Every finding on record at The Renaissance at Kessler Park

Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so who endanger the health and safety of resident or other resident for 2 of 5 residents (Resident #1 and Resident #2) reviewed for resident rights. The facility failed to ensure Resident #1 and Resident #2's call light was within reach of each resident for assistance. This failure could place residents at risk of needs not being met or delay in care in case of an emergency. Findings included: Record review of Resident #1's quarterly MDS dated [DATE] revealed; Resident #1 was a 66- year-old male, admitted to the facility on [DATE]. Active diagnoses included Hemiplegia (medical condition that causes paralysis on one side of the body), aphasia (brain disorder that affects how you speak, write, read, and understand language). He had a BIMS score of 02 which indicated cognition was severely impaired. Functional abilities; Required Substantial/maximal assistance with Roll left and right, sit to lying, lying to sitting on side or bed. Resident was dependent on helper for doing ALL of the effort for sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Functional Ability (Mobility) used a manual wheelchair. Record Review of resident #2's quarterly MDS 07/10/2026 revealed; Resident #2 was a 65- year-old male admitted to the facility on [DATE] with a BIMS score of 10 (moderate cognitive impairment). Active diagnoses included aphasia (brain disorder that affects how you speak, write, read, and understand language) Hemiplegia (medical condition that causes paralysis on one side of the body). Functional abilities; partial/moderate assistance with roll left and right, sit to lying, lying to sitting on side of bed. Substantial/maximal assistance sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Functional mobility manual wheelchair. Record review of Resident #1's Care plan revealed; Focus-Communication(impaired): Interventions-Ensure/provide a safe environment: Call light in reach.Focus- Resident #1 had an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner; Interventions- Ensure/provide a safe environment: call light in reach, adequate low glare light, Bed in lowest position and wheels locked. Avoid isolation.Focus- Falls had the potential for falls; Interventions- Place the resident's call light within reach and encourage the resident to use it for assistance as needed. Record review of Resident #2's care plan revealed; Communication (Impaired); interventions- Ensure/provide a safe environment; call light in reach, adequate low glare light, bed in lowest position and wheels locked. Avoid isolation.Focus- Resident #2 had an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Interventions- Ensure/provide a safe environment; call light in reach. Focus- Resident #2 had the potential for falls and had an actual fall related to lack of coordination, functional quadriplegia, CVA (Cerebrovascular accident) with R sided weakness, and chronic pain. Intervention; Place the resident's call light was within reach and encourage the resident to use it for assistance as needed. During an observation on 08/18/2026 at 10:54 AM, Resident #1 was lying on his back in bed B, observed a dark blueish bruise on the outside corner of left eye. Bed in the lowest position with right side of bed pushed against the wall and fall mat on the floor left side of the bed. Call light was observed on the floor behind the head of the bed. Resident #1 would verbally call out Help me, Help me. Able to move right arm and pulled the covers off to reveal his right foot. During an observation on 08/18/2026 at 10:57 AM, Resident #2 was lying in Bed A with his head of bed elevated. When prompted to push call light, Resident #2 shifted in bed looking for call light. He attempted to reach for the call light that was secured by a metal clap on the wall calendar next to Bed A. During an observation/interview 08/18/2026 at 11:05 AM, the DON stated Resident #1 would call out Help me and staff would go into the room to assist him with his needs. Residents #1 and #2 are frequently rounded on based on communication. The DON entered Resident #1's room and assisted Resident #1 with his socks, the DON then exited the room. Both Resident #1 and #2 continued to have call lights out of reach. Durning an observation/interview on 08/ 18/2026 at 11:12 AM, LVN A stated Resident #2 was able to use his call light, and both residents should have their call light within reach if they need assistance. Observation revealed prior to exiting the room call lights were placed within reach of each resident. During an interview on 08/18/2026 at 11:15 am, LVN B stated it was important for residents to have their call lights within reach because of resident safety. She stated the risk would be resident's needs would not be met. During an interview on 08/18/2026 at 11:19 AM, the Medical Records Staff stated she was also a CNA, and she helped out on the floor to provide direct care and catch the call light. She stated the call lights let staff know when a resident had needs. She stated call lights should be in reach for the resident to use. She stated the risk of call lights not being within reach is resident safety and needs are not met. During a second interview on 08/18/2026 at 2:48 PM, the DON revealed it was important that the call lights be in reach of each resident for their safety, the aides will make frequent rounds for residents that may not be able to cognitively understand how to use the call lights. The risk is that their needs are not being met. Record review of Call light policy was requested by email on 08/18/2026 at 1:45 PM and second request at 3:13 PM.

Based on observation, interview, and record review, the facility failed treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 5 residents (Resident#1) reviewed for resident rights. CNA A failed to feed Resident #1 in a respectful manner on 07/07/26 when she stood over Resident#1 while feeding him and talking with staff in the dining room. This failure could place residents at risk of decline of dignity. Findings included: Findings included: Record review of Resident#1's face sheet dated 07/07/26 reflected, Resident#1 was a [AGE] year old male, admitted on [DATE] and was diagnosed with Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery (This condition refers to a stroke caused by a blockage or narrowing in the left middle cerebral artery, leading to brain tissue death in its distribution area), unspecified sequelae of cerebral infarction (residual effects that persist after an ischemic stroke, affecting neurological, motor, cognitive, and sensory functions.)affecting right dominant side, hemiplegia (partial weakness on one side of the body) and hemiparesis (severe or complete paralysis), dysarthria following cerebral infarction (speech disorder that often occurs after a cerebral infarction, affecting the ability to articulate words clearly due to muscle weakness or coordination issues) and dysphagia following cerebral infarction (swallowing disorder that can lead to serious complications such as aspiration pneumonia, malnutrition). Record review of Resident#1's MDS, printed 07/07/26 reflected, Resident#1 had a BIMS of 99, which indicated he was not able to participate. Record review of Resident#1's care plan, undated, reflected Resident#1 had an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. Goals reflected, Resident#1 would participate to the best of their ability and maintain current level of functioning. Interventions reflected, eating: supervision or touching assistance. During an observation on 07/07/26 at 7:55 A.M., CNA A stood over Resident#1 and fed him egg and talked with other staff in the dining room. During an interview on 07/07/26 at 9:22 A.M., CNA B stated staff are supposed to sit down and feed residents for dignity and it was good for staff to talk to the residents at eye level. CNA B stated this could also prevent the resident from choking. Attempted to interview Resident#1 on 07/07/26 at 8:20 A.M., who did not respond back. During an interview on 07/07/26 at 9:30 A.M., CNA A stated staff are supposed to sit down and feed the residents at eye level. CNA A stated this was a respect and dignity concern because she would not want someone standing over her talking or feeding her. CNA A stated she was walked through the dining area and gave Resident#1 a spoon of his eggs and she was headed to her hall. CNA A stated she was not assigned the dining hall and rushed to get back to her hall that is why she did not sit down ro feed Resident #1. During an interview on 07/07/26 at 12:24 P.M., ADON stated staff should be seated and feed the residents at eye level. ADON stated this was a dignity concern because no one would like someone standing over them. ADON stated she was responsible for in servicing staff and she would do so. Record review of facility policy, dated 2/2016, titled Resident Rights reflected, .The resident has the right to a dignified existence.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 (Kitchen #1) reviewed for food safety in facility's only kitchen. The facility failed to ensure leftover food was labeled, dated, and stored properly in the refrigerator.The facility failed to ensure personal cups were kept in the designated area and not on the prep table. These failures place residents at risk of cross-contamination and foodborne illnesses.Findings included:During an observation on 05/12/26 at 7:30 AM, of the prep table, reflected meatloaf on a plate covered with saran wrap next to a disposable cup containing water and ice. During an interview on 05/12/26 at 8:50 AM, Dietary Aide A stated the plate on the table contained meatloaf. She stated the plate should have been thrown in the trash, but it was on the prep table all night. Dietary A stated staff were not allowed to work overtime, and she was not able to load any more dishes after 7:15 PM, to wash them after the previous night's meal. She stated she noticed the plate on the prep table when she left work the night before. Dietary A stated the person responsible for leaving the meatloaf on the prep table last night was one of the new cooks. Dietary A stated the intermediate person was not at work during the day of the interview on 05/12/26. Dietary Aide A stated the person responsible for not labeling, dating, and storing the meatloaf properly was the cook because they were supposed to put away all food at the end of the night, as well as turn in all food trays to her. Dietary Aide A stated her duties were to wash dishes, and sometimes she prepared drinks and served them to the residents. Dietary Aide A stated the risk of the meatloaf not being labeled, dated, and stored properly was that bacteria from insects and contamination could affect food served from the prep table. Dietary Aide A stated she did not notice the disposable cup on the prep table, but it should not have been there. She stated that if staff had personal drinks, they were supposed to carry them or place them in the area where their personal items belonged. Dietary Aide A stated all personal items were supposed to be placed in the office on the shelf in the corner. She stated the risk of staff leaving drinks on the prep table was cross-contamination, someone accidentally taking a sip, or the person having been sick, which could have led to spreading illness and affecting the resident's food. During an interview on 05/12/26 at 9:13 AM, [NAME] B stated she worked in the kitchen for 8 months. She stated her duties were to cook during the evening shift. [NAME] B stated she worked the night before and noticed the meatloaf on the prep table before she left. [NAME] B stated the meatloaf was an extra order for a resident, and the kitchen staff, who stayed later were supposed to deliver it, but she guessed they did not, because when she returned to work it was still on the prep table. [NAME] B stated the meatloaf was in the line for delivery, but she was not able to say why it was never delivered because she was not sure what happened after she left. She stated she was not sure which resident the meatloaf was intended for. [NAME] B stated it was not okay for the meatloaf to remain on the prep table all night and stated all leftover food was supposed to be discarded at the end of the night. She stated she had no way of knowing whether it had been left out on the prep table overnight. [NAME] B stated she was usually the person who cleaned up at the end of the night and ensured all food was put away or discarded. [NAME] B stated that if there was leftover food, she usually made sure it was labeled and dated with a use-by date and then placed in the refrigerator. [NAME] B stated the risk of the meatloaf not being labeled and dated with a use-by date was contamination if it was not properly contained. [NAME] B stated the person responsible for placing the disposable cup on the prep table was the new employee, [NAME] D, and that this was the second time she had placed her drinking cup on the prep table. [NAME] B stated she had tried explaining to [NAME] D where her drinking cup was supposed to go, but she did not think [NAME] D fully understood her because she did not speak English fluently and [NAME] B did not want to be harsh or rude to her. She stated the risk of the drinking cup being on the prep table was that it could contain bacteria and could spill onto food being prepared on the prep table. [NAME] B stated personal drinks were supposed to be placed in the manager's office on the shelf where kitchen staff's personal belongings were supposed to go. During an interview on 05/12/26 at 9:37 AM, Dietary Aide C stated she worked in the kitchen for one week. Dietary Aide C stated she was not sure why the meatloaf was on the prep table. She stated she worked in the morning but was not there for the evening shift. Dietary Aide C stated she thought the meatloaf belonged to one of the kitchen staff. Dietary Aide C stated she did not see the meatloaf on the table when she came in that morning and thought one of the kitchen staff was going to eat it. She stated the meatloaf should have been labeled and dated with a use-by date. Dietary Aide C stated she was told that if there was leftover food, it was supposed to be discarded. She stated the risk of the meatloaf not being labeled, dated, and stored properly was contamination. Dietary Aide C stated she was not sure who placed the drinking cup on the prep table, and she stated it was not okay for the drinking cup to be on the prep table. Dietary Aide C stated she was not sure where personal drinking cups were supposed to be placed, but stated there was a designated place, and she was just unsure where it was. Dietary Aide C stated personal cups were not supposed to be on the prep table and the risk was contamination. During an interview on 05/12/26 at 9:55 AM, [NAME] D stated she worked in the kitchen since 05/07/26. [NAME] D stated the drinking cup on the prep table was hers. [NAME] D stated staff were not supposed to have personal cups on the prep table. [NAME] D stated she was not sure where personal cups were supposed to be placed. [NAME] D stated it was her third day, and the kitchen staff had not told. [NAME] D stated the risk of the drinking cup being placed on the prep table was that it could spill into a resident's food and cause contamination. [NAME] D stated she saw Dietary Aide C put the meatloaf on the prep table earlier that morning. [NAME] D stated there should have been a label and use-by date on the meatloaf. [NAME] D stated that if she had leftover food, she would usually place a label and use-by date on the food. [NAME] D stated with the meatloaf not being labeled or dated with a use-by date, staff would not know whether it was old. [NAME] D stated the risk of the meatloaf not being labeled or dated with a use-by date was that it could have been old or could have made a resident sick if consumed. [NAME] D stated she had not received any training prior to being hired. During an interview on 05/12/26 at 10:07 AM, the temporary Dietary Manager stated she was filling in for the Dietary Manager. She stated it was her first day filling in. The temporary Dietary Manager stated she could not say for sure why [NAME] D had her drinking cup on the prep table. The temporary Dietary Manager stated staff were told they had a designated area where all personal belongings were supposed to go. The temporary Dietary Manager stated the specific area where staff were supposed to place their drinks was near the office, and staff could also eat in that area, so they did not have to go all the way to the break room. The temporary Dietary Manager stated the risk of the drinking cup being placed on the prep table was that saliva from the cup could get into a resident's food. The temporary Dietary Manager stated if a staff member did not wash their hands prior to placing the cup on the prep table, another risk was contamination of food. The temporary Dietary Manager stated all items in the kitchen were supposed to be labeled and dated with a use-by date, regardless of whether the item had just come off the vendor truck. The temporary Dietary Manager stated she was not aware there was food on the prep table and once she went into the kitchen she did not see anything on the prep table but stated she just arrived at work. The temporary Dietary Manager stated the risk of the meatloaf not being labeled and dated with a use-by date was that staff would not know how long the food was there and it could have been in the temperature danger zone, creating bacterial growth. During an interview on 05/12/26 at 4:16 PM, the Administrator stated the expectation of kitchen staff was to discard all leftover food at the end of the night and the meatloaf should not have remained on the prep table all night and should have been refrigerated. The Administrator stated the meatloaf should also have had a label and use-by date on it. The Administrator stated the risk of the meatloaf not having a label and use-by date was that it could have caused foodborne illness if consumed by a resident. The Administrator stated staff were expected not to eat or drink on the food line while preparing food in the kitchen. The Administrator stated if staff had food or drinks, they were supposed to be placed in the break room, and the risk of the drinking cup being placed on the prep table was that it could have caused illness in a resident. In an email on 05/21/2026 at 6:16 PM, the Administrator responded to an email regarding an email on how the kitchen staff are trained. The administrator emailed the permanent Dietary Manager regarding the trainings, and she forwarded his response reflected the following Aramark puts new employees with current employees for 4 days for training on menu, cooking instructions, ect. After 4 days they are then by themselves but still open for any questions they have. As well as they get training on for their food handler's certificate. Record Review of Dietary Aide C's employee record indicated she was hired on 08/14/25, a food handler's license, and a background check. Employee file did not have any training. Record Review of [NAME] D's employee record indicated she was hired on 05/05/26, an expired food handler's license, and a background check. [NAME] D's employee record did not have any trainings. Record review of the facility's policy titled, Food Safety and Sanitation Plan, dated 10/24/22, reflected, in part:11. Ready-to-Eat PHF Date MarkingReady-to-eat food would be clearly labeled using a calendar date to indicate the date the product was prepared and the date the product must be used or discarded.Commercially prepared PHF/TCS food products would be clearly labeled using a calendar date to indicate the date the product was opened and the date by which the product must be discarded. The use-by date must not have exceeded the manufacturer's established use-by date. During an interview on 05/12/26 at 4:30 PM, the DON stated there was not a policy for personal drinks or food for kitchen staff.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for 1(Resident #1) of 3 residents reviewed.The facility failed to update Resident #1's care plan to reflect a history of exit seeking behaviors.This failure could place residents at risk of not receiving proper care.Findings included:Record review of Resident #1's face sheet, 05/12/26, reflected an [AGE] year old male, admitted [DATE], diagnosed with Schizophrenia, unspecified, (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations ,delusions and disorganized thinking), Unspecified Dementia, moderate with other behavioral disturbance (progressive decline in cognitive function affecting memory, thinking and behavior, without a clearly identified subtype). Record review of Resident #1's face sheet reflected Resident#1 had a RP.Record review of Resident #1's elopement assessment, 01/16/26, revealed Resident #1 was assessed on 01/16/26 and was determined to be at 0.0 score, indicated a elopement low risk, which meant no plan of care needed.Record review of Resident #1's admission MDS assessment, dated 01/23/26, reflected Resident #1 had a BIMS of 10, indicated moderate cognitive impairment.Record review of Resident #1 Discharge MDS, dated [DATE] reflected, Resident#1 wandering-presence and frequency has the resident wandered? coded at behavior not exhibited. Resident#1 had a BIMS of 10, indicated moderate cognitive impairment.Record review of Resident#1 progress notes, dated 03/26/26 reflected:Progress notes dated 03/26/26 reflected, On 02/12/2026, this SW and DON met with [RP] to discuss exit-seeking behavior. Pt attempted to go to doors and was easily redirected. Pt was moved to a room on hallway away from doors and did not make further attempts to go to doors for several weeks. Pt was previously in secure unit at [local facility], but pt was removed from unit seven years prior to d/c to this facility. Pt was moved, as behavior maybe be related to adjusting to new facility. Written by SW.Record review of Resident #1's care plan, dated 03/27/26, reflected no record of history of elopement. On 03/21/26 Resident was observed standing up and pushing an exit door open, causing the alarm to go off. An aide nearby observed all this and ran after the resident and re-directed the resident back into the facility. Resident was then placed on 1:1 supervision until secure unit placement. DON, family member have been notified written by LVN D During an interview on 05/12/26 at 3:40 PM, the DON stated the elopement assessment was done when a resident left the facility and not for exit seeking behaviors. The DON stated the facility was focused on getting the resident transferred from the facility and the care plan was not updated. The DON stated the care plan was important so that everyone who provided resident care would know level o f care the resident needed./ During an interview on 05/12/26 at 4:20 PM, the Administrator stated the care plan needed to be person centered specific to the resident's care. The Administrator stated it was important to update the care plan to make sure residents received the proper care. The Administrator stated the head of nursing was responsible for care plan updates. Record review of facility policy titled, Comprehensive Care Plan, dated 02/10/21, reflected, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.,,6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed.

Based on interviews and record reviews, the facility failed to (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 3 residents reviewed for discharge or transfer.The facility failed to provide written notification to Resident #1's RP and Long-term care Ombudsmen. This failure could place residents at risk of improper transfer from the facility.Findings included:Findings included:Record review of Resident #1's face sheet, 05/12/26, reflected an [AGE] year old male, admitted [DATE], diagnosed with Schizophrenia, unspecified, (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations ,delusions and disorganized thinking), Unspecified Dementia, moderate with other behavioral disturbance (progressive decline in cognitive function affecting memory, thinking and behavior, without a clearly identified subtype). Record review of Resident #1's face sheet reflected Resident#1 had a RP.Record review of Resident #1's elopement assessment, 01/16/26, revealed Resident #1 was assessed on 01/16/26 and was determined to be at 0.0 score, indicated a elopement low risk, which meant no plan of care needed.Record review of Resident #1's admission MDS assessment, dated 01/23/26, reflected Resident #1 had a BIMS of 10, indicated moderate cognitive impairment. Record review of Resident #1 Discharge MDS, dated [DATE] reflected, Resident#1 wandering-presence and frequency has the resident wandered? coded at behavior not exhibited. Resident#1 had a BIMS of 10, indicated moderate cognitive impairment.Record review of Resident #1's progress notes, dated 03/26/26 and written by the DON, reflected, During the conversation on 3/25/26, writer informed resident's RP the resident was being transported to [local facility] with the MDS nurse and Wound care nurse present during the conversation. Record review of Resident #1's progress notes, dated 03/26/26 and written by the SW, reflected, On 02/12/2026, this SW and DON met with [RP] to discuss exit-seeking behavior. Pt attempted to go to doors and was easily redirected. Pt was moved to a room on hallway away from doors and did not make further attempts to go to doors for several weeks. Pt was previously in secure unit at [local facility], but pt was removed from unit seven years prior to d/c to this facility. Pt was moved, as behavior maybe be related to adjusting to new facility. RP was agreeable. When pt displayed exit seeking behaviors again, SW notified RP that pt attempted to exit and now pt will need to d/c to secure unit. RP confirmed understanding and requested a SNF close to RP, zip code .SW tried several facilities and RP not agreeable to any [specific locations. On 03/23/2026, pt requested this SW refer pt to [ local long term care facility].On morning of 03/25/2026, SW informed pt accepted by[local facility]. Liaison [from other facility] notified RP of acceptance and transfer, per SW request. SW f/u and confirmed liaison [from other facility] spoke with pt several times. DON spoke with pt as well, as this SW was out of office. Evening of 03/25/2026, SW informed by liaison that RP stating she was unaware of transfer and liaison was highly confused. Morning of 03/26/2026, SW informed RP wants pt transferred to [Another facility]. At 12:30 pm, this facility's liaison reports [RP] no longer wants to transfer pt and wants pt to remain at [local facility] Nothing else to note.Record review of Resident #1's care plan, dated 03/27/26, reflected no record of history of elopement.Record review of Resident#1 census, undated, reflected on 1/16/26 Resident#1 obtained a room at the facility. On 02/12/26 Resident#1 was transferred rooms. On 3/25/26 Resident was had a stop billing. During a telephone interview on 05/12/26 at 8:35 AM, Resident#1's RP stated she did not receive a notification in writing about Resident #1 being discharged . Resident #1's RP stated she did not want the resident to be transferred until she looked at the other facility. Resident #1's RP stated she received a call on 03/25/26 from another facility that said Resident #1 was transferred. During an interview on 05/12/26 at 9:30 AM, the SW stated Resident #1 was exit seeking on 02/12/26. Resident #1 was moved to a room away from the door. The SW stated on 0321/26, the resident pushed on the exit door, the alarm sounded and Resident #1 attempted to leave. The SW stated Resident #1 was placed on 1:1 supervision (one staff member is assigned to provide constant and continuous oversight to one individual, ensuring their safety and well-being) The Social Worker stated she communicated with Resident #1's family member by phone. Resident #1 was denied by some local facilities because the facilities did not have a secure unit or space. The SW stated a local facility accepted Resident #1 on date 03/25/26 and he was transferred on 03/25/26. The SW stated she was confused why Resident #1's RP was upset about the transfer because initially she was ok with the transfer and planned to visit the new facility on before the resident transferred/ The SW could not recall if she told the facility ombudsmen and/or volunteer. The SW stated she was responsible for assisting with finding placements and discharges. During a telephone interview on 05/12/26 at 3:44 PM, the facility ombudsmen stated he was not notified of Resident #1's transfer to another facility.During a telephone interview on 05/12/26 at 4:14 PM, the facility ombudsmen stated the volunteer ombudsmen had not been notified of Resident #1's transfer to another facility.During an interview on 05/15/26 at 4:16 PM, the Administrator stated the SW would email the ombudsmen about the resident being discharged . The Administrator checked her emails, and she could not find a email from the SW to ombudsmen about Resident #1 transfer. The Administrator stated she expected the SW to follow the policy and procedures for proper discharge and transfers of the residents.Record review of the facility policy titled, Transfer and Discharge (including AMA) (Against Medical Advice), revised 09/01/23, reflected, non-emergency transfers or discharges initiated by the facility. Return not anticipated. Document the reasons for the transfer or discharge in the residence, Medical records and in the case of necessity for the residence. Welfare and the resident needs cannot be met in the facility document. The specific resident needs that cannot be met. Facility attempts to meet the residents needs in the service available at the receiving facility to meet the needs document. Any danger to the health or safety of the resident or other individuals that failure to transfer or discharges would pose. At least 30 days before the resident transferred or discharged , the social Services director will notify the resident and the residence representative and writing in a language and manner that they understand. This time frame does not apply if the resident was has not resided in the facility for 30 days.d. A copy of the notice shall be provided to a representative of the office of the State Long-Term Care Ombudsmen.

Based on observation, 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 #10) of 4 residents reviewed for pharmaceutical services. The facility failed to ensure a package of Resident #10's Morphine Sulfate and MS Contin were immediately delivered to facility nursing staff by CNA A. This failure placed all 60 residents at the facility at risk of not receiving the therapy and/or care per provider orders to allow her to attain or maintain her highest practicable physical, mental, and psychosocial well-being.Findings included: Record review of Resident #10's Face Sheet revealed she was an [AGE] year-old resident admitted to the facility on [DATE] for long term care. Relevant diagnoses included end stage heart disease (irreversible condition where the heart cannot pump effectively to meet the body's needs,) dementia (decline in cognitive abilities,) and major depressive disorder (persistent feelings of sadness.) Record review of Resident #10's MDS assessment1, dated 07/20/2025, revealed she was cognitively intact with a BIMS score of 14. Resident #10 required partial/moderate assistance from staff with personal hygiene and was fully dependent upon staff with shower/baths, toileting, and lower body dressing. Record review of Resident #10's Physician Orders on 09/25/2025 at 10:45 am revealed:Admit to [HOSPICE] for End Stage Heart Disease with a start date of 09/03/2025. Morphine Sulfate (Concentrate) Oral Solution 10 MG/5 ML . Give 0.25 ml by mouth every 3 hours as needed for shortness of breath . with a start date of 02/28/2023. MS Contin Oral Tablet Extended Release 15 MG . Give 1 tablet by mouth two times a day for pain . with a start date of 01/14/2025. Record review of Resident #10's Comprehensive Care Plan dated 10/31/2024 revealed Resident has a terminal illness and is receiving hospice care . Dignity will be maintained, and the resident will be kept comfortable and pain free . In an interview and observation with Resident #10 on 09/23/2025 at 12:14 PM, she was resting in her bed. She reported she was clean, dressed, and was in no distress. She reported sufficient care and that she was recently placed on hospice for her terminal illness. She stated she recently received a package of her pain medication in the mail and after she opened the package, she later gave a staff member the package and asked her to give it to her nurse . She did not recall if she informed the staff that the package was her medication. She denied any incidents of her experiencing unmanageable pain and denied the facility failed to provide her with pain medication upon her request. In an interview with the facility's ADON on 09/25/2025 at 10:00 AM, she stated medications at the facility were typically delivered via the pharmacy, and only a nurse or medication aide can sign for the medication upon receipt. The hospice company for Resident #10 delivered her medications separately via [PARCEL COMPANY] and did not inform the facility prior, so they were not able to anticipate the delivery. She stated this delivery was addressed to the resident directly and delivered after hours. She stated the package was not labeled as medication and was taken to the resident's room like a normal package or mail delivery. She stated that the resident opened the package and asked CNA A to bring it to her nurse at that time. She stated CNA A took the package not knowing what it contained, left the room, and placed it on a linen cart nearby. CNA A then assisted another resident with care and forgot about it. She stated this was the last time the package was seen . She stated the facility ceased working with the specific hospice company to prevent this from happening in the future. Additionally, she in-serviced all staff on misappropriation of property and did a verbal counseling for CNA A for her conduct. Attempts to interview CNA A on 09/25/2025 at 10:40 and 11:18 AM were unsuccessful. Attempts to interview Resident #10's hospice company at 09/25/2025 at 11:17 and 09/26/2025 at 11:03 AM were unsuccessful. In an interview with the facility's Administrator on 09/25/2025 at 12:28 PM, she revealed medications at the facility were typically delivered via the pharmacy and brought straight back to the nurse's station. The hospice company for Resident #10 delivered her medications separately via [PARCEL COMPANY] and did not inform the facility prior. She stated initially she was not even sure what was in the package. She stated it was not considered a diversion ; she considered it a resident package that went missing after it was delivered to the resident. She stated her expectations were for all medications to go through pharmacy delivery so the appropriate staff can respond accordingly per facility policy. She stated she has terminated the contract with Resident #10's previous hospice company, moving forward, to prevent this from occurring again. She stated once she discovered Resident #10's medications were missing; she filed a police report with local law enforcement and was able to re-order the medications promptly. She stated she had Resident #10's medications already on hand, so the resident did not go without or miss any of her medications due to this incident. Record review of CNA A's Associate Disciplinary Memorandum dated 08/25/2025 revealed verbal counseling, and Employee failed to deliver package to nurse resulting in missing package . with future directives of delivery to nurse immediately upon receiving a package. Record review of facility's In-Service Program Attendance Record dated 08/15/2025 revealed twenty-seven staff signatures from nursing, kitchen, and other support staff. Subject matter included Misappropriation of Property . Resident property should be handled with care and concern and placed appropriately for safekeeping. Record review of facility's policy, Drug Diversion Guidelines, rev. 10/24/2022, revealed:1. Do not sign for receipt of controlled substances until you have inspected the delivery from the pharmacy that all ordered medications have arrived.2. The narcotic count sheet should be signed and quantity received should be indicated.3. Medications should be put in storage areas immediately and not left at nurses station or on medication room counters.4. Controlled substances should be stored in a double locked compartment at times including discontinued and overstocked medications.5. A drug count must be done at each shift change and should be done whenever the keys to the narcotic storage areas are exchanged from one staff to another.6. ALL controlled substances should be counted including those in the lock box in the refrigerator and overstock narcotics in medication room.7. Access to refrigerator lock box and overstock narcotics in medication room should be limited.8. Signing the narcotic shift count sheet means you are accepting responsibility for the controlled substances. Therefore, do not sign unless you are certain that all of the controlled substances are present and have not been adulterated/tampered with or altered in any way. Record review of facility's policy, Policy and Procedures . Receiving Controlled Substances rev. 08/2020, 11. Only licensed personnel may receive controlled substances from the pharmacy courier. Procedures for receiving controlled substances include: a. A nurse signs for the medications, including the controlled substances, on the pharmacy delivery ticket and inspects the medications.b. If a discrepancy or dispensing error is identified for a controlled substance, the nurse must notify the pharmacy at point of delivery. The nurse should document description of discrepancy/error on delivery packing slip/manifest and refuse/reject delivery of the affected medication(s).c. The receiving nurse transfers medications and accompanying inventory sheets to an authorized nurse on the unit (if different than the nurse who received the medication) or in accordance with facility policy.d. Two nurses, and/or in accordance with facility policy, witness placement of the controlled substances in the secured compartment of the medication cart.e. Controlled substance inventory sheets are filed appropriately. A hard-bound log book, or in accordance with facility policy, is utilized to track the controlled substance from delivery to disposition. All discrepancies, suspected loss, and/or diversion of medications, irrespective of drug type or class, are immediately investigated and a report filed.Policies developed by the facility in accordance with local/state regulations may supersede the procedures outlined in this policy . II. Loss of Supply of Medication:1. The DON investigates the suspected loss and research all the records related to medication receipt, its use since receipt, and all persons involved with medication administration and the supply of medication and identifies the last known point in time that the medication was available. The pharmacy should be notified, and the pharmacy should verify that the medication was dispensed. A thorough search is conducted in all drug storage areas, the residents' room, and any other locations where medications may have been used/placed during medication administration in an attempt to locate any missing container or medication supply.2. If the supply cannot be found after a thorough investigation has been completed, a supply must be obtained for the resident.3. Document the loss and the investigation process. Notify the prescriber and family if doses have been missed and/or follow facility policy.4. If the loss involves a controlled substance, all the controlled drug accountability procedures and documentation should be reviewed and audited. If the audit reveals a particular individual or individuals who might be suspected of involvement with the loss, appropriate disciplinary actions are taken and deferred to human resource policies.5. Appropriate agencies, required by state and federal law, will be notified.

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 two (Resident #1 and Resident #2) of four residents reviewed for infection control. 1.LVN B, LVN D, and CNA A did not wear gowns for PPE for Resident #1 who was on EBP during incontinent care and linen change. 2. The facility did not keep Resident #1 and Resident #2 ' s feeding pump pole free of a brown, thick substance, and a sticky dirt substance on both the poles, and the floor under the poles, while using the poles to feed Resident #1 and Resident #2. These failures affected residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings included: Resident#1 Review of Resident #1 ' s face sheet, dated 06/18/25, reflected she was a [AGE] year-old woman, admitted on [DATE], with diagnoses of sepsis (the body responds to an infection by attacking the body ' s own organs), pneumonia (a lung infection), a pressure ulcer, dysphagia (an inability to swallow properly), stroke, and gastronomy status (use of a feeding tube inserted into the stomach). Review of Resident #1 ' s care plans reflected the following care plans: Focus: Enhanced Barrier Precautions; Date Initiated- 04/05/2024; Goal: infection control intervention designed to reduce transmission of multidrug-resistant organisms; Interventions: use of PPE on the anticipated exposure to blood, body fluids, secretions, or excretions. Record review of Resident #1 ' s Medication Administration Record for 06/01/25 through 06/18/25 reflected an order for Enhanced Barrier Precautions for wound care, and g-tube care. every shift for EBP -Start Date- 04/18/2024 The order was checked off for each applicable shift on those dates. During a continuous observation on 06/18/25 from 09:18 AM to 09:50 AM, Resident #1 was connected to a feeding pump that was attached to a dirty pole. The pole was dirty with yellow and brown sticky substances on the pole and on the floor under the pole. Continuous observations also revealed Resident #1 had signage over her bed that read: Gloves and gowns should be donned if any of the following activities were to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Perform hand sanitation before entering the room and prior to leaving the room. CNA A and LVN B started to provide incontinent care and linen change. Neither CNA A nor LVN B wore a gown for PPE for a resident on EBP during incontinent care and linen change. Observation on 06/18/25 at 09:50 AM revealed LVN D walked into Resident #1 ' s room while CNA A and LVN B provided incontinent care and linen change for Resident #1. LVN D did not put on a gown; she wore gloves and stated she was going to complete a head-to-toe skin assessment while the residents ' skin was exposed. CNA A asked LVN D to get him linen before she got started and handed her the bag that was used to throw the used wipes, soiled diaper, and used gloves. LVN D returned to Resident #1 ' s room after disposing of the trash bag and getting linen. LVN D did not put on a gown for EBP. Resident #1 reported that her skin was itchy and LVN D put lotion on both the residents ' upper thighs and arms. No gowns were observed during this observation in the room, or outside of the door to the room. The isolation cart was observed to be empty. During an interview with LVN B on 06/18/25 at 09:58 AM, she stated it was the responsibility of anyone who noticed the IV pole and pump were dirty to clean them. She said that she did not notice the status of Residents#1 ' s pole, and had she noticed she would have informed housekeeping to clean it. LVN B stated the facility was a professional building and if someone looked around in Resident #1 ' s room and saw the dirty pole they would say we are not following infection control. LVN B stated that she was aware of EBP, and she should have worn a gown during incontinence care and linen change for Resident #1. LVN B said she forgot to wear one. She said wearing a gown was for Infection control. In an interview with CNA A on 06/18/25 at 10:00 AM, he said there were no gowns in Resident #1 ' s room, and he forgot to tell the central supply person to restock. He said that he was overwhelmed by being watched to provide incontinent care and that he was more focused on doing it the correct way that he forgot to wear his gown. He said EBP was for residents with tubes including g-tube and staff were supposed to wear gowns during care. He said the risk was for infection. Resident#2 Review of Resident #2 ' s face sheet, dated 06/18/25, revealed the resident was a [AGE] year-old male readmitted on [DATE] with diagnoses of sepsis (a serious condition in which the body responds improperly to an infection), other specified disease of intestine, Gastronomy status (fed by a tube into the stomach), infection and inflammation reaction due to indwelling urethral catheter (a tube that is inserted through the urethral to drain urine from the bladder into a bag). Review of Resident #2 ' s care plans reflected the following care plans: Focus: Enhanced Barrier Precautions; Date Initiated- 04/05/2024; Goal: infection control intervention designed to reduce transmission of multidrug-resistant organisms; Interventions: use of PPE on the anticipated exposure to blood, body fluids, secretions, or excretions. During an observation on 06/18/25 at 10:11 AM, revealed Resident #2 was connected to a feeding pump attached to a dirty pole. The pole was dirty with yellow and brown sticky substances on it. Above Resident #2 was a signage for EBP which read; Gloves and gowns should be donned if any of the following activities were to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Perform hand sanitation before entering the room and prior to leaving the room. Resident #2 ' s room did not have any gowns in the room. The isolation cart was empty. During an interview with RN C on 06/18/25 at 10:15 AM, it was revealed that Resident #2 ' s room did not have gowns in the isolation cart. RN C said that the Central supply person was responsible for refilling the isolation carts. He said the nurses and CNAs were responsible for monitoring and reporting to central supply if they needed more PPE. He said that he did not notice that the isolation was empty today otherwise he would have reported it. RN C said that he was aware of EBP precautions for MDRO ' s in residents with medical lines such as catheters, g-tubes, and wounds. He said the risk for not following infection precautions was the spread of infection. RN C said the pole in Resident #2 was dirty, but it was also old, and it appeared to have Rust or dirt and feeding on it. He said that he would tell the housekeeper to clean. He said all equipment should be kept clean for infection control. During an interview with housekeeping on 06/18/25 at 11:50 AM, it was revealed that the nurses were responsible for cleaning the pumps and feeding poles. She said that she was not aware that it was her responsibility. She said that unless the nursing staff asked her to clean it, she did not pay attention to medical equipment. She said that she has no problem cleaning and sanitizing equipment for infection control, had she been told. In an interview with LVN D on 06/18/25 at 1:13 PM, she stated she did not have to wear a gown for EBP for Resident #1 because she was not giving any medication via G-tube. She said that if she was not accessing the g-tube she did not need to wear PPE for EBP. She said EBP was used on residents with wounds, g-tube, dialysis ports and catheter. She said EBP was only needed when accessing those things. She said there was no Risk to Resident #1. In an interview with the Central Supply Coordinator on 06/18/25 at 1:26 PM, she said the isolation cart was restocked on Monday, Wednesday, and Friday. She said that if more gowns or supplies were needed the charge nurse had keys to central supply where they could get more items. She said that she did not work Monday and that could be why the gowns were out, but anyone could have refilled without waiting for her. She said PPE was important for infection control. During an interview with LVN E on 06/18/25 at 4:07 PM, he said he had been at the facility for 2 years. He said EBP was followed by wearing a gown, gloves, and mask if needed. He said EBP was to protect the residents and self from transferring infection. He said that they had enough PPE, and he had gone to central supply to get supplies when they have been out. He said everyone was responsible for notifying the right people when supplies were out. During an interview with the DON on 06/18/25 at 3:26 PM, she said the expectations were for a resident on EBP to have a sign on the door. EBP was to be followed for wounds, g-tube, trach, IV, and catheter. She said the expectation was that PPE was worn when staff were providing direct contact such as ADL because there was care potential for MDRO infections. She said all rooms with any isolation including EBP should have PPE readily available. She said the expectation was to have supplies restocked when they were low. She said PPE was worn for protection of the residents and of self, to be free of contamination. She said if PPE was not available the staff were to ask someone to get it. The DON said it was the responsibility of the Central Supply Coordinator, the ADON, and the DON to monitor that there was PPE and to make sure that they looked over the order supplies list. She said EBP was expected to be followed for infection control. The DON said IV poles should be kept clean by housekeeping and cleaning should be done daily. She said nurses were responsible for monitoring the equipment that was cleaned. She said communication was done with the housekeeping supervisor. She said the risk was when things were not cleaned was, they could have pests and bacteria. In an interview with the ADM on 06/18/25 at 4:51 PM, she said the expectation was that they had PPE available and to notify her immediately if they ran out. She said the responsibility was for the Central Supply Coordinator to make sure that they all had what they needed, and to notify her if they did not. She said having PPE was important to make sure they were taking proper precautions against infection. She said they were all responsible, including nursing, to have the proper supplies to do their work. The ADM said housekeeping staff were responsible for cleaning all equipment. She said she expected the nursing staff to tell them. She said that she would contact the contract housekeeping supervisor so that everyone was on the same page as to who was responsible for keeping equipment clean. She said staff would be educated in clean environments to prevent infection. The ADM said EBP policy and procedure should be followed. She said she was not sure why CNA A, LVN B and LVN D did not do it. Review of policy Infection Prevention and Control Program review date 03/26/24, reflected, . EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: a. Infection or colonization with an MDRO when Contact Precautions do not otherwise apply b. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status During high-contact resident care activities: · Dressing · Bathing/showering · Transferring · Providing hygiene · Changing linens · Changing briefs or assisting with toileting · Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator · Wound care: any skin opening requiring a dressing . Record review of facility policy Clinical Practice Guidelines: Cleaning and Disinfecting Portable Equipment dated 05/04/21, reflected . It is the policy of this facility to follow infection control principles to prevent spread of infection through contact with portable equipment in the resident ' s care environment .

Based on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding received appropriate care and services to prevent complications of enteral feedings for one (Resident # 1) of two residents reviewed for enteral feedings. 1.The facility failed to ensure Resident #1 was not laid flat in bed while her enteral feeding was still running. This failure placed residents with enteral feedings at risk of aspiration (entering the airways or lungs) and hospitalization. Findings Included: Review of Resident #1 ' s face sheet, dated 06/18/25, reflected she was a [AGE] year-old woman, admitted on [DATE], with diagnoses of sepsis (the body responds to an infection by attacking the body ' s own organs), pneumonia (a lung infection), a pressure ulcer, dysphagia (an inability to swallow properly), stroke, and gastronomy status (use of a feeding tube inserted into the stomach). Review of Resident #1 ' s MDS assessment, dated 03/25/25, reflected Resident #1 had unclear speech, impaired vision, was rarely able to understand others, and was rarely understood by others. Resident #1 had short and long-term memory impairment, with severely impaired ability to make daily decisions. She was able to remember staff names and faces, and that she was in a nursing home. The document reflected Resident #1 received more than half her nutrition through her gastronomy tube every day of the seven-day lookback period. Review of Resident #1 ' s physician orders for June 2025 reflected -Enteral feed order every shift [name of brand] 1.5 at 50 ml/Hr for 22 hours, 45 ml/hr water flush Record review of Resident #1 ' s care plans reflected the following care plans: -Focus: (Resident #1) requires the use of a feeding tube and is at risk for aspirations, weight loss, and dehydration. Feeding tube is related to: CVA, DYSPHAGIA & Decreased appetite. Date Initiated: 04/11/2022; Goal: (Resident #1) will be adequately nourished and remain within 5% of her ideal body weight through the next review date. Date Initiated: 04/11/2022; Administer tube feeding and water flushes as ordered. Date Initiated: 04/11/2022; Elevate head of bed 45 degrees or as ordered by physician while feeding tube is being used for feeding and at least 30 minutes after bolus or tube feedings. Date Initiated: 04/11/2022. - Focus: Resident is resistant to getting out of bed and at risk for injury, a decline in functional abilities, and not having their needs met in a timely manner. Date Initiated: 02/28/2025 Goal: · Resident will be clean, well groomed ( .) Date Initiated: 02/28/2025 Interventions: Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Date Initiated: 02/28/2025. Review of Resident #1 Medication Administration Record for 06/01/25 through 06/18/25 reflected an order for Enteral Feed Order; Every shift for Aspiration precautions Keep HOB always elevated 30 - 45 degrees - aspiration precautions. Start Date- 03/29/2022 The order was checked off for each applicable shift on those dates. During an observation on 06/18/25 at 11:38 AM, revealed Resident #1 was lying flat on her back with her g-tube connected to the feeding pump running. A display on the pump read RUNNING, FEED RATE 50 ml/hr, FLUSH 45 ml every 1 hrs. The bed remote for adjusting the bed was hooked in the middle of the headboard above Resident#1 ' s head. During an interview with CNA A and LVN B on 06/18/25 at 11:38 AM, it was revealed that they both did not know who had lowered the head of Resident #1 ' s bed. LVN B stated that she always made sure the head of the bed was raised at least 30 degrees to prevent aspiration. CNA A also stated that he was not the one who laid Resident #1 ' s head down. He said that he had been trained to notify the nurse to turn off the pump before lying the resident down. Both CNA A and LVN B both said they were not aware the head of Resident #1 ' s bed was lowered. They said if they had known, they would have raised it. They both said the risk to the resident on g-tube feeding being laid flat on their back was aspiration. In an interview with Resident #1 ' s family on 06/18/25 at 2:07 PM, She said that each time she had come to visit Resident #1 the head of her bed was flat and she had to ask someone to raise it. She said she had never seen Resident #1 adjust her own bed, but she could use the call light, which was never within her reach. She said Resident#1 could barely feed herself therefore she needed assistance with ADLs and being repositioned. Resident#1 ' s family did not recall whom she had spoken to about the bed being flat, but she said the family had notified staff whenever they found the bed down. She said she knew that lying flat while on g-tube feeding could cause aspiration pneumonia. During an interview with LVN E on 06/18/25 at 4:07 PM, he said he had been at the facility for 2 years and the expectation was that the residents during g-tube feeding should have their head of bed up at least 30 degrees. He said if the CNA was providing care, the expectation was that he would be notified so that he could turn off the feeding pump before the resident was laid flat. He said he always checked residents G-tube orders before any medications or restarting feeding after rest time. He said he always checked the g-tube for placement. He said the risk of lying in a resident flat while feeding was running was aspiration. During an interview with the DON on 06/18/25 at 3:26 PM, she stated the expectation for residents receiving nutrition via G-tube continuously was to have the head of the bed elevated at least 45 degrees. The DON said that the nurse was responsible for making sure they followed the policy for the G-tube administration. The DON said the risk for the resident of lying flat during feeding was aspiration. In an interview with the ADM on 06/18/25 at 4:51 PM, she said there were two residents who adjusted their own beds and laid the bed flat, one of them being Resident #1. She said all the staff were aware that Resident #1 liked to lay her bed flat. She said she did not know why LVN B and CNA A did not say so because they were aware of Resident #1 ' s behavior. The ADM said that Resident #1 ' s behavior of lying in her bed flat needed to be care planned moving forward. She said interventions, like that of using a wedge pillow to elevate her upper body while she was feeding, may be used. The ADM said the DON was new and might not yet be aware of Resident #1 ' s behavior of lying flat while on g-tube feedings. Review of the facility policy titled Clinical Practice Guidelines: care of Tube Feed Resident dated 01/20/21, reflected; Keep head of bed (HOB) elevated 30-45 degrees during feeding, keep HOB elevated for 30 minutes after feeding. If necessary to lower the HOB for a procedure turn off tube feeding, then return the patient to an elevated HOB position as soon as feasible.

Based on observation, interviews, and record review, the facility failed to provide a resident who was unable to carry out ADLs the necessary services to maintain grooming, and personal hygiene for one (Resident #1) of four residents reviewed for ADL care. Resident #1 ' s brief was soiled, and her bedding had a brown ring around her, with a strong ammonia odor, on 06/18/2025. This failure could affect residents by decreasing quality of life and contributing to skin breakdown. Findings included: Review of Resident #1 ' s face sheet, dated 06/18/25, reflected she was a [AGE] year-old woman, admitted on [DATE], with diagnoses of sepsis (the body responds to an infection by attacking the body ' s own organs), pneumonia (a lung infection), a pressure ulcer, dysphagia (an inability to swallow properly), stroke, and gastronomy status (use of a feeding tube inserted into the stomach). Review of Resident #1 ' s MDS assessment, dated 03/25/25, reflected Resident #1 had unclear speech, impaired vision, was rarely able to understand others, and was rarely understood by others. Resident #1 had short and long-term memory impairment, with severely impaired ability to make daily decisions. She was able to remember staff names and faces, and that she was in a nursing home. A staff assessment of her mood reflected no depression indicators. She was always incontinent in both the bowel and bladder. The document reflected Resident #1 received more than half her nutrition through her gastronomy tube every day of the seven-day lookback period. Resident #1 was dependent on staff for all ADL care. Review of Resident #1 ' s care plans reflected the following care plans: - Focus: ADLs: (Resident #1) has an ADL Self Care Performance Deficit and is at risk of not having their needs met in a timely manner. Performance deficit is related to: Decreased mobility and cognitive deficits, CVA with right sided weakness Date Initiated: 04/11/2022 Revision on: 04/23/2024 Goal: (Resident #1) will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date. Date Initiated: 04/11/2022 Revision on: 04/02/2025 Interventions: Eating: Total assist x1 with enteral feedings; Toileting: assist x1; Personal Hygiene: Oral care BID, Extensive assist of one; Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Date Initiated: 04/11/2022. - Focus: Incontinence: (Resident #1) is incontinent bowel/bladder related to decreased mobility, incontinence and impaired cognition. Date Initiated: 04/11/2022 Goal: (Resident#1) will remain free from skin breakdown due to incontinence and brief use through next review date. Date Initiated: 04/11/2022 Interventions: Check frequently for wetness and soiling and change as needed. Date Initiated: 04/11/2022 · Monitor for and report to MD s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date Initiated 04/11/2022. During an observation and interview on 06/18/25 at 09:12 AM, revealed Resident #1 was awake in bed with the head of her bed raised, and a call light clipped next to her. Resident #1 said that she had not been provided incontinent care since last night. Resident #1 said that she was soaked wet. She stated that it happened frequently, especially in the morning. Resident #1 said it was uncomfortable to lie in it, and it was itchy. An observation and interview on 06/18/25 at 09:18 AM, revealed CNA A removed Resident #1 ' s covers to expose her chuck (an absorbent pad placed under incontinent residents) which was soaked yellow with a brown ring around the area where the resident was lying. Her brief appeared to be soaked with urine and BM. The urine had a strong ammonia odor to it. CNA A said that he had changed Resident #1 that morning at 06:00 AM. He said Resident #1 urinated frequently, so she was the first one that he changed (incontinent care) when he started his shift that morning. An interview and observation on 06/18/25 at 09:20 AM revealed CNA A providing incontinent care on Resident #1 with LVN B assisting him. No skin issues were observed on Resident #1 ' s bottom or frontal areas at time of incontinent care. LVN B stated she could smell the strong urine smell and that the brown ring of urine was due to not providing incontinent care timely. LVN B said it was the CNA ' s duty to provide ADL care but nurses helped when needed. She said she, as the nurse, was responsible for making sure that it was done. LVN B said that she gave Resident #1 her medication and checked her blood sugar that morning, but she did not check to see if she was wet. LVN B said the risk was impaired skin and infection, such as urinary tract infections. An interview and observation on 06/18/2025 at 11:38 AM revealed CNA pulling back Resident #1 ' s blanket. Resident #1 was wet, but there was no evidence of a brown urine ring or strong ammonia odor to the urine. The urine was clear in color seen on the chuck pad. CNA A said that he had provided incontinent care to Resident #1 this morning despite what was seen. He said incontinent care was important to prevent skin breakdown and UTI. An interview with Resident #1 ' s family on 06/18/25 at 2:07 PM, revealed the family member had complained to the facility about finding Resident #1 soiled with urine covering her whole bedsheet on multiple occasions, including back in February when Resident #1 was hospitalized for pneumonia and a staph infection. She said Resident#1 could barely feed herself and needed assistance with ADLs and being repositioned. During an interview with the DON on 06/18/25 at 3:26 PM, it was revealed the expectation for ADL care and incontinent care was that it be provided in a timely manner, every two hours, or as needed. She said a brown ring of urine around a resident was an indication that they had not been provided incontinent care in a timely manner. She said all nursing staff were responsible for ADL care, and the nurse was responsible for monitoring that it was done. She said the risk to the resident was that it was the resident's right to dignity, and to prevent skin condition and pressure injuries. In an interview with the ADM on 06/18/25 at 4:51 PM, she said the expectation was ADL care was provided for all residents within a timely manner, and as needed. She said the risk to the residents was skin breakdown. Review of Facility policy titled Activities of Daily Living Care Guidelines revision date 02/11/2021, reflected Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene. The policy did not reflect how often incontinent residents should be changed.

Based on interviews, and record reviews, the facility failed to ensure each resident had the right to be free from abuse for four (Residents #1, #2, #3, #4) of 9 residents reviewed for Abuse. 1.The facility staff failed to ensure Resident #1 did not hit Resident #2, which resulted in Resident #2 getting a skin tear to his face in the dining room on 09/14/24. 2. The facility staff failed to ensure Residents #3 did not throw orange juice twice, at Resident #4, which resulted in Resident #4 hitting Resident #3 in the face and causing redness to Resident #3's face, in the dining room on 09/13/24. These failures could place residents at risk of injuries such as fractures, bruising, skin tears, and psychological harm resulting in decreased health and psycho-social well-being. Findings included: 1. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS score of 14 (No cognitive impairment), with medically complex conditions including diagnoses of HTN (high blood pressure), renal insufficiency (poor function kidney), DM (Diabetes Mellitus), aphasia (language disorder), non-Alzheimer's dementia (cognitive loss), hemiplegia (one sided weakness), seizure disorder (brain condition causes jerking movements) and depression (sadness). Record review Resident #1's Care Plan dated 08/29/23 revealed, Resident exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner. Resident curses at residents. Target date 03/27/25: Resident's verbally abusive behavior will not result in harm or injury to self or others through the next review date. Record review of Resident #1's Nurses Note dated: 09/15/2024 at 5:38 pm by RN A revealed, This writer was notified by staff of the above resident who got into an argument with another resident in the dinning [sic] room, Resident #1 was in another resident way to get to his table, Resident #1 refused to move out of the way but continued to argue with the other resident and approached the other resident and gave him a scratch to his left cheek. Both resident were separated for safety with no issues, head to toe assessment completed on the above resident. No noted new injuries or skin issues. Resident denies any pain or discomfort. Vital signs done - 128/74, 18, 97.7, 72, 98% on RA. Resident was educated on the importance of not causing any injuries to another resident. Resident verbalized understanding. FM called and notified, DON, ADON and Doctor aware. During an interview on 01/23/25 at 12:55 pm, Resident #1 was sitting in a scooter and stated a few months ago in the dining room, Resident #2 ran into her scooter because he said she would not move out of his way. She stated she was sitting at the table and Resident #2 just came and bumped her stomach into the table, then she pushed him. She stated he asked why did she hit him and she told him he should have apologized to her. She stated Resident #2 did not apologize and was not sure if he bumped into her on purpose so she pushed him. She stated they had not had any issues since then and they talked to each other and were now on friendly terms. She stated Resident #2 just talked to her today. She stated Resident #2 sat at a different table next to hers and when Resident #2 had to come by her to get to his table, she moved so he could get by without him having to ask. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS score of 12 (Moderate cognitive impairment). His diagnoses included Non-traumatic Brain Dysfunction (Brain injury), anemia (low iron), HTN (high blood pressure, aphasia (language disorder, cerebrovascular accident (Stroke), non-Alzheimer's dementia (Cognitive loss), seizure disorder brain condition causing jerking movements, depression (sadness), and psychotic disorder ( mental disorder/ disconnect from reality). Record review Resident #2's Care Plan dated 01/05/24 revealed, Resident has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: CVA, DEMENTIA, DELUSION D/O, MDD. Target date: 03/30/2025. He will maintain current level of cognitive function without a decline through the next review. Record review of Resident #2's Nurses Note dated 09/15/2024 at 5:57 pm by RN A revealed, This writer was notified by staff of the above resident who got into argument with another resident in the dinning [sic] room, the other resident (Resident #2) was on his way to get to his table, the other resident (Resident #1) refused to move out of the way but continued to argue with him while approaching towards him and gave him a scratch to his left cheek. Both resident were separated for safety with no issues, head to toe assessment completed on the above resident. No noted new injuries or skin issues. Resident denies any pain or discomfort. Vital signs done - 126/70, 18, 97.6, 70, 98% on RA. Resident stated that he is own RP, DON, ADON and Doctor made aware. During an interview on 01/23/25 at 1:10 pm, Resident #2 was sitting in a manual wheelchair and stated Resident #1 had a motorized wheelchair and was in the dining room a few months ago. She was just right there at the table, but she did not want to listen because she was listening to music and they started yelling at each other. He stated then the staff came to the dining room to stop them. He said Resident #1 did not hit him and they got along with each other now and Resident #1 moved to give him space to his table. Record review of the Facility's Provider Investigation Report dated 09/14/24 at 4:45 pm revealed, Resident #1 was blocking an aisle in the dining room and Resident #2 said Excuse me and asked Resident #1 if she could move up so he could get by. Resident #1 said No then Resident #2 attempted to move Resident #1's wheelchair. Resident #2 attempted to push her chair up a bit and Resident #1 became upset and started hitting Resident #1 in the face and cursing at him. Resident #2 grabbed Resident #1's hands and told her to stop hitting him in the face before he slaps her. Resident #2 said he did not hit women, then he let go of her hands and she scratched his cheek. Provider response: Both residents separated, Resident #1 placed on 1:1, Both residents referred to psych services physician notified, families notified yet both are their own RP, in-services started - abuse, residents with aggressive behaviors towards others. Findings: Confirmed. 2. Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS Score of 11 (Moderate cognitive impairment). He had diagnoses of non-traumatic brain dysfunction(brain dysfunction) Anemia (low iron), HTN (high blood pressure), renal insufficiency (kidney failure), hyperlipidemia (aphasia, CVA (stroke), Non-Alzheimer's Dementia (Cognitive loss), Anxiety (increase and anxious , Depression (sadness) and Schizophrenia (mental illness). Record review Resident #3's Care Plan dated 01/13/25 revealed, Behavioral Problem: Resident has a behavior problem as evidenced by: altercation with another resident. Target date 01/24/25: The president's behavior will not interfere with the delivery of care or services or result in harm to self or others through the next review date. Record review of Resident #3's Nurses Note dated 09/13/24 at 3:50 pm by LVN B revealed, Resident escorted to north nurse's station from dining room by a nurse who heard him yelling and cursing his table mate while raising his right hand up. He was redirected by the nurse but instead he continued to curse her in Spanish, another resident who understood what he was saying asked him to stop the curse words and instead went to his table tried to curse him too. The other resident asked him what he was going to do and that is when Resident #3 cursed him and threw a glass of juice at him, so the victim swang [sic] at him at hit his mouth area on right side. The other nurse ran and removed Resident #3 out from dining room immediately, and brought him to north hall, and notified this writer. Resident is cursing out saying to be left alone and that he will fight the other patient. He is very agitated and cursing at staff loudly, does not want to listen to anybody Resident was asked if he was in pain denied pain. informed that he should not go to the dining room rather go to his room but refused and stayed at the public TV (television) area. At this time, he was quiet and served coffee. Redirected to voice his needs instead of being frustrated. Verbalized understanding. He then agreed to have head to toe assessment, no swelling to mouth area, no pain or discomfort, DON, Doctor were notified. FM was also notified. Resident had got self-up in WC. placed on 1:1. BP 136/85, 90, 20, 97.0. During an interview on 01/23/25 at 12:41 pm, Resident #3 was sitting in a wheelchair and gestured (shaking his hand sideways) saying he had not thrown orange juice at anyone and had not ever cursed at or hit anyone. He stated no one had hit him. Record review of Resident #4's Annual MDS assessment dated [DATE] revealed a [AGE] year-old male who was admitted to the facility on [DATE], his BIMS score was 15 (no cognitive impairment). He had diagnoses of amputation (body part removal), anemia (low iron), hypertension (high blood pressure), PVN (brain disorder), renal failure (kidney failure), neurogenic bladder (urinary disorder), diabetes (High blood sugar) and no psychiatric or mood disorders. Record review Resident #4's Care Plan dated 08/14/23 revealed, The resident has an alteration in neurological status related to cerebral infarction. Target date 04/16/25: The resident, will be able to communicate needs daily through the review date. Record review of Resident #4's Nurses Note dated 09/13/24 at 2:21 pm by LVN C revealed, Nurse was in the dining room for breakfast when she heard a resident yelling and cursing another resident stated while he was in the dining room for breakfast he heard a nurse telling another resident to stop yelling at another resident and to get his hand out of the residents face, then he stated the resident started cursing the nurse out in Spanish calling her MF (mother cuss word), and other words, and I understood what he was saying and I informed him not to say that and then he started cursing me out and pour a glass of juice on me and then I swing back at him and then the nurse ran over to us and removed him Nurse immediately removed the resident that was cursing, head to toe assessment completed, no redness are [sic] bruising are injuries noted. MD notified, DON notified, and resident notified he is his own RP. Interviews on 01/23/25 and 01/24/25 was attempted with Resident #4 but he was unavailable. Record review of the Facility's Provider Investigation Report dated 09/13/24 at 7:45 am revealed, Resident #3 was in the dining room fussing about another resident sitting in his space at the dining room table. Resident #4 argued that Resident #3 was always picking on someone who could not fight for themselves. Then Resident #3 wheeled himself to Resident #4 started threatening to throw orange juice at him and Resident #4 dared him then Resident #3 threw it at Resident #4. Resident #3 grabbed a second cup of juice and began to throw more at Resident #4. Then Resident #4 became upset and wheeled his wheelchair to Resident #3 and hit him in the face. Both residents were separated, assessed and Resident #3 was assessed by LVN B he had some redness to his cheek from being hit in the face. No other injuries. Provider response: Both residents separated, Resident #3 placed on 1:1, both residents referred to psych services, physicians notified, families notified yet both are own RP, Inservice started on abuse, de-escalation of aggressive behavior with a questionnaire and re-educated staff to ensure they were in the assigned areas as required. Both of their medications reviewed and discovered that Resident #3 had a recent GDR of his psychiatric medications, and his medication has been readjusted back to previous level. Findings: Confirmed. During an interview on 01/24/25 at 12:47 pm, Floor Tech D stated after Breakfast a few months ago, she saw Resident #1 and #2 arguing at each other. She stated Resident #1 said Boy I'll knock you out and Resident #2 said I wish you would. She stated they were both yelling, and Resident #1 was swinging her arms at Resident #2. She stated there was no one in the dining room, then LVN E came to the dining room and took Resident #2 away and Resident #1 remained in the dining room with her. She stated they had not had any issues getting along since then. Interview on 01/24/25 at 1:53 pm, CNA F stated Resident #3 was mad about some coffee or something, then went to Resident #4's table and they started fighting each other. She stated they were both cursing, and Resident #4 called Resident #3 the B-word and she saw Resident #4 hit #3 in the face. She stated LVN E was in the dining room at the time and told Resident #4 to back up, back up because he had a motorized wheelchair. She stated LVN E separated them and stated she could not remember Orange Juice being thrown but both of them made contact hitting the other's face. She stated Resident #3's face was a little red one side. Interview on 01/24/25 at 2:12 pm, LVN E stated a few months ago in the dining room, somebody from the kitchen and other staff were getting the residents ready for breakfast. She stated she was doing blood pressure checks on some of the residents and Resident #3 got mad at another resident for taking his spot. She stated Resident #3 threw orange juice at Resident #4 then Resident #4 put his electric wheelchair in reverse and hit Resident #3 in the face. She stated Resident #3 had no skin alteration, skin tear or redness and then LVN B did Resident #3's skin assessment. She stated she took Resident #3 to his room to assess him and he had no injuries. Interview on 01/24/25 at 2:43 pm, CNA G stated a few months ago, Residents #1 and #2's breakfast trays were being passed out. She stated Resident #2 sat at the table next to Resident #1 and Resident #2 wanted Resident #1 to move over a little so he could get to his table. She stated then Resident #1 hit Resident #2 and was not sure who was watching the residents, but she alerted the nurses and they went to the dining room and intervened. She stated few months ago, around lunch during the 6:00 AM - 2:00 PM Shift, she saw the end part of Residents #3 and #4 incident. She stated by the time she went to the dining room the nurses had made it in there and was separating them. She stated the staff were passing out meals on the halls, when Residents #1, #2, #3 and #4's incidents occurred. She stated the facility normally had staff in the dining room but the days of these incidents, there were none in there. She stated Residents #1 ,#2 #3, and #4 had been getting along since then. Interview on 01/24/25 at 3:33 pm, Dietary Aide H stated a few months ago they were just about to start serving lunch and she was walking out of the kitchen. She stated Resident #1 was in her wheelchair and Resident #2 passed by and when he moved her up, she jumped up and started cursing. She stated she did not see Residents #1 and #2 hitting each other but they were hollering and cursing. She stated she then she got RN A and a CNA to come to the dining room because there was no staff in there. Interview on 01/24/25 at 3:42 pm, Weekend Receptionist I stated a while ago around lunch, the residents were going into the dining room and they had not started eating yet. She stated none of the nurses or CNA's were in the dining room because they were bringing residents to the dining room. She stated she was just coming out of the housekeeper's closet and was walking by the dining room and saw a housekeeper and RN A headed to the dining room. She stated she saw Resident #1 hitting Resident #2 and he had a scratch on his face and left arm and maybe his right arm also. She stated she helped separate them and Resident #2 said he was trying to get by and said Excuse me to Resident #1 but she did not move. She stated Resident #2 said he pushed Resident #1's chair forward because she was in the center of the area where he sat. She stated Residents #1 and #2 had not had any other issues since then. Interview on 01/24/25 at 5:28 pm, the DON stated a few months ago in the dining room, the staff reported Resident #1 hit Resident #2 and Resident #2 told Resident #1 to stop hitting him because he did not hit women. She stated the staff saw Resident #1 hit Resident #2 because one of the residents was blocking the other one from getting to their table. She stated it was reported they were both verbally abusive to each other and that Resident #1 had a scratch on his cheek. She stated a few days after she assessed Resident #1 and she did not see anything on his cheek and Resident #1 had no injuries. She stated Residents #1 and #2 had been getting along fine since then. She stated a few months ago staff reported Resident#4 was taking up for another resident who was in Resident #3's chair in the dining room. She stated Resident #3 said he did not like that resident in his seat then Resident #4 said Don't talk to that resident like that. She stated then Resident #3 started yelling at Resident #4 and they started yelling at each other. She stated then Resident #3 threw orange juice at Resident #4 and could not remember if anyone was hit. She stated Resident #4 hit Resident #3 then LVN E was able to separate them . Interview on 01/24/25 at 6:06 pm, the Administrator stated this past September 2024, the staff said Resident #2 asked Resident #1 to move, and Resident #1 started hitting at him and contact was made. She stated Resident #1 went to hitting him in the face and he said stop and grabbed her hands to stop her from hitting him. She stated the staff intervened and assessed Residents #1 and #2 and they had no injuries. She stated this incident was confirmed because of what the residents told her and review of the staff witness statements. She stated this past September 2024, staff reported Resident #3 threw orange juice at Resident #4 and said something in Spanish about a staff. She stated after Resident #3 threw orange juice Resident #4 hit Resident #3 in the face resulting in Resident #3 having redness to his face. She stated when she went to talk to Residents #3 and #4, Resident #3's face was no longer red and Resident #4 had no skin issues. She stated they had not had any issues since then. She stated it was discovered Resident #3 just had a GDR of his medications. She stated this was probably why Resident #3 was acting the way he was and his Doctor put him back on his previous medication dosage and he was doing much better. She stated everyone was responsible for ensuring the residents did not abuse each other but said she was ultimately responsible because she was the abuse coordinator. Record review of the facility's Abuse and Neglect policy dated 10/24/22 and revised 09/06/24 revealed, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse .Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, within hearing distance regardless of their age, ability to comprehend, or disability. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. III. Prevention of Abuse, Neglect: The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and VI. Prevention of Resident: The facility must make efforts to ensure all residents are protected from physical and psychological harm, as well as additional abuse, during and after the investigation.

Based on observation, interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, the medical record was maintained on each resident that were complete and accurately documented for 1 (Resident #49) of 8 residents records reviewed for treatment documentation. The facility failed to ensure Resident #49's orders for his tracheostomy and tracheostomy care were in the EMR. This failure could affect any resident, placing them at risk of inaccurate information and resulting inappropriate care. Findings included: Review of Resident #49's Admission Record, dated 08/29/24, reflected he was a [AGE] year-old male originally admitted on [DATE], and most recently readmitted on [DATE], with diagnoses of anoxic brain damage (brain damage from lack of oxygen), tracheostomy status (surgically inserted tube into airway for breathing), and acute and chronic respiratory failure with hypoxia (a condition in which the lungs do not properly exchange oxygen for carbon dioxide, resulting in low oxygen in the body.) Review of Resident #49's Quarterly MDS assessment, dated 07/30/24, reflected he was rarely or never understood, and rarely or never understood others. The staff assessment of memory reflected he appeared to have long and short-term memory problems, and severely impaired daily decision-making skills. Resident #49's range of motion was impaired on both sides of his body, in both upper and lower extremities. He was entirely dependent on staff for all care. The document reflected that Resident #49 had received oxygen therapy, tracheostomy care, and suctioning of his tracheostomy while a resident at the facility. Review of Resident #49's care plans reflected the following: Resident has a tracheostomy and is at risk for potential complications such as weight loss, increased secretions, congestion, infection, and respiratory distress. TRACHEOSTOMY TYPE: Shiley, size: 8.5 mm, secure with tracheostomy ties. Date Initiated: 03/14/2022 Revision on: 06/04/2024 o Resident will have clear airways with adequate ventilation through the next review date. Date Initiated: 03/14/2022 Revision on: 04/03/2024 Target Date: 09/05/2024 o Resident will have no signs or symptoms of infection at the tracheostomy site through the next review date. Date Initiated: 03/14/2022 Revision on: 04/03/2024 Target Date: 09/05/2024 o Administer medication as needed/ordered by the physician for episodes of anxiety. Provide support to prevent anxiety when episodes of shortness of breath occur. Date Initiated: 03/14/2022. Provide oxygen, humidity, tracheostomy care, and tubing changes as indicated by physician's orders Trach Size: 8.5 mm ID 7.5mm disposable inner cannula. Date Initiated: 03/14/2022; Revision on: 06/04/2024. Ensure that trach ties are secured at all times. Date Initiated: 03/14/2022 o Suction as needed for increased secretions and congestion. Date Initiated: 03/14/2022. Provide oral care daily and as needed. Date Initiated: 06/04/2024. Monitor/document for restlessness, agitation, confusion, increased heart rate (Tachycardia (rapid heart rate)), and bradycardia (heart beating too slowly). Date Initiated: 03/14/2022. Review of Resident #49's orders in the EMR on 08/29/24 reflected the only mention of a tracheostomy to be Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 1 vial via trach four times a day related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA. Review of Resident #49's MAR on 08/29/24 reflected no tracheostomy care documented for the month of August 2024. Review of a hand-written Respiratory Therapy note, dated 08/24/24, reflected the Respiratory Therapist had observed Resident #49 in his bed, and noted the resident was comfortable and noted the resident was not on oxygen. Review of a nursing progress note dated 08/26/24 reflected tracheostomy care had been provided by LVN A. Review of a nursing progress note dated 08/27/24 reflected a note by LVN B: ( .) trache also in place with PRN care being given suctioned times, one [sic] this shift Aspiration precautions maintained Will treat as ordered Review of a nursing progress note dated 08/27/24 reflected a note by LVN C: Trache in place clear secretions. Review of a nursing progress note dated 08/28/24 reflected a note by LVN B: Resident has trache in place tha [sic] requires PRN suctioning. Suctioning [sic] required once this shift with clear ;thin secretions being expelled. Review of a nursing progress note dated 08/29/24 reflected a note by the ADON: Trach care provided by this nurse for charge nurse, secreations [sic] clear with no complications while suctioning resident and providing patch care. Review of a nursing progress note dated 08/29/24 reflected a note by the ADON: Trach care provided by this nurse for charge nurse, secretions clear and scant, resident tolerated well. Review of an untitled document provided by the ADON, dated 08/29/24 3:08 PM reflected a full set of phone orders for Resident #49's tracheostomy care, addressed from the facility to the prescribing physician. Observation of Resident #49 on 08/27/2024 at 9:32 AM revealed him to be awake in his bed, and to have a tracheostomy. No obvious concerns were observed by the surveyor. Observation of Resident #49 on 08/29/2024 at 10:00 AM revealed him to be asleep in his bed, and to have a tracheostomy. Resident #49's tracheostomy had a humidifier, but was not connected to oxygen. No obvious concerns were observed by the surveyor. An interview on 08/29/24 1:17 PM with LVN B revealed Resident #49 was able to expel his excretions by coughing pretty well, so she usually only had to suction him once per shift, and it was important to not over-suction someone. She said that part of the care for the tracheostomy was to keep it clean and dry, change the gauze, and notice if there were any changes or concerns. She said Resident #49 was not alert, and was completely dependent on the staff, due to a brain injury, so they had to check on him. She said he was not on oxygen, only humidification, and was doing very well. An interview on 08/29/24 at 3:12 PM with the ADON revealed it had just been brought to her attention by staff that there were no orders for Resident #49's tracheostomy care in the EMR, and she had responded by putting them in immediately. She expressed that she was baffled, because she knew they were there, and she was investigating, but had not figured out what happened. She explained that Resident #49 was not a new admission, and had been in and out of the hospital. She said when he readmitted , their corporate would have deleted all of his previous orders, as was best practice, because someone could come back with new orders from the hospital that did not match their old ones. When he returned they would enter batch orders. They were standing orders that were grouped together, which would come into the queue in the EMR, and the admitting nurse would go through and verify them, and activate them. She said the orders might be things like an order to crush meds if necessary, and in this case, they would manually add the batch orders for a specific type of tracheostomy. The physician would approve the orders, then the resident would be evaluated by the respiratory therapist, and they might write new orders, if needed, which would be entered into the EMR. When someone was admitted it was the admitting nurse's responsibility to add any type of order. She said she had been asking questions of the staff, and she knew she had seen orders in for Resident #49, and his nurse also had seen them. She said they did not have any PRN or agency nurses working at the current time, and the nurses fortunately knew Resident #49's care, and had documented at least per shift in the progress notes, but they would normally check the care off in the MAR, as well. She said the orders directed the care, and it was possible that missing orders could cause someone to not receive appropriate care. An interview with the Administrator on 08/29/24 at 3:48 PM revealed her expectation was that the nurse would enter orders when a resident was admitted . She said they knew they were there, and it was like someone had hit the delete button on them. She said they were looking into what happened, but something was wonky. She said not having orders in the EMR could cause someone to receive improper care. Record review of the facility's policy titled Medication Reconciliation, dated 09/24/22, reflected Policy: This facility reconciles the resident's medications to ensure the resident is free of any significant medication errors. Definitions: Medication reconciliation refers to the process of verifying that the resident's current medication list matches the physician's orders for the purpose of providing the correct medications to the resident at all points throughout his or her stay. Policy Explanation and Compliance Guidelines: 1. Medication reconciliation involves collaboration with the resident/representative and multiple disciplines, including admission liaisons, licensed nurses, physicians, and pharmacy staff. ( .) 3. Pre-Admission Processes: a. Obtain current medication list from referral source (i.e. hospital, home health, hospice, or primary care provider). b. Obtain current medication/admission orders. ( .). d. Forward to nursing unit accepting the resident. ( .) 4. Admission Processes: ( .) b. Compare orders to hospital records, home or orders from healthcare entity, etc. Obtain clarification orders as needed. c. Transcribe orders in accordance with procedures for admission orders. d. The DON/designee reviews transcribed orders for accuracy and cosign the orders, indicating the review.

Based on observation, interview and record review the facility failed to serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen reviewed for food safety. The facility failed to use one utensil for each food item served during lunch. This failure could place residents at risk for food-borne illness and food contamination. Findings include: Observation on 08/28/2024 at 11:55 AM revealed [NAME] D used the same tongs to pick up and serve both pork loin and beef patties. [NAME] D repeated the serving actions again at 11:58 AM Observation on 08/28/2024 at 12:08 PM reflected [NAME] D used the tongs previously used to pick up pork loin and beef patties to pick up French fries. Interview on 08/28/2024 at 12:21 pm with [NAME] D revealed there was only one pair of tongs to use during lunch service. [NAME] D stated the risk of using one utensil to serve multiple food items would be food transfer. Interview on 08/28/2024 at 1:18 PM with Dietary Manager reflected each food item was supposed to have its own serving utensil. He stated that there were not enough tongs for each food item. The Dietary Manager stated the risk of using the same utensil to serve multiple food items placed the residents at risk of cross contamination. Record review of the facility's policy Food Safety and Sanitation Plan review date 07/22/2021 reflected nursing home residents risk serious complications form food borne illness as a result of their compromised health status. Unsafe food handling practices present a potential source of pathogen exposure for residents. Sanitary conditions must be present inI health care food service settings to promote safe handling.

Based on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of two residents reviewed for quality of care. The facility failed to call physician for an x-ray order of Resident #1's left wrist and hand in a timely manner, which resulted in delayed treatment for a period of 7 days without treatment. On 06/15/2024, approximately 7:45 AM CNA B reported to RN A, pain and swelling in Resident # 1's left hand. Left hand noted swollen. Resident # 1 revealed difficult to move at wrist, there was swelling and slight reddish bruising. Resident stated she fell on [DATE] after breakfast. Resident #1 was able to get herself up. Resident #1 assessed by RN A, DON notified. X-ray order was received from the APN to x-ray left wrist and hand on 06/15/2024 approximately at 7:45 AM. On 06/15/2024 at approximately 6:00 PM, Resident #1 had seizure activity and the resident was transfer to hospital for further evaluation. On 06/18/2024 at approximately 1:50 PM, Resident #1 returned to the facility. The resident complained of pain in the left wrist and hand on 06/19/24, 06/20/24, 06/23/24, and 07/01/24. On 7/01/24 an x-ray was ordered due to the pain; results indicated the resident had an acute displaced fracture of the distal metaphysis of the left radius. The noncompliance was identified as PNC. The IJ began on 06/18/24 and ended on 07/01/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of a delay in medical evaluation, treatment and decrease in quality of care by not ordering x-ray in a timely manner [14 days later] to protect resident from further pain. Findings included: Review of Resident #1's face sheet dated 07/09/2024 revealed the resident was a [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnosis included Multiple Fractures of Ribs, Bilateral, Initial Encounter for Closed Fracture (Broken or cracked ribs three or more in two places and did not break through skin); Disorder of Bone Density and Structure, Unspecified (Bone mass and mineral density decreases, causing disorder in bone Density and structure of bone changes); Dementia in Other Diseases Elsewhere Classified Moderate, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbances, and Anxiety (Caused by disorders of the brain: Memory Loss, Problem solving, emotional control, impaired thinking abilities that interfere with daily functioning). Review of Resident #1's quarterly MDS Assessment, dated 06/26/2024, revealed Resident #1 was usually understood by others and was able to understand others; the resident's cognitive assessment/BIMS Score was 06/15 indicating moderate cognitive impairment. Transferring between bed, chair, wheelchair, and standing position required supervision or touching with one person assist. Locomotion in the room required supervision with one-person assist. Review of Resident #1's care plan, undated, revealed Resident #1 was at risk for the following care areas: *Musculoskeletal status r/t diagnosis of osteopenia, and history of fractures. *ADL self-care performance deficit and at risk for not having her needs met in a timely manner. Goal: She will maintain a sense of dignity by being clean, dry, odor free and well-groomed through the next review. Intervention: Toilet use: requires x1 staff to assist, Transfer requires x1 staff assist with transferring, Bathing requires extensive assistance x1. Resident #1 at risk for falls related to unsteady balance and antidepressant use. Goal: will be free of falls by next review. Intervention: Call light within reach, encourage to call for assistance, resident has a history of unreported falls and getting self-up without notifying staff of the event; 06/14/2024 Fall; educated resident/family/caregivers about safety reminders and what to do if a fall occurs; fall mat to be beside the bed, keep needed items, water, etc. in reach, bed in lowest position, provide activities that promote exercise and strength building where possible. Review of Resident #1's progress notes dated 06/15/2024 at 7:45 AM, documented by RN A reflected: CNA B reported to writer pain and swelling to residents left hand. Left hand noted swollen with slight reddish bruising. Resident states difficult to move at wrist. Capillary refill < 3sec. Sensation intact. (Nurse pressed skin down on left hand and blood refilled within 3 seconds. Resident had feeling in her hand). Resident stated she fell yesterday after breakfast, and she got herself up. No other injuries noted. Neuros stable [Physician] and DON notified. On 06/15/2024 at approximately 7:45 AM, orders received from APN to x-ray left hand and wrist. Phoned family member. Message left. Resident medicated with PRN pain med. Continue to monitor. Resident at nurses' station at present. Alarm in place. X-ray ordered. Pain scaled noted on MARS for 06/15/2024 were documented as 0 on a scale of 0-10. Review of Resident #1's physician orders, dated 06/04/24, revealed a STAT x-ray to right clavical. Humerus, elbow, forearm, wrist and right hand and left hand was ordered but the x-ray start date is blank, indicating it was not completed. Review of Resident #1's physician orders, dated 06/15/24, revealed, an x-ray was ordered for the left wristand hand related to pain and swelling. Review of Nurse MAR documented by RN A reflected on 06/15/2024, 8:00AM, Ibuprofen Oral tablet 600 mg. Give 1 tablet by mouth every 6 hours as needed for moderate pain was administered to Resident #1. Resident #1's pain level was document as a 3 on a scale of 0 - 10. Review of Resident #1's progress note dated 06/15/2024 at 12:00 PM documented by RN A reflected: Resident up in w/c watching TV in lobby. No c/o pain or discomfort. States, No, only if I bend it. No signs of pain at this time. Hand supported/elevated. Neuros and VS stable. Continue to monitor. Review of Resident #1's progress notes dated 06/15/2024 at 6:00 PM documented by RN A reflected: Resident #1 was wheeled from dining room to room by CNA B states resident is acting drowsy. Resident #1 assisted to bed. Resident #1 noted with seizure activity. Unable to speak and noted eyes closed flashing back and forth. VS 97.8, 79, 18, 100/60. O2 Sat 94%. Resident positioned on side. [Telehealth] clinician provided healthcare consultation online with nurse and Resident #1. Seizure noted lasting 3-5 minutes. Resident #1's family member entered room and called residents name and resident was able to open eyes and focus on staff. Resident #1 was still nonverbal but was able to nod. Per [telehealth] clinician verbally to send resident out to ER for further evaluation. Family member aware and left at this time. EMS phoned and in route. Resident transferred to hospital ER. Family member phoned regarding which hospital as requested. Message left. Report phoned to ER. Spoke with ER Nurse. Also informed nurse of pending x-ray to left wrist and hand. DON/ADON notified. Review of Resident #1's physician orders, dated 07/01/24, revealed the resident was transported via ambulance for emergent care due to undisplaced fracture of the distal left radius. Review of Resident #1's progress notes dated 06/15/2024 at 7:50 PM documented by RN A reflected: Head to toe assessment performed. No other injuries at this time. Review of Resident #1's progress notes dated 06/15/2024 at 7:46 PM documented by the telehealth NP for Tele med visit reflected: Primary Chief Complaint: Seizure; History Present Illness: Appears to be having a seizure activity, eyes closed lids flashing, does not open to name called. [family member] in room with patient and nurse. Physical Exam: Exam findings per nurse and video observation. Physical Exam - Notes: Patient observed lying in bed, still in seizure status. Appears to be catatonic (person appears awake but seem unresponsive to environment/others) for observation. Unresponsive to commands by family member or nurse. Orders - ED transfer due to presentation and continued seizure activity. Disposition - Transfer to Emergency Department. Review of Resident #1's progress note dated 06/18/2024 at 1:50 PM documented by LVN C reflected: Resident readmitted to facility, arrived on a reclining chair accompanied by [EMS] driver. [EMS] said she happy to be home with a grin on her face. DR's NP notified at [2:47 PM]. Skin assessed, noted greyish bruising to left hand, no swelling but discomfort with movement. Bruised area on left elbow area from hospital IVs sites. [Resident #1's spouse] notified, Resident with no distress, no pain at this time, able to move all extremities with limited movement to bilateral upper extremities. New orders to STOP Ibuprofen, simvastatin and start on Atorvastatin and Aspirin. v/s 125/65, 70, 18, 97.5., 97% room air. Call light in reach, bed lowest position, water pitcher and resident's snacks in reach. Review of Resident #1's Regional Nurse Consultant's note dated 06/18/2024 at 12:17 PM reflected: Arrived on a stretcher. admitted from a hospital. Admitting Diagnosis: Possible CVA. Has a history of falls. Does not complain of pain. Review of Resident #1's progress note dated 06/19/2024 at 2:34 PM documented by LVN C reflected: Day 2 readmission left wrist and forearm bruised from post fall. No swelling noted. Pain at 4/10 this morning, medicated for pain with Tramadol 50mg, med was effective. Up in WC after shower, participated in therapy. Assisted with toileting every 2 hours, fall risk. Chair alarm in place and functioning. BP 132/67, 77, 97.9, 18, 97% room air. Review of Resident #1's progress note dated 06/20/2024 at 10:17 AM documented by LVN C reflected: Day 3 readmission left wrist and forearm bruised from post fall. No swelling noted. Pain to left wrist area, medicated for pain with Tramadol 50mg, med was effective. Review of Resident #1's progress note dated 06/22/2024 at 6:40 AM documented by RN A Reflected: Resident #1 requires daily skilled observation for, circulatory issues, genitourinary issues, musculoskeletal issues, or fracture(s), high-risk medication management, neurological issues, teaching/education, management, and evaluation of care plan. The resident is receiving PT services. OTHER OBSERVATIONS: Skilled charting in place. Resident denies pain/discomfort. Safety precautions in place related to fall risk. Needs anticipated. Continue to monitor. Review of Resident #1's progress note dated 06/23/2024 at 7:04 AM documented by LVN D reflected: Cont. to monitor resident r/t falls up in w/c at nurse station most of shift medicated x1 for left wrist/forearm pain left hand discolored. Review of Resident #1's progress note dated 06/23/2024 at 7:08 AM documented by RN A Reflected: Resident #1 requires daily skilled observation for, circulatory issues, genitourinary issues, musculoskeletal issues, or fracture(s), high-risk medication management, neurological issues, teaching/education, management, and evaluation of care plan. The resident is receiving PT services. OTHER OBSERVATIONS: Skilled charting in place. No acute distress noted. Safety precautions in place related to fall risk. Needs anticipated. Continue to monitor. Review of Resident #1's progress note dated 07/01/2024 at 4:16 PM documented by LVN E reflected: Patient received pain pill at this time per complaining of left-hand pain. The Pain was noted to be a 6 on a scale of 0-10 in the MARS. Review of Resident #1's nurse's note dated 07/01/2024 at 8:12 PM documented by LVN E reflected: Resident got order for left ulna x-ray d/t c/o pain; [radiology service] contacted. Review of Resident #1's progress note dated 07/01/2024 at 8:41 PM documented by LVN E reflected: X-ray report back with impression, acute undisplaced fracture of the distal metaphysis of the left radius in good position, no dislocation. MD notified, and gave order to send patient to ER, called and left message to the DON, notified ADON, and called Ambulance to transport Patient to [hospital ER]. Family member (R/P) notified. Patient not in any distress at this time. The following interviews revealed staff were knowledgeable and were in-serviced on fall protocols, assessing, following-up on changes/injuries, and notifying the appropriate parties: During an interview on 07/24/2024 at 10:45 AM with ADON revealed Resident #1 was alert and able to state her needs. Resident had a history of falls. The ADON revealed the interventions in place to protect Resident #1 from falls were a low bed, fall mat on floor, call light within reach, her personal items close to her, and there were times when Resident #1 was placed the in-TV area or here at the nurses station. Resident #1 would still try and get up. The ADON stated the steps nurses are to follow when a resident has a witnessed or unwitnessed fall. Complete a full assessment to check for injuries, contact Physician, family, DON, and Administrator. Order an x-ray right away. Follow-up with Physician with results. During an interview on 07/24/2024 at 11:00 AM with LVN F revealed the steps she would follow when a resident has a witnessed or unwitnessed fall. LVN F revealed that when a resident falls, she would complete a full head to toe assessment. If there are no injuries to the resident, resident is assisted up. If resident is injured, contact the Physician for orders for an x-ray. If x-ray shows a break or other injury will send to the hospital for further evaluation. Always have call light within reach, some residents are place in a low bed. LVN F has attended In-services r/t falls, protocols addressing falls, Fall Management. LVN F revealed that there have been several in-services she has attended. During an interview on 07/24/2024 at 11:15 AM with LVN G revealed that the facility has been focusing on Fall Management. LVN G revealed that the Therapy Director held an in-service on Different scenarios r/t to falls. LVN G revealed that a head-to-toe assessment must be completed. If the resident was hurt, it was best to lift resident with a Hoyer and contact the Physician for an order for an x-ray. Notify the DON and the family. If the resident had a head injury send them to the ER immediately. If the order is Stat, they get here within the hour and if it is not stat it could be longer. LVN G revealed she would complete a skin assessment, contact hospital to ask for information r/t the bruise, contact MD, DON, and family. Monitor area to make it does not get worse. She would ask MD for an order for x-ray. LVN G revealed if a previous x-ray order was pending and resident was transferred to hospital before x-ray was completed and you find out that hospital did not complete the x-ray, contact the doctor for an x-ray order, notify the DON, and the family. If resident is in a lot of pain, send to the hospital. If x-ray not follow-up on, resident could have an injury that has not been diagnosed causing more pain to resident. During an interview on 07/24/2024 at 12:27 PM with LVN H revealed that she was familiar with Resident #1. LVN H revealed that staff had to make sure the bed alarm was on Resident #1 while in bed or when she was in the wheelchair. LVN H revealed that the staff would have to set resident near or at the nurses' station to always monitor her. Resident #1 would still try to get up out of her wheelchair. Assessments were completed when a resident fell . In Resident #1's case, the Nurse and CNAs reassess a resident to develop interventions to prevent a resident from falling. Some of the interventions included were low beds, fall mat beside the bed, call light within reach, and keeping everything familiar to resident within reach, keep resident close to the nurses' station, complete a fall assessment, and have PT assess the resident. LVN H revealed she notifies the MD, the family, and the DON. LVN H revealed Nurses were to document in the Risk Management and in the resident's file. LVN H revealed she would contact the MD for X-ray orders. LVN H revealed she would ask the resident what their pain is on a scale of 0 - 10. If they were unable to answer, nurses would document facial expressions. LVN H revealed this would be documented in the PAIN MARS and the resident's progress notes. LVN H revealed the nurses must go behind the CNAs to make sure they are following the interventions. If resident returned from the hospital with a bruise, LVN H revealed she would contact the Doctor, ask the resident what happened if they could tell her, follow up with x-rays if doctor orders them or send them back to hospital per doctor's orders. If a previous x-ray order were pending and resident was transferred to hospital before x-ray was completed and you find out that hospital did not complete the x-ray in the hospital, LVN H would call the doctor to get x-ray orders again. LVN H has been to In-Services held on Falls, Fall Management, Change of Condition, X-Rays. LVN H revealed there have been in-Serviced recently. During an interview on 07/24/2024 at 2:40 PM RN A revealed that Resident #1 told CNA B that she had a fall. The fall was an unwitnessed fall on 06/14/2024. RN A revealed that Resident #1 had an injury to her wrist but did not complain of constant pain until 07/01/2024. RN A revealed that an order was received on 06/15/2024 from the NP, but Resident #1 had a seizure and was sent to the hospital on 06/15/2024. RN A revealed in her notes that she informed the ER Nurse there was a pending order for an x-ray for a left wrist and hand x-ray. Resident returned from the hospital on 06/18/2024 and Resident #1's wrist was bruised but not swollen. Resident #1 was not complaining of pain when she returned from hospital. RN A stated she did not know if the hospital completed the x-rays and did not order another x-ray. RN A revealed Resident #1 did not complain of pain on RN A's shift on 07/01/2024 but did complain of pain on evening shift. RN A should have ordered the x-ray the day resident returned from the hospital after reviewing the hospital notes revealed no x-ray completed to Resident #1's left wrist and hand. MRI and a CT scan were completed to find cause of resident's seizure and possible stroke. Failure was that no follow-up was completed r/t concerning x-ray. Resident #1 was having pain in wrist on 07/01/2024. During an interview on 07/24/2024 at 12:51 PM with LVN C revealed she was familiar with Resident #1 and had provided care to her. LVN C revealed Resident #1 has a history of going to bathroom by herself and falls. LVN C revealed staff check the residents every shift, especially for Resident #1. She stated the resident will try and get up out of bed without calling for assistance and after lunch she would try and go from the wheelchair to the bed. Then she falls. LVN C revealed Resident #1 told a CNA B that she fell and got herself up. (06/14/2024) LVN C revealed the nurses found out the next day on 06/15/2024 that the resident had a fall. LVN C recalled that RN A did contact the Doctor for an x-ray order. LVN C stated on 06/18/2024, she documented Resident #1's left wrist and forearm bruised for the next 3 days. Resident was sent to hospital before the x-ray was completed. Resident #1 was readmitted to facility on 06/18/2024. LVN C revealed she did not order an x-ray when she noticed the bruise to the left wrist and hand because the resident was not complaining of pain. Failure occurred during the 3 days due to there was no follow up for x-ray to resident's left wrist and hand until 07.01/2024 when resident began complaining of pain. During an interview on 07/24/2024 at 1:16 PM with CNA I revealed that he is familiar with Resident #1 and has provided care to her. CNA I revealed that Resident #1's bed would be in lowest position. Staff would have to put a bed alarm on her. When she was up in wheelchair, she would have the alarm on. As CNA I revealed that he was not sure when she had a fall. CNA I revealed that the bed is usually low to the floor, a mat next to the floor, the call light close to resident, her things close to her, and be monitored closely. CNA I had attended in-services on Falls, Fall Management, Change of Condition. CNA I revealed that he could not remember all of the in-services, but there have been many. CNA I did say a resident could have complications from not having an x-ray. During an interview on 07/24/2024 at 1:30 PM with LVN E revealed he was familiar with Resident #1 and provided care to Resident #1. LVN E was on duty on 07/01/2024 when Resident #1 began complaining of pain in her left wrist. LVN E gave Resident #1 a pain pill due to the pain she was in. LVN E revealed the wrist was bruised a swollen some. LVN E contacted the doctor to get an order for an x-ray. LVN E revealed the x-ray showed a fracture in the wrist. He contacted doctor with results, DON, ADON, and family. Doctor ordered resident to be sent to hospital. LVN E revealed that he would complete a skin assessment, contact the doctor or an x-ray it a resident returned from the hospital with bruising. LVN E stated if a previous x-ray had been ordered due to resident's fall and resident was sent out to the hospital before the x-ray was completed; then when the resident returned from the hospital he would contact the doctor for an order for x-ray. During an interview on 07/24/2024 at 1:45 PM with LVN K to ask questions r/t falls and injuries. LVN K revealed that she worked with Resident #1 on 06/23/2024 and noted resident's bruised left wrist and hand. Medicated resident 1X for pain. LVN K continued to monitor Resident #1's bruised left wrist and hand while on shift. LVN K revealed that if a resident had returned from the hospital with an unexplained bruise, she would complete a full skin assessment. Contact the doctor, the DON, and ADON. If needed ask doctor for an order for x-ray. Contact family. If x-ray shows an injury send resident back to the hospital per doctor's orders. What is the risk if you don't address a change of condition? LVN K revealed we are putting the resident in danger by not addressing their change of condition. Contact the doctor for an x-ray order. LVN K was not aware an x-ray had not been completed on Resident #1. During an interview on 07/24/2024 at 2:00 PM with LVN L to ask questions r/t falls and injuries. LVN L revealed that if a resident returned from the hospital with a bruise or injury, she would complete a skin assessment, call the physician, take orders on what to do. LVN L revealed there is a risk of resident getting worse if there is an injury that has not been addressed. LVN L revealed that you may not know how long the issue has been going on. She would be aggressive in addressing the issue because it could be fatal. If a previous x-ray order was pending and resident was transferred to hospital before x-ray was completed and you find out that hospital did not complete the x-ray in the hospital, LVN L would contact the doctor immediately for x-ray orders. During an interview on 07/24/2024 at 2:10 PM with CNA J revealed that she is familiar with Resident #1. CNA J revealed that inventions have been implemented for resident: low bed, but Resident #1 still would try to get out of bed. Then the staff would raise the bed to keep her in bed. When Resident #1 is up in wheelchair, she would be placed in tv area within eyesight from the nurse's station or at the nurse's station. There would be a chair alarm in the wheelchair and a bed alarm when she was in the bed. If the bed alarm goes off, the staff get the resident back up to prevent a fall. Resident #1's alarm goes off all the time. CAN J believes Resident #1's fall happened in the evening time. Resident #1 can walk a little. CNA J revealed that the staff would constantly tell Resident #1 that staff would not want her to fall. CNA J revealed she saw Resident #1 the last day she was at the facility but did not notice any injuries. CNA J revealed Resident #1 refused the interventions that were in place to prevent her from falling. CNA J has she had attended In-services on Falls, Fall Management, Change of Condition? CNA J Revealed she has attended several In-services in July. During interview on 07/24/2024 at 3:45 PM the DON revealed Resident #1 was fragile, has a cognitive decline, has a poor gait, can walk at times, used a wheelchair. The DON stated the resident sustain a fracture of left wrist The DON stated the nurses contacted the Physician to inform them of the fall. The DON stated when the Dr. orders an x-ray, if it was a regular order, the company could arrive there anytime but if the x-ray was stat, the radiology company should arrive within 4 hours. The DON stated if the resident was in a lot of pain, they are to contact the doctor to get orders to send to the hospital. The DON stated there was an order for an x-ray the day she went to the hospital on 06/15/2024. The nurse informed the ER nurse about the pending x-ray order for the left wrist when Resident #1 was transferred to ER. She stated the nurse called and tried to find if the x-ray was completed in the hospital, but the information could not be found. The DON revealed Resident #1 was not having any pain when she returned from hospital which was why was an x-ray not completed. On 07/01/2024 DON/Designee ordered X-ray of Resident #1's left ulna with an impression of an acute displaced fracture of the distal metaphysis of the left radius. The physician was notified of the finding and the resident was sent to the local emergency room and will not be returning to the facility. During an interview and record review on 07/24/2024 at 2:15 PM with the Administrator, DON, and Regional Nurse Consultant revealed documentation r/t Resident #1. They presented documentation for QAPI meeting held in the facility on 07/02/2024 that discussed the timeline of events that occurred with Resident #1's fall from 06/15/2024 - 07/01/2024; Performance Improvement Project Report; Staff Questionnaire r/t Resident #1's injury; and Safe Surveys. The following procedures, audits, and interventions presented to prevent further mistakes in resident's care: The DON/Designee completed a review of all Incident and Accidents for the prior 2 weeks to validate that any resident that required an X-ray had one completed timely if applicable. No other residents were identified as not receiving an x-ray if needed. The Social Service or designee completed alert resident interviews to validate that all residents felt safe and were receiving timely services if applicable. No issues were noted. The DON or designee provided education to all Licensed Nurses and C.N.A.'s on Notification of Change in condition to provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The DON/Designee provided education to all Licensed Nurses and C.N.A.'s on Fall Management to provide guidance types of falls, fall prevention measures, documentation of falls, investigation and follow up to falls, appropriate interventions with injuries, and follow up. The DON/Designee started reviewing in the morning meeting that any resident with a fall has a new fall assessment and pain assessment completed to alert nurse for possible new interventions. The DON/Designee began reviewing all Incident reports in morning meeting to validate that any resident that required diagnostic testing, had appropriate and timely interventions. The DON/Designee completed a Performance and Improvement Plan which is reviewed daily in the morning meeting to guide the facility in sustaining compliance. Record review of the facility Policy, Radiology and other Diagnostic Services and Reporting Revised: 07/26/2022 indicated the following: The facility must provide or obtain radiology and other diagnostic services when ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with State law. Stat Diagnostic Test - - STAT orders will be communicated to the appropriate diagnostic services by facility staff immediately with the expectation they will be performed/collected within 4 hours under normal circumstances. - If the STAT diagnostic test is not performed/collected within 4 hours from contacting the diagnostic service, contact the physician, and DON. Review of in-services and interviews, dated 06/15/2024, with nurses, DON, Regional Nurse Consultant revealed the facility implemented in-services on the following: Topic: Post Fall Management - 06/15/2024 Radiology orders for post fall incidents should be ordered at STAT for best practices. 1. STAT orders will be communicated to the appropriate diagnostic services By facility staff immediately with the expectation they will be performed/ Collected within 4 hours under normal circumstances. 2. If the STAT diagnostic test is not performed/collected within 4 hours from contacting the diagnostic service contact the physician and DON. If the resident is waiting for services to be performed and the injured location appears to be worsening inform the practitioner for potential ER transfer if indicated. Topic: Change of Condition - 07/02/2024 1. CNA or other non-licensed nursing staff recognize a resident's change of condition, the charge nurse must be notified immediately 2. Charge nurse must assess, gather vital signs and ask resident specific question (if possible) about their change of condition 3. Charge nurse must notify MD, resident's family or POA and DON and then document in Progress notes in PCC, add to 24-hour report and alert charting 4. ADONs will audit hospital orders for existing conditions, monitor nurse's notes to ensure there is not issues with resident after return Topic: Fall Demonstration Examples: Man on Floor! What's wrong with this picture? The noncompliance was identified as PNC. The IJ began on 06/18/24 and ended on 07/01/24. The facility had corrected the noncompliance before the survey began.

Based on record review, the facility failed to ensure a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body appoints the administrator who is licensed by the State, where licensing is required for one (Administrator) of one staff reviewed for administrative license. The facility failed to ensure the Administrator's license was current, which expired [DATE]. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents. Findings included: Internet search of, https://txhhs.my.site.com/TULIP/s/public-search, revealed the Administrator's license was issued on [DATE] and expired [DATE].

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 of 63 resident (Resident #1) reviewed for neglect, in that: The facility failed to report the allegation of neglect r/t falls for Resident #1 to the State Agency within required reporting timeframes. This failure placed residents at risk of ongoing neglect. Findings included: Record review of Resident #1's face sheet dated 07/09/2024 revealed a [AGE] year-old female admitted to the facility on 04/25/2001 and readmitted on [DATE] with a diagnoses of Multiple Fractures of Ribs, Bilateral (affecting both Rt. And Lt. sides of ribs), initial Encounter for Closed Fracture (occurs when multiple ribs are broken in multiple places, separating a segment which is free-floating and moves independently), Dementia in other Diseases Classified elsewhere, moderate without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety (a person is presenting signs and symptoms of dementia and lack symptoms of behavioral disturbances). Record review of Resident #1's MDS (Minimum Data Sheet) dated 06/26/2024 revealed Resident #1 BIMS (Brief Interview for Mental Status) score was noted to be 06/15 indicating severe cognitive impairment. Resident #1 required modified to total assistance making decisions regarding tasks and providing daily care. Resident requires minimal to maximum to prevent falls. Interventions in place to prevent falls noted on Care Plan noted as adaptive equipment available to resident, modified seating, Place frequently used items within reach, provide Reacher for resident, bed in low position, and appropriate footwear while ambulating. Medical records dated 06/05/2024, indicated Resident #1 had two unwitnessed falls. The first fall dated 06/04/2024, resident was found in the bathroom on the floor by the MA. The resident received a skin tear to the back of her right wrist and the back of her left wrist had a reddish discoloration. X-ray taken on 06/04/2024 reflected healed ORIFs distal radius and ulna multiple fractures of ribs and clavicle (a surgical procedure to treat a fractured ulna and radius (bones in forearm), multiple fractures of the ribs and clavicle (combination of injuries may result in decreased stability of the chest wall, making these patients prone to respiratory complications and prolonged hospitalization s), Left hand Arthritis (swelling in one or more joints causing pain and stiffness), Right hand NAD (hand numbness can be caused by damage, irritation, or compression of nerve or a branch of a nerve in arm or wrist). Medical records dated 06/15/2024, indicated resident had second unwitnessed fall on 06/14/2024. On 06/15/2024, CNA reported to RN Resident #1 had pain and swelling to her left hand. Resident #1 reported to the CNA that she had a fall the day before after breakfast and she got herself up. The NP ordered an x-ray to the left wrist and hand. On 06/15/2024 at 6:00 pm, Resident #1 became drowsy while in the dining room. Resident #1 was taken back to her room and placed in bed where she began to have a seizure. Resident #1 was sent to hospital and was admitted . The RN informed the ER nurse about the pending x-ray of Resident #1's left wrist and hand. Medical record dated 06/18/2024, indicated Resident #1 readmitted to facility. Skin assessed, noted greyish bruising to left hand, no swelling but discomfort with movement. Bruised area on left elbow area from hospital IVs sites. Medical record dated 06/19/2024, Day 2 readmission indicated Resident #1's left wrist and forearm bruised from post fall. Medical record dated 06/20/2024, Day 3 readmission indicated Resident #1's left wrist and forearm continued to be bruised from post fall. No swelling noted. Pain to left wrist area, medicated for pain with Tramadol 50mg, med was effective. Medical record dated 06/23/2024, indicated Resident #1 continued to be monitored r/t falls. Resident up in w/c at nurse station most of shift, medicated x1 for left wrist/forearm pain. Left hand discolored. Medical record dated 07/01/2024, indicated Resident #1 received pain pill at this time per complaining of left-hand pain. X-ray ordered of left ulna. X-ray report back with impression, acute undisplaced fracture of the distal metaphysis of the left radius in good position, no dislocation. The MD was notified and gave order to send patient to the ER. On 07/09/2024 at 3:45 p.m. interview with the Administrator, revealed that she is responsible for sending the reports to the CII provider number. The Administrator revealed that her expectations would be to notify the Provider Investigation Report within 2 hours or 24 hours and complete the 5-day Provider Investigation Report. The Administrator revealed that was not completed because Resident #1 was sent out to the hospital before the x-ray could be completed. The Administrator revealed that the facility administration must report all incidents with injuries to the CII provider immediately after the incident occurred. Asked Administrator if Resident #1's falls that occurred on 06/4/2024 and 06/14/2024 reported to the State? The Administrator revealed that the falls were not reported because they did not know there were any injuries the time of the falls. The fall that occurred on 06/04/2024, the results were received on 06/05/2024 resulting left wrist x ray: healed ORIFs distal radius and ulna. Clavicle: Multiple fractures of the ribs and clavicle. Hand: left hand arthritis. The fall was not reported to the State. The unwitnessed fall that occurred on 06/14/2024, an x-ray was ordered, but resident was sent to the hospital before the x-ray could be completed. Resident #1 was complaining of left hand, wrist, pain and swelling. On 06/15/2024, Resident #1 noted to have seizure activity while in dining room. Was transported to hospital. Resident return to facility on 06/18/2024. Hospital did not complete an X-ray of resident's right wrist. On July 1, 2024, resident continued to complain of pain in left wrist. Resident continued to have pain in left wrist from 06/14/2024 - 07/01/2024. Asked Administrator if incident was reported to SA. Administrator revealed no it was not reported to SA because Resident #1 was sent to hospital before an x-ray was completed. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 10/24/2022 revealed in part: the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. .Reporting all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegations do not involve abuse and do not result in serious bodily injury.

Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen tubing was dated. These failures affected residents and placed them at risk of not receiving the needed services for respiratory care. Findings include: Record review of Resident #1's face sheet, revealed an [AGE] year-old female was admitted on [DATE] with a primary diagnoses of DEMENTIA,WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE; CHRONIC RESPIRATORY FAILURE (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), Record review of Resident # 1's Medication Administration Record, dated May 2024 revealed change and label O2 tubing and humidifier bottle and clean O2 concentration filter weekly, every night shift every Sunday for oxygen. Start date 03/19/2023 shift 10 pm - 6 am. Record review of Resident #1's Care Plan dated 03/02/2024 revealed Resident had FOCUS care plan for Oxygen: Resident used oxygen therapy routinely or as needed and is at risk for ineffective gas exchange. Intervention: provide a nasal cannula for meals, as allowed by the physician. In an observation on 05/08/2024 at 10:50 A.M. revealed Resident #1 was lying in bed on her side with a nasal cannula positioned appropriately in her nostrils. The oxygen concentrator was powered on and appeared to be working properly. The nasal cannula tubing was not dated. Interview with LVN A on 05/08/2024 at 2:50 P.M reflected surveyor asked LVN A to accompany her to Resident #1's room to verify the nasal cannula tubing was not dated. LVN A declined and stated that she believed that the nasal cannula tubing was not dated. She stated that the night nurse scheduled on Sunday is responsible for dating and labeling nasal cannula tubing. Observation and interview with DON on 05/08/2024 at 3:12 P.M. reflected that the nasal cannula tubing was not labeled and dated; it was the responsibility of the Sunday night nurse to change and date nasal cannula tubing. The Nasal cannula tubing should be changed weekly to prevent the risk of infection. Review of the facility policy dated 02/10/2020 Respiratory: Oxygen Administration revealed Change disposable parts once a week and label with date and initials.

Based on interview and record review the facility failed to allow the resident representative the right to exercise the resident's rights to the extent those rights were delegated to the representative for 1 of 1 resident (Resident #1) reviewed for resident rights. The facility failed to provide Resident #1's medical records, when Resident #1's POA requested them on 02/07/24. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. The findings included: A record review of Resident #1's electronic Facesheet, dated 02/21/24, indicated Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses which included pressure ulcer of sacral region, other chronic pain, non-pressure chronic ulcer, arthritis, muscle weakness, lack of coordination, and repeated falls. A record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 10, which indicated his cognition was moderately impaired. A record review of Resident #1's Care Plan, revised 12/04/23, reflected Resident #1 was in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide selfcare and discharge planning is not needed. Either the family or the resident has requested that questions regarding return to the community only be asked on comprehensive assessments. The goals for this concern included Resident and families wishes will be honored through next review date and the interventions included Observe for change in conditions that may affect long-term care goals and notify the physician and responsible party as needed. In an interview on 02/23/24 at 2:02 PM, Resident #1's POA stated on 02/07/23 she was in the BOM's office and requested Resident #1's medical records. The POA stated the BOM told her she would need to request the records from the MRC. She stated the MRC passed by the BOM office and the BOM told the MRC that she had requested the records. The POA stated the MRC said ok and rolled her eyes. She stated she went to speak to the ADMN about the incident and the ADMN told her it was a process to get the records and could take 3 days. The POA stated the ADMN told her once the request was made, she had to send it to corporate and wait for approval before they could provide the medial records. The POA stated she still had not received the records. She stated she was the POA for Resident #1 and there was no reason she should not have received the records. The POA stated she was at the facility 2-3 days ago and tried to speak to the ADMN to follow up about the records, but she would not speak to her. The POA stated as of today, she still had not received the records. In an interview on 02/23/24 at 3:05 PM, the ADMN stated she did not speak to Resident #1's POA about requesting his medical records. The ADMN stated Resident #1's FM was entitled to receive his medical records because she was his POA. The ADMN stated the facility's process for requesting medical records included, the MRC completing a request form, the form would be forwarded to their corporate office, once the corporate office approved the form, she would notify the MRC, who would provide the records. The ADM stated she never received a request form from the MRC and the MRC was currently suspended due to another issue. When the ADMN was asked about Resident #1's POA reporting the incident with MRC in the BOM's office, she stated she did recall speaking to her about this. The ADMN called the BOM into her office. The BOM stated she did recall Resident #1's POA requesting Resident #1's medical records on 02/07/24. The BOM stated she told the POA that she did not handle medical records, but she notified the MRC. The BOM stated she was not sure what happened after that. The BOM stated she did speak to the ADMN about the medical records because the POA was at the facility she believed Tuesday (02/20/24) or Wednesday (02/21/24) and was upset that she still had not received the medical records and could not speak to the ADMN. The ADMN stated she did not recall that conversation with the BOM. In an interview on 02/23/24 at 3:21 PM, the MRC stated did recall Resident #1's POA requesting his medical records. She stated the BOM notified her that the POA was requesting the records. The MRC stated when she looked in PCC she did not see that Resident #1's FM was the POA. The MRC stated she contacted Resident #1's FM and the FM said that was incorrect and the ADMN had notarized the document for her being the POA. The MRC stated she asked the ADMN about it, and the ADMN verified Resident #1's FM was the POA. The MRC stated by that time it was at the end of the day and she left the facility. She stated she forgot to follow up the next day to fill out the form. The MRC stated she messed up and just forgot. She stated it was the POA's right to receive medical records. In a follow up interview on 02/23/24 at 4:15 PM, the ADMN stated Resident #1's POA had requested the records and the facility did not provide them. She stated it was the POA's right to receive the medical records and she would get them sent to the POA. A record review of the facility's policy titled Resident Rights, dated 02/23/16, reflected .b. In the case of a resident who has not been adjudged incompetent by the State court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by State law . d. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative . 6. Information and communication . a. The resident has the right to access personal and medical records pertaining to him or herself.

Based on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for one (South hall) of two halls reviewed for environment affecting 24 of 66 rooms. The facility failed to ensure the physical layout maximized resident independence and did not pose a safety risk on 2 of the 3 sections of the South hall which affected 24 of 66 rooms. This deficient practice could place residents at risk for falls and/or injury. Findings included: An observation on 01/17/24 at 9:18 AM on the South hall revealed a bed frame and mattress against the wall in between the entrance to rooms [ROOM NUMBERS]. At 9:20 AM a Hoyer lift (assistive device used to transfer residents between a bed and chair) was against the wall outside of room [ROOM NUMBER]. An extra bed frame was against the wall between rooms [ROOM NUMBERS]. At 9:21 AM an unlocked wheelchair was noted outside of room [ROOM NUMBER] and a mattress was leaning up against the wall. Two of the 3 sections of the South hall had equipment in the hallway. An observation on 1/17/24 at 9:22 AM of room [ROOM NUMBER] revealed Resident # 1 was the only resident staying in that room and he had his own wheelchair in his room and it was locked. An observation on 01/17/24 at 9:30 AM on the North hall revealed no equipment stored on the 3 sections that made up that side of the facility. An observation on 01/18/24 at 8:49 AM revealed a Hoyer lift was against the wall between room [ROOM NUMBER] and the nurses station. There was also a bed frame up against the wall between rooms [ROOM NUMBERS]. There was an unlocked wheelchair tucked under the head of the bed frame near the entrance of room [ROOM NUMBER]. In an interview and observation with the Maintenance Director on 1/18/24 at 8:52 AM he stated the aides knew where to put the Hoyer lifts when they were finished using them. He stated he was about to fix the bed that was currently on the hall. He stated the second bed that was on the hall yesterday he had fixed it and put it away. He stated the hallway was the only place for him to fix the beds unless he took them outside. When asked if there were any empty rooms he could use, the Maintenance Director did not respond. He stated he did not know who the wheelchair belonged to and stated that it was probably for one of the residents. The Maintenance Director motioned to CNA A asking him who the wheelchair belonged to. CNA A looked in 2 resident rooms near where the wheelchair was and shook his head no indicating the wheelchair did not belong to the residents in those rooms. At 8:55 AM when CNA A walked near the Maintenance Director, he stated he did not know who the wheelchair belonged to and he did not know who had placed it there. The Maintenance Director stated an unlocked wheelchair in the hallway was a risk because a resident could try to sit in it and could fall or get hurt. In an interview and observation with CNA B on 1/18/24 at 10:49 AM she stated she was the restorative aide and helped with patient transfers. CNA B stated the Hoyer lift should be placed in the shower room after use or it could be in the hallway if it was locked. When asked of the Hoyer lift next to her was locked she stepped over and said it was not locked and proceeded to lock it with her foot. CNA B stated the risk of having unlocked equipment in the hallway was residents could trip or fall. In an interview with RN C on 1/18/24 at 11:43 AM she stated the risk of having all those items in the hallway was posing an unnecessary risk to the residents. She stated residents could run into or bump into them and get hurt. RN C stated that the Administrator said that the Hoyer lifts needed to be in the shower room and not on the halls. In an interview with the ADM on 1/18/24 at 2:17 PM she stated the Hoyer lifts needed to stay in the shower room. She stated the hallways needed to be kept clear of anything that could be a hazard or cause a potential hazard to residents. TheADM stated they started in-servicing the staff and would continue to do so. A record review of the facility's policy titled Investigation of Incidents and Accidents, dated 12/3/20, reflected, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk (s). 3. Implementing interventions to reduce hazard(s) and risk(s) 'Hazards' refers to elements of the resident environment that have the potential to cause injury or illness All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the resident environment and the risk of a resident having an avoidable accident . A record review of the facility's undated policy titled Hydraulic Lift (Hoyer Lift), reflected, .18. Return lift to designated area when not in use. A record review of the facility's policy titled, Care, Cleaning and Storage of Equipment, revised 2/13/22, reflected, It is the policy that resident equipment be cared for, cleaned and properly stored to ensure safety and infection prevention Clean equipment is stored in clean utility room, central supply, or designated location established by the facility.

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 15 residents (Resident # 3 and Resident # 4) reviewed for wounds. The facility failed to ensure treatment and documentation of pressure ulcers for Resident # 3 and # 4 and failed to ensure orders from the hospital were correct and accurate for Resident # 4's pressure ulcers upon readmission. This failure could affect the residents, who received pressure ulcer care, by placing them at risk of unnecessary infection and worsening of pressure ulcers. Findings included: 1. Record review of Resident # 3's Admission Record dated 1/18/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] and had diagnoses of major depressive disorder, stage 4 pressure ulcer of sacral (located at the base of the spine) region, stage 3 pressure ulcer of left buttock, stage 4 pressure ulcer of right heel, stage 4 pressure ulcer of other site, unstageable pressure ulcer of sacral region, generalized muscle weakness and paraplegia (paralysis of the legs and lower body typically caused by spinal injury or disease). Record review of Resident # 3's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated intact cognition, he had unhealed pressure areas (all of which were present upon admission), was at risk for developing pressure areas, and his skin and ulcer treatments included a pressure reducing chair and bed, pressure ulcer care and applications of ointments/medications. Record review of Resident # 3's Care Plan, undated, revealed, Resident has a pressure ulcer and is at risk for infection, pain, and a decline in functional abilities, and interventions included but were not limited to Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling, and Low air loss mattress. Record review of Resident # 3's January 2024 MAR dated 1/17/24 revealed an order with a start date of 8/8/23 which reflected Suprapubic [(above the pubis)] Site- Perform Site Care and dressing change to site. Every night shift for Prophylaxis [(to prevent disease)]. There was no documented evidence the order was completed on 1/13/24. Resident # 3 had an order with a start date of 11/7/23 that reflected, Scrotum [(male reproductive structure under the penis)] Pressure Wound Cleanse with NSS or Wound Cleanser; Pat Dry with gauze; Apply Collagen sheet Calcium Alginate with silver. Cover dry dressing daily. every day shift for Wound Healing and PRN. There was no documented evidence the order was completed on 1/1/24, 1/2/24, 1/3/24, 1/6/24 and 1/7/24. Record review of Resident # 3's wound evaluation dated 1/11/24 written by the wound doctor revealed the wound progress on his stage 4 pressure wound to scrotum was not at goal. In an interview with Resident # 3 on 1/17/24 at 1:15 PM he revealed the staff had not been doing his wound care consistently. Resident # 3 stated his wound care was performed the night prior however he had missed 3 days before last night. Resident # 3 said there was a day where the nurse was about to do the wound care but she left at 2pm and told him the next shift nurse would do it but that person never came. He stated even prior to the bad weather, his wound care was inconsistent. He stated sometimes they did not have the supplies. He stated sometimes the doctor ordered one thing and the facility chose to do another. He stated, They know the wound is supposed to be done but if I don't say anything they will not say anything. In a telephone interview with LVN G on 1/18/24 at 12:10 PM she stated she worked at the facility on the 6th and 7th of January which were weekend days. She stated if there was a hole on the MAR it meant the order was probably skipped, missed or wasn't clicked off. LVN G stated she was not sure why the wound treatment was not signed off on the 6th and 7th of January 2024 For Resident # 3. LVN G stated it was kind of hectic on the weekends, the wound nurse did not work on weekends so they did what they could. LVN G stated sometimes the weekend supervisor would do treatments for her and perhaps that person forgot to click it off as completed. LVN G stated maybe Resident # 3 was not in the facility on those days. LVN G could not recall. LVN G stated if it was not documented it meant it was not done. In an interview with the Wound Doctor on 1/18/24 at 12:35 PM during wound assessment and treatment she conducted for Resident # 3. She stated that his wounds were improving. 2. Record review of Resident # 4's Admission Record dated 1/18/24 revealed a 48- year-old male admitted [DATE] with original admitted [DATE]. His diagnoses included bipolar disorder, muscle weakness and major depressive disorder. Record review of Resident #4's Discharge MDS dated [DATE] revealed he discharged to an acute hospital with an acute change in mental status and had 2 stage 4 pressure ulcers which had been present on admission. The BIMS score was not assessed on this MDS. Record review of Resident # 4's Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident # 4's Care Plan, undated, revealed, Resident has a pressure ulcer and is at risk for infection, pain, and a decline in functional abilities. Stage 4 to Left ischium [(the curved bone forming the base of each half of the pelvis)]& lower coccyx [(small triangular bone forming the lower portion of the spinal column)]. Unstageable to scrotum. Interventions included but were not limited to, Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling, Pressure relieving/reducing devices on bed/chair, and Provide incontinent care as needed. Record review of Resident # 4's January 2024 MAR dated 1/17/24 revealed an order with a start date of 1/7/24 which reflected Mupirocin External Ointment 2 % (Mupirocin) Apply to left ischium topically in the morning for wound Cleanse with N. S. pat dry, apply ointment, apply collagen powder, apply silver alginate, cover with dry dressing every day until resolved. There was no documented evidence on the MAR to indicate that the order was completed on 1/7/24, 1/8/24, 1/9/24, 1/10/24, 1/11/24, 1/12/24, 1/15/24 and 1/15624. The MAR also revealed an order to, PRESSURE WOUND LEFT ISCHIUM Cleanse with Dakins 1/4 solution pat dry apply Santyl ointment and Calcium Alginate . Cover with dry dressing Daily. every day shift for wound care with a start date of 9/23/23. There was no documented evidence on the MAR to indicate that the order was completed on 1/7/24 and 1/15/24. Record review of Resident # 4's wound evaluation dated 1/11/24 written by the Wound Doctor revealed his stage 4 pressure wound of the left ischium was not at goal, and his stage 4 pressure wound of the lower coccyx was, not at goal. In an interview with Resident # 4 on 1/17/24 at 1:31 PM he revealed the staff did his wound care daily. He stated his wound was trying to heal but just couldn't heal right. In an interview with LVN F on 1/18/24 at 11:51 AM she stated she typically documented wound care on the treatment MAR. She stated whatever orders they had on the MAR they could go in and click it to show it was completed. LVN F stated that if a treatment was not done it could be because they were short and they informed the next nurse to do that treatment. LVN F stated that in that situation she would not sign the MAR so that the next nurse would see that it was there and needed to be done. LVN F stated that normally on weekdays the wound nurse (LVN E) would complete wound treatments, however there was one resident (Resident #3) that did not want LVN E to do his wound, therefore the floor nurses did his wounds. LVN F stated she could see her TAR and the wound TAR so in case LVN E had already completed a treatment, she would see that it was done. LVN F stated if there was a hole on the MAR, it meant either the treatment was not done or someone forgot to sign that they did it, therefore the initials would not show. She stated that in the nursing world if it was not documented, it was not done. LVN F stated she worked the day shift Monday January 1st through Friday January 5th, 2024. When LVN F reviewed the TAR for Resident # 3, she saw that his wound treatment was not signed off from January 1st through the 4th 2024. LVN F stated that was her fault, she did not sign it out. She stated she was at the facility and did the treatments. LVN F stated she did not know how she missed documenting 4 days in a row. Additionally, LVN F reviewed the MAR/TAR for Resident # 4. LVN F stated that LVN E did the treatments for Resident # 4 and perhaps LVN E forgot to sign off on the Mupirocin order. LVN F pointed out that LVN E had signed off on a different order for the same wound that had the order for Mupirocin. Observation completed from 7:47 AM to 12:35 PM on 1/18/24 as Wound Doctor made rounds on 15 residents (Including Resident # 3 and Resident # 4) at the facility revealed infection control measures were followed and all dressings had been dated correctly. In an interview with LVN E on 1/18/24 at 12:55 PM she stated Resident # 4 went to the hospital and may have returned with the order for Mupirocin. LVN E stated the Mupirocin order was not showing on her TAR. LVN E stated if there was an order that she was responsible for the charge nurse would place it on her TAR. LVN E stated the order for Mupirocin should not exist because it was followed with Santyl. LVN E stated the charge nurse was responsible to review all orders when a resident returned from the hospital and reconcile them. LVN E sated the next level check would be the ADON to review the orders to ensure everything was good for a new admit or readmit. LVN E stated that in general it something was not documented it was not done. In an interview with RN C and the ADM on 1/18/24 at 1:57 PM, the ADM stated it was her expectation for nurses to document as they went while giving treatments. RN C stated she had the same expectation. RN C stated if the screen was green, they were good for their shift. RNC said if the wound nurse was not supposed to do a treatment it should be coded to the nurse MAR. RNC stated the situation with LVN F where documentation did not show on the MAR for 4 days straight for Resident # 3 was because the order was showing up on a different screen where the nurse could not document. RN C stated usually LVN E did the wound treatments, however since Resident # 3 did not want LVN E to do his treatments the respective hall nurses would do them. The issue was it was not showing on the TAR or MAR of the floor nurses. In reference to Resident # 4, RN C stated when a resident returned from the hospital, the nurse was to compare orders from before the hospitalization to the orders that came back from the hospital and call the doctor. The nurse was to ensure everything was reconciled or rectified before entering the orders into the electronic medical record. RN C stated the facility planned to recode things so that the expectations would be clearer between the floor nurses and the wound nurse. Record review of the facility policy titled Medication- Treatment Administration and Documentation Guidelines dated 2/10/20 revealed, 4. Administer the medication according to the physician order. 5. Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. Record review of the facility policy titled Medication Reconciliation dated 9-24-22 revealed, Admission Processes: a. Verify resident identifiers on the information received. b. Compare orders to hospital records, home or orders from healthcare entity, etc. Obtain clarification orders as needed. c. Transcribe orders in accordance with procedures for admission orders. D. The DON/designee reviews transcribed orders for accuracy and cosign the orders, indicating the review. E. Order medications from pharmacy in accordance with facility procedures for ordering medications. F. Verify medications received match the medication orders.

Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the resident's choices for 1 of 4 residents (Resident # 2) reviewed for quality of care. The facility failed to follow physician orders concerning a non-pressure wound of the left, lower medial (situated in the middle) buttock for Resident # 2. This failure could place residents at risk of delayed treatment of injuries, worsening of injuries, pain and infection. Findings Included: Record review of Resident # 2's Admission Record dated 1/18/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] and had diagnoses which included stage 3 pressure ulcer of the sacral (located at the base of the spine) region, chronic pain, and non-pressure chronic ulcer of skin of other sites with unspecified severity. Record review of Resident # 2's Quarterly MDS dated [DATE] revealed a BIMS score of 11 which indicated moderate cognitive impairment, he was dependent or substantial assistance was needed for transfers, received scheduled pain regimen, had unhealed pressure ulcers and was at risk for developing pressure ulcers, and received applications of ointments/medications for skin and ulcer injuries. Record review of Resident # 2's Care Plan, undated, revealed, Resident has the potential for the development of a pressure ulcer, and interventions included, Check frequently for wetness and soiling, every two hours and provide incontinence care as needed, and Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling. Another intervention listed was, Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Record review of Resident # 2's wound evaluation dated 1/4/24 written by the wound doctor revealed the resident had a non-pressure wound of the right medial knee with recommendation for collagen sheet and anasept gel, and a non-pressure wound of the left, lower, medial buttock that was >1 days in duration with recommendation for calcium alginate to be applied once daily for 30 days. Record review of Resident # 2's wound evaluation dated 1/11/24 written by the wound doctor revealed the resident's non pressure wound of the left, lower, medial buttock had, improved evidenced by decreased surface area, decreased necrotic tissue. Record review of Resident # 2's January 2024 MAR dated 1/17/24 revealed an order with a start date of 1/2/24 which reflected TAO to abrasion to left lower butt cheek daily until seen by wound care MD. The MAR reflected no documented evidence it was completed on 1/3/24, 1/4/24, 1/5/24, and 1/8/24. The MAR also revealed an order to Cleanse Lt. Lower buttocks with NS/wound cleanser pat dry apply calcium alginate cover with dry dressing daily was initiated on 1/9/24. Record review of Resident # 2's Progress Note dated 1/4/24 at 6:35 PM written by LVN E revealed, Wound care Dr [name] visiting. New order cleanse rt. Medial knee with ns/or wound cleanser pat dry apply. Collagen sheet and Anasept gel, cover with dry dressing 3 times weekly. Resident's [family member] visiting. She spoke with wound care Dr. and wound care nurse concerning [Resident # 2's] care. She states that she understands [Resident #2's] condition and the non-complaint of his wound to the coccyx [(small triangular bone forming the lower portion of the spinal column)]. Dr [name] educated wound is a stage four and that it was very bad. However, we were doing our best treat the wound to ensure its improvement. MD notified. Will continue to monitor and treat. In an interview with LVN D on 1/18/24 at 12:29 PM she stated either she or the wound nurse completed the order for the topical antibiotic ointment for Resident # 2. When LVN D reviewed the MAR and saw the missed days of documentation for the application of the antibiotic, she stated she was not sure why it was not showing as having been done. LVN D stated they had been applying the ointment to Resident # 2's bottom. LVN D stated she would go ask her supervisor why it looked like that on the TAR because based on the documentation it appeared like the treatment was not done. LVN D stated they had been taking care of that. In an interview with LVN D on 1/18/24 at 12:49 PM she stated the wound nurse LVN E did not have the order for the antibiotic treatment on her TAR, and that it was only showing up on the nurse MAR. LVN D stated that LVN E told her to discontinue the order for the antibiotic ointment because they were not doing that for the resident. LVN D clarified her statement from earlier interview explaining that she thought that she was being asked about the barrier cream earlier and not the antibiotic ointment. LVN D stated that LVN E put the barrier cream on for Resident # 2 daily, however the antibiotic ointment was not what LNV D or LVN E had applied to Resident # 2's bottom. In an interview with LVN E on 1/18/24 at 12:55 PM she stated Resident # 2 should not have an order for topical antibiotic ointment as it was the charge nurse who put that order in and when the wound doctor came on 1/4/24 the doctor ordered calcium alginate for that area. LVN E reviewed her progress note from 1/4/24 for Resident # 2 and realized that she did not include the non-pressure wound of the left, lower medial buttock and only included and started a new order for another area the wound doctor had recommended that day as well. LVN E stated the wound doctor recommended calcium alginate for the non-pressure area on 1-4-24 but somehow she missed that. LVN E stated she did put the order in for the calcium alginate to the non-pressure area on 1-9-24 and had been doing that daily since then. In an interview with RN C and the ADM on 1/18/24 at 2:11 PM, RN C stated the expectation was for nurses to complete orders as prescribed by the physician, to document and to reconcile the orders as needed. RN C stated once orders were received from the wound care physician, they were to be transcribed into the MAR so that they could begin following it right away. RN C stated the risk of not implementing the wound doctor's orders right away was worsening, deterioration and infection. Record review of the facility policy titled Medication- Treatment Administration and Documentation Guidelines reviewed 2/10/20 revealed, 4. Administer the medication according to the physician order. 5. Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. Record review of the facility policy titled, Following Physician Orders dated 9/28/21 revealed, For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Document the order by entering the order and the time, date, and signature on the physician order sheet. B. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of COVID-19. 1.The facility failed to screen staff and visitors for temperature prior to allowing entry into the facility. 2.The facility failed to screen residents for temperature and other signs and symptoms of Covid-19. An Immediate Jeopardy (IJ) was identified on 01/13/21 at 5:55 PM. While the IJ was removed on 01/14/21 at 8:51 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of widespread as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The IJ Template was provided to the Administrator on 01/13/22 at 6:43 PM. These failures placed residents at risk of exposure of Covid-19 virus which could result in serious illness, hospitalization , and/or death. Findings included: 1.An observation on 01/13/22 at 9:24 AM surveyor's temperature was not obtained by Medical Records staff member who was filling in for the receptionist at the front entrance as part of the screening process and surveyor was allowed entry to the facility. In an interview on 01/13/22 at 9:26 AM with Medical Records staff it was revealed the facility was not taking temperatures because per the CDC, temperatures were not necessary. In an interview with Receptionist A on 01/13/22 at 9:37 AM it was revealed it had been about a week and a half since they stopped taking temperatures as part of the screening process. Receptionist A stated the Administrator asked her to stop using the thermometers. Record review of visitor and staff screening logs from 01/12/22 to 01/13/22 prior to surveyor's arrival revealed temperatures were not documented nor was there a place for temperatures to be documented. In an interview with the Administrator on 01/13/22 at 10:15 AM it was revealed the facility stopped taking temperatures during the screening process when the CDC distributed the information. The administrator stated she would get the information for the surveyor from the CDC. The administrator also stated a fever was not an indicator of covid and that they were not taking temperatures in any of their buildings. The administrator did not mention how long ago they stopped taking temperatures. An interview with Payroll staff on 01/13/22 at 10:30 AM revealed typically when she came to the facility she was asked if she had a fever, cough, chills, other covid symptoms, if she traveled and then she would sign the form. The Payroll staff member stated they were not doing temperature checks any longer and this had stopped for a while. The Payroll staff member stated she believed it was because the CDC said temperatures were no longer required. The Payroll staff member stated she felt not taking a temperature could cause an illness to be missed. In an interview with Laundry staff on 01/13/22 at 10:57 AM it was revealed when she arrived to work today, she answered the covid questions, signed the paper and her temperature was not taken. In an interview with Med aide B on 01/13/22 at 11:21 AM it was revealed that when she came to work someone asked her covid symptom questions, she had to sign in, but her temperature was not taken. Med aide B stated the facility used to take temperatures as part of the staff and visitor screening process but did not mention when they stopped taking temperatures. In an interview on 01/13/22 at 11:24 AM LVN C revealed she was asked if she had a fever, cough and other covid symptoms during screening this morning. LVN C stated her temperature had not been obtained by the screener. In an interview on 01/13/22 at 11:58 AM the ADON stated her temperature was not taken when she came to work. The ADON stated she started a week and a half ago and had asked why temperatures were not being taken and was told that Corporate said fever was not an indicator of Omicron, a new variant of Covid-19. In an interview on 01/13/22 at 12:54 PM CNA D stated she came to work late that day around 10 AM and her temperature was obtained as part of the screening process. CNA D stated that when she came to work on the day prior (01/12/22) her temperature had not been obtained. In an interview on 01/13/22 at 4:42 PM CNA E stated temperatures were initially being taken as part of the screening process at the front but then it stopped. CNA E stated her temperature was taken that day for the first time since they had changed the process. Record review of employee screening logs revealed that the facility stopped taking temperatures as part of the screening process on December 17th, 2021, which was a whole month ago from 01/13/22 and had not taken temperatures since that date. In an interview on 01/13/22 at 1:53 PM the Administrator stated she reviewed the CDC guidance and it stated temperatures of visitors to the building were not required, yet the CDC guidance was not provided to the surveyor. When the surveyor asked the administrator if the facility should have been doing anything differently based on the information the Administrator reviewed from the CDC, the Administrator did not provide an answer. When the surveyor asked the administrator why the receptionist was recently observed holding a thermometer, the Administrator stated they changed the screening tool a few hours ago so they would be taking temperatures for visitors and staff moving forward. In an interview on 01/13/22 at 6:40 PM the DON was asked if omicron was the only variant of Covid-19 and she responded no, there was also the Delta variant. The DON also stated they were asking folks if they had a fever and were expecting them to be truthful just like the other questions about covid-19 symptoms. Record review revealed that as of 01/13/22 there were 9 staff and 6 residents positive for Covid-19. Record review of the facility's Covid-19 tracking spreadsheet revealed that the first covid case was from a staff member on 12/24/21. From 12/24/21 to 01/13/22, there were a total of 24 staff covid cases. Root cause analysis showed the first staff tested positive for COVID-19 was likely due to a community exposure. The first resident tested positive over the holidays and had visitors. Since temperatures were not taken since 12/17/21, all visitors had no documented proof of temperatures taken. All COVID-19 cases occurred after the facility stopped taking temperatures. Record review of the facility's Covid-19 tracking spreadsheet revealed that he first positive covid case from a resident was on 12/31/21. From 12/31/21 to 01/13/22, there were a total of 7 resident covid cases. Root cause analysis revealed the first positive staff member likely contracted COVID-19 outside in the community where the first positive resident likely contracted COVID-19 over the holidays when they had visitors. Since temperatures had not been taken since 12/17/21, all visitors over the holidays had no documentation of temperatures taken and if they had a fever or not. All positive cases of residents and staff occurred after 12/17/21. Record review of the facility's Covid-19 tracking spreadsheet revealed that LVN F tested positive for covid on 01/12/22. In a phone interview on 01/14/22 at 2:54 PM with LVN F it was revealed that prior to 01/12/22, she had last worked at the facility on Friday 01/07/22. LVN F stated she had been working in the covid unit since 12/31/22 when they had their first resident covid positive case. LVN F stated she was scheduled to work on Monday 01/10/22 and Tuesday 01/11/22 but she called off because she was feeling congested. LVN F stated she stayed home both days and took medication and felt fine on Wednesday 01/12/22. LVN F stated she came to work on 01/12/22 at 6am and her temperature was not obtained as part of the screening process. During the same phone interview, LVN F stated that the DON gave her a covid-19 test on Wednesday morning (01/12/22) around 10 AM. Her test was positive, so she was asked to leave the facility and did not work the entire shift. LVN F stated that on 01/12/22 she was assigned to work the North side which meant she worked with residents with and without covid-19. LVN F stated she always had full PPE on in the covid unit and explained the decontamination process that was used upon exiting the covid-19 unit before entering the cold side of the building again. Record review of LVN F's time sheet revealed on 01/12/22 she clocked in at 6:29 AM and clocked out at 11 AM. LVN F made contact with residents while positive for Covid-19 during the time she worked on 01/12/22. Record review of the facility's policy Surveillance Plan: Infection Control COVID19 Response, revised 1/4/22, revealed screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms The facility policy did not specify that temperatures should be taken. Record review of the COVID-19 Response Plan for nursing facilities version 4.1, dated 12/31/21, revealed Active screening - The CDC and CMS recommend, and the NF COVID-19 Response rules require, NFs screen all staff prior to entering the NF at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of or shortness of breath, new or change in cough, sore throat and other symptoms of COVID-19. If they are ill, have them put on a facemask per CDC guidance, immediately leave the NF, and self-isolate at home. DSHS has created a template screening log for facility staff that is available on the DSHS website. Facilities should also screen any essential visitors who are permitted to enter the building, including visiting health care providers. Maintain a log of all visitors who enter the building that at minimum includes name, current contact information, and fever and presence/absence of symptoms. 2. During resident record review in Point Click Care (PCC), surveyor could not locate resident screenings. In an interview with DON on 01/13/22 at 4:15 PM it was revealed that resident screenings were done on paper and not in PCC. At that time surveyor asked for documentation of resident screening. In an interview on 01/13/22 at 4:17 PM Resident #1 stated the nurse checked his temperature every few days. In an interview on 01/13/22 at 4:29 PM Resident #2 stated they had not taken her temperature in a long time. Resident B stated they used to take her temperature every day, but they did not do it anymore. In an interview on 01/13/22 at 4:31 PM Resident #3 stated the nurse checked his temperature once a week or something like that. In an interview on 01/14/22 at 1:42 PM Resident #4 stated that her temperature was not obtained every day by her nurse. In an interview on 01/14/22 at 5:27 PM Resident #5 stated the frequency with which her temperature was taken was dependent upon who the nurse was on a given day. Resident #4 stated that her temperature was taken more like every other day. In an observation on 01/13/22 at 4:35 PM when Surveyor returned to the conference room, there was a resident screening form dated 01/12/22 for residents on the 200 side of the building on the table, indicating that their covid-19 screening was completed on 01/12/22 and included temperatures. In an observation on 01/13/22 at 4:39 PM LVN G was completing her resident screening log. It was observed that the temperature column was already completed. LVN G was observed writing N's (meaning no) in the columns asking about other covid-19 symptoms. In an interview on 01/13/22 at 4:40 PM LVN G stated she was completing her log for that day, that she had already taken her temperatures and she was just filling in her N's (meaning no) for the other signs and symptoms of covid-19 in the remaining columns. Record review of the resident screening log for the 200 side of the building handed to the surveyor by LVN G revealed it was dated 01/11/22 even though LVN G had stated she was completing her log for that day which was 01/13/22. In an interview on 01/13/22 at 4:55 PM Surveyor informed DON that the resident screening logs for January 2022 from both the 100 and 200 side of the facility were needed for review. In an interview on 01/13/22 at 6:20PM right after the DON provided resident screening logs from the 100 side of the building, the DON was asked for the missing logs from the 200 side of the building. The DON stated she had asked someone else to get the remaining screening logs. Record review of resident screening logs from the 100 side of the building revealed that there was no screening documentation for 01/12/22 and 01/13/22. As of 01/13/22, there were forty-two residents living on the 100 side of the building. In an observation on 01/13/22 at 6:33 PM LVN G was filling in screening logs at the nurses' station. There was a screening log with missing information, such as resident name column was half filled in and some temperatures were missing that LVN G was writing on as surveyor approached the desk. In an interview on 01/13/22 at 6:33 PM surveyor asked LVN G where she was transcribing the information from and LVN G stated she was looking for her papers and began rummaging through some papers on the desk, but could not show surveyor what she was transcribing from. When surveyor asked LVN G what date the screening log was from that was not fully completed, LVN G stated she did not know. During this interview the DON came to the nurses' station and heard the surveyor asking LVN G the above questions and the DON did not say anything. Record review of the logs taken from LVN G revealed completed screening logs from 01/03/22, 01/04/22 and 01/05/22. The form that was being completed during the previous observation did not have a date yet. The incomplete form listed eight resident names and only had three temperatures listed. The incomplete form only had answers for the remaining covid-19 symptoms for 2 of the residents listed. No resident screening logs were provided for residents on the 200 side of the building for the following dates: 01/01/22 - 01/02/22, 01/06/22 - 01/10/22, and 01/13/22. As of 01/13/22, there were twenty-seven residents living on the 200 side of the building. Record review of the facility's policy Surveillance Plan: Infection Control COVID19 Response, revised 1/4/22, revealed Actively monitor all residents upon admission and at least daily for fever and respiratory symptoms (use latest COVID-19 CDC Guidelines). Record review of the COVID-19 Response Plan for nursing facilities version 4.1, dated 12/31/21, revealed Monitoring - Ask residents to report if they feel feverish or have symptoms of respiratory infection and COVID-19. Actively monitor all residents upon admission and at least [once] daily for fever and respiratory symptoms (including shortness of breath, new or change in cough, sore throat, and oxygen saturation). If the resident has fever or symptoms, implement recommended infection prevention and control (IPC) measures. On 01/13/22 at 6:43 PM the Administrator and DON were notified an Immediate Jeopardy was identified and a Plan of Removal was requested. The IJ template was provided. The facility's Plan of Removal was accepted on 01/14/22 at 2:11 PM and reflected the following: [name of the facility] 1. Immediate action(s) taken for the resident(s) found to have been affected include: The DON/ADON will immediately take the temperature of all residents, employees and visitors. The Administrator will validate that the Visitor Screening, Employee Screening and Resident COVID-19 Monitoring forms have a line item for temperatures and other COVID-19 Symptoms. No abnormal temperatures were identified 2. Actions to Prevent Occurrence/Recurrence: Include actions the facility will take to alter the process or systems to prevent a serious adverse outcome from occurring or recurring, and when those actions were completed. (Completion Date: __1/14/2022_) All employees will be in-serviced on Surveillance Plan: COVID-19 Response Policy which includes taking temperatures for residents daily and visitors, vendors and employees upon entry to the facility The DON/ADON will validate daily Resident COVID-19 Monitoring is completed and filled out for all COVID-19 symptoms daily. The DON will conduct the in-service for 100% of the employees and agency staff before they start the shift on the Surveillance Plan: COVID-19 Response Policy DON/ ADON will administer a post test to all employees and agency staff The in-service content will focus on; o What can individuals do to help combat COVID-19 such as; wear a mask, maintain social distancing, stay home when you are sick, encourage residents to wear face mask, gown, gloves o COVID-19 symptoms and reporting o Taking temperatures as part of COVID-19 monitoring for employees, visitors/vendors and resident o Handwashing o Wearing N95 or KN95 facemasks help to reduce the risk of spreading COVID-19 The Administrator/ Social Worker will validate daily that Visitor/Vendor Screening forms and Employee COVID-19 Screening form are completed daily. New employees will receive in-service on the Surveillance Plan: COVID-19 Response Policy before starting work during orientation. The DON will conduct the in-service. When a visitor/vendor has a temperature of 99.6 F or above, the screener will document the temperature and not allow the visitor/vendor enter the facility. o The screener will report the temperature to the Administrator or DON who review the visitor/vendors COVID-19 symptoms When an employee has a temperature of 99.6 F or above the employee will not be allowed entrance into the center. o A rapid COVID-19 test will be completed and all COVID-19 symptoms will be reviewed by Administrator or DON. o If rapid test is negative the employee will be restricted from working for 72 hrs. without a temperature or other COVID-19 symptoms o If the rapid test is positive the employee will be sent for a PCR test to confirm and placed on home self-isolation by Administrator or DON. o The employee will be given a copy of CDC Home Isolation Guidance. o If the employee PCR Test is positive The following work restrictions will be reviewed with the employee and followed by the facility if the PCR is positive. Work Restrictions for HCP with [CONDITION(S)]-CoV-2 Infection Vaccination Status Conventional Contingency Crisis Boosted, Vaccinated, or Unvaccinated 10 days OR 7 days with negative test +, if asymptomatic or mildly symptomatic (with improving symptoms) 5 days with/without negative test, if asymptomatic or mildly symptomatic (with improving symptoms) No work restriction, with prioritization considerations (e.g. asymptomatic or mildly symptomatic) For calculating day of test: 1.) for those with infection consider day of symptom onset (or first positive test if asymptomatic) as day 0; 2.) for those with exposure consider day of exposure as day 0. 3 .How the corrective action(s) will be monitored to ensure the practice will not recur: Facility's Checklists and Monitoring tools used to verify compliance, frequency, how long and responsible person. The audit completed by the Administrator/Social Worker and DON/ADON for COVID-19 Symptom Monitoring including temperature will continue for 30 days. All COVID-19 Monitoring forms will be initialed by the Administrator/Social Worker and the DON/ADON Audits will be reviewed monthly by the Quality Assurance Committee to monitor consistent substantial compliance Monitoring of the Plan of Removal included: Review of the facility's in-service records revealed: 1.The DON's name was listed as the facilitator of the in-services. The in-service topic was the Surveillance Plan: Infection Control COVID19 Response Policy with an emphasis on minimizing exposure and spread of respiratory pathogens including Covid-19, screening including temperature of all who enter the facility for signs and symptoms of covid, and denial of entry of those with signs or symptoms. 2. As of 01/14/22 at 8:51 PM a total of 44 staff employed at the facility had been in-serviced. Record review of visitor and employee screening logs revealed all staff and visitors were screened for temperature along with other covid-19 symptoms before being allowed entry into the building. Record review revealed all residents on both the 100 and 200 sides of the building were screened for temperature and other signs and symptoms of covid-19 on the 6am to 2pm shift on 01/14/22. Record review revealed the audit tool for the temperature log that was to be used for the subsequent thirty days was already being implemented with Administrator and SW signatures noted. Record review of the facility's policy Surveillance Plan: Infection Control COVID19 Response, revised 1/13/22, revealed Screening, including temperature, of all who enter the facility for signs and symptoms of COVID-19 (e.g., questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms Interviews conducted on 01/14/22 from 12:00 PM to 6:50 PM with staff from all three shifts, revealed staff were knowledgeable about why it was important for temperatures to be taken for all staff/visitors/residents and had been in-serviced about the screening process, symptoms of Covid-19, proper use of PPE, hand hygiene and infection control, they had to take a post-test, and for all staff interviewed at the facility, their temperatures were taken as part of the screening process at the front door. The nurses stated that they were in-serviced about screening residents for temperature and all other signs and symptoms of covid every shift. The interviewed staff included: DON, Receptionist H, Administrator, LVN C, Director of Rehab, CNA I, CNA D, CNA J, LVN K, LVN G, Dietary Consultant, Activities Director, Chef, Laundry staff, LVN L, CNA M, Med aide B, Med aide N, CNA O, and CNA P. In an interview with the DON on 01/14/22 at 12:00 PM it was revealed that it was important to check temperatures as opposed to just asking if someone has a fever because it was a way to verify if someone had an elevated temperature. DON stated she understood why this was identified as an IJ because the facility was not actually verifying if they had an elevated temperature as an indicator for covid. In an interview with the Administrator on 01/14/22 at 12:47 PM it was revealed it was important to take temperatures because it was a CDC recommendation as an indicator for one of the strands of covid and also because it was a requirement in the State covid response guidelines that had been provided to nursing facilities to follow. The administrator understood that this was identified as an IJ because they were not following the HHSC Covid response guidelines and it could put residents, staff and anyone else in the building in jeopardy to be infected with covid. Observations were made on 01/14/22 from 9:25 AM to 8:00 PM of staff and visitors being screened into the facility with temperatures being taken as part of the screening process. Interviews conducted on 01/14/22 from 1:40 PM to 5:35 PM with Residents revealed their temperatures had been obtained by their respective nurses on that date. The interviewed residents included: Resident #4, Resident #5 and Resident #6. An IJ was identified on 01/13/22. While the IJ was removed on 01/14/22, the facility remained out of compliance at a level of no actual harm with potential for more then minimal harm that is not immediate jeopardy with a scope of widespread as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (Resident #1) of three residents reviewed for quality of care. LVN A failed to provide appropriate interventions when Resident #1 experienced a change of condition on [DATE] at 6:25 AM, including a change in breathing, the presence of chest congestion, and his speech. Two hours after initially experiencing a change in condition Resident #1 was found non-responsive. He was pronounced dead at 9:25 AM on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility still monitoring the effectiveness of the Plan of Removal . These failures could place resident'sresidents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death. Findings included: Review of Resident #1's Face Sheet revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. Review of Resident #1's MDS assessment dated [DATE], revealed the resident's [DIAGNOSES REDACTED]. Review of Resident #1's nursing note dated [DATE] at 11:59 AM written by LVN A revealed , [DATE] the nurse did her round, resident was sleeping and opened his eyes when the nurse turned on the light, the nurse waved at the resident and turned the light back off. The nurse made rounds at 1:00 AM and resident was sleeping. Resident was sleeping when another resident walked in his room, the nurse went and got the other resident out of the room at 3:30 AM. When CNA changed him, that's when I did my last round, he was awake and responded when I said hi at 5:15 AM. At 6:25 AM The morning CNA called me in resident room, at this time resident appear to be congested, and rattling wet, I touched him and called his name and he answered. I contacted the nurse practitioner and before she could respond the CNA called me in resident's room. The resident gasped I called code and CPR was initiated. Coworker called 911 and CPR was performed until EMS took over and pronounced him at 9:25 AM . Review of Resident #1's nursing notes revealed no other entries on [DATE] or [DATE] regarding resident's change of condition. Review of Rresident #1's medical recordchart revealed oxygen saturation vitals onfor [DATE] at 2:01 PM was 64% on room air several hours after resident's death. The following vitals were documentated on ,[DATE] at 2:00PM; Review of Resident #1's clinical medical record revealed s there were no assessments completed was no documentation regarding change of condition such as SBAR. SBAR is The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition. Interview with LVN A on [DATE] at 3:00 PM revealed Resident #1 passed away. She stated at 10:22 PM on [DATE] she statedstated, he was fine and responsive. She stated he was checked on every two hours . She stated around 3:00 AM she went in the resident's room and he waved. She stated around 5:00 AM or 5:30 AM, a CNA changed the resident and he was fine. She stated he was fine during morning rounds and he talked back to her. She stated around 6:25 AM on [DATE] the morning CNA (CNA E) told her to check on the resident. She stated phlegm was coming out of the resident's mouth, he was experiencing respiratory issues, and was possibly aspirating .butaspirating. But was still responsive . She stated the CNA cleaned the resident's mouth. LVN A did not provide a clear explainationexplanation of aspirating. She stated around 6:00 or 6:30 AM she contacted the resident's nurse practitioner and left a voicemail. She stated at 6:28 AM she text messaged the nurse practitioner and did not receive a response. She then checked the resident's vitals and they were fine . LVN A stated she continued to monitor Resident # 1 but did not indicate any further actions taken. She stated around 8:00 AM she went to speak to the ADON about sending the resident to the hospital, and then thethen the CNA reported the resident was not doing well. She stated she rushed into the resident's room and his condition had worsened. She stated she told another nurse to call code blue and EMS. She stated she, the ADON, and a male staff performed CPR until the arrival of EMS. She stated the EMS pronounced the resident's death. She stated the ADON contacted the resident's family and the VA. She stated she followed facility protocol appropriately . and She stated if she had sent the resident to the hospital the hospital would have sent him right back. Interview with CNA E on [DATE] at 6:50 PM revealed at 6:25 AM on [DATE] Resident #1 looked different and weird. He stated the resident was not talking or breathing well . He stated the resident was not talking to LVN A. He stated LVN A checked the resident's vital signs and his vitals were good. He stated the resident was not speaking well and did not speak to LVN A at all. He stated at 8:45 AM the resident was a little worse, could not breathe, and was not talking. He stated he reported the change of condition to LVN A. He stated LVN A checked the resident's vital signs again and called 911. Interview with the ADON on [DATE] at 3:23 PM revealed Resident #1 had underlying issues that caused his death. She stated she clocked in at 8:30 AM and was told to go to Resident #1's room with the nurse. She stated upon arrival to the room, the resident was non-responsive. She yelled out code blue and started CPR. She stated the nurses and CNAs ran to call 911 and got the crash cart. She stated CPR was performed at 8:43 AM or 8:45 AM. She stated she initiated CPR and LVN A assisted. The ADON stated her understanding of the morning's events was that CNA ECNA E had gone into Resident #1's room to do rounds and reported to the nurse that the resident was having difficulty breathing breathing. She stated the LVN A called the physician around 6:25 AM but the physician still had not responded by 8:30 AM.AM. She stated she would have taken a full set of vitals since the resident was diabetic and checked to see if his airway was open, then completed a full assessment which would have contained vitals and SBAR. She mentioned an SBAR would have been completed had he not died . She stated she would have sent the resident to the hospital after not hearing back from the physician for 10 minutes. She stated LVN A was provided additional training but could not provide documentation. She stated she and the DON spoke with LVN A regarding notification of changes of condition. She stated there was no disciplinary action taken. Interview with the DON on [DATE] at 5:07 PM revealed she was not notified regarding Resident #1's change of condition. She stated she arrived at the facility at 8:45 AM on [DATE]. She stated she informed LVN A she should have sent the resident to the hospital. She stated the facility's protocol was to call the NP, ADON, and DON when there was a change of condition. She stated had she been contacted, LVN A would have received instructions to send the resident to the hospital. She stated a change of condition assessment would have been completed. The DON stated the cause of death was natural causes and the official death certificate had not been completed. Review of Associate Disciplinary Memorandum dated [DATE] revealed LVN A failed to notify per protocol and failed to document guidelines. Review of the facility policy Notification of Changes dated [DATE], revealed, To provide guidance on when to communicate acute changes in status to MD, NP, and/responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: a significant change in the physical, mental, or psychosocial status of the resident. An Immediate Jeopardy (IJ) was identified on [DATE] and the Administrator was informed, and a Plan of Removal was requested. The Facility Plan of Removal was accepted on [DATE]. The plan of removal reflected: 1. Immediate action(s) taken for the resident(s) found to have been affected include: On [DATE], Director of Nursing reviewed all current residents for change of condition. No residents were found with change of condition symptoms. On [DATE], Director of Nursing in serviced LVN A on Notification of Change Policy with Post Test, Telehealth Services Clinical Practice Guidelines, and the Resident Protection Abuse Policy with Post Test. On [DATE], Director of Nursing started in-service education to all license nurses regarding change of condition using the Notification of Change Policy with Post Test, Telehealth Services Clinical Practice Guidelines, and the Resident Protection Abuse Policy with Post Test. Medical Director was notified of immediate jeopardy by the Administrator 2. Actions taken/systems put into place to reduce the risk of future occurrence include: The following actions were taken to ensure occurrence or reoccurrence of process/system failure that could lead to serious adverse outcome and when those actions were completed. In-service education was started by the Director of Nursing/designee on Notification of Change with Post Test to provide guidance on when to communicate acute changes in status to MD, including MD contact via telehealth, NP, and / responsible party. Immediate Physician Notification - the physician is notified immediately and should respond timely (within minutes), if the physician does not respond, the Medical Director will be contacted before the resident is sent for emergency room evaluation. If the resident experiences an acute deterioration or life-threatening condition and the MD/NP cannot be contacted, the nurse will call 911 Non-Immediate Physician Notification - the physician is notified and there should be a return call during the same shift This education will continue until 100% of licensed nursing staff is completed. Post- test will be completed to validate knowledge base. Post Tests will be completed by [DATE] and any staff that has not had this education will not be allowed to return to work until this is completed. In-service education was started by the Director of Nursing/designee on Telehealth Services Clinical Practice Guidelines to provide guidance to meet resident's emergent and non-emergent change of conditions. This education will continue until 100% of licensed nursing staff is completed. Education will be completed by [DATE] and any staff that has not had this education will not be allowed to return to work until this is completed. In service education was started by the Director of Nursing/designee on the Resident Protection Abuse Policy with Post Test to provide guidance to ensure the resident is free from abuse, neglect, misappropriation of resident property, and exploitation, physical and chemical restraint not required to treat the resident's symptoms, involuntary seclusion and corporal punishment. This education will continue till 100% of staff is completed. Post- test will be completed to validate knowledge base. Post Tests will be completed by [DATE] and any staff that has not had this education will not be allowed to return to work until this is completed. In service education was started by the Director of Nursing/designee on the Clinical Documentation Guidelines to provide a record of the health status, including observations, measurements, history and prognosis and serves as the primary document describing healthcare services provided to the patient. This education will continue till 100% of staff is completed. This education will be completed by [DATE] and any staff that has not had this education will not be allowed to return to work until this is completed. 3. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing/designee will review residents daily for change of condition and timely MD notification. The Director of Nursing/designee will validate that acute changes of condition are communicated timely to the MD/NP. The acute changes of condition validation will be documented on a QAPI Tool daily for four weeks The Director of Nursing/designee will review documentation on residents with acute changes of condition daily for four weeks. 4. Findings from the plan of removal will be reviewed by the QAPI Committee and Medical Director. The Quality Assessment and Assurance Committee validates the actions taken are effectively resolving the cited issues and verifies the dates of completion. Monitoring of the Plan of Removal included the following: Interview with LVN B on [DATE] at 11:50 AM revealed he completed an in-service regarding abuse and notification of change in condition. He stated the in-service was about notifying the physician on-call immediately and following physician's orders. He stated the resident's family, DON, and Administrator were also notified. He stated if the physician did not call back, continue to call until there was an answer. He stated the facility informed him there was an IJ because something happened to a resident that passed. He stated the abuse policy was about reporting abuse; verbal, mental, sexual, misappropriation, neglect, and physical to the administrator. He stated the in-services and tests were completed on [DATE]. Interview with RN F on [DATE] at 12:12 PM revealed she received an in-service regarding abuse in [DATE]. She stated she received an in-service called change of condition about notifying the physician, family, and follow physician orders. She stated tele-health was also used to notify the physician after 7:00 PM during the week and all day on the weekend. She stated she informed the DON she knew what to do regarding change of condition and did not have to complete a test after her in-service. Interview with LVN C on [DATE] at 12:32 PM revealed he completed an in-service regarding abuse and change of condition. He stated the abuse in-service was about the different types, neglect, and timeframe to report to the administrator. He stated any time a resident has a change of condition a SBAR assessment was completed and the physician was notified. He stated he completed a test after the in-services. He stated the in-services were updates on information he already knew. Interview with LVN D on [DATE] at 12:41 PM revealed she completed an in-service regarding abuse and change of condition. She stated the abuse in-service was about physical, verbal, misappropriation, and sexual abuse, who to notify, and when to report. She stated the change of condition in-services was about notifying the physician, family, and management. Interview with the ADON on [DATE] at 3:38 PM revealed LVN A should have sent Resident #1 to the hospital within 10 minutes of change of condition and not being able to get ahold of the physician. She stated the nursing staff were in-serviced regarding change of condition and abuse. She stated the facility received an IJ because LVN A did not follow protocol regarding change of condition and documentation did not reflect actions taken. Interview with the DON on [DATE] at 3:47 PM revealed she made rounds, checked on nursing staff, followed up on tasks, demonstrations, in-services, clinicals check offs, and observations to ensure staff followed facility procedures and protocols. She stated the facility received an IJ because of poor documentation regarding Resident #1's condition, implementation of intervention, and lack of follow up. She stated the facility implemented new procedures and updated policy regarding telehealth and immediacy regarding change of condition. She stated the facility provided in-services, one on one, and group education to nursing staff. She stated the following in-services were completed; notification change of condition, abuse, and telehealth. Interview with the Administrator on [DATE] at 3:55 PM revealed he monitored his staff by having interdisciplinary team meetings to discuss issues that came up, QAPI plans, 24-hour report with nursing, and monthly education for staff. He stated he did not micro-manage staff and they were to bring issues to him or vice versa. He stated staff should align with the facility's goals. He stated the facility received an IJ because LVN A did not document she was following up with Resident #1. He stated, she knows as a nurse what should be done and did not give herself credit of work done with the resident. He stated notification of change of condition, abuse, and telehealth in-services were completed with staff. Review of the in-service, dated [DATE], revealed the facility conducted an updated training on facility policies notification of change, telehealth services, and abuse. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm this is not immediate jeopardy and a scope of isolated due to the facility still monitoring the effectiveness of the Plan of Removal.

Based on observation, interview and record review, it was determined that the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident # 15) of 22 residents reviewed for social services. The facility failed to appropriately intervene when Resident #15 expressed ideas of self-harm and being fearful of a staff member after allegations of verbal abuse. This failure caused a delay in appropriate care and treatment to Resident #15 as well as continued fear and psychological distress. Additionally these failures could affect the other 106 residents who resided at the facility by placing them at risk for decreased quality of life. Findings include: 1. Resident #15 was initially observed during rounds on 01/12/15 at 7:05 p.m. with Licensed Vocational Nurse C (LVN) The resident was in her room napping in her wheelchair. LVN C described the resident as being alert, orientated, and required assistance from staff with activities of daily living. LVN C stated Resident #15 is frequently incontinent of bladder and continent of bowel through a colostomy bag. LVN C further stated that Resident #15 was interviewable but she is often asleep due to her pain medications. She also stated that Resident #15 likes attention. Review of Resident #15's Face Sheet dated 05/01/14 revealed a current admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #15's most recent Minimum Data Set (MDS) assessment revealed it was a quarterly assessment dated [DATE]. The assessment reflected a BIMS (Brief Interview for Mental Status) of 09. According to the MDS assessment, the resident's cognitive skills for daily decision making were moderately impaired.Further review of the resident's MDS revealed resident had a mood severity score of 24 out of 27. Social Service Progress note dated 1/13/15 reflected the SW met with the resident regarding reports of allegation of verbal abuse. Resident #15 provided a description of a " skinny, black lady, real pretty. " Resident reported to SW " she treats me like[***]" and stated the staff member told her " you do this on purpose. " The SW documented the resident stated "I ' ve told my sister to find me a place out of here before I hurt myself " . Further the document revealed SW to document history of attention seeking behaviors. Offered Resident referral to a psych hospital and was declined. SW did not discuss any other interventions. SW documented resident denied suicidal thoughts. Interview with SW on 01/15/15 at 2:15 p.m. revealed that she interviewed Resident #15 but she did not advise ADMN that Resident #15 had made a statement about possibly hurting herself. SW stated she had not followed up on Resident #15's statement of wanting to hurt herself. She stated Resident #15 said did not have and suicidal thoughts and she did not think she (The resident) would hurt herself. An interview with Resident #15 on 01/14/15 at 12:16 p.m. revealed a staff member on night shift was verbally abusive to her. Resident 15 ' s eyes were watering and she was moving like she was anxious as she was talking with the surveyor. Resident #15 stated the staff member named Kathy Miller yells, curses at her, and refuses care related to her colostomy bag. The statements said were: " I am not cleaning up your[***] " " Why the [***] do I have to deal with this[***] " " You need to pick that up because you ' re [***] ing nasty and you stink. " Resident #15 stated when this happens she feels upset, hurt, embarrassed, and afraid to go to sleep at night. She further stated she is afraid to use her call light sometimes because she is afraid the staff member will start yelling at her if she needs help with her colostomy bag. Resident #15 stated " she treats me so bad. " In an interview with Nurse Consultant (NC) on 01/15/15 at 8:03 a.m. revealed Resident #15 ' s allegation was passed down verbally to the night supervisor but was not written in the 24 Hour Report. She stated that she will get it documented to monitor Resident #15 for 72 hours. Nurses notes reflected on 01/15/15, Resident #15 was put on 72 hour monitoring and one-on-one after Surveyor advised Admin and CRN that Resident #15 stated she was scared and that SW documented " Resident#15 said she needed to find her way out of her before she hurts herself. " In an interview with ADMIN at 01/15/15 at 3:30 p.m. revealed he advised the SW to interview Resident #15. He stated on 01/14/15, Resident #15's sister and physician were notified. He stated the rsedient's sister did not believe the resident would not do anything to herself. He also stated he read SW progress notes but did not know Resident #15 had made a comment about hurting herself and that the resident should have been put on 72 hour checks and placed with a staff member one on one. The facility 672 Resident Census and Conditions of Residents dated 01/14/15 and signed by the DON reflected a facility census of 106.

Based on observation, interview and record review, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with thecomprehensive assessment and plan of care for 1 (Resident # 15) of 22 residents reviewed for quality of care. The facility failed to apprpopriately intervene when Resident #15 expressed being fearful of a staff member and expressed self-harm ideas after reporting allegations of verbal abuse from a facility staff member. This failure caused a delay in appropriate care and treatment to Resident #15 as well as continued fear and psychological distress. Additionally these failures could affect the other 106 residents who resided at the facility by placing them at risk for decreased quality of life. Findings include: 1. Resident #15 was initially observed during rounds on 01/12/15 at 7:05 p.m. with Licensed Vocational Nurse C (LVN) The resident was in her room napping in her wheelchair. LVN C described the resident as being alert, orientated, and required assistance from staff with activities of daily living. LVN C stated Resident #15 is frequently incontinent of bladder and continent of bowel through a [MEDICAL CONDITION] bag. LVN C further stated that Resident #15 was interviewable but she is often asleep due to her pain medications. She also stated that Resident #15 likes attention. Review of Resident #15's Face Sheet dated 05/01/14 revealed a current admission date of [DATE] and [DIAGNOSES REDACTED]. Review of Resident #15's most recent Minimum Data Set (MDS) assessment revealed it was a quarterly assessment dated [DATE]. The assessment reflected a BIMS (Brief Interview for Mental Status) of 09. According to the MDS assessment, the resident's cognitive skills for daily decision making were moderately impaired.Further review of the resident's MDS revealed resident had a mood severity score of 24 out of 27. Social Service Progress note dated 1/13/15 reflected the SW met with the resident regarding reports of allegation of verbal abuse. Resident #15 provided a description of a " skinny, black lady, real pretty. " Resident reported to SW " she treats me like[***]" and stated the staff member told her " you do this on purpose. " The SW documented the resident stated "I ' ve told my sister to find me a place out of here before I hurt myself " . Further the document revealed SW to document history of attention seeking behaviors. Offered Resident referral to a psych hospital and was declined. SW did not discuss any other interventions. SW documented resident denied suicidal thoughts. Interview with SW on 01/15/15 at 2:15 p.m. revealed that she interviewed Resident #15 but she did not advise ADMN that Resident #15 had made a statement about possibly hurting herself. SW stated she had not followed up on Resident #15's statement of wanting to hurt herself. She stated Resident #15 said did not have and suicidal thoughts and she did not think she (The resident) would hurt herself. An interview with Resident #15 on 01/14/15 at 12:16 p.m. revealed a staff member on night shift was verbally abusive to her. Resident 15 ' s eyes were watering and she was moving like she was anxious as she was talking with the surveyor. Resident #15 stated the staff member named Kathy Miller yells, curses at her, and refuses care related to her [MEDICAL CONDITION] bag. The statements said were: " I am not cleaning up your[***] " " Why the [***] do I have to deal with this[***] " " You need to pick that up because you ' re [***] ing nasty and you stink. " Resident #15 stated when this happens she feels upset, hurt, embarrassed, and afraid to go to sleep at night. She further stated she is afraid to use her call light sometimes because she is afraid the staff member will start yelling at her if she needs help with her [MEDICAL CONDITION] bag. Resident #15 stated " she treats me so bad. " In an interview with Nurse Consultant (NC) on 01/15/15 at 8:03 a.m. revealed Resident #15 ' s allegation was passed down verbally to the night supervisor but was not written in the 24 Hour Report. She stated that she will get it documented to monitor Resident #15 for 72 hours. Nurses notes reflected on 01/15/15, Resident #15 was put on 72 hour monitoring and one-on-one after Surveyor advised Admin and CRN that Resident #15 stated she was scared and that SW documented " Resident#15 said she needed to find her way out of her before she hurts herself. " In an interview with ADMN at 01/15/15 at 3:30 p.m. revealed he advised the SW to interview Resident #15. He stated on 01/14/15, Resident #15's sister and physician were notified. He stated the rsedient's sister did not believe the resident would not do anything to herself. He also stated he read SW progress notes but did not know Resident #15 had made a comment about hurting herself and that the resident should have been put on 72 hour checks and placed with a staff member one on one. The facility 672 Resident Census and Conditions of Residents dated 01/14/15 and signed by the DON reflected a facility census of 106.

Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for one (Resident #1) of three residents, whose closed records were reviewed. Resident #1 experienced a 23 hour delay in treatment after x-ray results reflected the resident had sustained a [MEDICAL CONDITION] when the facility failed to immediately contact the physician with the results of the x-ray. This failure could have affected the facility's 13 residents, who were identified with falls and/or fractures, including Resident #1, and placed them at risk for the potential of a delay in treatment, which could result in unrelieved pain and further side effects as a result of the original injury such as blood clots or laceration of tissue. Findings included: The MDS assessment dated [DATE] reflected Resident #1, an [AGE] year old male, was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed Resident #1 did not have any falls since admission or the prior assessment. The MDS assessment reflected Resident #1 required the extensive assistance of one person physical assistance with his ADLs. Review of Resident #1's Interdisciplinary Care Plan dated 03/11/11 revealed: "Concerns/Needs/Problems - Hx of falls w/ potiential (sic) for further falls R/T cognitive deficit and weakness. Objection - Resident will not experience further falls thru next assessment period. Approach/Plan - 1. Assist w/bed mobility as needed and reposition prn. 2. Monitor PRN for needs. 3. Follow protocol in event of fall. 4. Therapy screen as needed for changes and needs. 5. Remind (Resident #7) not to attempt to transfer self to prevent falls. 6. Call light within reach at all times and answer in timely manner. 7. Notify family member and physician of any change in condition." Further review of the care plan revealed the care plan was reviewed on 06/13/11 and 09/07/11 with no changes or updates and to continue with the plan of care. This was the only care plan related to falls or fractures for Resident #1. Review of the facility's Incident/Accident Report dated 08/06/11 for Resident #1 revealed the following description of the incident: "Observed resident slipping from w/c among the circle of ...members to the floor. Sustained skin tear to Rt forehead, left index finger, Rt shoulder & hand multiple areas. Assisted up to wheelchair and back to bed. Denies any pain. Alert and oriented to name." Further review revealed the following under the heading, "Additional comments and/or steps taken to prevent recurrence: Resident #1 was assisted up in his w/c before sliding out. First aid was given to the skin tears and the Treatment Nurse was informed. Review of Resident #1's "Nurse's Notes" dated 08/06/11 at 11:00 AM revealed Resident #1 slipped from his wheelchair onto his right side. Resident #1 sustained skin tears on his forehead, right shoulder, right hand, left index finger and fourth knuckle of his left hand. The NP was notified and gave orders for x-rays, which included: skull series, right shoulder and right hip to rule out fractures due to the resident's history. Review of Resident #1's "Nurse's Notes" dated 08/06/11 at 9:35 PM revealed the x-ray results had been received and the PA was called, and they were waiting for the PA to call back. The results of the x-ray were also faxed to the PA's fax machine. Review of Resident #1's x-ray report dated 08/06/11 for Resident #1 revealed, "Exam: Hip Right - 2V (2 views). Right. Results: there is a right subcapital fracture with moderate displacement...." Review of Resident #1's Nurse's notes dated 08/07/11 at 8:30 PM revealed, "______ PA gave order to transfer (Resident #1) to Hospital ER to confirm x-ray results." This was 23 hours after the nurse received the x-ray results of the [MEDICAL CONDITION]. Review of Resident #1's entire clinical record revealed no evidence staff tried to contact the PA again prior to the PA giving the order to transfer Resident #1 to the ER at 8:30 PM on 08/07/11 (23 hours later). There was also no evidence facility staff tried to contact Resident #1's physician when the PA did not respond in a timely manner. During an interview on 01/06/12 at 9:10 AM, the DON was shown Resident #1's records and queried about the 23 hour delay in treatment after his x-rays revealed a fracture. The DON stated, "I don't have an answer for this. Usually I get a call." When queried what should happen if she could not be reached, the DON stated, "They call everyone." When queried about the nurses, who provided care for Resident #1 at the time of his injury, it was learned the nurses no longer worked at the facility. At that time, when asked what the facility's protocol was when nursing staff could not get in touch with a physician regarding a positive fracture result, the DON replied, "They call me. If we can't get in touch with a doctor, we send them (the resident) out." When asked what the maximum time nursing staff should wait before sending a resident to the ER, who has a fracture, the DON replied, "Thirty to sixty minutes. My nurses are very good about calling me." On 01/06/12 at 9:00 AM, Corporate Nurse M was asked about the facility's nursing protocol when a report was received a resident had sustained a fracture. Corporate Nurse M stated when the facility received a report the resident had sustained a fracture, "We send the resident to a local hospital." When Corporate Nurse M was asked about the facility's nursing protocol was when the facility had report a resident had sustained a fracture and the nurse could not contact the physician. She replied, "We send them out. They (nursing staff) should not wait more than an hour." The facility's CMS-802, Roster/Sample Matrix, provided by the facility on 12/31/11 reflected there were 13 residents identified with falls and/or fractures.