Every finding on record at Trinity Rehabilitation & Healthcare Center

Based on interviews and record review, the facility failed to provide mandatory behavioral health training for 9 of 17 direct care staff (CNA K, CNA F, CNA E, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director and the ADON) reviewed for training requirements.The facility failed to ensure effective communication training was provided to CNA K, CNA F, CNA E, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director and the ADONThis failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included:Record review of the personnel file for CNA K revealed a hire date of 05/19/2025 and no evidence of initial hire training on behavioral health.Record review of the personnel file for CNA F revealed a hire date of 05/22/2025 and no evidence of initial hire training on behavioral health.Record review of the personnel file for CNA E revealed a hire date of 06/29/2024 and no evidence of annual training on behavioral health.Record review of the personnel file for LVN A revealed a hire date of 12/10/2025 and no evidence of initial hire training on behavioral health.Record review of the personnel file for LVN L revealed a hire date of 01/06/2026 and no evidence of initial hire training on behavioral health.Record review of the personnel file for LVN M revealed a hire date of 10/06/2025 and no evidence of initial hire training on behavioral health.Record review of the personnel file for the Dietary Manager revealed a hire date of 03/06/2026 and no evidence of initial hire training on behavioral health.Record review of the personnel file for Activity Director revealed a hire date of 04/01/2026 and no evidence of initial hire training on behavioral health.Record review of the personnel file for ADON revealed a hire date of 12/05/2025 and no evidence of initial hire training on behavioral health.During an interview on 4/15/2026 at 10:00 AM, The ADON said he said was not aware that the training on behavioral health had not been completed on his hire date before he started resident care. He said initial training with assigned in a computer program and the staff completed the topics that were assigned by HR or corporate. He said he assisted with getting nursing staff trained during orientation prior to employment and annually. He said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care.During an interview on 04/15/2026 at 10:30 AM, HR said she was new to her position at the facility and was responsible for completing the orientation and other paperwork. She said she was not aware that behavioral health training had not been completed as required for all employees. She said going forward she would complete a checklist for the required training and ensure completion. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. HR said going forward she will make sure all training is completed before resident care is started and annually as required by regulations.During an interview on 4/15/2026 at 11:38 AM, The Administrator said the staff were initially trained by logging into a website and have continued to watch the training videos that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, behavioral health, effective communication, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required training during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said she would ensure there was a system in place and a check list for the training.During an interview on 4/15/2026 at 12:05 PM, The DON said She said responsible for ensuring the nursing received the required training on behavioral health during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care.Record review of a facility policy revised 02/2026 indicated, .Staff Development Program.Policy StatementAll personnel must participate in initial orientation and regularly scheduled in-service training classes.Policy Interpretation and Implementation1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs.2.The primary objective of our facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care.5.Required training topics include: j. Behavioral Health Fundamentals, Person-Centered Behavior Management and Dementia Care.

Based on interviews and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 9 of 17 direct care staff (CNA K, CNA F, CNA E, LVN A, LVN L, LVN M, the Dietary Manager, the Activity Director and the ADON) reviewed for training requirements.The facility failed to ensure mandatory training on standards, policies, and procedures for an infection prevention and control program effectively was provided to CNA K, CNA F, CNA E, LVN A, LVN L, LVN M, Dietary Manager, Activity Director and the ADONThis failure could place residents at risk of illness or spread of infections due to lack of staff training.Findings included:Record review of the personnel file for CNA K revealed a hire date of 05/19/2025 and no evidence of initial hire training on infection prevention and control.Record review of the personnel file for CNA F revealed a hire date of 05/22/2025 and no evidence of initial hire training on infection prevention and control.Record review of the personnel file for CNA E revealed a hire date of 06/29/2024 and no evidence of annual training on effective infection prevention and control.Record review of the personnel file for LVN A revealed a hire date of 12/10/2025 and no evidence of initial hire training on infection prevention and control.Record review of the personnel file for LVN L revealed a hire date of 01/06/2026 and no evidence of initial hire training on infection prevention and control.Record review of the personnel file for LVN M revealed a hire date of 10/06/2025 and no evidence of initial hire training on infection prevention and control.Record review of the personnel file for the Dietary Manager revealed a hire date of 03/06/2026 and no evidence of initial hire training on infection prevention and control.Record review of the personnel file for Activity Director revealed a hire date of 04/01/2026 and no evidence of initial hire training on infection prevention and control.Record review of the personnel file for ADON revealed a hire date of 12/05/2025 and no evidence of initial hire training on infection prevention and control.During an interview on 4/15/2026 at 10:00 AM, The ADON said he said was not aware that the training on infection control and prevention had not been completed on his hire date before he started resident care. He said initial training with assigned in a computer program and the staff completed the topics that were assigned by HR or corporate. He said he assisted with getting nursing staff trained during orientation prior to employment and annually. He said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care and spread infections.During an interview on 04/15/2026 at 10:30 AM, HR said she was new to her position at the facility and was responsible for completing the orientation and other paperwork. She said she was not aware that infection control training had not been completed as required for all employees. She said going forward she would complete a checklist for the required training and ensure completion. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. HR said going forward she will make sure all training is completed before resident care is started and annually as required by regulations.During an interview on 4/15/2026 at 11:38 AM, The Administrator said the staff were initially trained by logging into a website and have continued to watch the training videos that included abuse/neglect, blood borne pathogens, infection control, misuse of resident property, resident rights, behavioral health, effective communication, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required training during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said she would ensure there was a system in place and a check list for the training.During an interview on 4/15/2026 at 12:05 PM, The DON said She said responsible for ensuring the nursing received the required training on infection control during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care by spreading infections.Record review of a facility policy revised 02/2026 indicated, .Staff Development Program.Policy StatementAll personnel must participate in initial orientation and regularly scheduled in-service training classes.Policy Interpretation and Implementation1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs.2.The primary objective of our facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care.5.Required training topics include: e. The infection prevention and control program standards, policies and procedures.

Based on interview and record review, the facility failed to provide effective communications mandatory training for 6 of 17 direct care staff (CNA K, CNA F, LVN A, LVN L, LVN M and the ADON) reviewed for training requirements. The facility failed to ensure effective communication training was provided to CNA K, CNA F, LVN A, LVN L, LVN M and ADON.This failure could affect residents and place them at risk of miscommunication and social isolation due to lack of staff training. Findings included: Record review of the personnel file for CNA K revealed a hire date of 05/19/2025 and no evidence of initial hire training on effective communication. Record review of the personnel file for CNA F revealed a hire date of 05/22/2025 and no evidence of initial hire training on effective communication. Record review of the personnel file for LVN A revealed a hire date of 12/10/2025 and no evidence of initial hire training on effective communication. Record review of the personnel file for LVN L revealed a hire date of 01/06/2026 and no evidence of initial hire training on effective communication. Record review of the personnel file for LVN M revealed a hire date of 10/06/2025 and no evidence of initial hire training on effective communication. Record review of the personnel file for ADON revealed a hire date of 12/05/2025 and no evidence of initial hire training on effective communication. During an interview on 4/15/2026 at 10:00 AM, The ADON said he said was not aware that the training on effective communication had not been completed on his hire date before he started resident care. He said initial training with assigned in a computer program, and the staff completed the topics that were assigned by HR or corporate. He said he assisted with getting nursing staff trained during orientation, prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. During an interview on 04/15/2026 at 10:30 AM, HR said she was new to her position at the facility and was responsible for completing the orientation and other paperwork. She said she was not aware that effective communication training had not been completed as required for all employees. She said going forward she would complete a checklist for the required training and ensure completion. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. HR said going forward she will make sure all training is completed before resident care is started and annually as required by regulations.During an interview on 4/15/2026 at 11:38 AM, The Administrator said the staff were initially trained by logging into a website and have continued to watch the training videos that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, effective communication, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required training during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said she would ensure there was a system in place and a check list for the training. During an interview on 4/15/2026 at 12:05 PM, The DON said She said responsible for ensuring the nursing received the required training on effective communication during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. Record review of a facility policy revised 02/2026 indicated, .Staff Development Program.Policy StatementAll personnel must participate in initial orientation and regularly scheduled in-service training classes.Policy Interpretation and Implementation1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs.2.The primary objective of our facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care.5.Required training topics include: a. Effective communication with residents and family (direct care staff).

Based on interviews and record review, the facility failed to ensure the required minimum 12 hours annual in-service education was provided for 1 of 5 CNAs (CNA E) reviewed for training requirements.The facility did not provide the required 12 hours of annual in-service education to CNA F. This failure could place residents with dementia at risk of abuse, neglect, exploitation and poor quality of care by staff with inadequate training when caring for residents. The findings included:Record Review of a personnel file for CNA E indicated a hire date of 06/29/2024 and did not include the required 12 hours of annual in-service. The personnel file revealed no training for the year 2025 for Resident Rights, Abuse, Dementia, Infection Control, Effective communication, Falls, Restraints and Behavioral Health.Record review of electronic training for CNA E indicated she initiated training on 04/15/2026 after surveyor entrance on 04/1/2026 but training was not completed.During an interview on 4/15/2026 at 10:00 AM, The ADON said annual CNA training with assigned in a computer program and the staff completed the topics that were assigned by HR or the corporation. He said he assisted with getting nursing staff trained during orientation prior to employment and annually. He said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care.During an interview on 04/15/2026 at 10:30 AM, HR said she was new to her position at the facility and was responsible for completing the orientation and other paperwork. She was responsible for ensuring annual requirements were met. She said going forward she would complete a checklist for the required training and ensure completion. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. HR said going forward she will make sure all training is completed before resident care is started and annually as required by regulations.During an interview on 4/15/2026 at 11:38 AM, The Administrator said the staff were initially trained by logging into a website and have continued to watch the training videos that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, effective communication, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required training during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said she would ensure there was a system in place and a check list for the training.During an interview on 4/15/2026 at 12:05 PM, The DON said She said responsible for ensuring the CNA's received the required training prior to employment and annually. The DON said that the CNA Staff are to complete an additional 12 hours of training annually in addition to the required training assigned in the computer system. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care.Record review of a facility policy revised 02/2026 indicated, .Staff Development Program.Policy StatementAll personnel must participate in initial orientation and regularly scheduled in-service training classes.Policy Interpretation and Implementation1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs.2.The primary objective of our facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care.7.In addition to the in-service training requirements outlined above, nurse aides (CNAs) are required to complete no less than 12 hours annually of in-service training that is sufficient to ensure the continuing competency of nurse aides and address any specific areas of weakness identified in performance evaluations and through the facility assessment. This requirement can be met through the TX HHS Modules for CNAs and the Infection Control Module through TX HHS.12.Records are filed in the employee's personnel file or maintained by the Department Director.

Based on interviews and record review, the facility failed to ensure employees received the required training on Abuse, Neglect, and Exploitation and dementia management training for 1 of 17 (CNA E) reviewed for required training.The facility did not ensure Abuse, Neglect, and Exploitation and dementia management training was completed by the CNA E during annual training for 2025. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and poor quality of care by staff with inadequate training when caring for dementia residents. Findings included:Record review of the personnel files for CNA E indicated a hire date 06/29/2024. There was no evidence that CNA E had not completed the required annual training for Abuse, Neglect, and Exploitation and dementia management. Annual training was not completed by CNA E since her hire date 06/29/2024.Record review of electronic training for CNA indicated it was initiated by CNA E on 4/15/2026 but not fully completed, after entrance of the survey team on 04/13/2026.During an interview on 04/15/2026 at 10:30 AM, HR said she was new to her position at the facility and was responsible for completing the orientation and other paperwork. She said she was not aware that CNA E had not completed her assigned training on Abuse, Neglect, and Exploitation and dementia management training during annual training for year 2025. She said going forward she would complete a checklist for the required training and ensure completion. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. HR said going forward she will make sure all training is completed before resident care is started and annually as required by regulations.During an observation and interview on 4/15/2026 at 11:38 AM, the Administrator looked in the training files for CNA E and found no evidence in required annual training for Abuse, Neglect, and Exploitation and dementia management. The Administrator said the staff were initially trained by logging into a website and have continued to watch them that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required training during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the training.Record review of a facility policy revised 02/2026 indicated, .Staff Development Program.Policy StatementAll personnel must participate in initial orientation and regularly scheduled in-service training classes.Policy Interpretation and Implementation1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs.2.The primary objective of our facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care.5.Required training topics include: c. Preventing abuse, neglect, exploitation, and misappropriation of resident property including: (1) Activities that constitute abuse, neglect, exploitation or misappropriation of resident property; (2) Procedures for reporting incidences of abuse, neglect, exploitation or misappropriation of resident property; and (3) Dementia management and resident abuse prevention.

Based on interview and record review, the facility failed to provide the required education on the rights of the residents and the responsibilities of a facility to properly care for its residents for 1 of 17 employees (CNA E) reviewed for training requirements, in that:The facility failed to ensure that annually required education was provided on the rights of the residents and responsibilities of a facility to properly care for its residents were conducted with CNA E.This failure could affect residents and place them at risk of being uninformed due to lack of staff training. The findings were: Record review of the personnel file for CNA E revealed a hire date of 06/29/2024. There was no evidence of annual training since hire date on resident rights and the responsibilities of a facility to properly care for its residents. Record review of electronic records of training for CNA E indicated she initiated training on 04/15/2026, after surveyor entrance on 04/13/2026, but training was not completed.During an interview on 04/15/26 at 9:22 AM, the Human Resource Coordinator said she was responsible for ensuring the employees resident Rights training was completed annually and upon hire. The HR Coordinator said effective mandatory training should be completed on hire and annually to ensure that all employees are knowledgeable. The HR coordinator said CNA E's training was not completed annually as required by policy. During an interview on 04/15/26 at 11:38 AM, the Administrator said all mandatory training was required at the time of hire before any staff started employment. The Administrator said they were assigned annually. The Administrator said the risk for not completing resident rights training could cause the employee to not know what the rights were and could lead to violations. The Administrator said the HR Coordinator was responsible for ensuring all required training was completed upon hire and annually. During an interview on 04/15/26 at 12:05 PM, the DON stated she was responsible for monitoring for incomplete training modules of the nursing staff. The DON stated one reason for staff failing to complete training was a breakdown in communication. She stated the consequences to residents was they may not receive the care expected.Record review of a facility policy revised 02/2026 indicated, .Staff Development Program.Policy StatementAll personnel must participate in initial orientation and regularly scheduled in-service training classes.Policy Interpretation and Implementation1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs.2.The primary objective of our facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care.5.Required training topics include :.b. Resident rights and responsibilities;

Based on interviews and record review, the facility failed to develop, implement, and maintain an effective training program for 2 of 17 employees (Dietary Manager and the Activity Director) new and existing staff reviewed for training requirements. The facility failed to ensure the Activity Director was trained in effective communication, HIV, dementia, infection control and restraint reduction on hire.The facility failed to ensure the Dietary Manager was trained in falls, dementia, infection control and behavioral health on hire This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included:Record review of the personnel file for the Activity Director indicated she was hired at the facility on 04/01/2026 and did not have evidence of on hire training in effective communication, HIV, dementia, infection control and restraint reduction on hire. Record review of the personnel file for the Dietary Manager indicated she was hired at the facility on 03/10/2026 and did not have evidence that the Dietary Manager received annual training on ineffective communication, HIV, dementia, infection control and restraint reduction on hire.During an interview on 04/15/2026 at 10:30 AM, HR said she was new to her position at the facility and was responsible for completing the orientation and other paperwork. She said she was not aware that new hire training had not been completed as required for all employees. She said, going forward, she would complete a checklist for the required training and ensure completion. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. HR said going forward, she would make sure all training was completed before resident care was started and annually as required by regulations.During an interview on 4/15/2026 at 11:38 AM, the Administrator said the staff were initially trained by logging into a website and have continued to watch the training videos that included abuse/neglect, blood borne pathogens, HIV, misuse of resident property, resident rights, behavioral health, effective communication, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required training during orientation, prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said she would ensure there was a system in place and a check list for the training. During an interview on 4/15/2026 at 12:05 PM, the DON said she was responsible for ensuring the nursing staff received the required training during orientation, prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. Record review of a facility policy revised February 2026 indicated, .Staff Development Program.Policy StatementAll personnel must participate in initial orientation and regularly scheduled in-service training classes.Policy Interpretation and Implementation1. Staff development is defined as initial orientation, followed by regularly scheduled in-service training programs.2.The primary objective of our facility's Staff Development Program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care.5.Required training topics include:. (3) Dementia management and resident abuse prevention.e. The infection prevention and control program standards, policies and procedures; and.g. Restraint Reduction and Fall Prevention.j. Behavioral Health Fundamentals, Person-Centered Behavior Management and Dementia Care.l. Blood borne pathogens and HIV Training

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #16) reviewed for infection control. The facility failed to ensure CNA C and CNA D washed or sanitized their hands during incontinent care provided to Resident #16 on 4/14/2026.This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #16 dated 4/14/2026 reflected she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atrial fibrillation (irregular heart rhythm), major depressive disorder (persistent sadness or loss of interest in doing things), and GERD (acid reflux disease).Record review of a Quarterly MDS Assessment for Resident #16 dated 2/27/2026 indicated she did not have any impairment in thinking with a BIMS score of 15. She required substantial/maximal assistance with personal hygiene. She had an indwelling catheter and an ostomy. Urinary and bowel continence was not rated because she had a catheter or ostomy during the entire 7 day look back period.Record review of a care plan for Resident #16 indicated she had an indwelling catheter with interventions to provide catheter care at least one time per shift and after each bowel movement. During an observation on 4/14/2026 at 2:47 pm, in the room of Resident #16, CNA C and CNA D were in the room to provide incontinent and foley care. Staff entered the room with supplies in a plastic bag, and sanitized their hands and applied gloves and a gown. CNA C and CNA D pulled the linens down to the foot of the bed. Resident #16 was not wearing a brief and had a ileostomy (a surgical opening that brings the end of the small intestine through the opening to allow waste to leave the body in an external pouch) to her right upper abdomen and a urinary catheter (a tube placed in the bladder to drain urine) with a drainage bag attached that was attached to the bed frame on the side of the bed. CNA C removed wipes from the package and cleaned the resident's inner thighs and placed the wipes in the trash. CNA C removed a wipe and cleaned down the middle of the vagina from front to back and placed the wipe in the trash. CNA C removed a wipe and cleaned the foley tubing from near the insertion site down the tubing and placed the wipe in the trash. CNA D went to the other side of the bed and emptied the urine drainage bag and emptied the urine in the toilet. While in the bathroom CNA D removed her gloves and placed them in the trash and washed her hands. CNA D donned (put on) clean gloves. CNA C touched a clean brief that was on the nightstand and placed it on the bed near the resident with her dirty gloves. CNA C then removed her gloves and placed them in the trash and donned clean gloves without washing or sanitizing her hands. CNA D assisted with rolling the resident onto her right side, removed wipes from the package, wiped the resident's buttocks and perineal area from front to back, and placed the wipes in the trash. CNA D applied barrier cream using her left hand to the resident's buttocks and perineal area and removed the glove from her left hand only and placed it in the trash. CNA D used the hand sanitizer that was mounted on the wall and attempted to sanitize her left hand and placed a glove on her left hand only. CNA C applied the brief and secured it. Both staff repositioned Resident #16 in bed and doffed (took off) their gown and gloves in the room and placed them in the trash, and exited the room with the trash. CNA D washed her hands.During an interview on 4/14/2026 at 3:10 pm, CNA D said she was taught that one hand would be for dirty things, and the other hand for clean things. She said she removed the glove from her left hand because that was the hand she used to apply the barrier cream and was told she could just change the one glove. She said she sanitized that hand before she applied a clean glove.Record review of the CNA Skills Checklist for CNA D dated 3/24/2026 indicated the ADON was the examiner and CNA D was successful with hand washing and perineal/incontinent care with a female with or without a catheter.During an interview on 4/14/2026 at 3:13 pm, CNA C said, during the care provided to Resident #16, she should have changed her gloves when she moved from cleaning the front of her body to the back of her body. She said she touched the clean brief with her dirty gloves and did not sanitize between gloves changes. She said she did not know why she did not follow proper procedure and there was a risk for residents to get infections if they did not. Record review of a CNA Skills Checklist for CNA C dated 3/31/2026 indicated the ADON was the examiner and CNA C was successful with hand washing and perineal/incontinent care with a female with or without a catheter.During an interview on 4/15/2026 at 1:56 pm, the ADON said he was responsible for conducting skills check offs with the staff annually and upon hire. He said staff could not have one clean hand and one dirty. He said staff should remove both gloves and wash or sanitize between glove changes. He said hand hygiene should be done before care was started, when changing tasks from dirty to clean, between glove changes, and when care was complete. He said staff should never touch clean items with dirty gloves. She said residents could be at risk of infection control issues and planned to have more training with the staff. During an interview on 4/15/2026 at 2:15 pm, the DON said she was the IP for the facility, and she along with the ADON, were responsible for training staff on infection control, and sometimes it was done once a week. She said staff should not change one glove during care and should remove both gloves as they would both be contaminated. She said she would reeducate the staff and conduct random audits for proper hand hygiene. She said hand hygiene that included washing or sanitizing should be done before care was started and between glove changes. She said staff should never touch clean items with dirty gloves. She said if staff did not follow proper procedures, residents could be at risk of infections and UTI's.During an interview on 4/15/2026 at 2:31 pm, the Administrator said the IP had been training staff on infection control all the time and were required to do it annually and as needed. She said staff should not remove one glove during care and was not sure where CNA D received that information. She said staff should remove both gloves, perform hand hygiene, and never touch clean items with dirty gloves. She said hand hygiene should be performed between glove changes, and they should wash their hands. She said there was a risk of infections if staff did not follow the facility's policy. Record review of a facility policy titled Handwashing/Hand Hygiene revised August 2015 indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: e. before and after handling an invasive device (e.g., urinary catheters; m. after removing gloves .

Based on interviews and record reviews, the facility failed to ensure professional licensed, certified, or registered in accordance with applicable State laws standards of quality for 1 of 6 licensed staff (LVN B) reviewed for administration.The facility failed to ensure LVN B's nurse license did not expire as of [DATE].This failure could place residents at risk for not receiving nursing services from a licensed nurseThe findings include:Record review of a personnel file for LVN B indicated she was hired at the facility on [DATE].Record review of the Texas Board of Nursing verification for LVN B checked on [DATE] indicated her license expired [DATE].Record review of a daily staffing assignment/sign in log dated [DATE] revealed LVN B worked on this day as indicated by her initials.During an interview on [DATE] at 9:30 am, the DON said she was not aware LVN B had an expired nurse license.During an interview on [DATE] at 9:32 am, the Administrator said she was unaware LVN B had an expired nurse license until yesterday, [DATE]. She said she was conducting an audit of licensed nurses for the facility and discovered her license was expired. She said they immediately removed LVN B from the schedule.During an interview on [DATE] at 11:30 am, HR said she was responsible for conducting background checks and license verifications. She said they checked their license on hire and annually. She said she started in the position of HR back in [DATE]. She said the Administrator trained her and there was a corporate person she could reach out to. She said the last check for all licensed staff was checked in [DATE]. She said LVN B's expiration was missed, and she checked it [DATE]. She said the report she ran with the board of nursing was not thorough and did not reveal her expiration date, and she did not realize there was an additional step that was needed to see the expiration date. She said if licenses were not checked, residents could be at risk of having an unlicensed person working in the building. During a phone interview on [DATE] at 11:44 am, LVN B said the last day she worked was Sunday [DATE] and was currently off. She said she did not know her license had expired. She said her last renewal was in [DATE]. She said she was made aware that her license expired yesterday, [DATE], by the Administrator who texted her and said they had expired. She said she was told she would not be able to return to work until her license was active. She said she did not receive any email correspondence by the board of nursing, and thought it may have gone to a family member's email address, and they did not notify her.During a follow up interview on [DATE] at 2:31 pm, the Administrator said she discovered the expired license of LVN B yesterday, [DATE], and informed her she could not return to work until it was back active. She said it expired [DATE]. She said HR checked all the licensed employees in [DATE] and did not click to view the report to see the expiration dates. She said there was a risk for a lot to go wrong if they had unlicensed nurses working in the facility along with staff practicing out of scope. She said they would be reporting LVN B to the board of nursing.Record review of a facility policy titled Credentialing of Nursing Service Personnel revised [DATE] indicated, .Nursing service personnel who require a license or certification to provide resident care or treatment without direction or supervision within the scope of the individual's license or certification must present verification of such license .

Based on observations, interviews, and record reviews, the facility failed to serve food that was palatable for 1 of 1 meal reviewed for food palatability. (noon meal 4/14/26).The facility did not provide palatable and appetizing food for the residents receiving pureed food for the 10/28/2025 noon meal.This failure could place residents who received food from the kitchen at risk for diminished meal satisfaction and potential weight loss due to poor meal intake.Findings included:During interview during the initial tour on 4/13/26 at 10:58 am, Resident #49 said she ate meals in her room and complained of cold food.During an observation on 4/14/26 at 1:05 pm, the test trays left the kitchen after the dining room had been served. The test trays were observed by the surveyor after leaving the dining room and at 1:18 pm, the test trays were delivered to the conference room. The test trays consisted of 1 regular tray which included chopped chicken, rice, peas/carrots, and a roll, and 1 puree tray which included chicken, carrots, green beans, and roll. The covers were removed from the plates of food, and the puree food was felt to be cold. Temperature with surveyor's temperature gun showed 88 degrees . The regular food was warm, and the taste was ok. The puree food was cold to taste, and the green beans were bland.During an observation and interview on 4/14/26 at 1:25 pm, the DM checked temperature of pureed food with her thermometer as well, which was 88 degrees. The Dietary Manager tasted the green beans, made a face and said, those are awful, and she said the food was cold. She said if residents were served cold food, they might not eat it, which might make them lose weight.During an interview on 04/14/2026 at 2:28 pm, the Administrator said she would not want to be served cold food. She said if residents were served cold food, they might not eat, they might lose weight, and their health could decline. She said she would have the dietician do some extra training with the kitchen staff going forward to ensure meals were served hot.During an interview on 4/15/26 at 1:10 pm, the DON said if residents were being served cold food, they may not eat it and may be at risk for weight loss. She said, going forward, they would educate kitchen staff and may be getting an enclosed cart for taking trays down the hall.Record review of a facility policy titled Food Preparation and Service dated April 2019 indicated it did not address serving temperature of food on trays when served to residents in their rooms. It read: .Proper hot and cold temperatures are maintained during food service.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures accurate acquiring, receiving, dispensing, and administering of medications for 1 of 6 residents (Resident #16) reviewed for pharmacy services.The facility did not ensure LVN A watched Resident #16 take administered medications, and they were not left in her room on 4/14/2026.This failure could place residents at risk for the unsafe administration of medications. Findings included:Record review of an admission Record for Resident #16 dated 4/14/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atrial fibrillation (irregular heart rhythm), major depressive disorder (persistent sadness or loss of interest), and GERD (acid reflux disease).Record review of a Quarterly MDS Assessment for Resident #16 dated 2/27/2026 indicated she did not have any impairment in thinking with a BIMS score of 15. She required substantial/maximal assistance with personal hygiene.Record review of a care plan for Resident #16 did not indicate she was able to self-administer medications to herself.Record review of a MAR for Resident #16 for 4/14/2026 revealed: LVN A had her initials present for medication administration at 9:00 am for the following medications: ascorbic acid 500 mg tablet (1), loratadine 10 mg tablet (1), magnesium oxide 400 mg (1), multivitamin (1), saccharomyces 250 mg (1), and peppermint oil 180 mg (1).During an observation and interview on 4/14/2026 at 9:51 am, Resident #16 was in her room in bed awake. There was a cup of pills in a small plastic cup on her over bed table. She said the nurse gave them to her earlier, and she had not taken them yet. During an interview on 4/14/2026 at 9:58 am, LVN A said she worked as the medication nurse on the hall where Resident #16 resided. She said she gave Resident #16's morning medications to her but the roommate in the room started grimacing and she was distracted and did not make sure Resident #16 took her medication. She said they were trained to stay with the residents to ensure they took all their medications and never leave medications at the bedside for the residents to take. She said the resident was given her OTC medications that included: vitamin c 500 mg, loratadine 10 mg, magnesium 400 mg, multivitamin, peppermint oil, and saccharomyces bouvardia. She said she still needed to give the resident her routine prescription medications. She said if staff did not stay with the residents to ensure they took them, the residents could choke or not take them.During an interview on 4/15/2026 at 1:56 pm, the ADON said he was responsible for conducting skills check offs with the staff annually and on hire. He said he conducted skills check offs with the nurses and medication aides annually and on hire. He said the staff should stay in the room with the residents while they took the medications, and should never leave the room without ensuring they had taken them. He said there could be a lot of bad things that could happen and LVN A had a 1:1 in-service with the DON on yesterday 4/14/2026.During an interview with the DON on 4/15/2026 at 2:15 pm, she said she and the ADON were responsible for training the nursing staff and medication aides on medication administration. She said they did it frequently with random audits monthly. She said she did not have any residents in the facility that were able to self-administer medications. She said staff should make sure they were getting the medications, and watched the resident take and swallow them before they walked out of the room. She said she had a 1 on 1 verbal in-service with LVN A on yesterday 4/14/2026. She said if medications were left in the rooms for residents to take, there could be a risk of other residents entering the rooms and taking them or a risk of being overmedicated. She said they planned to continue monitoring going forward with random audits.During an interview on 4/15/2026 at 2:31 pm, the Administrator said the nurse managers were responsible for training staff on medication administration. She said they did not have any residents in the facility that were able to self-administer. She said staff should ensure and watch residents take their medications. She said residents could be at risk of not taking them, or other residents taking them if they were left in the rooms.Record review of a facility policy titled Medication Administration revised April 2019 indicated, .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely and after the completion of a Medication Self-Administration Evaluation .

Based on interview and record review, the facility failed to make sure a comprehensive care plan was prepared by an interdisciplinary team, that included but not limited to the participation of the resident and the resident representative for 1 of 4 residents (Resident #16) reviewed for care plans.The facility failed to ensure Resident #16 has care plan conferences at least every 3 months, and her representative, were invited to the resident care plan conferences.This failure could place residents at risk of not being able to provide input on their care, and receiving the care and services to meet their needs.Findings include:Record review of an admission Record for Resident #16 dated 4/14/2026 reflected she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of atrial fibrillation (irregular heart rhythm), major depressive disorder (persistent sadness or loss of interest in doing things), and GERD (acid reflux disease).Record review of a Quarterly MDS Assessment for Resident #16 dated 2/27/2026 indicated she did not have any impairment in thinking with a BIMS score of 15. She required substantial/maximal assistance with personal hygiene. She had an indwelling catheter and an ostomy. Urinary and bowel continence was not rated because she had a catheter or ostomy during the entire 7-day look back period.Record review of a care plan for Resident #16 dated 9/9/2025 indicated she had an indwelling catheter with interventions to provide catheter care at least one time per shift and after each bowel movement. Record review of a quarterly care plan conference summary for Resident #16 indicated her last care plan meeting was held on 12/10/2025 and the resident was not in attendance. She was invited and opted not to attend. The resident representative/family was not in attendance.During an observation and interview on 4/13/2026 at 2:59 PM, Resident #16 was in bed and said she was not sure about any care plan meetings and had not been asked to attend one since she has been at the facility.Attempted a phone interview with the previous MDS Coordinator on 4/15/2026 at 8:48 am, there was no answer and a voicemail message was left for a return phone call.During an interview on 4/15/2026 at 8:52 am, the SW said she started in December 2025, and at that point, the previous MDS Coordinator was responsible for the care plan meetings. She said she worked part time in the facility, and meetings were held every Wednesday. She said Resident #16 was scheduled for a meeting that day at 3 pm. She said she was not aware Resident #16 did not have her last meeting which should have been in March 2026.During an interview on 4/15/2026 at 10:23 am, the Regional MDS said the previous MDS Coordinator was responsible for the care plan meetings, but they had been recently reassigned to the SW. She said after the initial meeting, a resident would have a meeting every 90 days and prn after. She said if care plan meetings were not held, then the IDT team and staff would not know what care was needed or if they had the same goals initally. She said she was not aware Resident #16 did not have her scheduled meeting last month. She said residents and their RP's were invited to attend the care plan meetings.During an interview on 4/15/2026 at 2:31 pm, the Administrator said the Regional MDS was responsible for the care plans meetings. She said the facility did not have an MDS Coordinator in the facility at that time. She said the purpose of the meetings was for residents and RPs to be aware of what was going on and of any risks, along with ADL function. She said she planned to have the SW manage the care plan meetings going forward. She said she was not aware Resident #16 did not have her scheduled meeting last month. She said there was a risk of not being informed of what was going on with the residents if they did not have care plan meetings. She said residents and their RP's were invited to attend the care plan meetings.Record review of a facility policy titled Care Plans, Comprehensive Person-Centered revised December 2016 indicated, .A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 7. The care planning process will: a. facilitate resident and/or representative involvement .

Based on interview and record review, the facility failed to provide the resident and or the resident representative with a summary of the baseline care plan for 1 of 4 residents (Resident #58) reviewed for the base line care plans.The facility did not provide a summary of the Baseline Care Plan to Resident #58 or their Responsible Party (RP).This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff.Findings included:Record review of an admission Record for Resident #58 dated 4/14/2026 reflected she admitted to the facility on [DATE] and was [AGE] years old with a diagnosis of displaced intertrochanteric fracture of right femur (hip fracture), age related osteoporosis (brittle bones), and COPD (a group of lung disorders that affect breathing).Record review of an admission MDS assessment dated [DATE] indicated she had moderate impairment in thinking with a BIMS score of 12. She was dependent on staff for personal hygiene. Active participants in the assessment process were the Resident and family.Record review of a care plan for Resident #58 dated 2/26/2026 indicated to provide the Resident and their representative with a summary of the baseline care within 48 hours of admission. Interventions included the Resident will have all needs anticipated and met to ensure the highest practicable level of well-being and dignity preservation.Record review of the schedule for care plan meetings for the past 4 months (January 2026-April 2026) revealed Resident #58 was not scheduled for a care plan meeting. During an observation and interview on 4/13/2026 at 3:23 PM, Resident #58 was in her room sitting in a wheelchair, and said she had not had a care plan meeting since she was admitted to the facility.During an interview on 4/15/2026 at 8:52 am, the SW said she started at the facility in December 2025 and at that point the previous MDS Coordinator was responsible for the coordinating the care plan meetings. She said she worked part time in the facility and meetings were held every Wednesday. She said Resident #58 did not have any initial care plan meeting within 48 hours, and she did not know why. She said a new admission should have an initial meeting within 48-72 hours after admission and the resident and RP would be provided with a copy of the summary. During an interview on 4/15/2026 at 10:23 am, the Regional MDS said the previous MDS Coordinator was responsible for the care plan meetings, but it had been reassigned to the SW. She said if a resident was a new admission, then they should have a care plan meeting within 48 hours after admission, and the resident/family should be given a copy of the care plan. She said after the initial meeting, the meeting would be held every 90 days and PRN after. She said if care plan meetings were not held, the IDT team and staff would not know what care the resident needed or if they had the same goals initially.Attempted a phone interview with the previous MDS Coordinator on 4/15/2026 at 8:48 am, there was no answer and a voicemail message was left for a return phone call.During an interview on 4/15/2026 at 2:31 pm, the Administrator said the Regional MDS was responsible for the care plans, including the baselines, and should be done within 72 hours of admission and quarterly meeting thereafter. She said the purpose of the meeting was for the residents/RP to be aware of what was going on and any risks along with ADL function. She said going forward, the plan would be to have the SW manage the care plan meetings. She said residents/families could be at risk of not being informed of what was going on with them if the meetings were not conducted.Record review of a facility policy titled Care Plans-Baseline revised December 2016 reflected, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. 4. The resident and their representative will be provided a summary of the baseline care plan .

Based on interview and record review, the facility failed to ensure the facility coordinated with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition for 1 of 3 residents (Residents #45) reviewed for resident assessments.The facility did not refer Resident #45 to the appropriate state-designated mental health authority for review when she received a new diagnosis of bipolar disorder.This failure could affect residents with psychiatric diagnoses at risk of not receiving beneficial and needed services and care.Findings included:Record review of an admission Record for Resident #45 dated 4/14/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of dementia, bipolar disorder (alternating mood swings with extreme highs and lows), depression (loss of interest in doing things that affect daily life) and anxiety disorder (fear, dread, or worry that interferes with daily life).Record review of a Quarterly MDS Assessment for Resident #45 dated 2/20/2026 indicated she had severe impairment in thinking with a BIMS score of 3. She had psychiatric/mood disorders of anxiety disorder, depression, and bipolar during the 7 day look back period.Record review of a care plan for Resident #45 dated 3/22/2024 indicated she used a mood stabilizing medication related to bipolar disorder. Review of active physician orders dated 4/14/2026 for Resident #45 indicated she had a diagnosis of bipolar disorder with a start date of 3/6/2024.Record review of a psychiatric progress note for Resident #45 dated 3/20/2024 indicated her primary treating diagnosis was bipolar disorder.Record review of a PASRR Level 1 (PL1) for Resident #45 dated 2/26/2024 indicated she was negative for mental illness, intellectual disability, and developmental disability. Attempted a phone interview with the previous MDS Coordinator on 4/15/2026 at 8:48 am. There was no answer and a voicemail message was left for a return phone call.During an interview on 4/15/2026 at 10:23 am, the Regional MDS Coordinator said the previous MDS Coordinator was responsible for PASRR, but no longer worked at the facility and she was now completing the MDS assessments for the facility. She said they conducted an audit in December 2025 and January 2026, and they checked all residents in the facility that had a new psychiatric diagnosis and had form 1012 (a form used to evaluate if a resident with a negative PL1 screening needed a new positive screening due to the potential for mental illness or dementia) completed for them. She said if a resident received a new mental illness diagnosis, they were to complete a 1012 form and have the physician sign it along with submitting a new PL1 and PE if necessary. She said Resident #45 did not have a new PL1 after receiving the new diagnosis from the psychiatric physician and should have. She said residents could be a risk of not receiving benefits from PASRR if new mental illness diagnosis were given. During an interview on 4/15/2026 at 2:31 pm, the Administrator she said currently the Regional MDS was responsible for entering the PASRR information and form 1012's with new diagnosis of mental illness. She said the previous MDS Coordinator was responsible for Resident #45 and should have completed the form 1012 as soon as the new diagnosis was given. She said, going forward, they would review the diagnosis changes daily as they received them in the morning meetings, and if a new psychiatric diagnosis was received then a form 1012 would be completed. She said residents could be at risk of delays in services through PASRR, if they qualified for it, and new diagnosis were missed.Record review of a facility policy titled Preadmission Screening and Resident Review revised December 2024 indicated, .Our facility ensures compliance with all federal and state requirements regarding Preadmission Screening and Resident Review (PASRR) for individuals with serious mental illness, intellectual disability, or released conditions. 5. Resident Review (Significant Change) 1. A PASRR resident review will be requested when a resident experiences a significant change in condition suggesting the presence of mental illness that was not previously identified. 2. Social Services Director or designee is responsible for initiating referrals for Resident Review when indicated .

Based on interview and record review, the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the option he or she prefers for 1 of 4 residents (Resident #1) reviewed for resident rights.The facility failed to ensure Resident #1 had a signed medication consent form for Olanzapine (an antipsychotic medication) when ordered on 10/15/25.This failure could place residents at risk for treatment or services provided without their informed consent.Findings included:Record review of a facility face sheet dated 4/14/26 for Resident #1 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of pneumonia (infection in the lungs).Record review of a quarterly MDS assessment dated [DATE] for Resident #1 indicated a BIMS score of 13, which indicated she had intact cognition. She received antipsychotic medication.Record review of a comprehensive care plan dated 9/9/25 for Resident #1 indicated she used antipsychotic medication Olanzapine with an intervention that read: .Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of psychotropic medication drugs being given.Record review of a physician's order summary report dated 4/14/26 for Resident #1 indicated a physician's order dated 3/10/26 which read: .Olanzapine oral tablet 5mg . give one tablet by mouth one time a day related to major depressive disorder, recurrent, severe with psychotic symptoms.Record review of Resident #1's medication administration records for October 2025 through April 2026 indicated Resident #1 had been receiving Olanzapine daily as ordered.Record review of Resident #1's consents for medications revealed an HHSC form 3713 dated 10/15/25 had been uploaded into Resident #1's electronic medical record indicating she was to begin Olanzapine 5 mg every night for Major Depressive Disorder, severe, with psychotic symptoms on 10/15/25. The form had not been signed by Resident #1 or responsible party.During an interview on 04/15/2026 at 1:00 pm, the consultant pharmacist said she came to the facility every month and had been coming for about a year. She said she would keep track of GDRs, recommend GDRs, make care plan recommendations, and observe risks with medications. She said she did look for medication consents if they were due. She said she would not necessarily look for consents unless there was a new order. She said she would expect any resident that was on Olanzapine to have a signed consent in place. She said by not obtaining informed consent, residents could be at risk of side effects and that was why they should be monitored carefully.During an interview on 4/15/26 at 1:10 pm, the DON said she was unsure how the consent was scanned into the resident's chart without a signature. She said the ADON was responsible for ensuring consents were signed and in place. She said residents could be at risk for adverse side effects and families may not be made aware of the residents' condition if they were not informed and given the opportunity to consent to treatment.During an interview on 4/15/26 at 1:15 pm, the Administrator said nursing staff were responsible for ensuring medication consents were signed and in place for psychotropic medications. She said she would not want her mother in a facility to be given any psychotropic medications without giving consent. She said not getting consents obtained and signed prior to administering psychoactive medications could take away the residents right to being informed regarding their medications and could possibly take away their right to refuse treatment.During an interview on 04/15/2026 at 1:52 pm, the ADON said he was responsible for ensuring psychoactive consents were signed and in place. He said, going forward, he would have to hold the nursing staff accountable for ensuring informed consent was obtained prior to starting treatment. He said he tried to them often to ensure they were being done, but he had to work the floor often and sometimes things would be missed. He said he was not aware Resident #1 did not have a signed consent in place, or he would have had it signed before now. He said all psychotropic drugs needed to have consents completed before beginning treatment.Record review of a facility policy titled Psychotropic Medication Use dated January 2025 read: .Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated/effective and after informed consent is obtained.Antipsychotic/Neuroleptic medications will have consent obtained via the Texas Health and Human Services form 3713 .

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADL care. (Resident #10)The facility failed to ensure Resident #10 received timely incontinent care on 03/04/2026 which caused redness to inner thighs and excoriation to buttocks.This failure could place residents at risk of embarrassment, discomfort, and skin breakdown.Findings included:Record review of an admission Record dated 3/4/2026 for Resident #10 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, colostomy status (opening into the abdomen for the collection of stool), and hemiplegia affecting right dominant side (paralyzed on right side).Record review of a Quarterly MDS assessment dated [DATE] for Resident #10 indicated he had moderate impairment in thinking with a BIMS score of 12. He was dependent on staff for toileting hygiene. He had an indwelling catheter (for bladder contents to exit) and an ostomy (opening in the abdomen for bowel contents to exit),; urinary and bowel continence were not rated. He was at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries during the look back period.Record review of a care plan dated 1/27/2022 for Resident #10 indicated he had the potential for alteration in skin integrity. Interventions included to keep skin clean and dry, and provide incontinent care as quickly as possible following episodes of voiding or bowel movement.Record review of a care plan dated 8/10/2019 for Resident #10 indicated he had an ADL self-care performance deficit related to disease process. Interventions for toilet use were he required a colostomy, ensure dignity was maintained, privacy was provided and was clean, dry, and free from odor.During an observation and interview on 3/4/2026 at 9:09 am, CNA C and CNA D were in the room of Resident #10 to perform incontinent care. Both staff donned a gown prior to entering the room. Both staff washed their hands and applied gloves. Resident #10 was awake in bed, dressed in a hospital gown, and lying on an air mattress. His room had a strong smell of urine. Contractures were noted to both of Resident #10's hands, and his nails were long with a dark, brown substance underneath them. Resident #10 had a colostomy noted to his left lower abdomen, and a foley catheter that was draining clear, yellow urine into a drainage bag. CNA D placed a towel on his over the bed table as a barrier. CNA C pulled the linens back and a pillowcase was observed between his thighs that was soaked in urine that had a strong odor. CNA D removed the pillowcase and placed it into a plastic bag. Resident's #10's groin and inner thighs were wet, and redness was noted to his mid-thigh. His under pad was wet with urine and had a brown ring that extended to his upper back. Resident #10 had white, dried, flaky skin around the base of his penis. CNA D removed a wipe from a package and cleaned his penis at the base of the shaft and placed the wipe in the trash. CNA D removed more wipes and cleaned the shaft and insertion site of the foley down the tubing and placed the wipes in the trash. Resident #10 said his catheter had been leaking and started sometime during the night of 3/3/2026. CNA C rolled the resident onto his right side and CNA D removed the under pad and placed it in a bag. Resident #10's entire back was wet from urine. The skin on his back was wrinkled, and an old healed sacral wound was observed that was white with one small open area with the top layer of skin missing. CNA D placed a clean under pad under the resident's buttocks. Both staff told the resident he would get a shower and the resident said ok.During an interview on 3/4/2026 at 9:27 am, CNA C said the care provided to Resident #10 looked like he did not get changed last night 3/3/2026. She said his entire bed was wet and he had a bad urine odor. She said his nails were dirty, needed to be cleaned, and should be done on his shower days, but if he was diabetic, the nurse would trim his nails. She said they were to check the resident every 2 hours, and she would be angry if she was left in that condition. She said she cleaned Resident #10's nails Monday 3/2/2026 when she gave him a shower. She said Resident #10 did not have any redness or open areas on his buttocks when she gave him a shower on Monday 3/2/2026.During an interview on 3/4/2026 at 9:33 am, CNA D said that day was her fourth day working at the facility, and she was assigned to Hall 100 where Resident #10 resided. She said Resident #10 looked very raw like he had a bad rash down his legs and his under pad was wet with brown rings which meant he had been that way for a long time. She said they made rounds every 2 hours. She said her shift started at 6 am and that was her first time to provide incontinent care for Resident #10. She said she had been in his room earlier but only emptied his drainage bag for his catheter. She said she would be upset with the condition he was left in if it was her. She said she only checked the catheter and emptied it. She said residents could be at risk of skin breakdown if care was not provided timely.During an observation and interview on 3/4/2026 at 9:38 am, Resident #10 was in bed awake and said he had been at the facility for 4-5 years and things were good. He said his scheduled shower days were Mondays, Wednesdays, and Fridays, and they usually gave him a bed bath. He was alert to person, place, and time. He said staff came into his room last night 3/3/2026 a couple times to check on him and his catheter started leaking last night. He stated they placed something between his legs. He said that it was the first time someone came into his room that morning. He said they cleaned his nails sometimes, but they did not clean his nails on 3/2/2026. He said two people came into his room and gave him a bed bath on Monday 3/2/2026. He said he did not feel good about it when they did not provide care to him timely, and he could tell that he was wet. He stated he also did like his nails being dirty.During an interview on 3/4/2026 at 11:16 am, the DON said she was made aware of Resident #10 who was left soiled in urine. She said regardless of if a resident has a catheter and colostomy, staff should clean the anus, make sure the pad underneath them was clean and dry, and they needed to clean the penis and around the shaft. She said a minimum of every 2 hours, staff should go in and check on residents. She said the shift started at 6 am and care should have been done before 9 am. She said the staff should be doing walking rounds at the beginning of the shift with the staff that were leaving to ensure care was provided. She said nails should be cleaned at every shower, and he was diabetic and would not allow staff to cut his fingernails. She said if she was dependent, she would be enraged and dependent on staff to provide care. She said there was a risk of skin breakdown if care was not provided timely.During an interview on 3/4/2026 at 2:46 pm, the Administrator said staff should check on residents at a minimum of every 2 hours and as needed. She said the staff should conduct off going shift rounds and check them to make sure they were clean and dry. She said nails should be cleaned as needed and when visibly soiled. She said if she were not provided care timely and left wet, it would make her feel awful and it would be unacceptable. She said she expected staff to take care of the residents and make sure their needs were met. She said they started in-services with staff on rounding. She said there was a risk of skin breakdown, infections, or mental anguish if incontinent care was not provided timely.Record review of the facility's policy titled Activities of Daily Living (ADLs), Supporting revised March 2018 indicated, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, 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 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1's skin was appropriately assessed and treated resulting in skin breakdown. This failure could place all residents at risk of skin breakdown, infection, and hospitalization.Findings included: 1. Review of an admission Record dated 4/7/26 for Resident #1 indicated he was an [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of pneumonia (respiratory infection), type 2 diabetes, and acquired absence of right leg above the knee (amputation of right leg above the knee). Record review of an assessment MDS dated [DATE] indicated Resident #1 had intact cognition with a BIMS of 15. He required setup/clean-up assistance with eating and oral hygiene; he required partial assistance with upper body dressing and putting on/taking off footwear; he required substantial assistance with shower/bath; he required total assistance with toileting hygiene, and lower body dressing. He was always incontinent of bowel and bladder. He had no documented ulcers, wounds, or skin problems. He received skin treatments of applications of ointments/medications other than to feet. Record review of a comprehensive care plan dated 1/15/2025 indicated Resident #1 had bladder incontinence related to impaired mobility/physical limitations. Interventions were in place including providing incontinent care after each episode of incontinence. Record review of a comprehensive care plan dated 6/28/25 indicated Resident #1 had potential for alteration in skin integrity related to impaired mobility. Interventions were in place including weekly skin inspections, keeping skin clean and dry, and inform the physician, family, dietician, and DON of any new skin breakdown. During an interview on 4/7/26 at 10:50 a.m., Resident #1 said he frequently waited 30 minutes to an hour to receive incontinent care. Resident #1 said he was currently wet and had not been changed that day. Resident #1 said it made him feel bad not to receive the care he needed in the facility. Resident #1 said he had used his call light but staff would frequently answer his light and tell him they would return, but they would not come back. Resident #1 said he had pain and itching around his genitals. During an observation on 4/7/26 at 11:15 a.m., CNA A and CNA B assisted Resident #1 with incontinent care. CNAs donned appropriate PPE and utilized appropriate techniques during care provided, no deficient practice was noted. Observation of Resident #1's skin revealed his scrotum to be reddened with open wounds visualized on his right thigh/groin area. During an interview on 4/7/26 at 12:00 p.m., LVN C said Resident #1 had no active skin integrity issues. LVN C said Resident #1 had a resolved pressure ulcer on his backside. LVN C said no new skin integrity concerns had been reported to her, but staff may have reported issues to the treatment nurse. LVN C said she expected CNA staff to report any suspected skin integrity concerns to the charge nurse so it can be assessed. LVN C said the risk to residents for unreported skin integrity issues could be skin breakdown. During an interview on 4/7/26 at 1:40 p.m., CNA A said she changed Resident #1's brief around 6:15 a.m. and 11:15 a.m. that day. CNA A said she noted Resident #1 had redness to his genitals and surrounding skin, but it had been ongoing for about a week now. CNA A said she didn't report the redness to nursing staff because it comes and goes. CNA A said she just applied barrier cream to affected areas. CNA said she should report any skin issues to the nurse immediately upon noticing the changes. During an interview on 4/7/26 at 2:10 p.m., LVN D said she was the treatment nurse and Resident #1 had no open wounds to her knowledge and no active wound care orders. LVN D said no skin integrity concerns for Resident #1 had been reported to her. LVN D said she recently completed an inservice with staff about reporting skin conditions to nursing staff and the expectation was that CNAs report any skin integrity concerns to the nursing staff. LVN D said if a new skin issue was reported to her she would assess the resident, notify the provider, and obtain new orders for wound care. LVN D said the risk of not reporting skin integrity issues immediately could include skin breakdown and infections. During an observation on 4/7/26 at 2:25 p.m., LVN D conducted a skin assessment on Resident #1. LVN D noted open wounds to resident's right inner thigh and redness to resident's scrotum. LVN D applied a barrier cream to reddened skin and collected wound measurements. During an interview at 4/7/26 at 3:20 p.m., the DON said CNAs were expected to monitor residents for skin integrity issues and report any findings to the charge nurse. The DON said an immense amount of education regarding reporting changes of condition had been completed already. The DON said CNAs were expected to immediately report changes in resident skin condition to the nurse who will then assess resident and notify the provider. During an interview on 4/7/26 at 4:01 p.m., the ADM said she was ultimately responsible for supervision of all staff in the building. The ADM said CNAs were expected to report any change of condition in residents, including skin integrity concerns, should be reported immediately to the nurse; the nurse was then responsible for assessing the resident and notifying providers of any change of condition. The ADM said the risk to residents for untimely change of condition notifications would be delay of treatment. Review of a facility policy titled Perineal Care dated February 2001 indicated The purposes of this procedure are to provide cleanliness and comfort to the resident, the prevent infections and skin irritation, and to observe the resident's skin condition. Review of undated in-service titled Wound care In-service: Communication & Notification Protocol indicated .Notify wound care nurse immediately for: New Wounds, Skin Tears, Rashes, Redness or suspected pressure injuries, Any skin concern or abnormal finding. The in-service was attended by CNA A and CNA B. Review of a skin assessment dated [DATE] at 2:59 p.m. by LVN A conducted on Resident #1 indicated he had new moisture associated skin damage/incontinence associated dermatitis acquired in house. The wound measurements were 10 cm x 10 cm. Review of order summary for Resident #1 dated 4/7/26 indicated new wound care orders were received on 4/7/26 including .SCROTUM AND INNER RIGHT THIGH: Cleanse site with NS or wound cleanser, pat dry and apply zinc oxide. With each dressing change observe the woundand document.

Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 5 staff (CNA B) reviewed for nursing services.The facility failed to ensure CNA B properly and safely transferred Resident #4 while using a mechanical lift on 3/3/2026.This deficient practice could place residents at risk for injury and harm.The findings included: Record review of an admission Record for Resident #4 dated 3/5/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease, expressive language disorder (a communication disorder that affects a person's ability to express thoughts, ideas, or emotions using language), and osteoporosis (brittle bones).Record review of a care plan for Resident #4 revised 2/13/2026 indicated she had an ADL self-care performance deficit and limitation in physical mobility. Interventions for transfers indicated she required the use of a Hoyer Lift with two staff for transfers.Record review of a Quarterly MDS Assessment for Resident #4 dated 1/1/2026 indicated she was rarely/never understood. She was dependent on staff for all ADLs.Record review of a care plan for Resident #4 revised 2/13/2026 indicated she had an ADL self-care performance deficit and limitation in physical mobility. Interventions for transfers indicated she required the use of a Hoyer Lift with two staff for transfers.During an observation on 3/3/2026 at 12:15 pm, CNA A and CNA B were in the room of Resident #4 to transfer her using a mechanical lift. Both staff applied gloves to their hands. A mechanical lift was in the room. CNA B moved the mechanical lift and widened the base and placed the legs under the bed. Both staff applied the lift sling that was underneath the resident to the lift. CNA B did not lock the wheels and proceeded to lift the resident from the bed and CNA A assisted with guiding and holding onto the resident. CNA B closed the legs on the lift and moved it to the wheelchair. CNA B widened the base of the lift and lowered the resident into the wheelchair. As she was lowering the resident, one of the wheels lifted off the floor and CNA B stood on the lift to get the wheel to touch the floor. CNA A guided the resident in the wheelchair without any difficulty, and the sling was detached from the lift, and the lift was moved out of the way.During an interview on 3/3/2026 at 12:22 pm, CNA B said she should have locked the wheels on the lift, but she could not because the lock was broken. She said that lift was usually the only one they could use because the two other lifts operated by batteries and they were never fully charged. She said she had been trained in how to use the mechanical lift in the past. She said she told the DON that the lift was broken and they could not lock the wheels. She said it had been broken since she started and had been employed at the facility for about 3 months. She said she used the lift because it was all they had to use. She said she was not sure why one of the wheels came up from the floor when she used it. She said there could be a risk for the mechanical lift to tip over or injury could occur if the lift was broken and could not lock the wheels. She said she had refused to use that lift before but when she did, they treated her like she was lazy and as if she did not want to use it.During an observation and interview on 3/3/2026 at 12:50 pm, the DON said she removed the mechanical lift that was used to transfer Resident #4. The lift was in her office and demonstrated the lock worked on the lift. She said the lift only had one lock and it functioned properly.During a phone interview on 3/4/2026 at 10:16 am, CNA A said she did not notice that CNA B did not lock the wheels on the lift and was not aware the wheels on the lift did not lock. She said residents could fall and get hurt if the wheels did not lock on the lifts.During an interview on 3/4/2026 at 11:16 am, the DON said two people were required for the use of a mechanical lift. She said Resident #4 would require two people for transfers with a lift. She expected that the residents were secure, everything was arranged with one to work it and one to guide, when getting in position wheels should be locked. She said staff had competency check offs with the lift involving the two staff on hire, as needed, and annually. She said she could not find a competency checklist for the use of a mechanical lift for CNA A. She said residents could be at risk of falling and getting hurt if staff were not properly trained. She said the mechanical lift that was used only had one lock on one of the wheels and it worked. She said staff should not use equipment that would not work properly.During an interview on 3/4/2026 at 2:46 pm, the Administrator said new hires were given skills check offs that included the use of a mechanical lift on hire, as needed, and annually thereafter. She said staff should not use the mechanical lift if the locks did not work and should report it to the nurse, Maintenance, or the DON. She said there was a risk of an accident if staff did not lock the wheels while using the mechanical lift.Record review of competency skills for CNA B revealed she did not have a skills check off on hire, and none was provided before Surveyor exit 3/4/2026.Record review of a Hoyer lift transfer check list for CNA A dated 11/5/2025 indicated she completed the Hoyer lift transfer.Record review of a facility policy titled Competency of Nursing Staff revised May 2025 indicated, .6. Facility and resident specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #5) reviewed for infection control.The facility failed to ensure CNA A followed enhanced barrier precautions when she provided personal care that included dressing of Resident #5 on 3/3/2026.This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #5 dated 3/4/2026 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dysphagia (difficulty speaking), hypertension, and cerebral infarction (stroke).Record review of an Annual MDS Assessment for Resident #5 dated 2/9/2026 indicated she had severe impairment in thinking with a BIMS score of 3. She required substantial/maximal assistance with upper and lower body dressing.Record review of a care plan for Resident #5 revised 11/11/2025 indicated she had a stage 4 pressure ulcer to her right lateral ankle. Interventions included that she required EBP (Enhanced barrier precautions) gown and gloves were required to be worn during high contact care.Record review of active physician orders for Resident #5 dated 3/4/2026 indicated a physician order for enhanced barrier precautions during episodes of high-contact care that started on 11/4/2025.Record review of an order listing report for the facility dated 3/3/2026 indicated Resident #5 had an order for EBP with a start date of 11/4/2025.During an observation and interview on 3/3/2026 at 11:52 am, CNA A was in the room of Resident #5 dressing her. Resident #5 had a sign on her door for EBP. CNA A said she had performed incontinent care prior to Surveyor's entrance into the room. CNA did not have a gown on and was only wearing gloves. CNA A placed a shirt and a pair of pants on Resident #5 and repositioned the resident in bed. CNA A removed her gloves and placed them in the trash, exited the room, and sanitized her hands.During a phone interview on 3/4/2026 at 10:16 am, CNA A said the care she provided to Resident #5 on 3/3/2026, she was not aware Resident #5 was on EBP and did not notice the sign on the door. She said yesterday 3/3/2026 was her first day working on hall 100 where Resident #5 resided. She said usually if a resident were on EBP, there would be PPE in the hallway outside the room, and the resident did not have any in the hallway. She said if a resident was on EBP, then staff should wear a gown and gloves when care was provided that included dressing the resident. She said there was risk of spreading infections to other residents if they did not. She said she had training on EBP a long time ago.During an interview on 3/4/2026 at 11:16 am, the DON said Resident #5 was on EBP. She said if a resident was on EBP, staff should wear gowns and gloves to protect the residents and if residents had a wound like Resident #5 had a wound to her ankle. She said gowns and gloves should be worn during high contact care which included incontinent care, changing foleys, wound care, and dressing the resident. She said there was a risk for the potential of the residents to get an infection. She said she was the IP for the facility and would be responsible for ensuring that they were trained on infection control.During an interview on 3/4/2026 at 2:46 pm, the Administrator said staff had been trained on EBP with the last training being conducted December 2025. She said residents who were on EBP would have posted signs on the resident doors. Residents who required EBP included foley catheters, wounds, IVs, and ostomies. She said staff should wear gowns and gloves if the resident was on EBP while providing care that included dressing a resident. She said there was a risk of infections if they did not follow EBP.Record review of the facility policy titled Personal Protective Equipment-Enhanced Barrier Precautions revised April 2024 indicated, .To ensure personal protective equipment appropriate to specific task requirements is available at all time for staff residents when rendering high-contact direct care activities for residents with chronic wounds. 1. Enhanced barrier precautions refer to infection control interventions designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. 5. High contact resident care activities that require Enhanced Barrier Precautions (EBP), a. Dressing.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 6 residents reviewed for quality of care. (Resident # 4)The facility failed to ensure CNA A and CNA B properly and safely transferred Resident #4 while using a mechanical lift on 3/3/2026.This failure could result in a loss of quality of life due to injuries.Findings included:Record review of an admission Record for Resident #4 dated 3/5/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Alzheimer's disease, expressive language disorder (a communication disorder that affects a person's ability to express thoughts, ideas, or emotions using language), and osteoporosis (brittle bones).Record review of a care plan for Resident #4 revised 2/13/2026 indicated she had an ADL self-care performance deficit and limitation in physical mobility. Interventions for transfers indicated she required the use of a Hoyer Lift with two staff for transfers.Record review of a Quarterly MDS Assessment for Resident #4 dated 1/1/2026 indicated she was rarely/never understood. She was dependent on staff for all ADLs including transfers.Record review of a care plan for Resident #4 revised 2/13/2026 indicated she had an ADL self-care performance deficit and limitation in physical mobility. Interventions for transfers indicated she required the use of a Hoyer Lift with two staff for transfers.During an observation on 3/3/2026 at 12:15 pm, CNA A and CNA B were in the room of Resident #4 to transfer her using a mechanical lift. Both staff applied gloves to their hands. A mechanical lift was in the room. CNA B moved the mechanical lift, widened the base, and placed the legs under the bed. Both staff applied the lift sling that was underneath the resident to the lift. CNA B did not lock the wheels and proceeded to lift the resident from the bed and CNA A assisted with guiding and holding onto the resident. CNA B closed the legs on the lift and moved it to the wheelchair. CNA B widened the base of the lift and lowered the resident into the wheelchair. As she was lowering the resident, one of the wheels lifted off the floor and CNA B stood on the lift to get the wheel to touch the floor. CNA A guided the resident in the wheelchair without any difficulty, the sling was detached from the lift, and the lift was moved out of the way.During an interview on 3/3/2026 at 12:22 pm, CNA B said she should have locked the wheels on the lift, but she could not because the lock was broken. She said that lift was usually the only one they could use because the two other lifts operated by batteries and they were never fully charged. She said she had been trained in how to use the mechanical lift in the past. She said she told the DON that the lift was broken and they could not lock the wheels. She said it had been broken since she started and had been employed at the facility for about 3 months. She said she used the lift because it was all they had to use. She said she was not sure why one of the wheels came up from the floor when she used it. She said there could be a risk for the mechanical lift to tip over, or injury could occur if the lift was broken and could not lock the wheels. She said she had refused to use that lift before, but when she did, they treated her like she was lazy and as if she did not want to use it.During an observation and interview on 3/3/2026 at 12:50 pm, the DON said she removed the mechanical lift that was used to transfer Resident #4. The lift was in her office and demonstrated the lock worked on the lift. She said the lift only had one lock and it functioned properly.During a phone interview on 3/4/2026 at 10:16 am, CNA A said she did not notice that CNA B did not lock the wheels on the lift and was not aware the wheels on the lift did not lock. She said residents could fall and get hurt if the wheels did not lock on the lifts.During an interview on 3/4/2026 at 11:16 am, the DON said two people were required for the use of a mechanical lift. She said Resident #4 would require two people for transfers with a lift. She expected that the residents were secure, everything was arranged with one to work it, and one to guide the lift to the correct location and after getting in position the wheels should be locked. She said residents could be at risk of residents falling and getting hurt if staff were not trained. She said the mechanical lift that was used only had one lock on one of the wheels and it worked. She said staff should not use equipment that did not work properly.During an interview on 3/4/2026 at 2:46 pm, the Administrator said staff should not use mechanical lifts if the locks did not work and should report it to the nurse, Maintenance, or the DON. She said there was a risk of an accident if staff did not lock the wheels while using the mechanical lift. She stated she expected staff to follow policy and procedure.Record review of the facility's policy titled Safe Lifting and Movement of Residents revised July 2017 indicated, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 4. Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices . 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.

Based on observation, interviews, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 3 of 4 residents (Resident's #11, #12, and #13) reviewed for a change of condition.1. The facility failed to notify the wound care physician to obtain and implement wound care orders for Resident #11 until 10/20/25, 2 days after identifying unstageable pressure injury (a full-thickness tissue loss where the base of the ulcer is covered by slough or eschar, making it impossible to determine the depth of the wound) to right heel on 10/18/25.The facility failed to contact surgeon or wound care physician to obtain wound care orders for Resident #11 on 11/3/25 after debridement of pressure ulcer (the medical process of removing necrotic (dead) tissue from a wound) in surgeon's office on 11/3/25. 2. The facility failed to obtain and implement wound care orders for Resident #12 until 10/19/25 after admission on [DATE]. Resident was admitted with bilateral stage 4 pressure injuries (the most severe form of pressure ulcers. Deep, open wounds that extend through the skin and underlying tissues, potentially exposing muscle, tendons, or bone) to heels.3. The facility failed to monitor, and report wound status to wound care physician for Resident #13.An Immediate Jeopardy (IJ) was identified on 11/11/25 at 10:57 am. The IJ template was provided to the facility on [DATE] at 11:04 am. While the IJ was removed on 11/12/25 at 6:34 pm, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions.These failures could place residents at risk for developing new pressure injuries, infections, decreased quality of life, and death.Findings included:1. Record review of a face sheet dated 11/10/25 for Resident #11 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: pneumonia (an infection that inflames the air sacs in one or both lungs), dementia (a disease that affects memory, thinking, and the ability to perform daily activities), and nondisplaced fracture of first metatarsal bone (fracture of the big toe), right foot. Record review of a Medicare 5-day MDS assessment dated [DATE] for Resident #11 indicated a BIMS score of 15 indicating she was cognitively intact. She required moderate to maximum assistance with most ADLs. She was not coded for pressure ulcers.Record review of a comprehensive care plan dated 9/9/25 for Resident #11 indicated she had potential for alteration in skin integrity due to impaired mobility and had an intervention to inspect skin from head to toe no less than once per week and document/measure all abnormal findings. She also had an intervention to inform physician, family, dietician, and director of nursing of any new skin breakdown.Record review of an electronic health record for Resident #11 on 11/10/25 indicated there were no skin assessments completed between the dates of 9/2/25 and 9/15/25 and no skin assessments documented between the dates of 10/18/25 to 11/10/25. There was no physician's order for skin assessments.Record review of a nursing progress note dated 10/18/25 at 8:12 pm and signed by RN K for Resident #11 indicated a new skin issue was identified; an unstageable pressure ulcer/injury to right heel. Note indicated wound measurements were 3cm X 2cm X 0.1cm and eschar was 100%. There was no documentation of physician notification.Record review of a physician's order summary report dated 11/12/25 for Resident #11 indicated the following physician orders: .consult Dr. [Wound physician name] for wound to r heel. dated 10/20/25 .wound location: right heel - skin prep daily unstageable PI to right heel. dated 10/20/25.wound location: right heel - clean wound with wound cleanser or NS, pat dry, apply medihoney and wrap with kerlix daily. dated 11/10/25. There was no order for wound care on 10/18/25 (the day wound was identified) There was no order for daily dressing changes dated 11/3/25 from surgeons' office visit.Record review of a Treatment Administration Record dated 10/1/25 to 10/31/25 for Resident #11 indicated she did not receive her wound care as ordered on 10/22/25 and 10/23/25.Record review of a Treatment Administration Record dated 11/1/25 to 11/30/25 for Resident #11 indicated she did not receive her wound care as ordered on 11/3/25, 11/7/25, and 11/8/25.Record review of a physician's office visit note dated 11/3/25 for Resident #11 indicated she had a physician visit on 11/3/25 to follow up with her foot surgeon. Note read: .Focused wound exam: Right lower extremity wound: surgical incision well healed however there is a full thickness, decubitus ulceration to the posterior heel with fluctuate eschar. Wound measurements were: 2.5cm X 1.1cm X 0.1cm. Excisional debridement was performed and post debridement measurements were 2.7cm X 1.2cm X 0.3cm. Documentation read: .Nature of tissues removed: devitalized tissue, fat necrosis, and slough.; wound care and dressing was applied and post-operative instructions read: .continue with daily dressing changes. 2. Record review of a facility face sheet dated 11/10/25 for Resident #12 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: pneumonia (an infection that inflames the air sacs in one or both lungs), urinary tract infection (a common infection that can affect any part of your urinary system, including the bladder, kidneys, and urethra), and acute kidney failure (a sudden loss of kidney function). Record review of a Medicare 5-day MDS assessment dated [DATE] for Resident #12 indicated a BIMS score of 15, which indicated he was cognitively intact. He was dependent or required maximal assistance with most/all ADLs. He was coded for 2 stage 4 pressure ulcers.Record review of a comprehensive care plan dated 10/23/25 for Resident #12 indicated he had stage 4 pressure ulcers/pressure injuries to right heel and left heel with an increased potential for pressure ulcer/pressure injury development and/or potential for worsening/additional pressure ulcer injury related to immobility. He had an intervention to complete a head-to-toe skin assessment on a weekly basis.Record review of a physician's order dated 10/19/25 for Resident #12 indicated he had the following order: .Clean with wound cleanser, pat dry, apply medihoney and cover with non-adherent dressing, wrap with gauze to secure. Change daily and prn soiled. Record review of a physician's order summary report dated 11/10/25 for Resident #12 indicated he had the following physician's orders: .wound location: left heel: clean wound daily w/NS or wound cleanser, apply ca alg (calcium alginate) w/silver and cover with dry dressing. Change daily and prn (as needed) if soiled, not intact. dated 10/22/25 .wound location: right heel: clean wound with wound cleanser or NS (normal saline), apply ca alg w/silver and cover with dry dressing, change daily and prn if soiled/not intact. dated 10/22/25. There were no physician orders for wound care between 10/15/25 through 10/19/25.Record review of a facility form titled Admission/re-admission Report Form dated 10/15/25 for Resident #12 read: .Wounds to bilateral heels. Right heel requires drsg (dressing) change. and was signed by LVN F. Record review of a nursing progress note clinical admission dated 10/15/25 at 3:21 pm for Resident #12 indicated he had unstageable pressure ulcers to both heels and was signed by LVN L. Note indicated resident physician was notified of admission, and triplicate forms were sent. No documentation of notification of wounds, or request for wound care orders. 3. Record review of a facility face sheet dated 11/10/25 for Resident #13 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral infarction (stroke), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).Record review of a Quarterly MDS assessment dated [DATE] for Resident #13 indicated a BIMS score of 03, which indicated she had severely impaired cognition. She required maximum assistance with most/all ADLs. She was coded for 1 stage 4 pressure ulcer. Record review of a comprehensive care plan dated 10/29/25 for Resident #13 indicated she had a stage 4 pressure ulcer/pressure injury to her right lateral ankle with an increased potential for pressure ulcer/pressure injury development and/or potential for worsening/additional pressure ulcer/pressure injury related to immobility. She had interventions for complete head-to-toe skin assessments on a weekly basis, administer treatments as ordered, and low air loss mattress inflated at correct setting to maximize pressure relief. Record review of an electronic health record for Resident #13 on 11/10/25 indicated there were no skin assessments completed between the dates of 10/8/25 and 11/10/25.Record review of a wound care physician visit report dated 6/16/25 for Resident #13 indicated that Resident had a facility acquired stage 3 pressure ulcer to her right lateral ankle (the outer side of the right ankle) acquired on 6/2/25 and the wound measured 0.5cm X 0.5cm X 0.1cm with moderate serous exudate.Record review of a wound care physician visit report dated 10/20/25 for Resident #13 indicated that on 10/20/25 wound had progressed to a stage 4 pressure injury with measurements of 1cm X 0.8cm X 0cm with moderate serous exudate.During an observation and interview on 11/10/25 at 3:18 pm Resident #11 said she had been at the facility for approximately 6 weeks and was at home prior to being admitted to the facility. She said she had gone to the hospital with a broken foot and had a wound to her right heel. She said the wound to her heel had not been covered by a dressing in the last 3 days. She said prior to that they were putting a bandage on her heel and keeping it on for a week and it was supposed to be changed 3 times a week on Mondays, Wednesdays, and Fridays. She said she guessed the staff were just lazy. She said the wound had not been infected that she was aware of and had not said anything about wound care not being done as ordered. Resident #11 removed her sock from her right foot and showed this Surveyor her heel-area noted with slough present with a small amount of eschar in the wound bed. She said it had not been changed in 3 days. She said she was not refusing any care from the staff. She said it had been a while since she saw the wound care physician and the last time she saw him he did not look at her wound because it had a bandage on it. She said the wound did not hurt.During an interview on 11/10/25 at 10:12 am the ADON said if staff found new skin issues, they should be reporting to the nurse, and they let her (ADON) know as well. She said if the doctor did not give new orders, then staff would not write a progress note. She said nurses should have completed skin evaluations and assessments. She said there had been a huge problem with the nurses doing their assessments and evaluations. She said there was no one in the facility holding staff accountable to make sure things were done. She said they had even contacted staff to come in to complete their evaluations on their days off. She said the facility has had a problem for a long time with nurse administration not following through and not holding staff accountable for things that were not done. She said the facility did not have a treatment nurse and the nurses were responsible for completing the skin assessments and wound care in the facility. During a telephone interview on 11/11/2025 at 9:15 am the Wound Physician said he would visit the facility every 2 weeks and had been visiting the facility for the past 5 years. He said he only saw residents who had wounds, and his last visit was on 11/3/2025. He said usually a floor nurse would follow him. He said Resident #11 was last seen on 10/20/2025 and she had a wound to her right heel that was pressure ulcer-unstageable with dry eschar about the size of a quarter. Treatment orders were for skin prep and float heels. He said if a resident refused treatment, the nurses would document the refusal as he did not document anything on his notes. He said when he visited, he assessed the wounds, measured, debrided and provided recommendations. He said sometimes the wounds would deteriorate if the residents were noncompliant. He said he had not been notified within the past 2-3 months of any residents in the facility with a deterioration of wounds. He said the best person to talk to would be the nurses. He said he visited every other Monday and would be back in the facility on 11/17/2025.During a telephone interview on 11/11/2025 at 9:34 am LVN L said the facility did not have a treatment nurse in the facility, and the nurses were responsible for completing skin assessments daily and wound care. She said they have a schedule at the nurse's desk in a binder. She said with new admissions, she would assess the residents and conduct skin assessments. She said if a resident had a wound on admission, the nurse would measure the wounds, and when the wound care physician comes the wounds, he would also measure the wounds. She said she was not measuring the wounds daily nor weekly. She said if it looked like a wound was getting worse, she would measure it. She said the wound care was supposed to be done during the day, but sometimes wound care did not get done during the day shift and the night shift would sometimes complete the ones that she was not able to complete. She said if she noticed that a wound had worsened, she would notify the resident's primary medical doctor or the ADON because they do not have access to contact the wound physician. She said she had never seen him on her rotation. She said sometimes she was aware he had been there, and the residents would tell her if they had any new orders. She said she would then go and look to see if there were any new orders in the charting system. She said when a resident goes out to the hospital and then returns, the nurses were supposed to notify the Administrator, DON or ADON, medical doctor or family/RP of any new orders and changes in care. She said residents could be at risk of infection, and sepsis if they were not getting wound care as ordered or skin assessments are not done weekly.Record review of a facility policy titled Change in a Resident's Condition or Status dated March 2022 read: .Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. This was determined to be an Immediate Jeopardy (IJ) on 11/11/2025 at 10:57 am. The facility's Administrator, DON, ADON, MDS, and Regional Director of Clinical Operations were notified. The Administrator was provided with the IJ template on 11/11/2025 at 11:04 am. The following Plan of Removal (POR) submitted by the facility was accepted on 11/12/2025 at 3:45 pm.PLAN OF REMOVALF580: Notification of ChangeName of facility: [name of facility]Date: November 11, 2025, 11:04 am.Immediate action: Immediately upon notification of the alleged deficient practice of notification of change the facility implemented the following measures: On 11/11/25 at 2:40 pm, The Corporate Director of Clinical Operations contacted the facility wound care consulting provider to ensure no information had been relayed to him regarding the residents currently under his care. Residents #11, #12, and #13 were discussed with the MDS Coordinator and the Assistant Director of Clinical Operations, no new orders were received. Regarding Resident #11: The consulting wound care physician was contacted by the Corporate Director of Clinical Operations on 11/12/25 at 11:15 am and was informed of the resident being seen by the surgeon who performed her original right metatarsal surgery and during the appointment, the right heel pressure injury was debrided, and the wound condition had deteriorated since his last observation. Also reviewed measurements of the wound, and the notes from the surgeon and the treatment (Santyl) ordered by the outside surgeon. Explained that we received this information this morning but there was an order from the attending physician for a different order (Medihoney). The consulting wound care physician stated to go with the order given by the attending physician and inquire which consulting wound care physician the family and attending physician would like to use moving forward as they cannot both treat/bill for the resident. The resident representative was contacted by the Assistant Director of Nursing and informed of the debridement, deterioration of the wound, and inquired which consulting wound physician she would prefer to use for the pressure area to the left heel. The resident representative prefers to use the consulting wound care physician that comes to the facility. Regarding Resident #12: The wound care consulting physician was contacted by the Corporate Director of Clinical Operations on 11/12/25 at 11:15 am to inform of the most recent measurements and wound condition, no new orders were given. Regarding Resident #13: wound measurements and condition were compared to the most previous wound assessment with noted increase in size from previous observation. On 11/3/25 the wound measurements were 1.0 X 1.0 X 0.2 with 76-100% granulation and the measurements for 11/11/25 were 1.2 X 1.2 with 70% slough. The wound care consulting physician was notified by the MDS coordinator on 11/11/25 with no new orders received and he stated the wound was unavoidable related to residents' persistent position of right side lying. The resident representative was notified by the MDS Coordinator. On 11/11/25, the nursing administration team (Director of Nursing, Assistant Director of Nursing, and MDS Coordinator), with the assistance of the Corporate Director of Clinical Operations and the Assistant Director of Clinical Operations will compare all measurements and wound condition observations to the previous measurement/condition to ensure any area of deterioration/worsening are immediately reported to the Wound Care Physician and the resident's attending physician regarding wound care deterioration/worsening. On 11/11/25, all nurses present at the time of notification of the alleged deficient practice will be re-educated in the form of an in-service from the Assistant Director of Nursing regarding when to report skin issues to the provider vs. the wound care consulting physician, how to document physician communication regarding wound care and how to contact the wound care consulting physician. This in-service will continue until all nurses have been in-serviced and all nurses will receive re-education prior to beginning their next scheduled shift. Beginning 11/11/25 the Director of Nursing and the Facility Administrator will review the 24-hour report each day to ensure a progress note is written when the wound care physician visits each resident and when the wound care physician is contacted to update with changes in wound condition. All nurses on staff at the time of notification on 11/11/25 were provided with education by the administrative nursing team regarding the completion of the Skin Issues evaluation when a new wound is discovered or when a resident is admitted with a wound, to notify the Director of Nurses and Facility Administrator, to notify the attending physician and/or the consulting wound care physician to obtain treatment orders and begin treatment orders immediately upon receipt, to make a notation on the 24-hour report of the new wound and to inform the Certified Nurse Aides of the residents wound and any changes needed for the residents plan of care This in-service will continue until all nurses have been provided with education and no nurse will begin their next scheduled shift without receiving the education. On 11/11/25, the nurses present at the time of notification will be in-serviced by the administrative nursing team regarding admitting a resident with wounds, informing the physician of wound(s) discovered during the initial assessment, obtaining orders for treatment, ensuring orders for treatment are initiated immediately (not when electronic health record defaults to the next day), and inquiring about existing wound when receiving report from the discharging facility. This in-service will continue until all nurses are provided with the education and nurses will receive the education prior to beginning their next scheduled shift. On 11/11/25 all nurses present at the time of notification were provided with re-education regarding notification of the physician when there is a change in condition of a wound is noted. Nurses were reminded to document all physician interaction in the electronic health record. This in-service will continue until all nurses are provided with the education and nurses will receive the education prior to beginning their next scheduled shift. The facility has begun the process of replacing the current consulting wound care physician with a wound care company that will be onsite weekly, physically examine and evaluate all residents with wounds, provide wound progress reports, training to staff, and work directly with facility management to ensure treatment and services are provided to prevent and heal pressure ulcers. The wound care company was contacted by the Corporate Director of Clinical Operations on 11/11/25, to inquire about projected start date of their services. The response from the wound care company is still pending. Another provider has been contacted and is willing to provide wound care consultant nurse practitioner service with the facility within the next 30 days. A determination of which company to be used will be made no later than 11/12/25 at 5:00 pm. Beginning 11/12/25 at 4:00 pm a daily stand-down meeting will be held by the Facility Administrator and Director of Nursing to ensure all assigned wound care tasks, documentation, recommendations, physician notifications, and physician orders are carried out appropriately. On 11/11/25 at 4:00 pm an impromptu QAPI meeting will be conducted with the Facility Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations and Assistant Director of Clinical Operations. Facilities Plan to Ensure Compliance QuicklyThe facility nursing administration staff (Director of Nursing, Assistant Director of Nursing, and MDS Nurse) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will ensure all residents have a current skin assessment completed and documented in the electronic health record and all residents with wounds will be evaluated immediately to ensure all appropriate interventions are in place and the attending physician and consulting wound care physician have been notified. This task will be completed no later than 11:00 pm on 11/11/25. The State Surveyors monitored the Plan of Removal as follows:Resident #11 - Progress note dated 11/10/25-MDS nurse notified primary physician, resident and RP of wound. RP notification verified by telephone interview 11/12/25 at 10:59 am.Resident #12 - Progress note dated 11/11/2025-RP was notified about wounds to feet. RP notification verified by telephone interview on 11/12/2025 at 11:12 am. Progress note dated 11/12/25 indicated physician notification was made by Corporate Director of Clinical Operations.Resident #13 - Progress note dated 11/11/25 - Physician and RP notified of wound by MDS nurse. RP notification was verified by telephone interview on 11/12/25 at 12:20 pm.Record review of progress note dated 11/12/25 for Resident #11 indicated current measurements had been taken and compared to previous, and notification made to wound care physician by Corporate Director of Clinical Operations. Record review of a progress note dated 11/11/25 for Resident #12 indicated current measurements had been taken and compared to previous, with an improvement in size, by MDS nurse.Record review of a progress note dated 11/11/25 for Resident #13 indicated current measurements had been taken and compared to previous, and notification made to wound care physician by MDS nurse.Record review of in-service dated 11/11/25 covered when to report skin issues to the provider vs. the wound care consulting physician, how to document physician communication regarding wound care and how to contact the wound care consulting physician. In-service also covered admitting a resident with wounds, informing the physician of wound(s) discovered during the initial assessment, obtaining orders for treatment, ensuring orders for treatment are initiated immediately (not when electronic health record defaults to the next day), and inquiring about existing wound when receiving report from the discharging facility, and notification of the physician when there is a change in condition of a wound noted. Nurses were reminded to document all physician interaction in the electronic health record. This in-service was signed by 10 nurses and the administrator.Record review of a checklist for daily tasks for morning meetings, stand down meetings, and weekly skin reports.Record review of email dated 11/11/25 with a wound consulting company from the facility.Checklist to be used during meetings verified.Record review of an impromptu QAPI dated 11/11/2025 indicated that the Medical Director, Administrator, DON and ADON were present to discuss immediate jeopardies relating to wound care and physician notification.Record review verified all 58 residents in facility had new skin assessment done 11/11/25 and 11/12/25.Interviews conducted on 11/12/25 from 11:00 am to 5:11 pm indicated DON, MDS, ADON, Administrator, LVN L, LVN F, and LVN Q were all able to verbalize the process of admitting a new resident with wounds, the process of identifying a new wound, completion of skin assessments, physician notification, notification of family, how to document resident refusals and provider notifications, where to find physician's/providers contact information, how and when to put orders into electronic health record, and how to complete the TAR. IDT Team members, which included DON, MDS, ADON, and Administrator, all verbalized their responsibilities related to providing oversight and monitoring reports during daily meetings. Interviews conducted included staff from both day and night shifts.The Administrator was informed that the Immediate Jeopardy was removed on 11/12/2025 at 6:34 pm however, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 4 of 4 Residents (Resident's #11, #12, #13, and #16) reviewed for pressure injuries.1. The facility failed to complete weekly skin assessments after 10/18/25 for Resident #11 who admitted on [DATE] after ORIF (Open Reduction Internal Fixation) for fracture to right foot. She was admitted with no pressure ulcers and developed an unstageable pressure injury to Right heel on 10/18/25.The facility failed to obtain and implement wound care orders for Resident #11 for 2 days after identifying unstageable pressure injury to right heel on 10/18/25. The facility failed to implement dietary recommendations from 10/28/25 from the dietician for Resident #11. The facility failed to perform wound care treatments for 5 days in October and November 2025 for Resident #11.2. The facility failed to obtain and implement wound care orders for Resident #12 until 10/19/25 after admission on [DATE]. Resident was admitted with bilateral stage 4 pressure injuries to heels.The facility failed to complete head to toe skin assessment for Resident #12 on 10/25/25.The facility failed to perform wound care as ordered for Resident #12 for 3 days in October and November 2025.3. The facility failed to prevent deterioration of an existing pressure wound for Resident #13 when on 10/20/25 an existing stage 3 pressure wound progressed to a stage 4 pressure injury and increased in size. The facility failed to perform wound care as ordered for Resident #13 for 10 days in October and November 2025. The facility failed to complete weekly skin assessments after 10/8/25 for Resident #13.The facility failed to implement intervention of low air loss mattress from care plan dated 10/29/25 for Resident #13. 4. The facility failed to perform wound care as ordered for Resident #16 for 10 days for October 2025.The facility failed to complete weekly skin assessments for Resident #16 after 10/5/25.An Immediate Jeopardy (IJ) was identified on 11/11/25 at 10:57 am. The IJ template was provided to the facility on [DATE] at 11:04 am. While the IJ was removed on 11/12/25 at 6:34 pm, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions.These failures could place residents at risk for developing pressure injuries, decreased quality of life, infections, and death.Findings included:1. Record review of a facility face sheet dated 11/10/25 for Resident #11 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: pneumonia (an infection that inflames the air sacs in one or both lungs), dementia (a disease that affects memory, thinking, and the ability to perform daily activities), and nondisplaced fracture of first metatarsal bone (fracture of the big toe), right foot. Record review of a Medicare 5-day MDS assessment dated [DATE] for Resident #11 indicated a BIMS score of 15 indicating she was cognitively intact. She required moderate to maximum assistance with most ADLs. She was not coded for pressure ulcers.Record review of a nursing progress note type Clinical Admission dated 9/2/25 at 1:00 pm and signed by RN A for Resident #11 indicated she had a surgical wound to right dorsal 1st metatarsal phalangeal joint (the joint where the first metatarsal bone meets the proximal phalanx of the big toe), an abrasion to left medial calf (the back of the lower leg), and bruising to right dorsum right hand (the back or posterior surface of the right hand), and there was no documentation of a pressure injury to her right heel.Record review of a comprehensive care plan dated 9/9/25 for Resident #11 indicated she had potential for alteration in skin integrity due to impaired mobility and had an intervention to inspect skin from head to toe no less than once per week and document/measure all abnormal findings. She also had an intervention to inform physician, family, dietician, and director of nursing of any new skin breakdown.Record review of an electronic health record for Resident #11 on 11/10/25 indicated there were no skin assessments completed between the dates of 9/2/25 and 9/15/25 and no skin assessments documented between the dates of 10/18/25 to 11/10/25.Record review of a nursing progress note dated 10/18/25 at 8:12 pm and signed by RN K for Resident #11 indicated a new skin issue was identified; an unstageable pressure ulcer/injury to right heel. Note indicated wound measurements were 3cm X 2cm X 0.1cm and eschar was 100%. There was no documentation of physician notification.Record review of a Nutrition/Dietary Note dated 10/28/25 for Resident #11 read .Recommendation: 1. Vitamin C 500mg po (by mouth) daily. 2. Zinc sulfate 220mg daily po x 14 days 3. mvi/min (multivitamin with minerals) po daily 4. house supplement 60ml BID.Record review of a physician's order summary report dated 11/12/25 for Resident #11 indicated the following physician orders: .consult Dr. [Wound physician name] for wound to r heel. dated 10/20/25 .wound location: right heel - skin prep daily unstageable PI to right heel. dated 10/20/25.wound location: right heel - clean wound with wound cleanser or NS, pat dry, apply medihoney and wrap with kerlix daily. dated 11/10/25. There was no order for wound care on 10/18/25 (the day wound was identified) There was no order for daily dressing changes dated 11/3/25 from surgeons' office visit. There was no order for Vitamin C, Zinc Sulfate, Multivitamin with minerals, or house supplement.Record review of a visit note dated 11/3/25 for Resident #11 indicated she had a physician visit on 11/3/25 to follow up with her foot surgeon. Note read: .Focused wound exam: Right lower extremity wound: surgical incision well healed however there is a full thickness, decubitus ulceration to the posterior heel with fluctuate eschar. Wound measurements were: 2.5cm X 1.1cm X 0.1cm. Excisional debridement was performed and post debridement measurements were 2.7cm X 1.2cm X 0.3cm. Documentation read: .Nature of tissues removed: devitalized tissue, fat necrosis, and slough.; wound care and dressing was applied and post-operative instructions read: .continue with daily dressing changes. Record review of a Treatment Administration Record dated 10/1/25 to 10/31/25 for Resident #11 indicated she did not receive her wound care as ordered on 10/22/25 and 10/23/25. There was no documentation of resident refusal of treatments.Record review of a Treatment Administration Record dated 11/1/25 to 11/30/25 for Resident #11 indicated she did not receive her wound care as ordered on 11/3/25, 11/7/25, and 11/8/25. There was no documentation of resident refusal of treatments. 2. Record review of a facility face sheet dated 11/10/25 for Resident #12 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: pneumonia (an infection that inflames the air sacs in one or both lungs), urinary tract infection (a common infection that can affect any part of your urinary system, including the bladder, kidneys, and urethra), and acute kidney failure (a sudden loss of kidney function). Record review of a Medicare 5-day MDS assessment dated [DATE] for Resident #12 indicated a BIMS score of 15, which indicated he was cognitively intact. He was dependent or required maximal assistance with most/all ADLs. He was coded for 2 stage 4 pressure ulcers.Record review of a comprehensive care plan dated 10/23/25 for Resident #12 indicated he had stage 4 pressure ulcers/pressure injuries to right heel and left heel with an increased potential for pressure ulcer/pressure injury development and/or potential for worsening/additional pressure ulcer injury related to immobility. He had an intervention to complete a head-to-toe skin assessment on a weekly basis.Record review of a physician's order dated 10/19/25 for Resident #12 indicated he had the following order: .Clean with wound cleanser, pat dry, apply medihoney and cover with non-adherent dressing, wrap with gauze to secure. Change daily and prn soiled. Record review of a physician's order summary report dated 11/10/25 for Resident #12 indicated he had the following physician's orders: .wound location: left heel: clean wound daily w/NS or wound cleanser, apply ca alg (calcium alginate) w/silver and cover with dry dressing. Change daily and prn (as needed) if soiled, not intact. dated 10/22/25 .wound location: right heel: clean wound with wound cleanser or NS (normal saline), apply ca alg w/silver and cover with dry dressing, change daily and prn if soiled/not intact. dated 10/22/25. There were no physician orders for wound care between 10/15/25 through 10/19/25.Record review of a facility form titled Admission/re-admission Report Form dated 10/15/25 for Resident #12 read: .Wounds to bilateral heels. Right heel requires drsg (dressing) change. and was signed by LVN F. Record review of a nursing progress note clinical admission dated 10/15/25 at 3:21 pm for Resident #12 indicated he had unstageable pressure ulcers to both heels and was signed by LVN L. Note indicated resident physician was notified of admission, and triplicate forms were sent. No documentation of notification of wounds, or request for wound care orders. Record review of an electronic health record for Resident #12 on 11/10/25 indicated there were no skin assessments completed between the dates of 10/18/25 and 11/6/25 and no physician's order for skin assessments.Record review of a Treatment Administration Record dated 10/1/25 through 10/31/25 for Resident #12 indicated he did not receive treatments to heels as ordered on 10/23/25 and 10/27/25.Record review of a Treatment Administration Record dated 11/2/25 through 11/30/25 for Resident #12 indicated he did not receive treatments to heels as ordered on 11/7/253. Record review of a facility face sheet dated 11/10/25 for Resident #13 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral infarction (stroke), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).Record review of a Quarterly MDS assessment dated [DATE] for Resident #13 indicated a BIMS score of 03, which indicated she had severely impaired cognition. She required maximum assistance with most/all ADLs. She was coded for 1 stage 4 pressure ulcer. Record review of a comprehensive care plan dated 10/29/25 for Resident #13 indicated she had a stage 4 pressure ulcer/pressure injury to her right lateral ankle with an increased potential for pressure ulcer/pressure injury development and/or potential for worsening/additional pressure ulcer/pressure injury related to immobility. She had interventions for complete head-to-toe skin assessments on a weekly basis, administer treatments as ordered, and low air loss mattress inflated at correct setting to maximize pressure relief. Record review of an electronic health record for Resident #13 on 11/10/25 indicated there were no skin assessments completed between the dates of 10/8/25 and 11/10/25 and no physician's order for skin assessments.Record review of a Treatment Administration Record dated 10/1/25 to 10/31/25 for Resident #13 indicated she did not receive ordered treatments on 10/6/25, 10/8/25, 10/13/25, 10/22/25, 10/23/25, 10/27/25, and 10/28/25. There was no documentation of resident refusal of treatments. She had the following wound care order dated 5/22/25 and discontinued on 10/20/25: .Apply skin prep to right outer ankle once daily one time a day until redness resolved. and the following order dated 10/20/25: .Wound Location: right lateral ankle: clean wound to right ankle daily w wound cleanser or NS, apply ca alg and dry dressing. change daily or pm if soiled, not intact.Record review of a Treatment Administration Record dated 11/1/25 to 11/30/25 for Resident #13 indicated she did not receive ordered treatments on 11/3/25, 11/4/25, and 11/7/25. There was no documentation of resident refusal of treatments. She had the following order dated 10/20/25: .Wound Location: right lateral ankle: clean wound to right ankle daily w wound cleanser or NS, apply ca alg and dry dressing. change daily or pm if soiled, not intact.Record review of a wound care physician visit report dated 6/16/25 for Resident #13 indicated that Resident had a facility acquired stage 3 pressure ulcer to her right lateral ankle (the outer side of the right ankle) acquired on 6/2/25 and the wound measured 0.5cm X 0.5cm X 0.1cm with moderate serous exudate.Record review of a wound care physician visit report dated 10/20/25 for Resident #13 indicated that on 10/20/25 wound had progressed to a stage 4 pressure injury with measurements of 1cm X 0.8cm X 0cm with moderate serous exudate.4. Record review of an admission Record for Resident #16 indicated she was admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with type 2 diabetes (uncontrolled blood sugar) and hemiplegia following cerebral infarction affecting left non-dominant side (left sided weakness or paralysis following a stroke). She was discharged to the hospital on [DATE] following a fall. Record review of a Medicare/5 Day MDS assessment for Resident #16 indicated she had severe impairment in thinking with a BIMS score of 6. She had an unhealed pressure ulcer/injury that was classified as an unstageable wound due to coverage of the wound bed by slough and/or eschar.Record review of a care plan for Resident #16 dated 7/24/2025 indicated she had a pressure ulcer/injury to sacrum with an increased potential for worsening/additional pressure ulcers. Interventions included to evaluate/record/monitor healing, measure at least once a week, report declines to the MD. Record review of a skin assessment for Resident #16 dated 10/4/2025 indicated she had a wound to her coccyx that was a stage 3 wound that measured 8 cm x 4 cm x 4 cm with tunneling at 10 o'clock at 0.5 cm with 80% granulation.Record review of skin assessments for Resident #16 indicated there were not any other skin assessments by the facility after 10/5/2025.Record review of a wound physician note for Resident #16 dated 10/6/2025 indicated she had a stage 4 sacral pressure ulcer that measured 6 x 5 x 2 with undermining starting at 10 o'clock and ending at 3 o'clock at 3 cm deep. Record review of a wound physician note for Resident #16 dated 10/20/2025 indicated she had a stage 4 sacral pressure ulcer that measured 5.5 x 4.5 x 1.6 after he debrided the wound. Record review of active physician orders for Resident #16 dated 11/17/2025 indicated she had wound care orders for an unstageable sacral wound that started on 9/3/25 to be performed daily and prn. Record review of the TAR for Resident #16 dated 10/1/2025-10/31/2025 indicated she had 10 days without documentation on the TAR for wound care to an unstageable sacral wound that were blank that included: 10/3/2025, 10/6/2025, 10/8/2025, 10/13/2025, 10/15/2025, 10/18/2025, 10/22/2025, 10/23/2025, 10/26/2025, and 10/27/2025. There was no documentation that Resident #16 refused treatment for her wound.During an observation on 11/10/2025 at 9:51 am Resident #13 was observed not to have a low air loss mattress on her bed.During an observation and interview on 11/10/25 at 3:18 pm Resident #11 said she had been at the facility for approximately 6 weeks and was at home prior to being admitted to the facility. She said she had gone to the hospital with a broken foot and had a wound to her right heel. She said the wound to her heel had not been covered by a dressing in the last 3 days. She said prior to that they were putting a bandage on her heel and keeping it on for a week and it was supposed to be changed 3 times a week on Mondays, Wednesdays, and Fridays. She said she guessed the staff were just lazy. She said the wound had not been infected that she was aware of and had not said anything about wound care not being done as ordered. Resident #11 removed her sock from her right foot and showed this Surveyor her heel-area noted with slough present with a small amount of eschar in the wound bed. She said it had not been changed in 3 days. She said she was not refusing any care from the staff. She said it had been a while since she saw the wound care physician and the last time she saw him he did not look at her wound because it had a bandage on it. She said the wound did not hurt.During an observation and interview on 11/10/25 at 3:42 pm the MDS Coordinator said she performed wound care to Resident #11 earlier today (11/10/25). She said she put skin prep on her heel that had an unstageable wound that was scabbed over and was dry. She went to the room to observe the wound and asked the resident if she could look at her foot, the resident said she could, she removed her sock and observed the heel. She said the wound had drainage but had a scab earlier that was black that must have fallen off. She said she applied skin prep earlier and now the wound has slough. She said she would contact the wound physician. She said the resident's sock was wet with drainage.During an interview on 11/10/25 at 10:12 am the ADON said if staff found new skin issues, they should be reporting to the nurse, and they let her (ADON) know as well. She said if the doctor did not give new orders, then staff would not write a progress note. She said nurses should have completed skin evaluations and assessments. She said there had been a huge problem with the nurses not doing their assessments and evaluations. She said there was no one in the facility holding staff accountable to make sure things were done. She said they had even contacted staff to come in to complete their evaluations on their days off. She said the facility has had a problem for a long time with nurse administration not following through and not holding staff accountable for things that were not done. She said the facility did not have a treatment nurse and the nurses were responsible for completing the skin assessments and wound care in the facility. During a telephone interview on 11/11/2025 at 9:15 am the Wound Physician said he would visit the facility every 2 weeks and had been visiting the facility for the past 5 years. He said he only saw residents who had wounds, and his last visit was on 11/3/2025. He said usually a floor nurse would follow him. He said Resident #11 was last seen on 10/20/2025 and she had a wound to her right heel that was pressure ulcer-unstageable with dry eschar about the size of a quarter. Treatment orders were for skin prep and float heels. He said if a resident refused treatment, the nurses would document the refusal as he did not document anything on his notes. He said when he visited, he assessed the wounds, measured, debrided and provided recommendations. He said sometimes the wounds would deteriorate if the residents were noncompliant. He said he had not been notified within the past 2-3 months of any residents in the facility with a deterioration of wounds. He said if he was notified, the facility would notify the residents primary physician who would assess. He said the best person to talk to would be the nurses. He said he visited every other Monday and would be back in the facility on 11/17/2025.During a telephone interview on 11/11/2025 at 9:34 am LVN L said the facility did not have a treatment nurse in the facility, and the nurses were responsible for completing skin assessments daily and wound care. She said they have a schedule at the nurse's desk in a binder. She said with new admissions, she would assess the residents and conduct skin assessments. She said if a resident had a wound on admission, the nurse would measure the wounds, and when the wound care physician comes the wounds, he would also measure the wounds. She said she was not measuring the wounds daily nor weekly. She said if it looked like a wound was getting worse, she would measure it. She said the wound care was supposed to be done during the day, but sometimes wound care did not get done during the day shift and the night shift would sometimes complete the ones that she was not able to complete. She said if she noticed that a wound had worsened, she would notify the resident's primary medical doctor or the ADON because they do not have access to contact the wound physician. She said she had never seen him on her rotation. She said sometimes she was aware he had been there, and the residents would tell her if they had any new orders. She said she would then go and look to see if there were any new orders in the charting system. She said when a resident goes out to the hospital and then returns, the nurses were supposed to notify the Administrator, DON or ADON, medical doctor or family/RP of any new orders and changes in care. She said residents could be at risk of infection, and sepsis if they are not getting wound care as ordered or skin assessments are not done weekly.Record review of a facility policy titled Pressure Injury Risk Assessment dated March 2020 read: .Notify attending MD if new skin alteration noted. Record review of a facility policy titled Prevention of Pressure Injuries dated April 2020 read: .Evaluate, report, and document potential changes in the skin. This was determined to be an Immediate Jeopardy (IJ) on 11/11/2025 at 10:57 am. The facility's Administrator, DON, ADON, MDS, and Regional Director of Clinical Operations were notified. The Administrator was provided with the IJ template on 11/11/2025 at 11:04 am. The following Plan of Removal (POR) submitted by the facility was accepted on 11/12/2025 at 1:25 pm.PLAN OF REMOVALF686: Treatment/Services to Prevent/Heal Pressure UlcersName of facility: [name of facility]Date: November 11, 2025, 11:04 am.Immediate action: Immediately upon notification of the alleged deficient practice of treatment/services to prevent/heal pressure ulcers, the facility implemented the following measures: Resident #11 was not in the facility at the time of the wound care physician's visit on 11/3/25 as she was out at a doctor's appointment. On 10/20/25 the right heel wound measured 2.0 X 2.5 X 0.0 and on 11/11/25 the wound measured 1.9 X 2.7 X 0.0. The dietary recommendation written on 10/28/25 for Vitamin C 500mg QD, Zinc 220mg QD X 14 days, Multiple vitamins with supplement 1 QD and house 2.0 supplement 60cc QID was approved 11/4/25 with orders written 11/11/25. The consulting wound care physician was contacted by the Corporate Director of Clinical Operations on 11/12/25 at 11:15 am and was informed of the resident being seen by the surgeon who performed her original right metatarsal surgery and during the appointment, the right heel pressure injury was debrided and the wound condition had deteriorated since his last observation. Also reviewed measurements of the wound, and the notes from the surgeon and the treatment (Santyl) ordered by the outside surgeon. Explained that we received this information this morning but there was an order from the attending physician for a different order (Medihoney). The consulting wound care physician stated to go with the order given by the attending physician and inquire which consulting wound care physician the family and attending physician would like to use moving forward as they cannot both treat/bill for the resident. The resident representative was contacted by the Assistant Director of Nursing and informed of the debridement, deterioration of the wound, and inquired which consulting wound physician she would prefer to use for the pressure area to the left heel. The resident representative prefers to use the consulting wound care physician that comes to the facility. Resident #11 is scheduled to be seen by the wound care physician on 11/17/25. Resident #12's left heel wound measurement on 11/03/25 was 3.0 X 3.0 and the measurements on 11/11/25 were 1.1 X 1.2 X 0.1 and the right heel measured 2.5 X 2.0 X 0.3 on 11/03/25 then on 11/11/25 the wound measured 0.9 X 0.4 X 0.1 showing a significant improvement and the orders remained unchanged since 10/23/25. The wound care consulting physician was contacted by the Corporate Director of Clinical Operations on 11/12/25 at 11:15 am to inform of the most recent measurements and wound condition, no new orders were given. The resident representative was notified of the current wound condition by the MDS Coordinator on 11/11/25. The admitting nurse was provided with individual education regarding ensuring residents admitting with a wound have orders for treatment, notifying the physician to obtain orders for treatment and immediately rendering treatment upon admission. Resident #13's wound measurements and condition were compared to the most previous wound assessment with noted increase in size from previous observation. On 11/3/25 the wound measurements were 1.0 X 1.0 X 0.2 with 76-100% granulation and the measurements for 11/11/25 were 1.2 X 1.2 with 70% slough. The wound care consulting physician was notified by the MDS coordinator on 11/11/25 with no new orders received and he stated the wound was unavoidable related to residents' persistent position of right side lying. The resident representative was notified by the MDS Coordinator. Resident #16 was not in the facility at the time of notification. All nursing staff present at the time of notation were provided with an in-service prepared by the Corporate Director of Clinical Operations and given by the administrative nursing staff on how to document when a resident is not available for a visit by a consulting provider. This in-service will be initiated 11/11/25 and will continue until all nurses have been provided with the necessary education. The facility MDS coordinator evaluated all current wounds, measured wounds, and documented the condition of all wounds in the Skin Issue evaluation of the electronic health record on 11/11/25. On 11/11/25, the nursing administration team (Director of Nursing, Assistant Director of Nursing, and MDS Coordinator), with the assistance of the Assistant Corporate Director of Clinical Operations will compare all measurements and wound condition observations to the previous measurement/condition to ensure any area of deterioration/worsening are immediately reported to the Wound Care Physician and the resident's attending physician regarding wound care deterioration/worsening. This process will be completed on 11/11/25. On 11/11/25, all nurses present at the time of notification of the alleged deficient practice will be re-educated in the form of an in-service from the Assistant Director of Nursing regarding completion of weekly skin assessments. This in-service will include how to complete the assessment, what to look for, when to complete the assessment, what to document on the skin assessment, when to report skin issues to the provider vs. the wound care consulting physician, how to document physician communication regarding wound care. This in-service will continue until all nurses have been in-serviced and all nurses will receive re-education prior to beginning their next scheduled shift. Nurses will be provided with notification of consequences for failure to complete scheduled skin assessments during their shift. Beginning 11/11/25 Completion of skin assessments will be monitored Monday through Friday by the Director of Nursing and by the designated Weekend Nursing Supervisor on Saturday and Sunday. A complete head to toe skin inspection was completed by the Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Assistant Corporate Director of Clinical Operations on all residents on 11/10/25 to ensure any existing area of pressure injury is identified and treatment is initiated immediately; no new areas were identified. On 11/11/25, the nurses present at the time of notification will be in-serviced by the administrative nursing team regarding admitting a resident with wounds, informing the physician of wound(s) discovered during the initial assessment, obtaining orders for treatment, ensuring orders for treatment are initiated immediately (not when electronic health record defaults to the next day), and inquiring about existing wound when receiving report from the discharging facility. This in-service will continue until all nurses are provided with the education and nurses will receive the education prior to beginning their next scheduled shift. The Director of Nursing, Assistant Director of Nursing, MDS Coordinator and Facility Administrator will be provided with re-education on 11/11/25 by the Corporate Director of Clinical Operations and/or designee regarding the process for reviewing the missing documentation report for the Treatment Administration Record from the electronic health record. This in-service will include what action to take if documentation is missing. Beginning 11/12/25 every morning during the morning clinical meeting on Monday through Friday the missing documentation report for Treatment Administration Records will be reviewed by the Director of Nursing to ensure no treatment was missed or documentation was not completed. The Facility Administrator will ensure this task is completed each day. On 11/11/25 the Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator (administrative nursing team) were re-educated by the Director of Clinical Operations and the Assistant Director of Clinical Operations regarding daily review of admission records, admission order reconciliation, review of 24/72 hour report, and reviewing the missing order documentation report each morning during the morning meeting process. The Facility Administrator will be responsible for ensuring the daily review of the missed documentation report, admission record review, admission order reconciliation, and review of the 24/72-hour report. In the absence of the Facility Administrator the Director of Nursing will be responsible. The facility has begun the process of replacing the current consulting wound care physician with a wound care company that will be onsite weekly, physically examine and evaluate all residents with wounds, provide wound progress reports, training to staff, and work directly with facility management to ensure treatment and services are provided to prevent and heal pressure ulcers. The wound care company was contacted by the Corporate Director of Clinical Operations on 11/11/25, to inquire about projected start date of their services. The response from the wound care company is still pending. Another provider has been contacted and is willing to provide wound care consultant nurse practitioner service with the facility within the next 30 days. A determination of which company to be used will be made no later than 11/12/25 at 5:00 pm. The Facility Administrator and Administrative Nursing Team will be reviewing the nursing schedule to ensure one designated nurse is scheduled to review wounds, complete measurements, evaluate wound condition and prepare the weekly skin report at least once per week beginning 11/12/25. The weekly skin report will be reviewed by the Administrative Nursing Team and the Facility Administrator to ensure all interventions are present including supplements/vitamins as recommended by the registered dietician, support surfaces are appropriate for the residents and treatments are evaluated for effectiveness. The weekly skin report review meeting will begin 11/11/25 and will occur on Tuesday of each week. Beginning 11/12/25 at 6:00 pm, the Assistant Director of Nursing will divide daily treatments/wound care between the day shift and night shift to allow floor nurses more time to complete the treatment/skin assessment processes. Beginning 11/11/25 at 5:00 pm a daily stand-down meeting will be held by the Facility Administrator and Director of Nursing to ensure all assigned wound care tasks, documentation, recommendations, physician notifications, and physician orders are carried out appropriately. On 11/11/25 at 8:00 pm an impromptu

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free of any significant medication errors for 2 of 11 residents reviewed for medications. (Resident #4 and Resident #2)1.The facility failed to administer Metoprolol (a medication to treat high blood pressure) and Entresto (a medication to treat high blood pressure and treat heart failure) to Resident #2 on 10/6/25 at 9:00 pm as ordered.2. The facility failed to ensure Entresto 24/26 mg 1 tablet by mouth twice a day was ordered for Resident #4 when she was admitted to the facility from the hospital on 9/18/2025. 3. The facility failed to ensure Resident #4 received Eliquis (a medication used to treat and prevent blood clots) 5 mg 1 tablet by mouth twice a day as ordered by missing 8 doses in October 2025 and she was hospitalized from [DATE] to 10/28/2025 and diagnosed with atrial fibrillation with RVR (rapid ventricular response-rapid heart rate), acute on chronic systolic and diastolic heart failure along with a small pulmonary embolus in the right middle lobe of the lung (blood clot in the lung).On 11/5/2025 at 2:10 PM, an Immediate Jeopardy (IJ) was identified. While the Immediate Jeopardy was removed on 11/6/2025 at 4:15 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm that was not Immediate Jeopardy due to the facility continuing to monitor the implementation and the effectiveness of their Plan of Removal.These deficient practices could place residents at risk of physical complications, hospitalization, and death. Findings included:1.Record review of a facility face sheet dated 11/5/25 for Resident #2 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: acute and chronic respiratory failure with hypoxia (a condition where you don't have enough oxygen or too much carbon dioxide in your body), type 2 diabetes (uncontrolled blood sugar), and hypothyroidism (Underactive thyroid - a condition where the thyroid gland does not produce enough thyroid hormones, leading to a slowdown in metabolism).Record review of a Comprehensive MDS assessment dated [DATE] for Resident #2 indicated a BIMS score of 15, indicating her cognition was intact. She required maximal assistance with most ADLs. Record review of a Comprehensive Care Plan dated 7/10/25 for Resident #2 indicated she had hypertension (high blood pressure) and cardiomyopathy (a disease of the heart muscle). She had interventions to give medications as ordered.Record review of a physician's order summary report dated 11/5/25 for Resident #2 indicated she had the following physician's orders: Metoprolol Succinate ER (Extended Release) Oral tablet extended release 24-hour 25 mg (Metoprolol Succinate) Give 1 tablet by mouth one time a day related to hypertensive heart disease with heart failure; hold for heart rate less than 60, systolic blood pressure less than 100, or diastolic blood pressure less than 60 - dated 6/24/25. Entresto (Sacubitril-Valsartan) Oral tablet 49-51 mg Give 1 tablet by mouth two times a day related to other cardiomyopathies, hold if systolic blood pressure less than 100 or pulse less than 55 - dated 9/10/25.2. Record review of an admission Record for Resident #4 dated 11/4/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of acute on chronic diastolic heart failure (a sudden, life threatening condition in which your heart is unable to pump effectively), atrial flutter (a heart rhythm disorder), and hypertension (high blood pressure). She was discharged from the facility to the hospital on [DATE].Record review of an admission MDS Assessment for Resident #4 dated 9/25/2025 indicated she had moderate impairment in thinking with a BIMS score of 12. During the 7-day look back period, she took an anticoagulant. Record review of a care plan for Resident #4 dated 9/26/2025 indicated she was on anticoagulant therapy Eliquis related to atrial flutter. Interventions included to administer anticoagulant medications as ordered by the physician. Record review of hospital discharge records for Resident #4 dated 9/18/2025 indicated a medication list that included Entresto 24/26 mg 1 tablet by mouth two times a day. Eliquis 5 mg 1 tablet by mouth two times a day.Record review of a progress note by the NP for Resident #4 dated 9/30/2025 indicated her medication list consisted of Entresto 24/26 mg 1 tablet by mouth twice a day and Eliquis 5 mg 1 tablet by mouth twice a day.Record review of a progress note by the Medical Director for Resident #4 dated 10/2/2025 indicated she was on Entresto for hypertensive heart and chronic kidney disease with heart failure. Currently on Entresto 24/26 mg twice a day.Record review of a progress note by the NP for Resident #4 dated 10/7/2025 indicated the resident reported she was not always receiving her medications consistently; some days she only received one dose at night. Record review of a progress note by the NP for Resident #4 dated 10/14/2025 indicated she spoke to the cardiologist for Resident #4 to discuss Entresto and the cardiologist said there was no added benefit to taking it.Record review of a progress note for Resident #4 dated 10/26/2025 at 3 pm by RN A indicated, .res co[complained of] epigastric pain and RP is at bs[bedside], res has exertional sob but speaking full sentences, skin w/d 2 pitting edema (swelling in the legs/feet) noted. RP and resident request to go to hospital.Record review of hospital discharge summary for Resident #4 dated 10/29/2025 indicated she admitted to the hospital on [DATE] with chief complaints of shortness of breath and lower extremity edema. She was found to be in atrial fibrillation with RVR and was also found to have a small pulmonary embolus in the right middle lobe (blood clot in the lung). Record review of active physician orders for Resident #4 dated 11/4/2025 indicated an order for Eliquis 5 mg 1 tablet by mouth two times a day with a start date of 9/19/2025. There was no order for Entresto.Record review of a MAR for Resident #4 dated 10/1/2025 to 10/31/2025 indicated there were blanks on the MAR without any documentation noted for the following dates and time: 10/3/2025 at 5 pm, 10/4/2025 at 5 am, 10/6/2025 at 5 pm, 10/11/2025 at 5 am, 10/12/2025 at 5 am, 10/15/2025 at 5 am, 10/27/2025 at 9 pm, 10/28/2025 at 9 pm.During an observation and interview on 11/4/2025 at 9:10 AM, LVN Q was on hall 100 administering medications. She said there were two medication aides during the day shift, and one scheduled at night that stayed until 11 pm. She said she had been employed at the facility since April 2025. She said Resident #4 had shortness of breath on yesterday (11/3/2025), her vital signs were elevated, and she talked to the NP who told her to send Resident #4 out. She said Resident #4 had a pulmonary embolism before this hospital stay. She said she took care of Resident #4 at times and the resident wanted to choose what medications to take. She said Resident #4 was very difficult but alert and oriented to person, place, and time.During an interview on 11/4/2025 at 9:46 AM, the NP said the facility notified her about Resident #4 when she went to the hospital yesterday (11/3/2025) for shortness of breath, and prior to that hospital stay, had been diagnosed with a pulmonary embolism. She said Resident #4 was not compliant with taking Eliquis as ordered. She said Resident #4 may have had some form of dementia as she would argue with the staff. She said she told the RP that the staff could not force Resident #4 to take her medications. She said the facility kept her updated on changes in resident conditions. She said the RP for Resident #4 had her personal cell phone and would call when she had questions or concerns.During an interview on 11/4/2025 at 1:15 PM, the ADON said the admission nurse LVN L would have been the nurse responsible for ensuring the discharge medications from the hospital were entered for Resident #4 when she admitted to the facility in September. She said the charge nurses were responsible for entering and verifying medication orders. She said if a resident refused medications, there should be documentation in the MAR or on a progress note about the refusal. She said the MAR should have a (2) to signify the resident refused and if there was a blank, then it was not charted and they would not know if the medication was given or not. She said the facility was not aware that Resident #4 should have been ordered Entresto from the hospital discharge medication list in September 2025. She said she was not sure why it was overlooked.During an interview on 11/4/2025 at 2:04 PM, LVN F said the charge nurses were responsible for entering medication orders for a new admission from the hospital. She said residents could be at risk for medication errors or be given the wrong dose or medication, if medications were not entered correctly. She said Resident #4 was difficult at first as she often refused care and liked things done the way she wanted them done. She said if a resident refused medications or care, the charge nurse would try to talk to them and try to change their minds, and if they still refused, they would go to the DON, the Administrator, and notify the NP and family. She said on the MAR, if the resident refused medications, they were supposed to enter a code to show the refusal. She said nurses were responsible for administering medications like Entresto and Eliquis and not the medication aides.During an observation on 11/4/2025 at 2:43 PM, the nurse medication cart for the hall where Resident #4 resided with the LVN F present revealed Resident #4's medications were still in the cart, but there were no Entresto for her.During an interview on 11/4/2025 at 2:44 PM, MA R said Resident #4 refused medications at times from certain people. She said they were to document the refusal in the MAR and notify the charge nurse about the refusal. She said Resident #4 was difficult to care for. During a phone interview on 11/4/2025 at 3:38 PM, RN K said she had been employed at the facility since July 2025, working nights from 6 pm-6 am, and was assigned the hall where Resident #4 resided. She said Resident #4 was alert to herself and had problems with her memory and often did not remember what she did or did not do. She said Resident #4 would often report she had pain in her chest and went to the hospital with atrial fibrillation and recently had a pulmonary embolism. She said lot of the times Resident #4 was anxious and they would send her out to the ER when she wanted to go the hospital. She said Resident #4 was noncompliant with care and refused to take her medications with certain staff, but would usually take them with her. She said Resident #4 would still look at her cup and count everything to make sure what she was taking but would not remember what she did or not take. She said she tried to reassure Resident #4 that she took certain medications at different times of the day. She said if a resident refused to take their medications, she would try to talk to them. She said two times Resident #4 gave her an attitude, she allowed her to calm down, and went back and tried again and she was ok with taking her medications. She said if a resident refused medications, they were to document the refusal, and there was a place in the MAR to document the refusal. She said Eliquis would be administered by the nurse and not the medication aide. She said she was not sure why there would be any blanks on Resident #4's MAR but sometimes she would get behind on charting and would have to go back and make it up because she was busy taking care of other residents. She said she gave medications when they were due to be given. She said she was instructed that if something was not documented, then it was not done.During an interview on 11/4/2025 at 4:30 PM, LVN F said on 10/3/2025, she worked, and that evening prior to her getting off at 6 pm, RN K came in early, and she took the laptop as she finished her rounds a little after 5 pm. She said she and RN K did a narcotic count in the medication cart and she left the facility. She said RN K told her she would finish what she had left to complete that included administering medications. She said the MARs should not have blanks and something should be documented to indicate if the resident took the medication or if it was refused. She said if a medication was refused, there should have been documentation of the refusal. She said on 10/3/2025 she left her shift before 6 pm and RN K said she would take care of things she had left, including giving Resident #4 her Eliquis that was due at 5 pm.During a phone interview on 11/4/2025 at 6:23 pm, the NP said the cardiologist and the RP of Resident #4 did not want her to take the Entresto that was ordered on admission to the facility. She said she saw Entresto on her list of medications and she contacted the cardiologist on 10/14/2025 and was told they did not think Entresto would benefit her one way or another. She said the hospital had it on her discharge medication list, but the RP did not want the resident to take it. She said she was told by staff that Resident #4 would sometimes refuse medications at times. She said if the resident refused, then the staff needed to document the refusal and indicate that they did not give the resident the medication. She said the Eliquis was ordered for atrial fibrillation. She said on 10/26/2025-10/28/2025, Resident #4 was sent to the hospital and diagnosed with an embolism. She said the resident would sometimes not remember she was given medications and would say she had not received any. During a phone interview on 11/5/2025 at 8:32 AM, LVN L said she had been employed at the facility since July 2025 and worked day shift from 6 am-6 pm. She said she took care of Resident #4, who was stubborn at times and would refuse to take her medications. She said Resident #4 liked things her way and wanted to be in charge, and if they let her be in charge she would be compliant. She said Resident #4 refused care a lot including medications, but if they talked to her, she would allow certain people to administer them. She said if a resident refused, they were supposed to notify the physician, family, and document in a progress note. She said if Resident #4 or any residents refused, they were to chart and document the code (2) for refusal on the MAR. She said she was the admission nurse for Resident #4 when she was admitted to the facility. She said the discharge medication list for Resident #4 was in the packet provided by EMS from the hospital. She said she did not know why Entresto was not added to her medication orders, said she talked to the RP on the day of admission, and they discussed some of the medications that were ordered and compared her home list to the hospital list. Said the RP asked what medications had been ordered. She said she was not sure if she contacted the physician about reconciling the medications or not. She said when they entered the medications into the system, she thought the order went directly to the pharmacy to be filled. She said she was not aware if someone was looking to ensure orders were entered correctly. She said if medications were not entered correctly, it could be deadly, if they never received a medication, things could go left untreated. During a phone interview on 11/5/2025 at 9:01 AM, RN A said she had been employed at the facility for 6 months and worked day shift from 6 am-6 pm. She said she took care of Resident #4 when she was at the facility. She said she loved the resident, but Resident #4 would give other staff hell and Resident #4 would allow her to care for her when no one else could. She said Resident #4 would refuse to take some of her medications at times from the medication aides, but would take them later. She said a lot of Resident #4's refusals were that she wanted them done on her own time. She said the only time there would have been a blank on the MAR would be that she must have forgotten to mark that the resident took the medication. She said when she administered medications, she made sure it was for the right patient, gave them the medication, and then would document that it was given. She said it took a few seconds to document and sometimes she would get distracted. She said if it was not documented, then it was not done, and Resident #4 could be at risk for a blood clot if she was given the Eliquis that was ordered. During an interview on 11/12/2025 at 5:24 PM, the Administrator said residents' health could decline if they did not get their medications as ordered. She said the nurses were to notify the RP or family and educate them on risks if they refused. She said staff should document in the MAR/TAR, if they refused and state they refused. She said nurses were responsible for ensuring the residents receive the blood thinners. She said the nurse should oversee the medication aide to ensure medications were given. She said residents could run the risk of blood clots and other issues if they did not receive their medications as ordered. Record review of the facility's policy titled Adverse Consequences and Medication Errors revised November 2023 indicated, .6. Significant medication errors means one which causes the resident discomfort or jeopardizes his or her health and safety. 7. Examples of medication errors include: a. omission-a drug is ordered but not administered.Record review of the facility's policy titled Administering Medications revised April 2019 indicated, .Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall indicate the refusal in the electronic health record MAR. The number 2 (two) is chosen when administering the medication to indicate resident refused dose.This was determined to be an Immediate Jeopardy (IJ) on 11/5/2025 at 2:10 PM. The facility's Administrator, DOCC and DON were notified. The Administrator was provided with the IJ template on 11/5/2025 at 2:46 PM and a Plan of Removal was requested.The following Plan of Removal (POR) submitted by the facility was accepted on 11/6/2025 at 12:16 PM. Immediate action: Immediately upon notification of the alleged deficient practice of Significant Medication Error on 11/5/25 @ 2:52 pm, the facility implemented the following measures: The administrative nursing team (Director of Nursing, Assistant Director of Nursing and MDS Coordinator) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will complete medication order reviews for all residents admitted and re-admitted within the past 30 days (working from the most recent to the latest) to ensure no residents are in jeopardy or threat of harm; this task will be completed by 11:59 pm 11/05/25. The immediate chart reviews of the remaining residents admitted and re-admitted in the past 60 days (working from the those admitted 31 days ago to 60 days ago) will be completed by the administrative nursing team (Director of Nursing, Assistant Director of Nursing and MDS Coordinator) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations by 11:00 am on 11/06/25 to ensure accurate reconciliation of hospital discharge orders/admitting orders to those that were verified with the attending physician and transcribed into the electronic health record. The immediate chart reviews will ensure all diagnosis/health conditions of residents is being/has been addressed/noted in the electronic health record. On 11/5/25 at 6:15pm the Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator (administrative nursing team) were counseled and provided with an in-service by the Director of Clinical Operations and the Assistant Director of Clinical Operations regarding daily review of admission records, admission order reconciliation, review of 24/72 hour report, and reviewing the missing medication report each morning during the morning meeting process. The Facility Administrator will be responsible for ensuring the daily review of the missed medication report, admission record review, admission order reconciliation, and review of the 24/72-hour report. In the absence of the Facility Administrator the Director of Nursing will be responsible. All nurses and certified medication aides present at the time of the notification will be provided with in-service training regarding the admission/re-admission process, the admission/readmission medication reconciliation process, transcribing and carrying out physician orders, how to document different scenarios of medications not given (refused, spit out, held for vital signs outside of parameters, etc.), checking the dashboard throughout and at the end of their shift to ensure no medication documentation is missing. The immediate staff in-service will be conducted by the Administrative Nursing Team (Director of Nursing, Assistant Director of Nursing and MDS Coordinator) beginning on 11/05/2025 and will continue until all nurses and certified medication aides have been provided with the beforementioned education, the remaining nurses and certified medication aides will be educated prior to beginning their next shift. All newly hired nurses and certified medication aides will be educated regarding how to document missed doses, refused doses, and accessing the dashboard to ensure all doses are accounted for before the end of their shift before beginning their first assigned shift. An impromptu QAPI meeting was conducted on 11/5/25 at 6:49 pm with the Medical Director, Facility Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Corporate Director of Clinical Operations, and Assistant Corporate Director of Clinical Operations. The root cause analysis of the alleged deficient practice was reviewed and interventions to correct and prevent future occurrence were discussed. The Consultant Pharmacist was contacted by the Corporate Director of Clinical Operations on 11/6/25 at 10:39 am and discussed the alleged deficient practice, it was decided that effective immediately (11/6/25 at 11:00 am) all new and re-admissions to the facility will be reviewed by a pharmacist with the consultant pharmacy group every Monday, Wednesday and Friday. On 11/6/25 at 11:00 am the Consultant Pharmacist will review all residents admitted /re-admitted to the facility in the past 7 days. In addition to the regular medication regimen review the consulting pharmacist will reconcile current physician orders to those given from the discharging entity. Upon completion of his/her review, the consulting pharmacist will provide a summary of findings/recommendations to the Director of Nursing, Assistant Director of Nursing and Facility Administrator. Immediately upon receipt of the recommendations the Director of Nursing will ensure any physician recommendations are addressed and carried out. The recommendations from the consultant pharmacist will be reviewed during the morning meeting Monday through Friday and the Facility Administrator and Director of Nursing will verify they are complete with a physician acceptance or declination, orders corrected or changed as recommended/agreed to by physician, plan of care updated, and resident/resident representative informed of changes. On 11/6/2025 at 12:00 pm am the Corporate Director of Clinical Operations will provide an in-service to the Facility Administrator and administrative nursing staff (Director of Nursing, Assistant Director of Nursing, and MDS Coordinator) regarding the review of the pharmacy consultant admission/re-admission drug regimen review/medication reconciliation process that is to be reviewed during the morning meeting every Monday through Friday. The affected resident, Resident #4, was transferred to the hospital prior to surveyor entrance to the facility and remains in the hospital. The attending physician was notified of the alleged significant medication errors.Facilities Plan to ensure compliance quicklyThe facility nursing administration staff (Director of Nursing, Assistant Director of Nursing, and MDS Nurse) with the assistance of the Director of Clinical Operations and the Assistant Director of Clinical Operations will begin (on 11/6/25 @ 8:00 am) begin a full audit of all resident medication orders. This task will be completed no later than 11/6/225 at 2:00 pm.The State Surveyors monitored the Plan of Removal as follows: Record review indicated that eight residents admitted /readmitted in the past 30 days had their medication orders reviewed and medications that were ordered matched the orders for the referring entity.Record reviews indicated that four residents admitted /readmitted in the past 60 days had their medication orders reviewed.Record review of an in-service titled Reconciliation of Admission/re-admission Orders dated 11/5/2025 was signed by Administrator, DON, ADON, and MDS coordinator. Record review of an in-service titled Missing medication documentation/Med Pass Completion on Dashboard dated 11/5/2025 was signed by Administrator, DON, ADON, and MDS coordinator.Record review of an in-service titled Reconciliation of Admission/re-admission orders dated 11/5/2025 was signed by seventeen nurses and medication aides. Record review of an in-service titled Missing medication documentation/Med Pass Completion on Dashboard dated 11/5/2025 was signed by sixteen staff including nurses and medication aides.Record review of a QAPI sign-in sheet indicated meeting was held on 11/5/25 at 6:49 pm - 7:02 pm and was signed by Medical Director; Administrator; DON; ADON; and MDS Coordinator and was also attended by Director of Clinical Operations.During a phone interview on 11/6/2025 at 3:04 PM, the Pharmacy Consultant said she was contacted by the facility that day. She said she was going to take on a new active role by reviewing new admissions and readmissions for the medication orders. She said the pharmacist would conduct those reviews. She said she reviewed one resident that day (Resident #1) and made recommendations and sent them to the facility and the physician would review. She said new admissions would be reviewed by her on Mondays, Wednesdays, and Fridays and monthly once a month. The recommendations would be sent to the DON, ADON, and regional consultant.Record reviews of resident records indicated forty-nine resident medication orders were reviewed and there were not any issues noted. All had the correct orders entered into the resident record.During an interview on 11/6/2025 at 3:27 PM, the MDS Coordinator said she would be responsible for new admissions in the facility. She said she would get the hospital discharge orders before medical records and be the one to double check that the orders were entered correctly. She attended the morning meetings and discussed new admissions and findings, and conducted an admit chart check. If she worked on the floor as a charge nurse, she said she would have the ADON or DON check the orders. She said she would run an order listing daily and 24-hour report, and review the missing medication report. She said she would make sure all medications were transcribed into PCC with no missing medications. She said if the physician did not want the medication, make a note, and if a resident refused, make a note, notify the physician and before end of shift check to make sure all meds were completed. She said the facility had a QAPI meeting and discussed a resident (Resident #4) who did not get an order transcribed. During an interview on 11/6/2025 at 3:35 PM, the ADON said she would review the missed medication report and monitor it daily. She said, for Saturday and Sunday, would run a 3-day report on Monday and find out the reason and action that was needed. She said she would now be the second person for reviewing admissions. She said when the facility had a new admission, the MDS Coordinator would review hospital discharge paperwork. She said the facility now had a check off list for admissions for nursing staff and it would be attached to a medication summary and placed in the provider folder. She said the MDS Coordinator would review it the next morning. She said when a resident returned from the hospital, orders would be sent to pharmacist and any recommendations would be sent to her, and she would make changes and get approval. She said the MDS Coordinator would review and make sure nothing was missed. She said they had multiple staff changes in administrative staff were not aware of the proper procedures for medication reconciliation and not followed. She said the pharmacy consultant would review every time someone new admitted to the facility. She said during the morning meetings, they would discuss missed medications, refused medication, review order listings, change in conditions, labs, orders, x-rays, wounds, and treatments. During an interview on 11/6/2025 at 3:46 PM, the DON said she had been employed at the facility since 10/27/2025 and was new to long term care. She said she was still training and in orientation. She said every morning they would run the 24-hour report to review missed medications and risk management along with an order listing report to discuss during the morning meeting. She said if she were working as a nurse, she would make sure work and medications were completed and given, and document refusals along with notifying the physician and the family. She said she along with the ADON and MDS Coordinator would ensure new admission orders were reconciled. She said the facility would have the Pharmacy Consultant review new admissions and readmissions into the facility every Monday, Wednesday, and Friday. During an interview on 11/6/2025 at 3:50 pm, LVN E said on admissions, she would ensure all medication orders were accurately entered and would follow the checklist to ensure all assessments were done, all notifications were made appropriately. She said when she administered resident medications, she would immediately sign off on the MAR and if a medication were not given for any reason, she would immediately document the reason and make appropriate notifications. She said she would not leave any holes on the MAR, she would ensure everything was documented appropriately.During an interview on 11/6/2025 at 4:00 pm, MA O said after administering medications, she would immediately document the medication that was given. She said if a medication were not administered for any reason, she would notify the charge nurse immediately and document a reason why medication was not given. She said she would not leave holes in the MAR.During an interview on 11/6/2025 at 4:08 PM, the Administrator said she would be in charge to review the missed medication reports every morning and ensuring medications were being reconciled by the admitting nurse, entered in, corrected if needed and tracked. She said the DON, ADON, and MDS Coordinator would review as well. She said the Pharmacy consultant would look at new admissions and readmissions on Mondays, Wednesdays, and Fridays. She said the facility had an impromptu QAPI and discussed Resident #4's incident and went over the plan of correction and root cause analysis. She said in-services to the nurses and medication aides were conducted about refusals and if the medication aide documented to let the nurse know and document the refusal and notify the physician and family.The Administrator was informed that the Immediate Jeopardy was removed on 11/6/2025 at 4:15 PM. The facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 4 of 11 residents (Resident #1, # 7, #14, and #15) reviewed for quality of care.1.The facility failed to ensure RN A assessed, provided care, conducted and documented a neuro assessment, and notify the physician and family when Resident #1 fell and hit her head on 10/30/2025. 2. The facility failed to ensure a head-to-toe skin assessment was completed by a nurse after CNA G identified possible ant bites to Resident #15 on 10/9/25, and Residents #7 and #14 on 10/10/25.These failures could place residents at risk for not receiving appropriate care and treatment and or decline in their health.The findings included: 1.Record review of an admission Record for Resident #1 dated 11/5/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (loss of thinking, remembering, and reasoning skills), age related osteoporosis (brittle bones due to age), hypertension (high blood pressure), and atrial fibrillation (irregular heart rhythm). Record review of a Quarterly MDS Assessment for Resident #1 dated 10/8/2025 indicated she had severe impairment in thinking with a BIMS score of 3. She required partial/moderate assistance with sitting to standing. She required the use of a manual wheelchair for mobility. She had two falls since admission/entry without injury. Record review of a care plan for Resident #1 revised on 10/29/2025 indicated she had an actual fall. Interventions included: immediately after fall, assess resident for injury, obtain vital signs and initiate neuro checks. If unwitnessed or head involved, continue neuro checks and vital signs every 15 min x 1 hr., every 30 min x2 hr., every hr. x2 hrs. and every shift x72 hrs.Record review of a 24-hour report for Resident #1 dated 10/30/2025 indicated, knocked head on chair and has skin tear to mid forearm-small dressing in place.Record review of a 24-hour report for Resident #1 dated 10/31/2025 indicated, fall 10/30/2025 day shift, needs incident report and needs to notify family. Orders to send to ER.Record review of a progress note for Resident #1 dated 10/31/2025 at 5:37 AM by LVN N indicated, This nurse was asked by hall one aides if I was made aware of a fall resident had from morning shift. There is no incident report or note placed in chart.Record review of a progress note for Resident #1 dated 10/31/2025 at 2:04 PM by LVN L indicated, Resident had a fall on previous day shift large abrasion on forehead, increased lethargy around breakfast, with c/o of dizziness, neuros in place at this time, called [EMS] for transport to ER for a CT of the head per Physician's orders. RP notified.Record review of a facility in-service signed and dated 10/31/2025 indicated 59 staff were trained on timely response, notification, and documentation of resident events. 2. Record review of a facility face sheet dated 11/10/25 for Resident #15 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: epilepsy (seizure disorder) and dysphagia (difficulty swallowing). Record review of a Quarterly MDS assessment dated [DATE] for Resident #15 indicated he was unable to complete a BIMS assessment due to being rarely/never understood and he had moderately impaired cognition. He was dependent with most/all ADLs. Record review of a comprehensive care plan dated 2/3/25 for Resident #15 indicated he had the potential for an alteration in skin integrity and had an intervention for LVNs and RNs that read: .Inspect skin from head to toe no less than one time per week and document/measure all abnormal findings.Record review of a facility form titled Skin Monitoring: Comprehensive C.N.A. Shower Review dated 10/9/25 and signed by CNA G for Resident #15 indicated CNA G identified bites to Resident #15's abdomen around his belly button. Bottom of form read .Turn into DON after skin issues have been addressed. Shower sheet had not been signed off on by a nurse.Record review of an electronic health record for Resident #15 on 11/10/25 indicated there was no skin assessment completed by a nurse on 10/9/25 for Resident #15 and no nursing progress note dated 10/9/25 indicating Resident #15 had been assessed by a nurse for bites. There were no weekly skin assessments documented between 9/25/25 and 10/23/25.3. Record review of a facility face sheet dated 11/10/25 for Resident #7 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia (when the body does not get enough oxygen, leading to a condition known as hypoxia), type 2 diabetes (uncontrolled blood sugar), and dementia (a disease that affects memory, thinking, and the ability to perform daily activities). Record review of a Quarterly MDS assessment dated [DATE] for Resident #7 indicated a BIMS score of 15, indicating her cognition was intact. She required minimal assistance/was independent with most ADLs. Record review of a comprehensive care plan dated 6/15/22 for Resident #7 indicated she had the potential for alteration in skin integrity and had an intervention for LVNs and RNs that read: .Inspect skin from head to toe no less than one time per week and document/measure all abnormal findings.Record review of a facility form titled Skin Monitoring: Comprehensive C.N.A. Shower Review dated 10/10/25 and signed by CNA G for Resident #7 indicated CNA G identified multiple ant bites to Resident #7's shoulders, right arm, chest, and abdomen. Bottom of form read .Turn into DON after skin issues have been addressed. Shower sheet had not been signed off on by a nurse.Record review of an electronic health record for Resident #7 on 11/10/25 indicated there was no skin assessment completed by a nurse on 10/10/25 for Resident #7 and no nursing progress note dated 10/10/25 indicating Resident #7 had been assessed by a nurse for ant bites. There were no weekly skin assessments documented between the dates of 10/19/25 and 11/2/25.4. Record review of a facility face sheet dated 11/10/25 for Resident #14 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: chronic obstructive pulmonary disease (a group of lung diseases that includes emphysema and chronic bronchitis. It is characterized by obstructed airflow from the lungs, making it difficult to breathe), urinary tract infection (a common infection that can affect any part of your urinary system, including the bladder, kidneys, and urethra), and Alzheimer's disease (the most common cause of dementia - a disease that affects memory, thinking, and the ability to perform daily activities). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #14 indicated a BIMS score of 11, which indicated he had moderate cognitive impairment. He required moderate assistance with most ADLs.Record review of a comprehensive care plan dated 9/12/25 for Resident #14 indicated he had the potential for an alteration in skin integrity and had an intervention for LVNs and RNs that read: .Inspect skin from head to toe no less than one time per week and document/measure all abnormal findings.Record review of a facility form titled Skin Monitoring: Comprehensive C.N.A. Shower Review dated 10/10/25 and signed by CNA G for Resident #14 indicated CNA G identified eight visible bites to Resident #14's neck, back, and right leg. Bottom of form read .Turn into DON after skin issues have been addressed. Shower sheet had not been signed off on by a nurse.Record review of an electronic health record for Resident #14 on 11/10/25 indicated there was no skin assessment completed by a nurse on 10/10/25 for Resident #14 and no nursing progress note dated 10/10/25 indicating Resident #14 had been assessed by a nurse for ant bites. There were no weekly skin assessments documented between the dates of 9/24/25 and 10/15/25.During an observation and interview on 11/4/2025 at 9:10 AM, LVN Q was on hall 100 administering medications. She said she was working as the medication aide that day. She said the facility had two medication aides during the day, and one at night that stayed until 11 pm. She said she had been employed at the facility since April 2025. She said the facility did not have a treatment nurse, but did have a wound care physician that visited weekly. She said the nurses were responsible for completing the skin assessments weekly and as needed. During an interview on 11/5/2025 at 8:32 AM, LVN L said she worked on Halloween 10/31/2025. She said she was informed during report from the night nurse on 10/30/2025 that Resident #1 had a fall on Thursday 10/30/2025 during the day shift and that they needed to do an incident report and documentation. She said at breakfast on 10/31/2025, Resident #1 was groggy (sleepy) and had a huge abrasion to her forehead. She said the DON was informed and she notified the doctor and sent a picture to him, and she needed to send Resident #1 to the ER. She said she received orders and the doctor asked if it was such a bad fall, why was Resident #1 not sent out the day of the fall. She said she started neuros and checked Resident #1's blood pressure which was elevated along with her pupils being sluggish. She said she notified Resident #1's RP and the resident did not leave the facility until around 1 pm because EMS did not have any emergent vehicles for transport. She said she contacted another EMS for transport. She said RN A was the nurse who worked the day before (10/30/2025). She said she told the DON that Resident #1 was not acting like herself. She said when a resident had a fall, the nurse was supposed to assess them to see if they were safe to get up, obtain vitals and neuros, if necessary, and notify the doctor and family. She said if a resident hit their head, they normally would send the residents out for evaluation at the ER. She said residents could be at risk for injuries that might be untreated like death or brain bleeds if they were not assessed properly and timely. She said she had been trained on notifying the family and doctor, was told to not allow the nurse aides to get a resident off the floor until the nurse completed an assessment. She said proper notification would be needed and neuros needed to be started if a resident hit their head or it was an unwitnessed fall. She said nursing staff should complete a progress note and a fall risk management (incident report). During a phone interview on 11/5/2025 at 9:01 AM, RN A said she had been employed at the facility for 6 months and worked 6 am-6 pm and would work other shits at times. She said the last day she worked was on Thursday 10/30/2025. She said she was suspended pending an investigation with Resident #1. She said on 10/30/2025 at around 5 pm, she was at the nurse's desk, and the Activity Director informed her another resident having chest pain, and the resident was not assigned to her, but she was the only nurse around at that time. She said at the same time, CNA B told her that Resident #1 had a cut on her head and informed her it was ok,so they put a bandage on it until she could check Resident #1 and Resident #1 was in bed. She said when she went into the room to assess Resident #1, who was in bed, and Resident #1 said she was not sure how she injured herself. She said CNA B and CNA C were the nurse aides assigned to the hall where Resident #1 resided. She said both CNA B and CNA C told her they found Resident #1 on the floor. She said she thought Resident #1 tried to self-transfer and must have fallen. She said she checked Resident #1 from head to toe, and Resident #1 had an abrasion to her head, she conducted neuros and her vital signs were fine. She said Resident #1 told her she did not fall, but the resident had dementia. She said around 5:10 pm was the first time she saw Resident #1 and she checked neuros, and all the information was written down in her spiral because it was almost time for her to get off at 6 pm. She said she made herself a note to complete an incident report. She said she removed the steri strips from Resident #1's forehead and cleaned her head that had dried blood that measured 1 cm x 0.5 cm skin tear and placed a bandage on her head. She said the resident did not have any protrusions (sticking out) or a hematoma (a collection of blood outside of a blood vessel). She said Resident #1 was fine, and she gave report to the night shift nurse and informed her that Resident #1 had a skin tear on her forehead, and the oncoming nurse needed to complete an incident report. She said she did not document it on the 24-hour report, but had the information in her spiral book. She said she asked the Administrator if she could come in to work on 10/31/2025 to complete paperwork and was contacted before noon on 10/31/2025 to inform her that she was suspended. She said she started neuros on Resident #1, but did not document it in the facility paperwork. She said she left work without her work being completed and did not document what she had done. She said Resident #1 could have had a head bleed and the nurses would have been at fault because documentation was not done and not followed through. She said the facility documented the neuro assessment on paper neuros, and she RN A did not complete one. She said she sent documentation to the Administrator to show that she started neuros, but did not send it to the night shift nurse.During an interview on 11/5/2025 at 10:03 AM, CNA C said she had been employed at the facility since October 2025 and worked 6 am-6 pm and usually worked on hall 100 where Resident #1 resided. She said Resident #1 slouches down in her wheelchair sometimes and the staff have to pull her up but has never fallen out. She said on 10/31/2025 around 1 pm or 2 pm after lunch, CNA B pushed Resident #1 back to her room after lunch and was about to start a round with performing incontinent care. She said CNA B left Resident #1 in her room and gathered supplies. She said another resident called out down the hall and she went to see what happened with that resident. When CNA B entered Resident #1's room, the resident was on the floor and she heard her say oh no, she's on the floor. She said she ran to the room of Resident #1 and Resident 1#'s wheelchair was locked sitting by the bed, and when she fell, she either hit the chair or the trashcan, and she was bleeding from the middle of her forehead and asked Resident #1 who said she hit the chair. She said she was lying on the left side and was in between the trash can and the chair. She said they both (CNA B and CNA C) went and told RN A who was at the nurse station and were told she was handling another resident who was having chest pain. She said RN A told them to pick Resident #1 up and put her to bed, and she would check on her in a little bit. She said she asked RN A what to do about Resident #1's bleeding head, and RN A told her she would be there in a minute. She said she told CNA B that RN A told her to pick Resident #1 up and put her to bed, so they put her back to bed, covered her up and about an 1 and a half hour passed and RN A still had not entered the room to check on Resident #1. She said Resident #1's head was still bleeding, and RN A had not come back fast enough. She said she performed incontinent care for three residents and RN A still had not entered the room. She said the DON and ADON were both at work on 10/31/2025 and she did not want to go above RN A to report anything. She said she told RN A a second time that Resident #1's head was still bleeding and told RN A that she was going to get some supplies to cover Resident #1's head. CNA C said she entered the room, cleaned the wound, and placed steri strips on the open area that was about a nickel size. She said she looked down the hall and RN A was still at the nurse's desk and the resident she helped was gone to the ER. She said she never saw RN A go in the room to check on Resident #1. She said later she saw Resident #1 had a bandage that was on her forehead that was not completely attached around 5:30 pm. She said RN A later told her that the resident did not have a fall. She said they got off at 6 pm and told the night shift nurse aides that Resident #1 had a fall and the nurse (RN A) did not do anything about it, and she was complaining about being dizzy and her head was hurting. She said Resident #1 was not given any medication for her head, which she was aware. She said she worked the next day 10/31/2025, and someone was asking about what happened to Resident 1's head. She said the Administrator was made aware that Resident #1 had a fall on 10/30/2025, and she had to write a witness statement. She said if a resident was found on the floor, they were to notify the nurse, whoever was in charge, not move them, and wait for the nurse to evaluate the resident and check them. She said on Friday 10/31/2025, LVN L assessed Resident #1 on the day shift.During an interview on 11/5/2025 at 10:43 AM, CNA B said she had been employed at the facility since August 2025 and worked the day shift from 6 am-6 pm. She said Resident #1 was on the hall she was assigned that day 10/30/2025. She said she worked on 10/30/2025 and Resident #1 was fine that day, after lunch she was in her room ready to lie down and stepped out to get linens. She said she heard a loud bump, thought it was Resident #1, so she ran into her room and she was on the floor and it was sometime after lunch around 1:30 PM or so. She said there was a chair that was parallel to her bed, and she fell out of her wheelchair, and it looked like she hit the chair. She said she and CNA C entered the room, she told CNA C to get RN A, and CNA C came back and told her to put Resident #1 back to bed. She said they put her in bed knowing that they should not have, and thought RN A was coming and asked CNA C if she told RN A Resident #1 was bleeding from her head. She said it was a cut to her forehead. She said after they put Resident #1 in bed, they tried to clean her head, changed her, told RN A twice. She said the second time RN A was informed was after the dinner trays had been passed out (around 5 pm), RN A entered the room with her and that's when RN A assessed Resident #1. She said RN A took Resident #1's vital signs and provided treatment for her forehead. She said CNA C reported the fall to the night shift nurse aides. She said Resident #1 was her normal self and not complaining of any dizziness or headaches at that time. She said the Administrator contacted her on 10/31/2025 and asked about the incident. She said she was told to not move a resident, and they could not pick a resident off the floor until they had been assessed. She said she did not know that before and thought that the nurse should have come in to assess the resident immediately. She said they had an in-service on falls, who to report to, and not to pick them up until the nurse assessed the resident. During an observation and interview on 11/5/2025 at 12:37 PM, Resident #1 was in her room sitting up in bed awake eating her lunch. Resident #1 had a scab noted to her forehead with a wheelchair in her room with her bed in a low position. Resident #1 was alert to person with confusion noted.During a phone interview on 11/6/2025 at 9:27 AM, the Physician said he visited the facility once a week on Tuesdays and more often if needed. He said Resident #1 was one of his residents who had some intermittent times around September 2025 with her dementia getting worse. He said she had a history of falls; repeated falls most of the time when she tried to transfer herself. He said he was notified about a fall the morning after (10/31/2025) the nurse was still concerned that Resident #1 was dizzy and was asked by the facility about sending Resident #1 to the ER. He said the facility notified him about falls, and he would have told them to continue to monitor Resident #1 and let him know if anything was abnormal. He said they told him that Resident #1 possibly hit her head, and she had an abrasion. He said they sent him a photo image and reported Resident #1 complained of dizziness. He said Resident #1 was not taking any blood thinners which would increase her risk of bleeding. He said Resident #1 was sent to the ER for evaluation, but did not sustain any fractures; only a laceration to her forehead from the fall. During an observation and interview on 11/6/2025 at 11:42 AM, Resident #7 was in her room sitting on her rollator walker by the window. She was alert to person, place, and time. She said there had been a problem with ants in her room for a long time. She said she had some bites on her back not long ago from ants a few weeks ago. She said the ants were in her bed and everyone in the facility was aware. She said pest control came to the facility and treated her room. She said she had not seen any more since then. She said they treated her for the ant bites, and she was not allergic.During an observation and interview on 11/6/2025 at 11:55 AM, Resident #15 was sitting in a wheelchair in the dining room alert to person only. When asked if he had been bitten by ants, he said he had been in his bedroom on his body. He said he saw them in his room all the time.During an observation and interview on 11/6/2025 at 11:57 AM, Resident #14 was sitting on his walker in the dining room. He was alert to person, place, time, and situation. He said he had been at the facility since December 2024. He said he had ants in his room not long ago and was bitten by them in his bed. He said he had not seen any since then. He said the facility treated his ant bites, he was not allergic to the ants, and he did not like being bitten.During an interview on 11/10/2025 at 9:33 AM, CNA G said she was one of the shower techs for the facility and she worked Monday-Friday giving showers for the residents in the facility. She observed the shower sheets for Resident #7, #14 and #15 from October 2025. She said she signed the sheets and notified the ADON and the nurse for the residents and just verbalized what she observed on those days with the ant bites. She said either the ADON, or the nurse would go and check the resident's skin to see if it needed any medications or not. She said she saw the staff go into the room, but was not sure what they did. She said she did not see any ants in Resident #7's room. She said Resident #14 had ant bites and she reported them to the nurse. She said she saw someone from pest control came out to the facility and treat the rooms. She said she had not seen any more residents with ant bites since October 2025. During an interview on 11/10/2025 at 10:12 AM, the ADON said if staff found new skin issues, they should report them to the nurse, and they notified her as well. She said the staff were also to notify the physician and if the physician did not give orders, then staff would not write a progress note. She said nurses should have completed skin evaluations and assessments, and there was a huge problem with the nurse not doing those evaluations. She said the nurses were responsible for conducting skin evaluations weekly and as needed. She said there was no one in the facility to hold staff accountable to make sure things were being done. She said they had contacted staff, before, to come into the facility to complete their evaluations on their days off. She said the facility had a problem for a long time with nurse administration not following through and not holding staff accountable for things that were not done. During an interview on 11/12/25 at 12:40 pm, LVN Q said she had been working at the facility since April 2025 as a charge nurse. She said skin assessments were to be completed at least weekly on all residents, and were the responsibility of the charge nurse. She said if a CNA reported any skin issues to the charge nurse, the charge nurse should immediately do a thorough assessment and document any findings. She said if any issues were identified during this assessment, the physician should be notified for any new orders, along with the DON, Administrator, and Responsible Party or family member. She said if this was not done appropriately, further skin breakdown could occur.During an interview on 11/12/2025 at 5:24 PM, the Administrator said if a resident had a fall, the staff should notify the nurse and should evaluate the resident. She said the nurse should start a risk management assessment, check vital signs, and initiate neuros. She said all unwitnessed falls have a protocol in place to start neuros, notify RPs, the physician, and facility management. She said residents could be at risk of an adverse event. She said at no time should a resident be picked up off the floor without an assessment. She said RN A was terminated. She said skin assessments were the responsibility of the nurses and should be conducted weekly. She said if staff observed any skin issues, they were to report immediately to the charge nurse and then the charge nurse was to complete a head-to-toe assessment to determine best course of action and notify the physician and RPs. Record review of a termination form for RN A signed and dated 11/8/2025 by the Administrator indicated she was terminated for failing to properly assess, evaluate, or treat timely to a resident that had a fall with injury. Record review of the facility's policy titled Assessing Falls and Their Causes revised March 2018 indicated, .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. After a fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vitals as soon as it is safe to do so. If the fall is unwitnessed (resident found in floor) or the fall is witnessed and the resident was known to hit their head, neuro vital signs will be initiated and carried out per guidelines. 3. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 5. Notify the resident's attending physician and family in an appropriate time frame. Reporting: 1. Notify the following individuals when a resident falls: a. The resident's family; b. The Attending physician; The Director of Nursing Services; and d. The Nursing Supervisor on duty.

Based on observation, interview and record review the facility failed to ensure bedrails were assessed for the risk of entrapment of residents prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 9 of 31 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) reviewed for bed rails. 1. The facility failed to inform Resident #1, Resident#2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9 or their representative of the risks associated with the use of assist bars. 2. The facility failed to care plan for risks associated with assist bars, obtain consent for the use of assist bars, and obtain physician orders for use of assist bars. 3. The facility failed to ensure Resident #1 did not have his left arm caught between the assist bar and air mattress on [DATE]. 4. The facility failed to ensure Resident #1's left arm, head and neck were not between the assist bar and air mattress with his legs on the floor mat on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for entrapment with serious injury or death. Findings include: 1. Record review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included repeated falls, epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), congenital stenosis (abnormal spinal narrowing present at birth) and obstruction of esophagus, age related physical debility, spastic hemiplegia (muscles on one side of the body being in a constant state of contraction) affecting left nondominant side, dizziness and giddiness, and general muscle wasting and atrophy. Record review of Physician Orders dated [DATE], reflected Resident #1 had no orders for assist bars. Record review of Resident #1 ' s Progress Notes, between [DATE] through [DATE], reflected Resident #1 had a fall on [DATE] in his room and was found by LVN B with his left arm between the assist bar and bed. There were no bed safety assessments for use of assist bars on or after [DATE]. The resident had an additional fall in his room on [DATE] and was found unresponsive by CNA A and appeared grey in color with his left arm, head and neck between the assist bar and air mattress with his legs on the floor mat and CPR was immediately initiated by RN R at 6:50 p.m. EMS was called and arrived at 6:58 p.m. and Resident #1 was transferred to the hospital. Record review of Resident #1 ' s care plan, revised [DATE], reflected the resident had a history of falls and seizures with interventions to include: review information on past falls, attempt to determine cause of falls, record possible root causes, alter/remove any potential causes, if possible, educate resident/family/caregivers/IDT about causes, safety reminders and what to do if fall occurs, attempt to find the resident triggers for falls, attempting to self-toilet (initiate trial toileting program); confusion in the evening (encourage distraction activities in the evening); the resident needs a safe environment with even floors free from spills and/or clutter, and the bed in low position at night. The care plan did not address assist bars or risks associated with use of assist bars. Record review of Resident #1's most recent significant change in status MDS, dated [DATE], reflected he had a Brief Interview for Mental Status score of 03, which indicated severe cognitive impairment. Resident #1's functional status reflected he was non-ambulatory and required a two person assist for bed mobility. Record review of Resident #1's assessments between [DATE] and [DATE], reflected there were no bed safety assessments completed. Record review of incident report log between [DATE] through [DATE] reflected Resident #1 had a history of falls on [DATE] at 11:13 p.m., three falls on [DATE] at 1:00 p.m., 1:30 p.m., and 1:45 p.m., one fall on [DATE] at 10:45 p.m., one fall on [DATE] at 2:00 p.m., one fall on [DATE] at 1:45 a.m., two falls on [DATE] at 2:25 a.m. and 7:45 p.m., one fall on [DATE] at 12:45 a.m., two falls on [DATE] at 10:42 a.m. and 7:00 p.m. and [DATE] at 5:52 p.m. Record review of incident report written by LVN A, dated [DATE] at 2:00 p.m., reflected Resident #1 was found sitting on the floor with back up against the bed with his left arm between the mattress and railing. Bed was in lowest position. Resident was able to move his arm from between the bed and railing with assistance Resident #1 had a small abrasion to his left elbow and front right knee, resident was assisted to bed with gait belt, and resident was unable to give a description. Record review of incident report written by RN R, dated [DATE], reflected Resident #1 was found at approximately 6:50 p.m. by CNA A and noted to be .sitting on buttocks on floor with left arm around right-side bed rail and left side of neck/head lodged between mattress and side rail. Resident was grey in color, warm to touch and faint right-side jugular pul[s]e noted. [CNA A] notified this RN (RN R) that was across the hall at medication cart on resident's hall. I (RN R) entered room and [CNA A] and I placed resident on the floor and began CPR. [LVN T] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles while [CNA A] assisted with the [bag valve mask] and we swapped out after 5 cycles. [CNA B] joined in rotation. [AED] applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived Resident O2 sats [were] 95% on O2 2L [nasal canula]. Contacted emergency contact [RP W], [MD], and [DON] in report incident. Record review of, undated, witness statement by CNA A reflected he was taking residents out for their evening smoke break when a resident notified him that Resident #1 was on the floor. He immediately went to the room and saw Resident #1's head almost stuck in the side rail and he looked pale. CNA A reported he notified RN R that Resident #1 looked pale and was nonresponsive and RN R stayed in the room while he ran to get the crash cart. RN R and CNA A proceeded to do chest compressions until the paramedics arrived. Record review of, undated, witness statement, did not document a name and date, reflected at approximately 6:50 p.m., CNA A noted resident sitting on buttocks on the floor with left arm around right-side rail and left side of head/neck lodged between mattress and side rail, resident was grey in color, warm to touch, and faint jugular pulse noted to right side. CNA A notified RN R that was at medication cart across from residents' room. The witness statement reflected: I (RN R) entered room and [CNA A] and I (RN R) placed resident on floor and began CPR. [LVN B] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles and [CNA A] used [bag valve mask] and we swapped after 5 cycles CNA B joined in the rotation 3 cycles in CPR performed 10 min. [AED] was applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived resident O2 sat (oxygen saturation) was 95% on O2 2L (Liters) NC (Nasal Cannula). [RP W] contacted notified at [phone number] at 8:58 p.m. by RN A. She stated he is not DNR and is in the process of being placed on Hospice. Record review of Resident #1's hospital records, dated [DATE], reflected he presented to the ER post cardiac arrest, and he was found after he slid out of his bed with his head in the bed rail. When nursing found the resident, he did not have a pulse, CPR was initiated, upon EMS arrival patient had a pulse, and intubation was attempted but unable to place in a definitive airway. A transfer to other acute facility was ordered for a higher level of care due to acute exacerbation (worsening of airway function). Record review of the Provider Investigation Report, dated [DATE], reflected the following: .At approximately 1850 [6:50 p.m.] [CNA A] noted resident sitting on buttocks on floor with left arm around right side bed rail and left side of neck/head between mattress and side rail with chin resting on side rail. and Resident was noted to be sitting on buttocks on floor with left arm around right side of bed rail and left side rail and left side of neck/head lodged between mattress and side rail .resident was grey in color, warm to touch and faint right side jugular pulse noted . Provider Response [RN A] with the assistance of [CNA A] placed resident on the floor and began CPR while the other duty called 911 and prepared papers for transfer. RN began chest compressions for 5 cycles while CNA assisted with the [bag valve mask] bag and they swapped out after 5 cycles. [CNA B] assisted in the rotation. AED applied after first cycle fo CPR with no shock advised. When EMS on scene resident had O2 saturation of 95% on NC (nasal cannula) [at] 2/L O2 and a heartbeat was present. Resident placed on stretcher and transported out of facility. Resident emergency contact and attending physician notified of incident and transport by EMS. Investigation Summary Staff present/assisting with the emergency were interviewed. Statements have been and are being obtained. Staff member who was first on scene (CNA A) demonstrated exactly what he saw when entering resident room. The demonstration reveals the left arm between assist rail and mattress with head resting upon left shoulder and chin resident on the side rail, the neck free from pressure/compression. Upon interview [CNA A] indicated that when he entered the resident room the resident's neck/airway was not compromised and his chin was resting on the side rail .his shoulder blades and head were pressed in the area, but his neck was totally free. [CNA A] stated they did lower the rail or deflate the mattress but rather lifted the resident carefully up and over, then onto the ground. [CNA A] stated, 'his neck was free .his oxygen tubing was not on his face but on the ground.' [Resident #1's] bed, mattress, and assist rails were evaluated by maintenance to ensure no malfunction and proper fit to meet FDA standards, all equipment was in good working order and the distance measured between the air mattress and the assist rail was 2.5 inches. All statements were reviewed/analyzed as well as the re-enactment demonstration and it is not confirmed that the resident suffered strangulation in the assist rail as there was no pressure noted to be on the resident's airway. It is not confirmed that neglect occurred as the resident had no more than an hour before the last interaction with staff and this incident. Resident has a history of self-transfer attempts and all measures to prevent injury were in place (bed in lowest position, fall mats at bedside, door left open, and call light within reach.) Record review of witness statement by CNA B, dated [DATE] at 1:03 p.m., reflected the following: During my first rounds after clocking in I saw [Resident #1] in his bed awake, head of bed elevated, feet down. [Resident #1's] feet were hanging off the end of the bed, the sheets were on the floor. Resident repositioned in bed, new bedding on resident. Head elevated and feet elevated. Call light in reach. I continued on my rounds making my way down the halls. I was on the therapy hall when I hea[r]d [RN A] yell out HELP! Call 911 and got the crash cart. She and [CNA A] were looking for the [bag valve mask] bag, gave it to [RN A] and [CNA A] and I were rotating compressions. Doing roughly ,d+[DATE] each then switching. CPR for approximately ,d+[DATE] minutes before EMS arrived. They took over compressions, changed out the AED and got vital[s]. He was breathing when EMS arrived. During an interview on [DATE] at 9:28 a.m., the Administrator and the DON said Maintenance was responsible for the bed and assist bar installation and maintenance. The Administrator said he was not sure who last saw Resident #1 but it had been within the hour and the resident was initially at the hospital for altered mental status and failure to thrive before he returned from the hospital a couple hours prior to incident. The Administrator said Resident #1 returned on [DATE] at 4:00 p.m. and the incident occurred at 6:50 p.m. The Administrator and the DON said CNA A found him with his left arm, head and neck between the assist bar and air mattress with his legs on the floor. The Administrator and the DON said RN A assessed the resident and immediately began CPR, AED device was obtained, and resident was a full code when he returned from the hospital even though his RP had requested a DNR at the hospital, there was not a DNR in place prior to return. The Administrator and DON said EMS arrived and he was transported to the hospital and was anticipated to return on hospice. The Administrator and DON said the roommate was in the room but was unable to communicate and was not interviewable and RP W and attending physician were notified of the incident. During an observation on [DATE] at 10:00 a.m., Resident #31, roommate of Resident #1, was lying in bed free from apparent injury and appeared confused. Resident #31 did not respond to questions and the room appeared free from hazards and no assist bars were installed to beds in the room. During an interview, observation, and record review on [DATE] at 10:20 a.m., Resident #8 said she was recently admitted to the facility within 90 days for physical therapy. Resident #8 had assist bars installed to left and right side of her bed and said she used the bed rails on her bed to pull herself up and she had no concerns with them. Resident #8 said the facility had not reviewed the risks associated with using assist bars or obtained her consent to have them and the bed had them installed when she arrived at the facility. 2. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included muscle weakness (generalized), lack of coordination, post cholecystectomy syndrome (persistence of biliary colic or right upper quadrant abdominal pain with a variety of gastrointestinal symptoms similar to those in patients with cholecystitis prior to cholecystectomy), acute kidney failure, morbid (severe) obesity due to excess calories, acute cholecystitis (inflammation of gallbladder), and heart failure. Record review of Resident #8's chart reflected the care plan did not address bed rails/assist bars and there were no physician orders or assessments for assist bars located in resident's chart. Record review of Resident #8's MDS, dated [DATE], reflected she had a Brief Interview for Mental Status score of 13, which indicated intact cognition. Resident #8 had a functional status of 02 for lying to sitting on back of bed, which indicated she required substantial/maximal assistance for bed mobility. Record review of Resident #8's care plan, revised [DATE], reflected the resident had a risk of ADL self-performance deficit and limitations to physical mobility related to muscle weakness, lack of coordination and morbid obesity with interventions to include a two person assist for bed mobility. Assist bar intervention for mobility had an initiation date of [DATE]. There were no interventions in place for use of assist bars prior to [DATE]. Record review of Resident #8's progress note, dated [DATE], reflected: Resident assessed for the use of assist rails. Resident has impaired mobility r/t weakness and decreased strength secondary to morbid obesity, morbidity weakness, and other abnormalities of gait. Assist rails are used during incontinent care to assist in pulling [herself] from side to side and to provide leverage when transferring from the bed. Resident is able to verbalize the reason for the assist rail placement. Direct caregiver interviewed to verify resident use of side rails. Resident does not have a history of falling from the bed or seizure disorder. Resident may have assist rails in place. Progress notes reflected no risks were reviewed when using assist bar and consent was not obtained. Record review of Resident #8's physician orders reflected there were no orders in place for assist bars until [DATE] at 6:00 p.m., post State Surveyor intervention. 3. Record review of Resident #3's face sheet, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: malignant neoplasm (cancerous tumors) of unspecified ovary, anemia, recurrent depressive disorders, atherosclerotic heart disease (clogged artery) of native coronary artery, acute embolism (blood clot), thrombosis (formation or presence of blood clot) of left popliteal vein, pleural effusion (fluid in space surrounding lung), perforation of intestine, muscle weakness (generalized), surgical aftercare following surgery on the digestive system, and colostomy status. Record review of Resident #3's admission MDS, dated [DATE], reflected she had a Brief Interview for Mental Status score of 15, which indicated intact cognition and a functional status of limited assistance with one person assist for bed mobility. Record review of Resident #3's care plan, revised [DATE], reflected she had a problem of ADL self-performance deficit related to cancer and interventions included use of assist bar and one person assist for bed mobility. There were no additional interventions for assist bar prior to [DATE] at 6:00 p.m. Record review of Resident #3's physician orders reflected assist bar orders had a start date of [DATE] at 6:00 p.m. During an observation on [DATE] at 10:28 a.m., Resident #3 appeared to be resting in bed with air mattress and assist bar in place. 4. During an interview, observation, and record review on [DATE] at 10:30 a.m., Resident #9 said the facility had never reviewed the risks of using bed assist rails installed to her bed and did not know there were any risks. Resident #9 was lying in her bed with head of bed elevated and appeared well groomed, pleasant, and in no distress, and bed assist bars were installed on both sides to bed. Record review of Resident #9's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included: type 2 diabetes with diabetic neuropathic arthropathy (bone and joint changes that occur secondary to loss of sensation), age related osteoporosis (bone disease that develops when bone mineral density and bone mass decreases), lack of coordination, insomnia (sleep disorder), cognitive communication deficit, recurrent depressive disorders, atrial fibrillation (irregular heart rhythm), abnormalities of gait and mobility, age related cognitive decline, visual field defects, heart failure, muscle wasting and atrophy to right and left lower legs, generalized muscle weakness, difficulty in walking, unsteadiness on feet, malaise (general sense of being unwell), and age related physical debility. Record review of Resident #9's quarterly MDS, dated [DATE], reflected she had a Brief Interview for Mental Status score of 15, which indicated intact cognition. Resident #9's functional status was 05, setup or clean-up assistance required for resident who can independently complete activity for lying to sitting and rolling in bed. Record review of Resident #9's care plan, revised [DATE], reflected she had a risk of ADL self-care performance deficit and limitations in physical mobility related to fatigue/malaise/weakness with intervention to include use of assist bar for mobility with a date initiated of [DATE]. There were no assist bar interventions implemented prior to [DATE]. Record review of Resident #9's physician orders reflected an order for her assist bar was received on [DATE] at 6:00 p.m., following State Surveyor intervention. Record review of Resident #9's progress notes on [DATE] during POR monitoring, written by LVN C, dated [DATE] at 10:31 a.m., reflected telephone consent for assist bars were obtained by the representative and the risks for using bed rails were explained to include: risks of strangling, suffocating, bodily injury, or death. Record review of Resident #9's progress notes written by the DON, dated [DATE] at 7:36 p.m., reflected the resident was assessed for the use of assist rails with noted impaired mobility related to weakness and decreased strength secondary to muscle wasting and atrophy, and osteoporosis. Assist rails were used during incontinent care to assist in pulling [herself] from side to side and to provide leverage when transferring from the bed and the resident was able to verbalize the reason for the assist rail placement. The CNA's verify resident use of side rails and the resident did not have a history of falling from the bed or any seizure disorder. Resident #9 may have assist rails in place. During an interview and observation on [DATE] at 10:30 AM, Resident #9 said the facility never reviewed the risks of using her bed assist bars or obtained consent prior to install and did not know there were any risks involved. Resident #9 had bed assist bars installed on both left and right sides to the bed. During an interview on [DATE] at 11:36 AM, Maintenance said she had been employed at the facility for 3 years and was responsible for installation and maintenance of assist bars on beds. Maintenance said she did not know what happened to Resident #1 but was asked to measure the distance between the mattress to the grab bar. Maintenance said she took both bed rails and put them on the bed to see how far the mattress was able to move and measured the spacing to be 2 and a half inches. She was not aware of a facility policy for gap requirements between assist bars and beds and did not know where to find the information if needed but was asked to measure by the DON and corporate office. Maintenance said all beds and assist bars were the same except for geriatric beds. Maintenance said she had never measured the distance between the air mattress and bed before and [DATE] was the first time she had measured it because she was not aware of the space requirements. Maintenance said she never noticed any gaps between the mattress and assist bar and did not recall specifically looking for that and no similar incidents of entrapment had happened that she was aware of. Maintenance said if there was a staff member requesting an assist bar, they grabbed them off the bed and there was a key that went to it and that was how it was assembled to the bed. Maintenance said maintenance requests were placed in the maintenance book at the nursing station and computer system. All staff looked at the beds every day and did not have a routine safety check scheduled and there were no issues with assist bars and the air mattress was sufficient size for Resident #1. Maintenance said she was not aware of the potential risks assist bars posed to residents. There was usually a physician's order to install assist bars and she was notified by the nurse and assist bars were in good condition and secure. Maintenance said it was important for assist bars to be installed appropriately because residents could have a fall and not be able to get up by themselves and couple pose a risk of entrapment. Maintenance said all residents were physically able to use assist bars. During an interview and record review on [DATE] at 12:15 p.m., Maintenance provided an assist bar and observed attached warning label which indicated risk of entrapment to include. WARNING/SAFETY ALERT .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. Maintenance said there were residents with air mattresses and assist bars still at the facility and that the provided assist bar and manual, titled [Company L] Instructions For Use Service Manual, was used on all beds. Record review of Company L manual for the bed reflected optional assist bar installation instructions, on pg.17, indicating Power air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. During an interview and record review on [DATE] at 1:17 p.m., the DON said the ADON assisted her with questioning all CNA staff on assist bar knowledge to assess resident needs for rails. The DON said there were additional residents utilizing assist bars with air mattresses and provided a list. There were 28 residents with assist bars and currently five residents with assist bars and air mattresses at the facility to include Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. The DON said they kept air mattresses on the bed when residents were admitted with a wound and assist bar risks were reviewed prior to placing the mattress. The DON said it would either be herself or the floor nurses who were responsible for assist rail assessments and obtaining consent and informing their representative. The DON said staff were required to obtain consent for assist bars on admission or prior to install. Maintenance was responsible for installing bed rails and all nursing staff checked rails daily when in the room with the resident and would notify Maintenance verbally and responds when needed if there were any concerns. The DON said any gap between assist bars and mattresses over 2 and half or three inches would be out of compliance per facility policy. Record review of facility policy, dated [DATE] titled, Guidance for Industry and FDA Staff - Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, included a table, located on pg. 21, for Zone 3 Between rail and mattress with a dimensional limit of less than 120 mm (4 ,d+[DATE] inches) for the area between the inside surface of the rail and a compressed mattress. The DON said it was important to obtain consent and assess bed safety with assist bars installed since they posed a potential risk of entrapment. The DON said all staff had not been trained on the bed safety in-services and was waiting on the opposite rotation night shift and those staff had not returned to work since the incident occurred with Resident #1 on [DATE]. The DON said bed safety assessments may be available in the electronic health record under the evaluations tab, but she was not sure. 5. Record review of Resident #2's face sheet, dated [DATE], reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses including malaise (general sense of being unwell), fatigue, morbid (severe) obesity due to excess calories, generalized muscle weakness, repeated falls, age related physical debility, need for assistance with personal care, and muscle wasting and atrophy. Record review of Resident #2's quarterly MDS, dated [DATE], reflected she had a Brief Interview for Mental Status Score of 15, indicating she was cognitively intact and a functional status of 04 for bed mobility indicating she required supervision or touching assistance. Record review of Resident #2's physician orders reflected there were no orders for assist bars prior to [DATE] at 6:00 p.m. Record review of Resident #2's care plan, revised [DATE], revealed assist bars were not addressed prior to [DATE]. The care plan addressed assist bars on [DATE] following State Surveyor intervention. Record review of Resident #2's progress notes, dated between [DATE] through [DATE], reflected a bed assessment was completed on [DATE] and consent was obtained by Resident #2 for assist bars on [DATE] at 10:56 a.m. following State Surveyor intervention. 6. Record Review of Resident #4's facesheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses including pressure ulcer of sacral region, muscle weakness, morbid (severe) obesity due to excess calories, lack of coordination, dizziness and giddiness, and abnormalities of gait and mobility. Record review of Resident #4's 5 day MDS, dated [DATE], reflected she had a Brief Interview for Mental Status score of 14, indicating she was cognitively intact and had a functional status of 01 indicating she was dependent for bed mobility. Record review of Resident #4's care plan, revised [DATE], reflected assist bars were not addressed prior to [DATE]. Record review of Resident #4's physician orders reflect there no orders for assist bars prior to [DATE] at 6:00 p.m. Record review of Resident #4's progress notes, dated between [DATE] through [DATE], reflected she was assessed for assist bars on [DATE] and consent was obtained for assist bars on [DATE] following State Surveyor intervention. 7. Record Review of Resident #5's facesheet reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses including facial weakness following other cerebrovascular disease, dysphagia (difficulty in swallowing) following cerebrovascular disease, psychosis, major depressive disorder, psychosis (severe mental condition), muscle wasting and atrophy, generalized muscle weakness, abnormalities fo gait and mobility, lack of coordination, need for assistance with personal care, and history of falling. Record review of Resident #5's quarterly MDS, dated [DATE], reflected he had a Brief Interview for Mental Status score of 07, indicating severe cognitive impairment and had a functional status of extensive assist for bed mobilty and required a two person assist. Record review of Resident #5's care plan, revised [DATE], reflected assist bars were not addressed prior to [DATE]. Record review of Resident #5's physician orders reflect there no orders for assist bars prior to [DATE] at 6:00 p.m. Record review of Resident #5's progress notes, dated between [DATE] through [DATE], reflected he was assessed for assist bars on [DATE] and consent was obtained for assist bars on [DATE] and [DATE]. 8. Record review of Resident #6's facesheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses including fracture of right lower leg, muscle weakness, and initial encounter for fall. Record review of Resident #6's admission MDS, dated [DATE], reflected she had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact and a functional status of 03 indicating partial/moderate assistance for bed mobility. Record review of Resident #6's care plan, revised [DATE], reflected assist bars were not addressed prior to [DATE]. Record review of Resident #6's physician orders, reflected there were no orders for assist bars prior to [DATE] at 6:00 p.m. Record review of Resident #6's progress notes, dated [DATE], reflected a bed assessment was completed and consent obtained on [DATE] and there were no assessments for bed rails prior to [DATE]. 9. Record review of Resident #7's facesheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses including infection and inflammatory reaction due to internal right hip prosthesis (artificial body part), difficulty in walking, pain in right shoulder, muscle wasting and atrophy, restless leg syndrome, cataract, osteoarthritis, major depressive disorder, age-related physical debility, lack of coordination, abnormalities of gait and mobility, encounter for other surgical aftercare, insomnia (sleep disorder), morbid (severe) obesity due to excess calories, and diaphragmatic hernia (hole in muscle that separates chest from abdomen). Record review of Reside [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from physical restraints for 1 (Resident #1) of 31 residents reviewed for physical restraints. The facility failed to inform Resident #1 or their representative of the risks associated with use of assist bars, care plan for risks associated with assist bars/bed rails, obtain consent for the use of assist bars, obtain physician orders for use of assist bars, and implement interventions following an incident of entrapment with the assist bar. Resident #1 was found by LVN A on the floor in his room with his left arm caught between the assist bar and air mattress on [DATE] and had no interventions to address risk of entrapment following incident. Resident #1 was found by CNA A in his room with his left arm, head and neck between the assist bar and air mattress and his legs on the floor mat on [DATE] and CPR was initiated. Resident #1 expired at the hospital on [DATE] following intubation and responsible party withdraw of care. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for entrapment with serious injury or death. Findings included: 1. Record review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included repeated falls, epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), congenital stenosis (abnormal spinal narrowing present at birth) and obstruction of esophagus, age related physical debility, spastic hemiplegia (muscles on one side of the body being in a constant state of contraction) affecting left nondominant side, dizziness and giddiness, and general muscle wasting and atrophy. Record review of Physician Orders dated [DATE], reflected Resident #1 had no orders for assist bars. Record review of Resident #1 ' s Progress Notes, between [DATE] through [DATE], reflected Resident #1 had a fall on [DATE] in his room and was found by LVN B with his left arm between the assist bar and bed. There were no bed safety assessments for use of assist bars on or after [DATE]. The resident had an additional fall in his room on [DATE] and was found unresponsive by CNA A and appeared grey in color with his left arm, head and neck between the assist bar and air mattress with his legs on the floor mat and CPR was immediately initiated by RN R at 6:50 p.m. EMS was called and arrived at 6:58 p.m. and Resident #1 was transferred to the hospital. Record review of Resident #1 ' s care plan, revised [DATE], reflected the resident had a history of falls and seizures with interventions to include: review information on past falls, attempt to determine cause of falls, record possible root causes, alter/remove any potential causes, if possible, educate resident/family/caregivers/IDT about causes, safety reminders and what to do if fall occurs, attempt to find the resident triggers for falls, attempting to self-toilet (initiate trial toileting program); confusion in the evening (encourage distraction activities in the evening); the resident needs a safe environment with even floors free from spills and/or clutter, and the bed in low position at night. The care plan did not address assist bars or risks associated with use of assist bars. Record review of Resident #1's most recent significant change in status MDS, dated [DATE], reflected he had a Brief Interview for Mental Status score of 03, which indicated severe cognitive impairment. Resident #1's functional status reflected he was non-ambulatory and required a two person assist for bed mobility. Record review of Resident #1's assessments between [DATE] and [DATE], reflected there were no bed safety assessments completed. Record review of incident report log between [DATE] through [DATE] reflected Resident #1 had a history of falls on [DATE] at 11:13 p.m., three falls on [DATE] at 1:00 p.m., 1:30 p.m., and 1:45 p.m., one fall on [DATE] at 10:45 p.m., one fall on [DATE] at 2:00 p.m., one fall on [DATE] at 1:45 a.m., two falls on [DATE] at 2:25 a.m. and 7:45 p.m., one fall on [DATE] at 12:45 a.m., two falls on [DATE] at 10:42 a.m. and 7:00 p.m. and [DATE] at 5:52 p.m. Record review of incident report written by LVN A, dated [DATE] at 2:00 p.m., reflected Resident #1 was found sitting on the floor with back up against the bed with his left arm between the mattress and railing. Bed was in lowest position. Resident was able to move his arm from between the bed and railing with assistance Resident #1 had a small abrasion to his left elbow and front right knee, resident was assisted to bed with gait belt, and resident was unable to give a description. Record review of incident report written by RN R, dated [DATE], reflected Resident #1 was found at approximately 6:50 p.m. by CNA A and noted to be .sitting on buttocks on floor with left arm around right-side bed rail and left side of neck/head lodged between mattress and side rail. Resident was grey in color, warm to touch and faint right-side jugular pul[s]e noted. [CNA A] notified this RN (RN R) that was across the hall at medication cart on resident's hall. I (RN R) entered room and [CNA A] and I placed resident on the floor and began CPR. [LVN T] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles while [CNA A] assisted with the [bag valve mask] and we swapped out after 5 cycles. [CNA B] joined in rotation. [AED] applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived Resident O2 sats [were] 95% on O2 2L [nasal canula]. Contacted emergency contact [RP W], [MD], and [DON] in report incident. Record review of, undated, witness statement by CNA A reflected he was taking residents out for their evening smoke break when a resident notified him that Resident #1 was on the floor. He immediately went to the room and saw Resident #1's head almost stuck in the side rail and he looked pale. CNA A reported he notified RN R that Resident #1 looked pale and was nonresponsive and RN R stayed in the room while he ran to get the crash cart. RN R and CNA A proceeded to do chest compressions until the paramedics arrived. Record review of, undated, witness statement, did not document a name and date, reflected at approximately 6:50 p.m., CNA A noted resident sitting on buttocks on the floor with left arm around right-side rail and left side of head/neck lodged between mattress and side rail, resident was grey in color, warm to touch, and faint jugular pulse noted to right side. CNA A notified RN R that was at medication cart across from residents' room. The witness statement reflected: I (RN R) entered room and [CNA A] and I (RN R) placed resident on floor and began CPR. [LVN B] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles and [CNA A] used [bag valve mask] and we swapped after 5 cycles CNA B joined in the rotation 3 cycles in CPR performed 10 min. [AED] was applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived resident O2 sat (oxygen saturation) was 95% on O2 2L (Liters) NC (Nasal Cannula). [RP W] contacted notified at [phone number] at 8:58 p.m. by RN A. She stated he is not DNR and is in the process of being placed on Hospice. Record review of Resident #1's hospital records, dated [DATE], reflected he presented to the ER post cardiac arrest, and he was found after he slid out of his bed with his head in the bed rail. When nursing found the resident, he did not have a pulse, CPR was initiated, upon EMS arrival patient had a pulse, and intubation was attempted but unable to place in a definitive airway. A transfer to other acute facility was ordered for a higher level of care due to acute exacerbation (worsening of airway function). Record review of the Provider Investigation Report, dated [DATE], reflected the following: .At approximately 1850 [6:50 p.m.] [CNA A] noted resident sitting on buttocks on floor with left arm around right side bed rail and left side of neck/head between mattress and side rail with chin resting on side rail. and Resident was noted to be sitting on buttocks on floor with left arm around right side of bed rail and left side rail and left side of neck/head lodged between mattress and side rail .resident was grey in color, warm to touch and faint right side jugular pulse noted . Provider Response [RN A] with the assistance of [CNA A] placed resident on the floor and began CPR while the other duty called 911 and prepared papers for transfer. RN began chest compressions for 5 cycles while CNA assisted with the [bag valve mask] bag and they swapped out after 5 cycles. [CNA B] assisted in the rotation. AED applied after first cycle fo CPR with no shock advised. When EMS on scene resident had O2 saturation of 95% on NC (nasal cannula) [at] 2/L O2 and a heartbeat was present. Resident placed on stretcher and transported out of facility. Resident emergency contact and attending physician notified of incident and transport by EMS. Investigation Summary Staff present/assisting with the emergency were interviewed. Statements have been and are being obtained. Staff member who was first on scene (CNA A) demonstrated exactly what he saw when entering resident room. The demonstration reveals the left arm between assist rail and mattress with head resting upon left shoulder and chin resident on the side rail, the neck free from pressure/compression. Upon interview [CNA A] indicated that when he entered the resident room the resident's neck/airway was not compromised and his chin was resting on the side rail .his shoulder blades and head were pressed in the area, but his neck was totally free. [CNA A] stated they did lower the rail or deflate the mattress but rather lifted the resident carefully up and over, then onto the ground. [CNA A] stated, 'his neck was free .his oxygen tubing was not on his face but on the ground.' [Resident #1's] bed, mattress, and assist rails were evaluated by maintenance to ensure no malfunction and proper fit to meet FDA standards, all equipment was in good working order and the distance measured between the air mattress and the assist rail was 2.5 inches. All statements were reviewed/analyzed as well as the re-enactment demonstration and it is not confirmed that the resident suffered strangulation in the assist rail as there was no pressure noted to be on the resident's airway. It is not confirmed that neglect occurred as the resident had no more than an hour before the last interaction with staff and this incident. Resident has a history of self-transfer attempts and all measures to prevent injury were in place (bed in lowest position, fall mats at bedside, door left open, and call light within reach.) Record review of witness statement by CNA B, dated [DATE] at 1:03 p.m., reflected the following: During my first rounds after clocking in I saw [Resident #1] in his bed awake, head of bed elevated, feet down. [Resident #1's] feet were hanging off the end of the bed, the sheets were on the floor. Resident repositioned in bed, new bedding on resident. Head elevated and feet elevated. Call light in reach. I continued on my rounds making my way down the halls. I was on the therapy hall when I hea[r]d [RN A] yell out HELP! Call 911 and got the crash cart. She and [CNA A] were looking for the [bag valve mask] bag, gave it to [RN A] and [CNA A] and I were rotating compressions. Doing roughly ,d+[DATE] each then switching. CPR for approximately ,d+[DATE] minutes before EMS arrived. They took over compressions, changed out the AED and got vital[s]. He was breathing when EMS arrived. During an interview on [DATE] at 9:28 a.m., the Administrator and the DON said Maintenance was responsible for the bed and assist bar installation and maintenance. The Administrator said he was not sure who last saw Resident #1 but it had been within the hour and the resident was initially at the hospital for altered mental status and failure to thrive before he returned from the hospital a couple hours prior to incident. The Administrator said Resident #1 returned on [DATE] at 4:00 p.m. and the incident occurred at 6:50 p.m. The Administrator and the DON said CNA A found him with his left arm, head and neck between the assist bar and air mattress with his legs on the floor. The Administrator and the DON said RN A assessed the resident and immediately began CPR, AED device was obtained, and resident was a full code when he returned from the hospital even though his RP had requested a DNR at the hospital, there was not a DNR in place prior to return. The Administrator and DON said EMS arrived and he was transported to the hospital and was anticipated to return on hospice. The Administrator and DON said the roommate was in the room but was unable to communicate and was not interviewable and RP W and attending physician were notified of the incident. During an observation on [DATE] at 10:00 a.m., Resident #31, roommate of Resident #1, was lying in bed free from apparent injury and appeared confused. Resident #31 did not respond to questions and the room appeared free from hazards and no assist bars were installed to beds in the room. During an interview on [DATE] at 11:36 AM, Maintenance said she had been employed at the facility for 3 years and was responsible for installation and maintenance of assist bars on beds. Maintenance said she did not know what happened to Resident #1 but was asked to measure the distance between the mattress to the grab bar. Maintenance said she took both bed rails and put them on the bed to see how far the mattress was able to move and measured the spacing to be 2 and a half inches. She was not aware of a facility policy for gap requirements between assist bars and beds and did not know where to find the information if needed but was asked to measure by the DON and corporate office. Maintenance said all beds and assist bars were the same except for geriatric beds. Maintenance said she had never measured the distance between the air mattress and bed before and [DATE] was the first time she had measured it because she was not aware of the space requirements. Maintenance said she never noticed any gaps between the mattress and assist bar and did not recall specifically looking for that and no similar incidents of entrapment had happened that she was aware of. Maintenance said if there was a staff member requesting an assist bar, they grabbed them off the bed and there was a key that went to it and that was how it was assembled to the bed. Maintenance said maintenance requests were placed in the maintenance book at the nursing station and computer system. All staff looked at the beds every day and did not have a routine safety check scheduled and there were no issues with assist bars and the air mattress was sufficient size for Resident #1. Maintenance said she was not aware of the potential risks assist bars posed to residents. There was usually a physician's order to install assist bars and she was notified by the nurse and assist bars were in good condition and secure. Maintenance said it was important for assist bars to be installed appropriately because residents could have a fall and not be able to get up by themselves and couple pose a risk of entrapment. Maintenance said all residents were physically able to use assist bars. During an interview and record review on [DATE] at 12:15 p.m., Maintenance provided an assist bar and observed attached warning label which indicated risk of entrapment to include. WARNING/SAFETY ALERT .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. Maintenance said there were residents with air mattresses and assist bars still at the facility and that the provided assist bar and manual, titled [Company L] Instructions For Use Service Manual, was used on all beds. Record review of Company L manual for the bed reflected optional assist bar installation instructions, on pg.17, indicating Power air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. During an interview via phone on [DATE] at 2:00 p.m., RN R said she had been employed at the facility for a month and worked on Resident #1's hall. RN R said she was provided training on neglect via in-services but had not received training on assist bars following incident since she had not returned to work following the incident on [DATE] with Resident #1. RN R said Resident #1 was discharged from the hospital on [DATE] and she tried to obtain orders for feeding since the hospital did not send any orders with him and she knew previously that he was a tube feeder. RN R said Resident #1 fell constantly and he was being monitored constantly by staff and had him up at the nurses station the majority of time at night. RN R said she obtained feeding orders and put everything on the medication cart to go down the hall and administered a pain pill to his neighbor when she walked past his room and he was laying in his room at baseline. RN R said she entered the neighbors room and administered medication then crossed the hall to administer medication to another resident when CNA A notified her she needed to come to Resident #1's room. RN R said when she walked in Resident 31's room he was on the right side of the bed and his left arm was wedged on the other side between the mattress and the arm rail and his head was lodged there on his left side. RN R said he was sitting on his buttocks with his legs out straight, arm in the rail and the corner of his head an inch in on the throat area with his head turned to the right. RN R said she removed the resident from the rail and administered 2 cycles fo CPR when his color started to come back. RN A said the other nurse on duty called 911 and paramedics arrived 8 minutes later. RN R said the defibrillator was placed on the resident and CPR continued. RN R said his oxygen saturations were at 95% and he came with oxygen from the hospital but when he left the facility to be transferred to the ER he was breathing on his own. RN R said the ambulance remained outside for 30 to 45 minutes before leaving and she assumed they were placing an IV line. RN R said she called the hospital and was informed he was intubated. RN A said she last saw the resident at 6:45 p.m. on [DATE] when she told him she would be back to feed him. RN R said she notified the attending physician and representative of incident. RN R said Resident #1 had a history of rolling out of the bed while he was asleep, and she had not noticed any gaps between the assist bar and air mattress prior to this incident and she did not pay much attention to gap space requirements. RN R said it was important risks of assist bars were reviewed with residents to obtain consent and inform about the risks of entrapment if installed on air mattress beds. RN R said she had not returned to work since the incident and was supposed to have a meeting today about everything and she believed it was rescheduled for next week. RN R said she was not sure what space was allowed between the assist bar and air mattress, but she thought there should be no space in that zone. RN R said Maintenance was responsible for installing bed rails and all staff were responsible for checking bed safety on a routine basis, but RN R was not sure who did the assessment for assist bars and if she was responsible for completing and would have to consult with the DON. RN A said the IDT team was usually responsible for reviewing and obtaining orders for assist bars upon admission RN R said Resident #1 was able to physically use the assist bars for bed mobility. During an interview on [DATE] at 3:58 p.m., the Administrator said a QAPI meeting was not conducted following the reported incident with Resident #1 and the meeting would be around the middle of [DATE]. During an interview via phone on [DATE] at 5:17 p.m., CNA A said on [DATE] he found Resident #1 with his left arm, head and neck between the assist bar and mattress and the gap between the assist bar and bed appeared to be approximately 2 to 3 centimeters wide. CNA A said he last saw Resident #1 about 10 minutes prior to incident when he went in the room to remove his food tray and reported Resident #1 was at baseline. CNA A said he never saw him get stuck like that before in the assist bar. CNA A said he worked at the facility since the incident and had not received training on bed safety, and he felt training would be helpful. CNA A said he believed the gap amount allowed between the mattress and assist bar was 2 inches or 2 and half inches. CNA A said assist bars posed a risk of entrapment to all residents who were bed bound and on-air mattresses such as Resident #3 and it would be important for residents or representatives to know the risk of assist bars to include potential entrapment so they would have the knowledge needed to make the appropriate decision for use. CNA A said the nurses were responsible for ensuring bed safety but all staff could look at the beds and notify the nurse with any concerns. CNA A said he felt residents used the assist bars appropriately and only had a concern for resident with air mattresses and assist bars installed to bed that were not cognitively intact. CNA A said he did not know if residents were being notified of the potential risks with using assist bars and it would be the nurse's responsibility or the IDT team to do so upon admission. CNA A said he was not sure when the resident had his assist bars installed but CNA A had been at the facility for 2 years and believed the resident had always had them on his bed. During an interview via phone on [DATE] at 11:09 a.m., RP W said she was going to call the HHSC hotline number this afternoon with concerns related to Resident #1's DNR status she requested at the hospital but was not completed and thought the nurses notification of the resident receiving CPR was not appropriate. RP W said she was the medical and financial power of attorney for Resident #1 and on [DATE] she was notified by the nurse via phone that the resident was returned to the facility without a DNR being in place and the nurse did CPR on Resident #1, called 911, and the ambulance went to pick him up. RP W said the nurse told her the resident was really gray and was probably still deceased after RP W said the DNR process was initiated at the hospital. RP W said it upset her the nurse said it was okay CPR was initiated because he was probably still deceased . RP W said they intubated him at the hospital, removed it the next day and RP W said she had to watch him expire. RP W said Resident #1 expired on [DATE] at 7:14 p.m. after the hospital withdrew care around 1:30 p.m. RP W said the nurse called her on [DATE] at 8:58 p.m. and notified her Resident #1 was laying over the bed, his foot was hanging off the bed and was unresponsive. RP W said there was no mention of assist bars and had never been notified of the potential risks with using assist bars and had not been asked for consent for bed rails. RP W said she last visited Resident #1 a couple of months ago and was aware he had assist bars on his bed. During an interview via phone on [DATE] at 11:27 a.m., the hospital physician said Resident #1 was in the hospital in the beginning of October and was discharged on [DATE] to facility and returned to the hospital on a ventilator. RP W requested to withdraw care and he expired and felt it was a shame he did not pass peacefully and had to get intubated. During an interview on [DATE] at 11:47 a.m., the DON said she did not know when assist bars were installed on Resident #1's bed but Resident #1 had the assist bars since she has been employed at the facility in [DATE]. During an interview and record review on [DATE] at 10:50 a.m., the Administrator said there was a form to check for bed safety under maintenance electronic records and it showed checklists were overdue sometimes when it was completed early. The Administrator said he was able to log in and access the maintenance electronic records system at any time and Maintenance notified him if there were any Maintenance concerns. Review of maintenance electronic record logs, dated [DATE], reflected bed safety checks were overdue by one month for all residents. During an interview on [DATE] at 11:51 a.m., the DON said the facility did not obtain consent for bed rails to complete bed safety risk assessments for all residents with assist rails prior to Resident #1's incident on [DATE] because they were not aware they assist bars were considered to be bed rails and he was not assessed for risk of entrapment prior to bed rail install. The DON said there is a list with residents that use assist bars for nursing staff to refer to and she confirmed with corporate that assist bars were not treated as bed rails prior to Reisdent #1's incident. The DON said nursing staff would now be assessing and obtaining consent for use of assist bars since it was important for residents and representatives to be aware of associated risks such as entrapment. The DON said following Resident #1's self-reported incident on [DATE], interventions would be put in place for assist bars that include bed assessments and addressing assist bars in care plans. She said the IDT team is responsible for ensuring the resident have orders for assist rails. Review of facility policy, titled Bed Safety, revised [DATE], revealed the following: Policy Statement Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the timeframe, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: . 9. When using assist rails for any reason, the staff shall take measures to reduce related risks. 10. Assist rails shall not be used as protective restraints. This facility is a restraint free environment, 11. The staff shall report to the director of nursing and the administrator any deaths, serious illness and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. Review of facility policy, titled Abuse Prevention Program, revised [DATE], revealed the following: Policy Statement Our residents have the right to be free from abuse, neglect . This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences . Review of facility policy, titled Abuse Investigation and Reporting, revised [DATE], revealed: Policy Interpretation and Implementation Role of the Administrator . 5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Review of facility policy, titled Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures, revised [DATE], revealed: Policy Statement The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. Policy Interpretation and Implementation 1. The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures. 2. The Administrator has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the facility. These may include: a. The Director of Nursing Services; b. The Director of Social Services; c. The Director of Staff Development; d. Tho Director of Risk Management; e. The Assistant Administrator; f. The Medical Director; g. The Quality Assessment and Assurance Committee and h. Other staff members as determined by the Administrator. Review of facility policy, titled Investigating Injuries, revised [DATE], revealed: Policy Statement The administrator will ensure that all injuries are investigated. Policy Interpretation and Implementation 1. The director of nursing services or a designee will assess all injuries and document clinical findings in the clinical record. 2. If an incident/accident is suspected, a nurse or nurse supervisor will complete a facility-approved accident/incident form. The form will be disseminated to the appropriate individuals, for example the administrator and director of nursing services. 3. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) the extent of the injury; or (2) the location of the injury ( .the injury is located in an area not generally vulnerable to trauma); or (3) the number of injuries observed at one particular point in time; or (4) the incidence of injuries over time. 4. Documentation shall include information relevant to risk factors and conditions that could cause or predispose someone to similar signs and symptoms ( . receiving anticoagulants, having osteoporosis, having a movement disorder that results in thrashing movement, etc.). Any descriptions in the medical record shall be objective and sufficiently detailed (e.g., dimensions and lo cation of bruises), and should not speculate about causes. 5. The nursing staff shall discuss the situation with the attending physician or medical director to consider whether medical conditions or other risk factors could account for the findings. The medical director or attending physician shall review and verify conclusions about the possibility of a medical or other similar cause of the findings . Review of facility policy, titled Recognizing Signs and Symptoms of Abuse/Neglect, revised [DATE], revealed: .2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, menial anguish, or mental illness. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with actual harm that is not [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent physical restraints of residents for 1 (Resident #1) of 31 residents reviewed for physical restraints. The facility failed to inform Resident #1 or their representative of the risks associated with use of assist bars, care plan for risks associated with assist bars, obtain consent for the use of assist bars, and obtain physician orders for use of assist bars, and implement interventions following identified entrapment incident from assist bars. Resident #1 was found by LVN A on the floor in his room with his left arm caught between the assist bar and air mattress on [DATE] and had no interventions to address risk of entrapment following incident. Resident #1 was found by CNA A in his room with his left arm, head and neck between the assist bar and air mattress and his legs on the floor mat on [DATE] and CPR was initiated. Resident #1 expired at the hospital on [DATE] following intubation and responsible party withdraw of care. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for entrapment with serious injury or death. Findings included: 1. Record review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included repeated falls, epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), congenital stenosis (abnormal spinal narrowing present at birth) and obstruction of esophagus, age related physical debility, spastic hemiplegia (muscles on one side of the body being in a constant state of contraction) affecting left nondominant side, dizziness and giddiness, and general muscle wasting and atrophy. Record review of Physician Orders dated [DATE], reflected Resident #1 had no orders for assist bars. Record review of Resident #1 ' s Progress Notes, between [DATE] through [DATE], reflected Resident #1 had a fall on [DATE] in his room and was found by LVN B with his left arm between the assist bar and bed. There were no bed safety assessments for use of assist bars on or after [DATE]. The resident had an additional fall in his room on [DATE] and was found unresponsive by CNA A and appeared grey in color with his left arm, head and neck between the assist bar and air mattress with his legs on the floor mat and CPR was immediately initiated by RN R at 6:50 p.m. EMS was called and arrived at 6:58 p.m. and Resident #1 was transferred to the hospital. Record review of Resident #1 ' s care plan, revised [DATE], reflected the resident had a history of falls and seizures with interventions to include: review information on past falls, attempt to determine cause of falls, record possible root causes, alter/remove any potential causes, if possible, educate resident/family/caregivers/IDT about causes, safety reminders and what to do if fall occurs, attempt to find the resident triggers for falls, attempting to self-toilet (initiate trial toileting program); confusion in the evening (encourage distraction activities in the evening); the resident needs a safe environment with even floors free from spills and/or clutter, and the bed in low position at night. The care plan did not address assist bars or risks associated with use of assist bars. Record review of Resident #1's most recent significant change in status MDS, dated [DATE], reflected he had a Brief Interview for Mental Status score of 03, which indicated severe cognitive impairment. Resident #1's functional status reflected he was non-ambulatory and required a two person assist for bed mobility. Record review of Resident #1's assessments between [DATE] and [DATE], reflected there were no bed safety assessments completed. Record review of incident report log between [DATE] through [DATE] reflected Resident #1 had a history of falls on [DATE] at 11:13 p.m., three falls on [DATE] at 1:00 p.m., 1:30 p.m., and 1:45 p.m., one fall on [DATE] at 10:45 p.m., one fall on [DATE] at 2:00 p.m., one fall on [DATE] at 1:45 a.m., two falls on [DATE] at 2:25 a.m. and 7:45 p.m., one fall on [DATE] at 12:45 a.m., two falls on [DATE] at 10:42 a.m. and 7:00 p.m. and [DATE] at 5:52 p.m. Record review of incident report written by LVN A, dated [DATE] at 2:00 p.m., reflected Resident #1 was found sitting on the floor with back up against the bed with his left arm between the mattress and railing. Bed was in lowest position. Resident was able to move his arm from between the bed and railing with assistance Resident #1 had a small abrasion to his left elbow and front right knee, resident was assisted to bed with gait belt, and resident was unable to give a description. Record review of incident report written by RN R, dated [DATE], reflected Resident #1 was found at approximately 6:50 p.m. by CNA A and noted to be .sitting on buttocks on floor with left arm around right-side bed rail and left side of neck/head lodged between mattress and side rail. Resident was grey in color, warm to touch and faint right-side jugular pul[s]e noted. [CNA A] notified this RN (RN R) that was across the hall at medication cart on resident's hall. I (RN R) entered room and [CNA A] and I placed resident on the floor and began CPR. [LVN T] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles while [CNA A] assisted with the [bag valve mask] and we swapped out after 5 cycles. [CNA B] joined in rotation. [AED] applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived Resident O2 sats [were] 95% on O2 2L [nasal canula]. Contacted emergency contact [RP W], [MD], and [DON] in report incident. Record review of, undated, witness statement by CNA A reflected he was taking residents out for their evening smoke break when a resident notified him that Resident #1 was on the floor. He immediately went to the room and saw Resident #1's head almost stuck in the side rail and he looked pale. CNA A reported he notified RN R that Resident #1 looked pale and was nonresponsive and RN R stayed in the room while he ran to get the crash cart. RN R and CNA A proceeded to do chest compressions until the paramedics arrived. Record review of, undated, witness statement, did not document a name and date, reflected at approximately 6:50 p.m., CNA A noted resident sitting on buttocks on the floor with left arm around right-side rail and left side of head/neck lodged between mattress and side rail, resident was grey in color, warm to touch, and faint jugular pulse noted to right side. CNA A notified RN R that was at medication cart across from residents' room. The witness statement reflected: I (RN R) entered room and [CNA A] and I (RN R) placed resident on floor and began CPR. [LVN B] called 911 and printed paperwork for EMS. I began chest compressions for 5 cycles and [CNA A] used [bag valve mask] and we swapped after 5 cycles CNA B joined in the rotation 3 cycles in CPR performed 10 min. [AED] was applied after 1 cycle of CPR. Directions followed and no shock advised. When paramedics arrived resident O2 sat (oxygen saturation) was 95% on O2 2L (Liters) NC (Nasal Cannula). [RP W] contacted notified at [phone number] at 8:58 p.m. by RN A. She stated he is not DNR and is in the process of being placed on Hospice. Record review of Resident #1's hospital records, dated [DATE], reflected he presented to the ER post cardiac arrest, and he was found after he slid out of his bed with his head in the bed rail. When nursing found the resident, he did not have a pulse, CPR was initiated, upon EMS arrival patient had a pulse, and intubation was attempted but unable to place in a definitive airway. A transfer to other acute facility was ordered for a higher level of care due to acute exacerbation (worsening of airway function). Record review of the Provider Investigation Report, dated [DATE], reflected the following: .At approximately 1850 [6:50 p.m.] [CNA A] noted resident sitting on buttocks on floor with left arm around right side bed rail and left side of neck/head between mattress and side rail with chin resting on side rail. and Resident was noted to be sitting on buttocks on floor with left arm around right side of bed rail and left side rail and left side of neck/head lodged between mattress and side rail .resident was grey in color, warm to touch and faint right side jugular pulse noted . Provider Response [RN A] with the assistance of [CNA A] placed resident on the floor and began CPR while the other duty called 911 and prepared papers for transfer. RN began chest compressions for 5 cycles while CNA assisted with the [bag valve mask] bag and they swapped out after 5 cycles. [CNA B] assisted in the rotation. AED applied after first cycle fo CPR with no shock advised. When EMS on scene resident had O2 saturation of 95% on NC (nasal cannula) [at] 2/L O2 and a heartbeat was present. Resident placed on stretcher and transported out of facility. Resident emergency contact and attending physician notified of incident and transport by EMS. Investigation Summary Staff present/assisting with the emergency were interviewed. Statements have been and are being obtained. Staff member who was first on scene (CNA A) demonstrated exactly what he saw when entering resident room. The demonstration reveals the left arm between assist rail and mattress with head resting upon left shoulder and chin resident on the side rail, the neck free from pressure/compression. Upon interview [CNA A] indicated that when he entered the resident room the resident's neck/airway was not compromised and his chin was resting on the side rail .his shoulder blades and head were pressed in the area, but his neck was totally free. [CNA A] stated they did lower the rail or deflate the mattress but rather lifted the resident carefully up and over, then onto the ground. [CNA A] stated, 'his neck was free .his oxygen tubing was not on his face but on the ground.' [Resident #1's] bed, mattress, and assist rails were evaluated by maintenance to ensure no malfunction and proper fit to meet FDA standards, all equipment was in good working order and the distance measured between the air mattress and the assist rail was 2.5 inches. All statements were reviewed/analyzed as well as the re-enactment demonstration and it is not confirmed that the resident suffered strangulation in the assist rail as there was no pressure noted to be on the resident's airway. It is not confirmed that neglect occurred as the resident had no more than an hour before the last interaction with staff and this incident. Resident has a history of self-transfer attempts and all measures to prevent injury were in place (bed in lowest position, fall mats at bedside, door left open, and call light within reach.) Record review of witness statement by CNA B, dated [DATE] at 1:03 p.m., reflected the following: During my first rounds after clocking in I saw [Resident #1] in his bed awake, head of bed elevated, feet down. [Resident #1's] feet were hanging off the end of the bed, the sheets were on the floor. Resident repositioned in bed, new bedding on resident. Head elevated and feet elevated. Call light in reach. I continued on my rounds making my way down the halls. I was on the therapy hall when I hea[r]d [RN A] yell out HELP! Call 911 and got the crash cart. She and [CNA A] were looking for the [bag valve mask] bag, gave it to [RN A] and [CNA A] and I were rotating compressions. Doing roughly ,d+[DATE] each then switching. CPR for approximately ,d+[DATE] minutes before EMS arrived. They took over compressions, changed out the AED and got vital[s]. He was breathing when EMS arrived. During an interview on [DATE] at 9:28 a.m., the Administrator and the DON said Maintenance was responsible for the bed and assist bar installation and maintenance. The Administrator said he was not sure who last saw Resident #1 but it had been within the hour and the resident was initially at the hospital for altered mental status and failure to thrive before he returned from the hospital a couple hours prior to incident. The Administrator said Resident #1 returned on [DATE] at 4:00 p.m. and the incident occurred at 6:50 p.m. The Administrator and the DON said CNA A found him with his left arm, head and neck between the assist bar and air mattress with his legs on the floor. The Administrator and the DON said RN A assessed the resident and immediately began CPR, AED device was obtained, and resident was a full code when he returned from the hospital even though his RP had requested a DNR at the hospital, there was not a DNR in place prior to return. The Administrator and DON said EMS arrived and he was transported to the hospital and was anticipated to return on hospice. The Administrator and DON said the roommate was in the room but was unable to communicate and was not interviewable and RP W and attending physician were notified of the incident. During an observation on [DATE] at 10:00 a.m., Resident #31, roommate of Resident #1, was lying in bed free from apparent injury and appeared confused. Resident #31 did not respond to questions and the room appeared free from hazards and no assist bars were installed to beds in the room. During an interview on [DATE] at 11:36 AM, Maintenance said she had been employed at the facility for 3 years and was responsible for installation and maintenance of assist bars on beds. Maintenance said she did not know what happened to Resident #1 but was asked to measure the distance between the mattress to the grab bar. Maintenance said she took both bed rails and put them on the bed to see how far the mattress was able to move and measured the spacing to be 2 and a half inches. She was not aware of a facility policy for gap requirements between assist bars and beds and did not know where to find the information if needed but was asked to measure by the DON and corporate office. Maintenance said all beds and assist bars were the same except for geriatric beds. Maintenance said she had never measured the distance between the air mattress and bed before and [DATE] was the first time she had measured it because she was not aware of the space requirements. Maintenance said she never noticed any gaps between the mattress and assist bar and did not recall specifically looking for that and no similar incidents of entrapment had happened that she was aware of. Maintenance said if there was a staff member requesting an assist bar, they grabbed them off the bed and there was a key that went to it and that was how it was assembled to the bed. Maintenance said maintenance requests were placed in the maintenance book at the nursing station and computer system. All staff looked at the beds every day and did not have a routine safety check scheduled and there were no issues with assist bars and the air mattress was sufficient size for Resident #1. Maintenance said she was not aware of the potential risks assist bars posed to residents. There was usually a physician's order to install assist bars and she was notified by the nurse and assist bars were in good condition and secure. Maintenance said it was important for assist bars to be installed appropriately because residents could have a fall and not be able to get up by themselves and couple pose a risk of entrapment. Maintenance said all residents were physically able to use assist bars. During an interview and record review on [DATE] at 12:15 p.m., Maintenance provided an assist bar and observed attached warning label which indicated risk of entrapment to include. WARNING/SAFETY ALERT .Powered air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. Maintenance said there were residents with air mattresses and assist bars still at the facility and that the provided assist bar and manual, titled [Company L] Instructions For Use Service Manual, was used on all beds. Record review of Company L manual for the bed reflected optional assist bar installation instructions, on pg.17, indicating Power air mattress surfaces may pose a risk of entrapment. Prior to use, ensure the therapeutic benefits outweigh the risk of entrapment. During an interview via phone on [DATE] at 2:00 p.m., RN R said she had been employed at the facility for a month and worked on Resident #1's hall. RN R said she was provided training on neglect via in-services but had not received training on assist bars following incident since she had not returned to work following the incident on [DATE] with Resident #1. RN R said Resident #1 was discharged from the hospital on [DATE] and she tried to obtain orders for feeding since the hospital did not send any orders with him and she knew previously that he was a tube feeder. RN R said Resident #1 fell constantly and he was being monitored constantly by staff and had him up at the nurses station the majority of time at night. RN R said she obtained feeding orders and put everything on the medication cart to go down the hall and administered a pain pill to his neighbor when she walked past his room and he was laying in his room at baseline. RN R said she entered the neighbors room and administered medication then crossed the hall to administer medication to another resident when CNA A notified her she needed to come to Resident #1's room. RN R said when she walked in Resident 31's room he was on the right side of the bed and his left arm was wedged on the other side between the mattress and the arm rail and his head was lodged there on his left side. RN R said he was sitting on his buttocks with his legs out straight, arm in the rail and the corner of his head an inch in on the throat area with his head turned to the right. RN R said she removed the resident from the rail and administered 2 cycles fo CPR when his color started to come back. RN A said the other nurse on duty called 911 and paramedics arrived 8 minutes later. RN R said the defibrillator was placed on the resident and CPR continued. RN R said his oxygen saturations were at 95% and he came with oxygen from the hospital but when he left the facility to be transferred to the ER he was breathing on his own. RN R said the ambulance remained outside for 30 to 45 minutes before leaving and she assumed they were placing an IV line. RN R said she called the hospital and was informed he was intubated. RN A said she last saw the resident at 6:45 p.m. on [DATE] when she told him she would be back to feed him. RN R said she notified the attending physician and representative of incident. RN R said Resident #1 had a history of rolling out of the bed while he was asleep, and she had not noticed any gaps between the assist bar and air mattress prior to this incident and she did not pay much attention to gap space requirements. RN R said it was important risks of assist bars were reviewed with residents to obtain consent and inform about the risks of entrapment if installed on air mattress beds. RN R said she had not returned to work since the incident and was supposed to have a meeting today about everything and she believed it was rescheduled for next week. RN R said she was not sure what space was allowed between the assist bar and air mattress, but she thought there should be no space in that zone. RN R said Maintenance was responsible for installing bed rails and all staff were responsible for checking bed safety on a routine basis, but RN R was not sure who did the assessment for assist bars and if she was responsible for completing and would have to consult with the DON. RN A said the IDT team was usually responsible for reviewing and obtaining orders for assist bars upon admission RN R said Resident #1 was able to physically use the assist bars for bed mobility. During an interview on [DATE] at 3:58 p.m., the Administrator said a QAPI meeting was not conducted following the reported incident with Resident #1 and the meeting would be around the middle of [DATE]. During an interview via phone on [DATE] at 5:17 p.m., CNA A said on [DATE] he found Resident #1 with his left arm, head and neck between the assist bar and mattress and the gap between the assist bar and bed appeared to be approximately 2 to 3 centimeters wide. CNA A said he last saw Resident #1 about 10 minutes prior to incident when he went in the room to remove his food tray and reported Resident #1 was at baseline. CNA A said he never saw him get stuck like that before in the assist bar. CNA A said he worked at the facility since the incident and had not received training on bed safety, and he felt training would be helpful. CNA A said he believed the gap amount allowed between the mattress and assist bar was 2 inches or 2 and half inches. CNA A said assist bars posed a risk of entrapment to all residents who were bed bound and on-air mattresses such as Resident #3 and it would be important for residents or representatives to know the risk of assist bars to include potential entrapment so they would have the knowledge needed to make the appropriate decision for use. CNA A said the nurses were responsible for ensuring bed safety but all staff could look at the beds and notify the nurse with any concerns. CNA A said he felt residents used the assist bars appropriately and only had a concern for resident with air mattresses and assist bars installed to bed that were not cognitively intact. CNA A said he did not know if residents were being notified of the potential risks with using assist bars and it would be the nurse's responsibility or the IDT team to do so upon admission. CNA A said he was not sure when the resident had his assist bars installed but CNA A had been at the facility for 2 years and believed the resident had always had them on his bed. During an interview via phone on [DATE] at 11:09 a.m., RP W said she was going to call the HHSC hotline number this afternoon with concerns related to Resident #1's DNR status she requested at the hospital but was not completed and thought the nurses notification of the resident receiving CPR was not appropriate. RP W said she was the medical and financial power of attorney for Resident #1 and on [DATE] she was notified by the nurse via phone that the resident was returned to the facility without a DNR being in place and the nurse did CPR on Resident #1, called 911, and the ambulance went to pick him up. RP W said the nurse told her the resident was really gray and was probably still deceased after RP W said the DNR process was initiated at the hospital. RP W said it upset her the nurse said it was okay CPR was initiated because he was probably still deceased . RP W said they intubated him at the hospital, removed it the next day and RP W said she had to watch him expire. RP W said Resident #1 expired on [DATE] at 7:14 p.m. after the hospital withdrew care around 1:30 p.m. RP W said the nurse called her on [DATE] at 8:58 p.m. and notified her Resident #1 was laying over the bed, his foot was hanging off the bed and was unresponsive. RP W said there was no mention of assist bars and had never been notified of the potential risks with using assist bars and had not been asked for consent for bed rails. RP W said she last visited Resident #1 a couple of months ago and was aware he had assist bars on his bed. During an interview via phone on [DATE] at 11:27 a.m., the hospital physician said Resident #1 was in the hospital in the beginning of October and was discharged on [DATE] to facility and returned to the hospital on a ventilator. RP W requested to withdraw care and he expired and felt it was a shame he did not pass peacefully and had to get intubated. During an interview on [DATE] at 11:47 a.m., the DON said she did not know when assist bars were installed on Resident #1's bed but Resident #1 had the assist bars since she has been employed at the facility in [DATE]. During an interview and record review on [DATE] at 10:50 a.m., the Administrator said there was a form to check for bed safety under maintenance electronic records and it showed checklists were overdue sometimes when it was completed early. The Administrator said he was able to log in and access the maintenance electronic records system at any time and Maintenance notified him if there were any Maintenance concerns. Review of maintenance electronic record logs, dated [DATE], reflected bed safety checks were overdue by one month for all residents. During an interview on [DATE] at 11:51 a.m., the DON said the facility did not obtain consent for bed rails to complete bed safety risk assessments for all residents with assist rails prior to Resident #1's incident on [DATE] because they were not aware they assist bars were considered to be bed rails and he was not assessed for risk of entrapment prior to bed rail install. The DON said there is a list with residents that use assist bars for nursing staff to refer to and she confirmed with corporate that assist bars were not treated as bed rails prior to Reisdent #1's incident. The DON said nursing staff would now be assessing and obtaining consent for use of assist bars since it was important for residents and representatives to be aware of associated risks such as entrapment. The DON said following Resident #1's self-reported incident on [DATE], interventions would be put in place for assist bars that include bed assessments and addressing assist bars in care plans. She said the IDT team is responsible for ensuring the resident have orders for assist rails. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern with actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. Review of facility policy, titled Bed Safety, revised [DATE], revealed the following: Policy Statement Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the timeframe, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: . 9. When using assist rails for any reason, the staff shall take measures to reduce related risks. 10. Assist rails shall not be used as protective restraints. This facility is a restraint free environment, 11. The staff shall report to the director of nursing and the administrator any deaths, serious illness and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. Review of facility policy, titled Abuse Prevention Program, revised [DATE], revealed the following: Policy Statement Our residents have the right to be free from abuse, neglect . This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences . Review of facility policy, titled Abuse Investigation and Reporting, revised [DATE], revealed: Policy Interpretation and Implementation Role of the Administrator . 5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. Review of facility policy, titled Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures, revised [DATE], revealed: Policy Statement The Administrator is responsible for the overall coordination and implementation of our facility's abuse prevention program policies and procedures. Policy Interpretation and Implementation 1. The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures. 2. The Administrator has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the facility. These may include: a. The Director of Nursing Services; b. The Director of Social Services; c. The Director of Staff Development; d. Tho Director of Risk Management; e. The Assistant Administrator; f. The Medical Director; g. The Quality Assessment and Assurance Committee and h. Other staff members as determined by the Administrator. Review of facility policy, titled Investigating Injuries, revised [DATE], revealed: Policy Statement The administrator will ensure that all injuries are investigated. Policy Interpretation and Implementation 1. The director of nursing services or a designee will assess all injuries and document clinical findings in the clinical record. 2. If an incident/accident is suspected, a nurse or nurse supervisor will complete a facility-approved accident/incident form. The form will be disseminated to the appropriate individuals, for example the administrator and director of nursing services. 3. Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (1) the extent of the injury; or (2) the location of the injury ( .the injury is located in an area not generally vulnerable to trauma); or (3) the number of injuries observed at one particular point in time; or (4) the incidence of injuries over time. 4. Documentation shall include information relevant to risk factors and conditions that could cause or predispose someone to similar signs and symptoms ( . receiving anticoagulants, having osteoporosis, having a movement disorder that results in thrashing movement, etc.). Any descriptions in the medical record shall be objective and sufficiently detailed (e.g., dimensions and lo cation of bruises), and should not speculate about causes. 5. The nursing staff shall discuss the situation with the attending physician or medical director to consider whether medical conditions or other risk factors could account for the findings. The medical director or attending physician shall review and verify conclusions about the possibility of a medical or other similar cause of the findings . Review of facility policy, titled Recognizing Signs and Symptoms of Abuse/Neglect, revised [DATE], revealed:<br [TRUNCATED]

Based on interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 resident reviewed for accidents. (Resident #1 and Resident #2) The facility did not provide adequate supervision while traveling in facility van which resulted in Resident #1's fractured tibia and fibula to right leg. This failure could place residents who travel in the facility van at risk for accidents and injury. Findings included: 1) Record review of physician order dated July 2022 indicated Resident #1 was a [AGE] year-old female who originally admitted on [DATE] and readmitted on [DATE] and most recently on 4/25/22 with diagnoses including [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)] of liver. Resident #1 does not require special supervision, is interviewable without communication deficits, with the capacity to make informed decisions and has a BIMS score of 15 (MI)S dated 5-2-2022). This resident safely operates an electric wheelchair without assistance and requires total assistance of two staff members and a mechanical lift to transfer to/from the electric wheelchair. Record Review of local hospital discharge instructions dated 6/14/22 for Resident #1 indicated she had a mildly displaced right tibial plateau fracture and a mild displace proximal right fibula fracture. Resident #1 will need to follow up with an orthopedic within the next 1 to 2 days. Record review of provider investigation report dated 6/20/22 indicated the incident occurred on 6/14/22. Description of Allegation: On 6/14/22 at approximately 1:30pm Resident #1 was being transported to physician's appointment by Staff A. Resident #1 claimed that the driver of the transportation van, Staff A slammed on her breaks and caused Resident #1 to fall from electric wheelchair and was hurt. Investigative Review and Findings: The facility Administrator was contacted by Staff A stating I had to call 911 to have Resident #1 transferred to the hospital because she aggressively hit the brakes to keep from hitting the guy in front of them that was turning in the left-hand land that did not use his turn signal, and Resident #1 slid out of her chair on to the feet of her wheelchair and was complaining of pain. Upon further investigation it was determined there was another resident (Resident #2) and one other staff member (Staff B )present at the time of the alleged incident. All parties were interviewed as part of the investigation and root cause analysis. Resident #1 returned from hospital same day with discharge instructions that indicated she sustained a mildly displaced right tibial plateau fracture and a mild displaced proximal right fibula fracture and was to see and orthopedic surgeon in 1 to 2 days. Staff B was a passenger in the transport van for the purpose of assisting with resident at their appointments. Staff B confirmed in a statement provided to the facility that Staff A hit her brakes suddenly to avoid hitting the care in front of them. Resident #2 the other resident passenger in the facility transport van at the time of the incident, did not provide details of the incident other than I do not want to ride with that van driver ever again. The Findings of the facility investigation: Inconclusive as the seatbelt was not found to be compromised and the resident could not confirm the condition of the seatbelt (latched or unlatched) at the time of the incident. During an interview on 7/16/22 at 3:22 p.m., Resident #1 said last month she was involved in a wreck on her way to an appointment. She said Staff A was driving the facility's van and she sat directly behind the driver seat. Resident #1 said she recalled seeing the vehicle in front of them with their signal lights on, long enough for Staff A to either slow down, or change lanes. Then, short time later the same vehicle was on their breaks because the vehicle break lights were on and at that time, she did not feel the facility's van slow down and then suddenly Staff A hit the brakes on the facility's van hard to keep from hitting the vehicle in front of them. Resident #1 said her upper body physically slammed into back of the driver's seat, her bottom landed on the foot pedals of her electric wheelchair, her left leg was bent backwards, and her right leg was wedged in between the driver's seat and the front passenger seat. She said at that time her right leg was in pain from Staff A slamming on the breaks. Resident #1 said she felt Staff A was at fault because she was speeding and appeared to have been distracted by something because the vehicle in front of them provided enough notification and time for them to slow down or change lanes. Resident #1 said her electric wheelchair was properly secured and did not move, but somehow whenever Staff A slammed on the breaks, she slid out of her wheelchair causing her to slam into back of the driver seat. She said she had never ridden with Staff A prior to the wreck. Resident #1 said she was sent to hospital via ambulance from the scene of the incident. She said she was the only person in the van who was injured . Resident #1 said the ER told her she fractured her right leg as a result of the incident, but because she was already in a wheelchair, not weight bearing then a brace was not needed, but advised to stay off her right leg and to follow up with an orthopedic to look at her leg. She said days following the incident her leg would be in pain, but now she was doing better and not having as much pain. Resident #1 said she could not sit up in her electric wheelchair for longer than 5 hours or her right leg will start getting stiff and uncomfortable and she would have to lay down in bed to rest her right leg. Resident #1 said she did not have that issue prior to the accident . She said, the seat belt failed me causing me to slip out of my wheelchair causing me to fall onto the feet of my wheelchair causing injury. 2) Record review of physician order dated July 2022 indicated Resident #2 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with diagnoses including Dementia, [CONDITION(S)], [CONDITION(S)], and seizures. Record Review of MDS assessment, dated 6/15/22, indicates Resident #2 is cognitively intact with a BIMS score of 13. During an interview was attempted on 7/18/22 at 2:59p.m., with Resident #2 regarding the van accident, he was not interviewable and was not able to answer questions asked at that time . During a telephone interview on 7/18/22 at 8:46a.m., Staff A, was unreachable, a voice message was left; however, there was no return call received. During a telephone interview on 7/18/22 at 8:47a.m., Staff B, was unreachable, a voice message was left; however, there was no return call received. Record Review of employee complaint form dated 6/14/22 completed by Staff B stated coming into the facility the driver was going at least 65-75 MPH in a 55-speed limit and kept looking at her phone for calls, not paying attention and ran a motorcyclist off the road and said, oh wow I didn't see him. Record Review of Staff A's Employee Corrective Disciplinary Form dated 6/17/22 indicated Staff A hire date was on 4/22/22 and stated Specific reason for disciplinary action: Staff A was driving Resident #1 and Resident #2 to an appointment on 6/14/22 and it was reported to the Administrator by Staff A that she had to call EMS to have Resident #1 sent to the hospital. Staff A told Administrator that she aggressively hit her brakes and caused Resident #1 to fall out of her wheelchair. On the same day, Staff B said upon entering the facility on 6/14/22 Staff A was driving in excess of 65-75 MPH and kept looking at her phone not paying attention to the road and ran a motorcyclist off the road and said, oh wow I didn't see him. Corrective plan of action: Due to the nature and severity of the incident the facility had to terminate Staff A. During an interview on 7/18/22 at 3:55p.m., The Administrator said she terminated Staff A because she was a reckless driver for the entire day per witnesses. She said Upon completion of the investigation, Staff A employment was terminated. All other authorized drivers of the facility transport van were provided with an in-service regarding responsible driving, van security, van operations, and securing residents for transport. The facility policy regarding tracking and safe driver checks has been updated to include the installation of an application to each driver's mobile phone that is required to be engaged time tile van is in operation (with or without passenger' s present). Prior to becoming an authorized driver of the facility transportation van, all candidates must complete a full training with a skills checklist to ensure all facets of van operation/resident safety and security are fully comprehended, in addition to, a drive along road test with another authorized driver. Prior to transporting a resident, the driver will be required to complete the safety check log which includes the date/time of each trip, name of each resident transported, why they are transported, the seating for the resident during transport (wheelchair or vehicle seat), any passengers other than residents, and acknowledge that they have conducted a pre-trip inspection. Record review of the facility's undated Motor vehicle operation and driver selection criteria policy stated Facility has adopted this policy to enhance the safety of those individuals who operate motor vehicles on company business vehicle accidents can be costly to their company. More importantly, an accident may result in injury to you or injury to others can cause to damage to company property, your property or the property of others. If your job requires you to operate a vehicle for company business and you become authorized to operate a motor vehicle under the following criteria, we expect you to operate a motor vehicle in a safe, courteous and responsible manner.Operation any personal electronic device including a cellular phone while operating any company-owned or company-leased vehicle or while operating any vehicle on company business is strictly prohibited and may result in disciplinary action, including dismissal.

Based on interview, and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care, and subject to related physician orders and the resident's advance directives for one (Resident #1) of eight residents reviewed for CPR. The facility failed to ensure CPR was provided to Resident #1 who was a full code. On [DATE] CPR was not initiated by facility staff after Resident #1 was found not breathing, without a pulse, and unresponsive. EMS was not notified by the facility. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] at 4:45 a.m. to [DATE] at 2:00 p.m. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. These failures could place residents at risk of not receiving appropriate professional care and services. Findings included: Record review of the Resident Admission Record dated [DATE] indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with a recent readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's face sheet dated [DATE] indicated a directive in place for full code (in the event of [CONDITION(S)], CPR will be initiated). Record review of Resident #1's physician orders, dated February 2022, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's advance directive in her electronic health record indicated a selection for Full Code. Record review of Resident #1's care plan dated [DATE] indicated Resident #1 had exercised her right to maintain a full code status with all heroic measures to be performed in the event of an emergency. Interventions included: Honor the Resident wishes and inform staff of FULL CODE status. Record review of paper chart revealed Resident #1's Code Status was a Full Code. Record review of Resident #1's MDS, dated [DATE] revealed no indication for DNR advance directive. Record review of Resident #1's nursing note completed by LVN A, dated [DATE] at 5:37 a.m., indicated LVN A was called to Residents room at 4:50 a.m. Resident wasn't breathing when she entered the room. Upon assessment, no pulse or signs of life were found. No documentation the resident's body was stiff or had any rigor mortis. No documentation the resident's skin was cyanotic around lips or pale in color. Notified DON, JP (Justice of the Peace), and attempted to reach family member D, but didn't get an answer. Was able to reach family member E who said she would wake family member D up and give him the news. CNA provided postmortem care. JP arrive shortly after to pronounce and gave instructions to call Funeral Home. During an interview on [DATE] at 9:13 a.m., the DON said on [DATE] at 5:00 a.m., he received a call from LVN A, telling him that Resident #1 had passed, and wanted to know who she needed to call. She was told to call the MD, the family, and the JP. The DON got to work around 8:30 a.m. and was looking at the Resident's' chart and discovered she was a full code. LVN A told the DON she had gone back to the nurses' station after assessing the resident and saw that she was a full code. She was asked why she did not call 911 or start CPR and LVN A said, she was gone-no sign of life, eyes fixed, mouth open, no pulse, limbs were flaccid, and no sign of life. LVN A said the Resident did not have any change of condition prior to this. LVN B told the DON he checked pulses, and Resident's head and arms were cold. CNA C said she was making rounds around approximately 4:30 a.m. and noticed the Resident #1 was not breathing. She shook her with no response and then called for help. Both LVN A and LVN B came and checked her. CNA C said she had seen the Resident around ,d+[DATE]:30 a.m. when she assisted her to the bathroom. CNA C said the Resident did not need anything or have any issues. DON said BSL protocol should have been initiated, and CPR should have been done. The DON said DNR status is in PCC, (Point Click Care-electronic medical record software), it is on the shift report, and there is a red or green sheet of paper on every chart. Green=full code, Red=Do not resuscitate. The DON said his expectation was for staff to know Residents DNR status, as it is very accessible. It was critically important; they must know. It needs to be verbally discussed at each shift change. The DON said the LVNs will be terminated and report to the BON. During an interview on [DATE] at 9:52 a.m. the Administrator said she was notified of Resident #1's death by text message from the DON. Administrator said CPR should have been initiated until EMS arrived. She stated both LVN A and LVN B would be terminated and reported to the BON. Administrator said anyone who was a nurse or clinician should know the Residents code status ASAP, it should be included on the daily shift reporting by the nurses. Said it was very important for staff to know Resident code status as it was a life saving measure, they need to know to call 911 and initiate CPR to prevent loss of life. During a telephone interview on [DATE] at 10:22 a.m. LVN A said CNA C yelled out that Resident #1 wasn't breathing. LVN A and LVN B went to the room. Resident #1's color was yellow, mouth was drooping, and no movement. Said she checked the carotid pulse, (pulse felt over the carotid artery in the neck), and radial pulse, (pulse of the radial artery felt in the wrist), put her hand on Resident #1's stomach to check for breathing, and her eyes were set. She said she went to the desk to check the Resident's code status. LVN A saw she was a full code and asked LVN B what to do in this instance. He told her to call the DON. The DON told her to call the Doctor, the family, and the JP (Justice of the Peace). At approximately 5:10 a.m. LVN A called the NP Nurse Practitioner), and the NP said she was surprised. NP told LVN A to call the family. LVN A said CPR was not initiated as it was very obvious that she had passed at that point. She said if the Resident had showed any sign of life, she would have started CPR for sure. During a telephone interview on [DATE] 11:50 a.m. the NP said she had been notified of Resident #1's death, and that Resident was fine the day before. Resident #1 was recently diagnosed with Covid but was not ill. Resident #1 was a diabetic and had multiple medical comorbidities, (the presence of one or more conditions). Resident #1 was also not vaccinated. The NP said she did not know that CPR was not initiated, she figured that when staff called and told her the JP was coming that CPR was done. The NP said they should have done CPR. Even if she was gone, the nurse does not have the right to make that decision. You still start CPR and call 911. The NP said everyone one needs to do that. The NP said she had told the Medical Director about the death and would notify him of no CPR being done as well. She said she did not know if CPR would have changed the outcome, but it would have been nice to know that it was done. They need to know that every minute, every second counts. During a phone interview on [DATE] 12:44 p.m., LVN B said he was passing meds the night Resident #1 passed away. CNA C called for help, and he went to the resident's room. Resident was not responsive, not breathing. Resident #1's oxygen tubing was not in her nose, and he was unable to get any vital signs. There was nothing showing life. LVN A asked him what to do, and he told her to call the DON. LVN B said CPR should have been done. The Administrator and DON were notified of the Immediate Jeopardy (IJ) past-noncompliance on [DATE] at 3:45 p.m. IJ pas non-compliance was verified by staff interviews related to CPR, CPR initiation, honoring code status, following physician orders, and what to do when finding an unresponsive resident. Observations of residents were conducted, review of in-services related to CPR, advance directives, crash cart and AED (automated external defibrillator) inspection was completed. Review of Provider Investigation Report, revealed: An emergency response team leader was identified for each shift and noted on the nursing assignment sheet Mock code skills checks being implemented, nurse skills proficiencies are being updated and implemented Inservice for 911 activation implemented Inservice on staff expectations/roles during a code/emergency situation Inservice regarding the review of the facility policy regarding full code status, do not resuscitate (what do they mean where you can find them, who do you report this information to) and random interviews with staff will be used to monitor for effectiveness of in-service education. Review of Inservice Training Record titled Resident Emergency Guidelines for Residents with Full Code Status dated [DATE] indicated staff was educated on the following: 1. Upon discovering a residents need for emergency assistance: -The employee discovering the emergency will call for emergency assistance by LOUDLY announcing EMERGENCY ASSISTANCE (LOCATION). -Staff hearing the emergency call will immediately respond to the announced location. -The first nurse on scene should immediately assume control of the emergency. -The nurse will immediately assess the residents need for emergency assistance. -Upon verification of residents' code status FULL CODE, BSL Protocols will be followed as warranted by the clinical assessment. -The nurse will immediately direct the activation of the local 911 Emergency Services. -The nurse will direct residents' care adhering to BLS protocol and facility's capabilities. 2. A DNR audit review was started on all residents. 3. During facility investigation, DON identified issues with record keeping of CPR certification and facility is working to make changes. Review of Inservice Training Record titled Resident Code Status dated [DATE] indicated staff was educated on the following: - Upon admission, resident code status will be verified and appropriate orders place. -The resident code status will be prominently displayed in the residents' hard chart. -Red full-size paper .DNR -Green full-size paper .Full Code -Resident code status will be annotated on the 24-hour shift report. -Resident code status will be discussed at every change of shift. -The DON/ADON/DESIGNEE will be promptly notified of ALL CPR events. Review of facility policy, titled Emergency Procedure - Cardiopulmonary resuscitation, revised ,d+[DATE], revealed the following: Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden [CONDITION(S)]. General Guidelines 1. Sudden [CONDITION(S)] is a loss of heart function due to abnormal heart rhythms (arrhythmias). [CONDITION(S)] occurs soon after symptoms appear. It is a leading cause of death among adults. 2. A heart attack refers to impaired blood flow to the heart which leads to damage of the heart muscle. A heart attack can cause sudden [CONDITION(S)]. Typically, heart attacks are less sudden than SCA. 3. Victims of [CONDITION(S)] may initially have gasping respirations or may appear to be having a [CONDITION(S)]. Training in BLS includes recognizing presentations of SCA 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) 7. If the resident's DNR status in unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. 8. If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. Preparation for Cardiopulmonary Resuscitation 1. Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitation efforts, including non-licensed personnel. 2. The facility's procedure for administering CPR shall incorporate the steps covered in 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 3. The facility shall have a CPR Team for each shift in the case of an actual [CONDITION(S)]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. 4. The CPR Team in this facility shall include all nurses on duty who have received training and certification in CPR/BLS. 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. Emergency Procedure - Cardiopulmonary Resuscitation 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. 2. Initial BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: a. Following initial assessment, begin CPR with chest compressions b. Push hard to a depth of at least 2 inches (5cm) at a rate of at least 100 compressions per minute. c. Allow full chest recoil after each compression; and d. Minimize interruptions in chest compressions 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide2 breaths via ambu bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of [CONDITION(S)]. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. Review of facility policy, titles Advance Directives, dated [DATE], revealed the following: Policy Statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive . 18. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). Record review of A publication by the American Heart Association at https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_ 6.pdf, accessed [DATE] at 2:50 p.m., indicated .Immediate cardiopulmonary resuscitation (CPR) and early defibrillation, with and automated external defibrillator (AED), can more than double a victim's chance of survival. In fact, early defibrillation, along with CPR, is the only way to restore the victim's heart rhythm to normal in a lot of cases of [CONDITION(S)]. For every minute that passes without CPR and defibrillation, however, the chances of survival decrease by ,d+[DATE] percent. The 2020 update of AHA's Heart Disease and Stroke Statistics show that 23% of out-of-hospital cardiac arrests are shockable.

Based on interview, and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care, and subject to related physician orders and the resident's advance directives for one (Resident #1) of eight residents reviewed for CPR. The facility failed to ensure CPR was provided to Resident #1 who was a full code. On [DATE] CPR was not initiated by facility staff after Resident #1 was found not breathing, without a pulse, and unresponsive. EMS was not notified by the facility. An Immediate Jeopardy (IJ) was identified to have occurred from [DATE] at 4:45 a.m. to [DATE] at 2:00 p.m. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings included: Record review of the Resident Admission Record dated [DATE] indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with a recent readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's face sheet dated [DATE] indicated a directive in place for full code (in the event of [CONDITION(S)], CPR will be initiated). Record review of Resident #1's physician orders, dated February 2022, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's advance directive in her electronic health record indicated a selection for Full Code. Record review of Resident #1's care plan dated [DATE] indicated Resident #1 had exercised her right to maintain a full code status with all heroic measures to be performed in the event of an emergency. Interventions included: Honor the Resident wishes and inform staff of FULL CODE status. Record review of paper chart revealed Resident #1's Code Status was a Full Code. Record review of Resident #1's MDS, dated [DATE] revealed no indication for DNR advance directive. Record review of Resident #1's nursing note completed by LVN A, dated [DATE] at 5:37 a.m., indicated CNA C called LVN A was to Residents room at 4:50 a.m. Resident wasn't breathing when she entered the room. Upon assessment, no pulse or signs of life were found. Notified DON, JP (Justice of the Peace), and attempted to reach family member D, but didn't get an answer. Was able to reach family member E who said she would wake family member D up and give him the news. CNA provided postmortem care. JP arrived shortly after to pronounce and gave instructions to call Funeral Home. During an interview on [DATE] at 9:13 a.m., the DON said on [DATE] at 5:00 a.m., he received a call from LVN A, telling him that Resident #1 had passed, and wanted to know who she needed to call. She was told to call the MD, the family, and the JP. The DON got to work around 8:30 a.m. and was looking at the Resident's' chart and discovered she was a full code. LVN A told the DON she had gone back to the nurses' station after assessing the resident and saw she was a full code. She was asked why she did not call 911 or start CPR and LVN A said, she was gone-no sign of life, eyes fixed, mouth open, no pulse, limbs were flaccid, and no sign of life. LVN A said the Resident did not have any change of condition prior to this. LVN B told the DON he checked pulses, and Resident's head and arms were cold. No documentation the resident's body was stiff or had any rigor mortis. No documentation the resident's skin was cyanotic around lips or pale in color. Staff were asked to provide a written statement. CNA C said she was making rounds around approximately 4:30 a.m. and noticed the Resident #1 was not breathing. She shook her with no response and then called for help. Both LVN A and LVN B came and checked her. CNA C said she had seen the Resident around ,d+[DATE]:30 a.m. when she assisted her to the bathroom. CNA C said the Resident did not need anything or have any issues. The DON said BSL protocol should have been initiated, and CPR should have been done. The DON said DNR status is in PCC, (Point Click Care-electronic medical record software), it is on the shift report, and there is a red or green sheet of paper on every chart. Green=full code, Red=Do not resuscitate. The DON said his expectation was for staff to know Residents DNR status, as it is very accessible. It was critically important; they must know. It needs to be verbally discussed at each shift change. The DON said the LVNs will be terminated and report to the BON. During an interview on [DATE] at 9:52 a.m. the Administrator said she was notified of Resident #1's death by text message from the DON. Administrator said CPR should have been initiated until EMS arrived. She stated both LVN A and LVN B would be terminated and reported to the BON. Administrator said anyone who is a nurse or clinician should know the Residents code status ASAP. It should be included on the daily shift reporting by the nurses. Said it was very important for staff to know Resident code status as it was a life saving measure, they need to know to call 911 and initiate CPR to prevent loss of life. During a telephone interview on [DATE] at 10:22 a.m. LVN A said CNA C yelled out that Resident #1 wasn't breathing. LVN A and LVN B went to the room. Resident #1's color was yellow, mouth was drooping, and no movement. She said she checked the carotid pulse, (pulse felt over the carotid artery in the neck), and radial pulse, (pulse of the radial artery felt in the wrist), put her hand on Resident #1's stomach to check for breathing, and her eyes were set. She went to the desk to check the Resident's code status. LVN A saw she was a full code and asked LVN B what to do in this instance. He told her to call the DON. The DON told her to call the Doctor, the family, and the JP (Justice of the Peace). At approximately 5:10 a.m. LVN A called the NP (Nurse Practitioner), and the NP said she was surprised. NP told LVN A to call the family. LVN A said CPR was not initiated as it was very obvious, she had passed at that point. She said if the Resident had showed any sign of life, she would have started CPR for sure. During a telephone interview on [DATE] at 11:50 a.m. the NP said she had been notified of Resident #1's death, and that Resident was fine the day before. Resident #1 was recently diagnosed with Covid but was not ill. Resident #1 was a diabetic and had multiple medical comorbidities (the presence of one or more conditions). Resident #1 was also not vaccinated. The NP said she did not know that CPR was not initiated, she figured when staff called and told her the JP was coming that CPR was done. The NP said they should have done CPR. Even if she was gone, the nurse does not have the right to make that decision. You still start CPR and call 911. The NP said everyone one needs to do that. The NP said she had told the Medical Director about the death and would notify him of no CPR being done as well. She said she did not know if CPR would have changed the outcome, but it would have been nice to know it was done. They need to know every minute, every second counts. During a phone interview on [DATE] 12:44 p.m., LVN B said he was passing meds the night Resident #1 passed away. CNA C called for help, and he went to the resident's room. Resident was not responsive, not breathing. Resident #1's oxygen tubing was not in her nose, and he was unable to get any vital signs. There was nothing showing life. LVN A asked him what to do, and he told her to call the DON. LVN B said CPR should have been done. The Administrator and DON were notified of the Immediate Jeopardy (IJ) past-noncompliance on [DATE] at 3:45 p.m. IJ pas non-compliance was verified by staff interviews related to CPR, CPR initiation, honoring code status, following physician orders, and what to do when finding an unresponsive resident. Observations of residents were conducted, review of in-services related to CPR, advance directives, crash cart and AED (automated external defibrillator) inspection was completed. Review of Provider Investigation Report dated [DATE], revealed: An emergency response team leader was identified for each shift and noted on the nursing assignment sheet Mock code skills checks being implemented, nurse skills proficiencies are being updated and implemented Inservice for 911 activation implemented Inservice on staff expectations/roles during a code/emergency situation Inservice regarding the review of the facility policy regarding full code status, do not resuscitate (what do they mean where you can find them, who do you report this information to) and random interviews with staff will be used to monitor for effectiveness of in-service education. Review of Inservice Training Record titled Resident Emergency Guidelines for Residents with Full Code Status dated [DATE] indicated staff was educated on the following: 1. Upon discovering a residents need for emergency assistance: -The employee discovering the emergency will call for emergency assistance by LOUDLY announcing EMERGENCY ASSISTANCE (LOCATION). -Staff hearing the emergency call will immediately respond to the announced location. -The first nurse on scene should immediately assume control of the emergency. -The nurse will immediately assess the residents need for emergency assistance. -Upon verification of residents' code status FULL CODE, BSL Protocols will be followed as warranted by the clinical assessment. -The nurse will immediately direct the activation of the local 911 Emergency Services. -The nurse will direct residents' care adhering to BLS protocol and facility's capabilities. 2. A DNR audit review was started on all residents. 3. During facility investigation, DON identified issues with record keeping of CPR certification and facility is working to make changes. Review of Inservice Training Record titled Resident Code Status dated [DATE] indicated staff was educated on the following: - Upon admission, resident code status will be verified and appropriate orders place. -The resident code status will be prominently displayed in the residents' hard chart. -Red full-size paper .DNR -Green full-size paper .Full Code -Resident code status will be annotated on the 24-hour shift report. -Resident code status will be discussed at every change of shift. -The DON/ADON/DESIGNEE will be promptly notified of ALL CPR events. Review of facility policy, titled Emergency Procedure - Cardiopulmonary resuscitation, revised ,d+[DATE], revealed the following: Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden [CONDITION(S)]. General Guidelines 1. Sudden [CONDITION(S)] is a loss of heart function due to abnormal heart rhythms (arrhythmias). [CONDITION(S)] occurs soon after symptoms appear. It is a leading cause of death among adults. 2. A heart attack refers to impaired blood flow to the heart which leads to damage of the heart muscle. A heart attack can cause sudden [CONDITION(S)]. Typically, heart attacks are less sudden than SCA. 3. Victims of [CONDITION(S)] may initially have gasping respirations or may appear to be having a [CONDITION(S)]. Training in BLS includes recognizing presentations of SCA 4. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 5. Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) 7. If the resident's DNR status in unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. 8. If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. Preparation for Cardiopulmonary Resuscitation 1. Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who will direct resuscitation efforts, including non-licensed personnel. 2. The facility's procedure for administering CPR shall incorporate the steps covered in 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. 3. The facility shall have a CPR Team for each shift in the case of an actual [CONDITION(S)]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort. 4. The CPR Team in this facility shall include all nurses on duty who have received training and certification in CPR/BLS. 5. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. Emergency Procedure - Cardiopulmonary Resuscitation 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. 2. Initial BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: a. Following initial assessment, begin CPR with chest compressions b. Push hard to a depth of at least 2 inches (5cm) at a rate of at least 100 compressions per minute. c. Allow full chest recoil after each compression; and d. Minimize interruptions in chest compressions 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide2 breaths via ambu bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of [CONDITION(S)]. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. Review of facility policy, titles Advance Directives, dated [DATE], revealed the following: Policy Statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive . 18. The Interdisciplinary Team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS). Record review of A publication by the American Heart Association at https://www.heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_ 6.pdf, accessed [DATE] at 2:50 p.m., indicated .Immediate cardiopulmonary resuscitation (CPR) and early defibrillation, with and automated external defibrillator (AED), can more than double a victim's chance of survival. In fact, early defibrillation, along with CPR, is the only way to restore the victim's heart rhythm to normal in a lot of cases of [CONDITION(S)]. For every minute that passes without CPR and defibrillation, however, the chances of survival decrease by ,d+[DATE] percent. The 2020 update of AHA's Heart Disease and Stroke Statistics show that 23% of out-of-hospital cardiac arrests are shockable.

Based on interview and record review, the facility failed to notify the resident's physician of significant weight loss was identified for 1 of 7 residents reviewed for notification of changes. (Resident #1) The facility failed to notify Resident #1's physician when significant weight loss was identified on 11/5/21. Resident #1 lost 22.6 lbs. in 30 days. Resident #1 was admitted to the hospital on 11/17/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents at risk of not receiving the necessary interventions to avoid significant weight loss, malnutrition, and hospitalization . Findings included: Record review of Resident #1's face sheet, dated 11/30/21, indicated Resident #1 was initially admitted to the facility on [DATE], was readmitted on [DATE], and was discharged to the hospital on 11/17/21. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no dietary supplements ordered. Record review of the most recent MDS assessment, dated 9/23/21, indicated Resident #1 was cognitively intact, had no potential indicators of [CONDITION(S)], and had not rejected care during the assessment period. The assessment indicated Resident #1 required extensive assistance of two staff to transfer, and limited assistance of one staff to for eating, toileting, and personal hygiene. Resident #1 was always incontinent of bowel and bladder. The assessment indicated Resident #1 had no signs or symptoms of a swallowing disorder, weighed 181 lbs., and had neither gained nor lost more than 5% in the last 6 months. The assessment indicated Resident #1 had not been on a mechanically altered diet nor therapeutic diet while out of the facility but required both while a resident. The assessment indicated Resident #1 had no problems related to oral/dental status. Record Review of Resident #1's care plan, reviewed 10/26/21, indicated a focus area of potential undesirable weight loss. The goal indicated Resident #1 would maintain weight within 5% of baseline weight (unspecified), have no signs or symptoms of malnutrition, and consume at least 50% of at least 2 meals daily. Interventions included: *monitor/record/report to physician as needed signs and symptoms of malnutrition, to include emaciation, muscle wasting, or significant weight loss defined as greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. *monitor intake and record every meal. Alert nurse and offer an alternative if resident consumes less than 50% of meal. Record Review of Resident #1's weight summary indicated: *8/5/21 189.2 lbs. *9/3/21 181.0 lbs. *10/6/21 189.0 lbs. *11/5/21 166.4 lbs. Record review of a dietician consultation report for Resident #1, dated 9/24/21, indicated Resident #1's weight, obtained 9/3/21, was 181 lbs. The report indicated Resident #1 ate about 50% of meals and accepted 50% of snacks. The report indicated Resident #1's appetite was poor, per resident. The report indicated Resident #1 had no pressure wounds. The report recommended a goal of weight maintenance without significant weight change and that Resident #1 receive a House supplement 1.7 30cc twice a day. Record review of MARs for September 2021, October 2021, and November 1st through 17th did not indicate a supplement was ordered or given. Record review of meal intake documentation for amount eaten for Resident #1 indicated: October 2021 *10/1/21 Breakfast 26-50% *10/2/21 Breakfast 26-50% *10/4/21 Supper no meal intake recorded *10/6/21 Breakfast refused *10/7/21 Lunch 26-50% *10/9/21 Breakfast refused, supper no meal intake recorded *10/10/21 Breakfast no meal intake recorded, lunch no meal intake recorded *10/11/21 Breakfast refused, lunch refused, supper no meal intake recorded. *10/13/21 Supper no meal intake recorded *10/14/21 Breakfast refused, lunch refused, supper 0-25%. *10/1/6/21 Breakfast 26-50% *10/17/21 Breakfast refused; lunch refused *10/18/21 Breakfast refused, lunch refused, supper no meal intake recorded. *10/19/21 Breakfast refused, lunch refused, supper no meal intake recorded. *10/20/21 Breakfast no meal intake recorded, lunch no meal intake recorded *10/21/21 Breakfast 26-50%. lunch refused *10/22/21 Lunch 0-25% *10/23/21 Lunch refused, supper no meal intake recorded *10/24/21 Breakfast refused, lunch refused, supper no meal intake recorded *10/25/21 Breakfast 26-50%, lunch 0-25% *10/26/21 Breakfast 0-25%, lunch 26-50%, supper 0-25% *10/27/21 Breakfast refused; lunch Refused *10/28/21 Breakfast no meal intake recorded, lunch no meal intake recorded *10/29/21 Breakfast 26-50%, lunch 0-25% *10/30/21 Breakfast 26-50%, lunch 0-25% *10/31/21 Breakfast refused, lunch 0-25% November 2021 *11/1/21 Breakfast refused, lunch refused, supper 26-50% *11/2/21 Lunch refused, supper 0-25% *11.3.21 Lunch refused, supper 0-25% *11/4/21 Supper 26-50% *11/5/21 Breakfast refused; lunch refused *11/6/21 Breakfast 0-25%, lunch no meal intake recorded *11/7/21 Lunch refused, supper no meal intake recorded *11/8/21 Breakfast refused, lunch 0-25% *11/9/21 Breakfast 0-25%, lunch 0-25%, supper 0-25% *11/10/21 Breakfast 26-50, lunch 26-50%, supper no meal intake recorded *11/11/21 Breakfast 26-50, lunch 26-50% *11/12/21 Breakfast refused, lunch refused, supper refused *11/15/21 Breakfast refused, supper no meal intake recorded *11/16/21 Breakfast refused, lunch refused, supper refused *11/17/21 Breakfast 0-25%, lunch 26-50%, supper no meal intake recorded. Record Review of Resident #1's weight summary indicated: *8/5/21 189.2 lbs. *9/3/21 181.0 lbs. *10/6/21 189.0 lbs. *11/5/21 166.4 lbs. (22.6 lbs. weight loss since 10/6/21. Pounds lost/starting weight x 00 = percentage of weight loss. 22.6/189 x 100 = 11.96% weight loss) Record review of a nursing progress note dated 9/25/21 at 12:18 p.m., written by LVN A, indicated Resident #1 had refused breakfast and lunch. The resident stated that her family member was bringing her food. The resident asked for the breakfast tray to be removed and asked that the lunch tray not be brought to the room because she was not going to eat it. Record review of a nursing progress note dated 11/17/21 at 8:47 p.m., written by LVN H, indicated Resident #1 was being transferred to the hospital at the family's request because she had not eaten in four days. Record Review of hospital records titled Physician Documentation, written by Physician I and dated 11/17/21 at 10:57 p.m., indicated Resident #1 presented to the emergency room with complaints of Won't Eat and fever. Record review of hospital records titled History and Physical, written by Physician J and dated 11/18/21 at 12:18 p.m., indicated admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/30/21 at 10:28 a.m., the Admissions Director (AD) said she had talked to Resident #1 the day before she was transferred to the hospital (11/17/21). She said Resident #1 was refusing to eat and said she didn't feel like eating. During an interview on 11/30/21at 11:00 a.m., the ADM acknowledged that Resident #1 had weight loss of over 20 lbs. in a month (189 lbs. on 10/6/21 - 166.4 lbs. on 11/5/21 = 22.6 lbs. weight loss). The ADM said the scales were checked to make sure they were calibrated and that the scales were reading correctly. The ADM said the facility did not notify Resident #1's physician or family about significant weight loss. The ADM said the facility did not notify the dietician nor ask for a dietary consult in response to Resident #1's significant weight loss. The ADM said the facility did not start giving Resident #1 a dietary supplement to address her significant weight loss. The ADM said the facility did not reweigh Resident #1 to verify the weight loss. The ADM could not explain why no steps were taken to address Resident #1's significant weight loss. During an interview on 11/30/21 at 11:58 a.m., RA B said she provided care for Resident #1 every time she worked. RA B said Resident #1 would sometimes talk about things that were not there. She said Resident #1 was able to eat and drink without assistance, but that she refused meals frequently. RA B said when Resident #1 refused her meals she would tell the nurse but did not know what the nurses did after that. RA B said she could tell Resident #1 had lost a lot of weight by observing her. RA B said she had been a Restorative aide since August 2021 and was the person who weighed all the residents. RA B said after she obtained resident weights, she gave them to the DON or ADON so they can review them. RA B said if there was a significant change the DON or ADON would tell her to weight the resident again. RA B said a weight loss of over 20 lbs. sounded about right based on Resident #1's appearance. RA B said she told the nurses Resident #1 was not eating and that she had witnessed two other CNAs (unidentified) tell the nurses that she was not eating. RA B said anyone who worked at the facility could see that Resident #1 had lost weight. During an interview on 11/30/21 at 4: 08 p.m., RD C said she was the consulting dietician for the facility. RD C said she saw Resident #1 on 9/24/21 and noted that she had poor po (oral) intake. RD C said the goal for Resident #1 was to have weight maintenance without significant weight loss, and that she had recommended a dietary supplement, house supplement 1.7 30 ml (milliliters) twice a day. RD C said Resident #1 did not have significant weight loss at that time, and the facility usually contacted her if there were concerns about a resident losing weight. RD C said the facility had not contacted her about Resident #1's significant weight loss identified on 11/5/21. RD C said if there was weight loss Resident #1 should be weighed more than once a month. During an interview on 11/30/21 at 5:06 p.m., NA D said she had provided care for Resident #1. NA D said Resident #1 could eat on her own. NA D said sometimes Resident #1 would eat a little bit, but she rarely ate anything at all. NA D said the nurses (unspecified) knew because she reported it every time. During an interview on 11/30/21 at 5:40 p.m., LVN E said she took care of Resident #1 many times. LVN E said Resident #1's eating was a struggle for the facility because she would refuse a lot of the trays. LVN E said Resident #1 lost weight, and that you could tell she lost weight by observing her. During an interview on 11/30/21 at 6:35 p.m., the ADON said she had been Resident #1's nurse and had known her since she came to the facility from the hospital in August 2021. The ADON said Resident #1 would not eat the facility's food, and that her family member would bring her food during the day. The ADON said Resident #1 eventually got to the point where she would not eat that either. The ADON said Resident #1 had lost weight, but that the weight for November 5th, 2021 (166.4 lbs., loss of 22.6 lbs.) could not be right. The ADON said the facility decided to make sure that, going forward, the scale was calibrated before a resident was weighed. The ADON said Resident #1 was reweighed the next day. She said the weight was a little different, but not a huge difference, and was still significant weight loss. The ADON said she did not notify anyone of the significant weight loss. She said she should have notified the physician and Resident #1's family member about the weight loss. The ADON said she was not sure if the facility started weighing Resident #1 more frequently or not. The ADON could not explain why she had not notified anyone of Resident #1's significant weight loss. During an interview on 12/1/21 at 10:38 a.m., the DON said Resident #1's weight loss of 22.6 lbs., identified on 11/5/21, met the criteria for significant weight loss. The DON said he was aware of the weight loss and that the physician, dietician, and family should have been notified, and that the facility should have started weighing Resident #1 weekly. The DON could not explain why the notifications were not made. During a telephone interview on 12/1/21 at 12:23 p.m., PA F said he did not remember knowing that Resident #1 experienced a weight loss of greater than 20 lbs. in November. PA F said that much weight loss was significant, and if he had known about it, he would have investigated to determine the cause for the weight loss. During an interview on 12/1/21 at 2:04 p.m., the Dietary Manager (DM) said the health shake was delivered by the kitchen and comes on the resident' tray, but that the dietician had not recommended health shakes for Resident #1 and she was not receiving them. The DM said the dietary staff make a note if there was a lot of food left on the tray when it was returned to the kitchen. The DM said dietary staff had noticed that Resident #1 was not eating much at all, and that she had told the ADON. The DM said Resident #1 refuses the tray when the CNAs bring it into the room. During an interview on 12/1/21 at 2:59 p.m., MA G said she gave Resident #1 medications every day that she worked. MA G said Resident #1 did not have any orders for supplements and that she had not given her any supplements. MA G said if a supplement were ordered there would be a place on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 12/1/21 at 3:10 p.m., the DON said when the dietician consultant makes a recommendation, that recommendation goes to the DON, the ADON, to the corporate office, and the physician. The DON said the provider gets a letter specifying the recommendation and he can either agree or disagree with the recommendation. If he agrees he signs the letter and it was entered into the system as an order. During an interview on 12/1/21 at 3:25 p.m., the DON said the dietary recommendations from the dietician did not make it to the chart, and Resident #1 never received the supplement. He said there was no order for the supplement. The DON said he and the ADON would start tracking the recommendations. The DON said prior to this point there was no structured process for following up on the recommendations. During a telephone interview on 12/1/21 at 3:30 p.m., PA F said he could not say for sure if he received the dietary recommendations from the dietician or not. Record review of a facility provided In-Service Training dated 11/23/21 and titled Weight Monitoring System indicated: *Residents with a weight loss or gain of 5% in 30 days or less, 7.5% in 90 days or less, 10% in 180 days or less are considered significant. *Significant losses/gains must be addressed as soon as they are identified. The physician, dietician, and family must be notified. *The dietician is to be called and asked for direction/recommendations. *Automatically start weekly weights Record review of a Quality Assessment and Assurance Committee Action Plan, dated 11/24/21 indicated: *Identified Trend/Concern/Issue/Problem Statement and Goal - Weights not being reviewed according to the facility weight management protocol prior to being recorded in the electronic record. *Plan of Action 1] Follow weight management plan 2] The DON and ADON will do a review of all weights before recording into the electronic record. Weekly weights should be emailed to the RD within 24 hours of obtaining 3] Admission charts will continue to be checked for baseline values in weight and height. These baselines should also be compared to the hospital height/weight to ensure we are not too far off from what they had previously been. 4] All weights that reach the level of significant 5% in 30 days or 10% in 6 months or less, must have all correct notifications done within 24 hours of loss/gain being discovered. 5] The resident plan of care is to be updated with noted wight losses/gains. Record review of a facility policy dated September 2017, titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol indicated: *The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. *The staff and physician will define the individual's current nutritional status (weight, food intake and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition. *The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions. *The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions.

Based on interview and record review, the facility failed to provide nutritional care and services to each resident, consistent with resident's comprehensive assessment and failed to recognize, evaluate and address the need of each resident to include their clinical condition in one of seven residents reviewed for weight loss (Resident #1). Resident #1 had a significant weight loss identified on 11/5/21 of 22.6 lbs. in 30 days resulting in being transferred and admitted into the hospital. The admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to implement dietician recommendation of house supplements twice daily. The facility did not notify nor consult with a Resident #1's physician or the registered dietician regarding Resident #1's significant weight loss identified on 11/5/21. These failures could place residents at risk of not receiving the necessary interventions to avoid significant weight loss, malnutrition, and hospitalization . Findings included: Record review of Resident #1's face sheet, dated 11/30/21, indicated Resident #1 was initially admitted to the facility on [DATE], was readmitted on [DATE], and was discharged to the hospital on 11/17/21. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no dietary supplements ordered. Record review of the most recent MDS assessment, dated 9/23/21, indicated Resident #1 was cognitively intact, had no potential indicators of [CONDITION(S)], and had not rejected care during the assessment period. The assessment indicated Resident #1 required extensive assistance of two staff to transfer, and limited assistance of one staff to for eating, toileting, and personal hygiene. Resident #1 was always incontinent of bowel and bladder. The assessment indicated Resident #1 had no signs or symptoms of a swallowing disorder, weighed 181 lbs., and had neither gained nor lost more than 5% in the last 6 months. The assessment indicated Resident #1 had not been on a mechanically altered diet nor therapeutic diet while out of the facility but required both while a resident. The assessment indicated Resident #1 had no problems related to oral/dental status. Record Review of Resident #1's care plan, reviewed 10/26/21, indicated a focus area of potential undesirable weight loss. The goal indicated Resident #1 would maintain weight within 5% of baseline weight (unspecified), have no signs or symptoms of malnutrition, and consume at least 50% of at least 2 meals daily. Interventions included: *monitor/record/report to physician as needed signs and symptoms of malnutrition, to include emaciation, muscle wasting, or significant weight loss defined as greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. *monitor intake and record every meal. Alert nurse and offer an alternative if resident consumes less than 50% of meal. Record Review of Resident #1's weight summary indicated: *8/5/21 189.2 lbs. *9/3/21 181.0 lbs. *10/6/21 189.0 lbs. *11/5/21 166.4 lbs. Record review of a dietician consultation report for Resident #1, dated 9/24/21, indicated Resident #1's weight, obtained 9/3/21, was 181 lbs. The report indicated Resident #1 ate about 50% of meals and accepted 50% of snacks. The report indicated Resident #1's appetite was poor, per resident. The report indicated Resident #1 had no pressure wounds. The report recommended a goal of weight maintenance without significant weight change and that Resident #1 receive a House supplement 1.7 30cc twice a day. Record review of MARs for September 2021, October 2021, and November 1st through 17th did not indicate a supplement was ordered or given. Record review of meal intake documentation for amount eaten for Resident #1 indicated: October 2021 *10/1/21 Breakfast 26-50% *10/2/21 Breakfast 26-50% *10/4/21 Supper no meal intake recorded *10/6/21 Breakfast refused *10/7/21 Lunch 26-50% *10/9/21 Breakfast refused, supper no meal intake recorded *10/10/21 Breakfast no meal intake recorded, lunch no meal intake recorded *10/11/21 Breakfast refused, lunch refused, supper no meal intake recorded. *10/13/21 Supper no meal intake recorded *10/14/21 Breakfast refused, lunch refused, supper 0-25%. *10/1/6/21 Breakfast 26-50% *10/17/21 Breakfast refused; lunch refused *10/18/21 Breakfast refused, lunch refused, supper no meal intake recorded. *10/19/21 Breakfast refused, lunch refused, supper no meal intake recorded. *10/20/21 Breakfast no meal intake recorded, lunch no meal intake recorded *10/21/21 Breakfast 26-50%. lunch refused *10/22/21 Lunch 0-25% *10/23/21 Lunch refused, supper no meal intake recorded *10/24/21 Breakfast refused, lunch refused, supper no meal intake recorded *10/25/21 Breakfast 26-50%, lunch 0-25% *10/26/21 Breakfast 0-25%, lunch 26-50%, supper 0-25% *10/27/21 Breakfast refused; lunch Refused *10/28/21 Breakfast no meal intake recorded, lunch no meal intake recorded *10/29/21 Breakfast 26-50%, lunch 0-25% *10/30/21 Breakfast 26-50%, lunch 0-25% *10/31/21 Breakfast refused, lunch 0-25% November 2021 *11/1/21 Breakfast refused, lunch refused, supper 26-50% *11/2/21 Lunch refused, supper 0-25% *11.3.21 Lunch refused, supper 0-25% *11/4/21 Supper 26-50% *11/5/21 Breakfast refused; lunch refused *11/6/21 Breakfast 0-25%, lunch no meal intake recorded *11/7/21 Lunch refused, supper no meal intake recorded *11/8/21 Breakfast refused, lunch 0-25% *11/9/21 Breakfast 0-25%, lunch 0-25%, supper 0-25% *11/10/21 Breakfast 26-50, lunch 26-50%, supper no meal intake recorded *11/11/21 Breakfast 26-50, lunch 26-50% *11/12/21 Breakfast refused, lunch refused, supper refused *11/15/21 Breakfast refused, supper no meal intake recorded *11/16/21 Breakfast refused, lunch refused, supper refused *11/17/21 Breakfast 0-25%, lunch 26-50%, supper no meal intake recorded. Record Review of Resident #1's weight summary indicated: *8/5/21 189.2 lbs. *9/3/21 181.0 lbs. *10/6/21 189.0 lbs. *11/5/21 166.4 lbs. (22.6 lbs. weight loss since 10/6/21. Pounds lost/starting weight x 00 = percentage of weight loss. 22.6/189 x 100 = 11.96% weight loss) Record review of a nursing progress note dated 9/25/21 at 12:18 p.m., written by LVN A, indicated Resident #1 had refused breakfast and lunch. The resident stated that her family member was bringing her food. The resident asked for the breakfast tray to be removed and asked that the lunch tray not be brought to the room because she was not going to eat it. Record review of a nursing progress note dated 11/17/21 at 8:47 p.m., written by LVN H, indicated Resident #1 was being transferred to the hospital at the family's request because she had not eaten in four days. Record Review of hospital records titled Physician Documentation, written by Physician I and dated 11/17/21 at 10:57 p.m., indicated Resident #1 presented to the emergency room with complaints of Won't Eat and fever. Record review of hospital records titled History and Physical, written by Physician J and dated 11/18/21 at 12:18 p.m., indicated admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/30/21 at 10:28 a.m., the Admissions Director (AD) said she had talked to Resident #1 the day before she was transferred to the hospital (11/17/21). She said Resident #1 was refusing to eat and said she didn't feel like eating. During an interview on 11/30/21at 11:00 a.m., the ADM acknowledged that Resident #1 had weight loss of over 20 lbs. in a month (189 lbs. on 10/6/21 - 166.4 lbs. on 11/5/21 = 22.6 lbs. weight loss). The ADM said the scales were checked to make sure they were calibrated and that the scales were reading correctly. The ADM said the facility did not notify Resident #1's physician or family about significant weight loss. The ADM said the facility did not notify the dietician nor ask for a dietary consult in response to Resident #1's significant weight loss. The ADM said the facility did not start giving Resident #1 a dietary supplement to address her significant weight loss. The ADM said the facility did not reweigh Resident #1 to verify the weight loss. The ADM could not explain why no steps were taken to address Resident #1's significant weight loss. During an interview on 11/30/21 at 11:58 a.m., RA B said she provided care for Resident #1 every time she worked. RA B said Resident #1 would sometimes talk about things that were not there. She said Resident #1 was able to eat and drink without assistance, but that she refused meals frequently. RA B said when Resident #1 refused her meals she would tell the nurse but did not know what the nurses did after that. RA B said she could tell Resident #1 had lost a lot of weight by observing her. RA B said she had been a Restorative aide since August 2021 and was the person who weighed all the residents. RA B said after she obtained resident weights, she gave them to the DON or ADON so they can review them. RA B said if there was a significant change the DON or ADON would tell her to weight the resident again. RA B said a weight loss of over 20 lbs. sounded about right based on Resident #1's appearance. RA B said she told the nurses Resident #1 was not eating and that she had witnessed two other CNAs (unidentified) tell the nurses that she was not eating. RA B said anyone who worked at the facility could see that Resident #1 had lost weight. During an interview on 11/30/21 at 4: 08 p.m., RD C said she was the consulting dietician for the facility. RD C said she saw Resident #1 on 9/24/21 and noted that she had poor po (oral) intake. RD C said the goal for Resident #1 was to have weight maintenance without significant weight loss, and that she had recommended a dietary supplement, house supplement 1.7 30 ml (milliliters) twice a day. RD C said Resident #1 did not have significant weight loss at that time, and the facility usually contacted her if there were concerns about a resident losing weight. RD C said the facility had not contacted her about Resident #1's significant weight loss identified on 11/5/21. RD C said if there was weight loss Resident #1 should be weighed more than once a month. During an interview on 11/30/21 at 5:06 p.m., NA D said she had provided care for Resident #1. NA D said Resident #1 could eat on her own. NA D said sometimes Resident #1 would eat a little bit, but she rarely ate anything at all. NA D said the nurses (unspecified) knew because she reported it every time. During an interview on 11/30/21 at 5:40 p.m., LVN E said she took care of Resident #1 many times. LVN E said Resident #1's eating was a struggle for the facility because she would refuse a lot of the trays. LVN E said Resident #1 lost weight, and that you could tell she lost weight by observing her. During an interview on 11/30/21 at 6:35 p.m., the ADON said she had been Resident #1's nurse and had known her since she came to the facility from the hospital in August 2021. The ADON said Resident #1 would not eat the facility's food, and that her family member would bring her food during the day. The ADON said Resident #1 eventually got to the point where she would not eat that either. The ADON said Resident #1 had lost weight, but that the weight for November 5th, 2021 (166.4 lbs., loss of 22.6 lbs.) could not be right. The ADON said the facility decided to make sure that, going forward, the scale was calibrated before a resident was weighed. The ADON said Resident #1 was reweighed the next day. She said the weight was a little different, but not a huge difference, and was still significant weight loss. The ADON said she did not notify anyone of the significant weight loss. She said she should have notified the physician and Resident #1's family member about the weight loss. The ADON said she was not sure if the facility started weighing Resident #1 more frequently or not. The ADON could not explain why she had not notified anyone of Resident #1's significant weight loss. During an interview on 12/1/21 at 10:38 a.m., the DON said Resident #1's weight loss of 22.6 lbs., identified on 11/5/21, met the criteria for significant weight loss. The DON said he was aware of the weight loss and that the physician, dietician, and family should have been notified, and that the facility should have started weighing Resident #1 weekly. The DON could not explain why the notifications were not made. During a telephone interview on 12/1/21 at 12:23 p.m., PA F said he did not remember knowing that Resident #1 experienced a weight loss of greater than 20 lbs. in November. PA F said that much weight loss was significant, and if he had known about it, he would have investigated to determine the cause for the weight loss. During an interview on 12/1/21 at 2:04 p.m., the Dietary Manager (DM) said the health shake was delivered by the kitchen and comes on the resident' tray, but that the dietician had not recommended health shakes for Resident #1 and she was not receiving them. The DM said the dietary staff make a note if there was a lot of food left on the tray when it was returned to the kitchen. The DM said dietary staff had noticed that Resident #1 was not eating much at all, and that she had told the ADON. The DM said Resident #1 refuses the tray when the CNAs bring it into the room. During an interview on 12/1/21 at 2:59 p.m., MA G said she gave Resident #1 medications every day that she worked. MA G said Resident #1 did not have any orders for supplements and that she had not given her any supplements. MA G said if a supplement were ordered there would be a place on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 12/1/21 at 3:10 p.m., the DON said when the dietician consultant makes a recommendation, that recommendation goes to the DON, the ADON, to the corporate office, and the physician. The DON said the provider gets a letter specifying the recommendation and he can either agree or disagree with the recommendation. If he agrees he signs the letter and it was entered into the system as an order. During an interview on 12/1/21 at 3:25 p.m., the DON said the dietary recommendations from the dietician did not make it to the chart, and Resident #1 never received the supplement. He said there was no order for the supplement. The DON said he and the ADON would start tracking the recommendations. The DON said prior to this point there was no structured process for following up on the recommendations. During a telephone interview on 12/1/21 at 3:30 p.m., PA F said he could not say for sure if he received the dietary recommendations from the dietician or not. Record review of a facility provided In-Service Training dated 11/23/21 and titled Weight Monitoring System indicated: *Residents with a weight loss or gain of 5% in 30 days or less, 7.5% in 90 days or less, 10% in 180 days or less are considered significant. *Significant losses/gains must be addressed as soon as they are identified. The physician, dietician, and family must be notified. *The dietician is to be called and asked for direction/recommendations. *Automatically start weekly weights Record review of a Quality Assessment and Assurance Committee Action Plan, dated 11/24/21 indicated: *Identified Trend/Concern/Issue/Problem Statement and Goal - Weights not being reviewed according to the facility weight management protocol prior to being recorded in the electronic record. *Plan of Action 1] Follow weight management plan 2] The DON and ADON will do a review of all weights before recording into the electronic record. Weekly weights should be emailed to the RD within 24 hours of obtaining 3] Admission charts will continue to be checked for baseline values in weight and height. These baselines should also be compared to the hospital height/weight to ensure we are not too far off from what they had previously been. 4] All weights that reach the level of significant 5% in 30 days or 10% in 6 months or less, must have all correct notifications done within 24 hours of loss/gain being discovered. 5] The resident plan of care is to be updated with noted wight losses/gains. Record review of a facility policy dated September 2017, titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol indicated: *The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. *The staff and physician will define the individual's current nutritional status (weight, food intake and pertinent laboratory values) and identify individuals with anorexia, weight loss or gain, and significant risk for impaired nutrition. *The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions. *The physician and staff will monitor nutritional status, an individual's response to interventions, and possible complications of such interventions

Based on interview and record review the facility failed to ensure treatment and care in accordance with standards of practice was provided for 1 of 7 residents reviewed for insulin administration. (Resident #1) The facility did not: *clarify physician orders for checking Resident #1's blood sugars; *obtain parameters of when to notify the physician for high or low blood sugars; *obtain orders and parameters for the administration of [MEDICATION NAME] (a medication used to treat low blood sugar); *monitor and record blood sugar results in the residents clinical record; and *include blood sugar checks, administration of insulin and diabetic care in the resident's care plan. The resident was sent to the emergency room 2 times for low blood sugar. This failure could place residents receiving insulin at risk for emergency room visits, hospitalization and death. Findings included: Physician orders dated March 2020 indicated Resident #1 admitted [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. The physician orders did not indicate the resident had a [DIAGNOSES REDACTED]. The orders indicated Resident #1 was to receive the following to treat diabetes: *Humalog Solution 100 Unit/ML, 9 units subcutaneously before meals for diabetes and to hold if blood sugar was below 100; and *Insulin [MEDICATION NAME] solution ([MEDICATION NAME])100 Unit/ML 25 units subcutaneously (below the skin) at bedtime for diabetes. A physician order dated 3/10/20 indicated Humalog Solution 100 Unit/ml, 9 units before meals was discontinued. The MDS dated [DATE] indicated Resident #1's cognition was severely impaired. The resident was totally dependent for dressing, toilet use, and personal hygiene. The MDS did not indicate the resident was diabetic. The MDS indicated Resident #1 received insulin injections 5 of 7 days since admission/entry to the facility. The care plan 03/09/20 did not indicate Resident #1 received blood sugar checks or administration of insulin and did not address diabetic care. A MAR dated March 2020 indicated Resident #1 received [MEDICATION NAME] (a long-acting insulin medication used to treat diabetes) 100 Unit/ML, 25 units subcutaneously at bedtime for diabetes and blood sugar checks as follows: 03/08/20 at 7:00 PM: Dosage given with blood sugar of 142. 03/09/20 at 7:00 PM: Dosage given with blood sugar of 222. 03/10/20 at 7:00 PM: Dosage given with blood sugar of 207. 03/11/20 at 7:00 PM: No indication of dosage given with no recorded blood sugar. 03/12/20 at 7:00 PM: Dosage given with blood sugar of 258. A MAR dated March 2020 indicated Resident #1 was to receive Humalog (a fast-acting insulin used to treat diabetes) 100 Unit/ML, 9 units subcutaneously before meals for diabetes at 7:00 AM, 11:00 AM, and 4:00 PM. The MAR indicated to hold the Humalog for a blood sugar below 100. The MAR did not have blood sugar results recorded related to Humalog administration. The MAR indicated the following: 03/07/20 at 7:00 AM: 9 with nurse's initials 03/07/20 at 11:00 AM: 9 with nurse's initials 03/07/20 at 4:00 PM: 9 with nurse's initials 03/08/20 at 7:00 AM: 9 with nurse's initials 03/08/20 at 11:00 AM: 9 with nurse's initials 03/08/20 at 4:00 PM: no documentation 03/09//20 at 7:00 AM: 9 with nurse's initials 03/09/20 at 11:00 AM: 14 with nurse's initials 03/09/20 at 4:00 PM: 14 with nurse's initials 03/10/20 at 7:00 AM: 3 with nurse's initials 03/10/20 at 11:00 AM: 3 with nurse's initials 03/10/20 at 4:00 PM: indicated Humalog was discontinued During an interview on 03/19/20 at 5:00 PM, the ADON said 9 on the MAR meant see progress/nurse's notes, a 14 on the MAR meant dosage held and a 3 on the MAR meant resident not in the facility. Nursing notes related to Humalog administration for Resident #1 indicated the following: 03/07/20 at 7:00 AM: No note related to Humalog dosage and no recorded blood sugar 03/07/20 at 11:00 AM: No note related to Humalog dosage and no recorded blood sugar. 03/07/20 at 4:00 PM: Indicated Humalog Solution 100 Unit/ML inject 9 unit subcutaneously before meals for diabetes. Hold if blood sugar is below 100. There was no documentation of blood sugar or if dosage was given. 03/08/20 at 7:00 AM: No note related to Humalog dosage and no recorded blood sugar. 03/08/20 at 10:10 AM: Indicated Humalog Solution 100 Unit/ML inject 9 unit subcutaneously before meals for diabetes. Hold if blood sugar is below 100. There was no documentation of blood sugar or if dosage was given. 03/08/20 at 4:00 PM: No note related to Humalog dosage and no recorded blood sugar. 03/09/20 at 7:00 AM: No note related to Humalog dosage and no recorded blood sugar. 03/09/20 at 12:01 PM: Indicated Humalog dosage held for blood sugar of 83. 03/09/20 at 6:39 PM: Indicated Humalog dosage held for blood sugar of 92. 03/10/20 at 7:00 AM: No note related to Humalog dosage and no recorded blood sugar. (The MAR indicated the resident was not at the facility for the 7:00 AM dosage). A nursing note dated 03/10/20 at 8:01 AM indicated Resident #1 was limp, cold, non-responsive to verbal stimuli and sternum chest rub. The noted indicated the resident's blood sugar was 29 and she appeared to possibly be having [MEDICAL CONDITION] because her eyes exhibited [DIAGNOSES REDACTED] (eyes make repetitive, uncontrolled movements). The note indicted the resident's pupils were dilated and fixed and a [MEDICATION NAME] injection (used to treat very low blood sugar) was administered to the resident. The note indicated 911 was notified and Resident #1's blood sugar was 130 at 8:29 AM. Resident #1 was transported to the hospital via EMS. During an interview on 03/19/20 at 4:50 PM, CNA A said on the morning of 03/10/20 she entered Resident #1's room just before 8:00 AM to assist her to clean up and get dressed. CNA A said she spoke to Resident #1 calling her name and touched her on the arm to awaken her. Resident #1 did not respond. She yelled to another CNA to get the nurse right away. During an interview on 03/19/20 at 5:40 PM, LVN B he was Resident #1's primary nurse and he was alerted by a CNA A on 03/10/20 at approximately 8:00 AM that Resident #1 was unresponsive. He said he observed the resident's pupils were fixed and dilated. He said her blood sugar was 29 and he administered [MEDICATION NAME] and called 911. LVN B said he had last checked on the resident around 5:30 AM and had not yet checked her blood sugar or administered her insulin. He said he normally worked nights and did not normally administer Resident #1's Humalog. A nursing note dated 03/10/20 at 2:23 PM indicated Resident #1 arrived back to the facility with the [DIAGNOSES REDACTED]. A nursing note dated 03/10/20 at 2:32 PM indicated the physician assistant gave orders to discontinue Humalog and keep the [MEDICATION NAME] dosage the same. A nursing note dated 03/13/20 at 9:05 AM indicated Resident #1 was found unresponsive with foam coming from her mouth. The note indicated the nurse did multiple sternal rubs with no success and the resident's blood sugar was 45 at 8:25 AM. The note indicated the resident was given [MEDICATION NAME] and 15 minutes later her blood sugar was 49. The note indicated upon EMS arrival the resident's blood sugar was checked again and was 40. Resident #1 was transported to the hospital by EMS. Nursing notes included no assessment or record of Resident #1 returning to the facility on ,[DATE]//20. During a phone interview on 03/19/20 at 8:20 PM, LVN C said she was Resident #1's primary nurse when she returned from the hospital on [DATE]. She said she forgot to document an assessment of the resident when she returned from the hospital after 6:00 PM. LVN C said she did assess Resident #1 and checked her blood sugar several times during the night. LVN C said she recorded the blood sugars on her nursing report sheet. A nursing report sheet dated 03/13/20 indicated Resident #1 returned to the facility and blood sugar checks were 276, 184, and 151. There were no times recorded for Resident #1's return or the blood sugar checks. A nursing note dated 03/14/20 at 1:20 PM indicated Resident #1 transported via EMS to the hospital at 4:13 PM due to chest pain. During a phone interview on 03/19/20 at 4:20 PM, Resident #1's spouse said she had been diabetic for many years and was managed by taking pills. He said she had to start taking insulin while she was still at home and he took care of her. He said he managed her blood sugars at home by checking and recording the blood sugars. He said he had nurses who came to his home and reviewed the blood sugars and her insulin dosages. He said Resident #1 had never had an episode of low blood sugar with unresponsiveness at home. During an interview on 03/19/20 at 6:05 PM, LVN A said she recorded Resident #1's blood sugar in the nursing notes when she held the insulin dosage. LVN A said there was no place to record blood sugars on the MAR for Resident #1. During an interview on 03/19/20 at 5:30 PM, the ADON said Resident #1's blood sugar was checked before each meal and at bedtime. He said he could not prove the blood sugar checks were done because they were not documented on the MAR or in nursing notes. The ADON stated the facility did not obtain a physician's order for blood sugar checks for Resident #1. The ADON said blood sugars are normally recorded on the MAR at the time insulin dosage was given and he did not know why Resident #1's blood sugars were not recorded at the time on Humalog dosages. During an interview on 03/19/20 at 6:30 PM, the director of operations said he expected residents blood sugars to be monitored and documented with insulin administration. He said the facility had not accomplished that with Resident #1. He said the facility should have obtained an order for [REDACTED]. The Insulin Administration policy revised 09/14 indicated in part documentation would include The resident's blood glucose result, as ordered . The website https://www.diabetes.org/diabetes/medication-management/blood-glucose-testing-and-control/[DIAGNOSES REDACTED] accessed on 3/31/20 indicated Low blood sugar ([DIAGNOSES REDACTED]) is when your blood sugar levels have fallen low enough that you need to take action to bring them back up. This is usually when you blood sugar is less than 70.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and care was provided in accordance with professional standards for 1 of 6 residents reviewed for quality of care. (Resident #1) The facility did not thoroughly assess Resident #1's skin and identify sutures on both sides of her groin until 11 days after admission. Resident #1 had redness and warmth on her abdomen, groin and upper thighs and was admitted to the hospital with [REDACTED]. Findings Included: Physician orders dated (MONTH) 2019 indicated Resident #1 admitted on [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. The physician orders did not address care or monitoring of sutures from her peripheral vascular angioplasty (a procedure to open narrowed or blocked vessels that supply blood to the legs). General transfer orders from the hospital 05/22/19 indicated Resident #1 had [DIAGNOSES REDACTED]. The orders did not include orders for wound care or monitoring of surgical incisions. A nursing evaluation and history dated 05/22/19 indicated Resident #1 had no surgical wounds. A weekly skin assessment dated [DATE] indicated Resident #1 had no surgical wounds. There were no skin assessments in the clinical record for the week of 5/29/19 and 6/2/19. There were no other skin assessments in the clinical record for Resident #1. A baseline care plan initiated 05/25/19 did not indicate Resident #1 had surgical wounds. The MDS dated [DATE] indicated Resident #1 was cognitively intact, required extensive assistance with most ADLs, and had no surgical wounds. A treatment administration sheet dated (MONTH) (YEAR) did not include any monitoring or care of Resident #1's surgical incisions. A progress note dated 06/02/19 at 4:50 p.m. indicated Resident #1 was being transported to the hospital related to surgical incisions being red, swollen, and warm to the touch with moderate amounts of blood tinged drainage. A hospital discharge summary report dated 6/12/19 indicated Resident #1 was admitted on [DATE] with a primary [DIAGNOSES REDACTED]. The summary indicated the resident was Resident #1 was treated with [MEDICATION NAME] (an antibiotic used to treat bacterial infections) and underwent an incision and drainage of a left groin wound seroma (a collection of fluid under the surface of the skin). The discharge indicated Resident #1 was discharged on [DATE] with a wound VAC (vacuum-assisted closure of a wound ) to the left groin. During an interview on 06/13/19 at 9:35 a.m., LVN A said he admitted Resident #1 on 05/22/19. LVN A said he assessed some skin tears on the resident's arms but never completed her skin assessment. LVN A said he was unaware Resident #1 underwent a peripheral vascular bypass surgery at the hospital before being transferred to the facility and was unaware of her surgical wounds. During an interview on 06/13/19 at 9:50 a.m., CNA A said she assisted Resident #1 with bathing. CNA A said she was careful not to get the resident's stitches in her groin area wet because the resident's son said they were not supposed to get wet. CNA A said she never told a nurse about the stitches because she thought they knew about them. During an interview on 06/13/19 at 10:30 a.m., the MDS nurse said she completed the MDS dated [DATE] for Resident #1 based on the nursing evaluation dated 05/22/19. The MDS nurse said she was unaware Resident #1 had surgical wounds. During an interview on 06/13/19 at 10:50 a.m., LVN D said on 06/02/19 a CNA told her the dressings on Resident #1 were dirty. LVN D said she could not find any orders for dressing changes or wound care for Resident #1. LVN D said she assessed Resident #1 and saw she had sutures to both sides of the groin area that had a moderate amount of blood tinged drainage. LVN D said Resident #1's lower abdomen, both sides of her groin, and upper thighs were angry red and warm to the touch. LVN D said she reported the findings to the physician and received orders to send Resident #1 to the hospital for evaluation. During an interview on 06/13/19 at 11:30 a.m., the DON said Resident #1 was admitted to the facility with surgical incisions on both upper thigh/groin areas and the incisions were never assessed. The DON said Resident #1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The DON said the facility put measures in place to ensure residents were better assessed on admission and a complete report was received from the transferring facility. The DON said she had conducted multiple trainings on initial assessments, MDS, and skin assessments with all nursing staff. She said the following measures had been put in place: *A new form used to take a phone report from the discharging facility with staff in-serviced. *A new checklist for conducting the admission of a resident into the facility, and a re-admission for residents returning from the hospital to the facility with staff in-serviced. *CNAs were to complete a skin sheet with each shower or bath given and turn the sheet into the nurses daily with staff in-serviced. One LVN interviewed said he had been in-serviced on receiving reports from discharging facilities and the admission checklist. One CNA (shower aide) said she is completing shower sheets daily for residents. She said she had been using the sheets for a few days and she would fill one out for each resident she assisted with a bath and turn them in to the nurse. A facility policy and procedure titled Admission Assessment and Follow Up: Role of the Nurse, revised (MONTH) 2012, revealed in part .The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychological condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS .