6/15/2024. Intake #511237 2. Attending Physician for involved resident was notified of the incident by the nurse on 8/9/2024. 3. On 8/9/2024, Attending Physician was notified of medical records received on 8/9/24. 4. Director of nursing conducted a trauma assessment with male resident on 8/10/24 , trauma assessment finding was normal. If assessment was abnormal, physician would be notified and EMR updated to reflect interventions. 5. Assistant Dietary Manager was immediately suspended on 6/15/24. 6. The affected resident went to the hospital for assessment and evaluation 06/15/2024. 7. Witness statements were obtained by the Administrator 06/15/2024. 8. Witnesses involved were reinterviewed on 8/8/24 and 8/10/24 9. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with interview able residents on 6/17/24 and 8/9/24, 8/10/24. The non interviewable resident received a complete head to toe assessment on 8/11/2024. Any negative findings were immediately investigated, physician and responsible party notified and EMR with interventions. 10. The affected resident was referred to [psych hospital] for psychological assessment and to be picked up on services if needed on 8/9/2024. 11. Assistant Dietary Manager employment with the facility has been terminated on 8/8/2024 12. Staff re-educated on abuse/neglect and how to deescalate and respond to any incidents involving residents/staff or any alleged perpetrators on 08/08/2024 13. Staff re-educated on how to respond with incidents involving staff to resident inappropriate behaviors on 08/09/2024. 14. Resident EMR was updated to include scanned hospital records on 8/9/24 15. Resident care plan was updated on 8/10/24 16. Resident Medical DX was updated 8/10/24 17. Facility Administrator was terminated effective 8/10/2024 In-Service conducted Administrator and Director of Nursing (after re-educated below) re-educated facility staff on: 1. On 8/9/24 Director of Nursing and Administrator were re-educated by Regional Director of Operations on Abuse & Neglect Policy, verbal, physical, sexual abuse and implementation of appropriate interventions to ensure residents are not afraid and feel safe. Administrator and DON were also re-educated on de-escalation of residents with behaviors. 2. Staff in-service was initiated on 8/9/24. Staff members are being re-educated to report all allegations of abuse immediately upon notification to the Administrator who is the abuse coordinator. Re-education has an emphasis on de-escalation of residents with behaviors according to policy and resident safety with emphasis on creating an environment where residents do not feel afraid. Staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 3. Staff are being re-educated by the Director of Nursing on 08/09/2024 to recognize signs of a resident being abused and early recognition of residents that do not feel safe. All such suspicions must immediately be reported to the Administrator or Director of Nursing. 4. Staff were re-educated by the administrator/Director of Nursing or designee on de-escalation techniques when working with residents on 8/9/2024. 5. Staff were re-educated by the administrator/Director of Nursing or designee on de-escalation techniques including employees and residents involving inappropriate behaviors on 8/9/2024. 6. Facility nurses were re-educated 8/9/2024 to ensure residents are assessed and incident reports are completed following abuse allegations. 7. Facility staff were also re-educated by the administrator on implementation of interventions to ensure resident safety. Re-education was initiated on 8/9/2024. 8. The expected completion date will be 8/10/2024. Staff who have not been trained on Abuse & Neglect/ De-escalation will not be allowed to work until they have completed required in-services. 9. An interim administrator has been appointed and will start 8/12/2024. He will be educated on this Plan of removal and facility Abuse and neglect policy before he starts functioning as the facility administrator. Once a permanent facility Administrator is appointed, they will also be educated on this Plan of removal and the facility Abuse and Neglect policy. Implementation of Changes Staff will immediately inform the Administrator or Director of Nursing immediately when made aware of any abuse allegation. The administrator or director of nursing will ensure implementation of interventions for resident safety. A quick reference sheet of interventions has also been provided to staff and posted at the nurse's station. Alleged perpetrators will immediately be placed on one-on-one monitoring pending investigation and physician direction. If Alleged perpetrator is a staff member, Administrator, Director of Nursing or designee will immediately suspend perpetrator and will be asked to leave the facility immediately. All staff identified as an alleged perpetrator cannot return to work until approved by Regional Director of Operations or designee. The victim will be immediately assessed for injury, safety awareness, physician notification and continue to be monitored pending investigation and physician direction. Victim's Medical records will be updated to reflect any changes as needed. In the absence of the Administrator abuse allegations will be reported to the Director of Nursing. All allegations and incidents will be reviewed to the daily IDT team meeting to review for resident assessment and completion of an incident report. The Regional Director of Operations and Regional Nurse Consultant will be responsible for implementation of the process and will review the process weekly X3 months by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring 1. Administrator/DON or designee will complete daily reviews of each incident to make sure residents are assessed, incident reports are completed, and interventions are put in place during daily IDT meetings. 2. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents to ensure safety X2 months. 3. 5 Non interviewable residents will receive a head-to-toe physical assessment daily for two weeks then one per week X2 months. 4. The administrator and Director of Nursing will interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings will be documented on Abuse & Neglect monitoring form X2 months. 5. The facility Administrator/DON or designee will conduct random employee surveys on de-escalation daily x2 weeks, weekly x2 then monthly thereafter. 6. RDO and RNC will review and monitor all allegations and incidents for propriate implementation of interventions x4 months. 7. RDO or RNC will review grievances weekly which are in the facility grievance binder for three months to monitor for appropriate interventions x4 months. 8. Any adverse outcomes will be reported to the monthly QAPI Committee meeting with the Medical Director. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 8/9/2024. Involvement of QA On August 9th, 2024 an Ad Hoc QAPI meeting was held with the facility administrator, medical director, director of nursing, and social services director to review the plan of removal. Who is responsible for the implementation of the process? The Regional Director of Operations and Regional Nurse consultant will be responsible for the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 8/9/2024. The facility's implementation of the IJ Plan of Removal was verified on 08/12/24 through the following: Record reviews of the Facility in-services started on 08/08/24 through 08/12/24 reflected in-services were given to over 50 employees prior to the start of their shift. The in-services included information on abuse and neglect, de-escalation of behaviors, keeping incidents to only a small number of people, speaking calmly during situations, protecting the resident, and validating the resident's concerns. Safe surveys, staff post-tests, the reference sheet of quick interventions posted at each nurse's station, and Resident #1's updated care plan and diagnosis list was reviewed. An interview on 08/12/24 at 4:50 PM with Resident #1 and his RP revealed he was happy that the Assistant Dietary Manager and Administrator were no longer working at the facility. He said it would take time for him to feel comfortable again. An interview with the Regional Director of Operations on 08/12/24 at 7:00 PM revealed LVN H, the Assistant Dietary Manager, and the Administrator were terminated from employment. Interviews on 08/12/24 from 11:05 AM to 7:00 PM with 16 staff from all shifts (Cook M, Dietary Manager, Dietary Aide N, CNA O, CNA P, CNA Q, CNA U, CNA R, CNA S, CNA T, LVN U, LVN V, LVN W, RN X, RN Y, and LVN Z) revealed they were in-serviced on the facility's abuse policy, types of abuse, de-escalation of behaviors, when to report abuse, who to report abuse to, how to protect a resident during an abusive situation, and what to do if a resident reported they did not feel safe. The staff acknowledged that they received the in-services said they also took a post-test. An interview with the DON on 08/12/24 at 5:45 PM revealed his role in the Plan of Removal was to participate in all interventions for problems identified. He would be implementing interventions, educating staff, care planning, documentation, and notification. He said he had spoken with the staff and explained that they were there to help the residents and not think of them as problems. He said he was teaching the staff to listen to resident concerns and address them. The DON said he would complete daily reviews of each incident to make sure residents were assessed, incident reports were completed, and interventions were put in place. The DON said he or the Administrator would interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings would be documented on Abuse & Neglect monitoring form X2 months. The DON said all incidents were reported to him so he could confirm proper steps were taken and followed. He said he read the 24-hour report daily to ensure no issues were missed with IDT. He said his plan for Resident #1 was to visit him daily. The DON said failure to follow abuse and neglect policies and failure to do investigations could put the resident's life in danger. An interview on 08/12/24 at 6:45 PM with the Interim Administrator revealed it was his first day as Administrator. He said his role in the POR was to be the Abuse Coordinator. He said he would make sure all in-services and all allegations were reported to him. If a resident alleges an allegation the facility was not going to just write it off. He said he would fully investigate all allegations. He said he would complete daily reviews of each incident to make sure residents were assessed, incident reports were completed, and interventions were put in place during daily IDT meetings. He said the IDT team would review all things that happened the prior day. He said he and the DON would interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings Included: 2. Record review of Resident #2's Quarterly MDS with an ARD (Assessment Reference Date) of 05/24/2024 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 diagnoses included: Alzheimer's Disease (neurological disorder that affects memory, thinking and behavior), Age-Related Physical Debility, and Alcohol Abuse. Resident #2 had a BIMS score of 11 indicating a moderately impaired cognition. Resident #2 had disorganized thinking and no potential indicators of psychosis, but did have a behavioral presence of wandering. Record Review of Resident #2's Comprehensive Care Plan, dated 08/08/2024, revealed the following: Focus- [Resident #2] had impaired cognitive function/dementia or impair [TRUNCATED]

Based on interview and record review, the facility failed to implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of resident's, establish policies and procedures to investigate any such allegations for two (Residents #2 and #1) of eight residents reviewed for abuse. The facility failed to implement their abuse, neglect, and exploitation policy to ensure Resident #2 was safe from sexual abuse when Resident #3 was found by facility staff in her bed on 07/06/2024. The facility failed to follow their policy by not initiating criminal sexual abuse procedures when Resident #2 lacked the decision-making capacity to consent to a sexual act. The facility failed to contact law enforcement for further direction on the incident, after the incident occurred. The facility failed to implement their abuse, neglect, and exploitation policy to ensure Resident #1 was free from verbal and physical abuse by the Assistant Dietary Manager. The failed to conduct a thorough investigation for Resident #1's allegation of abuse. An Immediate Jeopardy (IJ) was identified on 08/08/24 at 5:00 PM and on 08/09/24 at 5:00 PM . The IJ template was provided to the facility on [DATE] at 5:44PM and on 08/09/24 at 5:24 PM and signed by the Administrator. While the IJ was removed on 08/12/2024 at 7:05PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures could place all residents at risk for victimization, abuse, and psychosocial harm. Findings Include: Record Review of the facility's policy titled, Abuse Prevention and Prohibition Program revealed a date of 10/24/2022. Facility policy revealed that, the facility will treat allegations as criminal sexual abuse wherein the facility determines that the resident does not have the decision-making capacity to consent to the sexual act. The proper authorities and individuals are notified immediately or within two hours including but not limited to . law enforcement. The resident is provided with the medical treatment and emotional support necessary to prevent further deterioration of his/her health and wellbeing. The resident is transported to the hospital or other destination as instructed by law enforcement. Record Review of the facility's policy revealed a section titled, Prevention. This section revealed that, The facility conducts an ongoing review an analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse Resident assessments and Care Planning are preformed to monitor resident needs. Record Review of Resident #2's Quarterly MDS assessment with an ARD of 05/24/2024 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 diagnoses included: Alzheimer's Disease, Age-Related Physical Debility, and Alcohol Abuse. Resident #2 had a BIMS score of 11 indicating a moderately impaired cognition. Resident #2 had disorganized thinking and no potential indicators of psychosis but did have a behavioral presence of wandering. Record Review of Resident #2's Comprehensive Care Plan, dated 08/08/2024, revealed the following: Focus- [Resident #2] had impaired cognitive function/dementia or impaired thought processes r/t Dementia. Goal- [Resident #2] will develop skills to cope with cognitive decline and maintain safety by the review date. Interventions/Tasks- [Resident #2] needs assistance with all decision making. Focus- [Resident #2] has a communication problem. Goal- [Resident #2] will be able to make basic needs known on a daily basis through the review date. Interventions/Tasks- Anticipate and meet needs, focus on a word, or phrase that makes sense, or responds to the feeling resident is trying to express. Record Review of Resident #2's comprehensive care plan did not reveal any alternations or interventions that were put into place for Resident #2 after the incidents occurred on 07/06/2024 and 04/25/2024. Record Review of Resident #3's Admission MDS with an ARD of 06/26/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's diagnoses included: Alcohol Dependence with Withdrawal, Unspecified Tremors and Generalized Muscle Weakness. Resident #3 had a BIMS score of 14 indicating no cognitive impairment. Resident #3 had no potential indicators of psychosis or wandering. Record review of the facility's investigation report, dated 07/14/2024, revealed that the incident occurred on 07/06/2024 at 10:30 pm between two facility resident's, Resident #2 and Resident #3. Witness statements revealed that LVN A was completing her rounds when she witnessed Resident #2 on top of Resident #3. LVN A left the room and got LVN B as a witness to return to the room. Upon return to Resident #2's room, LVN A and LVN B revealed that they saw Resident #3 sitting on the side of Resident #2's bed. Resident #3 proceeded to get up from the bed, pulled up his pants, and fastened his belt. Facility investigation report revealed that Resident #3 had the capacity to make informed decisions. The facility did not indicate if Resident #2 had the capacity to make informed decisions. Provider response from the facility's investigation report revealed that the facility separated both residents and Resident #3 was asked to return to his room. A head-to-toe assessment was attempted but declined by Resident #2. MD, Family (did not indicate who), and facility Ombudsman were notified, safe survey rounds were completed by the facility. Facility investigation findings revealed the facility was unable to substantiate the findings. The facility concluded that Resident #3 was discharged to the community on 07/10/2024 and that the facility will continue to support Resident #2. Facility investigation report revealed that the local law enforcement was not notified and Resident #2 was not sent out to the hospital for a SANE (Sexual Assault Nurse Examination) at any time during or at the conclusion of the investigation. Record review of document titled, [Facility Name] Incidents by Incident Type dated for 08/08/2024 revealed that an incident report was initiated by the facility on 07/06/2024 for Resident #2, but not for Resident #3. Incident report for Resident #2 revealed a date of 07/06/2024 at 9:56 PM and incident category of , Other Incidents. Incident report for Resident #2 revealed to be crossed out which indicated the incident report to be deleted. Review of document revealed no other incident report initiated for Resident #2. Record review of a document titled, Progress Notes with a date of 07/07/2024, revealed that the nurse was going for her ward rounds during shift change and entered Resident #2's room where she observed Resident #2 and a male resident in a sexual position. The incident at that time was reported to the DON, Administrator, and Weekend Supervisor. Resident #2's sons were notified, and a message was left. Resident #2's NP (Nurse Practioner) was notified. Record review of a document titled, Progress Note, dated for 07/07/2024 revealed that Resident #2 refused a skin assessment to be performed. Record review of a document titled, Progress Note, dated for 07/08/2024 revealed that Resident #2 refused a skin assessment to be performed. Record review of Resident #2's document titled, Progress Note, dated for 07/09/2024 revealed that labs were ordered. Resident #2 continued to attempt to go downstairs via elevator, staff continued to re-direct and educate. Record review of a document titled, Trauma Screen, dated for 07/08/2024 revealed that Resident #2 did not reveal any signs of trauma after the incident. The document revealed that during the trauma screen interview Resident #2, laughed anxiously when [she was] asked about the incident that occurred on Saturday. Record review of a document titled, Psychiatric Subsequent Assessment revealed a date of Service of 07/22/2024 for Resident #2. Document revealed the reason for the referral [for psychiatry services] was anxiety and worrying and the chief complaint was possible abuse. Document revealed that staff witnessed Resident #2 in an intimate position with another resident. Mental Status Examination revealed that Resident #2's thought process was illogical, associations and thought content was unable to be assessed as Resident #2 was non-verbal. Resident #2's insight and judgement were both poor. Record Review of Resident #3's document titled, Nurse Administration Record revealed an order that stated, Resident to be on one on one observation, every shift for observation. Order start date 07/06/24 at 2301 and D/C (Discontinue) date of 07/17/24 at 0913. Interview with LVN A on 08/10/2024 at 3:12PM revealed that she was the nurse for Resident #2 on 07/06/2024. LVN A revealed that she walked into Resident #2's room and observed Resident #2 on top of Resident #3 in bed. LVN A revealed that she did not witness penetration as there was not enough light in the room. LVN A revealed that she alerted LVN B for a witness. LVN A revealed that they both saw Resident #3 pulling up his pants and fastening his zipper while still in Resident #2's room. LVN A revealed that Resident #3 exited Resident #2's room and she alerted the Weekend Supervisor of the incident. LVN A revealed that Resident #2 was placed on every 15-minute checks but was unaware there was not a physician order or alternation to Resident #2's plan of care. LVN A revealed that Resident #2 did not have the capacity to consent, and wandered constantly, but was easily re-directed. Interview with LVN B on 08/06/2024 at 1:14 PM revealed that she was the nurse for Resident #2 on 07/06/2024. LVN B revealed that she did not witness Resident #3 enter Resident #2's room. She revealed that LVN A alerted her during her rounds that she discovered Resident #2 on top of Resident #3. When she arrived to the room, she saw Resident #3 with his shirt unbuttoned, belt unbuckled and pants unbuttoned. LVN B revealed she alerted the Weekend Supervisor who alerted the Administrator. LVN B stated that Resident #2 was started on every 15- minute checks but could not state if Resident #3 began any enhanced monitoring that night. LVN B revealed that this behavior for Resident #2 was off her baseline. LVN B revealed that Resident #2 did not have the capacity to consent. LVN B revealed that Resident #3 resided on the first floor of the facility and Resident #2 resided on the second floor of the facility . LVN B revealed that residents had access to utilize the elevator from top to bottom floor at any time of the day and night without restriction. Interview with LVN C on 08/12/2024 at 11:34 AM revealed that she was the nurse for Resident #3 on 07/07/2024 from 6AM-10PM. LVN C was unsure why the one-on-one monitoring order did not start the night the incident occurred as per the NAR the order started on 07/06/24. LVN C revealed she did sign off on the one-to-one monitoring order, but no staff member was continuously monitoring Resident #3. LVN C revealed she and her CNA had other resident's they had to take care of and attend to their needs. LVN C revealed she did observe Resident #3 throughout her shift as she could. LVN C was unable to reveal documentation for Resident #3's location during her assigned shifts or reveal if Resident #3 had access to Resident #2 during her assigned shifts. LVN C revealed that residents did have access to utilize the elevator from top to bottom floor at any time of the day and night without restriction. Interview with RN D on 08/12/2024 at 3:42 PM revealed that she was the nurse for Resident #3 on 07/08/24, 07/09/24 and 07/10/24. RN D revealed that she was aware the order stated one-to-one monitoring and she signed off on the order during those shifts but revealed that Resident #3 was not on one-to-one monitoring during that time. RN D revealed that herself and her CNA had other resident's assigned to them during those shifts and were unable to perform one to one monitoring for Resident #3 and attend to the other resident's' needs. RN D did not reveal if she alerted the DON or physician of their inability to meet Resident #3's needs per the physician's order. RN D revealed that every time Resident #3 was in the hallway, she would monitor him. RN D was unable to reveal documentation for Resident #3's location during her assigned shifts or reveal if Resident #3 had access to Resident #2 during her assigned shifts. RN D revealed that resident's did have access to utilize elevators from the top to bottom floor at any time of the day and night without restriction. RN D revealed a risk of not following physicians' orders would be enlarging an issue already present for that resident. Interview with RN E on 08/09/2024 at 4:00 PM revealed that she was the nurse for Resident #3 on 07/07/2024 during the 10PM-6AM shift as indicated on Resident #3's MAR. RN E revealed that she did sign off on the one-to-one monitoring order, and that she and her CNA had multiple resident's that night and were unable to monitor the resident on a one-to-one basis throughout the shift. RN E did not reveal if she alerted the DON or physician of their inability to meet Resident #3's needs per the physician's order. RN E revealed she did check on Resident #3 periodically throughout her shift. RN E was unable to reveal documentation for Resident #3's location during her assigned shifts or reveal if Resident #3 had access to Resident #2 during her assigned shifts. RN E stated she was unaware of what the one-to-one order constituted. RN E revealed that resident's had access to utilize the elevator from the top to bottom floor at any time of the day and night without restriction. Interview with LVN F on 8/12/2024 at 10:00 AM revealed that she did not remember Resident #3 or signing off on the one-to-one monitoring order. LVN F revealed that she did not remember having a resident on any type of enhanced monitoring. LVN F revealed she never worked with just one resident before or seen any other staff member be assigned to just one resident for enhanced monitoring. LVN F revealed that resident's had access to utilize the elevator from the top to bottom floor at any time of the day and night without restriction. Interview with the LVN Weekend Supervisor on 08/08/2024 at 12:49 PM revealed that she was the nurse supervisor on the weekends for the facility. The LVN Weekend Supervisor revealed that she was alerted by LVN A and B that Resident #2 and Resident #3 were caught having intercourse. The LVN Weekend Supervisor revealed that no staff member witnessed penetration since the room was dark at the time of discovery. Resident #3 left Resident #2's room independently but reported to staff that Resident #2 wanted to go with him to his room. The LVN Weekend Supervisor revealed she was unaware if Resident #3 was placed on enhanced monitoring on 07/06/2024 and could not remember receiving an order from the medical director for enhanced monitoring. The LVN Weekend Supervisor revealed that Resident #2's cognition varies and she had severe deficits in her short-term memory. Interview with RP #1 on 08/08/2024 at 10:25 am revealed that she was aware of the incident that occurred between Resident #2 and Resident #3. RP #1 revealed that she was told by staff that Resident #2 was found in bed with a male resident. RP #1 revealed that she was shocked by the event as that was not like Resident #2's baseline behavior. RP #1 revealed that she visited Resident #2 the next day, 07/07/2024 and Resident #2 did not reveal any physical markings or changes in behavior. RP #1 revealed that she was unaware Resident #2 refused to go to the hospital after the incident occurred for further examination and was not aware Resident #2 refused head-to-toe assessments after the incident occurred. RP #1 revealed she requested the facility to ensure that Resident #2 had no more contact with Resident #3. RP #1 revealed she was unsure what interventions were put into place or what the outcome of the facility investigation was. RP #1 was aware that Resident #3 discharged from the facility. RP #1 was unaware of what interventions were put into place to prevent repeated victimization of Resident #2. RP#1 revealed she was aware of the incident that occurred on 04/25/24 between Resident #2 and a male staff member, but was not aware of any interventions that were put into place to protect Resident #2 from further victimization. RP #1 revealed she was aware Resident #2 has been on psychiatric services, admitted to psychiatric services unknown by RP #1. Interview with RP #2 on 08/08/2024 at 10:50 am revealed that he was the Power of Attorney for Resident #2. RP #2 revealed that he was unaware of the incident that occurred between Resident #2 and Resident #3. RP #2 revealed that he was alerted of the incident back in April of 2024 between Resident #2 and a male staff member. RP #2 revealed that he was unsure of what interventions were put into place to prevent repeated victimization of Resident #2. RP #2 revealed that he would defer to Resident #2's medical team to determine Resident #2's decision making abilities and abilities to consent. RP #2 revealed he was not alerted by the facility that Resident #2 refused to go to the hospital or refused head-to-toe assessments. RP #2 revealed that he was unaware that the facility investigated the incident or what the outcome of the investigation was. Interview with NP #4 on 08/08/2024 at 3:22 PM revealed that she had been the Psychiatric Nurse Practitioner for Resident #2 for a year and half. NP #4 revealed that she worked with the facility and Resident #2 for medication management related to her behaviors. NP #4 revealed that she was alerted by the facility of the event that occurred between Resident #2 and Resident #3 and the facility requested an updated evaluation. NP #4 revealed that there were no medication adjustments performed or changes in behaviors for Resident #2 after the incident. NP #4 revealed that Resident #2 reacted impulsively, is not aware of the potential consequences related to her actions, and lacks the foresight to make safe and sound decisions. NP #4 was not aware of any interventions that the facility took after the incident occurred for Resident #2. NP #4 revealed that she was not referred for services for Resident #3 and was not familiar with his care. Interview with MD G on 08/12/2024 at 9:10 AM revealed that she had been the attending physician for Resident #2 for two years. MD G revealed that she was alerted of the incident between Resident #2 and Resident #3 by the Administrator. MD G revealed the Administrator stated to her that Resident #2 and Resident #3 were found engaging in a sexual act, but no penetration was confirmed. MD G revealed after the incident she ordered labs and requested psych services for Resident #2. MD G revealed she did not order for Resident #2 to go to the hospital for a SANE. MD G revealed she could not remember if she did order enhanced monitoring for Resident #2 after the incident, but it was her expectation of the facility to contact her or her Nurse Practitioner to receive an order for any type of enhanced monitoring before initiating. MD G revealed she was unaware the facility initiated enhanced monitoring for Resident #2 without a physician's order. MD G revealed it is her expectation of the facility to call her or her Nurse Practioner for any changes or alterations in their resident's plan of care. MD G revealed that she spoke with the facility's psych provider for Resident #2 and confirms that Resident #2 does not have the capacity to consent or make safe and sound decisions independently. MD G revealed she did not discuss with the facility after the incident occurred about resident #2's ability to consent. Interview with the Facility Social Worker on 08/08/2024 at 11:27 AM revealed that she was alerted of the incident between Resident #2 and Resident #3 on the Monday following the incident as the incident occurred on a weekend. The Social Worker revealed that she interviewed Resident #2 on 07/08/24 to conduct a trauma informed screening. She revealed that Resident #2 had no alternations in behavior or physical markings after the incident. She revealed that Resident #2 had no signs of trauma, but she did indicate in the trauma screening that Resident #2 had anxious responses when asked about the incident. She revealed that Resident #2 stated, they only kissed and did not want to discuss the incident anymore. The Social Worker revealed she interviewed Resident #3 and he stated to the Social Worker that he was in love with Resident #2. The Social Worker revealed that she believed that Resident #2's cognitive and judgement abilities are related to the situation. The Social Worker confirmed that Resident #2 was on continued psychiatry and psychology services. The Social Worker revealed that she was unsure of what interventions were put into place for Resident #2 or Resident #3 after the incident occurred. She revealed that Resident #3 was issued a NOMNC (Notice of Medicare Non-Coverage) for a discharge date of [DATE] based on his therapy progress. The Social Worker revealed that Resident #2 was in a similar incident back in April 2024 with a male staff member. The male staff member was terminated from the facility and the facility's investigation revealed that the male staff member kissed the resident. The Social Worker could not reveal any interventions or alterations that were put into place for Resident #2 to prevent repeated victimization after this incident. Interview with the DON on 08/12/2024 at 5:47 PM revealed that he was alerted of the incident between Resident #2 and Resident #3 on 07/06/2024 by facility staff. The DON revealed that he was alerted that Resident #2 was found on top of Resident #3, there was no evidence of penetration, but suspicion of a sexual position. The DON revealed that Resident #2 and Resident #3 were separated from one another and both resident's were placed on enhanced monitoring. The DON revealed that Resident #2 was not sent out to the hospital for further examination or law enforcement was not contacted as there were no indicators of sexual coercion or force. The DON revealed that Resident #2 was in a similar incident back in April 2024 with a male staff member. The male staff member was terminated from the facility and the facility's investigation revealed that the male staff member kissed the resident. The DON could not reveal any interventions or alterations that were put into place for Resident #2 to prevent repeated victimization after this incident. The DON revealed that it was his expectation that the nursing staff would reach out to the physician for orders and direction after an incident involving possible sexual abuse occurs. The DON revealed that facility staff did not reach out to MD G for enhanced monitoring orders, but instead used nursing judgement. The DON revealed that he was unsure why Resident #3's orders were for one-to-one monitoring every shift as he was certain they were for Every 15-minute checks. The DON revealed he was unaware the nursing staff for Resident #3 was not executing the orders as written and ordered by the Medical Director. The DON revealed that he was unsure if Resident #2 and Resident #3 had contact with one another due to the order not being executed per physicians' orders. The DON revealed that there was not an additional staff member assigned to Resident #3 for one-to-one monitoring as he thought the orders were for 15-minute checks, which he revealed could be completed without an additional staffed nurse or CNA (Certified Nursing Assistant). The DON revealed that it was his expectation for staff, when, executing a one-to-one monitoring order, that the resident would be kept in proximity of that assigned staff member at all times during the duration directed in the order. The DON revealed that he was unsure why Resident #2's care plan did not reveal any alterations or interventions that were put into place after this incident and the incident that occurred on 04/25/2024 with a male staff member. The DON revealed risks for not following physicians' orders would be inadequate care delivery. Interview with the Administrator on 08/08/2024 at 2:20 PM revealed that he was first alerted of the incident on 07/06/2024 by LVN Weekend Supervisor that Resident #2 was caught in bed with Resident #3. There was an assumption of intercourse at that time, but the Administrator revealed that they only kissed based on the facility investigation. The Administrator revealed that the two residents were separated after the incident and placed on enhanced monitoring but was unsure if the physician gave the order for enhanced monitoring for either resident. Resident #2's [family members] were contacted after the incident occurred. The Administrator revealed he reported the incident to the state survey agency but did not contact law enforcement as he viewed the incident as consensual between both residents. The Administrator revealed that Resident #2 refused head to toe assessments and she was not sent out to the hospital for further examination as the incident was considered consensual. The Administrator was asked on what basis he believed the event was consensual between the two residents given MD G and NP #4's statements, the Administrator revealed it was in his opinion that Resident #2 had the ability to consent. The Administrator revealed that Resident #2 was in a similar incident back in April 2024 with a male staff member. The male staff member was terminated from the facility and the facility's investigation revealed that the male staff member kissed the resident. The Administrator could not reveal any interventions or alterations that were put into place for Resident #2 to prevent repeated victimization after this incident. The Administrator revealed that this sexual behavior for Resident #2 was typical of her baseline and labeled Resident #2 as hypersexual. The Administrator was asked on what basis of information did he conclude that Resident #2 was hyper-sexual, he directed the surveyor back to NP #4. The Administrator revealed that Resident #3 was discharged from the facility on 07/11/2024. The Administrator did not give any risks for not executing physicians' orders properly or risks for not identifying or alternating resident's plan of care after incidents of victimization occur. On 08/08/2024 at 5:44PM an Immediate Jeopardy (IJ) was identified. The Administrator and Director of Nursing was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The facility's Plan of Removal was accepted on 08/11/2024 at 4:34 PM and included: 1. Administrator submitted a self-report to HHSC regarding the incident on 7/6/24 Intake #516319 2. Attending Physician for involved residents was notified of the incident on 7/6/24. 3. Social Worker conducted a trauma assessment with female resident on 7/8/24. 4. Male resident was placed on 1:1 monitoring by facility staff 7/6/24. 5. Male resident has been discharged from facility on 7/10/24. 6. Licensed Nurse tried to conduct a head-to-toe assessment on female resident, but she refused even after several attempts on 7/6/24 an on 7/7/24. 7. Female resident refused to go out to the hospital for further evaluation on 7/6/24. 8. The Director of Nursing began obtaining witness statements from staff. On 7/6/24. 9. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with interview able residents on 7/9/24. 10. Both residents were referred to [psych provider] for psychological assessment and to be picked up on services if needed on 7/9/24 11. Female resident was placed on 1 on 1 on 8/8/24 12. Female resident seen by [psych provider] services on 8/9/24 13. New Safe Surveys completed on 8/9/24 and 8/10/24 14. Facility Administrator was terminated effective 8/10/2024 15. Referrals for female resident's alternate placement on an all-female unit have been sent out, female resident's [family member] agreed to the plan of discharge on 8/11/24 16. The female residents plan of care and EMR was updated on 08/08/2024 to reflect that this resident will remain on one-to-one supervision until resident is discharged . 17. A facility wide audit on residents with dementia, PTSD or history of sexual violence was completed by Director of Nursing on 08/11/2024. No other residents were identified to be at risk for victimization at this time. A trauma assessment will be completed on all new residents to identify those at risk of victimization and alternate/appropriate placement will be immediately sought for those that are at risk. 18. Reviewed current Abuse and Neglect Policy to ensure it is appropriate for staff to follow and protect residents from abuse and neglect on 8/8/24. In-Service conducted. The Director of Nursing/Designee (after re-educated below) re-educated facility staff on: 1. On 8/8/24 Director of Nursing and Administrator were re-educated on Abuse & Neglect Policy and implementation of appropriate interventions to ensure resident safety by Regional Director of Operations. 2. Staff in-service was initiated on 8/8/24. Staff members are being re-educated to report all allegations of abuse immediately upon notification to the Administrator who is the abuse coordinator. Staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 3. Facility staff were also re-educated by the administrator on implementation of interventions to ensure resident safety. Re-education was initiated on 8/8/2024. 4. The expected completion date will be 8/9/2024. Staff who have not been trained on Abuse & Neglect will not be allowed to work until they have completed required in-services. 5. In - service/ ADHOC QAPI completed with Medical Director on 8/9/24 on abuse and neglect policy. 6. An interim administrator has been appointed and will start 8/12/2024. He will be educated on this Plan of removal and facility Abuse and neglect policy before he starts functioning as the facility administrator. Once a permanent facility Administrator is appointed, they will also be educated on this Plan of removal and the facility Abuse and Neglect policy. 7. Social worker was re-educated by Regional Director of Operations on 8/11/2024 to complete a trauma assessment on all new residents to identify those at risk of victimization and immediately seek alternate/appropriate placement for those identified to be at risk. 8. The Regional Director of Operations and Director of Nursing re-educated facility staff on enhanced monitoring and expectations. Re-educated completed on 8/11/2024. Implementation of Changes: Staff will immediately inform the Administrator or Director of Nursing immediately when made aware of the any abuse allegation. The administrator or director of nursing will ensure implementation of interventions for resident safety. A quick reference sheet of interventions has also been provided to staff and posted at the nurse's station. In the absence of the Administrator, abuse allegations will be reported to the Director of Nursing. The Regional Director of Operations and Regional Nurse Consultant will be responsible for implementation of the process and will review the process weekly X3 months by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring: 1. Administrator/DON or designee will complete daily reviews of each incident for proper interventions during daily IDT meetings. 2. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents to ensure safety x 2 months 3. 5 Non interviewable residents will receive a head-to-toe physical assessment daily for two weeks then one per week x 2 months 4. The Administrator, Director of Nursing or designee will interview fiv [TRUNCATED]

Based on observations, interview, and record review, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to ensure alleged violations were thoroughly investigated for 2 (Residents #1 and #2) of 6 residents reviewed for resident abuse. The facility failed to ensure Resident #1's abuse allegation from 06/15/24 was thoroughly investigated. The facility failed to ensure Resident #2's abuse allegation was thoroughly investigated for 07/26/24. An Immediate Jeopardy (IJ) was identified on 08/09/24 at 5:00 PM. The IJ template was provided to the facility on [DATE] at 5:24PM and signed by the Administrator. While the IJ was removed on 08/12/2024 at 7:05PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure placed residents at risk for serious injuries, abuse, and serious harm due to their allegations not being thoroughly investigated. Findings included: 1. Record Review of Resident #1's Admission MDS Assessment, dated 05/19/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. He was cognitively intact. He did not have any behaviors. His diagnoses included stroke, heart failure, and hemiplegia (paralysis of one side of the body.) Review of Resident #1's Care Plans , not dated, reflected: Resident had a history of making false allegations/inaccurate statements as evidenced by previously accusing/stating: Makes up stories of falling, explained the same fall with different version to other nurses Interventions: If statements were determined to be inaccurate, staff will reorient and redirect as needed with reassurance and reality orientation. Listen openly to allegations/inaccurate statements and offer clarification as needed. Resident had potential to demonstrate verbally abusive behaviors related to ineffective coping skills, and poor impulse control. Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Evaluate for side effects of medications. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. Psychiatric/Psychogeriatric consult as indicated. Record review of Resident #1's Progress Notes, dated 06/15/24 at 7:20 pm reflected: Resident came to the nursing station to complain that he requested a double portion, but he was served with one portion of meal at dinner. He was offered another tray of dinner, but he refused and said that he was going downstairs. 7:26 PM Nurse was notified by the weekend supervisor that the resident wanted to go into the kitchen, but he was prevented from going in and he started altercation with the kitchen personnel. It was reported that the resident called the police. The resident came upstairs and said get my meds ready because I'm going out. Nurse had his medication prepared but the resident never came back to take his scheduled night medication. 8:15 PM A CNA came and told this nurse that the resident just left with his [family member] to the hospital. Note documented by LVN H. Review of Resident #1's Facility Self-Report dated 06/15/24 reflected: It was reported to Administrator on 6/15/24 that Resident #1 and the Assistant Dietary Manager had a verbal altercation. It was then reported to that the resident said that the Assistant Dietary Manager hit him in the chest. When the Administrator interviewed Resident #1 , he said the Assistant Dietary Manager also threw his walker and grabbed him by the throat. The Assistant Dietary Manager was interviewed and he denied ever putting a hand on the resident. The Administrator interviewed staff and residents that were in the dining room and kitchen when the altercation happened. In all of the Administrator interviews, everyone stated that they never saw the Assistant Dietary Manager put his hands on Resident #1. They also all said that it was the resident who was the aggressor, yelling and cursing at the kitchen staff. Investigation findings were unconfirmed because there was no witnesses that ever saw the Assistant Dietary Manager touch or hit the resident. In all interviews the witnesses stated Resident #1 was the aggressor and the one that was yelling and cursing. The Assistant Dietary Manager was allowed to come back to work from suspension. 1. Staff was in-serviced on abuse, neglect and dealing with aggressive behavior. 2. The Assistant Dietary Manager was allowed to return to work. 3. Resident #1 was presented a Behavior contract. Staff Witness Statements from the incident reflected: Resident #1 - The resident went to the kitchen to get double portions and the kitchen told him that they would send him another tray. He left and went back upstairs, and they could not find the tray. He came back downstairs and told them again that his tray was not up there. They told him that they would get him another tray once they finish with the other residents. He was standing in the door to the kitchen when he said the Assistant Dietary Manager came at him saying we are not going to do this Resident #1. Resident #1 then said that the Assistant Dietary Manager grabbed his walker and threw it about 10 feet. He then said that the Assistant Dietary Manager grabbed his neck and hit him in the chest. Resident #1 then stated that he took his shirt off to point at his chest that he had a pacemaker and then put his arms to his side and started saying that he did not touch anyone. Assistant Dietary Manager - Resident #1 was cursing at the cook about getting double portions. The Assistant Dietary Manager came to the door and asked the resident to not cuss at the employees. He stepped back into the kitchen and the resident called him a bitch. The Assistant Dietary Manager stated that he asked the resident, what you just said to me? The Assistant Dietary manager then said that he never put a hand on him. The Assistant Dietary Manager then stated that the resident tried to hit him but did not hit him. The resident then took his shirt off and started yelling that people were touching him. Dietary Aide I - He was working in the kitchen when Resident #1 came to the kitchen and was asking for more food. He stated that the resident started yelling at the cook and stating that he did not get double portions. The Dietary Aide I got the resident another plate and the resident still kept yelling at the staff. Dietary Aide I went and got the Assistant Dietary Manager to help with the resident, so they could finish the trays for the other residents. Dietary Aide I then said the Assistant Dietary Manager asked the resident to step out of the doorway to the kitchen. Resident #1 continued to yell and cuss at the Assistant Dietary Manager. The resident was getting more aggressive, and they tried to calm him down. Dietary Aide I stated that he never saw the Assistant Dietary Manager touch or hit Resident #1. Dietary Aide J - He stated that he never saw the Assistant Dietary Manager hit or touch Resident #1. He then stated that Resident #1 was the aggressor during the altercation. CNA K - see attached statement. (No statement attached.) Review of Resident #1's Hospital Records, dated 06/15/24, reflected the resident was an assault victim with a right chest wall contusion (bruise), neck strain, back strain, and contusion on his left ankle. There was no police report for 06/15/24. There was no facility incident report for 06/15/24. There was no resident assessment for 06/15/24. There was no trauma assessment for 06/15/24. The Surveyor requested the police report on 08/09/24 at 3:45 PM from the police department. An observation and interview with Resident #1 on 08/08/24 at 1:25 PM revealed he said he was assaulted on 06/15/24 by the Assistant Dietary Manager. He said he was supposed to get extra food and went down to get it and the Assistant Dietary Manager got in his face and threw his walker. He said it took 4-5 people to get him off of him. Resident #1 said he was scared of him and did not feel comfortable eating food from him. The resident said he had bruises on his neck and chest on 06/15/24 and went to the hospital. He said they took images of his chest and pacemaker. He said the right side of his chest was still sore. The resident said he currently was ordering take-out food and his RP complained because it was $100/day. The resident said his food was almost always messed up. Resident showed the Surveyor a piece of over-cooked, dry bacon and said all three of his meals were messed up. The resident said he thought his walker was messed up because the Assistant Dietary Manager threw it. The resident said when he would go to the kitchen and see him, they whispered about him. The resident said he did not feel safe getting his food from the Assistant Dietary Manager. The Administrator walked over during the conversation and the resident showed the Administrator the piece of bacon. The Administrator said ok and walked away. An interview on 08/08/24 at 1:15 PM with the Assistant Dietary Manager revealed on 06/15/24 an incident occurred. He said on Resident #1's tickets he was supposed to get large portions. The resident would say he did not get them, but he did. He said on 06/15/24, Resident #1 came to the kitchen and had a tray with him. The resident also had a tray upstairs, and a 3rd one that the cook had. The Assistant Dietary Manager said when saw the resident he was arguing with the cook even though he had 3 trays. The resident was riled up, cussing, and the Assistant Dietary Manager took the tray from the resident. The resident told him he was, nothing but a bitch anyway. The Assistant Dietary Manager said he turned around, walked back to the resident and asked what he said. He repeated, you're nothing but a bitch. The Assistant Dietary Manager told Resident #1 that he was not going to call him a bitch. The Assistant Manager said he was angry and yelling back at the resident and the other staff was trying to keep both him and the resident calm. The resident ran up on the Assistant Dietary Manager and changed his mind and moved back. The Assistant Dietary Manager said he raised his voice at the resident and Resident #1 called the police. The Assistant Dietary Manager said he told the resident he was not going to be threatening his staff. The Assistant Dietary Manager said there was another incident when the resident came to the kitchen, but when he saw the Assistant Dietary Manager, the resident left. He is a headache, and he is one of a kind. The Assistant Dietary Manager said he had been trained to de-escalate behaviors and that is why he stepped into the situation. He said he did not receive any disciplinary action but was suspended pending investigation. He said [NAME] L no longer worked at the facility and the Dietary Manager was off on 06/15/24. An interview on 08/08/24 at 1:35 PM with Dietary Aide J revealed he had worked at the facility for 2 months. He said on 06/15/24 he was washing the dishes and heard Resident #1 yelling and being mean to the staff. He said he went to the front and the Assistant Dietary Manager and the resident were cursing at each other and were in each other's face. Dietary Aide I said it got to a point where the argument was dying down and then the resident called the Assistant Dietary manager a bitch. The resident started cursing at all of the kitchen staff and the Assistant Dietary Manager responded and he got escalated. The Assistant Dietary Manager was upset. He was standing in the doorway and they were close to each other. HE went to grab the resident and was told not to put my hands on him. He stood by the resident's right shoulder and was facing the Assistant Dietary Manager to separate them. He said the Assistant Dietary Manager did not calm the situation, and he did not see them touch each other. Dietary Aide J said the Assistant Dietary Manager should have calmed down and let the situation go because the resident was about to leave by himself. The resident had a history of lashing out and then walking away. The police showed up 15 minutes later and the Assistant Dietary Manager left for the day. Dietary Aide J said he had to sign a paper but did not receive any in-services following the incident. An interview on 08/08/24 at 3:00 PM with CNA K revealed she had worked at the facility since 2022. She said on 06/15/24 Resident #1 got his tray and he said he did not get double portions. [NAME] L looked at his tray and said that he did receive double portions. The Assistant Dietary Manager came in and told the resident to step out of the kitchen. Resident #1 called the Assistant Dietary Manager the N word and stupid. The Assistant Dietary Manager was standing in the doorway of the kitchen. Resident #1 said he would slap the fuck out of the Assistant Dietary Manager. CNA K said she told the resident to come to her and told the resident he had to wait for his tray. Resident #1 reached across CNA K and tried to punch the Assistant Dietary Manager. CNA K said she told the Assistant Dietary Manager to back off and to walk away. CNA K said she got the tray for Resident #1. CNA K said the Assistant Dietary Manager escalated the situation and that she had to step in between them and back up Resident #1 for the Assistant Dietary Manager. She said the Assistant Dietary Manager should have walked away. An interview on 08/12/24 at 2:30 PM with LVN H revealed she was the nurse for Resident #1 on 06/15/24. She said she was told there was an incident in the kitchen and dining room and that Resident #1 we went in the kitchen and was insulting staff and calling them names. She said the LVN Weekend Supervisor was handling the situation. She said when the resident came back to her following the altercation he said he needed to get his medications. Resident told her that he went to the kitchen to get food and he was attacked and insulted by staff. LVN H said she did not know if anyone attacked him because he was always making up stories. She said the resident told her he went to the hospital, but she did not assess him before he left or when he got back. She said the resident was wearing a shirt. She said she did not believe that anyone attacked him and she did not know why he was a resident in the facility. She said she did not complete an incident report because she was not there when it happened. An interview on 08/12/24 at 4:15 PM with the LVN Weekend Supervisor revealed she did not work the weekend of 06/15/24. An interview on 08/08/24 at 2:10 PM with the Administrator revealed on 06/15/24, he got a call the afternoon or evening that Resident #1 and the Assistant Dietary Manager had the altercation. He said when he arrived the police were wrapping up their investigation and gave him the police report number. The Administrator said he did get the police report. He said Resident #1 left the facility with his friend. The Administrator said he interviewed the staff in the dining room and interviewed the resident when he came back. The Administrator called the Assistant Dietary Manager and suspended him. The Administrator said he found in his interviews with staff the common denominator was that Resident #1 was the aggressor. He was loud and arguing with the cook and he did not feel he got double portions. He kept trying to go in the kitchen with his walker. He said the staff got the Assistant Dietary Manager and asked him to please not go in the kitchen. Resident #1 yelled more and took his shirt off and thought he was ready to fight the Assistant Dietary Manager. The Administrator said staff did not see the Assistant Dietary Manager touch Resident #1. Resident #1 said he took his shirt off and said he had a pacemaker. The Assistant Dietary Manager denied throwing the walker and no one observed him throw the walker. Resident #1 said he was going to the hospital to have his pacemaker checked out. The Administrator said staff were supposed to de-escalate situations and re-direct residents and remove them form the situation. The Administrator said staff were not supposed to yell at residents and staff had to separate the Assistant Dietary Manager and Resident #1, because Resident #1 was being aggressive. He said he suspended the Assistant Dietary Manager but felt the Assistant Dietary Manager handled the situation appropriately. The Administrator said the resident said he was going to the hospital, but he did not think he went. An interview on 08/09/24 at 12:05 PM with the DON revealed he did not know that there was no assessment or incident report for Resident #1 for 06/15/24. He said he did not know about the results of the hospital records for 06/15/24. An interview on 08/09/24 at 12:15 pm Administrator revealed the facility did not do an assessment because Resident #1 left, and the facility did not do incident reports for verbal aggression. An interview on 08/09/24 at 2:50 PM with the Medical Director revealed Resident #1 was his resident. He said he knew the resident had frequent altercations and was only aware of the resident's most recent hospitalization on [DATE]. He said he did not know what the hospital records for 06/15/24 said. He said he did not expect that the facility would have done a more thorough investigation if they did not know he went to the hospital. Record review of the facility policy, Abuse Prevention and Prohibition Program, revised 10/24/22, reflected: I. VI. Investigation A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. i. The Facility has protocols for investigations of theft/misappropriation of resident property abuse. B. If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee, may appoint a member of the Facility's management team (the Investigator) to investigate the alleged incident. i. If the investigation is delegated, the Administrator provides the Investigator with any supporting documents related to the alleged incident. C. The Investigator may take some or all of the following steps: i. Reviews all relevant documentation; ii. Reviews the resident's medical record to determine events preceding the alleged incident; iii. Interviews the person(s) making the incident report; iv. Interviews any witnesses to the alleged incident; v. Interviews the resident (as medically appropriate); vi. Interviews the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; vii. Interviews Facility Staff members who have had contact with the resident during the period of the alleged incident . The Administrator was notified of the Immediate Jeopardy on 08/09/24 at 6:10 PM due to the above failures and provided the IJ template to Corporate DON. A Plan of Removal was requested. The facility's plan of removal was accepted on 08/11/24 at 4:35 PM and included the following: 1. Administrator submitted a self-report to HHSC regarding the incident on 06/15/2024. Intake #511237 2. Attending Physician for involved residents was notified of the incident by the nurse on 08/09/2024. 3. Social worker conducted a trauma screen with male resident on 8/10/2024, trauma screen finding was normal. If trauma screen had been abnormal, physician would be notified and EMR updated to reflect interventions. 4. Assistant Dietary Manager was immediately suspended on 6/15/24. 5. A copy of the residents' hospital records has been obtained and reviewed by the Director of Nursing and residents attending physician on 8/9/2024. 6. A new online request for a copy of the police report was submitted on 8/10/2024 by the administrator. 7. A complete head to toe assessment was completed on the resident on 8/10/2024. 8. Witness statements were obtained by the Administrator on 6/15/2024. 9. Witnesses reinterviewed on 8/8/24 and 8/10/24 10. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with interview able residents on 08/09/2024. The non interviewable resident received a complete head to toe assessment on 08/09/2024. Any negative findings were immediately investigated, physician and responsible party notified and EMR with interventions. 11. Affected resident was referred to [psych hospital] for psychological assessment and to be picked up on services if needed on 06/21/2024. 12. Assistant Dietary Manager employment with the facility was terminated on 8/08/2024. 13. Trauma screen completed by the social worker on 8/10/24 post record review, results were normal. 14. Resident seen by Team Health psychologist on 8/10/24. 15. Hospital records reviewed and uploaded on 8/8/24 by the Medical Records Director. 16. Physician notification of hospital records received on 8/9/24 by the Director of Nursing. 17. Care plan updated to reflect receipt of hospital records on 8/10/24, MDS coordinator. 18. Medical dx updated to reflect hospital records on 8/10/24 , by MDS coordinator. 19. New incident report completed on 8/10/24, the Director of Nursing. 20. Facility Administrator was terminated effective 8/10/24 In-Service conducted Director of Nursing or designee (after re-educated below) re-educated facility staff on: 1. On 8/9/24 Director of Nursing and Administrator were re-educated by the Regional Director of Operations on Abuse & Neglect Policy, verbal, physical, sexual abuse and implementation of appropriate interventions to ensure residents are not afraid and feel safe. Administrator and Director of Nursing were also re-educated on how to complete thorough investigation of incidents including completion of assessments, offering resident treatment, obtaining hospital records and obtaining police reports. 2. Post test completed with Administrator and DON on thoroughly investigating Abuse and neglect on 8/9/24 3. Staff in-service by the Administrator, DON or designee was initiated on 8/9/24. Staff members are being re-educated to report all allegations of abuse immediately upon notification to the Administrator who is the abuse coordinator. Re-education has an emphasis on De-escalation. Preventing abuse also involving staff and resident safety with emphasis on creating an environment where residents do not feel afraid. Staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 4. Staff are being re-educated by the Administrator, DON or designee to recognize signs of a resident being abused and early recognition of residents that do not feel safe. All such suspicions must immediately be reported to the Administrator or Director of Nursing on 8/9/24 5. Facility nurses were re-educated 8/9/2024 to ensure residents are assessed and incident reports are completed following abuse allegations. 6. Facility staff were also re-educated by the administrator on implementation of interventions to ensure resident safety. Re-education was initiated on 8/9/2024. 7. The expected completion date will be 8/10/2024. Staff who have not been trained on Abuse & Neglect will not be allowed to work until they have completed required in-services. 8. An interim administrator has been appointed and will start 8/12/2024. He will be educated on this Plan of removal and facility Abuse and neglect policy before he starts functioning as the facility administrator. Once a permanent facility Administrator is appointed, they will also be educated on this Plan of removal and the facility Abuse and Neglect policy. Implementation of Changes The regional Director of Operations and the Regional Nursing Consultant will review all incidents and allegations to ensure thorough investigations are completed daily x3 months then weekly their after. Staff will immediately inform the Administrator or Director of Nursing immediately when being made aware of the any abuse allegation. The administrator or director of nursing will ensure implementation of interventions for resident safety. A quick reference sheet of interventions has also been provided to staff and posted at the nurse's station. Alleged perpetrators will immediately be placed on one-on-one monitoring pending investigation and physician direction. The victim will be immediately assessed for injury, safety awareness, physician notification and continue to be monitored pending investigation and physician direction. Victim's Medical records will be updated to reflect any changes as needed. In the absence of the Administrator abuse allegations will be reported to the Director of Nursing. All allegations and incidents will be reviewed to the daily IDT team meeting to review for resident assessment and completion of an incident report. The Regional Director of Operations and the Regional Nurse Consultant will be responsible for implementation of the process and will review the process daily X3 months then weekly their after by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring 1. Administrator/DON or designee will complete daily reviews of each incident to make sure residents are assessed, incident reports are completed, and interventions are put in place during daily IDT meetings. 2. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents to ensure safety X2 months. 3. 5 Non interviewable residents will receive a head-to-toe physical assessment daily for two weeks then one per week x2 months. 4. The administrator and Director of Nursing will interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings will be documented on Abuse & Neglect monitoring form x2 months. 5. RDO and RNC will review and monitor all allegations and incidents for appropriate implementation of interventions x3 months. 6. RDO or RNC will review grievances weekly which are in the facility grievance binder for three months to monitor for appropriate interventions x4 months. 7. Any adverse outcomes will be reported to the monthly QAPI Committee meeting with the Medical Director. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 8/9/2024. Involvement of QA On August 9th, 2024 an Ad Hoc QAPI meeting was held with the facility administrator, medical director, director of nursing, and social services director to review the plan of removal. Who is responsible for the implementation of the process? The Regional Director of Operations and Regional Nurse Consultant will be responsible for the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 8/9/2024 The facility's implementation of the IJ Plan of Removal was verified through the following: Record reviews of the Facility in-services started on 08/08/24 through 08/12/24 reflected all in-services were reviewed and were given to over 50 employees. The remaining employees were to be in-serviced prior to the start of their shift. The in-services included information on abuse and neglect, de-escalation of behaviors, keeping incidents to only a small number of people, speaking calmly during situations, protecting the resident, and validating the resident's concerns, resident assessments, and completing thorough investigations. Resident #1's documentation and assessments reflected in the plan of removal were reviewed and in the electronic heal record. Safe surveys were reviewed, the quick reference sheet was posted at the nurse's station, and the QAPI meeting sign-in sheet for 08/09/24 was reviewed. An interview on 08/12/24 at 4:50 PM with Resident #1 and his RP revealed he was happy that the Assistant Dietary Manager and Administrator were no longer working at the facility. He said it would take time for him to feel comfortable again. An interview with the Regional Director of Operations on 08/12/24 at 7:00 PM revealed LVN H, the Assistant Dietary Manager, and the Administrator were terminated from employment. Interviews on 08/12/24 from 11:05 AM to 7:00 PM with 16 staff from all shifts (Cook M, Dietary Manager, Dietary Aide N, CNA O, CNA P, CNA Q, CNA U, CNA R, CNA S, CNA T, LVN U, LVN V, LVN W, RN X, RN Y, and LVN Z) revealed they were in-serviced on the facility abuse policy, types of abuse, de-escalation of behaviors, when to report abuse, who to report abuse to, how to protect a resident during an abusive situation, what to do if a resident reported they did not feel safe, and when to complete assessments. The said they received all in-services and completed the post-tests. An interview with the DON on 08/12/24 at 5:45 PM revealed his role in the Plan of Removal was to participate in all interventions for problems identified. He would be implementing interventions, educating staff, care planning, documentation, and notification. He said he had spoken with the staff and explained that they were there to help the residents and not think of them as problems. He said he was teaching the staff to listen to resident concerns and address them. The DON said he would complete daily reviews of each incident to make sure residents were assessed, incident reports were completed, and interventions were put in place. The DON said he/Administrator would interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings would be documented on Abuse & Neglect monitoring form X2 months. The DON said all incidents were reported to him so he could confirm proper steps were taken and followed. He said he read the 24-hour report daily to ensure no issues were missed with IDT. He said his plan for Resident #1 was to visit him daily. The DON said failure to follow abuse and neglect policies and failure to do investigations could put the resident's life in danger. An interview on 08/12/24 at 6:45 PM with the Interim Administrator revealed it was his first day as Administrator. He said his role in the POR was to be the Abuse Coordinator. He said he would make sure all in-services and all allegations were reported to him. If a resident alleges an allegation the facility was not going to just write it off. He said he would fully investigate all allegations. He said he would complete daily reviews of each incident to make sure residents were assessed, incident reports were completed, and interventions were put in place during daily IDT meetings. He said the IDT would review all things that happened the prior day. He said he and the DON would interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings Included: 2. Record review of Resident #2's Quarterly MDS with an ARD (Assessment Reference Date) of 05/24/2024 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 diagnoses included: Alzheimer's Disease (neurological disorder that affects memory, thinking and behavior), Age-Related Physical Debility, and Alcohol Abuse. Resident #2 had a BIMS score of 11 indicating a moderately impaired cognition. Resident #2 had disorganized thinking and no potential indicators of psychosis, but did have a behavioral presence of wandering. Record Review of Resident #2's Comprehensive Care Plan, dated 08/08/2024, revealed the following: Focus- [Resid [TRUNCATED]

Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for each resident that included measurable objectives and time frames that met the resident's medical, nursing and mental needs for two (Resident #2 and Resident #1) out of 3 residents reviewed for care plans. The facility failed to identify individualized interventions and objectives in the comprehensive care plan for Resident #2, after Resident #2 was involved in an alleged sexual abuse incident with a male staff member on 04/25/2024. The facility failed to protect Resident #2 who was a prior victim of abuse and unable to give consent for sexual activity. The facility failed to identify individualized interventions and objectives in the comprehensive care plan for Resident #2 after Resident #2 was involved in a sexual abuse incident with a male resident on 07/06/2024. This failure could place residents at risk for repeated victimization. After administrative review, an IJ was identified on 08/22/24. The Administrator and Regional Director of Operations were notified and an IJ template was provided on 08/22/24 at 9:54 AM. While the IJ was removed on 08/12/2024 at 7:05PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. Findings Included: Record Review of Resident #2's Quarterly MDS assessment with an ARD of 05/24/2024 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2's diagnoses included: Alzheimer's Disease, Age-Related Physical Debility, and Alcohol Abuse. Resident #2 had a BIMS score of 11 indicating a moderately impaired cognition. Resident #2 had disorganized thinking, no potential indicators of psychosis, but did have a behavioral presence of wandering. Record Review of Resident #2's care plan reviewed on 08/08/2024 reflected it did not include Resident #2's involvement with the incidents that occurred on 07/06/2024 and 04/25/2024. Resident #2's care plan did not include any measurable objectives or interventions that were put into place for Resident #2 after the incidents occurred. Record review of the facility's investigation report for the incident that occurred between Resident #2 and Resident #3, dated 07/14/2024, revealed that the incident occurred on 07/06/2024 at 10:30pm between two facility residents, Resident #2 and Resident #3. Witness statements revealed that LVN A was completing her rounds when she witnessed Resident #2 on top of Resident #3. LVN A left the room and got LVN B as a witness to return to the room. Upon return to Resident #2's room, LVN A and LVN B revealed that they saw Resident #3 sitting on the side of Resident #2's bed. Resident #3 proceeded to get up from the bed, pulled up his pants, and fastened his belt. Facility investigation report revealed that Resident #3 had the capacity to make informed decisions. The facility did not indicate if Resident #2 had the capacity to make informed decisions. Provider response from the facility's investigation report revealed that the facility separated both residents and Resident #3 was asked to return to his room. A head-to-toe assessment was attempted, but declined by Resident #2. MD, Family (did not indicate who), and facility Ombudsman were notified, safe survey rounds were completed by the facility. Facility investigation findings revealed the facility was unable to substantiate the findings. The facility concluded that Resident #3 was discharged to the community on 07/10/2024 and that the facility will continue to support Resident #2 . Facility investigation report revealed that the local law enforcement was not notified and Resident #2 was not sent out to the hospital for a SANE (Sexual Assault Nurse Examination) at any time during or at the conclusion of the investigation. Interview with LVN A on 08/10/2024 at 3:12 PM revealed that she was the nurse for Resident #2 on 07/06/2024. LVN A revealed that she walked into Resident #2's room and observed Resident #2 on top of Resident #3 in bed. LVN A revealed that she did not witness penetration as there was not enough light in the room. LVN A revealed that she alerted LVN B for a witness. LVN A revealed that they both saw Resident #3 pulling up his pants and fastening his zipper while still in Resident #2's room. LVN A revealed that Resident #3 exited Resident #2's room and she alerted the Weekend Supervisor of the incident. LVN A revealed that Resident #2 was placed on every 15-minute checks, but was unaware there was not a physician order or alternation to Resident #2's plan of care. LVN A revealed that Resident #2 does not have the capacity to consent, Resident #2 wanders constantly, but is easily re-directed. LVN A revealed that she was unsure of what interventions were put in place to protect Resident #2 from repeated victimization. LVN A revealed she could not recall the incident between Resident #2 and a male staff member. Interview with LVN B on 08/06/2024 at 1:14 PM revealed that she was the nurse for Resident #2 on 07/06/2024. LVN B revealed that she did not witness Resident #3 enter Resident #2's room, she revealed that LVN A alerted her during her rounds that she discovered Resident #2 on top of Resident #3. When she arrived to the room she saw Resident #3 with his shirt unbuttoned, belt unbuckled and pants unbuttoned. LVN B revealed she alerted the Weekend Supervisor who alerted the Administrator. LVN B stated that Resident #2 was started on every 15 minute checks, but could not state if Resident #3 began any enhanced monitoring that night. LVN B revealed that this behavior for Resident #2 was off her baseline. LVN B revealed that Resident #2 does not have the capacity to consent. LVN B revealed she was unsure of what interventions or alterations were made to Resident #2's plan of care to protect her from repeated victimization. LVN B revealed she was not familiar with the incident between Resident #2 and a male staff member and did remember any details of the incident. Interview with RP #1 on 08/08/2024 at 10:25 am revealed that she was aware of the incident that occurred between Resident #2 and Resident #3. RP #1 revealed that she was told by staff that Resident #2 was found in bed with a male resident. RP #1 revealed that she was shocked by the event as that was not like Resident #2's baseline behavior. RP #1 revealed that she visited Resident #2 the next day, 07/07/2024 and Resident #2 did not reveal any physical markings or changes in behavior. RP #1 revealed that she was unaware Resident #2 refused to go to the hospital after the incident occurred for further examination and was not aware Resident #2 refused head-to-toe assessments after the incident occurred. RP #1 revealed she requested the facility to ensure that Resident #2 had no more contact with Resident #3. RP #1 revealed she was unsure what interventions were put into place or what the outcome of the facility investigation was. RP #1 was aware that Resident #3 discharged from the facility. RP #1 was unaware of what interventions were put into place to prevent repeated victimization of Resident #2. RP#1 revealed she was aware of the incident that occurred on 04/25/24 between Resident #2 and a male staff member, but was not aware of any interventions that were put into place to protect Resident #2 from further victimization. RP #1 revealed she was aware Resident #2 has been on psychiatric services, admitted to psychiatric services unknown by RP #1. Interview with RP #2 on 08/08/2024 at 10:50 am revealed that he was the Power of Attorney for Resident #2. RP #2 revealed that he was unaware of the incident that occurred between Resident #2 and Resident #3. RP #2 revealed that he was alerted of the incident back in April of 2024 between Resident #2 and a male staff member. RP #2 revealed that he was unsure of what interventions were put into place to prevent repeated victimization of Resident #2. RP #2 revealed that he would defer to Resident #2's medical team to determine Resident #2's decision making abilities and abilities to consent. RP #2 revealed he was not alerted by the facility that Resident #2 refused to go to the hospital or refused head-to-toe assessments. RP #2 revealed that he was unaware that the facility investigated the incident or what the outcome of the investigation was. Record review of a document titled, Progress Notes, with a date of 04/27/2024 revealed a late entry note for 04/25/2024. Document revealed that the DON notified RP #2 for Resident #2 to notify him regarding an incident that occurred of inappropriate behavior from staff. DON notified [family member] that the employee was not in the facility at that time and the matter was pending investigation. Record review of a document titled, Health Status Note, with a date of 4/27/2024 revealed a late entry note from 04/25/2024. Document revealed that Resident #2 was inappropriately touched on the lips by a staff member. Resident #2 reported that the staff member, was her friend and friends do kiss. Interview with the Administrator on 08/08/2024 at 2:20PM revealed that Resident #2 was in a similar incident on 04/25/2024 with a male staff member. The male staff member was terminated from the facility and the facility's investigation revealed that the male staff member kissed the resident. The Administrator could not reveal any interventions or alterations that were put into place for Resident #2 to prevent repeated victimization after this incident. The Administrator revealed that the facility takes an interdisciplinary approach for care plans and no singular individual is responsible for updating each residents' care plan needs. Interview with Social Worker on 08/12/2024 at 10:02AM revealed that the MDS Nurse was responsible for ensuring that each care plan is personalized. The Social Worker revealed that the while the facility does take an interdisciplinary approach to care planning, the MDS Nurse is responsible for ensuring the data and information is inputted into the care plan. The Social Worker revealed that if the MDS Nurse was out of the facility, the DON or ADON would be responsible for care planning any interventions or objectives. The Social Worker revealed a risk for not personalizing or creating interventions after incidents occur for residents's would be a lapse of care for the resident. Interview with MDS Nurse on 08/12/2024 at 9:28AM revealed that she was the only MDS Nurse in the facility. MDS Nurse revealed that there is an interdisciplinary approach to care plans and care planning and it is the responsibility of all interdisciplinary leadership to ensure care plans are accurate and reflect the resident's current needs. The MDS Nurse revealed that she was off during the incidents that occurred between Resident #2 and Resident #3 and Resident #2 and a male staff member. The MDS revealed during the time she was off, the interdisciplinary team is responsible for updating all resident's plan of care as the facility takes an interdisciplinary approach to care plans. The MDS Nurse revealed that each resident was discussed in a weekly meeting and alterations to their plan of care are discussed during those meetings. The MDS Nurse revealed that she was unsure why Resident #2's care plan did not reflect the two incidents that occurred on 04/25/24 and 07/06/24 or any interventions that were put into place. The MDS Nurse could not reveal any alterations that were made to Resident #2's plan of care or any risks to the residents for not personalizing resident's plan of care or creating interventions after incidents occur. Interview with DON on 08/12/2024 at 5:47PM revealed that care plans should be personalized according to the resident's current needs. The DON revealed that the facility does take an interdisciplinary approach when it comes to care planning. The DON revealed that it is the responsibility of himself and the Administrator to ensure care plans are up to date and reflect the resident's current needs. The DON revealed he was unsure why Resident #2's care plan did not reflect the incidents that occurred on 07/06/24 and 04/25/24. The DON revealed Resident #2's care plan should have been updated to reflect all interventions that were put into place after the incidents occurred. The DON revealed a risk to not personalizing resident's plan of care or creating interventions after incidents occur are the opportunity for missed care. A Comprehensive Care Plan/Care Plans policy was requested by the surveyor to the RDO on 08/12/24 at 7:45AM. The facility did not present a current policy on Care Plans/Comprehensive Care Plans. Record Review of the facility's policy titled, Abuse Prevention and Prohibition Program revealed a date of 10/24/2024. Facility policy contained a section titled, Prevention and revealed that, The facility conducts an ongoing review and analysis of abuse incidents and implement corrective actions to prevent future occurences of abuse Resident Assessments and Care Planning are preformed to monitor resident needs. Record Review of the facility's MDS Coordinator- LVN/LPN Job Description dated December 2023 revealed that the MDS Nurse will assist the DON or designee with identification of physician orders and verbal reports to assure the MDS and care plan are reflective of those changes. After administrative review, an IJ was identified on 08/22/24. The Administrator and Regional Director of Operations were notified. The Administrator and Regional Director of Operations were provided with the IJ template on 08/22/24 at 9:54AM. The facility's Plan of Removal was accepted on 08/11/2024 at 4:34 PM and included: Identify responsible staff/what actions taken: 1. Administrator submitted a self-report to HHSC regarding the incident on 07/06/2024. Intake #516319 2. Attending physician for involved residents was notified of the incident on 07/06/2024. 3. Social Worker conducted trauma assessment with female resident on 07/08/2024. 4. Male resident was placed on 1:1 monitoring by facility staff on 07/06/2024. 5. Male resident was discharged from the facility on 07/10/2024. 6. Licensed Nurse tried to conduct a head-to-toe assessment on female resident, but she refused even after several attempts on 07/06/2024 and on 07/07/2024. 7. Female resident refused to go to the hospital for further evaluation on 07/06/2024. 8. The Director of Nursing began obtaining witness statements from staff on 07/06/2024. 9. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with interview able residents on 07/09/2024. 10. Both residents were referred to [psych provider] for psychological assessment and to be picked up on services if needed on 07/09/2024. 11. Female Resident care plan was updated on 8/10/24. 12. Female resident is on one on one as of 8/8/24. 13. Female seen by Psychologist on 8/9/24. 14. Orders are clarified to specify what is expected of one on one 8/10/24. 15. Facility Administrator was terminated effective 8/10/2024. 16. Referrals for female resident's alternate placement on an all-female unit have been sent out, female resident's [family member] agreed to the plan of discharge on 08/11/2024. 17. The female residents plan of care and EMR was updated on 08/08/2024 to reflect that this resident will remain on one-to-one supervision until resident is discharged . 18. A facility wide audit on residents with dementia, PTSD or history of sexual violence was completed by Director of Nursing on 08/11/2024. No other residents were identified to be at risk for victimization at this time. A trauma assessment will be completed on all new residents to identify those at risk of victimization and alternate/appropriate placement will be immediately sought for those that are at risk. In-Service conducted: Administrator and Director of Nursing (after re-educated below) re-educated facility staff on: 1. On 8/8/24 Director of Nursing and Administrator were re-education on Abuse & Neglect Policy and implementation of appropriate individualized interventions to ensure resident safety by Regional Director of Operations. 2. Staff in-service was initiated on 8/8/24. Staff members are being re-educated to report all allegations of abuse immediately upon notification to the Administrator who is the abuse coordinator. Staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 3. Facility staff were also re-educated by the administrator on implementation of interventions to ensure resident safety. Re-education was initiated on 8/8/2024. 4. The expected completion date will be 8/9/2024. Staff who have not been trained on Abuse & Neglect will not be allowed to work until they have completed required in-services. 5. An interim administrator has been appointed and will start 8/12/2024. He will be educated on this Plan of removal and facility Abuse and neglect policy before he starts functioning as the facility administrator. Once a permanent facility Administrator is appointed, they will also be educated on this Plan of removal and the facility Abuse and Neglect policy. 6. Social worker was re-educated by Regional Director of Operations on 8/11/2024 to complete a trauma assessment on all new residents to identify those at risk of victimization and immediately seek alternate/appropriate placement for those identified to be at risk. 7. The Regional Director of Operations and Director of Nursing re-educated facility staff on enhanced monitoring and expectations. Re-educated completed on 8/11/2024. Implementation of Changes: Staff will immediately inform the Administrator/DON or designee immediately when made aware of the any abuse allegation. The administrator/director of nursing or designee will ensure implementation of interventions for resident safety. A quick reference sheet of interventions has also been provided to staff and posted at the nurse's station. In the absence of the Administrator, abuse allegations will be reported to the Director of Nursing. The Regional Director of Operations and the Regional Nurse Consultant will be responsible for implementation of the process and will review the process weekly X3 months by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring: 1 Administrator/DON or designee will complete daily reviews of each incident for proper individualized interventions during daily IDT meetings. 2. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents to ensure safety X2 months. 3. 5 Non interviewable residents will receive a head-to-toe physical assessment daily for two weeks then one per week X2 months. 4. The administrator and/or Director of Nursing will interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings will be documented on Abuse & Neglect monitoring form. Staff interviews will continue for x2 months. 5. RDO and RNC will review and monitor all allegations and incidents for propriate implementation of interventions x3 months. 6. RDO or RNC will review grievances weekly which are in the facility grievance binder for three months to monitor for appropriate interventions then monthly thereafter. 7. RDO or RNC will review care plans post investigation to verify individualized care plans concerning allegations of abuse to prevent repeated victimization daily X4 week, then weekly X4 and monthly thereafter. 8. Any adverse outcomes will be reported and reviewed during the monthly QAPI Committee meeting with the Medical director. Involvement of Medical Director: The Medical Director was notified about the immediate Jeopardy on 8/8/2024. Involvement of QA: On August 9th, 2024 an Ad Hoc QAPI meeting was held with the Facility Administrator, Medical Director, Director of Nursing, and Social Services Director to review the plan of removal. Who is responsible for implementation of process? The Regional Director of Operations and Regional Nurse consultant will be responsible for the implementation of the new process. On 08/12/2024 at 8:30AM the surveyor began monitoring the facility's Plan of Removal. Record Review of Resident #2's Comprehensive Plan of Care dated 08/12/204, revealed the following: Focus- [Resident #2] has a psychosocial well-being problem (actual or potential) r/t alleged Sexual Assault Goal- [Resident #2] will demonstrate adjustment to nursing home placement by/through review date. Interventions- Assist/encourage/support resident to set realistic goals, Resident will be provided 1 on 1 care/supervision until discharge, continue psych services (psychology and psychiatry) Focus- [Resident #2] is an alleged SA victim r/t perpetrator observed kissing her. Male resident observed in [Resident #2's] room. Goal- [Resident #2] will be free from sexual assault through review date. Interventions- [Resident #2] is on 1-on-1 care until alternate placement, psych consult. Review of document titled, Trauma Screen with a date of 08/12/2024 revealed that a trauma screen was conducted with Resident #2. Trauma screen revealed that Resident #2 does have a history of trauma related events in her life and that Resident #2 stated the trauma experience she has is bearing five kids. Review of document titled, Progress Notes dated for 08/08/2024 revealed a new order was initiated for Resident #2 to monitor her on one to one monitoring. Review of several documents titled, Progress Notes, one note dated for 08/09/2024, three notes dated for 08/10/2024, one note dated for 08/11/2024 and one note dated for 08/12/2024 revealed that resident #2 was on one-to-one monitoring. Observation on 08/11/2024 at 11:45AM revealed Resident #2 in her room with a staff member stationed outside the door documenting her location. Observation on 08/12/2024 at 11:05AM revealed Resident #2 in the facility courtyard with a staff member close by documenting her location. Observation on 08/12/2024 at 1:24PM revealed Resident #2 in the facility gym with a staff member close by documenting her location. Interview with the Regional Director of Operations on 08/12/2024 at 10:00AM revealed that the MDS nurse was re-educated on care plans, appropriate interventions and goals. Interviews with 16 staff members who worked all shifts on 08/12/2024 at 11:09AM to 08/12/2024 at 5:30PM revealed: Staff were able to show return demonstration that they were in-serviced regarding the plan of removal, sexual abuse prevention and identification, how to identify residents who are at risk of increased victimization and plan of care alterations for Resident #2. Staff was able to verbalize that the abuse coordinator is now the Interim Administrator, and his contact number is posted around the facility. Staff was able to verbalize that the plan of care has been updated for Resident #2 to reflect 1:1 enhanced monitoring. Nursing staff was able to verbalize that after a sexual abuse incident or alleged incident occurs, they would immediately contact the abuse coordinator, physician for that resident, responsible party for that resident and the DON. Nursing staff was able to verbalize that after a sexual abuse incident or alleged incident occurs, they would ensure resident safety, report and being skin/psychosocial assessments. Staff Interviewed Included: [NAME] L, Dietary Manager, DA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN W, RN X, RN Y, LVN Z. Interview with the DON on 08/12/2024 at 6:05PM revealed that his role in the plan of removal was to participate in all interventions that are associated with all the problems that have been identified. DON revealed that the interventions included, educating staff, participating to ensure the care plan was in place and followed and communicating with physicians and other providers. DON revealed that he would complete a daily audit of all incidents and accidents and that he would review the 24 hour report daily with the interdisciplinary team every morning. DON revealed that the facility has been communicating with resident #2's family daily and that the family has decided to move the resident to an all-female memory care unit. During the Plan of Removal monitoring, Resident #2 was currently still residing in the facility and remained on 1:1 enhanced monitoring. Interview with the Interim Administrator on 08/12/2024 at 6:25PM revealed that he was the new administrator for the facility effective 08/12/2024. The Interim Administrator revealed that his role in the Plan of Removal was to ensure, along with the Regional Director of Operations, that the plan of removal was implemented effectively and efficiently. The Interim Administrator revealed that he had been in-serviced on the facility plan of removal and the facility ANE policy. The Interim Administrator revealed that he, along with the DON would complete daily reviews of each incident report to ensure that proper individualized interventions are implemented and in place. The Interim Administrator revealed he would also complete five staff member interviews for a two-month period for return demonstration of the in-serviced topics. The Interim Administrator revealed that his work would be audited by the Regional Director of Operations and Regional Nurse Consult to ensure compliance of the plan of removal. Interview with the Regional Director of Operations on 08/12/2024 at 7:00PM revealed that his role in the plan of removal was to oversee alongside the Regional Nurse Consult, the implementation of the plan of removal. The Regional Director of Operations revealed that his expectation for the Interim Administrator is to follow-up on all allegations thoroughly, investigate all allegations and take action when necessary The Regional Director of Operations revealed that alongside the Regional Nurse Consult they will monitor, and review care plans post investigation to ensure individualized interventions are put into place, review grievances weekly for three months and monitor and review all allegations and incidents for three months. The Interim Administrator and Regional Director of Operations were notified the Immediate Jeporady was removed on 08/12/24 at 7:05 PM, however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of seven residents reviewed for improper transfers. The facility failed to ensure Resident #1 was transferred according to his Care Plan using a Hoyer. An Immediate Jeopardy (IJ) was identified on [DATE] at 03:56 PM. The IJ template was provided to the facility on [DATE] at 3:58 PM and signed by the Administrator. While the IJ was removed on [DATE] at 12:26 PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. These failures resulted in hospitalization due to an improper transfer whereas Resident #1 received a fracture and underwent surgery to repair the fracture. Findings included: Review of Resident #1's quarterly MDS assessment, dated [DATE], revealed he was an [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included Age-related Osteoporosis (bone disease that develops when bone mineral density and bone mass decreases,), Osteopenia (loss of bone density), Muscle Weakness (decrease in muscle strength), Lack of Coordination, Congestive Heart Failure (heart muscle does not pump blood well), Acute Respiratory Failure (he lungs can't release enough oxygen into your blood), etc. The MDS reflected Resident #1 had a BIMS (a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 13 indicating cognition was intact. The functional abilities and goals section indicated Resident #1 required extensive assist with bed mobility and transfers, mechanical lift with 2 persons. Review of Resident #1's care plan revised on [DATE] revealed Resident #1 had an ADL Self Care Performance Deficit r/t Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe), Impaired balance (Loss of balance or unsteadiness), Limited Mobility (any physical impairment that impacts a person's ability to move around freely, easily, and without pain), Musculoskeletal impairment (conditions that can affect your muscles, bones, and joints), chronic pain (pain that lasts for over three months), COPD (chronic obstructive pulmonary disease), CHF (heart failure), abnormal posture (rigid body movements and chronic abnormal positions of the body), lack of coordination (problems coordinating how your muscles work), difficulty in walking, muscle wasting (thinning of muscle mass). Interventions included lying to sitting on bed side substantial/maximal assistance; sit to stand (not attempted due to medical condition or safety concerns); chair/bed-to-chair transfer dependent: Hoyer lift times 2 person assist, etc. Review of Resident #1's PT Sessions and Evaluations dated [DATE] under the Functional Mobility Assessment Section revealed, Transfers: Sit to stand and Chair/bed-to-chair transfer = Not attempted due to medical conditions or safety concerns. It also revealed, Amount of assist needed to sit at edge of bed: Current Value changed from Max (A) times 2 to Unable and Time patient can sit unsupported: Current Value changed from 20 seconds to Unable. Review of Resident #1's PT Encounter Summary dated [DATE], it revealed, We started our day as we usually do. Checked on the evaluations for the day, and reviewed notes as appropriate. After which, PT-student said she would go to round up patients to treat. I stayed at the gym to look over other documents due for the day. At 10:21am, PT-student called me saying she needed help. I asked where she was and said she's in [Resident #1]'s room. When I arrived in the room, PT-student was sitting on the floor beside [Resident #1]'s bed with Resident #1 beside her, laying on his back. I immediately alerted LVN A about [Resident #1]'s fall. LVN A went to the room with me to assess Resident #1. Resident #1 reported that his right hip hurts, there was also a scratch/abrasion on [Resident #1]'s right middle toe - but other than that, no other injuries were noted. I saw another staff member walk past and alerted her as well that we need help to get Resident #1 off the floor and then three male nurses arrived. The three male nurses attempted to get Resident #1 off the floor but was unable to. They put a Hoyer sling underneath and was able to use the Hoyer machine to lift Resident #1 off the floor. Resident #1 was positioned in bed, and I handed him the bed control so he can comfortably position himself. The bolster was put back in place, along with the 2 pillows underneath his calf, and the fall mat was returned beside his bed. We spoke to Resident #1 and made sure he was comfortable on his bed and asked if he needed anything else. We left the room and made sure his bedside table, bed control, and call light was within reach. I spoke to PT-student on the stairwell to clarify what happened. I have read her statement and it was what she told me as well. I educated PT-student on the indicators on how this particular patient was not appropriate for a 1-person transfer (PT-student has demonstrated good clinical judgement in the past that did not indicate anywhere near any kind of this incident happening or her missing these signs) 1) on ocular inspection, the patient was at least 6 feet tall, weighing at least 200 lbs; 2) There was no goal for transfers; 3) Patient required 2 person assist with supine side-lying activity due to poor trunk control and 2-/5 manual muscle testing of bilateral lower extremities - which we had always done together when treating him/we evaluated the patient together; and 4) There was a Hoyer sling on top of his wheelchair indicating patient was a Hoyer transfer. Review of Resident #1's Pain Evaluation dated [DATE] at 1:00 PM revealed his pain level was at a 3 and described as intermittent aching and he was given one HYDROcodone-Acetaminophen Oral Tablet 7XXX,d+[DATE] mg. Review of Resident #1's progress notes revealed: [DATE] at 10:35 AM eINTERACTS BAR Summary for Providers Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Falls - At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP ,d+[DATE] - [DATE] 07:35Position: Sitting l/arm - Pulse: P 61 - [DATE] 10:39 Pulse Type: Regular - RR: R 16 - [DATE] 12:36 - Temp: T 97.7 - [DATE] 12:36 Route: Forehead (non-contact) - Weight: W 222.0 lb - [DATE] 17:07 Scale: Wheelchair [DATE] at 11:25 General Progress Note: Resident alert and oriented, doing therapy session, including strengthening and mobility. unable to transfer from bed to w/c resident was ease down to the floor on his back. resident with history of pain on right hip call out pain on right knee and discomfort on his right hip; MD called immediate X-Ray obtained; Mar Updated. [FAM A] called with information; FAM A talked to [Resident #1] and resident stated that I did not have a fall, but I was put down in front on the Bed. Resident resting in bed with eyes opened. [DATE] at 11:35 General Progress Note: This nurse was alerted to room by Therapy Staff that resident was on the floor, upon entering room resident was lying on the floor on his back, head to toe assessment was performed, resident call out of pain to right hip and right knee, resident was transferred safely to bed, MD notified, order was given for immediate X-Rays to right hip, right knee, and right tibia and right fibula, PRN Medication Norco was administered, Responsible Party was notified. [DATE] at 12:34 Lab Note Text: X-Ray called immediately to [Company]: Order Number: 42947239 [DATE] at 2:27 PM General Progress Note: Notified NP of resident's X-Ray results which indicated acute fracture to right lower leg. Order given by NP to transfer resident to ER for further evaluation and treatment. Responsible Party was made aware. Review of the facility's Ad Hoc QAPI dated [DATE] revealed, Resident #1 sustained an assisted fall during a transfer with PT-student which resulted in a fracture to his right leg. An X-Ray was ordered, pain assessment completed, pain medication was given, and Resident #1 was sent to the ER. In an interview with FAM A on [DATE] at 01:15 PM, she stated she had a video of the PT-student in Resident #1's room and she attempted to pick him up without any help, a gait belt, nor a Hoyer. FAM A stated the PT-student dropped her father on the floor and he yelled out, he broke his leg, and she dismissed what he was saying. FAM A stated the PT-student told Resident #1 his leg was not broken; you are okay. The PT-student then moved his broken leg and kept telling him it was okay. FAM A stated the PT-student reported it as a minor incident. FAM A stated the facility called and told her what happened. FAM A stated she started reviewing the video and she could hear Resident #1 in the video and the transfer procedures were not followed. FAM A stated Resident #1 was scheduled for surgery tomorrow on [DATE]. Review of FAM A's video recording on her phone on [DATE] at 01:15 PM, revealed the PT-student attempted multiple times to pull Resident #1 to a standing position. The PT-student counted to three and attempted to pull Resident #1 up. On the fifth attempt, Resident #1 and the PT-student fell on to the floor. The PT-student used her cell phone and called the CI and informed her they had fallen and requested assistance. In an interview with ADON A on [DATE] at 02:30 PM, he stated during the morning meeting yesterday ([DATE]), he received a call from LVN A. LVN A informed him Resident #1 had fallen. ADON A stated he arrived upstairs Resident #1 had been placed back in bed. ADON A stated Resident #1 said it was a little incident. ADON A stated the roommate, Resident #2 chimed in and said, No one was going to move me because she just dropped him on the floor. ADON A stated LVN A told him a PT-student tried to transfer Resident #1 and in the middle of the transfer Resident #1 could not make it, so the PT-student eased him onto the floor. ADON A stated he called the DOR for a report and to come upstairs with the PT-student. ADON A stated three of the PT staff arrived at the room, and they explained it was a student that tried to transfer Resident #1 by herself. ADON A stated he called the MD and explained when he touched Resident #1's right foot he called out in pain. ADON A stated the doctor ordered an X-Ray on Resident #1's hip, knee and ankle. ADON A stated he told FAM A to review the camera and she came to the facility and spoke with the DON. ADON A stated the DON called him and said he just reviewed the video camera and to call 911 right away. ADON A stated he called the doctor back and informed her they would be sending Resident #1 out opposed to waiting on the X-Ray results. ADON A stated Resident #1 received a broken bone of the tibia going towards the ankle. In an interview with the ADM on [DATE] at 03:50 PM, he stated the fracture was confirmed the same day. The ADM stated it was a witnessed incident, nothing was mentioned of neglect and Resident #1 had a BIMS of 13. The ADM stated Resident #1 said he did not fall, but that is the great thing about videos because it can help cut through inconsistencies. The ADM stated Resident #1 lost his balance while the PT-student was trying to assist him. Review of Resident #1's hospital paperwork revealed, on Tuesday, [DATE] at 3:09 pm, patient presented with RLE (right lower extremity) pain. Patient was being transferred at his nursing facility when he was dropped. He has a deformity to the right anterior tibia. He denies hitting his head and LOC (level of consciousness). In an interview with Resident #2 on [DATE] at 11:00 AM, he stated he did not see anything due to the curtain being pulled. Resident #2 stated he heard Resident #1 crash on the floor, and he could see Resident #1 a little beneath the curtain. Resident #2 stated he did not see the staff that entered the room, but he heard all the commotion. In an interview with the DON on [DATE] at 11:25 AM, he stated the ADON reported to him on [DATE] that Resident #1 sustained a fall. The DON stated the ADON said it was an assisted fall on a failed transfer from Resident #1's bed to chair. The DON stated he instructed the ADON to assess Resident #1 properly and report it to the MD. The DON stated FAM A walked into his office and showed him a video. The DON stated he watched the video of the transfer, which was really an assisted fall. The DON stated he did not have the heart to watch the video and it broke him to see what he saw. The DON stated it was a difficult position for the resident. The DON stated he stopped the conversation with FAM A and had his staff call 911. The DON stated EMS arrived before FAM A left his office. The DON stated an X-Ray had already been completed in-house. The DON stated after Resident #1 arrived at the hospital, the results of the in-house X-Ray confirmed a fracture which was reported to FAM A and the doctor. The DON stated after the incident, they had started in-servicing and training on transfers, gait belt use, fall prevention and renewing competencies. The DON stated they had an Ad Hoc QAPI and addressed the concerns with the monitoring of transfers in place for 7 days, once a week for one month, and once a month for 3 months. The DON stated that Resident #1 was a Hoyer transfer. The DON stated the DOR reported the PT-student had gone to the floor to get different residents to bring down for therapy, but they were not ready. The DON stated the PT-student had entered Resident #1's room because he was on her schedule. The DON stated the PT-student started her field work at the facility on [DATE]. In an interview with the DOR on [DATE] at 11:50 AM, she stated the PT-student started her field work at the facility on [DATE]. The DOR stated the PT-student had already completed two 3-month rotations in Outpatient Care. The DOR stated universities sent students enrolled in this type of program anywhere within the United States. The DOR stated this had been the PT-student's first rotation in a long-term care setting. The DOR stated therapy followed the school's syllabus and the facility's Competency Checklist. The DOR stated the CI supervised and checked off the PT-student's completed tasks. The DOR stated after a student started, they received a tour of the facility and started shadowing their instructor (documentation, evaluations, treatments, etc.). The DOR stated the PT-student started treating Residents alongside the CI and each week they progressively increased her caseload. The DOR stated the PT-student saw half of the Residents and the CI tended to the other half. The DOR stated she observed the PT-student and the CI during Week 2 with less-complexed residents. The DOR stated the PT-student was never assigned to treat Resident #1 alone. The DOR stated Resident #1 was on the PT-student's schedule, but the PT-student and the CI had always provided services to him together in his room. The DOR stated the PT-student told them she had gone to get two different residents across the hall from Resident #1, but they were not ready. The DOR stated the PT-student had gone to see Resident #1, trying to salvage her day. The DOR stated the PT-student informed her Resident #1 said he wanted to get up and she said, Let's do it. The DOR stated the PT-student retrieved Resident #1's wheelchair and placed it at the edge of his bed and the goal was to stand Resident #1 up and place him in the wheelchair. The DOR stated the PT-student said Resident #1 could not make it and since the wheelchair was close, the goal was the wheelchair, and they went down. The DOR stated the PT-student participated in Resident #1's Therapy Care Plan and Goals on her second day. The DOR stated Care Plans were part of the PT-student's first evaluation. The DOR stated she did not foresee anything worse than a fracture due to the mechanics of the fall. In an interview on [DATE] at 12:25 PM, the RDOT stated PT-students were assigned via their recruiter. The RDOT stated after the student started, they followed a Competency Checklist. The RDOT stated the first couple of days was a lot of observations. The RDOT stated when the CI felt the PT-student was ready, they allowed them to participate in treatments and documentation. The RDOT stated the PT-student assisted with evaluations, progress notes, and discharges. The RDOT stated the PT-student was scheduled to graduate in [DATE]. The RDOT stated based on the CI's observation, she could give the PT-student as much work as the PT-student could handle. The RDOT stated they started with simpler cases and there were never any concerns with the PT-student. The RDOT stated they completed bed mobility, sitting on the edge of the bed, and worked on strengthening. The RDOT stated the PT-student got Resident #1 to the edge of the bed, got him ready, attempted to get him up with a lack of clinical judgement for sure, and it went south. The RDOT stated she did not know why the PT-student did it, especially if she tried multiple times without success. The RDOT stated Resident #1's transfer status was part of his PT evaluation. The RDOT stated the PT-student wrote a statement and was dismissed from the facility. The RDOT stated they reported the incident to the PT-student's school. In an interview on [DATE] at 01:00 PM with the CI, she stated she was not in the room when it happened. The CI stated the PT-student was supposed to round residents up and bring them down to therapy. The CI stated the PT-student entered Resident #1's room and attempted to complete his therapy in the room alone. The CI stated previously when she and the PT-student treated Resident #1, it was always the two of them and she was surprised the PT-student attempted to do it by herself. The CI stated the PT-student had been doing good and the PT-student thought she could do it on her own. The CI stated her, and the PT-student completed Resident #1's sessions in bed. The CI stated Resident #1 was a Hoyer transfer even when transferred to his wheelchair, the Hoyer would be used. The CI stated Resident #1's treatment was for him to sit on the side of the bed and that was why there was always two therapists present because he was just that weak. The CI stated she had worked at the facility over 5 years, and she never completed Resident #1's therapy by herself. The CI stated she spoke with the PT-student after the incident, and the PT-student stated she lowered the resident down to ease the fall. The CI stated the PT-student called her on the phone and said she needed help. The CI stated she arrived at the room and called out for nurse's assistance. The CI stated after a student started field training at the facility, the student would shadow her for one week to get oriented to paperwork, assessments, evaluations, etc. The CI stated she would complete a Competency Skills Checklist to make sure the PT-student was able to complete all tasks. The CI stated she would gradually give a PT-student more complex cases with less supervision. The CI stated the PT-student had already accomplished these tasks. The CI stated the PT-student was trained on gait belt use, proper transfer techniques, assessment of a resident, how to complete evaluations and treatments. The CI stated PT-students are not trained on Hoyer use due to it not being a skilled service, it was a Nursing task. The CI stated the PT-student was proactive with her learning and took on cases easily in which she demonstrated good clinical judgement. The CI stated they were flabbergasted by this incident. The CI stated the PT-student had trained at the facility for 5 weeks. The CI stated the PT-student related her [NAME] with real treatment well. The CI stated this had been a lapse in the PT-student's judgement. The CI stated the worse that could had happened was the resident could have received a head injury and died . Observation on [DATE] at 10:00 AM at [Hospital], Resident #1 was observed to be sleeping peacefully and not in pain. HRN awakened Resident #1 to speak with Surveyor. In an interview on [DATE] at 10:03 AM at [Hospital], Resident #1 stated he was okay and not in pain. Resident #1 stated the PT-student entered his room and attempted to stand him up. Resident #1 stated he was too heavy for the PT-student. Resident #1 stated he told the PT-student he weighed 220 lbs. Resident #1 stated the PT-student kept trying to stand him. Resident #1 stated they fell ed to the floor, and the PT-student had him twisted up. Resident #1 stated the PT-student dropped him, and it was painful. Resident #1 denied he told the PT-student he wanted to sit in his wheelchair. Resident #1 stated he never discussed his wheelchair with the PT-student. In an interview on [DATE] at 10:25 AM at [Hospital], the HRN confirmed Resident #1 was admitted on [DATE] at 3:09 pm. HRN stated Resident #1 had a fall at the nursing home and received a right ankle fracture. HRN stated Resident #1 had surgery on [DATE]. HRN stated there were no concerns listed by the doctor, nor the ER. HRN stated there was nothing medically going on except treatment of the fracture. HRN stated there was no timeframe for discharge because they were waiting for PT to evaluate Resident #1. HRN stated Resident #1 was unable to tolerate a lot of PT and required care when discharged . HRN stated she had been Resident #1's nurse since he admitted 3 days ago. HRN stated Wednesday morning ([DATE]), she told Resident #1 she needed to turn him to provide incontinent care and he was afraid and told her, Please do not drop me. HRN stated Resident #1 said she looked small like the girl that dropped him so he was scared she would drop him too. HRN stated she informed Resident #1 PT was going to stop by and was panicked because he feared being dropped. HRN stated the doctor notes from ,d+[DATE] stated [Resident #1] had been bed-bound status for almost one year. The Nursing Facility staff tried to get him to stand up and get into his wheelchair. During the past one year, the facility had used a Hoyer. [Resident #1] could not hold his balance, fell on the floor, and broke his right ankle. In an interview on [DATE] at 11:15 AM, the MD stated she was made aware Resident #1 fell . The MD stated Resident #1 had not experienced a recent change in condition. The MD stated she understood a PT-student was trying to do a transfer by herself. The MD stated Resident #1 was usually non-ambulatory and required extensive assistance due to weakness. The MD stated the PT-student should have requested assistance. The MD stated Resident #1 fell , received a fracture, and required surgery. In an interview with the PT-student on [DATE] at 11:15 AM, after exiting the facility, she stated she was familiar with Resident #1's care. The PT-student stated she had never treated Resident #1 alone; her CI was always with her. The PT-student stated it was her first time where she trained in a Long-Term Care setting. The PT-student stated she was familiar with Resident #1's mobility and strength and stated, I knew he had poor lower extremity strength, and he was 90% immobile and was in bed most of the time. The PT-student stated the only treatment she and her CI had completed with Resident #1 was sitting him on the side of the bed. The PT-student stated she had never sat Resident #1 on the side of the bed by herself. The PT-student stated she had never transferred Resident #1 to his wheelchair but stated this was what he wanted to do. The PT-student stated she attempted to move Resident #1 to his wheelchair because during the time of her being a student, she was given 100% supervision on Week 5 even though the goal did not need to be met until further along in her clinical rotation. The PT-student stated this was her first week doing things alone. The PT-student stated Resident #1 told her he wanted to get out of bed, and it was something him and her attempted and it went downhill from there. The PT-student stated she showed empathy for Resident #1 as he said he just wanted to kind of get up. The PT-student stated she attempted a technique she learned in school known as a Dependent Transfer where a resident does not have any strength at all, and you could swivel them into the chair. The PT-student stated she thought it was something she could attempt to do with Resident #1, but it was not the outcome of what happened. The PT-student stated it would have been safer to seek assistance prior to starting the transfer due to Resident #1's size, his height, and his diminished strength in his lower body. The PT-student stated she should had called for assistance. The PT-student stated she had access to Resident #1's Care Plan. The PT-student stated she had previously discussed with her CI that Resident #1required two-person assistance. The PT-student stated it had been an oversight in her own clinical judgment. The PT-student stated it was her judgment and her CI had previously told her if she was going to transfer Resident #1, he was a 2-person assist. The PT-student stated again it was a clinical oversight on her part. The PT-student stated for transfers, she was aware that Resident #1 was a 2-person assist. The PT-student stated 100% for sure she could say it was a mistake for her to attempt to transfer Resident #1 by herself. The PT-student stated she does not feel that anyone else was at fault, she just believed per her Syllabus she was more advanced. The PT-student stated she was made aware of Resident #1's condition. The PT-student stated she does not want to know or think about the worse that could have happened. Review of facility's policy titled Abuse Prevention and Prohibition Program dated [DATE], revealed: I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Review of facility's untitled policy titled Transfer of Residents it stated: Purpose: to provide the form of transfer best suited to the residents' needs and to maintain resident safety during the procedure. Policy I. A Licensed Nurse and/or the Director of Rehabilitation Services assess and determine lifting and transfer requirements and the procedure used for each resident. The procedure is recorded in the resident's Care Plan. II. Residents must be lifted or transferred according to the determined procedure. III. Residents who require assistance in transferring will be transferred using a gait/transfer belt or with a lift. V. Mechanical lift procedures are used on any resident unable to independently pivot or transfer. Procedure II. Assisting to Chair A. One Person Pivot Transfer (resident must be able to bear weight) An Immediate Jeopardy (IJ) was identified on [DATE] at 3:56 PM. The IJ template was provided to the facility on [DATE] 3:58 PM and signed by the Administrator. A plan of removal was requested at that time. The facility's plan of removal was accepted on [DATE] at 12:26 PM and reflected: Summary of Details which lead to outcomes. F689 Free of Accident Hazards/Supervision/Devices On [DATE] during a complaint survey at The Hillcrest of North Dallas at 18648 Hillcrest Road, Dallas, TX 75252. On [DATE] the HHSC surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility allegedly failed to provide supervisory services. When resident #1 was being transferred at his nursing facility he was dropped. Has a deformity to the R anterior tibia. The notification of the alleged immediate jeopardy states as follows: An [AGE] year-old male with a BIMS of 13 admitted to the facility on [DATE]. His diagnoses include Age-related Osteoporosis, Osteopenia, Muscle Weakness, Lack of Coordination, Dementia, Acute Respiratory Failure, etc. He required a Hoyer when transferring and two therapists at bedside during therapy. An in-house Stat X-Ray was performed, and he was sent out prior to the results. EMS transferred the resident to Medical City [NAME] where the hospital paperwork states he presented with RLE pain. Patient was being transferred at his nursing facility when he was dropped. Has a deformity to the R anterior tibia. Denies hitting his head and LOC. Identify residents who could be affected. All Residents who require assistance to be transferred have the potential to be affected. Identify responsible staff/ what action taken. 1. Physical Therapist Student was immediately removed from the facility. 2. We contacted the school and informed them that the Physical Therapist Student was being removed from the student fieldwork program and could not return to the facility. In-Service conducted. 1. Therapy staff was re-educated on mechanical lifts and gait belts appropriate transfer training, transfer status and protocol for falls which include do not move residents, call for assistance and have nurse to assess on [DATE]. 2. Education is being provided to nursing staff on fall prevention, and transfers with mechanical lifts and gait belts on [DATE]. 3. Education is being provided to nursing staff to check the KARDEX to know plan of care and transfer technique [DATE]. Implementation of Changes Change of policy for student supervision - Clinical supervisor must provide close, direct supervision and oversight to student clinicians Providing patient care in the following circumstances: To make an initial determination of competence. When a student clinician is performing assigned treatment or activity with a patient for the first time. When the student clinician is learning a new skill or technique. When the student clinician's performance assessment/evaluation identifies issues (e.g. conduct, clinical performance, capacity) with potential to interfere with delivery of competent, quality and ethical rehabilitative care. In all other treatment circumstances, the student clinician must be in line of sight of the clinical supervisor when providing direct patient care. The clinical supervisor should be available to intervene and/or correct student performance, as necessary. Director of Rehabilitation has been in-service on the new policy change [DATE]. Clinical Instructors have been in-serviced on the new policy change [DATE]. Audit of fall assessments and care plans are being completed and appropriate interventions will be put in place as needed by [DATE]. Therapy staff was re-educated on mechanical lifts and gait belts appropriate transfer training, transfer status and protocol for falls which include do not move residents, call for assistance and have nurse to assess on [DATE]. Education is being provided to nursing staff on fall prevention, and transfers with mechanical lifts and gait belts on [DATE]. Education is being provided to nursing staff to check the KARDEX to know plan of care and transfer technique [DATE]. Monitoring DOR/Designee will monitor staffing to ensure that any student therapist will be closely monitored to follow the new policy. DOR/Designee will review the effectiveness of this daily X 7 days and weekly X 4 weeks, then X 3 monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discovery. The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted on [DATE] and ongoing. The Administrator/DON will review the effectiveness of this daily X 7 days and weekly X 4 weeks, then X 3 monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discovery. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on [DATE] [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure residents received care, consistent with professional standards of practice to prevent pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable and received the necessary treatment and services, to promote healing for three (Resident #1, #2, and #3) of five residents reviewed for wounds. 1. Resident #3 had wounds that included an unstageable pressure ulcer on her right shoulder that was not covered, treated or known about by the facility. According to the WCP, the wound was at least 4 days old. Resident #3 had a physician's order for an air loss mattress that the facility was not using. Resident #3 also had new wounds that included: Unstageable (Due to Necrosis) Sacrum that was greater than 6 days old and a wound on her left upper buttock with days of duration unknown. There were no skin assessments or documented knowledge of the wounds for September 2020 prior to state surveyor intervention. 2. Resident #2 had a Stage II pressure ulcer on her right buttock that was uncovered and an irritated, red area at the brief line of her right buttock that were not treated or assessed by the facility. Resident #2 did not have treatment orders for her wounds. Resident #2 also had new wounds that included: an arterial wound of the right, third toe that was at least 6 days old, arterial wound on her left, second toe and a wound on the right, medial, first toe with days of duration unknown. There were no skin assessments or documented knowledge of the wounds for September 2020 prior to state surveyor intervention. 3. Resident #1 had a Stage IV pressure ulcer on her left foot, between her first and second toe that was uncovered. She had physician orders for wound care that were not being followed. An Immediate Jeopardy/Immediate Threat was identified on 09/30/20. While the Immediate Jeopardy was removed on 10/02/20, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 09/30/20. These failures placed residents at risk of pain,[MEDICAL CONDITION] and worsening of pressure sores. Findings included: 1. Review of Resident #3's face sheet, dated 09/29/20, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #3's MDS (minimum data assessment), dated 08/05/20, reflected the resident was at risk for pressure ulcer development, but had not developed any pressure ulcers. Review of the Physician Orders for Resident #3 reflected: 01/14/20 Weekly skin assessment once a day on Tuesdays. 01/15/20 Clean left heel with normal saline and apply skin prep. Off load the site every shift 01/28/20 Daily skin check 02/07/20 Air Mattress 09/18/20 Daily Wound Treatment: Clean wound on left hip with normal saline, pat dry, and apply dry dressing daily. Review of Resident #3's Treatment Administration Records for September 2020 reflected: 1. The nursing staff documented they checked every shift to make sure the resident was lying on an air loss mattress. Observations revealed the resident was not lying on an air mattress. 2. Weekly skin checks were documented as being performed on the 2:00 PM - 10:00 PM shift on Tuesdays. No wounds were listed in the documentation. Review of Resident #3's Care Plans for September 2020 revealed she was not care planned for wounds or risk of wounds. Resident #3's Weekly Skin Assessments for 09/01/20 - 09/28/20 reflected the assessments were not documented as being completed. Review of Resident #3's POC (Plan of Care) Responses (CNA documentation) dated 09/28/20 reflected the resident had a wound on her shoulder and buttock. There were no physician orders or nurse assessments documented on 09/28/20. Resident #3's Wound Care Physician (WCP) Notes reflected: September 2020 - No documentation provided by the facility. 10/01/20 - Initial Evaluation: Wound of the Right Shoulder Size: 2.7 x 3.0 x not measurable centimeters Duration: At least 4 days Wound treatment ordered Unstageable (Due to Necrosis) Sacrum Size: 5.0 x 8.0 x 0.3 centimeters Duration: Greater than 6 days Wound treatment ordered Wound of the left, upper hip Size: 03.6 x 6.2 x 0.2 centimeters Duration: Greater than 6 days Wound treatment ordered Wound of the left, upper buttock Size: 1.6 x 4.0 x 0.2 centimeters Duration: not documented Wound treatment ordered There was no documentation in the WCP notes to indicate the wounds were unavoidable. Review of Resident #3's Nurse Notes reflected: 09/17/20 9:39 PM Wound noted on left hip 9.2 x 4.5 centimeters. Wound cleaned with normal saline and dry dressing applied. There were no nurse notes documented for her other wounds for 09/01/20 to 09/28/20. An observation and interview on 09/29/20 at 1:15 PM on the 2nd floor revealed Resident #3 was lying in bed on her left side. The resident's right shoulder was exposed, because her gown was loose and had slipped down. The resident had a necrotic unstageable wound, approximately the size of a tennis ball on her right shoulder. The wound had a black, necrotic scab with surrounding redness. The resident was moaning, and said she was hurting. Her untouched lunch tray was on the bedside table. Resident #3 had throat congestion. CNA D entered the resident's room. The CNA repositioned the resident and checked the resident's brief to see if incontinence care was needed. Direct Care Staff B entered the resident's room. She looked at the wound on Resident #3's shoulder and stated she had not seen it before. CNA D said she saw the wound earlier that morning, unknown time, and she told LVN M about it. The resident did not have an air loss mattress. An interview on 09/29/20 at 1:45 PM with LVN M revealed she was not aware of a wound on Resident #3's shoulder. She stated the resident did have a wound on her left hip and she had changed the dressing earlier that day, 09/29/20. She stated there was no report from staff or documentation to tell her the resident had a wound on her shoulder. She stated CNA D did not tell her about the wound. 2. Review of Resident #2's face sheet, dated 09/29/20, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #2's MDS (minimum data assessment), dated 07/07/20, reflected the resident was at risk for pressure ulcer development, but had not developed any pressure ulcers. Review of the Physician Orders, dated 02/03/20, for Resident #2 reflected: Daily skin check and report any findings to the charge nurse. There were no Physician Orders for wound care. Review of Resident #2's Care Plan, dated 06/13/19, reflected: Resident is at risk for pressure ulcers related to cerebral infarction and impaired mobility. Review of Resident #2's Braden Scale, dated 09/01/20, revealed the resident was at mild risk for pressure ulcer development. Resident #2's most recent Weekly Skin Assessment, dated 09/23/20, reflected the resident did not have any skin issues. Resident #2's Wound Care Physician Notes reflected: September 2020 - No wounds 10/01/20 - Initial Evaluation Arterial wound of the right, third toe Size: 0.5 x 0.5 x not measurable centimeters Duration: At least 6 days Wound treatment ordered Arterial wound of the left, second toe Size: 0.2 x 0.2 x not measurable centimeters Wound treatment ordered Wound of the right, medial buttock Size: 0.5x 0.5 x 0.2 centimeters Wound treatment ordered Wound of the right, medial, first toe Size: 0.5 x 0.5 x 0.2 centimeters Wound treatment ordered There was no documentation in the WCP notes to indicate the wounds were unavoidable. Review of Resident #2's Nurse Notes for September 2020 revealed there were no nurse notes regarding the resident's wounds. An interview and observation on 09/29/20 at 10:25 AM in Resident #1's room revealed her roommate, Resident #2 was lying in bed. Resident #2 was able to answer some questions. She said she did not know if she had any wounds. Resident #1 interjected and said Resident #2 had wounds on her thigh. Direct Care Staff B entered the resident room. Resident #2 stated she moved into the room a few days ago. The resident had a suitcase with belongings leaning against the wall. CNA C entered the resident room. Direct Care Staff B and CNA C provided incontinence care to Resident #2. The resident had a wound in the crease below her right buttock that was dark red and not open. It measured approx. 3.5 x 2.0 centimeters. Resident #2 also had a Stage II pressure ulcer on her right buttock. It measured approximately 1.5 x 1.5 centimeters with very shallow depth. Neither wound had a dressing. Direct Care Staff B stated she did not work with Resident #2 that morning and did not know if the nurse knew about the wounds. She stated she would tell the nurse about the wounds. An interview on 09/29/20 at 10:43 AM with LVN A revealed Resident #2 was assigned to her and she did not have treatment orders for her wounds. 3. Review of Resident #1's face sheet, dated 09/29/20, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #1's MDS (minimum data assessment), dated 08/06/20, reflected the resident was at risk for pressure ulcer development, and had a Stage IV pressure ulcer with application of dressings to her feet. Review of the Physician Orders, dated October 2020, for Resident #1 reflected: 02/05/20 Daily skin check and report any findings to the charge nurse. 05/12/20 Complete weekly skin assessment once a day on Mondays. 07/10/20 Pressure Wound of Left, Proximal, Medial First Toe. Clean with normal saline, pat dry then apply collagen powder and Mupirocin (antibiotic ointment), cover with dry dressing daily. Review of Resident #1's Care Plan, dated 01/06/20, reflected: Pressure Ulcer - initial care plan for the pressure ulcer Stage IV pressure ulcer to Left Proximal Medial First toe. Measurement 0.4 x 0.3 x 0.2 centimeters. Facility Approach: Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin every week. Treatment: Clean pressure ulcer with normal saline, pat dry, apply collagen rope with silver; mupirocin and cover with dry protective dressing once daily. Review of Resident #1's Braden Scale, dated 09/24/20, revealed the resident was not at risk for pressure ulcers. Review of Resident #1's POC (Plan of Care) Responses (CNA documentation) from 09/27/20 To 10/03/20 revealed facility CNAs documented the resident's skin was clear of any skin problems. Resident #1's most recent Weekly Skin Assessment, dated 09/24/20, did not include an assessment of the pressure ulcer. Review of Resident #1's Nurse Notes revealed: 09/17/20 11:07 AM Resident had a telehealth facetime visit with the Wound Care Doctor today, wound measurements between left great toe, and second toe: 0.3 x 0.3 centimeters. Per the Wound Care Doctor, there is great improvement compared to last visit. Will continue to monitor. Resident #1's Wound Care Physician Notes reflected: 09/24/20 Stage IV Pressure Wound of the left, proximal, medial, first toe. Size: 0.5x 0.2 x 0.2 centimeters Wound Progress: Deteriorated Wound treatment ordered 10/01/20 Stage IV Pressure Wound of the left, proximal, medial, first toe. Size: 0.5x 0.5 x 0.2 centimeters Wound Progress: Deteriorated Wound treatment ordered There was no documentation in the WCP notes to indicate the wounds were unavoidable. An observation and interview on 09/29/20 at 9:35 AM revealed Resident #1 was in a room located on the 2nd floor of the facility. The resident had a wound on her left toe with a deep open area, no redness. It measured approximately 0.5 x 0.5 x unknown depth, centimeters. Resident #1 stated her toe wound hurt and throbbed. She said it was supposed to have a dressing on it, but it fell off either Sunday (09/27/20) or Monday (09/28/20). The resident stated she did not know how often the dressing was supposed to be changed. An observation and interview on 09/29/20 at 9:55 AM revealed LVN A walked into Resident #1's room. She looked at the resident's wound and stated she did not know what her treatment orders were. LVN A walked out of the room and back to the medication cart to look for Resident #1's treatment orders. LVN A returned to the resident's room and stated the wound between the 1st and 2nd toe was supposed to be covered with a bandage and Collagen powder. LVN A stated she was assigned to the resident and was also assigned to her on 09/28/20. She stated she did not provide the wound care for the toe wound because she did not have time. She stated she did not ask for help to complete the treatment and did not give a reason. An observation and interview on 09/29/20 at 12:45 PM revealed Resident #1 and Resident #2 were in their room. They said they were still waiting to receive wound care. An interview on 10/01/20 at 3:57 PM with LVN E, evening shift, revealed she had recently worked, unknown date, with Residents #1 and #2. She stated Resident #1 had a toe wound and on her shift, she would make sure the dressing was intact. She said 6:00 AM - 2: 00 PM shift was responsible for dressing changes. She said she was not aware of wounds on Resident #2. She stated if a nurse was notified about a wound, the nurse was supposed to measure and document the wound, notify the doctor, provide treatment, and notify the family. An observation and interview on 09/29/20 at 1:35 PM with the DON revealed he was not aware of the wounds on Residents #1, #2, and #3. He went to the 2nd floor to see them. He stated the facility did not have an assigned Wound Care Nurse. He stated the Wound Care Physician made rounds every Thursday with the nurse assigned to the resident. He entered Resident #3's room. He assessed the resident's shoulder. CNA D was in the room when the DON entered. The DON asked CNA D about the wound. She said she had already reported it to LVN M. The Investigator asked about the resident's ordered air loss mattress. The DON said she was not lying on one and he did not know why. The DON left Resident #3's room and walked into Resident #1 and #2's room. He repositioned the residents to look at their wounds. Staff, unknown name, entered the residents' room to assist the DON. An interview on 09/29/20 at 2:50 PM with the DON revealed he conducted an investigation regarding the wounds on Residents #1, #2, and #3. He said he instructed the nurses to assess the wounds on all 3 residents and contact the physician. He stated CNA D did not immediately report Resident #3's wound to the nurse. He stated LVN A was running late with her medication administration and did not do her wound care and did not ask for help. He said he was going to complete an in- service and add the nurse was supposed to ask for help if they need it. The DON said he was not aware the state surveyor asked LVN A about Resident #1 and Resident #2's wounds. He stated agency staff did not receive specific wound care in-services when they were hired, and the facility tried to capture them on general in-services. He stated nurses were supposed to complete weekly skin assessments on all residents. He stated the CNAs were supposed to notify the nurse about any skin change and the nurses were supposed to immediately call the doctor, get orders, and notify the family. An interview on 09/29/20 at 4:36 PM with the Administrator revealed she did not know why Resident #3 did not have her ordered air loss mattress. She stated she would have the staff at the facility look for the air mattress and that it might have gotten left on the COVID unit when the resident moved from the 1st floor to the 2nd floor. She stated she did not know why the facility had residents with wounds that had not been reported and/or treated. Interviews with the DON on 09/30/20 at 10:54 AM and 09/30/20 at 12:45 PM revealed the facility completed a skin sweep to assess for new wounds the night of 09/29/20. He stated the facility identified residents that had new wounds. The DON reported he had to send LVN M home because she refused to complete wound care for Resident #3 on 09/30/20. He also stated the CNAs told him that because of her demeanor they did not like to report findings to her. An interview 09/30/20 at 12:55 PM the Medical Director stated she thought the facility was having an issue with wounds because the ADON assigned to wounds left employment. She stated a large number of residents moved within the facility and were working with new staff. She said the facility did not have a history of issues with wound care. An interview on 10/02/20 at 1:30 PM with CNA I revealed staff were supposed to notify the nurse if they found a new wound and they were supposed to document the skin issue in the computer kiosk. An interview on 10/02/20 at 1:40 pm with CNA D revealed she had received an in-service from the DON and staff were supposed to notify the nurse if they identified a wound, but there were nurses she did not feel comfortable reporting to. She said she was supposed to notify the DON if she did not want to notify the nurse. She stated when she did tell the nurses about wounds, she assumed they were addressed, but sometimes found the issues had not been taken care of. She stated staff were also supposed to document skin issues on the computer kiosk. An interview on 10/02/20 at 1:45 PM with LVN A revealed she had been working at the facility for one week. She said she did not receive any in-services regarding wound care when she started employment. She stated when she was notified about a wound she was supposed to call the doctor and get orders to treat the wound. An interview on 10/02/20 at 10:50 AM with the Wound Care Nurse from a sister facility revealed she reviewed the skin sweep sheets completed on 09/29/20 by the facility. Some residents she re-assessed had wounds not listed. She said Resident #2's wounds were not documented on any of the facility skin sweep sheets and that she had identified multiple wounds on the resident when she assessed her on 09/30/20. She stated she provided the facility with a wound care binder of policies and procedures as well as wound care check-offs to assess competency of the nurses. An interview on 10/02/20 at 3:40 PM with the Wound Care Physician revealed he conducted weekly telemedicine rounds at the facility for wounds that were reported to him. He stated he would complete his rounds with the nurse assigned to the residents. He stated he was not aware of any wounds that had worsened but there were a few instances when he had to tell the nurse to change soiled dressings. He stated he was not aware of Resident #3's wounds and the resident was supposed to be on an air mattress. He stated the facility could improve wound care at the facility if the facility would have a nurse dedicated to provide wound care. An interview on 10/02/20 at 3:30 PM with the DON revealed he had worked at the facility for one month. He stated the facility's current procedure for identifying wounds was for staff and nurses to complete routine skin assessments and document findings on the shower sheets. He stated he conducted random skin audits to oversee the wound care program. He stated the CNAs were supposed to report a new finding (skin change) to the nurse, the nurse was supposed to notify the physician and obtain treatment orders. The facility was not able to provide any wound care policies or procedures. An interview on 10/02/20 at 10:50 AM with a WCN from a sister facility (arrived on 09/30/20 at unknown time) revealed she had to provide the facility with a copy of Wound Care Policies and Procedures from her facility. An Immediate Jeopardy/Immediate Threat was identified on 10/01/20. The Administrator, VP of Operations, and DON were notified of the Immediate Jeopardy on 10/01/20 at 5:10 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 10/02/20 at 4:15 PM and reflected the following: Resident #1 dressing was replaced and ordered obtained. Dressing replaced 9/29/20 and order obtained 9/29/20 Resident #2 order was obtained and implemented - Order was obtained and implemented 10/1/20 Resident #3 order was obtained and implemented, and air mattress provided. Order was obtained and implemented 9/30/20 and air mattress provided 9/30/20 Residents #1-3 Wounds were reassessed, measured, and documented on 10/1/20 by the Director of Nursing/designee. Residents who reside in the facility have the potential skin sweep was done by members of nursing management beginning on 9/29/20 to identify concerns regarding skin integrity. The physician was notified of any new area identified for treatment orders. An audit of residents who had room moves in the last 7 days was done to validate that any specialty mattresses was moved with the resident. This was completed on 9/30/202. Skin sweep was completed 9/30/20 on all 69 residents. All new issues identified where updated on skin sheet. New physician orders were obtained as needed with all wounds identified. Family was notified. 10 Residents with skin issues were identified in skin sweep. Residents with treatment orders for pressure ulcers was audited by members of nursing management to identify any missed treatments. Wounds were assessed and treatments were applied as ordered. This was completed by members of nursing management on 9/30/2020 - One new resident was identified to need an air mattress. Order was obtained 10/1/2020 and air mattress was provided on 10/1/2020 Care plans were updated by members of nursing management to reflect current wound status and air mattress if applicable. This was completed by October 2, 2020. The Director of Nursing was re-educated by the Clinical Consultant on 9/30/2020 on the expectations of oversite on the skin processes. This included: o validating that skin audits are completed weekly by a review of those that due each day o Validate weekly wound measurements by a review of the wound log weekly o A review of signed shower sheets indicating a skin integrity concern to validate addressing as indicated will be done weekly for 3 months then randomly thereafter. o Random audit of wound dressings to validate that date of dressing correlates with order weekly for 3 months then randomly thereafter o Validate that air mattresses ordered are in place and room moves occur validating that air mattress was moved also weekly for 3 months then randomly thereafter. o Rounding daily Monday through Friday to validate skin prevention measures are in place/occurring o If there is a discrepancy in the care plan related to the air mattress, the care plan should be updated and/or mattress applied to bed o Updating the comprehensive care plan, to include approaches to prevent further skin breakdown or worsening of inherited pressure injury as part of the clinical morning meeting process The Director of Nursing will re-educate the charge nurses on the above information. This will be done prior to the weekend charge nurses starting their shift. The Director of Nursing was able to verbalize education given and indicated understanding. The Licensed Nurses were re-educated on the following: 10/1/2020 to 10/2/2020 o That the licensed nurse is expected to perform weekly Focused Skin Observation on all residents identifying areas of skin impairment and notifying physician of any area identified for orders for treatments. - o Notifying the physician for implementing a treatment o Measuring wound(s) weekly/observing wound characteristics with every treatment documented in the medical record. o In the event of a room move the nursing transferring is to report to the receiving nurse the measures in place for prevention of pressure ulcers. o Validating approaches are in place throughout shift including the mattresses that may be required to be moved with the resident in the event of a room move. Education on following physician order to include the implementation of an air mattress upon receipt of order. o If a C.N.A provides the information that a skin integrity concern has been identified, the nurse assigned to the patient is to sign the shower sheet and address as indicated and the C.N.A. will make a copy and give to Director of Nursing. If not in facility will slide under door. o If the care plan does not reflect the air mattress is applicable, the care plan is to be updated to reflect. o The Certified Nursing Assistants were re-educated on the expectation of reporting to the nurse any skin integrity issue for intervention. If a C.N.A provides the information that a skin integrity concern has been identified, the nurse assigned to the resident is to sign the shower sheet and address as indicated and the C.N.A. will make a copy and give to Director of Nursing/designee This re-educated was completed by [DATE]. Any clinical staff member not receiving by this date will receive prior to next scheduled shift. This will be presented to agency staff and new hires. Anyone not receiving will be presented prior to next scheduled shift. The Director of Nursing / designee will be reviewing the body audits completed each day Monday through Friday and the charge nurse on weekends to validate that any skin integrity concern identified was addressed with MD notification and order obtained and implemented and then round to validate that skin prevention is in place and occurring. The Director of Nursing / designee will communicate with the charge nurse each weekend this expectation and validate at the end of the weekend if any skin integrity concerns were identified it was addressed as indicated. Care plans will be reviewed as part of the clinical morning meeting process and weekly meeting by the Director of Nursing / designee to validate that any new order for air mattress is reflected on the care plan and wound status is accurately reflected. Residents with MD orders for dressing changes will be audited daily for 7 days then Monday through Friday for 4 weeks to validate that dressings were changed as ordered by the physician. If dressing found not to have been changed as ordered, the physician will be notified for further direction and the nurse will be re-educated or disciplined per the progressive disciplinary process. The Director of Nursing / designee will make rounds with the wound physician to validate that the wound log accurately reflects the current status of the wound. This will be weekly for 4 weeks then monthly for 2 additional months. Ad Hoc QAPI was held on 9/30/20 The Medical Director was notified of the Immediate Jeopardy on 9/30/2020 This data will be reviewed in Quality Assurance Performance Improvement for a period of three months. Any concern will be addressed as identified. Monitoring of the facility's Plan of Removal included the following: Interviews and observations were conducted on 10/03/20 starting at 12:10 PM and continued through 10/05/20 at 6:00 PM with 12 staff members from various shifts regarding in-services which included performing weekly skin assessments, notifying the physician and implementing a treatment as needed, documenting wound characteristics with every treatment, verifying presence of ordered air loss mattresses, following physician orders for wound treatment, and CNA requirements if they identified a wound. The staff were able to explain the process for identifying wounds, completing wound care, ensuring wound treatments were in place, and ensuring physician orders were followed. Observations revealed a sample of residents assessed had wounds. The wounds were documented, treated, and dressed per orders. Interviewed staff members and shifts were: LVN K- worked 6:00 AM to 2:00 PM Direct Care Staff B- worked all shifts LVN M- worked 6:00 AM to 2:00 PM RN F- worked 6:00 AM to 2:00 PM CNA D- worked 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM CNA L - worked 6:00 AM to 2:00 PM LVN N - worked all shifts RN O - worked 10:00 PM to 6:00 AM CNA P - worked 6:00 AM to 2:00 PM LVN Q - worked 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM RN R - worked 2:00 PM to 10:00 PM LVN H - worked 6:00 AM to 2:00 PM Observations revealed a sample of residents assessed had wounds. The wounds were documented, treated, and dressed per orders. An interview on 10/05/20 at 5:00 PM with the VP of Operations revealed going forward the facility would be following the plan of removal to address wound care issues. Additionally, he was going to ensure the DON had the help he needed to oversee the program. An Immediate Jeopardy/Immediate Threat was identified on 09/30/20. While the Immediate Jeopardy was removed on 10/02/20, the facility remained out of compliance at a scope of pattern and a severity level of harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal.

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the transmission of disease and infection; follow accepted national standards; follow standard and transmission-based precautions to prevent spread of infections, including when and how isolation should be used for 41 of 71 residents reviewed for infection control. 1.The facility failed to implement and maintain contact precautions and ensure staff utilized Personal Protective Equipment (PPE) appropriately to prevent cross contamination between residents positive with COVID-19 and residents who were not positive for [MEDICAL CONDITION]. 2.The facility failed to track and trend the COVID-19 infection of the facility to ensure residents were cohorted appropriately based on their exposure to the COVID-19 virus within a hot, warm, or cold unit. An Immediate Jeopardy/Immediate Threat was identified on 10/01/20. While the Immediate Jeopardy was removed on 10/04/20, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 10/01/20. These failures placed residents at risk of exposure to COVID-19, which could result in serious illness, hospitalization , or even death. Findings included: An observation on 09/29/20 at 9:15 AM revealed no residents were in the front entryway of the facility. Staff were wearing surgical masks/N95 masks, and face shields. The facility had 2 floors and the COVID unit was on the 1st floor. Hall 200 was the COVID Unit, Hall 100 was the Quarantine Unit. On 09/26/20, Hall 100 and Hall 200 became the COVID unit. The 2nd floor, Halls 300 and 400, were not part of the COVID unit. The COVID unit had double doors with Do not enter signs posted. The entrance used by staff to enter the COVID unit was an outside door with an area to don and doff PPE. Interviews on 09/29/20 at 9:20 AM and 10/01/20 at 8:55 AM with the Administrator and DON revealed the facility was having a COVID-19 outbreak. The facility was testing residents and staff weekly using a COVID POC test (point of care [MEDICATION NAME] test with rapid results) and if a resident tested positive, the resident was moved to the COVID unit on the 1st floor of the facility. (Hall 200 was the COVID Unit, Hall 100 was the Quarantine Unit. On 09/26/20, Hall 100 and Hall 200 became the COVID unit.) The 2nd floor, Halls 300 and 400 were not part of the COVID unit. The facility would then order a PCR test (polymerase chain reaction) test with results typically taking 1-3 days to receive to confirm the resident had the COVID-19 virus. If the resident tested negative with the PCR test, the resident was supposed to be placed in quarantine in a room on the 2nd floor, non-COVID unit. The facility was using the PCR test as confirmation of the results following concerns and guidance from the Health Department that the POC machine may have been giving false positive results. Review of the Facility's COVID-19 Daily Template, dated 09/09/20 reflected Hall 200 on the first floor was the COVID unit. Review of the Facility's COVID-19 Daily Template, dated 09/29/20 reflected: Census: 68 Total # of Staff Positive: 9 Total # of Staff pending test results: 0 # of facility Staff Member Deaths: 0 Total # of Recovered Staff: 2 Total # of Residents/Clients Positive: 40 Of the total #, how many positive residents are still in facility? 38 Of the total #, how many positive residents moved to hospital? 2 Total # of Residents/Clients pending test results: 0 Total # of Deaths in Facility: 1 (09/17/20) Total # of Resident Deaths in Hospital: 3 (09/18/20, 09/20/20, 09/25/20) COVID Positive Residents discharged from Facility/services: 0 Total # of Recovered Residents: 0 1. Review of Resident #1's face sheet, dated 09/29/20, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the Facility's Census Detail by Resident, dated 09/01/20 - 10/01/20, for Resident #1 reflected: 09/01/20 Resident resided in room [ROOM NUMBER]-A (1st floor) - prior to it being a COVID unit 09/04/20 Resident moved to room [ROOM NUMBER]-B (1st floor) - Became a quarantine unit on 09/09/20 and changed to a COVID unit on 09/26/20 09/27/20 Resident moved to room [ROOM NUMBER]-B (2nd floor, non-COVID unit) Review of Resident #1's PCR Laboratory Results Summary, dated 09/15/20, reflected she was tested for the COVID-19 virus on 09/09/20. Her results were received on 09/15/20. Her results were negative. Review of the facility's Respiratory Illness List, dated 09/28/20, and received from the Administrator revealed it did not contain information about Resident #1.The facility did not provide an accurate Respiratory Line List with Resident #1's information prior to exit. Review of Resident #1's Progress Notes reflected: 09/27/20 6:06 AM Received report to accept resident from first floor because resident tested negative for COVID-19 . RP (representative party) made aware of the move to second floor. RN F 09/27/20 7:23 AM Resident transferred to second floor for non-exposure to COVID-19; resident remains negative for COVID-19 and was tested again immediately before going upstairs with negative result .resident sent to second floor through the outside door where second floor nurse received resident .routine meds and controlled meds counted signed, co-signed by another nurse and handed over to the receiving nurse. RN O An observation on 09/29/20 at 9:35 AM revealed Resident #1 was in a room located on the 2nd floor of the facility. She resided on Hall 300. Both Halls 300 and 400 had rooms with residents who were and were not in isolation. Some rooms had isolation signs and PPE outside the door and some rooms had no isolation signs or PPE outside of the door. There was not a cold unit or warm unit identified. There was not an isolation sign on Resident #1's door and there was no PPE available outside of the door. Resident #1 was interviewed at that time and said she was upset because she was moved from the first floor on 09/27/20 at 1:30 AM. She said she did not know why she was moved and she wanted to go back. She said her concerns were reported to the DON and Administrator. An observation and interview on at 09/29/20 at 9:55 AM with LVN A revealed she walked into Resident #1's room wearing a mask and face shield only. She was not wearing an isolation gown. She looked at the resident's wounds and walked out of the room back to the medication cart. LVN A returned to the resident's room and discussed her ordered wound care treatments with the resident. LVN A said she was assigned to care for the resident. LVN A returned to her medication cart and continued passing medications to other residents. 2. Review of Resident #2's face sheet, dated 09/29/20, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #2's PCR Laboratory Results Summary revealed no lab results. There were no POC results documented. Review of the Facility's Census Detail by Resident, dated 09/01/20 - 10/01/20, for Resident #2 reflected: 09/01/20 Resident resided in room [ROOM NUMBER]-A (1st floor) Became a quarantine unit on 09/09/20 and changed to a COVID unit on 09/26/20. 09/27/20 Resident moved to room [ROOM NUMBER]-A (2nd floor, non-COVID unit) Review of the facility's Respiratory Illness List, dated 09/28/20, and received from the Administrator reflected it provided some information about COVID test results for some of the residents. It did not contain information about Resident #2. The facility did not provide an accurate Respiratory Line List with Resident #2's information prior to exit. Review of Resident #2's Progress Notes reflected: 09/25/20 12:55 PM Resident continue(s) on contact and droplet isolation R/T exposure to COVID-19. All required isolation equipment available in the room and all services provided to the resident in her room . 09/27/20 1:30 AM Resident transferred to second floor for non-exposure to COVID-19; resident has remain(ed) negative for COVID-19 and was tested again immediately before going upstairs with negative result . RN O An interview and observation on 09/29/20 at 10:25 AM in Resident #1's room revealed her roommate, Resident #2 was lying in bed. Direct Care Staff B entered the resident room, wearing a mask and face shield only. Resident #2 had a frequent productive cough. The resident said she had moved into the room a few days prior. The resident had a suitcase with belongings leaning against the wall. CNA C entered the resident room wearing a mask and face shield only. Direct Care Staff B and CNA C provided incontinence care to Resident #2. Neither staff member was wearing an isolation gown to provide care and they said they were not assigned to the resident. Both staff members were observed in the hall walking into other resident rooms who were not in isolation. An observation and interview on 09/29/20 at 12:45 PM revealed Resident #1 and Resident #2 were in their room. There was not an isolation sign on the door and there was no PPE available outside of the door. An interview on 09/29/20 at 2:50 PM with the DON revealed Resident #1 and Resident #2 were moved from the 1st floor to the 2nd floor on 09/27/20. He said the residents were moved because the facility had received PCR results which indicated they did not have COVID and the facility wanted them moved as soon as possible to prevent continued exposure to COVID. He said both residents were supposed to be in quarantine after moving from the 1st floor for 14 days. He said staff were supposed to wear a gown, mask, face shield, and gloves when they entered their room. He said he was not aware that Residents #1 and #2 did not have isolation signs posted or PPE outside of their room. He said originally both residents were on Hall 100, on the first floor, that was supposed to be the quarantine unit. He said the entire first floor had to be converted to a COVID unit because they had too many positive cases. He said the 1st floor was converted to a full COVID unit the weekend of 09/26/20 and 09/27/20. The DON did not provide the Investigator with a full list of lab results for all residents prior to exit despite request. An interview on 10/05/20 at 11:45 AM with RN F revealed she was the nurse for Resident #1 and Resident #2 when they were moved from the 1st floor to the 2nd floor. She said she did not put them in isolation on the 2nd floor because she thought they were in quarantine on the 1st floor already. She said she thought they were moving to the 2nd floor because they did not have COVID. An interview on 10/01/20 at 3:57 PM with LVN E revealed she was assigned to provide care to residents on the 2nd floor including Resident #1 and Resident #2. She said staff did not know if a resident was supposed to be in isolation unless there was an isolation sign posted on the door and PPE outside of the room. 3. Review of Resident #3's face sheet, dated 09/29/20, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the Facility's Census Detail by Resident, dated 09/01/20 - 10/01/20, for Resident #3 reflected: 09/01/20 Resident resided in room [ROOM NUMBER]-A (2nd floor, non-COVID unit) 09/08/20 Resident moved to room [ROOM NUMBER]-A (1st floor, COVID unit) 09/17/20 Resident moved to room [ROOM NUMBER]-B (1st floor, quarantine unit) 09/26/20 Resident moved to room [ROOM NUMBER]-A (2nd floor, non-COVID unit) Review of the facility's Respiratory Illness List, dated 09/28/20, and received from the Administrator reflected Resident #3 had POC positive results on 09/08/20, PCR negative results on 09/11/20, and PCR negative results on 09/22/20. Review of Resident #3's PCR Laboratory Results Summary, dated 09/15/20, reflected she was tested for the COVID-19 virus on 09/11/20. Her results were received on 09/15/20. Her results were negative. The resident was not moved from the COVID unit to the quarantine unit on 09/15/20 when she tested negative. This placed her at increased risk for exposure to [MEDICAL CONDITION]. Review of Resident #3's Progress Notes reflected: 09/08/20 8:08 PM DON notifies(d) MD and family of new [DIAGNOSES REDACTED]. 09/08/20 8:19 PM DON notifies(d) son of room change and no concerns voiced at this time. 09/09/20 4:39 PM Alert and able to make needs known, total care with ADL's (activities of daily living) no signs and symptoms of COVID noted . 09/18/20 6:18 AM Resident slept well through the night, all vitals stable, turned and re-positioned q2hrs (every 2 hours). Resident talks to self loudly all night waking up nearby residents . No coughing/sob (shortness of breath)noted . 09/20/20 6:45 PM Resident still not able to eat or take medication, VS very low. BP (blood pressure) 82/64, p (pulse) 105, 02 (blood oxygen saturation) 85% room air (low), temp (temperature) 98.1. 09/25/20 1:27 PM Resident continue(s) on contact and droplet isolation R/T (related to) exposure to COVID-19. There were no progress notes for Resident #3's room moves on 09/17/20 and 09/26/20. An observation and interview on 09/29/20 at 1:15 PM on the 2nd floor revealed Resident #3 was lying in bed on her left side. There was not an isolation sign posted on the door and there was no PPE outside of the door. The Resident had throat congestion. CNA D entered the resident's room. She was wearing a mask and face shield only. CNA D was not wearing an isolation gown. The CNA repositioned the resident and checked the resident's brief to see if incontinence care was needed. Direct Care Staff B entered the resident's room, wearing a mask and face shield only. Both staff left the room and were observed walking into other resident rooms. An observation and interview on 09/29/20 at 1:35 PM with the DON revealed he went to the 2nd floor to see the residents. He entered Resident #3's room wearing a mask only. CNA D was in the room when the DON entered. She was wearing a mask and face shield only. The DON left Resident #3's room and walked into Resident #1 and #2's room. The DON was wearing a mask only. He repositioned the residents. Staff, unknown name, entered the residents' room to assist the DON. She was wearing a mask and face shield only. Observations on 09/30/20 at 12:45 PM and 1:45 PM on the COVID unit, 1st floor, revealed all staff were wearing full white suits with N95 masks and face shields. There was no divide between Hall 100 and Hall 200. There was not a separate quarantine unit. Staff, unknown names, observed entering and exiting resident rooms. Staff did not don and doff isolation gowns to provide care to individual residents before entering resident rooms. LVN G was assisting Resident #4 (COVID positive) and LVN H was providing care to Resident #5 (COVID positive). Neither LVN was wearing isolation gowns while providing care to the residents. Both nurses left the residents' room and walked into other resident rooms without putting on isolation gowns. An interview on 10/01/20 at 4:30 PM with LVN G revealed she was assigned to work on the 1st floor (COVID unit). She said Resident #4 was one of her residents. She said staff were supposed to wear full PPE (white suit, mask, face shield, gloves) and don and doff an isolation gown before entering/exiting a resident's room. She said she forgot to put on an isolation gown prior to entering Resident #4's room. She said she never changed her PPE except for her isolation gown and gloves unless she was leaving for her shift. An interview on 10/01/20 at 6:12 PM with LVN H revealed she was assigned to work on the 1st floor (COVID unit) and Resident #5 was one of her residents. She said staff were supposed to wear full PPE (white suit, mask, face shield, gloves) and don and doff an isolation gown before entering/exiting a resident's room. She said she would get busy and forget to put on an isolation gown before entering a resident's room. An interview on 10/02/20 at 1:30 PM with CNA I revealed he was assigned to work on the 2nd floor and that some residents were in isolation and some residents were not. He said residents who were supposed to be in isolation had a sign on their door. He said there was not a list for staff to refer to for confirmation if the isolation signs were correct. He said that sometimes the nurse assigned would tell him who needed to be in isolation. He said he did not know who was responsible for ensuring the information was correct. He said he thought the rapid increase in COVID positive cases in the facility was due to the hiring of agency staff and them forgetting to wear their PPE in isolation rooms. He said when he observed it happen, he would remind them to put PPE on. An interview on 10/02/20 at 1:40 PM with CNA D revealed she had worked at the facility for about a week. She said she was assigned to residents on the 2nd floor who were in isolation and residents who were not. She said she did not know who was supposed to be in isolation unless they had a sign on their door. She said she had received in-services regarding PPE usage when she was hired. An interview on 10/02/20 at 1:45 PM with LVN A revealed she had been with the facility for one week. She was assigned to work on the 2nd floor. She said the only information she received regarding infection control was that she would have her temperature taken, she was supposed to wear PPE, and the facility had some residents in a COVID unit. She said residents who were supposed to be in isolation had a sign on their door and she passed the information in shift to shift report. She said she thought Resident #1 and Resident #2 were supposed to be in isolation because they had refused to take a test for COVID. She said she was not sure about other staff, but sometimes she did not wear full PPE to go into an isolation room. She said she was probably supposed to wear an N95 mask but was not wearing it. (She said she did have one). She said sometimes, if she was just answering a light, she did not wear full PPE in the isolation rooms. An interview on 10/02/20 at 1:50 PM with CNA J revealed it was her third day working at the facility. She said she was assigned to residents on the 2nd floor and some were in isolation and some were not. She said in the isolation rooms staff were supposed to wear gloves, gown, mask, shoe covers, and a face shield. She said staff could wear a surgical mask, a KN95 mask, or 2 surgical masks in those rooms. An interview with the DON on 10/02/20 at 3:30 PM revealed he had been working at the facility for one month. He said he was responsible for overseeing the infection control program. He said the facility previously had a COVID team that would assist with the COVID infection oversight. He said the Administrator was at home and an ADON had resigned leaving him as the only person left on the team. He said he often worked on the floor as a floor nurse. He said he was trying to cover four different jobs. He said he felt like the facility had an increase in COVID cases because the facility did not have a separate hot, warm, and cold unit. He said the facility only had a hot and a warm unit. He said not having dedicated staff wearing the correct PPE in the COVID unit could have led to the increase in cases. He said he did not know why the facility did not have a separate cold unit for residents who never tested positive and did not leave the facility. Interviews on 09/29/20 at 4:36 PM, 9/30/20 4:45 PM, and 10/01/20 at 8:55 AM with the Administrator and DON revealed the facility had an increase in COVID cases from 09/09/20 to 09/29/20 and the facility had 41 residents who had tested positive for COVID. The Administrator said that staff on the COVID unit, 1st floor, were supposed to wear full PPE and don and doff an isolation gown over their white suit when entering resident rooms to provide care. The Administrator said that originally the facility used a POC testing machine to test residents. The first 6 residents tested positive using the POC machine on 09/08/20. They were all placed on the COVID unit, Hall 200 on the 1st floor together. The facility did a PCR test on all 6 residents on 09/10/20 to confirm the POC results. Only 1 of the 6 residents tested positive using the PCR test. She said the 1 positive resident was transferred to another facility. The other 5 residents were tested at the next testing cycle, unknown date, and all tested positive for COVID with the PCR test. She said when the facility started using the POC machine they found many of the results were positive, but when they followed up with the PCR test they would show negative results. They said they contacted the Health Department about the issues with the POC machine. The Health Department told them that in order to count the test as positive, they needed to get PCR confirmation. They contacted the POC machine company who told them they never had issues with false positives and to re-calibrate the machine. The Administrator said the facility continued to use the POC machine and move residents based on the POC results only in order to meet the mandate for weekly testing. All of the residents in the facility were tested with the POC machine on 09/19/20. A few of the residents that tested positive had symptoms of COVID (names of resident's unknown.) All residents that tested positive were moved to the COVID unit, first floor. It was unknown if she was talking about Hall 100 or Hall 200 on the 2nd floor as being the COVID unit. On 09/22/20, all facility residents were tested using the PCR test. Those lab results were not received until 09/25/20, 09/26/20, and 09/27/20. Some of the residents, including Resident #1 and Resident #2 tested negative and were moved back out of the COVID unit. She said residents were moved off the COVID unit to the 2nd floor when they received negative results from the PCR test. She said those residents were supposed to be placed in isolation when they were transferred to the 2nd floor because the PCR test took more than one day to get results and the residents would have been exposed on the COVID unit. She said staff were supposed to wear all their PPE and be taking more precautions for going into those rooms for isolation and wearing a gown into those rooms. She said she did not know why Resident #1 and Resident #2 were not in isolation but thought the staff might have thought they were not supposed to be in isolation since they tested negative for COVID. She said Resident #1 and Resident #2 were moved either Saturday night or Sunday night. She said the Medical Director was contacted when the results for the residents were received. She said Resident #1 did have a POC test and the test was negative for COVID prior to her move to the 2nd floor. The Administrator said she notified the nurse downstairs (COVID unit) and the CNA upstairs (non-COVID unit) to move the residents upstairs. The DON said he used the same POC machine to test Resident #6 on 09/29/20 and she was moved to the 1st floor COVID unit while the facility was waiting on PCR test results. Review of the facility's Respiratory Illness List, dated 09/28/20 reflected Resident #6 was not on the list. Review of the Census Detail by Resident Report, dated 09/01/20 to 10/01/20 reflected Resident #6 never moved rooms. Her room was on the 1st floor. The Administrator and DON said they were not doing contact tracing for the facility's COVID infections. The Administrator said she suspected that the infection was spread when Resident #7 was moved from quarantine on the 1st floor, following a hospital visit. The resident tested negative for COVID using the POC test on 09/08/20 and was moved to the 2nd floor. Following the move, he was tested using the PCR test. The facility received the results indicating Resident #7 tested positive on 09/16/20. She said the residents in the rooms close to Resident #7 became symptomatic and they tested positive for COVID too. An interview on 09/30/20 at 12:55 PM with the Medical Director revealed residents were moved to the 2nd floor if they tested negative for COVID with the PCR test. She said she thought the residents were supposed to be on quarantine after they were moved to the 2nd floor. She said residents with a POC positive result and/or residents who were symptomatic for COVID were supposed to remain on the 1st floor of the facility in the COVID unit. She said she was not sure how many residents had been transferred to the 2nd floor from the COVID unit. A review of a Resident Sample taken from the facility's Respiratory Illness List, dated 09/28/20 and combined with the Census Detail by Resident, dated 09/01/20 to 10/01/20 reflected multiple discrepancies. It showed Residents were not always moved based on test results. Some residents remained on Hall 100 or Hall 200 even if they had a negative test result. Resident #8 - 09/05/20 PCR test negative. readmitted from the hospital to Hall 200, COVID unit 09/08/20 POC test positive 09/11/20 PCR test negative. Resident stayed on Hall 200 09/17/20 Resident moved to Hall 100, quarantine unit 09/19/20 POC test negative. Resident stayed on Hall 100 09/24/20 PCR test positive. Resident stayed on Hall 100 Resident #9 - 09/01/20 Resident assigned to room upstairs, Hall 400 09/08/20 POC test positive. Moved to Hall 200, COVID unit 09/11/20 PCR test negative. Resident stayed on Hall 200 09/17/20 Moved to Hall 100, quarantine unit 09/19/20 POC test negative, stayed on Hall 100 09/24/20 PCR test positive, stayed on Hall 100 Resident #10 - 09/01/20 Resident assigned to room on Hall 100 09/08/20 POC test negative, stayed on Hall 100 09/14/20 PCR test positive, stayed on Hall 100, and resident passed away on 09/18/20 An interview on 10/02/20 at 9:45 AM with the VP of Operations for the facility revealed the facility still did not have a complete list showing Resident POC results, Resident PCR results, or a complete Respiratory Illness List. He asked the state surveyor to tell him which residents were supposed to be on the warm unit. He said he was reviewing the census and comparing it with PCR test results. He said he identified that Residents #1, #2, and #3 were supposed to be in isolation. He said he originally thought Hall 200 was the COVID hall and Hall 100 was supposed to have been the quarantine hall, but he did not know the dates the designations occurred. An interview on 10/05/20 at 9:45 AM with the Health Department Representative assigned to the facility revealed the facility did not keep him up to date with the facility's increase in COVID cases. He said the Administrator contacted him when they identified they had three positive cases and she was questioning the results of the POC machine. Additionally, the Administrator used the POC machine to test residents multiple times a day. The Health Department said he told the Administrator the facility needed to obtain a PCR test to confirm the POC results and to only use the POC machine once a day on a resident. Review of the facility's Infection Prevention and Control Policies and Procedures, Coronavirus Disease 2019 (COVID-19), not dated, reflected: Because [DIAGNOSES REDACTED]-CoV-2/COVID-19 is an emerging disease the severity of its transmissibility is unknown. It is a rapidly evolving situation and the facility should refer to the Center for Disease & Prevention (CDC) .for up to date information. 9. Facility staff should practice droplet precautions, in addition to strict Standard Precautions, when examining a resident with respiratory infection. Policy: C .The facility Infection Preventionist is responsible for surveillance of respiratory illnesses on an on-going basis with specific attention to the identification of [DIAGNOSES REDACTED]-CoV-2/COVID-19. Infection Preventionist Monitors CDC website .Monitors CDC recommendations for pandemic prevention and response . Administrator Coordinates overall facility response during pandemic situation . Director of Nursing Assumes responsibility in the chain of command in the event the Administrator or Assistant Administrator is not available. Designates unit(s) as [DIAGNOSES REDACTED]-CoV-2/COVID-19 treatment area(s) . Review of the facility's Coronavirus Disease 2019 (COVID-19) Pandemic Prevention and Response Plan, revised on 04/15/20, reflected: 1. Provides essential training on infection control measures related to [DIAGNOSES REDACTED]-CoV-2/COVID-19 .2. Re-trains staff in use of masks, gloves, and infection control measures during pandemic. Review of the facility's Infection Control-Standard Precautions, updated December 2014 reflected: Gloves .c. Change gloves between tasks and procedures on the same patient after contact . Mask, Eye Protection, Face Shield a. Wear a mask and eye protection or a face shield to protect the mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities that are likely to generate splashes or sprays . Gown a. Wear a gown to protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions; b. Remove a soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other patients or environments. Review of Centers for Disease Control and Prevention's Responding to Coronavirus (COVID-19) in Nursing Homes, updated 04/30/20, and accessed from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html reflected: .Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Resident with new-onset suspected or confirmed COVID-19 Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. HCP should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents. Considerations for use of COVID testing to inform cohort decisions. If testing supplies or capacity are limited, testing of symptomatic HCP and symptomatic residents should be prioritized. If unit-wide or facility-wide testing is not available in response to newly identified [DIAGNOSES REDACTED]-CoV-2 infected residents or HCP, moving any residents other than those confirmed to have COVID-19 should be done with caution given the risk of asymptomatic infection; in those situations, all recommended COVID-19 PPE should be used during care of all residents on the affect(TRUNCATED)

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse and neglect were immediately reported, including injuries of unknown origin, but not later than 2 hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury 24 hours after the allegations were made, to the State Survey Agency for three (Residents #12, #50 and #29) of three residents reviewed for bruises and injuries of unknown origin. 1. Facility staff failed to notify the Abuse Coordinator/ADM of suspicious bruises when Residents #12. #50 and #29 were observed to have brusing on their bodies of unknown origin. 2. The Abuse Coordinator failed to report to the State Survey Agency suspicious bruises when Residents #12, #50 and #29 were observed by nursing staff to have bruising to their bodies of unknown origin. An Immediate Jeopardy (IJ) was identified on 05/10/19. While the IJ was removed on 05/11/19, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated, due to the facility still monitoring the effectiveness of the Plan Removal. These failures could affect residents by placing them at risk for abuse and untreated injuries of unknown origin, delays in necessary care and a potential deterioration in condition. Findings included: 1. Resident #12's MDS Quarterly Resident assessment dated [DATE] reflected he was a [AGE] year old male admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. He had moderate cognitive impairment, and required one-person physical assistance for bed mobility, locomotion and transfers. Review of Resident #12's comprehensive care plan last dated 04/18/19 reflected no history of blood thinners, bruises or injuries of unknown origin. Interview with the ADM on 05/08/19 at 1:38 PM revealed she was the abuse prevention coordinator. She stated staff could report abuse allegations to their charge nurses, but her number was available. Interview with Resident #12 and his family member on 05/09/19 at 12:32PM revealed Resident #12 could answer simple yes/no questions but could not elaborate on any substantial questions about his care. During the interview with the family member, Resident #12 was moving his body around in bed and his sheets came off, exposing part of his right leg. At that point, a large purple bruise was observed on his upper right outer thigh. Resident #12 said he did not know where the bruise was from. The family member said the resident received hospice services Monday through Friday and a hospice CNA was supposed to be giving him a bed bath, so she wondered why the bruise was not reported by hospice if they saw it. She said the facility had not notified her of the resident's bruise. She said the facility called her about a week prior to tell her he was found in between his bed and the wall on the floor but had reported no injuries or complaints of pain. Interview with LVN [NAME] on 05/09/19 at 12:47 PM revealed she did not know that Resident #12 had any bruises on his body. She came to his room to assess him after surveyor began inquiring about the injury. She asked Resident #12 what happened. He said he did not know. She proceeded to look at the bruise. The bruise was observed to be on the outer right front and back thigh, and was dark purple. LVN [NAME] said, Oh, wow as she pulled back the covers. She asked him to turn over to look at his skin. He tried to turn to the side but started moaning in pain. He indicated his inner right thigh was hurting. At that point, LVN [NAME] observed a secondary large purple bruise on his inner right thigh up to his groin. Interview with ADON H on 05/09/19 at 12:52PM revealed no one reported Resident #12's bruises to her. She wondered if it was from the last fall on 4/29/19, then said it looked fresh. ADON H and LVN [NAME] then proceeded to evaluate his skin and he indicated he was in pain. When ADON H asked him if he wanted something for pain, he said Please! LVN [NAME] proceeded to administer Resident #12 prn [MEDICATION NAME] and said to wait for further evaluation until the medication was working. Interview and observation with CNA I on 05/09/19 at 12:58 PM revealed he provided incontinent care to Resident #12 that morning and saw the bruises. CNA I said he initially saw the bruise on Resident #12's thigh the morning before, on 05/08/19. He said he reported the bruises to the charge nurse that worked the 10pm- 6am shift and she said okay and that she knew about it. He did not know her name nor was he able to describe her with any detail. CNA I said he did not report it to anyone else. He was unable to state how the bruises manifested. Review of CNA I's Point of Care flow sheet (computer system used by CNAs to document care) reflected he documented on 05/08/19 and 05/09/19 that Resident #12 had bruising under the section Indicate any skin problem for the resident. It did not reflect where the bruise was, how many, or follow up. There was no additional information given. Interview with the DON on 05/10/19 at 11:15PM revealed the CNA Point of Care Flow sheets were reviewed by herself and the nursing management team for completion only, not content. Interview with LVN [NAME] on 05/09/19 at 1:02 PM revealed she had found where RN F documented Resident #12's bruise in a nursing note on 05/07/19. LVN [NAME] said it was not documented on the nursing 24-hour report or else she would have seen it. LVN [NAME] said she had tried to do a skin assessment on him several days go, but he refused it. She said a hospice aide was present on 05/07/19 and Resident #12 had gotten up to be showered, so the hospice aide would have seen the bruises. LVN [NAME] continued to express surprise Resident #12 had bruises and said she knew nothing about it. Interview with ADON H on 05/09/19 on 1:14 PM revealed Resident #12's bruises were concerning but she felt it could be a latent bruise manifesting from his fall on 4/29/19. She said the deep purple color though, negated that idea because it just happened. She remembered seeing hospice the day prior but the hospice aide did not mention anything to the facility about a bruise. ADON H said the bruises needed to be reported to the ADM who was the abuse/neglect coordinator. Review of the facility's 24-hour nursing report from 05/04/19-05/09/19 revealed no documentation of bruises for Resident #12. Observation of Resident #12 on 05/09/19 at 1:32 PM revealed he had been medicated with [MEDICATION NAME] for the past thirty minutes and LVN [NAME] proceeded with measuring his bruises. Resident allowed LVN [NAME] to measure his outer thigh which was 40cm x14 ½ cm. When it came to his inner thigh, he was assisted to lift his leg up for a measurement of the bruise, but he cried out in discomfort and said it hurt. LVN [NAME] said that was the hip Resident #12 had the most recent [MEDICAL CONDITION] and surgery in (MONTH) (YEAR). She pointed to his surgery scar on the outer thigh which went directly through the bruise. LVN [NAME] said if she would have been the one to find the bruise, she would have noted it on the 24-hour report with the measurements, completed an incident report and notified her manager. She stated the only documentation she could locate on Resident #12's bruises were the nurses note on 5/7/19 written by RN F. Further interview with LVN [NAME] on 05/09/19 at 1:50PM revealed she was able to get the inner thigh bruise measurement for Resident #12 and it was 20 ½cm x 18cm. She provided an incident report at that time for the bruises she had just completed and described the bruises as dark purple in color and painful to inner leg. Interview with the hospice provider on 05/09/19 at 1:52PM revealed the hospice aide was in the field and she would relay the request for a telephone interview. Hospice aide did not return call. Interview with LVN [NAME] on 05/09/19 at 1:57 PM revealed ADON H had just ordered a stat x-ray for Resident #12. Review of a nursing progress note written by RN F on 05/07/2019 at 4:06PM reflected, During head to toe assessment, nurse noted purple color large bruise to right outer hip and on right inner thigh. Nurse asked resident if he fell . Resident stated, 'I did not fall'. Denied being in pain at this time. Will continue to monitor. There were no other nursing progress notes mentioning Resident #12's bruises before or after this entry. Interview with ADON H on 05/09/19 at 2:12 PM revealed she was with RN F who had initially discovered the bruise on 05/07/19. She said she had just in-serviced RN F on reporting protocol of bruises and injuries of unknown origin to the ADM. Interview with RN F on 05/09/19 at 2:24 PM revealed she remembered earlier in the week, she could not remember the specific day, she came to work and did her routine rounds. Normally, Resident #12 was under his blanket, but that day he was naked and she said she noticed a bruise on his left side and inner side of his right thigh. She said the main bruise was on the outer thigh and a little bruise on the inner, like the size of her palm. She said he denied falling. She said she touched and palpated it and he said he was not in pain, so she felt it may have been from the fall he had a week prior on 04/29/19. She said she was present for that fall on 04/29/19 and did an assessment and he had no injuries and his skin looked good throughout that shift. She said when she found the bruise on 05/07/19, no one had reported it to her prior to that. She said she completed a nursing progress note but did not complete an incident report. RN F said she knew she was supposed to write an incident report, but she thought since she had done one for the fall on 04/29/19, it would cover the current bruise on 05/07/19. She said she did not tell ADON H or LVN [NAME] about the bruises on Resident #12. Interview with the ADM on 05/09/19 at 3:01 PM revealed she had not observed Resident #12's injuries and had not been told about the bruises until that afternoon. She said she did not know anything about it. Interview with CNA J on 05/09/19 at 5:30 PM revealed she worked with Resident #12 on 05/09/19 on the 2pm-10pm shift (after the bruise had been identified by the surveyor) and his skin was good. She said she checked him for incontinence and did not see any new or old bruises on his thighs. She claimed she saw his legs. She was asked several times if there was bruising to the resident's right thigh, and she responded no. Interview with the DR on 05/10/19 at 9:58 AM revealed he was not notified of Resident #12's bruises but should have been because of the nature and size of the bruise. He said he was called by the facility the day prior on 05/09/19 and he came out on 05/10/19 and had just finished assessing him prior to the interview. He said he did not think the bruises came from a fall, but he could not be certain where they came from. He said since Resident #12 was on hospice, the facility was not doing labs, therefore he could not see if there was anything going on internally. He said Resident #12 was not on any blood thinners, but the bruising could possibly be from coagulopathy, which was the body's inability to clot blood. He said when a resident was starting to decline towards the end of life, the organs start to shut down and the ability to coagulate could be compromised. He said if that was occurring, any touch or pressure could cause that kind of bruising under the skin, or something internally could be happening, deep in the tissue, but he could not be sure. Review of Resident #12's stat x-ray obtained on 05/09/19 revealed no fracture. Interview with the DON on 05/10/19 at 11:13 AM revealed she had been thinking about Resident #12's bruising. She remembered the previous week, he had gotten up in his wheelchair with the use of a Hoyer lift while a family member was visiting. She said the sling used crisscrossed between his legs right where the bruising was on the side of the right thigh and she thought it possibly could have been from that but could not be certain. Interview with LVN K on 05/10/19 at 11:21 AM revealed she worked overnights on Resident #12's hall. She said no CNA had reported any bruises or falls to her for Resident #12 over the past few overnight shifts. She said she was new to the facility. The past week (05/06/19 through 05/10/19) was the first week she was by herself as a charge nurse. LVN K said she expected to be told about any resident who had a bruise. She said she would then complete an incident report and if it was a bruise of unknown origin, she would call the DON and then start the process to see if they could determine where it came from. Interview with the ADM on 05/10/19 at 12:22 PM revealed she did not know about the bruising to Resident #12 until the day prior after the surveyor began making inquiries. She said she had not yet observed the bruises for Resident #12 even though she had been notified of them on 05/09/19, an investigation had not been started. Interview with LVN L on 05/10/19 at 1:51 PM revealed she worked the overnight shift for the past few nights and knew Resident #12. She said no one reported to her that he had any bruises. She said the nurse who she relieved, RN F, did not indicate any injuries of unknown origin or bruises for Resident #12 when she gave her report at change of shift, only that he had complained of pain and told her there was a hospice comfort pack available. She did not indicate to LVN L where Resident #12's pain was. LVN L said she only saw Resident #12 asleep during her shift. She said CNA I never told her there was a bruise on Resident #12 and by the time his shift started, she would have already been on her way home. LVN L said she had not been informed that Resident #12 had a bruise on his inner and outer thigh; it was not on the 24-hour report. She said her expectation for a large bruise was it should be reported to her. She said the CNAs were trained well and had experience and knew if they saw anything at all, they reported it. 2. Resident #50's MDS Quarterly Resident assessment dated [DATE] reflected he was an [AGE] year old male admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. He had severe cognitive impairment and required one-person physical assistance for locomotion and transfers. Review of Resident #50's comprehensive care plan last dated 04/6/19 reflected no history of blood thinners, bruises or injuries of unknown origin. Interview and observation of Resident #50 on 05/08/19 at 9:00AM revealed he was sitting in a chair in the hallway. Dark purple bruises the sizes of large playing cards on both forearms were seen on the top of both arms. There was a bruise the size of a fingerprint on residents' upper right arm as well as a skin tear to the lower right arm covered with a butterfly bandage. There was a skin tear observed to the left side of his neck and an injury to the left ear covered with a butterfly bandage. Resident #50 attempted to speak but speech was not clear or understandable. Interview on 05/08/19 at 1:23PM with Resident #50's family member revealed someone from Resident #50's family visits him daily. They reported they noticed the bruises on Resident #50 on 05/07/19 when they came to visit him, and he was dressed in a long sleeve shirt they felt to be inappropriate for the hot weather (Temperature was 84 degrees on 05/07/19, https://www.wunderground.com/history/daily/us/tx/dallas/KDAL/date/history/daily/us/tx/dallas/KDAL/date/2019-5-7, retreived 05/28/19). The family member stated when changing Resident #50's shirtm they noticed the bruises and became upset. They stated they went to some of the staff on the floor about the bruises and could not get any answers, so they went to the ADON. They stated they insisted the ADON see the bruises and when she did she stated she had no idea what happened. She stated she let her know that other family members visited the resident on 05/06/19 and had not seen the bruises due to resident having on a long shirt. Interview with ADM on 05/09/19 at 12:34PM revealed she was aware Resident #50 had a skin tear and bruising. She stated she had not reported the incident because she had not determined if the injuries where reportable or not. Interview with CNA Y on 05/09/19 at 2:18pm revealed she assisted Resident #50 with putting on his shirt, shorts, socks and shoes on 05/09/19 and denied seeing any bruising or skin issues. She stated the last time she had worked with Resident #50 was a week prior and she had not noticed any bruising then. She stated she did notice the skin tear on his ear but not his neck during that same shift. She stated she did not report the injury to his ear because it was bandaged, and she figured it had already been handled. They rotate, and she'd been off for five days. Further interview with CNA Y at 05/09/19 at 3:04pm revealed she asked the ADON what happened to Resident #50 and was told that he fell Friday. Interview with LVN N on 05/09/19 at 3:37 pm revealed she completed an incident report for Resident #50 when he fell on [DATE]. She stated she did not witness the fall but was notified and went to the TV room where he was sitting on the floor and she assisted with assessing and putting him in a chair. She denied any injuries where obtained during the fall. She reported she was told that Resident #50 had an incident with side rails over the weekend that caused the skin tear to his arm. But she was not sure. She stated when she arrived at work 05/06/19 she noticed Resident #50's arms where bruised, a skin tear on neck and he had a little blood coming out his ear. She stated she was not sure what happened to his ear but believed the bruising on his arms could have been from the fall. She stated his family came to her yesterday and reported he has low platelets count and that could be the reason for the bruising. Interview with LVN X on 05/09/19 at 1:28pm revealed she works weekends 6:30 am to 10:30pm. She stated she worked with Resident #50 on 5/04/19 and 5/05/19. She stated she did an incident report on 05/04/19 because Resident#50 hit his right arm on the bed causing a skin tear and bruising. She stated Resident #50 is confused however she asked him did he hit his arm on the bed and he told her yes. She stated she also saw blood on resident enable bars. She stated she did not remember any marks on his face or neck. She stated she did not notice any bruising outside of the skin tear and bruise to his right arm on 05/05/19. Review of Resident #50's clinical record and facility incident reports revealed his bruises were not investigated. Interview on 05/09/19 at 2:30 pm with ADON revealed she was notified of Resident #50's fall on 05/04/19. She stated she was not aware if resident hit anything during his fall but knows he did have a fall that could have caused delayed bruising. She reported Resident #50's family came to her after changing his shirt and noticing the bruising and she reported that they could have come from delayed bruising from his fall. She stated resident's family indicated that resident had low platelet count but did not want her to check him. She stated she expected to see documentation in regard to things that happen to the resident and had yet to see anything regarding Resident #50's injuries. Interview with ADM on 05/09/19 at 12:34PM revealed she was aware or Resident #50's brusing and skin tear. She stated he had a fall however she was had not seen the injuries. She stated all injuries where not reportable and she had not seen his yet. Review of patient/resident incident/accident investigation worksheet signed by DON undated completed by LVN N on 05/03/19, revealed Resident #50's fall was investigated on 05/03/19 and revealed no visible injuries or complaints of pain. There was no mention fo brusing on the resident. 3. Review of the undated Admission Report Form for Resident #29 revealed she was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of (MONTH) 2019 consolidated Physician order [REDACTED]. During observation of incontinent care for Resident #29 on 05/08/19 at 2:12 PM, bright purple bruises were noted on the shin area of bilateral lower extremities. CNA C reported that the nurse was aware of the bruises. CNA C said she did not report the bruises because they had previously been reported and documented by a certified nurse aide, but she was not sure which one. Review of Resident #29's clinical chart revealed there was no evidence or documentation provided to indicate the bruises had been reported. Interview with LVN [NAME] on 05/08/19 at 2:35 PM revealed she was not aware of any bruising and none had been reported to her. Interview with LVN F on 05/08/19 at 2:30 PM revealed she was not aware of any bruising on Resident #29. No bruises had been reported to her. She said she was just coming on duty. Interview and observation on 05/08/19 at 2:42PM revealed LVN [NAME] and LVN F went immediately to assess Resident #29. Documentation of their findings indicated; Fresh looking bruises to BUE (bilateral upper extremity)and BLE's (bilateral lower extremity). Bruises as follows: Left arm deep purple bruise 7cm x 6cm; Right arm with deep purple bruise 10cm x 11cm; Left lower leg with three bruises-1). 2cmx4cm 2). 5cmx3cm 3). 1cmx2cm; Right lower leg with three bruises- 1). 1cmx2cm 2). 4cm x5cm 3). 1cmx1cm; Bilateral upper ext's bruising due to resident rubbing/hitting arm rest while propelling w/c. Further investigation for BLE. Bruising due to improper transfers, hitting lower legs with bed and or w/c. Resident denies pain or discomfort when asked. ROM WNL for her without facial grimaces or vocalization of pain. Observation of Resident #29 on 05/10/19 at 10:45 AM revealed the bruises were fading. No additional bruises were observed. Review of Resident #29's clinical records and incident reports revealed no investigation had been completed related to his bruises/injuries of unknown origin. 4. Interview with the DON on 05/11/19 at 12:33PM revealed when CNAs saw a bruise, they were supposed to report it to the charge nurse and the abuse/neglect coordinator. If the abuse/neglect coordinator was not in the building, the charge nurse would report it. She said the bruises staff have been trained on to report as suspicious was anything that was red or purple, or if they felt it should not be there and was not a part of the resident's normal body. Once reported, the abuse/neglect coordinator would make the final determination along with an RN. She said the CNAs were supposed to fill out a skin sheet whenever they saw an injury or a bruise. She said CNA I did not fill a skin sheet out for Resident #12. Then the two ADONs were supposed to review the CNA skin sheets daily and on Mondays they review for the previous weekend. The DON said the point of the ADONs reviewing the CNA skin sheets was to see if there were any notations on them that were of concern, such as bruises or injuries of unknown origin. She said all injuries of unknown origin, including bruises, should be reported to the ADM and the DON. She said she provided training during orientation on abuse, neglect and exploitation and reporting procedures. She said an injury of unknown origin was an injury that cannot be explained and the root cause could not be identified. She said she and the ADM were responsible for reporting injuries of unknown origin to HHSC and investigating the incident. 5. The facility's current Abuse Protocol policy revised 03/08/17 revealed, Policy: .3. The facility's leaders will conduct a prompt investigation of any allegation received of suspected abuse; . Procedures .Component IV: Identification 1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect; .Component VI: Investigation .4. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions, .8. Guidelines for investigating: A/ Immediately assess the resident/patient at the time of discovery of alleged abuse, B. Document assessment in the medical record, C. Maintain the resident's/patient's protection during the investigation, D. Notify the attending physician and the resident's/patient's legally responsible party, E. Notify the Administrator, Director of Nursing, and Social Worker regardless of the time of day. 6. An Immediate Jeopardy was identified on 05/10/19 at 4:30PM and the ADM and DON were notified on 05/10/19 at 4:45PM. A plan of removal was requested at that time. The Plan of Removal was accepted on 05/11/19 at 5:00PM and reflected: The Facility failed to identify, evaluate/assess, investigate, and report injuries/bruises of unknown origin to the state agency. The residents identified to have bruises had the areas assessed, reported to state agency and investigation. All residents who reside in the facility have the potential to be affected by the alleged deficient practice. Therefore, a facility skin sweep was conducted by members of nursing management team, (DON), (ADONB), (ADON H) and RCC, to identify any bruises/injuries of unknown origin. This skin sweep was started on (MONTH) 9, 2019 and was completed on (MONTH) 10, 2019. The results of our skin sweep noted one individual with scattered bruising to bilateral arms and she is unable to verbalize how they occurred. The Administrator, (ADM), LNFA and the Director of Nursing, (DON), were re-educated by the (RVP), on (MONTH) 10, 2019 regarding the identification, evaluation/assessment, investigation, of how to prevent abuse and neglect, care planning, and reporting of bruises/injuries of unknown origin. Certified nursing assistants were re-educated by Members of the nursing management team, named above starting on 05/10/19 and completed by (MONTH) 13, 2019 at 4pm by members of nursing management regarding the expectation that during skin observations during care any bruises/injury of unknown origin, will be documented on the shower sheet and given to the charge nurse. Any bruise/injury of unknown origin identified will be reported to charge nurse and the charge nurse will evaluate/ assess and notify the administrator or DON for thorough investigation and reporting to the state agency. Licensed nurses were re-educated, by Members of the nursing management team, named above starting on 05/10/19 and completed by (MONTH) 13, 2019 at 4pm, regarding the expectation that skin evaluations should include the identification of bruises/injuries of unknown origin with assessment of area, thorough and accurate documentation of findings, care planning and reporting to the Director of Nursing or Administrator for reporting to appropriate state agencies. If certified nursing assistants identify a bruise/injury of unknown origin and reports to the charge nurse, the area is to be evaluated and assessed and if identified as injury of unknown origin the Director of Nursing/administrator is to be notified. The DON/Administrator/or designee will thoroughly investigation and report to the state agency. Any member of nursing management, licensed nurse or Certified Nursing Assistant not receiving this re-education by this (MONTH) 11, 2019 cannot return to work prior to completion of the education. The Administrator and or DON will ensure the competency of education by test, completion of education and monitoring of the education from in-services on prevention; identification and notification of abuse and neglect, CNA-Identifying and Notifying of skin integrity changes; and Nurses-Assessment and Documentation. This education will also be presented in New Hire Orientation by a member of the nursing management team. The Assistant Directors of Nursing/designee will review the 24hour reports, incident reports and the Facility Activity Report from Matrix medical records system daily to identify the documentation of any bruise/injury of unknown origin that has not been reported and investigated by the Administrator or DON. The Administrator and/or Director of Nursing will follow the appropriate reporting guidelines for abuse neglect, exploitation, misappropriation of resident property, and injuries of unknown origin. The Assistant Directors of Nursing/designee will review licensed nurse skin evaluations Daily by the DON/ADON/or designee for 4 weeks, then weekly for 2 additional months, to monitor for the identification of any bruises not reported to nursing management for assessment, investigation and a proper reporting to state agency. The Director of Nursing will randomly audit the 24hour reports, incident reports and the facility activity report and licensed nurse skin evaluation weekly for 4 weeks and monthly for 2 additional months to validate compliance with the identification, evaluation/assessment, reporting and investigating of any bruise/injury of unknown origin. The (MD) was notified (MONTH) 10, 2019 at 8:27pm of the Immediate Jeopardy. An ad hoc QAPI was held (MONTH) 10, 2019 for review of this plan. Results of the 24hour report, incident report, facility activity report, and weekly skin evaluation audits will be presented to the Quality Assurance Performance Improvement (QAPI) Committee monthly for a period of 3 months for review and recommendation. Any areas of concern identified will be addressed by the Administrator or designee, at time of discovery. The Administrator will be responsible for the Plan of Removal and will be monitoring. 7. Monitoring of the plan of removal revealed: Interviews were conducted on 05/11/19, 05/12/19 and 05/13/19 with 17 nursing staff (10 nurses-LVN A, LVN B, LVN H, LVN M, LVN Q, LVN S, RN T, RN U, LVN X and LVN Z) and seven CNAs (CNA G, CNA O, CNA P, CNA R, CNA V, CNA W, CNA Y) across all three shifts, the weekend and including PRN staff to ensure they had been properly in-serviced on reporting of bruises and injuries of unknown origin, documentation of such findings, evaluation/assessment requirements by nursing of bruises, definition of abuse and injury of unknown origin and time frames for reporting abuse. Staff interviewed verified that had been in-serviced and had received training on the identification, evaluation, assessment, reporting and documentation protocol for bruises and injuries of unknown origin. No concerns were identified during the two days of monitoring and the facility was able to train all nursing staff that were working during that time. During the course of the monitoring, the facility completed skin checks for 100% of the residents and no additional injuries of unknown origin or suspcious bruising were identified. Interview with the DON occurred on 05/11/19 at 12:14 PM were she said she felt the IJ occurred because there was a lack of sense of urgency, and assumptions which goes back to being subjective versus objective. She thought it happened through lack of consistency. The ADM and DON were informed on 05/11/19 at 5:00PM that the Immediate Jeopardy was removed and that the facility remained out of compliance at a severity of potential for more than minimal harm and a scope of isolated.

Based on interview and record review, the facility failed to have evidence that all allegations of abuse and neglect were thoroughly investigated for three (Residents #12, #50 and #29) of 18 residents reviewed for abuse and neglect. The A facility failed to investigate bruises/injuries of unknown origin for Residents #12, #50 and #29. An Immediate Jeopardy (IJ) was identified on 05/10/19. While the IJ was removed on 05/11/19, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated, due to the facility still monitoring the effectiveness of the Plan Removal. These failures placed residents at risk for abuse and neglect resulting in further injuries, fear and untreated injuries of unknown origin. Findings included: 1. Resident #12's MDS Quarterly Resident assessment dated [DATE] reflected he was a [AGE] year old male admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. He had moderate cognitive impairment, and required one-person physical assistance for bed mobility, locomotion and transfers. Review of Resident #12's comprehensive care plan last dated 04/18/19 reflected no history of blood thinners, bruises or injuries of unknown origin. Interview with the ADM on 05/08/19 at 1:38 PM revealed she was the abuse prevention coordinator. She stated staff could report abuse allegations to their charge nurses, but her number was available. Interview with Resident #12 and his family member on 05/09/19 at 12:32PM revealed Resident #12 could answer simple yes/no questions but could not elaborate on any substantial questions about his care. During the interview with the family member, Resident #12 was moving his body around in bed and his sheets came off, exposing part of his right leg. At that point, a large purple bruise was observed on his upper right outer thigh. Resident #12 said he did not know where the bruise was from. The family member said the resident received hospice services Monday through Friday and a hospice CNA was supposed to be giving him a bed bath, so she wondered why the bruise was not reported by hospice if they saw it. She said the facility had not notified her of the resident's bruise. She said the facility called her about a week prior to tell her he was found in between his bed and the wall on the floor but had reported no injuries or complaints of pain. Interview with LVN [NAME] on 05/09/19 at 12:47 PM revealed she did not know that Resident #12 had any bruises on his body. She came to his room to assess him after surveyor began inquiring about the injury. She asked Resident #12 what happened. He said he did not know. She proceeded to look at the bruise. The bruise was observed to be on the outer right front and back thigh, and was dark purple. LVN [NAME] said, Oh, wow as she pulled back the covers. She asked him to turn over to look at his skin. He tried to turn to the side but started moaning in pain. He indicated his inner right thigh was hurting. At that point, LVN [NAME] observed a secondary large purple bruise on his inner right thigh up to his groin. Interview with ADON H on 05/09/19 at 12:52PM revealed no one reported Resident #12's bruises to her. She wondered if it was from the last fall on 4/29/19, then said it looked fresh. ADON H and LVN [NAME] then proceeded to evaluate his skin and he indicated he was in pain. When ADON H asked him if he wanted something for pain, he said Please! LVN [NAME] proceeded to administer Resident #12 prn [MEDICATION NAME] and said to wait for further evaluation until the medication was working. Interview and observation with CNA I on 05/09/19 at 12:58 PM revealed he provided incontinent care to Resident #12 that morning and saw the bruises. CNA I said he initially saw the bruise on Resident #12's thigh the morning before, on 05/08/19. He said he reported the bruises to the charge nurse that worked the 10pm- 6am shift and she said okay and that she knew about it. He did not know her name nor was he able to describe her with any detail. CNA I said he did not report it to anyone else. He was unable to state how the bruises manifested. Review of CNA I's Point of Care flow sheet (computer system used by CNAs to document care) reflected he documented on 05/08/19 and 05/09/19 that Resident #12 had bruising under the section Indicate any skin problem for the resident. It did not reflect where the bruise was, how many, or follow up. There was no additional information given. Interview with the DON on 05/10/19 at 11:15PM revealed the CNA Point of Care Flow sheets were reviewed by herself and the nursing management team for completion only, not content. Interview with LVN [NAME] on 05/09/19 at 1:02 PM revealed she had found where RN F documented Resident #12's bruise in a nursing note on 05/07/19. LVN [NAME] said it was not documented on the nursing 24-hour report or else she would have seen it. LVN [NAME] said she had tried to do a skin assessment on him several days go, but he refused it. She said a hospice aide was present on 05/07/19 and Resident #12 had gotten up to be showered, so the hospice aide would have seen the bruises. LVN [NAME] continued to express surprise Resident #12 had bruises and said she knew nothing about it. Interview with ADON H on 05/09/19 on 1:14 PM revealed Resident #12's bruises were concerning but she felt it could be a latent bruise manifesting from his fall on 4/29/19. She said the deep purple color though, negated that idea because it just happened. She remembered seeing hospice the day prior but the hospice aide did not mention anything to the facility about a bruise. ADON H said the bruises needed to be reported to the ADM who was the abuse/neglect coordinator. Review of the facility's 24-hour nursing report from 05/04/19-05/09/19 revealed no documentation of bruises for Resident #12. Observation of Resident #12 on 05/09/19 at 1:32 PM revealed he had been medicated with [MEDICATION NAME] for the past thirty minutes and LVN [NAME] proceeded with measuring his bruises. Resident allowed LVN [NAME] to measure his outer thigh which was 40cm x14 ½ cm. When it came to his inner thigh, he was assisted to lift his leg up for a measurement of the bruise, but he cried out in discomfort and said it hurt. LVN [NAME] said that was the hip Resident #12 had the most recent [MEDICAL CONDITION] and surgery in (MONTH) (YEAR). She pointed to his surgery scar on the outer thigh which went directly through the bruise. LVN [NAME] said if she would have been the one to find the bruise, she would have noted it on the 24-hour report with the measurements, completed an incident report and notified her manager. She stated the only documentation she could locate on Resident #12's bruises were the nurses note on 5/7/19 written by RN F. Further interview with LVN [NAME] on 05/09/19 at 1:50PM revealed she was able to get the inner thigh bruise measurement for Resident #12 and it was 20 ½cm x 18cm. She provided an incident report at that time for the bruises she had just completed and described the bruises as dark purple in color and painful to inner leg. Interview with the hospice provider on 05/09/19 at 1:52PM revealed the hospice aide was in the field and she would relay the request for a telephone interview. Hospice aide did not return call. Interview with LVN [NAME] on 05/09/19 at 1:57 PM revealed ADON H had just ordered a stat x-ray for Resident #12. Review of a nursing progress note written by RN F on 05/07/2019 at 4:06PM reflected, During head to toe assessment, nurse noted purple color large bruise to right outer hip and on right inner thigh. Nurse asked resident if he fell . Resident stated, 'I did not fall'. Denied being in pain at this time. Will continue to monitor. There were no other nursing progress notes mentioning Resident #12's bruises before or after this entry. Interview with ADON H on 05/09/19 at 2:12 PM revealed she was with RN F who had initially discovered the bruise on 05/07/19. She said she had just in-serviced RN F on reporting protocol of bruises and injuries of unknown origin to the ADM. Interview with RN F on 05/09/19 at 2:24 PM revealed she remembered earlier in the week, she could not remember the specific day, she came to work and did her routine rounds. Normally, Resident #12 was under his blanket, but that day he was naked and she said she noticed a bruise on his left side and inner side of his right thigh. She said the main bruise was on the outer thigh and a little bruise on the inner, like the size of her palm. She said he denied falling. She said she touched and palpated it and he said he was not in pain, so she felt it may have been from the fall he had a week prior on 04/29/19. She said she was present for that fall on 04/29/19 and did an assessment and he had no injuries and his skin looked good throughout that shift. She said when she found the bruise on 05/07/19, no one had reported it to her prior to that. She said she completed a nursing progress note but did not complete an incident report. RN F said she knew she was supposed to write an incident report, but she thought since she had done one for the fall on 04/29/19, it would cover the current bruise on 05/07/19. She said she did not tell ADON H or LVN [NAME] about the bruises on Resident #12. Interview with the ADM on 05/09/19 at 3:01 PM revealed she had not observed Resident #12's injuries and had not been told about the bruises until that afternoon. She said she did not know anything about it. Interview with CNA J on 05/09/19 at 5:30 PM revealed she worked with Resident #12 on 05/09/19 on the 2pm-10pm shift (after the bruise had been identified by the surveyor) and his skin was good. She said she checked him for incontinence and did not see any new or old bruises on his thighs. She claimed she saw his legs. She was asked several times if there was bruising to the resident's right thigh, and she responded no. Interview with the DR on 05/10/19 at 9:58 AM revealed he was not notified of Resident #12's bruises but should have been because of the nature and size of the bruise. He said he was called by the facility the day prior on 05/09/19 and he came out on 05/10/19 and had just finished assessing him prior to the interview. He said he did not think the bruises came from a fall, but he could not be certain where they came from. He said since Resident #12 was on hospice, the facility was not doing labs, therefore he could not see if there was anything going on internally. He said Resident #12 was not on any blood thinners, but the bruising could possibly be from coagulopathy, which was the body's inability to clot blood. He said when a resident was starting to decline towards the end of life, the organs start to shut down and the ability to coagulate could be compromised. He said if that was occurring, any touch or pressure could cause that kind of bruising under the skin, or something internally could be happening, deep in the tissue, but he could not be sure. Review of Resident #12's stat x-ray obtained on 05/09/19 revealed no fracture. Interview with the DON on 05/10/19 at 11:13 AM revealed she had been thinking about Resident #12's bruising. She remembered the previous week, he had gotten up in his wheelchair with the use of a Hoyer lift while a family member was visiting. She said the sling used crisscrossed between his legs right where the bruising was on the side of the right thigh and she thought it possibly could have been from that but could not be certain. Interview with LVN K on 05/10/19 at 11:21 AM revealed she worked overnights on Resident #12's hall. She said no CNA had reported any bruises or falls to her for Resident #12 over the past few overnight shifts. She said she was new to the facility. The past week (05/06/19 through 05/10/19) was the first week she was by herself as a charge nurse. LVN K said she expected to be told about any resident who had a bruise. She said she would then complete an incident report and if it was a bruise of unknown origin, she would call the DON and then start the process to see if they could determine where it came from. Interview with the ADM on 05/10/19 at 12:22 PM revealed she did not know about the bruising to Resident #12 until the day prior after the surveyor began making inquiries. She said she had not yet observed the bruises for Resident #12 even though she had been notified of them on 05/09/19, an investigation had not been started. Interview with LVN L on 05/10/19 at 1:51 PM revealed she worked the overnight shift for the past few nights and knew Resident #12. She said no one reported to her that he had any bruises. She said the nurse who she relieved, RN F, did not indicate any injuries of unknown origin or bruises for Resident #12 when she gave her report at change of shift, only that he had complained of pain and told her there was a hospice comfort pack available. She did not indicate to LVN L where Resident #12's pain was. LVN L said she only saw Resident #12 asleep during her shift. She said CNA I never told her there was a bruise on Resident #12 and by the time his shift started, she would have already been on her way home. LVN L said she had not been informed that Resident #12 had a bruise on his inner and outer thigh; it was not on the 24-hour report. She said her expectation for a large bruise was it should be reported to her. She said the CNAs were trained well and had experience and knew if they saw anything at all, they reported it. 2. Resident #50's MDS Quarterly Resident assessment dated [DATE] reflected he was an [AGE] year old male admitted to the facility on [DATE] with active [DIAGNOSES REDACTED]. He had severe cognitive impairment and required one-person physical assistance for locomotion and transfers. Review of Resident #50's comprehensive care plan last dated 04/6/19 reflected no history of blood thinners, bruises or injuries of unknown origin. Interview and observation of Resident #50 on 05/08/19 at 9:00AM revealed he was sitting in a chair in the hallway. Dark purple bruises the sizes of large playing cards on both forearms were seen on the top of both arms. There was a bruise the size of a fingerprint on residents' upper right arm as well as a skin tear to the lower right arm covered with a butterfly bandage. There was a skin tear observed to the left side of his neck and an injury to the left ear covered with a butterfly bandage. Resident #50 attempted to speak but speech was not clear or understandable. Interview on 05/08/19 at 1:23PM with Resident #50's family member revealed someone from Resident #50's family visits him daily. They reported they noticed the bruises on Resident #50 on 05/07/19 when they came to visit him, and he was dressed in a long sleeve shirt they felt to be inappropriate for the hot weather (Temperature was 84 degrees on 05/07/19, https://www.wunderground.com/history/daily/us/tx/dallas/KDAL/date/history/daily/us/tx/dallas/KDAL/date/2019-5-7, retreived 05/28/19). The family member stated when changing Resident #50's shirtm they noticed the bruises and became upset. They stated they went to some of the staff on the floor about the bruises and could not get any answers, so they went to the ADON. They stated they insisted the ADON see the bruises and when she did she stated she had no idea what happened. She stated she let her know that other family members visited the resident on 05/06/19 and had not seen the bruises due to resident having on a long shirt. Interview with ADM on 05/09/19 at 12:34PM revealed she was aware Resident #50 had a skin tear and bruising. She stated she had not reported the incident because she had not determined if the injuries where reportable or not. Interview with CNA Y on 05/09/19 at 2:18pm revealed she assisted Resident #50 with putting on his shirt, shorts, socks and shoes on 05/09/19 and denied seeing any bruising or skin issues. She stated the last time she had worked with Resident #50 was a week prior and she had not noticed any bruising then. She stated she did notice the skin tear on his ear but not his neck during that same shift. She stated she did not report the injury to his ear because it was bandaged, and she figured it had already been handled. They rotate, and she'd been off for five days. Further interview with CNA Y at 05/09/19 at 3:04pm revealed she asked the ADON what happened to Resident #50 and was told that he fell Friday. Interview with LVN N on 05/09/19 at 3:37 pm revealed she completed an incident report for Resident #50 when he fell on [DATE]. She stated she did not witness the fall but was notified and went to the TV room where he was sitting on the floor and she assisted with assessing and putting him in a chair. She denied any injuries where obtained during the fall. She reported she was told that Resident #50 had an incident with side rails over the weekend that caused the skin tear to his arm. But she was not sure. She stated when she arrived at work 05/06/19 she noticed Resident #50's arms where bruised, a skin tear on neck and he had a little blood coming out his ear. She stated she was not sure what happened to his ear but believed the bruising on his arms could have been from the fall. She stated his family came to her yesterday and reported he has low platelets count and that could be the reason for the bruising. Interview with LVN X on 05/09/19 at 1:28pm revealed she works weekends 6:30 am to 10:30pm. She stated she worked with Resident #50 on 5/04/19 and 5/05/19. She stated she did an incident report on 05/04/19 because Resident#50 hit his right arm on the bed causing a skin tear and bruising. She stated Resident #50 is confused however she asked him did he hit his arm on the bed and he told her yes. She stated she also saw blood on resident enable bars. She stated she did not remember any marks on his face or neck. She stated she did not notice any bruising outside of the skin tear and bruise to his right arm on 05/05/19. Review of Resident #50's clinical record and facility incident reports revealed his bruises were not investigated. Interview on 05/09/19 at 2:30 pm with ADON revealed she was notified of Resident #50's fall on 05/04/19. She stated she was not aware if resident hit anything during his fall but knows he did have a fall that could have caused delayed bruising. She reported Resident #50's family came to her after changing his shirt and noticing the bruising and she reported that they could have come from delayed bruising from his fall. She stated resident's family indicated that resident had low platelet count but did not want her to check him. She stated she expected to see documentation in regard to things that happen to the resident and had yet to see anything regarding Resident #50's injuries. Interview with ADM on 05/09/19 at 12:34PM revealed she was aware or Resident #50's brusing and skin tear. She stated he had a fall however she was had not seen the injuries. She stated all injuries where not reportable and she had not seen his yet. Review of patient/resident incident/accident investigation worksheet signed by DON undated completed by LVN N on 05/03/19, revealed Resident #50's fall was investigated on 05/03/19 and revealed no visible injuries or complaints of pain. There was no mention fo brusing on the resident. 3. Review of the undated Admission Report Form for Resident #29 revealed she was a [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of (MONTH) 2019 consolidated Physician order [REDACTED]. During observation of incontinent care for Resident #29 on 05/08/19 at 2:12 PM, bright purple bruises were noted on the shin area of bilateral lower extremities. CNA C reported that the nurse was aware of the bruises. CNA C said she did not report the bruises because they had previously been reported and documented by a certified nurse aide, but she was not sure which one. Review of Resident #29's clinical chart revealed there was no evidence or documentation provided to indicate the bruises had been reported. Interview with LVN [NAME] on 05/08/19 at 2:35 PM revealed she was not aware of any bruising and none had been reported to her. Interview with LVN F on 05/08/19 at 2:30 PM revealed she was not aware of any bruising on Resident #29. No bruises had been reported to her. She said she was just coming on duty. Interview and observation on 05/08/19 at 2:42PM revealed LVN [NAME] and LVN F went immediately to assess Resident #29. Documentation of their findings indicated; Fresh looking bruises to BUE (bilateral upper extremity)and BLE's (bilateral lower extremity). Bruises as follows: Left arm deep purple bruise 7cm x 6cm; Right arm with deep purple bruise 10cm x 11cm; Left lower leg with three bruises-1). 2cmx4cm 2). 5cmx3cm 3). 1cmx2cm; Right lower leg with three bruises- 1). 1cmx2cm 2). 4cm x5cm 3). 1cmx1cm; Bilateral upper ext's bruising due to resident rubbing/hitting arm rest while propelling w/c. Further investigation for BLE. Bruising due to improper transfers, hitting lower legs with bed and or w/c. Resident denies pain or discomfort when asked. ROM WNL for her without facial grimaces or vocalization of pain. Observation of Resident #29 on 05/10/19 at 10:45 AM revealed the bruises were fading. No additional bruises were observed. Review of Resident #29's clinical records and incident reports revealed no investigation had been completed related to his bruises/injuries of unknown origin. 4. Interview with the DON on 05/11/19 at 12:33PM revealed when CNAs saw a bruise, they were supposed to report it to the charge nurse and the abuse/neglect coordinator. If the abuse/neglect coordinator was not in the building, the charge nurse would report it. She said the bruises staff have been trained on to report as suspicious was anything that was red or purple, or if they felt it should not be there and was not a part of the resident's normal body. Once reported, the abuse/neglect coordinator would make the final determination along with an RN. She said the CNAs were supposed to fill out a skin sheet whenever they saw an injury or a bruise. She said CNA I did not fill a skin sheet out for Resident #12. Then the two ADONs were supposed to review the CNA skin sheets daily and on Mondays they review for the previous weekend. The DON said the point of the ADONs reviewing the CNA skin sheets was to see if there were any notations on them that were of concern, such as bruises or injuries of unknown origin. She said all injuries of unknown origin, including bruises, should be reported to the ADM and the DON. She said she provided training during orientation on abuse, neglect and exploitation and reporting procedures. She said an injury of unknown origin was an injury that cannot be explained and the root cause could not be identified. She said she and the ADM were responsible for reporting injuries of unknown origin to HHSC and investigating the incident. 5. The facility's current Abuse Protocol policy revised 03/08/17 revealed, Policy: .3. The facility's leaders will conduct a prompt investigation of any allegation received of suspected abuse; . Procedures .Component IV: Identification 1. Staff members will identify and assess suspected or alleged reports of abuse or neglect, focusing on objective and observable evidence, such as suspicious bruising, witness reports regarding unusual occurrences or patterns or trends of potential abuse or neglect; .Component VI: Investigation .4. Investigations are prompt, comprehensive and responsive to the situation and contain founded conclusions, .8. Guidelines for investigating: A/ Immediately assess the resident/patient at the time of discovery of alleged abuse, B. Document assessment in the medical record, C. Maintain the resident's/patient's protection during the investigation, D. Notify the attending physician and the resident's/patient's legally responsible party, E. Notify the Administrator, Director of Nursing, and Social Worker regardless of the time of day. 6. An Immediate Jeopardy was identified on 05/10/19 at 4:30PM and the ADM and DON were notified on 05/10/19 at 4:45PM. A plan of removal was requested at that time. The Plan of Removal was accepted on 05/11/19 at 5:00PM and reflected: The Facility failed to identify, evaluate/assess, investigate, and report injuries/bruises of unknown origin to the state agency. The residents identified to have bruises had the areas assessed, reported to state agency and investigation. All residents who reside in the facility have the potential to be affected by the alleged deficient practice. Therefore, a facility skin sweep was conducted by members of nursing management team, (DON), (ADONB), (ADON H) and RCC, to identify any bruises/injuries of unknown origin. This skin sweep was started on (MONTH) 9, 2019 and was completed on (MONTH) 10, 2019. The results of our skin sweep noted one individual with scattered bruising to bilateral arms and she is unable to verbalize how they occurred. The Administrator, (ADM), LNFA and the Director of Nursing, (DON), were re-educated by the (RVP), on (MONTH) 10, 2019 regarding the identification, evaluation/assessment, investigation, of how to prevent abuse and neglect, care planning, and reporting of bruises/injuries of unknown origin. Certified nursing assistants were re-educated by Members of the nursing management team, named above starting on 05/10/19 and completed by (MONTH) 13, 2019 at 4pm by members of nursing management regarding the expectation that during skin observations during care any bruises/injury of unknown origin, will be documented on the shower sheet and given to the charge nurse. Any bruise/injury of unknown origin identified will be reported to charge nurse and the charge nurse will evaluate/ assess and notify the administrator or DON for thorough investigation and reporting to the state agency. Licensed nurses were re-educated, by Members of the nursing management team, named above starting on 05/10/19 and completed by (MONTH) 13, 2019 at 4pm, regarding the expectation that skin evaluations should include the identification of bruises/injuries of unknown origin with assessment of area, thorough and accurate documentation of findings, care planning and reporting to the Director of Nursing or Administrator for reporting to appropriate state agencies. If certified nursing assistants identify a bruise/injury of unknown origin and reports to the charge nurse, the area is to be evaluated and assessed and if identified as injury of unknown origin the Director of Nursing/administrator is to be notified. The DON/Administrator/or designee will thoroughly investigation and report to the state agency. Any member of nursing management, licensed nurse or Certified Nursing Assistant not receiving this re-education by this (MONTH) 11, 2019 cannot return to work prior to completion of the education. The Administrator and or DON will ensure the competency of education by test, completion of education and monitoring of the education from in-services on prevention; identification and notification of abuse and neglect, CNA-Identifying and Notifying of skin integrity changes; and Nurses-Assessment and Documentation. This education will also be presented in New Hire Orientation by a member of the nursing management team. The Assistant Directors of Nursing/designee will review the 24hour reports, incident reports and the Facility Activity Report from Matrix medical records system daily to identify the documentation of any bruise/injury of unknown origin that has not been reported and investigated by the Administrator or DON. The Administrator and/or Director of Nursing will follow the appropriate reporting guidelines for abuse neglect, exploitation, misappropriation of resident property, and injuries of unknown origin. The Assistant Directors of Nursing/designee will review licensed nurse skin evaluations Daily by the DON/ADON/or designee for 4 weeks, then weekly for 2 additional months, to monitor for the identification of any bruises not reported to nursing management for assessment, investigation and a proper reporting to state agency. The Director of Nursing will randomly audit the 24hour reports, incident reports and the facility activity report and licensed nurse skin evaluation weekly for 4 weeks and monthly for 2 additional months to validate compliance with the identification, evaluation/assessment, reporting and investigating of any bruise/injury of unknown origin. The (MD) was notified (MONTH) 10, 2019 at 8:27pm of the Immediate Jeopardy. An ad hoc QAPI was held (MONTH) 10, 2019 for review of this plan. Results of the 24hour report, incident report, facility activity report, and weekly skin evaluation audits will be presented to the Quality Assurance Performance Improvement (QAPI) Committee monthly for a period of 3 months for review and recommendation. Any areas of concern identified will be addressed by the Administrator or designee, at time of discovery. The Administrator will be responsible for the Plan of Removal and will be monitoring. 7. Monitoring of the plan of removal revealed: Interviews were conducted on 05/11/19, 05/12/19 and 05/13/19 with 17 nursing staff (10 nurses-LVN A, LVN B, LVN H, LVN M, LVN Q, LVN S, RN T, RN U, LVN X and LVN Z) and seven CNAs (CNA G, CNA O, CNA P, CNA R, CNA V, CNA W, CNA Y) across all three shifts, the weekend and including PRN staff to ensure they had been properly in-serviced on reporting of bruises and injuries of unknown origin, documentation of such findings, evaluation/assessment requirements by nursing of bruises, definition of abuse and injury of unknown origin and time frames for reporting abuse. Staff interviewed verified that had been in-serviced and had received training on the identification, evaluation, assessment, reporting and documentation protocol for bruises and injuries of unknown origin. No concerns were identified during the two days of monitoring and the facility was able to train all nursing staff that were working during that time. During the course of the monitoring, the facility completed skin checks for 100% of the residents and no additional injuries of unknown origin or suspcious bruising were identified. Interview with the DON occurred on 05/11/19 at 12:14 PM were she said she felt the IJ occurred because there was a lack of sense of urgency, and assumptions which goes back to being subjective versus objective. She thought it happened through lack of consistency. The ADM and DON were informed on 05/11/19 at 5:00PM that the Immediate Jeopardy was removed and that the facility remained out of compliance at a severity of potential for more than minimal harm and a scope of isolated.

Based on interview and record review it was determined the facility failed to ensure the resident's right to be free from neglect for one (Resident #1) of six residents reviewed for neglect. Resident #1, a resident with a full code status, was found without pulse or respiration on [DATE]. RN E failed to perform CPR and call 911. As a result, Resident #1 expired on [DATE]. On [DATE], an Immediate Jeopardy was identified as Past Noncompliance at a severity level of IJ due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. While the Immediate Jeopardy (IJ) was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated, because the facility continued to monitor the effectiveness of the plan of removal. This failure placed 49 residents, whose code status was full code, at risk for not receiving CPR and other life-saving treatments. Findings included: Review of Resident #1's closed clinical record reflected on the face sheet, [DATE], that the resident was a [AGE] year-old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The code status on the face sheet was listed as DNR. Further review of Resident #1's clinical record provided no evidence of a DNR. Review of Resident #1's computer generated Physician order [REDACTED]. Review of the facility Admission Agreement for Resident #1, dated [DATE], and executed by her family member on [DATE], revealed it did not acknowledge DNR identification was provided to the facility. A copy of the living will was not provided to the facility at the time of admission. Review of Resident #1's MDS assessment, dated [DATE], revealed she had moderate cognitive impairment and received hospice services. Review of Resident #1's care plan generated on [DATE] with problem onset dated [DATE] revealed she was alert and oriented X3 (describes a resident who is awake and oriented to who they are, where they are and date and time of recent events) with some forgetfulness, and the resident would be informed of her right to complete advance directives to direct her medical care. The Resident's desires will be honored. Review of Resident #1's Social Service History on Admission, dated [DATE] (sic) at 4:51 PM and completed by the SW, reflected advance directives were reviewed with Resident #1. The resident did not have advance directives in place. Resident #1 was able to make herself understood and understood others. Interview with the SW on [DATE] at 10:50 AM revealed she did not discuss code status with Resident #1 because the code status was already in the computer as DNR. The SW stated Resident #1 was able to make her own decisions. Review of Resident #1's nurse's notes revealed the following: [DATE] at 3:30 PM by LVN A - resident's family member called the facility and stated the resident was coughing and had pneumonia. The nurse went to the resident's room and observed resident lying in bed. The resident verbalized called her husband to call 911 to carry her to the hospital because she was coughing and had pneumonia. The resident was alert and oriented X3 but forgetful. Unproductive cough noted. Rales (also known as crackles which can be a sign of [MEDICAL CONDITION] or pneumonia in the elderly) to bilateral lung medial to lower lobes noted. [DATE] at 3:47 PM by RN E - hospice notified. [DATE] at 6:36 PM by LVN A - hospice nurse at facility, completed assessment. New order received for [MEDICATION NAME] 0.5mg tabs PRN for anxiety and agitation. Resident and responsible party notified. [DATE] at 8:42 PM by LVN A - resident observed in fowler's position (head elevated at a 45 degree angle to promote oxygenation), head to right side. Called the resident's name twice, but resident unresponsive. Unable to obtain vital signs. Notified facility supervisor RN E. [DATE] at 8:45 PM by RN E - resident observed unresponsive. Code status on face sheet DNR. Hospice notified. Hospice on call staff instructed staff not to initiate CPR and CPR is not and should never be performed on their client. Nurse informed hospice would be sending a nurse to pronounce resident. [DATE] at 8:56 PM by RN E - hospice nurse arrived and restated CPR would not be performed on their client. Hospice nurse assessed and pronounced resident. Hospice nurse notified family. [DATE] at 9:30 PM by LVN A - hospice nurse here to assess resident. Hospice notified the family after dropping the phone, the hospice said, it seems the family is not ready, because the son is telling (sic) her to drop the phone and go start CPR. [DATE] at 9:35 PM by RN E - resident's family member called 911, resident was transported to the hospital per family's request. Attempts were made to contact RN E, but without success. Interview with LVN A on [DATE] at 3:06 PM revealed she was the nurse on duty when Resident #1 expired. LVN A stated Resident #1's family member spoke with weekend supervisor stating resident wanted to go to the hospital. LVN A stated she did not remember if Resident #1 voiced wanting to go the hospital. LVN A revealed she went to the resident's room to complete an assessment. She remembered Resident #1 was agitated. LVN A stated she notified the hospice nurse who came to assess the resident and administered medication and notified the family. LVN A revealed she did not find an order in the paper chart indicating Resident #1 was a DNR. She stated the only order regarding code status was the DNR listed in the computer chart. Review of the facility's Provider Investigation Report, dated [DATE], revealed the facility reported Resident #1 was found unresponsive in her room on [DATE]. RN E assessed the resident and notified hospice who pronounced her death. CPR was not initiated. DNR was noted in electronic chart, but upon investigation the facility was unable to obtain the out of hospital DNR. Facility initiated audit of all resident charts and staff training regarding resident code status. Interview with the Administrator on [DATE] at 11:00 AM revealed the facility had a copy of Resident #1's History and Physical from the hospice company, signed by the attending physician, that reflected Resident #1 had a DNR. The Administrator stated the facility did not have a copy of the DNR. Review of Resident #1's hospice History and Physical, dated [DATE], reflected Resident #1 admitted to hospice with chronic [MEDICAL CONDITION]. It further reflected any additional changes to plan of care would be based upon clinical course in accordance with an out of hospital DNR which is executed on the chart. Interview with the DON on [DATE] at 8:15 AM revealed Resident #1 was only in the facility for 15 days. The ADON completed the admission. When the ADON completed the admission she wrote an order in the computer that Resident #1 was a DNR without actually seeing the DNR. The DON stated the ADON entered the order for the DNR based on what she was told by the hospice company. The DON explained that on the day of the incident, the hospice nurse was notified Resident #1 was unresponsive. The hospice nurse came to the facility and assessed the resident. The hospice nurse pronounced Resident #1's death and notified the family. The DON explained when the hospice nurse notified the family, the family stated Resident #1 was a full code not a DNR and demanded the hospice nurse begin CPR. The DON stated Resident #1's family called 911 and she was sent to the local hospital at which time she resident had already expired. The DON revealed following the incident it was discovered the facility did not have a DNR in place for Resident #1. The DON stated the ADON had already been terminated prior to the incident for another incident. Attempts were made to contact the ADON, but without success. Interview with the Administrator on [DATE] at 8:43 AM revealed facility staff never had the conversation with Resident #1's family regarding code status. The Administrator stated the hospice company never provided the facility with paperwork regarding Resident #1's code status. Interview with the AD on [DATE] at 9:40 AM revealed Resident #1's family never provided a DNR for the resident. The AD stated the family never stated whether Resident #1 was a full code or DNR. She stated she recalled the family member being concerned about the resident being on hospice and did not want her to be in and out of the hospital. The AD revealed she never received a clear answer from the family regarding Resident #1's advance directives. The AD explained families were provided information regarding advance directives at the time of admission. She stated if a family did not provide information regarding advance directives, she would follow up with the family with the help of the social worker. The AD revealed she did not follow up with Resident #1's family regarding advance directives. She stated she could not recall if she informed the nursing department regarding Resident #1's code status. The AD stated if she had the DNR paperwork she provided it to the nurses. Interview with the hospice team manager on [DATE] at 3:15 PM revealed Resident #1 never had a DNR in place. The hospice company did not have a DNR on file for Resident #1. She explained hospice services were provided to Resident #1 when she was in the community prior to admission to the facility. The hospice team manager stated she recalled the family did not want a DNR. She stated she was not sure where the facility obtained the information that Resident #1 was DNR. Review of Nursing Facility and Hospice Routine Care Services Agreement, dated [DATE], revealed the following: Coordination of Services: section 4.4 stated, Hospice shall provide the following information to Nursing Facility for each Hospice patient: (i) The most recent Hospice Plan of Care specific to each Hospice Patient; (ii) Hospice election form and any advance directives specific to Hospice Patient. Review of the facility's current hospitalization and Emergency Care policy and procedure for hospice residents in the facility dated February 2014 revealed, Emergency care should be consistent with the patient's stated wishes in advance directives and physician orders. Review of Social Services Policies and Procedures: Advance Directives, dated [DATE], revealed the following: Do-Not-Resuscitate (DNR) Identification and/or Orders: 1) The proper DNR consent form must be obtained and signed by the patient/resident indicating their wishes. If the resident wishes to be a DNR the decision must be clearly and concisely documented in resident's chart. The executed DNR must be provided in the resident's medical record. The Director of Nursing or designee reviews the medical record to verify DNR documentation is complete is accordance with policy. The Director of Nursing or designee will establish a system to alert direct care staff regarding a resident's CPR status. Review of the facility's current Policy and State Requirement for Advance Directives dated [DATE] revealed Absent any appropriate DNR Order/Identification, the facility staff will respond to medical emergencies with CPR measures and a Full Code will be instituted. On [DATE] at 11:33 AM, the Administrator was notified it was determined these failures placed Resident #1 and other residents in an IJ situation from [DATE] through [DATE]. The Plan of Removal was accepted [DATE] at 12:11 PM. The Plan reflected the following: --Monthly the DON and Administrator will ensure Hospice companies have a binder for each resident receiving hospice services at the respective nurses' station. The Administrator and DON will ensure the binder has the following items to include: Demographic Sheet, Code Status, Power of Attorney documents, Plan of Care, Nurse Aide notes, Nurse notes, and other service notes. --On [DATE], DON completed a 100% audit of code status for each resident and the physician order [REDACTED]. The audit revealed that all residents with an order for [REDACTED]. No negative findings were noted. --In-Service/Training Completed: Admission staff, licensed nurses, and social workers were reeducated regarding policies relating to advanced directives by the DON starting on [DATE] through [DATE]. --On [DATE], Regional Nurse will provide education to the DON, Admissions Director and Social Services Director regarding policies related to advance directives. On [DATE], education will be initiated with all Direct Care Staff by the Director of Nursing and Assistant Directors of Nursing to include appropriate response if a resident is found unresponsive. Staff were tested by verbal question and answer by the Director of Nursing and thereafter random verbal question and answer. --The Facility requested that Hospice educate staff regarding the requirement of nursing facilities in relation to the code status of residents being housed in a facility under their care to include: documentation of end-of-life discussions to be included in the Facility chart and the need for an executed Out-of-Hospital Do Not Resuscitate if the resident requests no Cardio-pulmonary Resuscitation in the event of [MEDICAL CONDITION]. The facility will ensure continuity of care and communication with hospice providers through education of the facility policy on advance directives and verification of required documents prior to admission. --The Plan of Removal's Monitoring Section reflected the DON will complete a monthly reconciliation of code status on to ensure that those residents who have elected a Do Not Resuscitate status have an executed Out-of-Hospital Do Not Resuscitate in their individual chart located at the nurses' station. --The DON will monitor the results of the audits and report the results to the monthly Quality Assurance and Performance Improvements committee. --The DON and/or new Assistant Directors of Nursing will review code status of new admissions within 24 hours to assure those residents with an order for [REDACTED]. --The DON or Designee will conduct a 100% audit of code status for each resident on a monthly basis. For those residents who have chosen to execute an Out-of-Hospital Do Not Resuscitate, the form will be physically visualized by the Director of Nurse and or Assistant Directors of Nursing and placed in a hard chart located at the respective nurses station. The physician order [REDACTED]. Review of the In-Service Attendance Record Sheet, dated [DATE], revealed training was held with licensed nurses including RN E and LVN A, social worker and admissions director regarding resident code status, advance directives and verification of code status. Review of the facility's In-Service Attendance Record Sheet dated [DATE] through [DATE] for nursing staff including RN E and LVN A revealed training was conducted regarding code status, verification of orders and advance directives. Interviews with nursing staff from all three shifts regarding training and resident code status (AD, SW, LVN B, LVN C, LVN D, LVN A, LVN F, LVN G, LVN H) revealed all were able to identify residents on hospice and where to locate hospice information (binders stored behind nursing station). All stated they carried a list on them with all residents' code status. All stated that if a resident did not have a DNR the resident was considered a full code. All stated if a resident requested to go the hospital, the resident request was honored. Review of clinical records for five residents (Resident 2, 3, 4, 5 and 6) revealed all correct and current code status documentation was in place indicating whether resident was full code or DNR. On [DATE] at 12:11 PM, the Administrator was notified the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. Advance Directive and Code Status Report, dated [DATE], reflected 49 residents were identified as full code.

Based on interview and record review it was determined the facility failed to implement their written policies and procedure that prohibited neglect of resident for one (Resident #1) of six residents reviewed for neglect. Resident #1, a resident with a full code status, was found without pulse or respiration on [DATE]. RN E failed to perform CPR and call 911. As a result, Resident #1 expired on [DATE]. On [DATE] an Immediate Jeopardy was identified as Past Noncompliance at a severity level of IJ due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. While the Immediate Jeopardy (IJ) was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated, because the facility continued to monitor the effectiveness of the plan of removal. This failure placed 49 residents, whose code status was full code, at risk for not receiving CPR and other life-saving treatments. Findings included: Review of Abuse, Neglect and Misappropriation policy and procedure revealed neglect is defined as the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. The facility's leadership prohibits neglect, mental or physical abuse, including involuntary seclusion and misappropriation of a resident's property and/or funds. Review of Nursing Facility and Hospice Routine Care Services Agreement, dated [DATE], revealed the following: Coordination of Services: section 4.4 stated, Hospice shall provide the following information to Nursing Facility for each Hospice patient: (i) The most recent Hospice Plan of Care specific to each Hospice Patient; (ii) Hospice election form and any advance directives specific to Hospice Patient. Review of the facility's current hospitalization and Emergency Care policy and procedure for hospice residents in the facility dated February 2014 revealed, Emergency care should be consistent with the patient's stated wishes in advance directives and physician orders. Review of Social Services Policies and Procedures: Advance Directives dated [DATE] revealed the following: Do-Not-Resuscitate (DNR) Identification and/or Orders: 1) The proper DNR consent form must be obtained and signed by the patient/resident indicating their wishes. If the resident wishes to be a DNR the decision must be clearly and concisely documented in resident's chart. The executed DNR must be provided in the resident's medical record. The Director of Nursing or designee reviews the medical record to verify DNR documentation is complete is accordance with policy. The Director of Nursing or designee will establish a system to alert direct care staff regarding a resident's CPR status. Review of the facility's current Policy and State Requirement for Advance Directives dated [DATE] revealed Absent any appropriate DNR Order/Identification, the facility staff will respond to medical emergencies with CPR measures and a Full Code will be instituted. Review of Resident #1's closed clinical record reflected on the face sheet, [DATE], that the resident was a [AGE] year-old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The code status on the face sheet was listed as DNR. Further review of Resident #1's clinical record provided no evidence of a DNR. Review of Resident #1's computer generated Physician order [REDACTED]. Review of the facility Admission Agreement for Resident #1, dated [DATE], and executed by her family member on [DATE], revealed it did not acknowledge DNR identification was provided to the facility. A copy of the living will was not provided to the facility at the time of admission. Review of Resident #1's MDS assessment, dated [DATE], revealed she had moderate cognitive impairment and received hospice services. Review of Resident #1's care plan generated on [DATE] with problem onset dated [DATE] revealed she was alert and oriented X3 (describes a resident who is awake and oriented to who they are, where they are and date and time of recent events) with some forgetfulness, and the resident would be informed of her right to complete advance directives to direct her medical care. The Resident's desires will be honored. Review of Resident #1's Social Service History on Admission, dated [DATE] (sic) at 4:51 PM and completed by the SW, reflected advance directives were reviewed with Resident #1. The resident did not have advance directives in place. Resident #1 was able to make herself understood and understood others. Interview with the SW on [DATE] at 10:50 AM revealed she did not discuss code status with Resident #1 because the code status was already in the computer as DNR. The SW stated Resident #1 was able to make her own decisions. Review of Resident #1's nurse's notes revealed the following: [DATE] at 3:30 PM by LVN A - resident's family member called the facility and stated the resident was coughing and had pneumonia. The nurse went to the resident's room and observed resident lying in bed. The resident verbalized called her husband to call 911 to carry her to the hospital because she was coughing and had pneumonia. The resident was alert and oriented X3 but forgetful. Unproductive cough noted. Rales (also known as crackles which can be a sign of [MEDICAL CONDITION] or pneumonia in the elderly) to bilateral lung medial to lower lobes noted. [DATE] at 3:47 PM by RN E - hospice notified. [DATE] at 6:36 PM by LVN A - hospice nurse at facility, completed assessment. New order received for [MEDICATION NAME] 0.5mg tabs PRN for anxiety and agitation. Resident and responsible party notified. [DATE] at 8:42 PM by LVN A - resident observed in fowler's position (head elevated at a 45 degree angle to promote oxygenation), head to right side. Called the resident's name twice, but resident unresponsive. Unable to obtain vital signs. Notified facility supervisor RN E. [DATE] at 8:45 PM by RN E - resident observed unresponsive. Code status on face sheet DNR. Hospice notified. Hospice on call staff instructed staff not to initiate CPR and CPR is not and should never be performed on their client. Nurse informed hospice would be sending a nurse to pronounce resident. [DATE] at 8:56 PM by RN E - hospice nurse arrived and restated CPR would not be performed on their client. Hospice nurse assessed and pronounced resident. Hospice nurse notified family. [DATE] at 9:30 PM by LVN A - hospice nurse here to assess resident. Hospice notified the family after dropping the phone, the hospice said, it seems the family is not ready, because the son is telling (sic) her to drop the phone and go start CPR. [DATE] at 9:35 PM by RN E - resident's family member called 911, resident was transported to the hospital per family's request. Attempts were made to contact RN E, but without success. Interview with LVN A on [DATE] at 3:06 PM revealed she was the nurse on duty when Resident #1 expired. LVN A stated Resident #1's family member spoke with weekend supervisor stating resident wanted to go to the hospital. LVN A stated she did not remember if Resident #1 voiced wanting to go the hospital. LVN A revealed she went to the resident's room to complete an assessment. She remembered Resident #1 was agitated. LVN A stated she notified the hospice nurse who came to assess the resident and administered medication and notified the family. LVN A revealed she did not find an order in the paper chart indicating Resident #1 was a DNR. She stated the only order regarding code status was the DNR listed in the computer chart. Review of the facility's Provider Investigation Report, dated [DATE], revealed the facility reported Resident #1 was found unresponsive in her room on [DATE]. RN E assessed the resident and notified hospice who pronounced her death. CPR was not initiated. DNR was noted in electronic chart, but upon investigation the facility was unable to obtain the out of hospital DNR. Facility initiated audit of all resident charts and staff training regarding resident code status. Interview with the Administrator on [DATE] at 11:00 AM revealed the facility had a copy of Resident #1's History and Physical from the hospice company, signed by the attending physician, that reflected Resident #1 had a DNR. The Administrator stated the facility did not have a copy of the DNR. Review of Resident #1's hospice History and Physical, dated [DATE], reflected Resident #1 admitted to hospice with chronic [MEDICAL CONDITION]. It further reflected any additional changes to plan of care would be based upon clinical course in accordance with an out of hospital DNR which is executed on the chart. Interview with the DON on [DATE] at 8:15 AM revealed Resident #1 was only in the facility for 15 days. The ADON completed the admission. When the ADON completed the admission she wrote an order in the computer that Resident #1 was a DNR without actually seeing the DNR. The DON stated the ADON entered the order for the DNR based on what she was told by the hospice company. The DON explained that on the day of the incident, the hospice nurse was notified Resident #1 was unresponsive. The hospice nurse came to the facility and assessed the resident. The hospice nurse pronounced Resident #1's death and notified the family. The DON explained when the hospice nurse notified the family, the family stated Resident #1 was a full code not a DNR and demanded the hospice nurse begin CPR. The DON stated Resident #1's family called 911 and she was sent to the local hospital at which time she resident had already expired. The DON revealed following the incident it was discovered the facility did not have a DNR in place for Resident #1. The DON stated the ADON had already been terminated prior to the incident for another incident. Attempts were made to contact the ADON, but without success. Interview with the Administrator on [DATE] at 8:43 AM revealed facility staff never had the conversation with Resident #1's family regarding code status. The Administrator stated the hospice company never provided the facility with paperwork regarding Resident #1's code status. Interview with the AD on [DATE] at 9:40 AM revealed Resident #1's family never provided a DNR for the resident. The AD stated the family never stated whether Resident #1 was a full code or DNR. She stated she recalled the family member being concerned about the resident being on hospice and did not want her to be in and out of the hospital. The AD revealed she never received a clear answer from the family regarding Resident #1's advance directives. The AD explained families were provided information regarding advance directives at the time of admission. She stated if a family did not provide information regarding advance directives, she would follow up with the family with the help of the social worker. The AD revealed she did not follow up with Resident #1's family regarding advance directives. She stated she could not recall if she informed the nursing department regarding Resident #1's code status. The AD stated if she had the DNR paperwork she provided it to the nurses. Interview with the hospice team manager on [DATE] at 3:15 PM revealed Resident #1 never had a DNR in place. The hospice company did not have a DNR on file for Resident #1. She explained hospice services were provided to Resident #1 when she was in the community prior to admission to the facility. The hospice team manager stated she recalled the family did not want a DNR. She stated she was not sure where the facility obtained the information that Resident #1 was DNR. Review of Nursing Facility and Hospice Routine Care Services Agreement, dated [DATE], revealed the following: Coordination of Services: section 4.4 stated, Hospice shall provide the following information to Nursing Facility for each Hospice patient: (i) The most recent Hospice Plan of Care specific to each Hospice Patient; (ii) Hospice election form and any advance directives specific to Hospice Patient. On [DATE] at 11:33 AM, the Administrator was notified it was determined these failures placed Resident #1 and other residents in an IJ situation from [DATE] through [DATE]. The Plan of Removal was accepted [DATE] at 12:11 PM. The Plan reflected the following: --Monthly the DON and Administrator will ensure Hospice companies have a binder for each resident receiving hospice services at the respective nurses' station. The Administrator and DON will ensure the binder has the following items to include: Demographic Sheet, Code Status, Power of Attorney documents, Plan of Care, Nurse Aide notes, Nurse notes, and other service notes. --On [DATE], DON completed a 100% audit of code status for each resident and the physician order [REDACTED]. The audit revealed that all residents with an order for [REDACTED]. No negative findings were noted. --In-Service/Training Completed: Admission staff, licensed nurses, and social workers were reeducated regarding policies relating to advanced directives by the DON starting on [DATE] through [DATE]. --On [DATE], Regional Nurse will provide education to the DON, Admissions Director and Social Services Director regarding policies related to advance directives. On [DATE], education will be initiated with all Direct Care Staff by the Director of Nursing and Assistant Directors of Nursing to include appropriate response if a resident is found unresponsive. Staff were tested by verbal question and answer by the Director of Nursing and thereafter random verbal question and answer. --The Facility requested that Hospice educate staff regarding the requirement of nursing facilities in relation to the code status of residents being housed in a facility under their care to include: documentation of end-of-life discussions to be included in the Facility chart and the need for an executed Out-of-Hospital Do Not Resuscitate if the resident requests no Cardio-pulmonary Resuscitation in the event of [MEDICAL CONDITION]. The facility will ensure continuity of care and communication with hospice providers through education of the facility policy on advance directives and verification of required documents prior to admission. --The Plan of Removal's Monitoring Section reflected the DON will complete a monthly reconciliation of code status on to ensure that those residents who have elected a Do Not Resuscitate status have an executed Out-of-Hospital Do Not Resuscitate in their individual chart located at the nurses' station. --The DON will monitor the results of the audits and report the results to the monthly Quality Assurance and Performance Improvements committee. --The DON and/or new Assistant Directors of Nursing will review code status of new admissions within 24 hours to assure those residents with an order for [REDACTED]. --The DON or Designee will conduct a 100% audit of code status for each resident on a monthly basis. For those residents who have chosen to execute an Out-of-Hospital Do Not Resuscitate, the form will be physically visualized by the Director of Nurse and or Assistant Directors of Nursing and placed in a hard chart located at the respective nurses station. The physician order [REDACTED]. Review of the In-Service Attendance Record Sheet, dated [DATE], revealed training was held with licensed nurses including RN E and LVN A, social worker and admissions director regarding resident code status, advance directives and verification of code status. Review of the facility's In-Service Attendance Record Sheet dated [DATE] through [DATE] for nursing staff including RN E and LVN A revealed training was conducted regarding code status, verification of orders and advance directives. Interviews with nursing staff from all three shifts regarding training and resident code status (AD, SW, LVN B, LVN C, LVN D, LVN A, LVN F, LVN G, LVN H) revealed all were able to identify residents on hospice and where to locate hospice information (binders stored behind nursing station). All stated they carried a list on them with all residents' code status. All stated that if a resident did not have a DNR the resident was considered a full code. All stated if a resident requested to go the hospital, the resident request was honored. Review of clinical records for five residents (Resident 2, 3, 4, 5 and 6) revealed all correct and current code status documentation was in place indicating whether resident was full code or DNR. On [DATE] at 12:11 PM, the Administrator was notified the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. Advance Directive and Code Status Report, dated [DATE], reflected 49 residents were identified as full code.

Based on interview and record review, the facility failed to provide each resident the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of six residents reviewed for DNR status. Resident #1, a resident with a full code status, was found without pulse or respiration on [DATE]. RN E failed to perform CPR and call 911. As a result, Resident #1 expired on [DATE]. On [DATE] an Immediate Jeopardy was identified as Past Noncompliance at a severity level of IJ due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. While the Immediate Jeopardy (IJ) was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated and a severity level of actual harm because the facility continued to monitor the effectiveness of the plan of removal. This failure placed 49 residents, whose code status was full code, at risk for not receiving CPR and other life-saving treatments Findings included: Review of Resident #1's closed clinical record reflected on the face sheet, [DATE], that the resident was a [AGE] year-old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The code status on the face sheet was listed as DNR. Further review of Resident #1's clinical record provided no evidence of a DNR. Review of Resident #1's computer generated Physician order [REDACTED]. Review of the facility Admission Agreement for Resident #1, dated [DATE], and executed by her family member on [DATE], revealed it did not acknowledge DNR identification was provided to the facility. A copy of the living will was not provided to the facility at the time of admission. Review of Resident #1's MDS assessment, dated [DATE], revealed she had moderate cognitive impairment and received hospice services. Review of Resident #1's care plan generated on [DATE] with problem onset dated [DATE] revealed she was alert and oriented X3 (describes a resident who is awake and oriented to who they are, where they are and date and time of recent events) with some forgetfulness, and the resident would be informed of her right to complete advance directives to direct her medical care. The Resident's desires will be honored. Review of Resident #1's Social Service History on Admission, dated [DATE] (sic) at 4:51 PM and completed by the SW, reflected advance directives were reviewed with Resident #1. The resident did not have advance directives in place. Resident #1 was able to make herself understood and understood others. Interview with the SW on [DATE] at 10:50 AM revealed she did not discuss code status with Resident #1 because the code status was already in the computer as DNR. The SW stated Resident #1 was able to make her own decisions. Review of Resident #1's nurse's notes revealed the following: [DATE] at 3:30 PM by LVN A - resident's family member called the facility and stated the resident was coughing and had pneumonia. The nurse went to the resident's room and observed resident lying in bed. The resident verbalized called her husband to call 911 to carry her to the hospital because she was coughing and had pneumonia. The resident was alert and oriented X3 but forgetful. Unproductive cough noted. Rales (also known as crackles which can be a sign of [MEDICAL CONDITION] or pneumonia in the elderly) to bilateral lung medial to lower lobes noted. [DATE] at 3:47 PM by RN E - hospice notified. [DATE] at 6:36 PM by LVN A - hospice nurse at facility, completed assessment. New order received for [MEDICATION NAME] 0.5mg tabs PRN for anxiety and agitation. Resident and responsible party notified. [DATE] at 8:42 PM by LVN A - resident observed in fowler's position (head elevated at a 45 degree angle to promote oxygenation), head to right side. Called the resident's name twice, but resident unresponsive. Unable to obtain vital signs. Notified facility supervisor RN E. [DATE] at 8:45 PM by RN E - resident observed unresponsive. Code status on face sheet DNR. Hospice notified. Hospice on call staff instructed staff not to initiate CPR and CPR is not and should never be performed on their client. Nurse informed hospice would be sending a nurse to pronounce resident. [DATE] at 8:56 PM by RN E - hospice nurse arrived and restated CPR would not be performed on their client. Hospice nurse assessed and pronounced resident. Hospice nurse notified family. [DATE] at 9:30 PM by LVN A - hospice nurse here to assess resident. Hospice notified the family after dropping the phone, the hospice said, it seems the family is not ready, because the son is telling (sic) her to drop the phone and go start CPR. [DATE] at 9:35 PM by RN E - resident's family member called 911, resident was transported to the hospital per family's request. Attempts were made to contact RN E, but without success. Interview with LVN A on [DATE] at 3:06 PM revealed she was the nurse on duty when Resident #1 expired. LVN A stated Resident #1's family member spoke with weekend supervisor stating resident wanted to go to the hospital. LVN A stated she did not remember if Resident #1 voiced wanting to go the hospital. LVN A revealed she went to the resident's room to complete an assessment. She remembered Resident #1 was agitated. LVN A stated she notified the hospice nurse who came to assess the resident and administered medication and notified the family. LVN A revealed she did not find an order in the paper chart indicating Resident #1 was a DNR. She stated the only order regarding code status was the DNR listed in the computer chart. Review of the facility's Provider Investigation Report, dated [DATE], revealed the facility reported Resident #1 was found unresponsive in her room on [DATE]. RN E assessed the resident and notified hospice who pronounced her death. CPR was not initiated. DNR was noted in electronic chart, but upon investigation the facility was unable to obtain the out of hospital DNR. Facility initiated audit of all resident charts and staff training regarding resident code status. Interview with the Administrator on [DATE] at 11:00 AM revealed the facility had a copy of Resident #1's History and Physical from the hospice company, signed by the attending physician, that reflected Resident #1 had a DNR. The Administrator stated the facility did not have a copy of the DNR. Review of Resident #1's hospice History and Physical, dated [DATE], reflected Resident #1 admitted to hospice with chronic [MEDICAL CONDITION]. It further reflected any additional changes to plan of care would be based upon clinical course in accordance with an out of hospital DNR which is executed on the chart. Interview with the DON on [DATE] at 8:15 AM revealed Resident #1 was only in the facility for 15 days. The ADON completed the admission. When the ADON completed the admission she wrote an order in the computer that Resident #1 was a DNR without actually seeing the DNR. The DON stated the ADON entered the order for the DNR based on what she was told by the hospice company. The DON explained that on the day of the incident, the hospice nurse was notified Resident #1 was unresponsive. The hospice nurse came to the facility and assessed the resident. The hospice nurse pronounced Resident #1's death and notified the family. The DON explained when the hospice nurse notified the family, the family stated Resident #1 was a full code not a DNR and demanded the hospice nurse begin CPR. The DON stated Resident #1's family called 911 and she was sent to the local hospital at which time she resident had already expired. The DON revealed following the incident it was discovered the facility did not have a DNR in place for Resident #1. The DON stated the ADON had already been terminated prior to the incident for another incident. Attempts were made to contact the ADON, but without success. Interview with the Administrator on [DATE] at 8:43 AM revealed facility staff never had the conversation with Resident #1's family regarding code status. The Administrator stated the hospice company never provided the facility with paperwork regarding Resident #1's code status. Interview with the AD on [DATE] at 9:40 AM revealed Resident #1's family never provided a DNR for the resident. The AD stated the family never stated whether Resident #1 was a full code or DNR. She stated she recalled the family member being concerned about the resident being on hospice and did not want her to be in and out of the hospital. The AD revealed she never received a clear answer from the family regarding Resident #1's advance directives. The AD explained families were provided information regarding advance directives at the time of admission. She stated if a family did not provide information regarding advance directives, she would follow up with the family with the help of the social worker. The AD revealed she did not follow up with Resident #1's family regarding advance directives. She stated she could not recall if she informed the nursing department regarding Resident #1's code status. The AD stated if she had the DNR paperwork she provided it to the nurses. Interview with the hospice team manager on [DATE] at 3:15 PM revealed Resident #1 never had a DNR in place. The hospice company did not have a DNR on file for Resident #1. She explained hospice services were provided to Resident #1 when she was in the community prior to admission to the facility. The hospice team manager stated she recalled the family did not want a DNR. She stated she was not sure where the facility obtained the information that Resident #1 was DNR. Review of Nursing Facility and Hospice Routine Care Services Agreement, dated [DATE], revealed the following: Coordination of Services: section 4.4 stated, Hospice shall provide the following information to Nursing Facility for each Hospice patient: (i) The most recent Hospice Plan of Care specific to each Hospice Patient; (ii) Hospice election form and any advance directives specific to Hospice Patient. Review of the facility's current hospitalization and Emergency Care policy and procedure for hospice residents in the facility dated February 2014 revealed, Emergency care should be consistent with the patient's stated wishes in advance directives and physician orders. Review of Social Services Policies and Procedures: Advance Directives, dated [DATE], revealed the following: Do-Not-Resuscitate (DNR) Identification and/or Orders: 1) The proper DNR consent form must be obtained and signed by the patient/resident indicating their wishes. If the resident wishes to be a DNR the decision must be clearly and concisely documented in resident's chart. The executed DNR must be provided in the resident's medical record. The Director of Nursing or designee reviews the medical record to verify DNR documentation is complete is accordance with policy. The Director of Nursing or designee will establish a system to alert direct care staff regarding a resident's CPR status. Review of the facility's current Policy and State Requirement for Advance Directives dated [DATE] revealed Absent any appropriate DNR Order/Identification, the facility staff will respond to medical emergencies with CPR measures and a Full Code will be instituted. On [DATE] at 11:33 AM, the Administrator was notified it was determined these failures placed Resident #1 and other residents in an IJ situation from [DATE] through [DATE]. The Plan of Removal was accepted [DATE] at 12:11 PM. The Plan reflected the following: --Monthly the DON and Administrator will ensure Hospice companies have a binder for each resident receiving hospice services at the respective nurses' station. The Administrator and DON will ensure the binder has the following items to include: Demographic Sheet, Code Status, Power of Attorney documents, Plan of Care, Nurse Aide notes, Nurse notes, and other service notes. --On [DATE], DON completed a 100% audit of code status for each resident and the physician order [REDACTED]. The audit revealed that all residents with an order for [REDACTED]. No negative findings were noted. --In-Service/Training Completed: Admission staff, licensed nurses, and social workers were reeducated regarding policies relating to advanced directives by the DON starting on [DATE] through [DATE]. --On [DATE], Regional Nurse will provide education to the DON, Admissions Director and Social Services Director regarding policies related to advance directives. On [DATE], education will be initiated with all Direct Care Staff by the Director of Nursing and Assistant Directors of Nursing to include appropriate response if a resident is found unresponsive. Staff were tested by verbal question and answer by the Director of Nursing and thereafter random verbal question and answer. --The Facility requested that Hospice educate staff regarding the requirement of nursing facilities in relation to the code status of residents being housed in a facility under their care to include: documentation of end-of-life discussions to be included in the Facility chart and the need for an executed Out-of-Hospital Do Not Resuscitate if the resident requests no Cardio-pulmonary Resuscitation in the event of [MEDICAL CONDITION]. The facility will ensure continuity of care and communication with hospice providers through education of the facility policy on advance directives and verification of required documents prior to admission. --The Plan of Removal's Monitoring Section reflected the DON will complete a monthly reconciliation of code status on to ensure that those residents who have elected a Do Not Resuscitate status have an executed Out-of-Hospital Do Not Resuscitate in their individual chart located at the nurses' station. --The DON will monitor the results of the audits and report the results to the monthly Quality Assurance and Performance Improvements committee. --The DON and/or new Assistant Directors of Nursing will review code status of new admissions within 24 hours to assure those residents with an order for [REDACTED]. --The DON or Designee will conduct a 100% audit of code status for each resident on a monthly basis. For those residents who have chosen to execute an Out-of-Hospital Do Not Resuscitate, the form will be physically visualized by the Director of Nurse and or Assistant Directors of Nursing and placed in a hard chart located at the respective nurses station. The physician order [REDACTED]. Review of the In-Service Attendance Record Sheet, dated [DATE], revealed training was held with licensed nurses including RN E and LVN A, social worker and admissions director regarding resident code status, advance directives and verification of code status. Review of the facility's In-Service Attendance Record Sheet dated [DATE] through [DATE] for nursing staff including RN E and LVN A revealed training was conducted regarding code status, verification of orders and advance directives. Interviews with nursing staff from all three shifts regarding training and resident code status (AD, SW, LVN B, LVN C, LVN D, LVN A, LVN F, LVN G, LVN H) revealed all were able to identify residents on hospice and where to locate hospice information (binders stored behind nursing station). All stated they carried a list on them with all residents' code status. All stated that if a resident did not have a DNR the resident was considered a full code. All stated if a resident requested to go the hospital, the resident request was honored. Review of clinical records for five residents (Resident 2, 3, 4, 5 and 6) revealed all correct and current code status documentation was in place indicating whether resident was full code or DNR. On [DATE] at 12:11 PM, the Administrator was notified the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still in-servicing staff and monitoring the effectiveness of the Plan of Removal. Advance Directive and Code Status Report, dated [DATE], reflected 49 residents were identified as full code.