Every finding on record at Twin Pines Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed ensure the coordination of assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 4 residents (Resident #1) reviewed for PASRR services. Resident #1's NFSS form to request services was not completed and submitted within the required 20 business days of the IDT meeting conducted on 10/02/2025. This failure could place residents identified as intellectually or developmentally disabled at risk of not receiving specialized services and equipment to meet their needs. The findings included: Record review of Resident #1's admission sheet dated 5/14/2026 with an original admission date of 10/04/2024, documented a [AGE] year-old-male resident with diagnoses including cerebral palsy (a group of neurological conditions that affect muscle movement, posture, and coordination often caused by a brain injury or abnormal development of the brain before, during, or shortly after birth), seizures, intellectual disabilities, and scoliosis (a side-to-side curve of the spine). Record review of Resident #1's quarterly MDS assessment dated [DATE], documented a BIMS score of 5 indicating severe cognitive impairment and recorded a positive response in Section GG - Functional Abilities GG0120. Mobility Devices Check all that were normally used in the last 7 days C. Wheelchair (manual or electric). Further review of the assessment recorded the diagnoses of cerebral palsy and seizure disorder in Section I - Active Diagnoses. Record review of Resident #1's order summary included orders for a wheelchair with an order date of 02/18/2026, physical therapy with an order date of 5/19/2026, and for occupational therapy with an order date of 5/19/2026. A wheelchair was ordered as May use wheelchair. Physical therapy was ordered as resident to be seen 5 x/week for 60 days that includes Therapeutic Exercises, Therapeutic Activities, Neuromuscular reeducation, Manual therapy, Wheelchair management training and Group therapy. Occupational therapy was ordered as eval and TX 3 x per week X 30 days. POC to include Ther-ex, Ther-Act, Neuro-[NAME], ADLs, endurance, cardio, and safety awareness. Record review of Resident #1's care plan with an initiation date of 10/04/2024, documented the resident has IDD and is PASRR positive. Patient with DX of Cerebral Palsy, with a goal of Resident will have the specialized services recommended by local authority per PASRR Specialized Services program as needed. Further review of the care plan noted The resident has Cerebral Palsy. with a goal of The resident will be able to function at the fullest potential possible as outlined by the treatment team. Record review of Resident #1's IDT LIDDA HSP dated 10/09/2025, documented the resident had agreed to continue PASRR services, and that the resident was receiving physical therapy through Part B three times a week. Further review of the service plan noted a custom wheelchair was needed, and the resident was currently borrowing one from the nursing facility until he could get his own. Record review of an email sent by PASRR to the Administrator on 02/20/26 documented the HHSC PASRR unit had not received a request for specialized services from the facility within 20 business days following the date that the services were agreed to in the IDT meeting which occurred on 10/09/2025. Record review of Resident #1's NFSS submission documented a service request for physical therapy on 3/05/2026, and noted the resident used a wheelchair as a means of mobility within the facility. Record review of Resident #1's PCSP dated 4/07/2026, documented in Section A3300. Local Authority Comments No DME required. During an interview with the DOR on 6/02/2026 at 1:44 PM, the DOR stated Resident #1 had received physical therapy and occupational therapy services since he became a resident of the facility on 10/04/2024 through a preferred partners health plan offered to residents of the facility. The DOR stated they discussed the use of a custom wheelchair during the last IDT meeting on 4/07/2026, and the resident declined the custom wheelchair in favor of his standard wheelchair which he had used since admission. The DOR further stated the IDT meetings were conducted with the resident and the representative from the LIDDA and held annually and quarterly. The DOR stated she did not know if the LIDDA representative submitted a report to the portal. During an interview with the Social Worker on 6/02/26 at 1:59 PM, the Social Worker stated Resident #1 refused the offer of a custom wheelchair. During an interview with the MDS RN on 6/02/26 at 3:39 PM, the MDS RN stated IDT meetings were conducted annually and quarterly for residents who needed services, and meetings were set up by the LIDDA. The MDS RN stated the facility provided services and specialized equipment if a resident required it, regardless of a resident's PASRR status. The MDS RN stated it was her responsibility to submit the annual IDT reports to the state, and it was the responsibility of the LIDDA to submit quarterly IDT reports to the state. During an interview with the MDS LVN on 6/02/2026 at 3:49 PM, the MDS LVN stated if there was an update to a resident's plan, the facility needed to send a new NFSS to the state, but the IDT report needed to be submitted regardless of any changes in the resident's care. During an observation and interview with Resident #1 on 6/03/2026 at 10:33 AM, the resident was observed sitting in his standard wheelchair in his room while visiting with a family member on video. Resident #1 stated he did not prefer the recommended custom wheelchair to his standard wheelchair and wanted an electric one. Record review of the facility policy titled PASRR Nursing Facility Specialized Services Policy and Procedure, revised 2023, noted Policy: It is the policy of Creative Solutions in Healthcare facilities to ensure NFSS Forms are submitted timely and accurately. and 9. The facility only has 20 business days from the Date of the PCSP meeting to submit a completed and accurate NFSS Form.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 4 of 6 residents (Resident #8, #2, #75, and #43) reviewed for accuracy of records: 1. Nursing staff failed to document medication administration in the MAR for Resident #8 on 2/1/2026, 2/9/2026, 2/16/2026 and 2/17/2026.2. The facility failed to document wound care dressing changes on the TAR for Resident #2 on 02/06/2026, 02/07/2026, 02/10/2026, and 02/11/2026.3. The facility failed to ensure Resident #75's MAR accurately reflected when the resident's Fluticasone nasal spray was administered and when it was not for February 2026.4. The facility failed to document wound care dressing changes on the TAR for Resident #43 on 2/5/26, 2/6/26, 2/7/26, and 2/10/26. These failures could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.The findings included: 1.Record review of Resident #8's face sheet, dated 02/18/2026 revealed a [AGE] year-old female with an initial admission 2/28/2020 and a readmission on [DATE] with diagnoses of; Ogilvie syndrome (sever, sudden swelling of the large intestine), diverticulitis (digestive disease causing bulging pouches in the intestine), and atherosclerotic heart disease (plaque build up in the arteries). Record review of Resident #8's MDS, dated [DATE] revealed BIMS score of 11, which indicated moderate cognitive impairment. Record review of Resident #8's doctor orders revealed, Dicyclomine HCl Oral Tablet 20 MG (Dicyclomine HCl), Give 1 tablet by mouth every 6 hours for IBS. Record review of Resident #8's MAR indicated no documentation of medication administration on 2/1/2026, 2/9/2026, 2/16/2026 and 2/17/2026. During an interview on 2/20/2026 at 8:50 am, CMA G stated that the Dicyclomine HCl was administered to Resident #7 but he forgot to click the administration box in the MAR. 2.Record review of Resident #2's face sheet dated 02/17/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of unspecified injury of the head. Record review of Resident #2's BIMS assessment dated [DATE] revealed a BIMS of 0 out of 15 suggesting severe cognitive impairment. Record review of Resident #2's Order Summary Report dated 02/17/2026 reflected the following: - cleanse stage 3 to left heel with normal saline, pat dry with 4 x 4 gauze. Apple Santyl gel and calcium alginate sheet to wound bed and cover with dry dressing every day shift for wound healing until resolved with order date 02/05/2026 with no end date. Record review of Resident #2's MAR/TAR for February 2026 reflected there was no documentation for left heel wound care on 02/06/2026, 02/07/2026, 02/10/2026, and 02/11/2026. Record review of Resident #2's care plan provided on 02/17/2026 revealed a focus area for the following: .Resident with a stage 3 pressure wound to left heel with treatment in place, revision date of 02/10/2026, with interventions including follow facility policies/protocols for the prevention/treatment of skin breakdown initiated on 11/21/2025 During an interview on 02/18/2026 at 2:53 p.m., LVN D stated the missing documentation on Resident #2's MAR/TAR for wound care could have resulted from being pulled to work on the floor and fell behind on her documentation in the electronic record but documented on a paper form instead. LVN D stated she made sure wound care was done for Resident #2 and all other residents requiring wound care. During an interview on 02/19/2026 at 1:45 p.m., LVN D stated if there was missing documentation on the MAR/TAR it looked like it was not completed. 3. Record review of Resident #75's face sheet dated 2/18/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included moderate persistent asthma, anxiety disorder, heart failure, kidney failure, and allergic rhinitis (runny nose). Record review of Resident #75's most recent comprehensive MDS assessment dated [DATE] reflected the resident had a BIMS score of 11, which indicated moderate cognitive impairment. Record review of Resident #75's Order Summary Report dated 2/18/26 reflected the following: - Fluticasone Propionate Nasal Suspension 50 mcg/act, 1 spray in both nostrils two times a day related to allergic rhinitis, with order date 1/5/26 and no end date -Levothyroxine Sodium Tablet 200 MCG, Give 1 tablet by mouth one time a day. Record review of Resident #75's MAR for February 2026 reflected the following for Fluticasone Propionate nasal spray: - AM dose was not administered 2/7, 2/8, 2/9, 2/12, 2/15, 2/16 - PM dose was not administered 2/2, 2/4, 2/9, 2/10, 2/11, 2/16, 2/17 -No documentation of medication administration on 2/17/2026 for Levothyroxine Sodium. Resident #75's MAR reflected the Fluticasone Propionate nasal spray was administered to the resident on the following days: - AM dose administered 2/1-2/6, 2/10-2/11, 2/13-2/14, and 2/17-2/18 - PM dose administered 2/1, 2/3, 2/5-2/8, and 2/12-2/15 During an interview on 2/18/26 at 2:09 p.m., MA K stated she routinely worked with Resident #75 and stated the resident did not refuse medications. MA K stated when a medication was not available or if a medication was refused, the code other was used on the MAR and then the system would prompt the staff to enter a progress note that indicated why the medication was not given. MA K stated she had marked other on Resident #75's MAR which indicated the resident did not have Fluticasone nasal spray available. MA K stated she had reported the medication not being in the medication cart to the ADON and the night shift nurse LVN L. MA K stated she did not recall Resident #75 ever receiving a dose of Fluticasone nasal spray from her for the month of February 2026 because it had not been available. MA K stated they were not allowed to leave the MAR blank because it could be assumed the medication was not given. During an interview on 2/18/26 at 2:35 p.m., the ADON stated, the electronic MAR was designed in a way in which if a medication was not available, the computer system would prompt the staff to use the code 9 for other and then the system would prompt the staff to write a progress note that would indicate why the medication was not given. The ADON stated she had not been made aware Resident #75's Fluticasone nasal spray was not in stock. The ADON stated there were no designated staff assigned to order medications, it would be whatever floor nurse was working at the time, and a CMA was also capable of ordering medications. The ADON stated she was not aware of a process in place for auditing the MAR for discrepancies. The ADON stated it was not acceptable to leave blanks on the MAR because it would look like the resident did not receive their medication or treatment. The ADON stated if a resident was not getting prescribed medications, and depending on the medication, it could be detrimental to their health. The ADON stated, Resident #75's Fluticasone nasal spray should have been provided by the physician's orders and by the resident's needs. During an interview on 2/19/26 at 8:43 p.m., MA I stated she recalled ordering Resident #75's Fluticasone spray and it's been in the building. MA I stated Resident #75's Fluticasone nasal spray was here the other day, there was none, I could not find it, it was in the building, but I could not find it. MA I stated, I was not intentionally marking that it (Fluticasone nasal) spray was given when the medication was not available, it was probably marked in haste when documenting on the MAR/TAR. MA I stated if a resident was not receiving prescribed medications the resident could get sick and in the case of Resident #75's nasal spray, she could develop a runny nose and have a hard time breathing. MA I stated, it was not acceptable to leave blanks on the MAR because it could indicate the medication was not given. During an interview on 2/19/26 at 9:00 a.m., Resident #75 stated she finally received a dose of Fluticasone spray on 2/19/26, but it had been several weeks since she had been given the medication. Resident #75 stated she was told the nasal spray was on order or was not available. During an interview on 2/19/2021 at 9:07 am, DON stated she investigated why there are holes in the MAR. The DON stated she interviewed the staff that were assigned on those days and found out that medications were given but the staff did not click the administration button. The DON stated that it should have been documented to prove that it was done and to prevent any discrepancies in the MAR. During an interview on 2/20/2026 at 8:50 am, CMA G stated that the Levothyroxine Sodium was administered to Resident #75 but he forgot to click the administration box in the MAR. 4. Record review of Resident #43's face sheet dated 2/19/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included disorders of bone density and structure. Record review of Resident #43's most recent comprehensive MDS assessment dated [DATE] reflected that the resident was cognitively intact for daily decision-making skills and had a stage 3 pressure ulcer (a full thickness skin loss where the damage extends through the skin into the fatty tissue). Record review of Resident #43's Order Summary Report dated 2/19/26 reflected the following: - cleanse wound to right buttock with normal saline, pat dry with 4 x 4 gauze. Pack wound with collagen powder, calcium alginate sheet, and cover with dry dressing daily and as needed with order date 2/3/26 and no end date. Record review of Resident #43's MAR/TAR for February 2026 reflected there was no documentation for right buttock wound care on 2/5, 2/6, 2/7, and 2/10. Record review of Resident #43's comprehensive care plan with revision date 2/18/26 reflected the resident had a pressure ulcer to the right buttock with interventions that included to follow facility policies/protocols for the prevention of skin breakdown. During an interview on 2/17/26 at 11:22 a.m., Resident #43 stated she had a wound on the right buttock for approximately one month and the bandage was not changed every day, except when needed. During an interview on 2/19/26 at 11:27 a.m., LVN D stated the missing documentation on Resident #43's MAR/TAR for wound care could have resulted from being pulled to work on the floor and fell behind on her documentation. LVN D stated, wound care was not missed, that is something I make sure of. LVN D stated, if there was missing documentation on the MAR/TAR it could be assumed the care was not done. LVN D stated it was not acceptable. Record review of the facility document titled Documentation, undated, reflected in part, .Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident and or soft resident file. It may include observations, investigations, and communications of the resident involving care and treatment. It has legal requirements regarding accuracy and completeness, legibility and timing. Special form in the clinical record are utilized in nursing documentation such as.medication sheets.Goal.The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.Complete documentation as needed in a timely manner. Records review of facility policy titled, Documentation reflected, complete documentation in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 18 residents (Residents #48, #98, #83, and #43) reviewed for infection control: 1. The facility failed to ensure MA I sanitized the blood pressure cuff used between Resident #48, #98, and #83.2. The facility failed to ensure LVN D wore proper PPE while providing wound care to Resident #43 who was on EBP status. These failures could place residents at risk for cross-contamination and infection and could result in illness due to improper care practices.The findings included: 1. Observation on 2/19/26 beginning at 7:59 a.m. during the medication pass revealed, CMA I obtained Resident #48's blood pressure prior to administering medications, then took the same blood pressure cuff and obtained Resident #98's blood pressure and then took the same blood pressure cuff and obtained Resident #83's blood pressure without sanitizing the blood pressure cuff between resident use. During an interview on 2/19/26 at 8:32 a.m., MA I stated, the blood pressure cuff used on Resident #48, #98, and #83 was a blood pressure cuff she personally owned. MA I stated she did not believe the blood pressure used between the residents was contaminated because I placed the blood pressure cuff over their clothes. MA I stated, I usually spray it (the blood pressure cuff) with bleach sanitizer after the completion of medication pass. MA I stated she had not been taught about sanitizing a blood pressure cuff while working for the facility and used her medication aide knowledge. MA I stated she would have sanitized the blood pressure cuff if a resident had slobber on their arm I would have cleaned it (the blood pressure cuff) after using it, but I don't really think it's necessary. That's my opinion. 2. Record review of Resident #43's face sheet dated 2/19/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included disorders of bone density and structure. Record review of Resident #43's most recent comprehensive MDS assessment dated [DATE] reflected that the resident was cognitively intact for daily decision-making skills and had a stage 3 pressure ulcer (a full thickness skin loss where the damage extends through the skin into the fatty tissue). Record review of Resident #43's Wound Progress Note dated 2/10/26 and authored by the NP reflected the resident had an improving Stage 3 pressure wound to the right buttock and a treatment plan that included to clean the wound with wound cleanser, apply Iodoform packing strip, Calcium alginate and dry dressing changes daily and as needed if dressing was dislodged, saturated, or soiled. Record review of Resident #43's comprehensive care plan with revision date 2/18/26 reflected the resident had a pressure ulcer to the right buttock with interventions that included to follow facility policies/protocols for the prevention of skin breakdown. Resident #43's comprehensive care plan did not reflect the resident was on EBP status related to the pressure wound. During the wound care observation on 2/19/26 at 11:43 a.m., LVN D put on a pair of gloves, did not put on a gown, and removed Resident #43's bandage from the right buttock. Resident #43 was observed with an open wound on the right buttock that had moderate serosanguineous drainage (thin pink to light red drainage) emitting from the wound and observed on the bandage. LVN D was observed squatting over Resident #43's bed and her forearms resting on the resident's bed while providing wound care. During an observation and interview on 2/19/26 at 11:27 a.m., LVN D, after she completed wound care to Resident #43 stated the resident was on EBP status related to the open wound to the right buttock, but there was no evidence of a PPE cart with proper equipment and supplies or an EBP sign which indicated the resident was on EBP status. LVN D stated the EBP sign was gone and the PPE cart was moved. LVN D stated she usually wore a gown when providing Resident #43 with wound care but I can reassure you this was an honest mistake. I was nervous. LVN D stated the purpose for wearing a gown was in case the resident had excessive drainage, and the drainage should get on her and could possibly result in the spread of infection. LVN D stated not wearing proper PPE such as a gown could result in spreading an infection to somebody else. During an interview on 2/19/26 at 4:46 p.m., the DON stated nursing staff, when providing wound care, were supposed to be wearing a gown per the EBP rules. The DON stated the purpose for wearing proper PPE for residents on EBP was because it was to prevent the spread of infection. The DON stated there should have been a sign posted outside of Resident #43's room that indicated the resident was on EBP status. The DON stated the EBP sign was supposed to alert staff to the use of proper PPE when providing direct contact care. Record review of the facility document titled Fundamentals of Infection Control Precautions, undated, reflected in part, .A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.Gowns and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganisms in the LTCF. Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures.Non-invasive resident care equipment is cleaned daily or as need (sic) between use by the nursing assistant. Record review of the facility document titled Enhanced Barrier Precautions dated 4/1/24 reflected in part, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident activities.EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident activities.EBP are indicated for residents with any of the following.chronic wounds.Examples.pressure ulcers.The facility will ensure PPE and alcohol-based hand rub are readily accessible to staff. Discretion may be used in the placement of supplies which may include placement near or outside the resident's room.Communication to Staff.The facility will utilize postings outside the room and [electronic record] to communicate to staff if a resident requires EBP.

Based on interviews, and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or related condition for level II resident review upon a significant change in status assessment for 1 of 7 residents (Resident #3) reviewed for PASARR accuracy. The MDS Coordinator failed to refer Resident #3 after newly diagnosed mental illness for level II resident review. This deficient practice could place the residents at risk of not receiving the necessary mental health care and services.The findings included: Record review of Resident #3's face sheet, dated 02/17/2026, revealed a [AGE] year-old female admitted to the facility on [DATE], with a primary diagnosis of unspecified dementia (decline in cognitive function). Record review of Resident #3's MDS, dated [DATE], revealed the resident's BIMS score was 10 out of 15 which suggested moderate cognitive impairment. Record Review of Resident #3's diagnosis information on the face sheet dated 02/17/2026 revealed diagnoses of Schizoaffective disorder, bipolar type (mental health condition characterized by symptoms both schizophrenia and mood disorder, specifically mania) with an onset date of 03/09/2023 and Bipolar disorder, current episode depressed, moderate (a mental condition characterized by significant mood swings, including manic episodes and depressive episodes) with an onset date of 02/29/2024. Record review of Resident #3's PASARR Level 1 screening, dated 02/27/2023 and completed at the hospital, revealed section C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness recorded as a no. Record review of Resident #3's PASARR Level 1 screening, dated 02/27/2023 and completed at the nursing facility, revealed section C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness recorded as a no. Record review of Resident #3's PASARR screenings revealed no referral for level II review. During an interview on 02/19/2026 at 11:40 a.m., the MDS Coordinator M stated they were responsible for looking over PASSAR documents when a resident is admitted and reviewing the clinical record for accuracy for the PASSAR assessment. The MDS Coordinator M confirmed Resident #3 had mental health diagnoses after being admitted to the nursing facility. The MDS Coordinator M stated the importance of an accurate PASSAR would be residents receiving the services they need. The MDS coordinator M stated they would need to submit form 1012 to correct the PASSAR assessment. The MDS Coordinator M stated Resident #3 had not been referred for a level II review but that they should have been referred to the local mental health authority upon a new mental health diagnosis. During an interview on 02/19/2026 at 4:49 p.m., the DON stated the MDS coordinators should be reviewing the PASSAR assessments for accuracy. The DON stated if a resident has a newly diagnosed mental illness it is important to refer the resident so they can get the proper services they need. Record review of the facility's policy, Form 1012 Policy & Procedure with instructions, no date, revealed: Procedure: When to Prepare: The NF completes Form 1012 following:-an individual's diagnosis is changed

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 18 residents (Resident #50, and #90) reviewed for dignity. 1. The facility failed to ensure the ADON was not standing while feeding Resident #50.2. The facility failed to ensure MA H was not standing while feeding Resident #90. These failures could place residents at risk for diminished quality of life, loss of dignity and self-worth. The findings included: 1. Record review of Resident #50's face sheet, dated 2/20/26, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (progressive mental deterioration), dementia (decline in cognitive function), and Trisomy 21 (genetic condition caused by presence of an extra copy of chromosome 21). Record review of Resident #50's most recent quarterly MDS assessment, dated 1/13/26, reflected the resident was severely cognitively impaired for daily decision-making skills, required setup or clean-up assistance with eating, had a swallowing disorder which caused coughing or choking during meals, and required a mechanically altered diet. Record review of Resident #50's comprehensive care plan with initiation, date 7/11/25, reflected the resident had an ADL self-care deficit and interventions included to provide supervision with eating as needed. During an observation and interview on 2/20/26 at 9:12 a.m. revealed the ADON standing over Resident #50's left side feeding the resident. The ADON stated she was not supposed to be standing while feeding the resident because it was not respectful or dignified. The ADON stated, I'll take accountability, you should never stand while feeding the resident. 2. Record review of Resident #90's face sheet, dated 2/20/26, reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia with behavioral disturbance, diabetes, and muscle weakness. Record review of Resident #90's most recent quarterly MDS assessment, dated 2/5/26, reflected the resident was severely cognitively impaired for daily decision-making skills, required setup or clean-up assistance with eating, and required a mechanically altered diet. Record review of Resident #90's comprehensive care plan with revision date 1/28/23 reflected the resident had an ADL self-care performance deficit with interventions that included one-person staff assistance with eating. During an observation and interview on 2/20/26 at 9:17 a.m., revealed MA H standing over Resident #90's right side feeding the resident. MA H stated she should feed the resident at eye level; I was just trying to get her to eat. During an interview on 2/20/26 at 9:36 a.m., the DON stated, standing while feeding a resident was a dignity issue. The DON stated, we should be at eye level while feeding a resident, otherwise it looks like it's intimidating. Record review of the facility document titled Resident Rights, undated, reflected in part, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality .

Based on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 4 residents (Resident #66) reviewed for laboratory services: The facility failed to obtain a digoxin drug level (digoxin is a medication used to manage atrial fibrillation [rapid heart rate] or heart failure; obtaining digoxin levels determines therapeutic effects and toxicity effects) for Resident #66 as ordered by the physician. This deficient practice could place residents at risk for a delay in identifying or diagnosing a problem, adjusting medications, and ensuring treatment needs were identified and addressed.The findings included: Record review of Resident #66's face sheet dated 2/19/26 reflected an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertensive heart disease without heart failure, hyperlipidemia (high cholesterol), hypertension (elevated blood pressure) and atrial fibrillation (irregular heart rhythm). Record review of Resident #66's most recent quarterly MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills. Record review of Resident #66's Order Summary Report dated 2/19/26 reflected the following:- CBC, and CMP, TSH every 3 months (Jan, Apr, Jul, Oct) with order date 7/29/24 and no end date- Digoxin [levels] every 3 months with routine labs (Oct, Jan, Apr, July) with order date 9/11/24 and no end date- Digoxin tablet 125 mcg, give 1 tablet by mouth one time a day related to atrial fibrillation; hold for heart rate less than 60, with order date 7/29/24 and no end date Record review of Resident #66's comprehensive care plan with revision date 9/11/24 reflected the resident had hypertension, and hyperlipidemia related to coronary artery disease with interventions that included to administer medications as ordered. Resident #66's comprehensive care plan reflected the resident had hyperlipidemia with interventions that included to administer medication as ordered and lab to be drawn as ordered, promptly reviewing results and reporting to the MD. Record review of Resident #66's medical record reflected there were no digoxin level results in the record after July 2025. Resident #66's record was missing physician ordered digoxin level results for October 2025, and January 2025. During record review and interview on 2/19/26 at 1:48 p.m., LVN J stated she had worked for the facility for approximately 14 years and gave up her position as the facility ADON around October 2025 and was now on the schedule as a floor nurse. LVN J stated she was aware Resident #66 was prescribed Digoxin routinely. LVN J reviewed Resident #66's medical record and stated, the last digoxin level drawn for Resident #66 was July 2025, but no digoxin levels were drawn for October 2025 and January 2025 per physician's orders. LVN J stated, as the former ADON, she used to be responsible for ensuring routine physician ordered labs were carried out by obtaining a physician order and inputting the lab order into the computer system which would then be sent electronically to the lab. LVN J stated, somehow the labs got missed (for Resident #66) and was not sure what the system (for carrying out lab orders) was now. LVN J stated it was important to obtain digoxin levels because it determined whether or not the medication was working effectively by determining if the resident received too much or not enough digoxin. During an interview on 2/19/26 at 2:05 p.m., the DON stated she had recently been given the position as the DON approximately two months ago and had educated the nursing staff at the time she accepted the position. The DON stated she instructed the nursing staff, at the time a resident was admitted , to obtain physician orders for labs and at that time, fill out a lab requisition form and place it in a lab binder that was labeled for each month which indicated when a lab test was due. The DON stated, this is for all of the floor nurses. Including myself and the ADON. The DON stated she felt the missing digoxin levels for Resident #66 fall on me, but my staff needs to take accountability. The DON stated, it was her expectation that standing lab orders had to have requisitions and placed in the lab binder under the tab in which the lab was due. The DON stated she routinely audited medical records, including auditing for completed scheduled labs. The DON stated, we are accountable for that, I cannot make excuses. Right now, we have a system failure. During an interview on 2/19/26 at 3:30 p.m., requested by the NP, she stated, the facility recently switched to a new lab and nobody knew how to use it. The NP stated, at the time the facility switched to the new lab the former DON was responsible for ensuring scheduled labs were carried out, but when she left, nobody had been fully trained on it. The NP stated that the new lab system required lab requests be input into the computer system, but paper requisitions still had to be used and placed in the lab binder. The NP stated obtaining digoxin levels was important because if the level was too high it could mean toxicity and if the digoxin levels were too low it could mean the medication was not working or not therapeutic. The NP stated that digoxin level results typically for Resident #66 showed the resident had been stable and realistically could be monitored every 6 months instead of every 3 months.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 6 medication carts reviewed for storage of drugs and biologicals.The facility failed to ensure the 100-hall medication cart was locked and secured.These deficient practices could place residents at risk of medication misuse or drug diversion.The findings included: During an observation and interview on 2/19/26 at 7:23 a.m. revealed the 100-hall medication cart was left unlocked and unattended. Interview with MA I revealed the unlocked medication cart observed on the unit was assigned to RN C. MA I stated, RN C was in a resident room assessing a resident. During an interview on 2/19/26 at 7:26 a.m., RN C stated she was in a room assessing a resident who had fallen. RN C stated she should not have left the 100-hall medication cart unlocked and unattended because other residents or visitors could gain access to the cart and take medications that did not belong to them which could result in an adverse reaction and depending on the medication not prescribed for them, they could overdose. During an interview on 2/19/26 at 4:41 p.m., the DON stated a medication cart should never be left unlocked and unattended because it was potential for medication discrepancies. The DON stated an unlocked medication cart could provide access to somebody who should not have access to the cart and could result in a medication being taken that did not belong to them. Record review of the facility document titled Medication Storage in the Facility dated 2025 reflected in part, .Medications and biologicals are stored safely, securely, and properly.The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 residents (Resident #75) reviewed for pharmacy services. The facility failed to ensure Resident #75 received Fluticasone Propionate Nasal Spray (a steroid spray used to treat nasal allergy symptoms) as prescribed by a physician. This failure could place residents at risk of not receiving their prescribed medications and a decreased quality of life.The findings included: Record review of Resident #75's face sheet dated 2/18/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included moderate persistent asthma, anxiety disorder, heart failure, kidney failure, and allergic rhinitis (runny nose). Record review of Resident #75's most recent comprehensive MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making skills. Record review of Resident #75's Order Summary Report dated 2/18/26 reflected the following:- Fluticasone Propionate Nasal Suspension 50 mcg/act, 1 spray in both nostrils two times a day related to allergic rhinitis, with order date 1/5/26 and no end date Record review of Resident #75's MAR for February 2026 reflected the following for Fluticasone Propionate nasal spray:- AM dose was not administered 2/7, 2/8, 2/9, 2/12, 2/15, 2/16- PM dose was not administered 2/2, 2/4, 2/9, 2/10, 2/11, 2/16, 2/17 During an interview on 2/18/26 at 2:09 p.m., MA K stated she routinely worked with Resident #75 and stated the resident did not refuse medications. MA K stated when a medication was not available or if a medication was refused, the code other was used on the MAR and then the system would prompt the staff to enter a progress note that indicated why the medication was not given. MA K stated she had marked other on Resident #75's MAR which indicated the resident did not have Fluticasone nasal spray available. MA K stated she had reported the medication not being in the medication cart to the ADON and the night shift nurse LVN L. MA K stated she did not recall Resident #75 ever receiving a dose of Fluticasone nasal spray from her for the month of February 2026 because it had not been available. During an interview on 2/18/26 at 2:35 p.m., the ADON stated, the electronic MAR was designed in a way in which if a medication was not available, the computer system would prompt the staff to use the code 9 for other and then the system would prompt the staff to write a progress note that would indicate why the medication was not given. The ADON stated she had not been made aware Resident #75's Fluticasone nasal spray was not in stock. The ADON stated there were no designated staff assigned to order medications, it would be whatever floor nurse was working at the time, and a MA was also capable of ordering medications. The ADON stated she was not aware of a process in place for auditing the MAR for discrepancies. The ADON stated if a resident was not getting prescribed medications, and depending on the medication, it could be detrimental to their health. The ADON stated, Resident #75's Fluticasone nasal spray should have been provided by the physician's orders and by the resident's needs. During an interview on 2/19/26 at 8:43 p.m., MA I stated she recalled ordering Resident #75's Fluticasone spray and it's been in the building. MA I stated Resident #75's Fluticasone nasal spray was here the other day, there was none, I could not find it, it was in the building, but I could not find it. MA I stated she had trained MA K on ordering medications and was aware all the nursing staff, including the MA staff, could order medications. MA I stated if a resident was not receiving prescribed medications the resident could get sick and in the case of Resident #75's nasal spray, she could develop a runny nose and have a hard time breathing. During an interview on 2/19/26 at 9:00 a.m., Resident #75 stated she finally received a dose of Fluticasone spray on 2/19/26, but it had been several weeks since she had been given the medication. Resident #75 stated she was told the nasal spray was on order or was not available. During an interview on 2/19/26 at 9:51 a.m., the DON stated Resident #75's Fluticasone nasal spray was found in a medication cart after the ADON was instructed to check all the medication carts on 2/18/26. The DON stated there was no procedure for checking regular medication deliveries and how they were distributed except for controlled medications. Record review of the facility document titled Medication Orders dated 2025 reflected in part, .Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe.Procedure.Call, fax, or electronically submit the medication orders to [pharmacy].Medication orders are recapped on a monthly basis when the prescriber signs the computer physician order summary. This is reviewed by a designated nurse each month before giving it to the prescriber to sign. Record review of the facility document titled Receiving Medications from Pharmacy dated 2025 reflected in part, .Medications and related products are received from the pharmacy supplier on a timely basis. The facility maintains accurate records of medications ordered and receipt of.

Based on observation, interview and record review, the facility failed to ensure the residents' right to personal privacy and confidentiality of his or her personal medical records for 1 of 18 residents (Resident #84) reviewed for privacy and confidentiality: The facility failed to ensure RN C did not leave Resident #84's patient information exposed on her computer screen. This failure could place residents at risk of having personal medical information disclosed and placed them at risk for misuse of the information. The findings included: Record review of Resident #84's face sheet dated 1/19/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cellulitis (swelling and skin infection), diabetes, asthma, and shortness of breath. During an observation and interview on 2/19/26 at 7:23 a.m., the computer screen mounted on top of the medication cart in the 100 unit revealed Resident #84's medical information. CMA I stated the computer mounted on the medication cart was being used by RN C who was assessing a resident in the resident's room. During an observation and interview on 2/19/26 at 7:26 a.m., RN C stated she was in a room assessing a resident who had a fall. RN C stated she should not have left her computer screen open exposing Resident #84's medical information because it was considered a HIPPA violation. During an interview on 2/19/26 at 4:4a p.m., the DON stated exposed resident information on a computer screen was considered a HIPPA violation. Record review of the facility document titled Resident Rights, undated, reflected in part, .The facility must protect and promote the rights of the resident.Privacy and confidentiality - The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 18 residents (Resident #43) reviewed for care plans: The facility failed to ensure Residents #43's Care Plan reflected she was on EBP status related to a pressure wound. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.The findings included: Record review of Resident #43's face sheet dated 2/19/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included disorders of bone density and structure. Record review of Resident #43's most recent comprehensive MDS assessment dated [DATE] reflected that the resident was cognitively intact for daily decision-making skills and had a stage 3 pressure ulcer (a full thickness skin loss where the damage extends through the skin into the fatty tissue). Record review of Resident #43's Wound Progress Note dated 2/10/26 and authored by the NP reflected the resident had an improving Stage 3 pressure wound to the right buttock and a treatment plan that included to clean the wound with wound cleanser, apply Iodoform packing strip, Calcium alginate and dry dressing changes daily and as needed if dressing was dislodged, saturated, or soiled. Record review of Resident #43's comprehensive care plan with revision date 2/18/26 reflected the resident had a pressure ulcer to the right buttock with interventions that included to follow facility policies/protocols for the prevention of skin breakdown. Resident #43's comprehensive care plan did not reflect the resident was on EBP status related to the pressure wound. During the wound care observation on 2/19/26 at 11:08 a.m., LVN D removed Resident #43's bandage from the right buttock and the resident was observed with an open wound that had moderate serosanguineous drainage (thin pink to light red drainage) emitting from the wound and observed on the bandage. During an observation and interview on 2/19/26 at 11:27 a.m., LVN D, after she completed wound care to Resident #43 stated the resident was on EBP status related to the open wound to the right buttock, but there was no evidence of a PPE cart with proper equipment and supplies or an EBP sign which indicated the resident was on EBP status. LVN D stated the EBP sign was gone and the PPE cart was moved. During a joint interview on 2/19/26 at 4:07 p.m., RN F and RN E, who developed MDS assessments revealed the comprehensive care plan was developed collaboratively with the nursing staff. RN F and RN E, after reviewing Resident #43's comprehensive care plan stated EBP status was not care planned and should have been. RN E stated LVN D, who provided wound care to Resident #43, or the unit nurses should have revised the comprehensive care plan to include EBP status. RN E and RN F stated the comprehensive care plan was important because it tells the residents' story and it helps the staff to know what to do. During an interview on 2/19/26 at 4:46 p.m. the DON stated, resident comprehensive care plans could be developed by any nursing staff, including nurses who worked on the units, members of the interdisciplinary team, the ADON, and the DON. The DON stated EBP status for a resident was supposed to be care plan because it provided a picture of the residents and how to take care of them.

Based on observation, interview and record review the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, for 2 of 2 residents (Resident #58, Resident #71), reviewed for accidents, in that: 1.The facility failed to ensure Resident #58 did not have scissors in her room. 2.The facility failed to ensure Resident #71 did not have scissors in her room. These failures could place residents at risk of injury and contribute to avoidable accidents and a decline in health.The findings include: 1.Record review of Resident #58's face sheet dated 02/18/2026 revealed a [AGE] year-old female admitted to the facility on [DATE], with a primary diagnosis of Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (experiencing a decline in cognitive abilities). Record review of Resident #58's MDS dated [DATE] revealed a BIMS of 6 out of 15 indicating severe cognitive impairment and recorded the needed use of supervision or touching assistance with hygiene and dressing. Record review of Resident #58's care plan provided on 02/18/2026 revealed a focus area for the following: Resident prefers to manicure own nails with nail clippers but is not safe to keep at bedside, initiated on 11/04/2016, with interventions including Encourage/remind resident to use bell to call for assistance. Check on resident at routine intervals to assess needs, monitor safety issues and offer/provide assistance as needed initiated on 11/04/2016. 2. Record review of Resident #71's face sheet dated 02/18/2026 revealed a [AGE] year-old female admitted to the facility on [DATE], with a primary diagnosis of unspecified protein-calorie malnutrition (severe nutritional disorder). Record review of Resident #71's MDS dated [DATE] revealed a BIMS of 4 out of 15 indicating severe cognitive impairment and recorded the needed use of supervision or touching assistance to set up or clean-up assistance with hygiene and dressing. Record review of Resident #71's care plan provided on 02/18/2026 revealed a focus area for the following: . the resident has impaired cognitive function/dementia or impaired thought processes, initiated on 10/11/2025, with interventions including Monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status initiated on 10/11/2025. During an observation on 02/17/2026 at 11:28 a.m., revealed Resident #71 had scissors lying on their bed. During an observation on 02/17/2026 at 12:02 p.m., revealed Resident #58 had scissors by their bedside. During an observation on 02/18/2026 at 7:58 a.m., revealed Resident #71 had scissors lying on their chair next to the bedside. During an observation on 02/18/2026 at 8:00 a.m., revealed Resident #58 had scissors lying on their dresser. During an interview on 02/18/2026 at 8:00 a.m., Resident #58 stated she was not aware that she could not have scissors and has not been told anything about them by staff. Resident #58 stated they use the scissors to open things because staff can take a while to come to the room. Resident #58 stated other residents do not come into their room and they have not hurt themselves with the scissors either. During an interview on 02/18/2026 at 3:05 p.m., Resident #71 stated staff have not said anything to Resident #71 about having scissors. Resident #71 stated they use scissors to open things like cookies or wrapped items. Resident #71 stated other residents do not come in their room and they have not hurt themselves with the scissors either. During an interview on 02/18/2026 at 3:07 p.m., CNA A stated Resident #58 needed assistance with going to the restroom and had more falls. CNA A stated Resident #71 needed assistance with bathing. CNA A stated residents are not allowed to have nail clippers or scissors in their rooms and if they did, CNA A would have to let a nurse know. CNA A stated Resident #58 should not have scissors because they have become less alert. CNA A stated right now Resident #71 was more alert but if Resident #71 was not CNA would take the scissors. CNA A stated sometimes residents may wander in and out of rooms due to confusion. CNA A stated the risk to residents that have scissors in their room could be residents might cause danger to themselves. During an interview on 02/18/2026 at 3:27 p.m., LVN B stated Resident #58 has declined a lot and is currently on hospice. LVN B stated Resident #71 needed assistance with their hygiene care. LVN B stated residents cannot have anything that can be harmful to them or sharps in their rooms. LVN B stated if a resident could have something sharp it would be in their care plan. LVN B confirmed both Resident #58 and Resident #71 did not have scissors care planned. LVN B stated they had not seen residents wander in and out of other residents' rooms. When asked what the danger would be for a resident to have scissors in their room, LVN B stated it could be fatal. During an interview on 02/18/2026 at 3:55 p.m., the DON stated residents cannot have any sharps, anything that can be used as a weapon or anything that is a safety hazard in their rooms. The DON stated if a resident could have sharps in their room, it would be care planned and there would have been an associated risk assessment completed but that the facility tries not to allow sharps in residents rooms at all. The DON stated they were not aware of any resident in the facility that is care planned to have scissors in their room. When asked what the danger would be for a resident to have scissors in their room the DON stated the resident could hurt themselves or others. When asked what policy is used for sharps in residents' rooms the DON stated the Event reporting policy. Record review of the facility's policy, Event Reporting; Completion of, no date, did not address hazards or residents having scissors but revealed:The facility will complete an Event report on variances that occur within the facility.

Based on interviews, and record review, the facility failed to preadmissions screen for individuals with a mental disorder and individuals with intellectual disability for 2 of 7 residents (Resident #3 and Resident #36) reviewed for PASARR accuracy.The MDS Coordinator failed to accurately screen Resident #3 for mental illness upon admission to the facility. The MDS Coordinator failed to accurately screen Resident #36 for mental illness upon admission to the facility. This deficient practice could place the residents at risk of not receiving the necessary mental health care and services.The findings included: 1. Record review of Resident #3's face sheet, dated 02/17/2026, revealed a [AGE] year-old female admitted to the facility on [DATE], with a primary diagnosis of unspecified dementia (decline in cognitive function). Record review of Resident #3's MDS, dated [DATE], revealed the resident's BIMS score was 10 out of 15 which suggested moderate cognitive impairment. Record Review of Resident #3's diagnosis information on the face sheet dated 02/17/2026 revealed a diagnosis of Major Depressive Disorder, recurrent, moderate (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life without behaviors not normal to resident) with an onset date of 02/27/2023. Record review of Resident #3's PASARR Level 1 screening, dated 02/27/2023 and completed at the hospital, revealed section C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness recorded as a no. Record review of Resident #3's PASARR Level 1 screening, dated 02/27/2023 and completed at the nursing facility, revealed section C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness recorded as a no. 2. Record review of Resident #36's face sheet, dated 02/18/2026, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease (progressive lung disease that makes it difficult to breathe). Record review of Resident #36's MDS, dated [DATE], revealed the resident's BIMS score was 6 out of 15 which suggested severe cognitive impairment. Record Review of Resident #36's diagnosis information on the face sheet dated 02/11/2026 revealed a diagnosis of bipolar disorder, unspecified, (a mental condition characterized by significant mood swings, including manic episodes and depressive episodes) with an onset date of 10/14/2024. Record review of Resident #36's PASARR Level 1 screening, dated 10/14/2024 and completed at the hospital, revealed section C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness recorded as a no. Record review of Resident #36's PASARR Level 1 screening, dated 10/14/2024 and completed at the nursing facility, revealed section C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness recorded as a no. During an interview on 02/19/2026 at 11:40 a.m., the MDS Coordinator M stated they were responsible for looking over PASSAR documents when a resident is admitted and reviewing the clinical record for accuracy for the PASSAR assessment. The MDS Coordinator M confirmed both Resident #3 and Resident #36 were marked as no for mental illness on their PASSAR. The MDS Coordinator M confirmed both Resident #3 and Resident #36 having a mental illness. The MDS Coordinator M stated the importance of an accurate PASSAR would be residents receiving the services they need. The MDS coordinator M stated they would need to submit form 1012 to correct the PASSAR assessment. During an interview on 02/19/2026 at 12:07 p.m., the MDS Coordinator N stated they were responsible for looking over PASSAR documents when a resident is admitted and reviewing the clinical record for accuracy for the PASSAR assessment. The MDS Coordinator N confirmed Resident #36 was marked as no for mental illness on their PASSAR. The MDS Coordinator N confirmed Resident #36 with having a mental illness. The MDS Coordinator N stated the importance of an accurate PASSAR would be residents having a good quality of life, getting their full benefits and for their safety. During an interview on 02/19/2026 at 4:49 p.m., the DON stated the MDS coordinators should be reviewing the PASSAR assessments for accuracy. The DON stated it is important for PASSAR screenings to be accurate, so residents are provided with their appropriate care. Record review of the facility's policy, PASRR Level 1 Screen Policy and Procedure, revised 3-6-2019, revealed:Procedure:The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations.

Based on observation, interviews and record reviews, the facility failed to ensure comprehensive care plan was developed within seven days of the completion of the comprehensive assessment and were reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 resident of 5 residents (Resident #3) reviewed for comprehensive care plans. The facility failed to revise Resident #3's comprehensive person-centered care plan after her quarterly MDS assessment to reflect she required moderate assistance with the ADL of eating, needed a mechanically altered diet, magic cup with lunch and pureed meat with gravy. This deficient practice could place residents at risk of a lack of assistance with care. Record review of Resident #3's electronic face sheet dated 02/06/2026 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: fracture of lower end of left femur a break or injury to the thighbone, the longest and strongest bone in the body), fracture of the lower end of right radius (break in the lower end of the larger forearm bone near the wrist), vascular dementia (common form of dementia caused by an impaired supply of blood to the brain and causes memory loss and loss of intellectual functioning), Down Syndrome (a genetic condition and causes varying degrees of intellectual disability, developmental delays and distinct physical features) and bradycardia (resting heart rate that is slower than normal). Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected, she was sometimes understood and could usually understand. She scored a 0 of 15 on her BIMS which signified her cognitive status was severely impaired. She required moderate assistance with eating. She was on a mechanically altered diet while a resident. Record review of Resident #3's comprehensive person-centered care plan dated 03/20/25 reflected Focus, has an ADL self-care performance deficit, is on a regular diet, may have on a divided plate. Her need for moderate assistance with eating was not noted. Her mechanical soft diet, magic cup and pureed meat with gravy were not noted. Record review of Resident #3's Active Orders as of 02/06/2026 reflected diet, regular diet, mechanical soft texture, regular consistency, magic cup with lunch pureed meat with gravy, may have divided plate, order dated 11/13/2025. Observation on 02/06/2026 at 08:05 am in the assisted dining room of Resident #3 revealed she was assisted with eating and had a mechanical soft diet for breakfast. Observation on 02/06/2026 at 1:17 pm of Resident #3 being assisted with lunch in the assisted dining room revealed she had a magic cup and a mechanical soft diet. During an interview on 02/06/2006 at 2:09 pm with RN A, the MDS nurse, she stated she did not know why Resident #3's comprehensive person-centered care plan did not reflect her assistance with eating, magic cup at lunch, pureed meat with gravy and a mechanical soft diet. She stated the care plan needed to be reviewed and revised after the resident's last comprehensive assessment, and it was not. During an interview on 02/06/2006 at 2:46 pm, the DON stated the comprehensive person-centered care plan needed to be accurate to reflect what care a resident required. She stated as a team the care plan needed to be reviewed and revised after her MDS assessment. During an interview on 02/06/2026 at 3:28 pm, the interim ADM stated the residents care plan was important because it showed the care the residents required. Record review of the facility's undated policy and procedure titled Comprehensive Care Planning reflected The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 5 residents (Resident #1 and #2) reviewed for comprehensive person-centered care plans. 1.The facility failed to ensure a care plan was developed to address Resident #1 required a divided plate (a durable 3 or 4-section that have high sides and partitions to aide one-handed scooping, prevent spilling, and assist those with arthritis [joint inflammation] or dementia). 2.The facility failed to ensure a care plan was developed to address Resident #2 required a mechanical soft diet and a divided plate. These deficient practices could place residents at risk of not receiving the type of care required and result in unmet needs.The findings included: 1.Record review of Resident #1's electronic face sheet dated 02/06/2026 reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: type II diabetes mellitus (chronic metabolic disorder characterized by high blood glucose levels, resulting from the body's inability to produce sufficient insulin or effectively use the insulin it produces), major depressive disorder (a serious common mental health condition characterized by at least two weeks of persistent, severe sadness, hopelessness, and a loss of interest in activities), hemiplegia and hemiparesis (total paralysis of one side of the body, and a milder, partial weakness on one side) following other cerebrovascular disease (a group of conditions that impair blood flow to the brain) affecting left non-dominant side, moderate intellectual disabilities (a neurodevelopmental condition that involves developmental delays in cognitive, social, and practical adaptive skills) and cerebral palsy (permanent neurological disorders appearing in infancy or early childhood that affect body movement, muscle tone, coordination or posture). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he could usually understand and usually be understood. He scored an 8 of 15 on his BIMS which signified his cognitive status was moderately impaired. He had the ability to use suitable utensils to bring food and/or liquids to the mouth and swallow food and/or liquid once the meal is placed before him. He was noted to have a therapeutic diet; no weight loss was reflected. Record review of Resident #1's comprehensive care plan dated 07/16/2025 reflected Focus, potential risk for malnutrition with RCS/LCS/NSOT diet. The divided plate was not reflected in the care plan. Record review of Resident #1's Active Orders as of: 02/06/2026 reflected Diet, RCS/LCS/NSOT diet regular texture, regular consistency, divided plate, only pink sugar, order date 10/04/2024. Observation on 02/06/2026 at 08:00 am of Resident #1 in the assisted feeding dining room reflected he had a plastic divided plate for his breakfast food. His hands had involuntary muscle contractions (spasticity) or uncontrolled movements (dyskinesia), which resulted in fixed positions like tightly clenched fists, fisted hands, or stiff wrist flexion from his cerebral palsy. Observation on 02/06/2026 at 1:00 pm of Resident #1 in his room reflected he received a lunch tray, and his food was in a plastic divided plate. The DON assisted Resident #1 by feeding him his lunch. During an interview on 02/06/2026 at 1:05 pm with Resident #1, he stated it was easier to eat his food with a divided plate. During an interview on 02/06/2026 at 11:18 am, the ST stated she evaluated Resident #1 months ago and recommended he needed a divided plate to eat. She stated Resident #1 required assistance because of his hand deformities caused by his cerebral palsy. 2. Record review of Resident #2's electronic face sheet dated 02/06/2026 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Alzheimer's disease progressive, irreversible neurodegenerative brain disorder that causes the slow destruction of memory, thinking, and cognitive skills), major depressive disorder (a serious common mental health condition characterized by at least two weeks of persistent, severe sadness, hopelessness, and a loss of interest in activities), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and anxiety (feeling of fear, dread, and uneasiness that acts as a normal reaction to stress). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he could usually understand and usually was understood. He scored 01 of 15 on his BIMS which signified his cognitive status was severely impaired. He required set up service and was able to eat with supervision. He was noted to be on a therapeutic diet. Record review of Resident #2's comprehensive care plan dated 07/11/2025 reflected Focus, resident has an ADL self-care performance deficit, interventions, eating, supervision as needed, Focus, resident is on a regular diet. The resident's mechanical soft texture and his need for a divided plate were not noted on his care plan. Record review of Resident #2's Active Orders as of 02/06/2026 reflected Diet, regular diet, mechanical soft texture, regular consistency, divided plate, drinks in coffee cups, double liquids, order date 10/15/2025. Observation on 02/06/2026 at 1:15 pm of Resident #2 eating in the assisted dining room revealed his food was mechanical soft texture. During an interview on 02/06/2006 at 2:09 pm with RN A, the MDS nurse, she stated she did not know why the divided plates were not in either Resident #1 or Resident #2's comprehensive care plan, and Resident #2's mechanical soft texture was not noted. RN A stated the comprehensive person-centered care plan needed to reflect what the resident needed for care, and result in missed needs. During an interview on 02/06/2006 at 2:46 pm, the DON stated the comprehensive person-centered care plan needed to be accurate to reflect what care a resident required. During an interview on 02/06/2026 at 3:28 pm, the interim ADM stated the residents care plan was important because it showed the care the residents required. Record review on 02/06/2026 at 1:15 pm of Resident #2's meal ticket reflected mechanical soft texture. Record review of the facility's undated policy and procedure titled Comprehensive Care Planning reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.

Based on observation, interview and record review the facility failed to ensure each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 2 of 14 residents (Resident #2 and Resident #3) reviewed for resident call system . The facility failed to provide a working communication system that was easily at reach, which would allow Resident #2 and Resident #3 the ability to safely call staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings include:Resident #2 Record review of Resident #2's face sheet, dated 11/26/2025, revealed s an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included dementia (memory, thinking, difficulty), chronic obstructive pulmonary disease (chronic progressive lung disease), heart failure (hypertension (high blood pressure), malaise (feeling of general discomfort), muscle wasting, muscle weakness, history of falling and lack of coordination. Record review of Resident #2's quarterly MDS assessment dated [DATE], revealed Resident #2 had a BIMS score of 09 indicating moderate impairment. The MDS also revealed Resident #2 was partial to moderate assistance with transfers for toileting and shower transfers. Resident #2 was supervision or touching assistance with bed transfers. Record review of Resident #2's care plan dated 11/11/2025 revealed Potential for falls due to reported history of frequent falls while at home. Osteoporosis (disease that weakens the bones and make them more likely to break), impaired cognitive functioning and safety awareness with dementia, incontinence with some control present, Arthritis and arthritic joint pain, neuropathy, decline in functional independence, weakness, impaired balance, unsteady gait, and cardiovascular and psychotropic medication administration. Interventions were Call light in easy reach. Remind resident to call for staff assistance when needed and answer call promptly. Check on the resident at routine intervals to assess needs, monitor safety issues and offer assist as needed. Resident has experienced a decline in functional independence for mobility with increased weakness and reduced endurance. Potential for improved function and return to prior levels of independence with skilled PT interventions. Interventions were Call light in easy reach. Encourage/remind resident to call for staff assist as needed. Check on her at routine intervals to assess needs, monitor safety issues and offer assistance as needed. Resident #3 Record review of Resident #3's face sheet, dated 11/26/2025, revealed s a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included heart failure, dementia (memory, thinking, difficulty), protein-calorie malnutrition (inadequate intake of both protein and calories), atrial fibrillation (abnormal heart rhythm), skin cancer, anxiety (feeling of uneasiness or worry), constipation and major depressive disorder (mental health disorder characterized by persistent depressed mood). Record review of Resident #3's admission MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 00 indicating severe cognitive impairment. The MDS also revealed Resident #3 was partial/moderate assistance with all transfers. Record review of Resident #3's care plan dated 11/08/2025 revealed The resident has Oxygen Therapy intervention was Provide reassurance and allay anxiety (to calm or relieve feeling of worry and nervousness): Have an agreed-on method for the resident to call for assistance (call light,). Stay with the resident during episodes of respiratory distress. The resident has a communication problem related to Neurological symptoms. Interventions were Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, avoid isolation. Resident is at risk of falls related to actual fall on 11/19/2025. Interventions were Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation of Resident #2 on 11/26/2025 at 8:07a.m., revealed her call light was on the floor under the top of her bed. Resident #2 was lying in her bed. During an observation of Resident #3 on 11/26/2025 at 8:15a.m., revealed was on his bedside table out of Resident #3's reach. Resident #3 was laying in his bed. An interview was attempted with Resident #3 on 11/26/2025 at 8:16a.m., revealed Resident #3 was nonverbal. During an interview with Resident #3's private sitter on 11/26/2025 at 10:57a.m., revealed that she had worked for Resident #3's family for two weeks. She said Resident #3's call light has always been on his bedside table and not in his reach ever since she started working with him. She said that she felt like Resident #3 could use the call light if needed something. During an interview with the ADM on 11/26/2025 at 2:47p.m., revealed the facility did not have policy for call light placement. During an interview with CNA A on 11/26/2025 at 2:54p.m., revealed the policy for call light placement was the call light must be within the reach of the resident. She said all staff were responsible for making sure the call light was in the resident's reach. She said the call light should be within reach of the resident any time the resident was in the room. She said if the call light was not in the reach of the resident the resident could get hurt or really need assistance. She said the DON and ADM monitored to ensure residents call lights were within their reach. She said it was monitored through observation. During an interview with LVN B on 11/26/2025 at 3:05p.m., revealed the call lights need to be within the residents reach. She also said the person who was in the resident's room last was to make sure the call light was within the reach of the resident. She said the call light should always be within the resident's reach. She said if the call light was not within the reach of the resident could fall because the resident tried to do something by their self. She said the nurses monitored to ensure the call lights were within reach of the resident. She said the nurses monitored by observation. She said some of the resident's would throw the call lights onto the floor and staff should be rounding on those residents more frequently. She said she was not sure why Resident #2 and Resident #3's call lights were not within their reach. During an interview with the DON on 11/26/2025 at 3:34p.m., revealed she was not sure if there was a policy for call light placement. However, she did say the expectation was the call light to always be in reach of the resident. She said anyone who went into the resident's room was responsible for making sure the call light was within reach of the resident. She said the call light should be within the resident's reach every time they are in there room. She said if the call light was not placed in reach of the resident could cause the resident to be in distress and upset the resident. She said the staff on the hall were to monitor to ensure the call light was within reach. She also said anytime a staff went into the room and the call light was not within the resident's reach the staff should put it within the resident's reach immediately. She said management were to do rounds every morning and ask the residents if they were having any issues or concerns. She said she did not know why call lights were not within reach of Resident #2 or Resident #3. During an interview with the ADM on 11/26/2025 at 4:02p.m., She said she expected the call light to be in reach of the resident. She said that the last person in the resident's room was responsible for ensuring the call light was within reach of the resident. She said that managers did champion rounds and that call light placement was one of the things the managers check. She said the call light should be in the reach of the resident any time the resident was in their room. She said if the call light was not in the resident reach the resident could have skin breakdown, be on the floor or needs help getting off the toilet. She said department managers monitored to ensure that residents call lights were within their reach. She said the department managers monitored through doing rounds. She said she did not know why Resident #2 and Resident #3's call lights were not within their reach. Record review of Resident Rights dated 03/09/2025 revealed The facility must provide equal access to quality care.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure the MDSN, and the ST knocked on Resident #1's door before entering the resident's rooms. This failure could place residents at risk of feeling like their privacy was invaded or cause psychosocial harm and emotional distress. Findings included:Record review of Resident #1's face sheet, dated 11/26/2025, revealed s a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included muscle weakness, difficulty in walking, lack of coordination, cognitive communication deficit (problems with communication), malaise (feeling of general discomfort), insomnia, (difficulty sleeping) major depressive disorder (mental health disorder characterized by persistent depressed mood), and hypertensive emergency (a severe, acute elevation in blood pressure). Record review of Resident #1's admission MDS assessment dated [DATE], revealed Resident #1 had a BIMS score of 15 indicating cognitive response. During an observation of 200-hall on 11/26/2025 at 11:01a.m., revealed Resident #1 was in the bathroom and her call light was on. The MDSN did not knock on Resident #1's door before entering. During an observation of 200-hall on 11/26/2025 at 11:04a.m., revealed Resident #1 was sitting in her wheelchair by her bed when the ST walked into her room without knocking. During an interview with the MDSN on 11/26/2025 at 11:03a.m., revealed she was trained on resident rights. She said staff were to knock on the door and get permission to enter, introduce themselves. She said staff were supposed to knock anytime they wanted to enter a resident's room. She said the resident may feel like their privacy was invaded. She said the nurses was responsible for monitoring to ensure staff were knocking. She said the charge nurse monitored through observations. She said the resident's door was open and her light was on. She said that she should have knocked before entering. During an interview with the ST on 11/26/2025 at 11:09a.m., revealed she was trained on resident rights. She said the policy was that she needed to knock on a resident's door and say therapy. She said staff should knock anytime they wanted to enter a resident's room. She said staff not knocking on the resident's door was disrespectful and intrusive. She also said all residents should get the same respect. She said any administrative staff who were walking around should be monitoring staff not knocking. She said she did not knock on Resident #1's door because she was trying to get the light off before someone else came to the room. she said she should have knocked before entering the room. During an interview with Resident #1 on 11/26/2025 at 11:15a.m., revealed staff always walked into her room without knocking. She said she would like for staff to knock anytime they wanted to come into her room. She said it upsets her when staff just walk into her room and invade her privacy. During an interview with the DON on 11/26/2025 at 3:34p.m., revealed she and staff were trained on resident rights. She said the policy for knocking was a resident right dignity issue. She also said that staff needed to knock and announce themselves. She said the facility was the resident's home and staff were to always knock before entering the resident's room. She said how the resident felt when staff did not knock depended on the resident. She said the DON and the ADM monitored to ensure staff were knocking. She said the DON and ADM monitored by doing observations. She said she did not know why the MDSN, and the ST did not knock before entering Resident #1's room. During an interview with the ADM on 11/26/2025 at 4:02p.m., revealed she and staff were trained on resident rights. She said the policy for knocking was staff were to knock and wait for a response. She said she would knock on a resident's door even when she would put up a resident's clothes. She said all staff should knock before entering a resident's room. she also said if staff were in the middle of a task and had to walk out to get something, she would not expect the staff to knock again. She said if staff did not knock a resident could get startled or upset. She also said it was disrespectful for staff not to knock before entering a resident's room. She said that the management team monitored to ensure staff were knocking. She said management monitored by doing rounds and should be asking the resident's if staff were knocking. She said she did not know why the MDSN, and the ST did not knock on Resident #1's door. Record review of Resident Rights Policy, dated 03/09/2000, revealed, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must respect the residents right to personal privacy.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 2 of 5 residents (Residents #1 and #2) reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive person-centered care plan with interventions to address Resident #1's behavior of unbuckling the seat belt when transported in the facility van. On 6/13/2025, Resident #1 fell forward while being transported and sustained a laceration to her forehead. 2. The facility failed to develop a person-centered care plan with interventions that addressed Resident #2's fall on 06/18/2025. An IJ was identified on 07/12/2025. The IJ template was provided to the facility on [DATE] at 3:30 PM. While the IJ was removed on 07/13/2025 at 4:20 PM, the facility remained out of compliance at a scope of isolation and severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. These failures could affect residents who have care areas not addressed by the care plans by not having their behavioral needs identified and addressed and putting them at risk of not having their health and safety needs met. The findings included:1. Record review of Resident #1's admission Record (Face Sheet) dated 07/11/2025 revealed she was a [AGE] year-old resident admitted to the facility on [DATE], readmitted on [DATE] and was discharged on 06/13/2025. Diagnoses listed on the admission Record included heart failure, kidney failure with dependance on dialysis (medical treatment to filter waste and excess water from the blood through a specialized machine), syncope (irregular heartbeat), bradycardia (slow heartbeat), and vascular dementia (impaired cognitive thinking due to constricted blood flow). Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 5 out of 15 which indicated her cognitive skills for daily decision making were severely impaired; was dependent for transfers, and had no other behavioral symptoms not directed toward others. Record review of Resident #1's Physician Order Summary Report, dated 07/12/2025, revealed an order initiated on 01/17/2025 for dialysis on Monday, Wednesday, and Friday at 12:00 PM at a local dialysis center. Record review of Resident #1's Nurses Notes from 03/11/2025 to 06/12/2025 revealed there was no notation of Resident #1 trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport. Record review of Resident #1's Nurses Notes dated 06/13/2025 by the DON, revealed Resident had a fall. Location: in facility van during transport to dialysis. Cognition/Behavior at Time of Event: Cognitive Impairment. The fall caused a skin tear to above left eyebrow.new/bleeding.Administrator received call from Van Driver of resident fall in van. Upon arrival to scene, noted resident on floor of van face down with head partially under 2nd row of seats. Blood noted on floor and on resident's hair. Cream colored emesis (vomit) noted on wc [wheelchair] and unable to check vs [vital signs]. Respirations slow and irregular. 911 called per van driver. Ems arrived and transported to ER. The MD was notified on 06/13/2025 at 12:02 PM. Resident #1's Responsible Party was notified on 06/13/2025 at 11:52 AM. Interventions in place prior to fall: None, Interventions initiated in response to fall: none. Record review of Resident #1's Nurse's Notes dated 06/13/2025 by LVN H revealed the nurse received a call from the hospital emergency room regarding Resident #1's medication list which was faxed to the hospital and the nurse was informed the resident had another episode of vomiting at the hospital and was intubated (a tube inserted into the mouth and throat to hold open the airway so air can be pushed in and out of the lungs via machine) at that time. Record review of Resident #1's Event Nurses' Note-Fall, dated 06/13/2025, revealed the resident had an unwitnessed fall in the facility van during transport to dialysis sustaining a skin tear above her left eyebrow. Resident #1's responsible party was notified on 06/13/2025 at 11:52 AM and her physician was notified on 06/13/2025 at 12:02 PM. Under Interventions in place prior to this fall had None of the above was checked. Under Interventions initiated in response to this fall had None of the above checked and no interventions were listed. Record review of hospital records dated 6/20/2025 revealed Resident #1 had a CT (Computed tomography - type of imaging using x-ray techniques to obtain detailed images) of head was completed 06/19/2025 and showed no acute intracranial finding. Further review reviewed Resident #1 was treated for and placed on seizure precautions and treated also for sepsis-resolved (condition where the body's responses to infection causes injury to its own tissues and organs), likely secondary to aspiration pneumonia (lung infections caused by inhaling something other than air into your lungs, such as food or vomit), and Paroxysmal Atrial Fibrillation (noted she converted to normal sinus rhythm on 6/16/2025). Telephone interview with Family Member #1 on 07/11/2025 at 12:08 p.m. revealed Resident #1 was no longer in hospital and had been moved to a different nursing facility but was still fighting an infection and very weak. He stated Resident #1 had a history of falls but expected the facility to know this and take appropriate precautions. He stated he felt the facility should have sent extra staff instead of just the driver to help take care of vulnerable residents. During interview with the Van Driver on 07/09/2025 at 3:57 PM, she stated she had pulled out of facility to transport Resident #1 to dialysis when she heard Resident #1 make a loud noise, checked her rearview mirror and saw Resident #1 vomiting. The Van Driver stated she started to pull over to get off the road when she saw Resident #1 stiffen up and fall forward, landing face first on the floor of the van. She stated she called the Administrator, who instructed her to call 911. Further interview revealed the Van Driver stated she had secured Resident #1 securely inside the van but believed Resident #1 unfastened the seatbelt as she had done that before on at least 2 occasions in the past. Further interview with the Van Driver on 07/10/2025 at 4:15 p.m. revealed that she stated there were two other prior incidents of Resident #1 removing her seatbelt and trying to stand up in the van. She stated the first incident happened about 2 months prior to the June 13th incident, where Resident #1 took her seatbelt off and she told Resident #1 to keep her seatbelt fastened because she could fall. She stated the second incident happened about 2 weeks prior to the June 13th incident, where Resident #1 attempted to pull herself up to standing by pulling on the seat in front of her during transport. The Van Driver stated she reported one of the incidents to LVN -A, and one incident to the Administrator, who told her to contact therapy to ask what could be done, and therapy told her they could tilt her wheelchair backwards so she couldn't grab things. During an interview with LVN-A on 07/10/2025 at 11:44 a.m., she stated that sometime during that first week of June 2025, the Van Driver came to the Nurse's station after returning Resident #1 back to facility from dialysis, and told her, the DON and former ADON, who were all standing at the nurse's station, that Resident #1 had tried to stand up in the van during transport. LVN-A stated she educated Resident #1 about not standing up in the van, that it was dangerous, and she stated Resident #1 denied that she had done that. LVN-A further stated that she did not report the incident to anyone because the DON was standing at the Nurse's station with her when the Van Driver reported the incident and had instructed her to educate Resident #1 on not unbuckling her seatbelt. During an interview on 7/11/25 at 9:41 AM, the Activity Director stated that he and the other Van Driver were the only 2 employees that transported residents. The Activity Director stated he transported Resident #1 several times and he had seen her undo her seatbelt in the past. He stated he educated Resident #1 to not unbuckle her seat belt, but she got anxious and unbuckled it. He stated he reported the incident to the Van Driver so that she could monitor for the behavior. Record review of Resident #1's Care Plan initiated 07/03/2022 for The resident is risk for falls due to dx [diagnosis] of syncope [irregular heartbeat]. Resident had action [sic] fall in facility van causing laceration to forehead initiated 07/03/2022 and revised 06/14/2025 revealed it did not address the resident's behavior of unbuckling the seat belt and no new interventions were listed. Record review of Resident #1's other Care Plan focus areas revealed there was no care plan for her behaviors of trying to unbuckle the seatbelt and standing up when transported in the van. Interview on 07/10/2025 at 4:30 PM with the Administrator revealed she had never been informed of Resident #1 unbuckling or standing up in the van. She stated she had been informed by the Van Driver of an incident that occurred about 2 months prior to the current incident, where the Van Driver reported Resident #1 had attempted to slide out of her wheelchair and that was when she suggested the Van Driver check with therapy to see if wheelchair could be modified. Interview on 07/11/2025 at 11:45 PM with PT B revealed she confirmed a CNA had asked what could be done about Resident #1 leaning forward in wheelchair. PT B stated she instructed the CNA and Resident #1's family member how to recline the wheelchair and there was no documentation available about the instruction provided. Interview on 07/11/2025 at 11:46 AM with Administrator, revealed had she known about prior incidents of Resident #1 unbuckling her seat belt and trying to stand up in van, she would have assigned an escort to accompany Resident #1 during transport or sought other ambulance transportation services. Interview on 07/12/2025 at 2:04 PM, MDS Nurse RN C stated if a resident had a behavior of removing their seatbelt while being transported, the Administrator would be informed along with the DON, and any interventions implemented would be care planned. MDS Nurse RN C stated Resident #1's Care Plan and MDS were completed by anther MDS nurse who no longer worked in the facility. MDS Nurse RN C reviewed Resident #1's care plan for falls and stated she did not see anything in Resident #1's Care Plans about her behavior of unbuckling the seatbelt when transported in the facility van, and only had just one statement about the resident having a fall in the facility van causing a laceration to her forehead. MDS Nurse RN C stated the harm of not having the behavior of unbuckling the seatbelt during transport in the care plan could result in an injury. Interview on 07/12/2025 at 2:15 PM with the Administrator, she stated the process for reporting resident behaviors was for the nurse to document in the resident's chart the behavior so it could be discussed in daily meetings or directly tell the DON or Administrator. She stated the Interdisciplinary Team (IDT) would be responsible for developing interventions to address the behavior to ensure the resident's safety. The Administrator stated it was her understanding that the behavior [of unbuckling the seatbelt] was not addressed in Resident #1's care plan and the harm could result in further injury. 2. Record review of Resident #2's admission record dated 07/08/2025 revealed she was an [AGE] year-old woman admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: Vascular Dementia-Severe (impaired cognitive thinking due to constricted blood flow), Schizoaffective Disorder (a mental health condition that includes both symptoms of schizophrenia, such as hallucinations and delusion and mood disorders), and Poly- osteoarthritis (condition where cartilage in multiple joints wears down causing bones to rub against each other leading to pain and stiffness). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment and she was assessed as needing substantial/maximal assistance for transfers. Record review of Resident #2's Nurses Notes dated 06/18/2025 at 6:06 p.m. by LVN-I, revealed the resident had an unwitnessed fall from the low bed in her room onto the floor next to the bed sustaining a skin tear that was 2cm. to her right hand, and complaining of head, neck, right arm and right leg pain. Under Interventions in place prior to this fall had Floor mat, Low bed. Under Interventions initiated in response to this fall had Floor mat, Low bed, neuro-checks. Record review of Resident #2's Nurses Notes dated 06/18/2025 at 10:55 p.m. by LVN-I revealed resident had returned from the ER with a diagnosis of right knee patella (kneecap) fracture, with knee immobilizer in place. Record review of Resident #2's Care Plan initiated 07/03/2022 for The resident is risk for falls r/t Poor communication/comprehension.Resident H/O fall out of bed due to self positions to the point of being on the edge initiated 07/03/2022 and last revised 07/07/2023, revealed it was not revised to address the resident's actual fall on 06/18/2025 and no new interventions were listed. Record review of Resident #2's other focus areas of Care Plan initiated 07/03/2022 revealed there was no care plan or new interventions which addressed her fall on 06/18/2025. Interview with CNA-K on 07/09/2025 at 1:52 p.m. revealed she stated she had completed check and change with Resident #2 about an hour before her fall and stated she put the bed in the lowest position, and the head of bed was just slightly elevated. Then as she was walking down hall with LVN-H to leave at end of her shift, she heard Resident #2 mumbling, looked in her room and saw her on the floor, face down. She stated she also observed the bed was not in the lowest position, and the head of the bed was straight up at 90-degree angle. The fall mat was in place by her bed. Interview with LVN-H on 07/10/2025 at 10:40 a.m. revealed she works day shift and was getting ready to leave for the day when she heard Resident #2 talking from her room, and when she went to check on her, found Resident #2 lying on the mat on the floor next to her bed. LVN-H stated she observed that Resident #2's head of bed was up to the full 90 degrees, and the bed was not in lowest position, and stated that Resident #2 had been observed to work the bed controller in the past. LVN H stated she believed Resident #2 had accidentally changed position of bed as she manipulated the bed controller. She stated they always make sure her call light was within reach but does not believe she understands its purpose as Resident #2 will push the button on the call light, but when they answer, she cannot say what she needed or why she activated the light. Interview on 07/10/2025 at 5:59 p.m. with LVN-I revealed she works night shift and had just come on duty on 6/18/2025 when she was called into Resident #2's room after she had been found on the floor. She stated Resident #2 was lying on the mat on the floor next to her bed, and that the mat had been in place. However, she noted the bed was not in its lowest position and the head of the bed was in an upright position and stated Resident #2 will take the bed controller and randomly press buttons on it, which can move her bed out of the lowest position. LVN-I stated they have done interventions to keep her from falling again, such as moving the bed controller to the end of the bed to keep her from moving the bed up higher and moving things away from her bed that she can grab, like the drawers out of her dresser. Interview with the DON on 07/11/2025 at 8:28 a.m. revealed all acute incidents such as falls are discussed in the morning team meetings and the team discusses actions/interventions needed. She did not remember specifically what was discussed regarding Resident #2's fall on 6/18/2025. The DON stated that the MDS Nurse is responsible for revising the care plan per the quarterly and annual MDS assessments, and the DON and ADONs are responsible for updating care plans for acute changes. The DON did not know why there was no care plan revision done following Resident #2's fall on 06/18/2025 and -stated that could result in staff not being aware of the care needs of the residents, and could result in acute events such as falls happening again. During an interview with the Administrator on 07/11/2025 at 10:16 a.m., the Administrator stated that Resident #2's fall on 06/18/2025 was addressed by the team in the morning clinical meeting to review causes of the fall and devise new interventions to prevent other falls in future. The Administrator stated that interventions were put into place, including moving furniture to create a safe space, and moving the bed controller away from Resident #2's reach, so that she could not move the bed out of the recommended low bed position. The Administrator further stated however, that Resident #2's care plan was not revised to include these new interventions to prevent further falls but should have been. She stated that either the MDS Nurse or DON can update the care plan to include new focus areas and interventions after discussion in the morning clinical meeting and did not know why Resident #2's care plan was not revised. The Administrator stated not updating the care plan to include all relevant new information such as interventions put in place to prevent falls, could result in staff not having the needed information to care for the Resident properly. Record review of facility policy titled Fall Policy, undated revealed The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as requires and Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall. Record review of facility policy titled Comprehensive Care Planning, undated, revealed The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. This was determined to be an Immediate Jeopardy (IJ) on 07/13/2025 at 3:30 PM. The facility Administrator and Area Regional Director of Operations were notified. The Administrator was provided with the IJ template on 07/13/2025 at 3:30 PM. On 07/13/2025 the facility provided a plan of removal. The Plan of removal was accepted on 07/13/2025 at 7:05 PM. It was documented as follows: The following in-services were initiated by the Regional Compliance nurse and DON on 7/11/25. Any staff member not present or in-serviced on 7/11/25 will not be allowed to assume their duties until in-serviced. Direct Staff to include therapy staff.1. Implementing interventions to minimize the risk of falls. 2. Fall Prevention Policy 3. Reporting incidents, accidents and changes in condition that may impair resident safety, to the administrator/DON immediately. Direct care staff in-service over management of behaviors (both in the facility and during van transportation) that may lead to injury and when to notify physician and nursing leadership and administrator. This was completed by the Director of Nursing on 7/12/2025. Any staff member not in-serviced on 7/12/2025 will not be allowed to assume their duties and sign to verify understanding. DON/ADON/Administrator will review entries on the dashboard and monitor to assure that the changes were implemented and added to the resident care plan and kisok as appropriate. An abuse and neglect in-service was initiated on 7/12/2025 by the facility Administrator. Any staff member who is not present for the in-service will not be allowed to assume their duties until attending in-service and signing to verify understanding. Van drivers received in-service education on 7/12/2025 by the facility Administrator that if a resident unbuckles their seatbelt during van transportation, the van will be pulled over at the nearest safe place. The driver will sit with the resident and call for assistance. Signature was obtained to signify verbal understanding. Facility transportation staff were removed from transport duties and counseled by Administrator on 07/11/2025 on Van Driving policy. All transportation staff retrained on Incident Reporting Policy to Administrator on 7/11/25 by administrator. The Medical Director was notified of the immediate jeopardy situation on 7/12/25 at 5:54 PM by the facility Administrator. Ad Hoc (something done for a specific, immediate need) QAPI meeting will be held on 7/11/25 to discuss the IJ and review plan of removal. Any falls/incidents that occur over the weekend will be reported to the facility administrator and/or DON. On 07/12/2025, the facility Administrator was in-serviced one-one-one by the Area Director of Operations about ensuring interventions are put into place following an incident. Signature verbalized understanding. All behaviors will be reported to facility Administrator/DON; interventions will be discussed with IDT and interventions implemented and care planned. Behaviors will be documented in chart and reviewed daily in stand-up. All new interventions added to the care plan will be shared with the staff in a written update on the facility dashboard (in the electronic documentation system) available to all direct care staff. DON/ADON/Administrator will review entries on the dashboard and follow to assure that the changes were implemented and added to the resident care plan and kiosk as appropriate. If a resident unbuckles their seatbelt during van transportation, the van will be pulled over at the nearest safe place. The driver will sit with the resident and call for assistance. Real time computer software key word alert and the 24-hour report will be reviewed in morning stand up 5x weekly by the intradisciplinary team, to assess for any documented changes in resident behavior or other incidents. Any interventions will be put in place and added to the facility dashboard for the staff review. Prior to any van transport, the Administrator/DON will review, with the van driver, any special needs for resident safe transport and put them in place prior to the beginning of transportation. Any modifications will be noted on the van transportation calendar. Monitoring: DON and Administrator will review all falls, incidents and accidents and unsafe behaviors during the morning meeting to ensure appropriate interventions have been implemented. These will continue to be reviewed 5x weekly until the identified issue has been resolved and interventions are in place. The weekend supervisor will review the real time system and 24-hour report and report any newly identified issues to DON/Administrator. Identified incidents, accidents and or unsafe behaviors will be added to a tracker for Administrator and DON to complete with interventions and weekly follow up to assure that said interventions are in place and satisfactory to assure the residents' safety. If it is determined not to be effective, new interventions will be added and tracked. This will be done for a period of 6 weeks or until substantial compliance is achieved, reviewed by the QAPI committee prior to any changes. DON and Administrator will review all falls, incidents and accidents during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented and plan of care updated to assure staff know how to care for resident after an event or change in condition. Monitoring will take place weekly for a minimum of 6 weeks. The above will be reviewed during the facility monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained. Incidents involving van transport will be reviewed 5x weekly in morning meetings to determine if there were any incidents. The IDT will discuss any necessary interventions to prevent future events and update the residents' plan of care as appropriate. This will continue for a period of 6 weeks and PRN thereafter as determined by the QAPI committee. Regional Compliance Nurse/Area Director of Operations will review incidents and accidents at least once weekly to assure that appropriate interventions are in place to address incidents, accidents and changes in condition were made at the facility level. Verification of the facility's POR for F656 was as follows:Record review of an In-Service Form dated 07/12/2025 revealed the Administrator had in-serviced the Van Driver on If a resident unbuckles their seatbelt during van transportation, the van will be pulled over at the nearest safe place. The driver will sit with the resident and call for assistance. Record review of an In-Service Training Attendance Roster dated 07/12/2025 revealed the Administrator was trained by the Area Director of Operations to ensure interventions were in place for any reported unsafe conditions, reported falls or other accidents/unusual occurrences. Record review of an In-Service Training Attendance Roster dated 07/12/2025 revealed the Administrator was trained by the Area Director of Operations on Abuse and Neglect. Record review of an untitled sheet revealed the Administrator notified the Medical Director of the IJ on 07/12/2025 at 5:50 PM. Record review of a printed calendars of residents who were transported to appointments from 06/15/2025 to 07/12/2025, revealed which residents had escorts accompany them when they were transported in the van, and it was also noted what days the Administrator rode in the van with the Van Driver. Record review of the Behavior Monitoring Tracker revealed residents who had behaviors would be tracked daily with what the behavior was, if there was an intervention placed, if it was care planned and if it was effective. There were 6 weeks of sheets for the monitoring. Record review of an undated employee list revealed the facility had 89 full time employees and 32 part-time/prn employees for a total of 121 employees. Record Review of an In-service record log revealed all 121 employees had been in-serviced by phone or in person on reporting allegations of abuse/neglect immediately to the Administrator; any unsafe conditions that must be reported to the Administrator immediately; all falls and/or other accidents or unusual occurrences would be reported to the administrator; any unsafe behaviors or incidents that occurred on the van during transport needed to be reported to the Administrator and DON immediately; all unsafe behaviors that could lead to a fall must be reported immediately to the Administrator; and on the Fall Policy. In an interview on 07/12/2025 at 4:23 PM, the Administrator stated the SOC was Standard of Care which was a weekly meeting that was held to discuss resident care. Interviews on 07/12/2025 from 4:40 PM to 7:00 PM and 07/13/2025 from 8:30 AM to 4:00 PM with 29 employees out of 121 employees (25 full time employees, 4 prn/part time employees) which consisted of 1 RA (RA W), 2 MA (MA T, MA U), 2 Housekeepers (Housekeeper Q, Housekeeper R), 10 CNAs (CNA L, CNA M, CNA N, CNA O, CNA X, CNA Y, CNA K, CNA BB, CNA AA, CNA Z) 3 of them worked 6 PM to 6 AM shift, 4 LVNs (LVN I, LVN H, LVN J, LVN P) 2 of them worked 6 PM to 6 AM shift), 3 dietary employees (Dietary Aide T, Dietary Supervisor E, and [NAME] S), 1 Activity Director, 1 Van Driver, 2 PTA (PTA EE, PTA CC), 1 OTA (OTA DD) revealed the had received the in-service training as indicated in the POR for F656. All the employees stated they would report any signs of abuse to the Abuse Coordinator who was the Administrator, they had her phone number to contact her. They also stated they would report immediately to the abuse coordinator any falls or unsafe behaviors to the administrator which included any unsafe behaviors when residents were transported in the van. The employees stated they had been in-serviced on the facility's Fall Prevention policy and interventions to minimize falls and provided examples of how that could be done. In an interview on 07/13/2025 at 10:41 AM the Van Driver stated she works full time as the van driver; and received training on reporting incidents, on when to pull the van over, on when to report anything to the administrator about unusual behaviors that occurred when a resident was transported, reporting unusual behaviors from residents. Van Driver D said she was also trained to report any falls a resident had to the administrator, the DON and nurse. The Van Driver stated she was also trained to report any signs of abuse or neglect to the administrator immediately. The Van Driver said she received one-on-one training about the fall with Resident #1, was retrained by administrator on transporting residents, and the Administrator rode with her for a whole week in June 2025. Then the administrator rode with her twice a week for four weeks, then the administrator would randomly ride with her. The Van Driver stated she the Administrator was riding with her twice a week for two more weeks. The Van Driver said she would print out daily the calendar of the residents who would be transported; record on the calendar any behaviors from the resident when they were transported and provided the calendar to the administrator at the end of the day. The Van Driver stated she was also in-serviced recently on abuse and neglect; and would report it immediately to the administrator. In an interview on 07/13/2025 at 2:03 PM, DON stated they would review in the morning meeting which resident would need an escort when transported to their scheduled appointment. The DON said residents who had falls were reviewed daily in the morning meeting. The DON stated she and the Administrator had in-serviced the employees on Abuse and Neglect, on Falls, who to report to, what to report for abuse or neglect, and fall prevention. The DON stated staff were to report to her or the Administrator if they had witnessed any unsafe behaviors from a resident or when the resident was transported. The DON stated if a resident had a fall, the charge nurse would notify her of the fall. The DON said they would review the falls throughout the day to see how they could be prevented. The DON stated the monitoring would be done with the monitoring tools that were developed and reviewed in the daily morning meeting, the weekly SOC meeting and QAPI meetings. The DON stated they would review which residents need to have an escort or need to have a contracted transport company take a resident to dialysis if needed. The DON said they had an Ad Hoc QAPI meeting on 7/11/2025 with the department heads, the Administrator, the Area Director of Operations; and the Medical Director was informed by the Administrator. The DON said she and the ADON would review the 24-hour summary to see if there were any changes that happened such as falls or behaviors and to see if they were reviewed. The DON stated the resident's dashboard would be reviewed throughout the day for any falls or behaviors that would need to be addressed. The DON said she and the Administrator were reviewing residents who were going to be transported, and it was discussed if the resident needed to have an escort. The DON stated the SOC meeting was held weekly on Fridays, and they would review residents who had a fall or accident to see if any interventions were needed. In an interview on 07/13/2025 at 2:23 PM, the Administrator stated the interventions implemented included re-educating all staff on reporting unusual occurrences, and an employee could not return to work unless they received the training. The Administrator said all staff were provided her phone number to contact her to report any abuse or unsafe behaviors. The Administrator stated a monitoring tool was implemented to review all falls in the morning meeting

Based on interviews and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 2 residents (Residents #1 and #2) reviewed for accidents. 1. The facility failed to identify and address hazards and risk in Resident #1's environment when staff failed to ensure they addressed Resident #1's behavior of unbuckling the seatbelt during transport in the facility van. On 06/13/2025, Resident #1 sustained a fall during van transport, with the seat belt noted to be on the wheelchair but the fastener unlatched, resulting in a laceration to her forehead. 2. The facility failed to identify and address hazards and risk in Resident #2's environment when staff failed to ensure they addressed Resident #2's fall on 06/18/2025. An Immediate Jeopardy (IJ) was identified on 07/11/2025. The IJ template was provided to the facility on [DATE] at 10:39 p.m. While the IJ was removed on 07/13/2025 at 4:20 p.m., the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of their plan of removal. This failure could place residents at risk for accidents injuries, hospitalization and death related to unsafe vehicle transport. The findings included: 1.Record review of Resident #1’s admission record dated 07/08/2025 revealed she was a [AGE] year-old woman admitted on [DATE] with re-admission on [DATE], and with diagnoses which included: End-Stage Renal disease (condition where kidneys lose the ability to remove waste and balance fluids in balance requiring dialysis); Syncope (fainting or temporary loss of consciousness) and collapse; Vascular Dementia (impaired cognitive thinking due to constricted blood flow) and Bradycardia (slow heart beat). Record review of Resident #1’s Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 5, indicating severe cognitive impairment, and was assessed as being dependent for transfers, and had no behavioral symptoms. Record review of Resident #1’s Care Plan initiated 07/03/2022 revealed a focus area for “The resident is risk for falls due to dx [diagnosis] of syncope,” and included “Resident had action [sic] fall in facility van causing laceration to forehead” initiated 07/03/2022 and revised 06/14/2025. There were no interventions listed which addressed the resident’s behavior of unbuckling the seat belt and no new interventions for this fall were listed. Record review of Resident #1’s other focus areas in her Care Plan initiated 07/03/2022, revealed there was no other focus areas for her behavior of trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport. Record review of Resident #1’s Physician Order Summary Report, dated 07/12/2025, revealed an order initiated on 01/17/2025 for dialysis at 12:05 PM on Monday, Wednesday, and Friday at a local dialysis center. Record review of Resident #1’s Nurses Notes from 03/11/2025 to 06/12/2025 revealed there was no notation of Resident #1 trying to stand up during transport or for trying to unbuckle her seatbelt in the facility van during transport. Record review of Resident #1’s Progress Note dated 6/13/2025 at 11:22 a.m. by the DON revealed “Resident had a fall. Location: in facility van during transport to dialysis. Cognition/Behavior at Time of Event: Cognitive Impairment. The fall caused a skin tear to above left eyebrow. new/bleeding….Administrator received call from Van Driver of resident fall in van. Upon arrival to scene, noted resident on floor of van face down with head partially under 2nd row of seats. Blood noted on floor and on resident’s hair. Cream colored emesis (vomit) noted on wc [wheelchair] and unable to check vs [vital signs]. Respirations slow and irregular. 911 called per van driver. Ems arrived and transported to ER…” The MD was notified on 06/13/2025 at 12:02 PM. Resident #1’s Responsible Party was notified on 06/13/2025 at 11:52 AM. “Interventions in place prior to fall: None, Interventions initiated in response to fall: none.” Record review of Resident #1’s Nurse’s Notes dated 06/13/2025 by LVN-H revealed the nurse received a call from the hospital emergency room regarding Resident #1’s medication list which was faxed to the hospital and the nurse was informed the resident had another episode of vomiting at the hospital and was intubated (a tube inserted into the mouth and throat to hold open the airway so air can be pushed in and out of the lungs via machine) at that time. Record review of Resident #1’s Event Nurses’ Note-Fall, dated 06/13/2025, revealed the resident had an unwitnessed fall in the facility van during transport to dialysis sustaining a skin tear above her left eyebrow. Resident #1’s responsible party was notified on 06/13/2025 at 11:52 AM and her physician was notified on 06/13/2025 at 12:02 PM. Under “Interventions in place prior to this fall” had “None of the above” was checked. Under “Interventions initiated in response to this fall” had “None of the above” checked and no interventions were listed. Record review of hospital records dated 6/20/2025 revealed Resident #1 had a CT (Computed tomography – type of imaging using x-ray techniques to obtain detailed images) of head was completed 06/19/2025 and showed “no acute intracranial finding”. Further review revealed Resident #1 was treated for and placed on seizure precautions and treated also for sepsis-resolved (condition where the body’s responses to infection causes injury to its own tissues and organs), likely secondary to aspiration pneumonia (lung infections caused by inhaling something other than air into your lungs, such as food or vomit), and Paroxysmal Atrial Fibrillation (noted she converted to normal sinus rhythm on 6/16/2025). Telephone interview with Family Member #1 on 07/11/2025 at 12:08 p.m. revealed Resident #1 was no longer in hospital and had been moved to a different nursing facility, but was still fighting an infection and very weak. He stated Resident #1 had a history of falls, but expected the facility to know this and take appropriate precautions. He stated he felt the facility should have sent extra staff instead of just the driver to help take care of vulnerable residents. During an interview on 07/09/2025 at 3:57 p.m., the Van Driver stated that she loaded Resident #1 in the van on 06/13/2025, leaving facility at 11:16 a.m. and after pulling out onto the road, she heard Resident #1 make a loud noise, and saw in the rear-view mirror that Resident #1 had vomit coming from her mouth. She stated that as she attempted to turn to pull off to the side of road, she saw Resident #1 stiffen up and fall forward out of the wheelchair and land face down on the floor of the van. The Van Driver stated she called the Administrator who told her to call 911. The Van Driver further stated that she had secured Resident #1 securely in her wheelchair into the van with 4 straps that were attached to the L-bar of Resident #1’s wheelchair frame, but stated she believed Resident #1 had unbuckled her seatbelt, because she had unbuckled her seatbelt during transport in the past. Further interview with the Van Driver on 07/10/2025 at 4:15 p.m. revealed that she stated there were two other prior incidents of Resident #1 removing her seatbelt and trying to stand up in the van. She stated the first incident happened about 2 months prior to the June 13th incident, where Resident #1 took her seatbelt off and she told Resident #1 to keep her seatbelt fastened because she could fall. She stated the second incident happened about 2 weeks prior to the June 13th incident, where Resident #1 attempted to pull herself up to standing by pulling on the seat in front of her during transport. The Van Driver stated she reported one of the incidents to LVN -A, and one incident to the Administrator, who told her to contact therapy to ask what could be done, and therapy told her they could tilt her wheelchair backwards so she couldn’t grab things. During an interview with LVN-A on 07/10/2025 at 11:44 a.m., she stated that sometime during that first week of June 2025, the Van Driver came to the Nurse’s station after returning Resident #1 back to facility from dialysis, and told her, the DON and former ADON, who were all standing at the nurse’s station, that Resident #1 had tried to stand up in the van during transport. LVN-A stated she educated Resident #1 about not standing up in the van, that it was dangerous, and she stated Resident #1 denied that she had done that. LVN-A further stated that she did not report the incident to anyone because the DON was standing at the Nurse’s station with her when the Van Driver reported the incident and had instructed her to educate Resident #1 on not unbuckling her seatbelt. During an interview with the DON on 07/10/2025 at 4:54 p.m., the DON stated she was never made aware of any prior incidents of Resident #1 taking off her seatbelt or trying to stand up out of her wheelchair during van transport. Interview on 07/10/2025 at 4:30 p.m. with the Administrator revealed she had inspected the van after the incident and observed vomit on the chest strap when she pulled it out from the retracting device, indicating the chest strap had been in place across Resident #1’s chest when she first started to vomit and believed Resident #1 may have pressed down on her abdomen with her hand when she vomited, accidentally pushing on the release button of the seatbelt. When asked about any prior incidents, the Administrator stated that the Van Driver had informed her of an incident where Resident #1 had attempted to slide down out of her wheelchair, could not remember the exact date, but thought it might have been a couple of months prior to the current incident, and that was when she suggested the Van Driver check with therapy to see if wheelchair could be modified. She stated the Van Driver never told her Resident #1 had unbuckled her seatbelt or tried to stand up in van. She stated the Van Driver came back and told her therapy stated the wheelchair could be tilted back slightly, and they agreed that was what they were going to try to do to address the problem. The Administrator further stated that if Resident #1 had intentionally tried to undo her seatbelt or stand up in the van during transport she would expect that to be reported to her, but no one ever had. She stated the team never met to discuss the incident reported to her of Resident #1 trying to slide out of the wheelchair and the intervention they discussed about the therapy assessment of the wheelchair was never care planned but should have been. Interview with PT - B on 07/11/2025 at 11:46 a.m. revealed she confirmed a CNA had come down to ask about what could be done about Resident #1 leaning forward in wheelchair and PT-B instructed CNA and Resident #1’s family member how to recline the wheelchair. No documentation available as Resident #1 was not on services at this time. Interview with the Activity Director on 7/11/2025 at 9:41 a.m. revealed that he also transports residents in the van to recreational activities, but will also transport residents at times to their medical appointments when the primary Van Driver is out sick. He stated the primary Van Driver and he are the only staff who transported residents at the facility. The Activity Director stated he had transported Resident #1 in the van many times and had observed her undo her seatbelt or try to stand up in van during transport several times. The Activity Director further stated he educated Resident #1 not to unbuckle her seat belt, but stated she would get anxious at times and forget. The Activity Director stated he reported this behavior of unbuckling her seatbelt during transport to the primary Van Driver so she could be aware and monitor but did not report the incidents to anyone else. During a telephone interview with the Van Driver on 07/11/2025 at 11:54 a.m., she stated that she did not recall the Activity Director ever informing her or warning her about Resident #1’s behavior of unbuckling her seatbelt during transport. During an interview with the Administrator on 07/11/2025 at 11:46 a.m., the Administrator stated that had she known Resident #1 had incidents of unbuckling her seatbelt in van during transport, she would have assigned an escort to go along with her during transport or contracted with local company for ambulance transportation services for Resident #1. 2. Record review of Resident #2’s admission record dated 07/08/2025 revealed she was an [AGE] year-old woman admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: Vascular Dementia-Severe (impaired cognitive thinking due to constricted blood flow), Schizoaffective Disorder (a mental health condition that includes both symptoms of schizophrenia, such as hallucinations and delusion and mood disorders), and Poly- osteoarthritis (condition where cartilage in multiple joints wears down causing bones to rub against each other leading to pain and stiffness). Record review of Resident #2’s Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating severe cognitive impairment and she was assessed as needing substantial/maximal assistance for transfers. Record review of Resident #2’s Nurses Notes dated 06/18/2025 at 6:06 p.m. by LVN-I, revealed the resident had an unwitnessed fall from the low bed in her room onto the floor next to the bed sustaining a skin tear that was 2cm. to her right hand, and complaining of head, neck, right arm and right leg pain. Under “Interventions in place prior to this fall” had “Floor mat, Low bed.” Under “Interventions initiated in response to this fall” had “Floor mat, Low bed, neuro-checks.” Record review of Resident #2’s Nurses Notes dated 06/18/2025 at 10:55 p.m. by LVN-I revealed resident had returned from the ER with a diagnosis of right knee patella (kneecap) fracture, with knee immobilizer in place. Record review of Resident #2’s Care Plan initiated 07/03/2022 for “The resident is risk for falls r/t Poor communication/comprehension….Resident H/O fall out of bed due to self positions to the point of being on the edge” initiated 07/03/2022 and last revised 07/07/2023, revealed it was not revised to address the resident’s actual fall on 06/18/2025 and no new interventions were listed. Record review of Resident #2’s other focus areas of Care Plan initiated 07/03/2022 revealed there was no care plan or new interventions which addressed her fall on 06/18/2025. Interview with CNA-K on 07/09/2025 at 1:52 p.m. revealed she stated she had completed check and change with Resident #2 about an hour before her fall and stated she put the bed in the lowest position, and the head of bed was just slightly elevated. Then as she was walking down hall with LVN-H to leave at end of her shift, she heard Resident #2 mumbling, looked in her room and saw her on the floor, face down. She stated she also observed the bed was not in the lowest position, and the head of the bed was straight up at 90-degree angle. The fall mat was in place by her bed. Interview with LVN-H on 07/10/2025 at 10:40 a.m. revealed she works day shift and was getting ready to leave for the day when she heard Resident #2 talking from her room, and when she went to check on her, found Resident #2 lying on the mat on the floor next to her bed. LVN-H stated she observed that Resident #2’s head of bed was up to the full 90 degrees, and the bed was not in lowest position, and stated that Resident #2 had been observed to work the bed controller in the past. LVN H stated she believed Resident #2 had accidentally changed position of bed as she manipulated the bed controller. She stated they always make sure her call light was within reach but does not believe she understands its purpose as Resident #2 will push the button on the call light, but when they answer, she cannot say what she needed or why she activated the light. Interview on 07/10/2025 at 5:59 p.m. with LVN-I revealed she works night shift and had just come on duty on 6/18/2025 when she was called into Resident #2’s room after she had been found on the floor. She stated Resident #2 was lying on the mat on the floor next to her bed, and that the mat had been in place. However, she noted the bed was not in its lowest position and the head of the bed was in an upright position and stated Resident #2 will take the bed controller and randomly press buttons on it, which can move her bed out of the lowest position. LVN-I stated they have done interventions to keep her from falling again, such as moving the bed controller to the end of the bed to keep her from moving the bed up higher and moving things away from her bed that she can grab, like the drawers out of her dresser. Interview with the DON on 07/11/2025 at 8:28 a.m. revealed all acute incidents such as falls are discussed in the morning team meetings and the team discusses actions/interventions needed. She did not remember specifically what was discussed regarding Resident #2’s fall on 6/18/2025. The DON stated that the MDS Nurse is responsible for revising the care plan per the quarterly and annual MDS assessments, and the DON and ADONs are responsible for updating care plans for acute changes. The DON did not know why there was no care plan revision done following Resident #2’s fall on 06/18/2025 and -stated that could result in staff not being aware of the care needs of the residents, and could result in acute events such as falls happening again. During an interview with the Administrator on 07/11/2025 at 10:16 a.m., the Administrator stated that Resident #2’s fall on 06/18/2025 was addressed by the team in the morning clinical meeting to review causes of the fall and devise new interventions to prevent other falls in future. The Administrator stated that interventions were put into place, including moving furniture to create a safe space, and moving the bed controller away from Resident #2’s reach, so that she could not move the bed out of the recommended low bed position. The Administrator further stated however, that Resident #2’s care plan was not revised to include these new interventions to prevent further falls but should have been. She stated that either the MDS Nurse or DON can update the care plan to include new focus areas and interventions after discussion in the morning clinical meeting and did not know why Resident #2’s care plan was not revised. The Administrator stated not updating the care plan to include all relevant new information such as interventions put in place to prevent falls, could result in staff not having the needed information to care for the Resident properly. Record review of facility policy titled “Fall Policy”, undated revealed “The DON or designee will be responsible for investigating all resident falls to attempt to determine the cause and need for new interventions as requires” and “Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall.” This was determined to be an Immediate Jeopardy (IJ) on 07/11/2025. The Administrator was provided with the IJ template on 07/11/2025 at 10:39 PM. On 07/12/2025 the facility provided a plan of removal. The Plan of removal was accepted on 07/12/2025 at 11:33 AM. It is documented as follows: The following in-services were initiated by the Regional Compliance nurse and DON on 7/11/25. Any staff member not present or in-serviced on 7/11/25 will not be allowed to assume their duties until in-serviced. Direct Staff to include therapy staff. 1. Implementing interventions to minimize the risk of falls. 2. Fall Prevention Policy 3. Reporting all incidents and accidents to the administrator immediately. Facility transportation staff was removed from transport duties and counseled by Administrator on 07/11/2025 on Van Driving policy. All transportation staff retrained on Incident Reporting Policy to Administrator on 7/11/25 by administrator. The medical director was notified of the immediate jeopardy situation on 7/11/25 at 10:30 pm by administrator. Ad Hoc QAPI meeting will be held on 7/11/25 to discuss the IJ and review plan of removal. Any falls/incidents that occur over the weekend will be reported to the facility administrator and/or DON. Monitoring: DON and Administrator will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. DON and Administrator will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. Above will be reviewed during the facility monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained. Incidents involving van transport will be reviewed 5x weekly in morning meeting to determine if there were any incidents. This will be continued for a period of 6 weeks and PRN thereafter as determined by the QAPI committee. Verification of the facility’s POR for F689 was as follows: Record review of an AD Hoc QAPI Contributors signature page dated 07/11/2025 revealed a meeting was held with the Administrator, DON, Medical Director, Social Services, Activity Director and three other employees. Record review of an undated, untitled sheet revealed the Medical Director was notified on 07/11/2025 at 11:04 AM of the IJ situation by the Administrator. Record review of an Incident/Fall Review Monitoring Tool revealed all falls would be reviewed 5 days per week for 6 weeks. Record review of a Falls Review Monitoring Tool revealed the Administrator and the DON would discuss falls and interventions implemented weekly at a SOC (Standard of Care) meeting that was held with the Administrator, DON, and other Interdisciplinary Team members. Record review of the QA Monitoring Tool revealed falls and incidents and if interventions were implemented would be reviewed monthly at the QAPI Meetings that will be held on 07/15/2025 and 08/19/2025. Record review of the Van Incident Monitoring Tool revealed all incidents involving van transport were reviewed five times a week for 6 weeks by the DON and Administrator. Record review of an undated employee list revealed the facility had 89 full time employees and 32 part-time/prn employees for a total of 121 employees. Record review of an In-service record log, dated 07/12/2025 revealed all 121 employees had been in-serviced by phone or in person on reporting allegations of abuse/neglect immediately to the administrator; any unsafe conditions must be reported to the administrator immediately; all falls and/or other accidents or unusual occurrences would be reported to the administrator; any unsafe behaviors or incidents that occur on the fan during transport needs to be reported to the administrator and DON immediately; all unsafe behaviors that could lead to a fall must be reported immediately to the administrator; and on the Fall Policy. In an interview on 07/12/2025 at 4:23 PM, the Administrator stated the “SOC” was Standard of Care which was a weekly meeting that was held to discuss resident care. Interviews on 07/12/2025 from 4:40 PM to 7:00 PM and 07/13/2025 from 8:30 AM to 4:00 PM with 29 employees out of 121 employees (25 full time employees, 4 prn/part time employees) which consisted of 1 RA (RA W), 2 MA (MA T, MA U), 2 Housekeepers (Housekeeper Q, Housekeeper R), 10 CNAs (CNA L, CNA M, CNA N, CNA O, CNA X, CNA Y, CNA K, CNA BB, CNA AA, CNA Z) 3 of them worked 6 PM to 6 AM shift, 4 LVNs (LVN I, LVN H, LVN J, LVN P) 2 of them worked 6 PM to 6 AM shift), 3 dietary employees (Dietary Aide T, Dietary Supervisor E, and [NAME] S), 1 Activity Director, 1 Van Driver, 2 PTA (PTA EE, PTA CC), 1 OTA (OTA DD) revealed the had received the in-service training as indicated in the POR for F689. All the employees stated they would report any signs of abuse to the Abuse Coordinator who was the Administrator, they had her phone number to contact her. They also stated they would report immediately to the abuse coordinator any falls or unsafe behaviors to the administrator which included any unsafe behaviors when residents were transported in the van. The employees stated they had been in-serviced on the facility’s Fall Prevention policy and interventions to minimize falls and provided examples of how that could be done. In an interview on 07/13/2025 at 10:41 AM the Van Driver stated she works full time as the van driver; and received training on reporting incidents, on when to pull the van over, on when to report anything to the administrator about unusual behaviors that occurred when a resident was transported, reporting unusual behaviors from residents. Van Driver D said she was also trained to report any falls a resident had to the administrator, the DON and nurse. The Van Driver stated she was also trained to report any signs of abuse or neglect to the administrator immediately. The Van Driver said she received one-on-one training about the fall with Resident #1, was retrained by administrator on transporting residents, and the Administrator rode with her for a whole week in June 2025. Then the administrator rode with her twice a week for four weeks, then the administrator would randomly ride with her. The Van Driver stated she the Administrator was riding with her twice a week for two more weeks. The Van Driver said she would print out daily the calendar of the residents who would be transported; record on the calendar any behaviors from the resident when they were transported and provided the calendar to the administrator at the end of the day. The Van Driver stated she was also in-serviced recently on abuse and neglect; and would report it immediately to the administrator. In an interview on 07/13/2025 at 2:03 PM, DON stated they would review in the morning meeting which resident would need an escort when transported to their scheduled appointment. The DON said residents who had falls were reviewed daily in the morning meeting. The DON stated she and the Administrator had in-serviced the employees on Abuse and Neglect, on Falls, who to report to, what to report for abuse or neglect, and fall prevention. The DON stated staff were to report to her or the Administrator if they had witnessed any unsafe behaviors from a resident or when the resident was transported. The DON stated if a resident had a fall, the charge nurse would notify her of the fall. The DON said they would review the falls throughout the day to see how they could be prevented. The DON stated the monitoring would be done with the monitoring tools that were developed and reviewed in the daily morning meeting, the weekly SOC meeting and QAPI meetings. The DON stated they would review which residents need to have an escort or need to have a contracted transport company take a resident to dialysis if needed. The DON said they had an Ad Hoc QAPI meeting on 7/11/2025 with the department heads, the Administrator, the Area Director of Operations; and the Medical Director was informed by the Administrator. The DON said she and the ADON would review the 24-hour summary to see if there were any changes that happened such as falls or behaviors and to see if they were reviewed. The DON stated the resident’s dashboard would be reviewed throughout the day for any falls or behaviors that would need to be addressed. The DON said she and the Administrator were reviewing residents who were going to be transported, and it was discussed if the resident needed to have an escort. The DON stated the SOC meeting was held weekly on Fridays, and they would review residents who had a fall or accident to see if any interventions were needed. In an interview on 07/13/2025 at 2:23 PM, the Administrator stated the interventions implemented included re-educating all staff on reporting unusual occurrences, and an employee could not return to work unless they received the training. The Administrator said all staff were provided her phone number to contact her to report any abuse or unsafe behaviors. The Administrator stated a monitoring tool was implemented to review all falls in the morning meeting to ensure interventions were implemented and was care planned. The Administrator said the SOC tool would be used weekly to verify the interventions were listed, if the staff knew about the interventions, and would be reviewed at the next QAPI meeting. The Administrator stated a van monitoring tool was implemented to ensure if anything happened during transport was recorded. The Administrator said the monitoring sheet was reviewed daily to determine if a resident needed an escort or need an ambulance to transport them. The Administrator stated the van drivers would turn in the van monitoring tool at the end of the day with notes about if a resident tried to stand up, any issues with their chair, or if they looked weak. The Administrator said the Van Driver was retrained on transporting residents in the van. The Administrator stated after the incident with Resident #1 she rode in the van daily for the first week, then the second week she rode in the van a twice a week. The Administrator stated an Ad Hoc QAPI meeting was held on 07/11/2025 with the department heads and Area Director of Operations. The Administrator said staff were retained about un-safe behaviors to be reported immediately to her or the DON. The Administrator stated when employees see a resident exhibiting behaviors, they were to stay with the resident to make sure they are safe, call for help, then report it to the administrator. The Administrator said they have a clinical care meeting and will follow-up on the entries on the resident’s clinical record dashboard for behaviors with instructions for that resident, and the interventions were added to the resident’s care plan. The Administrator stated if something happened on the weekend, staff would contact the Administrator. The Administrator said the Van Driver and Activity Director were in-serviced to pull over when a resident did something unsafe in the van and then call her. The Administrator said she a calendar was used with residents who have appointments to determine if a resident needed to have an escort to their appointment. The Administrator stated she and the DON would review all falls to make sure the i

Based on observations, interviews, and record reviews the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 3 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on his Quarterly MDS assessment, signed as completed on 02/11/2025, for a fall with major injury that occurred on 01/12/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Record review of Resident #1's Admission Record, dated 04/17/2025, reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Record review of Resident #1's Diagnosis Report, dated 04/17/2025, reflected a primary and admitting diagnosis of Hemiplegia (partial to complete loss of muscle function of one side of the body) and Hemiparesis (muscle weakness of one side of the body) following an unspecified cerebrovascular disease (a group of conditions that affect the blood flow and blood vessels in the brain) affecting the left non-dominant side, epilepsy (a brain disorder that causes seizures), and other reduced mobility. Record review of Resident #1's Nursing Note, dated 01/12/2025 at 09:31 p.m. by LPN A, reflected Resident #1 had an unwitnessed fall in his room on 01/12/2024. LPN A noted the fall caused a fracture to Left leg. Record review of Resident #1's Fall Nurses Note 12hr, signed 01/17/2025 with effective date 01/15/2025 by LPN A, reflected Resident #1 sustained a fracture to his left leg with swelling and a brace applied for intervention. Record review of Resident #1's Quarterly MDS, signed as completed on 02/11/2025 by the RN Assessment Coordinator B, reflected assessment observation end date of 01/29/2025. Resident #1 had a BIMS score of 10 indicating he was mildly impaired, he required substantial/maximal assistance for transferring from lying to sitting on the side of the bed or sitting to standing; and he had two or more falls since admission/entry or reentry or the prior assessment with no injury. He was documented as had no major injury since admission/entry or reentry or prior assessment. The assessment description for major injury included bone fractures. An observation and interview with Resident #1 on 04/17/2025 at 04:25 p.m., revealed Resident #1 was lying in his bed with his head and shoulders slighted elevated watching television. Resident #1 appeared clean and groomed. His call light, a side table, and a bedside urinal bottle were in reach. The resident had two grab bars attached to both sides of his upper bed. Resident #1 revealed he had fallen a couple times at the facility. He stated on one fall he broke his leg. He stated staff responded okay and he felt safe at the facility. He revealed he continued to go to therapy. During an interview on 04/17/2025 at 05:55 p.m., RN Assessment Coordinator B stated for falls, the DON would discuss the falls that were active or historical with the care team. She stated the DON was also responsible for care planning and assigning the interventions for a resident. She stated the facility had not had a DON since around Thanksgiving of the prior year, and the new DON had just started. She stated without a DON, the responsibility had fallen to the ADONs. She stated she and the other facility MDS Assessment Coordinator were responsible for ensuring the accuracy of the MDS Assessments; however, she stated they had to go off the information they could see, and they did not have a system in place to manually track the facility falls. She revealed when completing an MDS assessment there was a tab in the EMR that would trigger for any active or historical falls the resident being assessed had. She revealed when the information on a fall or incident was not completed or still open, then that fall history would not pull into the information they used to complete the assessments. She stated a missed fall on the MDS assessment would not have impacted the resident's care in the slightest if the care plan was updated with the interventions enacted for that fall. During an interview and record review on 04/17/2025 at 06:21 p.m., RN Assessment Coordinator B stated in the EMR, when reviewing the risk management tab, it showed a resident's active incidents and, on another page, the closed incidents. Record review of Resident #1's Historical Incidents Report, undated and accessed on 04/17/2025 by RN Assessment Coordinator B, revealed Resident #1 had a fall incident on 01/12/2025 at 08:05 p.m. The incident was noted as closed on 03/11/2025 at 02:50 p.m. RN Assessment Coordinator B stated she assumed Resident #1's fall on 01/12/2025 was not closed until 03/11/2025 because they were unable to determine his injury. During an interview on 04/17/2025 at 07:13 p.m., the DON stated she had just started working at the facility on 04/09/2025. She stated it would be the MDS Coordinator's responsibility to ensure the MDS assessments were accurate. She stated an RN was required to review a completed MDS assessment and sign it to indicate the assessment was accurate and complete. She stated if an MDS assessment was not accurate for fall history, but the care plan was updated with the appropriate interventions following the fall, then the inaccuracy in the assessment would not impact the resident's care. During an interview on 04/17/2025 at 07:18 p.m., the ADMIN revealed every weekday morning she would go over the incidents and accidents that occurred during the night with the care team, and then the care team would also have a stand down meeting at the end of the day to discuss anything that happened during that day. She stated she also believed incidents and accidents would appear on the staff's dashboard when they logged into the EMR. She stated during the care team discussions, they discussed what happened, interventions, and the necessity to update the care plan. She stated the MDS Coordinators were supposed to attend both daily meetings. She stated she believed it was the MDS Consultant's responsibility to initially catch MDS errors, but the facility also had a compliance nurse. She stated the MDS Coordinator would sign the MDS Assessments, but then the MDS Consultant would check them. She stated she was unsure if the MDS Consultant checked every MDS Assessment. The ADMIN stated the DON would normally be the person responsible for completing the facility incident documentation in the EMR, but in the absence of the DON, the compliance nurse was working on them. She stated the compliance nurse would have been able to see if any incidents were still open and she was usually at the facility weekly or able to do them offsite. The ADMIN stated the compliance nurse was able to communicate with the ADONs if there were any sections of an incident report that needed completion. The ADMIN revealed that if the care plan was updated appropriately after a resident fall, then an inaccurate MDS Assessment would not impact the residents care but may impact the facility's reimbursement for that care. Record review of facility policy, Resident Assessment, noted as a section of the Nursing Policy & Procedure Manual 2003, revealed 7. Each assessment will be conducted or coordinate with the appropriate participation of health professionals. Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to transport Resident #1 to a scheduled appointment with an oncologist, MD F as ordered on 02/10/2025. This failure could place residents at risk for not receiving appropriate care and treatment and or a decline in their health. Findings included: Record review of Resident #1's Admission Record, dated 02/13/2025, reflected Resident #1 was a [AGE] year-old male. He was admitted on [DATE]. MD G was noted as Resident #1's attending physician. Record review of Resident #1 Diagnosis Report, dated 02/13/2025, reflected Resident #1 was noted to have diagnoses including secondary malignant neoplasm (a cancerous tumor either caused by a prior cancer treatment or a tumor unrelated and in a new location from a prior cancer) of unspecified site, squamous cell carcinoma (a type of skin cancer) of skin of scalp and neck, unilateral paralysis of vocal cords (a condition in which one vocal cord cannot move or has limited movement) and larynx (voice box), and localized enlarged lymph nodes (swollen clusters of immune system cells). Record review of Resident #1's Admission MDS, signed as completed on 11/17/2024, reflected Resident #1 had a BIMS score of 13, indicating he was cognitively intact. He was documented as requiring substantial/maximal assistance with sit to stand, chair/bed-to-chair transfers, and car transfers. He used a wheelchair and required supervision or touching assistance when wheeling 50 feet with two turns and 150 feet. His active diagnoses included cancer. Record review of Resident #1's Care Plan, dated as last review completed 01/24/2025, reflected Resident #1 had a communication problem r/t paralysis of left side vocal cords due to localized enlarged lymph nodes resulting in squamous cell carcinoma of left side of neck. Resident also with mets [Metastasis; a process by which cancer cells spread to other parts of the body] to chest. Interventions included: Anticipate and meet needs., initiated 11/09/2024. Record review of Resident #1's Progress Notes reflected: - A Nursing Progress Note, effective date 02/04/2025 at 03:05 p.m. by LPN C, [Oncologist Office Manager] with [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM[sic]. - A Nursing Progress Note, effective date 02/10/2025 at 03:48 p.m. by ADON A, CONTACTED [MD F] REGARDING SCHEDULING RESIDENT APPOINMENT [sic] NO ANSWER VM WAS LEFT WITH CONTACT INFO. Record review of Resident #1's Order Recap Report, dated 02/13/2024 with order dates 11/08/2024 - 02/28/2025, reflected an order, order dated 02/04/2025 with start date 02/10/2025 and end date 02/11/2025, ordered by MD G, [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM one time only for 1 Day. Order status was noted to be documented as Completed. Record review of Resident #1's 2/1/2025 - 2/28/2025 Treatment Administration Record, dated as printed on 02/13/2025, reflected the order [MD F] called at this time and appt for this resident was made for Monday 2/10/25 @ 2:00PM one time only for 1 Day. The order was documented as Administered by LPN E on 02/10/2025 at 10:32 a.m. During an interview on 02/13/2025 at 10:21 p.m., Resident #1's RP stated Resident #1 had missed an oncology appointment due to the transportation not having been scheduled. Resident #1's RP stated Resident #1 had cancer that had not progressed far but was virulent (rapidly harmful), which indicated Resident #1 could not miss any of his cancer treatment appointments. During an interview on 02/13/2025 at 12:04 p.m., Resident #1 reported the facility had canceled prior appointments he was scheduled due to lack of transportation. Resident #1 stated he believed he missed two appointments but was not sure. Resident #1 stated the facility was aware he missed his appointments and felt that the facility was not good about taking him to his appointments. During an interview on 02/13/2025 at 02:00 p.m., the Transportation Nurse stated the facility procedure for scheduling resident appointments was for the nurses on Resident #1's side of the facility to first put in the order for the appointment and then they would also put in the appointment on the appointments calendar. The Transportation Nurse stated she was made aware of upcoming appointments by reviewing the appointment calendar and she would also be knowledgeable of scheduled appointments she had scheduled herself. She stated she was unaware of Resident #1 having had missed any appointments scheduled in January or February (of 2025). During an interview on 02/13/2025 at 02:15 p.m., LPN E stated the facility procedure for scheduling resident appointments was for the nurse who received the appointment to put in the appointment order once scheduled and then to put the appointment on the appointment calendar. LPN E stated it was the responsibility of the nursing staff to correctly schedule appointments and that the appointment calendar was specifically for transportation scheduling. LPN E stated she was Resident #1's nurse on the day he had a scheduled radiation appointment, 02/10/2025. She stated she notified her nursing aides and reminded Resident #1 of his appointment that morning so he would be ready for transportation at 01:00 p.m. She stated he was ready, dressed, and with his paperwork for the appointment prepared prior to her leaving for a lunch break. She said that when she returned from her lunch break, she was asked by ADON A why Resident #1 missed his appointment. She stated at that time she verified that the resident's appointment was ordered, which she had already marked as completed prior to her break. She stated she also checked the appointment calendar and found that his appointment on the calendar was no longer present. She stated she remembered his appointment having been on the calendar earlier that morning but that she had been previously observed that appointments could be deleted or disappear. She did not state that she had reported her observations of appointments having been deleted. She stated she did not know for certain how Resident #1's appointment did not show on the appointment calendar once reviewed following his missed 02/10/2025 appointment. During an interview on 02/13/2025 at 02:29 p.m., ADON B stated she was aware Resident #1 missed his radiology appointment. She stated a radiology appointment was pretty important for the Resident's care and that a resident should not miss any appointments unless there was an outlying reason. During an interview on 02/13/2025 at 02:41 p.m., the Oncologist Office Manager for MD F confirmed Resident #1 missed his scheduled 02/10/2025 appointment. She stated MD F was unavailable for interview; however, she stated that the 02/10/2025 appointment was Resident #1's first appointment with MD F which meant the doctor would not be able to estimate the impact on Resident #1's health for having a 8-day delay in appointment visits. Attempted interview on 02/13/2025 at 03:20 p.m. with MD G, Resident #1's primary physician. MD G's office staff member reported he was unavailable for interview. During an interview on 02/13/2025 at 03:33 p.m., ADON A stated she was aware Resident #1 recently missed an appointment. ADON A stated she was not sure of what caused the missed appointment. ADON A stated her understanding was that the appointment was not on the appointment calendar and the van driver would have then not been aware of the appointment. She stated Resident #1 was ready to go to his appointment but between 01:30 p.m. and 02:00 p.m., he did not get picked up by transportation. She stated she believed LPN E was on break during that time. ADON A stated that appointments were communicated to nursing staff through the 24-hour report, the Medication Administration Report which shows the appointment order, and on the transportation calendar. ADON A stated she was unsure if the transportation nurse had access to the 24-hour report but did have access to the transportation calendar. ADON A stated following Resident #1's missed appointment, she spoke with LPN E and re-educated LPN E on her responsibility to ensure the residents leave for their scheduled appointments. During an interview on 02/13/2025 at 04:38 p.m., the ADMIN stated she and the ADONs review the transportation calendar each morning during their morning meeting. The ADMIN revealed she believed access to the transportation calendar was restricted to only the nursing staff and department managers. She stated appointments could be rescheduled and or deleted but was unsure how to view a report to show that information. She stated nursing staff would typically make appointments and they were to then put the appointment in the transportation calendar, which would communicate the scheduled appointment with the transportation nurse. The ADMIN stated the facility did not have a formal procedure or monitoring report to ensure that scheduled appointments were put both into the resident's orders and onto the transportation calendar. The ADMIN stated that the facility's biggest confusion was that scheduled appointments needed to be in both places and if an appointment was not on the transportation calendar, there would be a miscommunication. The ADMIN stated every appointment was important and Resident #1's condition could worsen if he was not making his appointments. Record review of facility policy Appointments, labeled as part of Nursing Policy & Procedure Manual 2003, reflected The facility will assist with outside facility resident appointments to ensure the resident attends any scheduled appointment., and under procedure, 2. If facility transportation is to be used, the staff member responsible for transportation will be notified to schedule the appointment.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that: The facility failed to supervise Resident #1 who eloped from the facility on 06/21/24. The noncompliance was identified as PNC. The IJ began on 06/21/24 and ended on 06/22/24. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings included: Record review of the face sheet for Resident #1, dated 11/15/24, revealed the [AGE] year-old male resident was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (a condition of cognitive impairment that can have occur for various reasons), peripheral vascular disease ( a circulatory condition in which narrowed blood vessels reduce blow flow to the extremities), and bipolar disorder ( a mental health condition that causes extreme mood swings). Record review of Resident #1's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of a 8 which indicated that the Resident was cognitively impaired. The MDS indicated that the resident exhibited a moderate risk of wandering behavior. Record review of the Quarterly care plan for Resident #1, initiated on 8/8/22, revealed the resident had a risk of wandering behavior. The interventions included identifying the pattern of wandering, observation, and provided structured activities. Further review revealed the resident's care plan was changed on 6/21/24 to include the resident's elopement on 6/21/24. Record review of wandering assessment for Resident #1, dated 4/17/24, noted the resident had a history of wandering aimlessly and was at low risk for elopement. The wandering assessment was revised on 6/21/24 to include the elopement incident. Record review of the physician order summary for Resident #1, dated 6/20/24, revealed the resident was under the care of the medical director for medication management and behavior monitoring. Record review of the one-on-one supervision log for Resident #1, dated 6/21/24, revealed the resident was under continuous one-on -one supervision by nursing staff upon return to the facility from the elopement including supervision during the resident's transfer to the hospital on 6/21/24. Record review of the facility's incident report dated 6/21/24 revealed that the facility's van driver began looking for the Resident #1 at 8:15 a.m. on 6/21/24. Code Orange for elopement protocol was called at the facility on 6/21/24 at 8:30 a.m. Family and physician notifications were initiated. All of the facility's rooms were searched with all other residents' whereabouts being noted. The facility staff conducted a search of the facility grounds and surrounding locale. Resident #1 was located several blocks for the facility at 8:50 a.m. at a convenience store. Local law enforcement was also at this location at the time. Resident #1 was brought back to the facility and a full head to toe assessment was conducted by nursing staff with no injuries noted. Resident #1's physician ordered that Resident #1 be transported to the hospital on 6/21/24 at 9:15 a.m. for further evaluation. The summary of the incident report finding was that the Resident went out of one of the facility entrance doors but the elopement was unwitnessed. Record review of world weather.info website revealed the morning temperature on 6/21/24 in [NAME], TX was 77 degrees Fahrenheit. Review of Google Maps revealed that on 6/21/24 Resident #1 would have crossed one street, E Mockingbird Lane to arrive at the convenience store located at 2602 E Mockingbird Lane, [NAME], TX. Observation from 11/13/24 to 11/15/24 between the hours of 8:00 a.m. and 4:00 p.m., of all the resident corridor hallways revealed the door alarms were in working order. Observation on 11/15/24 at 9:45 a.m. with the Administrator revealed that all of the facility's exit doors were tested for door alarm efficacy with no concerns noted. During an interview with the Administrator on 11/14/24 at 9:55 a.m. regarding the elopement incident, the Administrator stated that Resident #1 had eloped from the facility on 6/21/24 sometime around 8:00 a.m. The Administrator stated that the facility's van driver began looking for the Resident #1 at 8:15 a.m. on 6/21/24. Code Orange for elopement protocol was called at the facility on 6/21/24 at 8:30 a.m. Family and physician notifications were initiated. All of the facility's rooms were searched with all other residents' whereabouts being noted. The facility staff conducted a search of the facility grounds and surrounding locale. Resident #1 was located several blocks for the facility at 8:50 a.m. at a convenience store. Local law enforcement was also at this location at the time. Resident #1 was brought back to the facility and a full head to toe assessment was conducted by nursing staff with no injuries noted. Resident #1's physician ordered that Resident #1 be transported to the hospital on 6/21/24 at 9:15 a.m. for further evaluation. The Administrator stated that she had ordered on 6/21/24 that all facility's exit doors be checked for door alarm and closure viability. The Administrator advised that all of the facility's resident assessments for elopement were updated on 6/21/24. During an interview with the Assistant Maintenance Director on 11/15/24 at 10:45 a.m., the Assistant Maintenance Director stated that regular inspections of all of the facility's exit doors for alarm and door closure effectiveness are done three times a week. Record review of the undated facility's policy titled, Elopement Prevention and Elopement Response revealed, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. The Administrator was notified on 11/15/24 at 3:00 p.m., that a past non-compliance IJ situation had been identified due to the above failure. It was determined the failures placed Resident #1 in an IJ situation on 6/21/24. The facility implemented the following interventions. The Quarterly care plan for Resident #1 initiated on 5/15/24 revealed was changed on 6/21/24 to include the resident's elopement on 6/21/24. Record review of wandering assessment for Resident #1 was revised on 6/21/24 to include the elopement incident. All of the residents in the facility on 6/21/24 had their elopement risk assessments reviewed and updated. During an interview on 11/14/24 from 11:10 a.m. to 11:55 a.m. with Charge Nurse A, Guest Relations Staff B, Occupational Therapist Staff C, ADON D, Housekeeping Supervisor E, and Van Driver F, they stated that they had participated in the elopement exercise to find Resident #1 on 6/21/24. These staff were all present in the building at the time of the elopement by Resident #1. They stated they had been re-inserviced on the elopement protocol on 6/21/24 and were aware of what to do to monitor and intervene with residents who have exit-seeking behaviors. During an interview with the Human Resources Director (HR Q) on 11/14/24 at 12:30 a.m., she confirmed stated that all of the facility's active staff had been in-serviced on the elopement protocol on 6/21/24. During an interviews on 11/14/24 from 1:00 p.m. to 2:00 p.m. the following staff (Activity Director, CNA G, CNA H, CNA I, COTA J, LVN K, RN L, [NAME] M, DA N, DA O, DA P, HR R, Housekeeper S, Housekeeper T, MA U, MA V, PTA W, PTA X, Rehab Director Y, RA Z stated they had been in-serviced on elopement protocol call Code Orange, what to do when a resident was missing by calling Code Orange, telling staff, and searching for the resident, and what to do when a resident was trying to elope-try and re-direct the resident, tell the nurse, and stay with the resident.

Based on observation, interview, and record review, the facility failed to ensure that food that accommodates resident allergies, intolerances, and preferences for 1 of 8 residents (Resident #13) reviewed for resident allergies, intolerances, and preferences, in that: On 09/04/2024 Resident #13 was given meatloaf with egg causing an allergic reaction. Requiring Resident #13 to use emergency medication and be transferred to the hospital for further evaluation. The noncompliance was identified as PNC. The IJ began on 09/04/24 and ended on 09/05/24. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk of harm, serious injury, or death. Findings were: Record review of Resident #13's face sheet dated 11/13/2024, revealed an original admitted [DATE] and a re-admitted [DATE] with diagnoses of: personal history of anaphylaxis (a severe, life-threatening allergic reaction), chronic obstructive pulmonary disease (lung disease making it hard to breathe), angina pectoris (chest pain/discomfort). Record review of Resident #13's MDS, dated [DATE], showed a BIMS score of 13 indicating intact cognition. Record review of Resident #13's Care Plan, dated 10/23/2024, showed, Allergic to Influenza Vaccine Live, Chicken Derived Substance, Levaquin and Eggs. Record review of Resident #13's electonic health record revealed on 09/24/2024 Resident #13 was given meatloaf for lunch which contained egg as a binding agent. Record review of nursing note dated 9/4/2024 revealed Resident #13 alerted nursing staff via call light that he was having symptoms of allergic reaction after consuming meatloaf and self-administered epi-pen at bedside. Record review of nursing note dated 9/4/2024 revealed Resident #13 alerted nursing staff via call light that he was having symptoms of allergic reaction after consuming meatloaf and self-administered epi-pen at bedside. - 9/4/2024 at 16:02 [4:02 p.m.], Resident Tranfered to [hospital name] ER By EMS, NP notified at 13:32 [1:32 p.m.], DX: Allergic Reaction, Epi-pen administered at 13:12 [1:12 p.m.], Resident is his own RP and Family [family member name] notified, DON in room and aware, O2 at 15L per non-rebreather mask administered. Tongue was swollen at time of epi-pen given and hd subsided by the time EMS arived at 13:35 [1:35 p.m.]. V/S B/P-150/90, P-84, R-14, T-97.1 O2 Sat 100% via non-rebreather mask at 15L. Resident has allergy to eggs and chicken derived substances. Meatloaf tray present in Room, but tray looked untouched. Report called into to ER Nurse at [hospital name] hospital at 13:46 [1:46 p.m.]. called [hospital name] ER for patient status. ER Nurse reported to this nurse at 15:59 [3:59 p.m.] that patient is stable but unsure if he is being admitted or returning to facility. - 9/4/2024 at 21:26 [9:26 p.m.], At 21:19 [9:19 p.m.] resident returned from ER per facility van with no N/O. Resident up walking and V/S 158/107 P-85, R-18, T-97.4, O2 sat 100%. Resident eating noodles from home in room. no c/o Epi-pen in lock box at bed side Record review of Resident #13's hospital record, dated 9/4/2024, revealed: Allergic reaction secondary to eggs. Record review of written statement from cook dated 9/4/2024 showed, I know I made meatloaf for lunch didn't follow the recipe . During an interview on 11/13/2024 at 1:00 p.m. with DFN stated that prior to giving the meatloaf to the resident, she had asked CC if egg was used, and CC denied using egg. She stated after the allergic reaction to the resident and once the resident returned from the hospital, she again asked CC if egg was used. She stated CC admitted to using egg in the meatloaf. During an interview with Resident #13 on 11/13/2024 at 1:30 p.m., the resident stated he did recall the incident in question. He said injected himself with his epi-pen which he keeps in his room in a locked box. He said he found out later that they had used egg in the meatloaf he had consumed during lunch on 9/4/2024. He stated he has had no further issues. An interview was attempted on 11/15/2024 at 12:53 p.m. with the Cook. There was no answer and voice message was left for a return call. At 12:55 p.m. a person returned the call form the cook's phone number and said this was not the cook's number anymore and to stop calling this number. The facility administration staff were notified on 11/15/2024 at 3:00 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Resident #13 in an IJ situation on 9/4/2024. Prior to the investigation on 11/13/2024, the facility had put into place interventions to prevent allergic food reactions. Interventions included: Assessment of Resident #13 was completed on 09/04/24. Inservice training to all dietary staff related to food allergies and food preparation for residents with food allergies was conducted on 08/31/2024 and 09/05/2024, after the incident occurred. Simplified menus created with resident regarding safe foods and preferences, completed 9/5/2024. All residents with known allergens will have colored meal cards at every meal completed 9/5/2024. All meals will be made separately and in a designated area completed 9/5/2024. All meals will be approved by DFN and RN then taken to resident by authorized staff completed 9/5/2024. Resignation of [NAME] on 9/5/2024. ANE training was completed for all staff, including the dietary staff, on 11/11/2024. During an interview on 11/14/2024 from 12:00 p.m. and 12:30 p.m. with dietary staff [NAME] M, DA N, DA O and DA P, they stated they had participated in the in-service regarding food allergies and food preparation for residents with food allergies. During an interview on 11/14/2024 from 1:00 p.m. to 2:00 p.m. the following staff, CNA G, CNA H, CNA I, RN L, [NAME] M, DA N, DA O, DA P, stated they had been in-serviced on Abuse, Neglect and Exploitation regarding identification, interventions and reporting ANE. During an interview on 11/14/2024 at 4:20 p.m. with LVN AA stated that for residents with food allergies, their food was prepared separately from other residents and that nurses had to go to the kitchen to check the tray before it was given to the resident. During an interview on 11/14/2024 at 4:49 pm with Dietary Supervisor stated that residents with food allergies trays were prepared in separate area. For food preparation the meal ticket listed the resident's allergies and dietary staff keep a copy of the resident lists with food allergies in the kitchen too. Only 1 dietary person prepared the food for residents with food allergies to help prevent cross-contamination of allergens. On 11/15/2024, Records reviewed showed, Dietary staff have been re-educated regarding resident's specific allergy to chicken and eggs. A simplified menu was created with the resident regarding safe foods and his preferences. The DM and/or designee checks residents food trays for potential allergens. The Charge Nurse will also check food trays for potential allergens prior to serving. Observation on 11/15/2024 at 12:00 p.m. revealed dietary staff prepared trays for residents that have a food allergy. There was only 1 staff that prepared the trays for residents with food allergies. The trays were prepared in another area of the kitchen, away from the regular food. Observed that the meal tickets with residents with food allergies were color coded.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of eighteen residents reviewed for elopement. The facility failed to implement measures to adequately supervise Resident #1 and prevent her from eloping the facility on 12/23/2022. The failure could place residents at risk for possible elopement, serious injuries, and harm. The noncompliance was identified as Past Non-Compliance. The Immediate Jeopardy began on 12/18/2022 and ended on 12/27/2022. The facility had corrected the noncompliance before the survey began. Findings include: Record review of Resident #1's Face Sheet dated 12/27/2022 revealed a [AGE] year-old woman who admitted to the facility on [DATE] with diagnoses Parkinson's Disease (a disorder of the nervous system that affects movement, often including tremors), Dementia (a general term for impaired ability to remember, think, or make decisions), Schizophrenia (a chronic mental illness characterized by delusions, hallucinations, and disordered thinking), and Muscle Wasting and Atrophy (the shrinking of muscle or nerve tissue). discharge date noted as 12/24/2022 at 7:00 p.m. to Other Nursing home. Record review of Resident #1's MDS dated [DATE] revealed Resident#1's BIMS score was 07 (scores 00-07 suggest severe impairment), and the resident had wandered daily. The resident required supervision or limited assistance with activities of daily living. Record review of Resident #1's Care Plan noted as last care plan review completed 12/24/2022 revealed, noted Focus initiated 11/21/2022, resident is at risk for wandering. Resident #1 Care Plan included Focus initiated 12/27/2022, Resident Elopement; noted Goal, Resident will remain secure and safe without any other elopements; and noted Interventions include: Q15 monitoring and Resident referred to a secured care unit. Record review of Resident #1's Order Summary Report dated 12/28/2022 and noted as Active Orders As of: 12/24/2022, revealed the following order: Behavior Monitoring 29. Wandering . Order dated to start on 11/09/2022 and status Active. Record review of Resident #1's Elopement Risk Assessment effective date 11/01/2022 at 2:00 p.m. revealed Resident #1 ambulates independently or with device, understands and verbalizes acceptance of need for nursing home care, and has had no attempts to leave own residence/facility. Record review of Resident #1's Elopement Risk Assessment effective date 12/7/2022 at 10:46 a.m. revealed Resident #1 ambulates independently or with device, has had statements and/or threats to leave facility, has moderately impaired cognitive skills for daily decision making, has had one or more previous attempts to leave facility in last year, has restless behaviors, does not recognize stop lights and signs, does not know precautions when crossing streets, and does not know location of current residence. Record review of Resident #1's Progress Note dated 12/18/2022 at 5:47 p.m., written by LVN B, revealed [3:00 p.m.]- Resident was down A-Wing and she opened door and walked out of facility . Record review of Resident #1's Progress Note dated 12/18/2022 at 8:24 p.m., written by LVN C, revealed F/U for elopement earlier today. Resident wandering about facility at this time. Doesn't appear to be seeking an exit at this time. Record review of Resident #1's Progress Note dated 12/21/2022 at 9:05 p.m., written by LVN C, revealed Resident continues with confusion and wandering . Record review of Resident #1's Progress Note dated 12/22/2022 at 4:04 p.m., written by LVN B, revealed resident still with increased weakness and confusion . Record review of Resident #1's Progress Note dated 12/22/2022 at 8:52 p.m., written by LVN C, revealed Resident continue with confusion and wandering. Record review of Resident #1's Progress Note dated 12/23/2022 at 10:00 p.m., written by LVN A, revealed Bring to this nurse attention by aide of Hall E .that resident was not in the facility. Instructed all the staffs to search for her. On call nurse informed. Approximately about 11 pm, a gentleman called the facility .He informed that [Resident #1] was found on the road and he told this nurse EMS had picked her and already on the way to [the hospital] at [city] . Record review of Resident #1's Elopement Risk Assessment effective date 12/23/2022 at 10:00 p.m. revealed Resident #1 ambulates independently or with device, understands and verbalizes acceptance of need for nursing home care, has moderately impaired cognitive skills for daily decision making, has had zero previous attempts to leave residents/facility, has no restlessness or anxiety, does not recognize stop lights and signs, does not know precautions when crossing streets, and does know location of current residence. Additional information included Resident is wanderer, calm, not angry/aggressive behavior or threatening to leave facility. Record review of Police Event Report dated 12/27/2022 revealed, call received 12/23/2022 at 10:21:26 p.m. Event Notes include female came running into the street and fell . Record review of Apple Maps reflected the location Resident #1 was found, was approximately 1.5 miles from the nursing facility. Record review of the weather conditions on 12/23/2022, according to the National Weather Service accessed 01/02/2022, revealed the low temperature at 17 degrees Fahrenheit and high temperature was 35 degrees Fahrenheit. Record review of Resident #1' hospital Emergency Department record dated 12/27/2022, arrival date and time 12/23/2022 at 10:55 p.m. revealed admitting diagnosis of Trauma, Head with history of Abrasion after fall crossing street. The patient is nursing home resident. Trauma. Record review of Resident #1's Event Nurses' Note 12hr- Elope or Attempt effective date 12/23/2022 at 10:00 p.m. revealed resident's physician was notified on 12/23/2022 at 11:46 p.m., resident's responsible party was notified on 12/23/2022 at 11:50 p.m., interventions initiated by the nurse included: 1 on 1 supervision and Interval monitoring- Q15 minutes monitoring; and Resident #1's cognition or behavior at the Time of Event (elopement) included: Cognitive Impairment and Exit seeking. Record review of Resident #1's Readmission Nurses' Note effective date 12/24/2022 at 2:00 a.m., written by LVN A, revealed resident readmitted from the hospital or ER following a fall when she was eloped. Resident #1 noted as arriving by EMS. Resident noted as with having Short Term Memory problem, decisions are poor, resident alert, oriented to person and place, and with clear speech. Resident with noted exhibiting behavior of wandering. Record review of Resident #1's Elopement Risk Assessment effective date 12/24/2022 at 2:17 a.m. revealed Resident #1 ambulates independently or with device, understands and verbalizes acceptance of need for nursing home care, has moderately impaired cognitive skills for daily decision making, has had one or more previous attempts to leave facility in last year, has restless behaviors, does not recognize stop lights and signs, does not know precautions when crossing streets, and does not know location of current residence. Record review of Resident #1's Initial Skin assessment dated [DATE] at 2:00 a.m. revealed resident with laceration on chin. Interview with CNA A on 12/28/2022 at 7:16 p.m. CNA A revealed on the night of Resident #1's elopement, Resident #1 was requesting to help put other residents to bed. CNA A revealed she redirected Resident #1 by asking her to clean up around the sink. CNA A revealed that she last saw Resident #1 slightly after 9:00 p.m. prior to being called to assist another CNA on a different hall. CNA A revealed that upon return to her hall, Resident #1 was no longer next to the sink and CNA A could not locate Resident #1 in her room. CNA A revealed that she immediately told the charge nurse (LVN A) that she could not locate Resident #1. CNA A revealed that LVN A directed her and another CNA to check the other facility halls and once checked, LVN A called the code for a missing resident. CNA A revealed that following checking the facility again and checking outside, she was notified that Resident #1 was picked up by EMS. CNA A denied Resident #1's behavior or mood to be different on the day of elopement but revealed that there were times Resident #1 would say she wanted to go home. CNA A denied being notified of Resident #1's prior elopement on 12/18/2022. CNA A revealed that if a resident was an elopement risk an intervention would be to keep all the exits secure and to make sure there are alarms, so if anyone tried to get out the alarm would go off. CNA A revealed that she did not believe there were alarms on the front door or E-wing doors. CNA A revealed that an elopement is a high risk for a resident because it may result in the resident going on the road, walking on the road, getting into a car with someone they do not know, or they could fall down when they are outside. CNA A revealed that Resident #1 was transferred or her safety, where she can be behind locked doors and would not be able to wander so much. Interview with LVN A on 12/28/2022 at 09:11 a.m. LVN A revealed that on the night of Resident #1's elopement, Resident #1 was observed at 9:30 p.m. helping other residents. LVN A revealed she redirected Resident #1 by giving her a sandwich and walking her to her room. LVN A revealed that not long after redirecting Resident #1, CNA A approached her and notified her that she could not find Resident #1. LVN A revealed that she initiated a search of the facility and contacted the on-call nurse. LVN A revealed that around 11:00 p.m. she received a call from an anonymous gentleman reporting that Resident #1 had been located, that EMS had picked her up, and that Resident #1 was being transferred to the ER. LVN A revealed that Resident #1 returned to the facility around 2:30 a.m. and had lacerations on her chin that required sutures. LVN A revealed that Resident #1's behavior and mood were not unusual on the night of her elopement. LVN A revealed that Resident #1 had insomnia, wandering was normal for her, and she liked to participate and help the staff. LVN A revealed that Resident #1 would sometimes look for exits, but it was rare, and she was not an exit seeker. LVN A revealed that interventions in place for wanderers includes completing a head count and extra monitoring for the resident. LVN A revealed that some of the doors of the facility did not lock, and CNAs usually would sit in front of those doors to watch the hall. LVN A revealed that elopements put residents at a big risk and that the facility may not have someone there to watch the doors all the time. Interview with the DON on 12/28/2022 at 12:33 p.m. The DON revealed that to her knowledge, Resident #1 was not considered an elopement risk prior to her elopement on 12/23/2022. The DON revealed that Resident #1 would frequently ambulate around the facility and interact with staff. The DON revealed that Resident #1 was pleasantly confused but easily redirected. The DON revealed that she was not notified of Resident #1's elopement on 12/18/2022. The DON revealed that she discovered the 12/18/2022 incident while reviewing Resident #1's chart following the 12/23/2022 elopement. The DON revealed that the high elopement risk score on the 12/7/2022 Elopement Risk Assessment was the result of an error. The DON revealed that the nursing staff member that completed the 12/7/2022 Elopement Risk Assessment completed an admission assessment versus a standard assessment and contradicted herself in the report. The DON revealed that Resident #1 had had some falls but had not had a change in condition prior to the elopement. Record review of the facility's policy Elopement Prevention, dated revised 10/27/2010, labeled MM TIW WA 03-1.0 revealed, Environmental Modification .5. Use door locks that are out of reach/sight to prevent wanderers from opening doors. 6. Use door alarms or monitoring devices to notify staff when residents try to leave the facility .8. If applicable, consider resident for a secured unit. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation from 12/18/2022 through 12/27/2022. The facility took the following actions to correct the noncompliance on 12/18/2022 through 12/27/2022: Record review of Resident #1's Q 15 Minute Monitoring document dated 12/24/2022 with time range: 2:00 a.m. to 8:15 p.m., revealed Resident #1 was monitored every fifteen minutes from return to the facility to discharge. Record review of Resident #1's Discharge Summary dated 12/24/2022 at 7:00 p.m. revealed resident to be discharged on [DATE] with course of treatment noted as transferred to a locked unit for safety. Record review of the facility's self-report titled Assessment History, printed 12/28/2022 at 6:45 p.m. revealed all facility residents were re-assessed with the Elopement Risk Assessment - V 2 between 12/23/2022 to 12/28/2022. Record review of In-service documentation, dated 12/23/2022 to 12/27/2022, revealed an In-service on Elopement and an In-service on Abuse/Neglect was provided to all employees. Interview with LVN D on 12/29/2022 at 2:39 p.m. and LVN E on 12/29/2022 at 3:18 p.m. revealed they had been in-serviced on the facility elopement policy and procedures. Record review of facility's Quality Assurance meeting sign-in sheet, dated 12/26/2022, revealed that the interdisciplinary team met to discuss Resident #1's elopement. Observations on 12/28/2022 from 10:11 a.m. to 10:46 a.m., of the facility's entry, facility staff side entry, and hall doors, with DOM, all exit doors were checked. Exit door from Restorative Therapy room was without an alarm; however, facility entry door into restorative therapy room was locked upon inspection. The facility's front door was not locked or activated alarm during inspection but was monitored by a receptionist present at the entry door. Interview with the DOM revealed he had installed the door alarms on the side entry/exit doors for Halls A, B, C, D, and E, the front entry door, and the staff side entry door on 12/27/2022 around 11:00 p.m. The DOM revealed the doors located at the end of the halls were previously alarmed with maglocks; however, the side hall doors were previously without alarms. The DOM revealed that he does not know if it was determined which door Resident #1 eloped from. Interview with the DON on 12/28/2022 at 12:33 p.m. The DON revealed that the actions put into place to protect Resident #1 from further elopement included placing Resident #1 on monitoring and placing her at another facility. The DON revealed that following the elopement, staff were in-serviced, and the DOM installed alarms on the doors as an immediate necessity. The DON revealed that the locks and alarms on all the doors is the biggest change to occur following the incident. The DON revealed that the change will allow staff to react timely. Interview with the ADMIN on 12/28/2022 at 2:16 p.m. The ADMIN revealed that immediately following the notification of a resident elopement, a QAPI meeting was called to review the facility's elopement protocols, and in-services were initiated on the Code Orange, Elopement protocol. The ADMIN revealed that Resident #1 was placed on monitoring following her return from the hospital and stayed on monitoring until her transfer to a secured unit. The ADMIN revealed that the facility was having maglocks installed on all the doors with the goal to complete by 1/21/2023. The ADMIN revealed that at the time of the elopement, all the facility doors were not alarmed because the facility did not admit residents that were exit seeking. The ADMIN revealed that Resident #1 was discharged due to her requiring a higher level of care for safety precautions. The ADMIN revealed that an elopement puts a resident at risk for falling, having the possibility of injury or duress. The ADMIN revealed that a resident elopement results in stress for the resident physically and emotional stress to the staff.

Based on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 facility reviewed for administration, in that: The Administrator and DON did not monitor to follow-up on missed medications administered to 21 residents (Residents #3, #5, #8, #11, #14, #15, #27, #30, #37, #39, #54, #56, #57, #60, #70, #73, #76, #86,#94, #195, and #247) by facility nursing staff. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 06/04/2021. While the IJ was removed on 06/08/2021, the facility remained out of compliance at a severity of potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern until interventions were put in place to ensure residents received medication and treatments as ordered by their physicians. These deficient practices could result in residents at risk of not receiving the necessary care and services, and could result in worsening or exacerbation of chronic medical conditions, hospitalization , and death due to lack of oversight. The findings were: During an interview with LVN Z on 06/06/2021 at 1:12p.m., she stated that medication is ordered by faxing an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN Z confirmed that delays in receiving medication to the facility occur frequently, and she does not know why. She stated sometimes she attempts to find time to contact the Pharmacy. LVN Z confirmed that the facility had an e-kit with emergency medications, but she did not know there was a reference guide sitting on top of the e-kit that lists which medications are stocked inside it. LVN Z said, There are a lot of e-kits and you just have to go through all of them when you are looking for medications. During an interview with LVN AA on 06/06/2021 1:44p.m., she stated, We order medication but if there is a problem with the pharmacy, such as insurance issues or ordering too soon, that information goes to the DON and she works out the problems. If we notice that it has been a long time [since we have received the medication], sometimes we call the pharmacy and confirm when we are going to receive the medication. During an interview with LVN Q on 06/06/2021 at 2:24p.m., she stated that they mark on the e-mar that the medication was unavailable, and the day shift is expected to follow up with the pharmacy because it is difficult to get ahold of anyone at the pharmacy after 11:00 p.m. When questioned regarding medication available at the facility in the e-kits, she answered, Agency [nurses] do not have access to the e-kit. I put a [nurse] note in chart that the medication is not available, waiting on pharmacy or on order. During an interview with the DON on 06/04/2021 at 5:44p.m., she stated that she was unaware that residents were not receiving medications. The DON was asked if she receives a report of what medications were missed in a 24-hour period. She stated, It does not automatically [generate]. We have to go in and look at it. I know that the [electronic records system] allows us to look at reports, but that is time consuming and I don't know what reports we have access to. We use a communication report that the charge nurses type up every shift. They should be typing [missed medications] on that. If a charge nurse doesn't put it on the communication report, we don't know to follow up on it. The burden lies on the nurse to put the information there so we can follow up. The DON was asked how many days a medication can be marked unavailable to give before it gets noticed. The DON replied, We have e-kits. [The nurse] could have called and told me a medication wasn't here. They are supposed to be calling me. I look at any new orders to see if it is here. That's our biggest safety net for trying to keep these things from happening. The DON was asked if there are specific processes in place for medication receipt from the pharmacy and getting the medication to the proper place, like a medication cart, to be distributed to the residents. The DON replied, We do have processes in place, but did not elaborate further. During an interview with the DON and the Administrator on 06/04/2021 at 5:48 p.m., the DON and the Administrator revealed neither were aware of the missed medications identified by the survey team throughout the survey process. Further interview with the DON and Administrator revealed administration relied on verbal reports received from nursing staff to monitor medication administration and confirmed reports such as Missed Medication Report and 24 Hour Report generated by the facility's electronic records system had not been utilized to identify medication administration errors. During an interview with the consulting pharmacist on 06/07/2021 at 2:27p.m., the consulting pharmacist was asked about negative clinical impacts from residents missing their medications for multiple days. The consulting pharmacist confirmed there could be negative clinical impacts. Record review of the facility policy, Administration, effective date 11/28/2017, revealed, Objective: To attain or maintain the optimal physical, mental, and psychosocial well-being of each resident. Policy: A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator was notified on 06/04/2021 at 9:13 p.m., in person, that an Immediate Jeopardy situation was identified, surveyor emailed the IJ template to the Administrator on 02/02/2021 at 9:14 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 06/05/2021 at 4:59 p.m. and included: . The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: . An audit was initiated on 6/4/21 based on the information and findings brought to the DON and ADON by the survey team on 6/4/21. There was one resident identified as having a medication pending delivery on 6/4/21 on the report, however the medication was administered the same day when it arrived on 6/4/21. A head to toe assessment was completed with no exceptions or adverse reactions noted. . Medication Incident Reports were completed on 6/4/21 for all residents who did not receive medications as scheduled. . DON and/or ADON will review Missed Medication report during morning meeting daily for four weeks; then weekly for two months to ensure compliance with regulations. The DON and/or ADON will submit the medication audit reports and medication cart audit results to the Administrator weekly for four weeks and then monthly for two months. . The Administrator and DON will be responsible for ensuring all staff including Agency staff who work in the facility who were educated via phone sign their commitment letter and in-service sign in sheet at their next scheduled shift and will utilize an active employee checklist to ensure 100% completion. DON and/or ADON will review Medication Audit report on all residents during morning meeting daily for four weeks; then weekly for two months. Initiated: 6/4/21 Expected Completion: August 2021 . Adhoc QAPI meeting held on 6/4/21 with Inter Disciplinary Team (IDT) to review and discuss items identified by surveyor regarding Immediate Jeopardy. A Plan of Removal was developed, implemented, and completed as designed in this document. The survey team confirmed the plan of removal had been implemented sufficiently to remove the IJ by: .An audit was initiated on 6/4/21 based on the information and findings brought to the DON and ADON by the survey team on 6/4/21. There was one resident identified as having a medication pending delivery on 6/4/21 on the report, however the medication was administered the same day when it arrived on 6/4/21. A head to toe assessment was completed with no exceptions or adverse reactions noted. --Verified via interview with the DON on 06/07/2021 at TIME and record review of facility document, Head to Toe Assessment form for Resident #81. .Medication Incident Reports were completed on 6/4/21 for all residents who did not receive medications as scheduled. --Verified via record review of facility documents, Medication Incident Report for Residents #81, #247, #115, #54, #39, #37, #57, and #64. DON and/or ADON will review Missed Medication report during morning meeting daily for four weeks; then weekly for two months to ensure compliance with regulations. --Verified via interview with Administrator on 06/08/2021 at 8:28 a.m., interview with DON on 06/07/2021 at 8:42 a.m., and record review of the facility documents, Missed Medication Report, dated 06/05/2021, 06/06/2021, 06/07/2021, and 06/08/2021. The DON and/or ADON will submit the medication audit reports and medication cart audit results to the Administrator weekly for four weeks and then monthly for two months. --Verified via interview with Administrator on 06/08/2021 at 8:28 a.m., interview with DON on 06/07/2021 at 8:42 a.m. . The Administrator and DON will be responsible for ensuring all staff including Agency staff who work in the facility who were educated via phone sign their commitment letter and in-service sign in sheet at their next scheduled shift and will utilize an active employee checklist to ensure 100% completion. --Verified via interview with Administrator on 06/08/2021 at 8:28 a.m., interview with DON on 06/07/2021 at 8:42 a.m. DON and/or ADON will review Medication Audit report on all residents during morning meeting daily for four weeks; then weekly for two months. Initiated: 6/4/21 Expected Completion: August 2021 --Verified via interview with Administrator on 06/08/2021 at 8:28 a.m., interview with DON on 06/07/2021 at 8:42 a.m. . Adhoc QAPI meeting held on 6/4/21 with Inter Disciplinary Team (IDT) to review and discuss items identified by surveyor regarding Immediate Jeopardy. A Plan of Removal was developed, implemented, and completed as designed in this document. --Verified via interview with the Administrator on 06/08/2021 at 8:28 a.m., interview with DON on 06/07/2021 at 8:42 a.m. and record review of the IDT meeting sign in sheet. On 06/08/2021 at 11:50 a.m. the Administrator was informed the facility remained out of compliance at a severity of potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility requiring more time to monitor the plan of removal for effectiveness.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of medications for 21 of 22 residents (Residents #3, #5, #8, #11, #14, #15, #27, #30, #37, #39, #54, #56, #57, #60, #70, #73, #76, #86,#94, #195, and #247) reviewed for pharmacy services. 1. Resident #3 missed 3 doses of her medication, calamine lotion, for itching, 5 doses of her medication, [MEDICATION(S)] 40mg, for [CONDITION(S)], 3 doses of her medication, [MEDICATION(S)] 5mg, for [CONDITION(S)] of knee, 7 doses of her medication, [MEDICATION(S)] AF cream 1%, for fungal infection, 1 dose of her medication, [MEDICATION(S)] extended release 500mg, for [CONDITION(S)], 11 doses of her medication, [MEDICATION(S)] 7.5-325mg, for chronic pain related to [CONDITION(S)] of knee, and 8 doses of her medication, potassium chloride crystals 80mEq, for shortness of breath/wheezing. 2. Resident #5 missed 2 doses of his medication, Miconazole [MEDICATION(S)] cream 2%, for cutaneous candidiasis. 3. Resident #8 missed 4 doses of her medication, [MEDICATION(S)] delayed release 125mg, for [CONDITION(S)], 3 doses of her medication, [MEDICATION(S)] 112mcg, for [CONDITION(S)], 8 doses of her medication, [MEDICATION(S)] cream 10% for vaginal dryness, 3 doses of her medication, [MEDICATION(S)] 100mg, for type 2 diabetes mellitus, and 1 dose of her medication, [MEDICATION(S)] 0.5mg, for anxiety disorder. 4. Resident #11 missed 2 doses of her medication, [MEDICATION(S)] ointment 5mg/Gm, for eye irritation and drainage, 1 dose of her medication, [MEDICATION(S)] 50mcg, for [CONDITION(S)], and 1 dose of her medication, Prevachol 40mg, for [CONDITION(S)]. 5. Resident #14 missed 2 doses of his medication, [MEDICATION(S)] Liquid 15mL, for supplement, 1 dose of his medication, [MEDICATION(S)] solution 100mg/mL, for conversion disorder with seizures or convulsions, 2 doses of his medication, [MEDICATION(S)] 10mg, for recurrent depressive disorder, 3 doses of his medication, [MEDICATION(S)] packet 0.8GM, for [CONDITION(S)], 2 doses of his medication, [MEDICATION(S)] 2.5mg, for [CONDITION(S)], 1 dose of his medication, [MEDICATION(S)] 10mg, for recurrent depressive disorder, 1 dose of his medication, Acidophilus capsule, for supplement, and 1 dose of his medication, [MEDICATION(S)] Tears solution 0.5%, for dry eyes. 6. Resident #15 missed 4 doses of her medication, Klor-Con M10 tablet extended release 10 MEQ (potassium Chloride Crystals ER), for essential hypertension and [CONDITION(S)], 6 doses of her medication, [MEDICATION(S)] Capsule 50 mg, for anxiety disorder, and 1 dose of her medication, [MEDICATION(S)] 20mg, for heart failure. 7. Resident #27 missed 14 doses of her medication, [MEDICATION(S)] 100mcg, for [CONDITION(S)], 2 doses of her medication, [MEDICATION(S)] solution 100mg/mL, for unspecified convulsions, 4 doses of her medication, Multivitamin Liquid 5mL, for supplement, 1 dose of her medication, [MEDICATION(S)] 12.5mg, for hypertensive heart disease, and 2 doses of her medication, Mucinex Fast-Max Liquid 10-850-400 mg/mL 800mg, for sore throat and cough. 8. Resident #30 missed 2 doses of her medication, [MEDICATION(S)] Coneta suspension reconstituted extended release 25mg, for [CONDITION(S)] disorder and 1 dose of her medication, Prevachol 20mg, for [CONDITION(S)]. 9. Resident #37 missed 17 doses of her medication, [MEDICATION(S)] Ointment 2%, for [CONDITION(S)]. 10. Resident #39 missed 8 doses of medication, [MEDICATION(S)] ER tablet extended release, for pain in thoracic region, 1 dose of his medication, [MEDICATION(S)] 20mg, for [CONDITION(S)], 1 dose of his medication, [MEDICATION(S)] 10mg, for [CONDITION(S)] disorder, 1 dose of his medication, [MEDICATION(S)] sodium 100mg, for constipation, 1 dose of his medication, [MEDICATION(S)] 1000mg, for type 2 diabetes mellitus, and 1 dose of his medication, [MEDICATION(S)] delayed release 250mg, for mood (affective) disorder. 11. Resident #54 missed 4 doses of his medication, [MEDICATION(S)] 24mcg, for constipation, 4 doses of his medication, [MEDICATION(S)] 150mg, for conversion disorder with seizures or convulsions, 1 dose of his medication, [MEDICATION(S)] delayed release 500mg, for mood disorder with depressive features, 1 dose of his medication, [MEDICATION(S)] 5mg, for mood disorder with depressive features, 2 doses of his medication, Klor-Con M20 extended release 20mEq, for [CONDITION(S)], 1 dose of his medication, [MEDICATION(S)] 75mcg, for [CONDITION(S)], and 1 dose of his medication, [MEDICATION(S)] 125mcg, for [CONDITION(S)]. 12. Resident #56 missed 1 dose of his medication, [MEDICATION(S)] 40mg, for secondary hypertension, 1 dose of his medication, [MEDICATION(S)] 70/30 suspension 100 unit/mL (Insulin NPH), for type 1 diabetes mellitus with diabetic [CONDITION(S)], 13 doses of his medication, [MEDICATION(S)] packet 8.4Gm, for [CONDITION(S)], and 1 dose of his medication, [MEDICATION(S)] 10-325mg, for muscle wasting and atrophy. 13. Resident # 57 missed 11 doses of her medication, [MEDICATION(S)] solution 0.02-0.005% eyedrops, for [CONDITION(S)] and 9 doses of her medication, [MEDICATION(S)] 75mg, for [CONDITION(S)] heart disease. 14. Resident #60 missed 1 dose of her medication, asorbic acid 500mg, for supplement, 2 doses of her medication, [MEDICATION(S)] Liquid 15mL, for supplement, and 1 dose of her medication, [MEDICATION(S)] 64.8mg, for convulsions. 15. Resident #70 missed 1 dose of his medication, [MEDICATION(S)] 500mg, for type 2 diabetes mellitus, 4 doses of his medication, [MEDICATION(S)] 7.5-325mg, for pain in unspecified joint, and 1 dose of his medication, [MEDICATION(S)] 5mg, for dementia. 16. Resident # 73 missed 31 doses of her medication, First-Omeprazole Suspension, for gastro-[CONDITION(S)] reflux disease. 17. Resident #76 missed 2 doses of her medication, [MEDICATION(S)] 8mg, for [CONDITION(S)] and 4 doses of her medication, [MEDICATION(S)] delayed release, for gastro-[CONDITION(S)] reflux disease. 18. Resident # 86 missed 2 doses of her medication, [MEDICATION(S)] solution 100units/ML (Insulin [MEDICATION(S)]), for diabetes. 19. Resident # 94 missed 5 doses of her medication, [MEDICATION(S)] Packet 2.4 GM, for [CONDITION(S)] and 3 doses of her medication, [MEDICATION(S)] Patch 24-hour 0.4 mg/hr, for [CONDITION(S)]. 20. Resident #195 missed 3 doses of his medication, [MEDICATION(S)] 10mg, for [CONDITION(S)], 3 doses of his medication, [MEDICATION(S)] Tears solution 0.5%, for dry eyes, 2 doses of his medication, [MEDICATION(S)] 5mg, for [CONDITION(S)], 1 dose of his medication, [MEDICATION(S)] 50mg, for hypertensive heart disease with heart failure, and 3 doses of his medication, [MEDICATION(S)] 500-125mg, for pneumonia. 21. Resident #247 missed 2 doses of his medication, Sevelamer 800mg, for hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, 1 dose of his medication, [MEDICATION(S)] sodium 100mg, for constipation, 2 doses of his medication, [MEDICATION(S)] 25mg, for hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, 9 doses of his medication, [MEDICATION(S)] 100mg, for secondary hypertension, 8 doses of his medication, [MEDICATION(S)] 2.5mg, for appetite stimulant, 3 doses of his medication, [MEDICATION(S)] solution 20Gm/30mL, for constipation, and 1 dose of his medication, [MEDICATION(S)] 5mg, for muscle spasm. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medication, could result in worsening or exacerbation of chronic medical conditions, hospitalization , and/or death. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 06/04/2021. While the IJ was removed on 06/08/2021, the facility remained out of compliance at a severity of potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility requiring more time to monitor the plan of removal for effectiveness. The findings were: 1.Record review of Resident #3's face sheet, dated 6/3/2021, revealed an admitted [DATE] with diagnoses that included heart failure, [CONDITION(S)], polyneuropathy, anxiety disorder, and [CONDITION(S)]. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #3's physician orders, dated 6/03/2021, revealed the following orders: - Calamine Lotion. Apply to arms topically one time a day for itching with a start date of 09/26/2020. - [MEDICATION(S)] Calcium tablet 40mg. Give one tablet by mouth at bedtime for [CONDITION(S)] with a start date of 08/02/2020. - [MEDICATION(S)] tablet 5mg. Give one tablet by mouth two times a day for [CONDITION(S)] of knee with a start date of 08/02/2020. - [MEDICATION(S)] AF cream 1% . Apply to nail beds topically three times a day for fungal infection with a start date of 10/ . - [MEDICATION(S)] extended release 12 hour 500mg. Give one tablet by mouth two times a day for [CONDITION(S)] with a start date of 02/01/2020. - [MEDICATION(S)] 7.5-325mg. Give one tablet by mouth three times a day for chronic pain related to [CONDITION(S)] of knee with a start date of 12/14/2020 - Potassium Chloride Crystals 60mEq. Give 60mEq by mouth at bedtime every two days for shortness of breath/wheezing with a start date of 01/30/2021 Record review of Resident #3's MAR from January to June 2021 revealed that the number nine was utilized to indicate there was a corresponding nurse's note in the resident's chart for further information regarding the medication administration. The key on each MAR indicated, 9 = other/see nurse's note. Resident #3 did not receive the following medications and indicated the corresponding nurse note: - Calamine lotion 04/28/2021 [8:50a.m.]: not available - Calamine lotion 04/29/2021 [8:37a.m.]: medication not on cart, not available - Calamine lotion 05/04/2021 [9:00a.m.]: pending receipt from pharmacy - [MEDICATION(S)] 02/20/2021 [9:00p.m.]: (blank) - [MEDICATION(S)] 04/27/2021 [9:00p.m.]: - - [MEDICATION(S)] 04/30/2021 [9:00p.m.]: - - [MEDICATION(S)] 05/01/2021 [9:00p.m.]: - - [MEDICATION(S)] 05/02/2021 [9:00p.m.]: - - [MEDICATION(S)] 04/18/2021 [9:00p.m.]: not available - [MEDICATION(S)] 04/27/2021 [9:00p.m.]: - - [MEDICATION(S)] 04/30/2021 [8:06p.m.]: - - [MEDICATION(S)] cream 04/11/2021 [10:11p.m.] not available - [MEDICATION(S)] cream 04/17/2021 [8:38p.m.] not available - [MEDICATION(S)] cream 04/18/2021 [9:14p.m.] not available - [MEDICATION(S)] cream 04/28/2021 [9:00a.m.] not available - [MEDICATION(S)] cream 04/29/2021 [8:38a.m.] medication not on cart, not available - [MEDICATION(S)] cream 04/29/2021 [1:26p.m.] medication not on cart, not available - [MEDICATION(S)] cream 04/29/2021 [9:00p.m.] medication unavailable - [MEDICATION(S)] 03/16/2021 [6:25p.m.] not cleared by morning med aide - [MEDICATION(S)] 02/04/2021 [2:52p.m.] the medication requires a triplicate prescription. It was ordered. M.D. office contacted to inform of the needed refill. Medication is not yet in the med cart. - [MEDICATION(S)] 02/04/2021 [10:17p.m.] awaiting arrival from pharmacy - [MEDICATION(S)] 03/07/2021 [7:54p.m.] awaiting pharmacy - [MEDICATION(S)] 03/08/2021 [7:40a.m.] pharmacy has not sent the refill - [MEDICATION(S)] 03/08/2021 [1:31p.m.] waiting on delivery - [MEDICATION(S)] 03/08/2021 [8:37p.m.] pending pharmacy [Physician W] aware - [MEDICATION(S)] 03/09/2021 [7:00a.m.] medication has not been approved for refill - [MEDICATION(S)] 03/09/2021 [2:02p.m.] insurance rejected refill - [MEDICATION(S)] 03/09/2021 [6:53p.m.] pending pharmacy [Physician W] aware - [MEDICATION(S)] 03/10/2021 [7:00a.m.] no medication available - [MEDICATION(S)] 03/10/2021 [1:02p.m.] no medication on hand - potassium 02/03/2021 [10:23p.m.] no [due to] order completed - potassium 02/05/2021 [8:03p.m.] no [due to] order completed - potassium 02/07/2021 [7:45p.m.] order already completed - potassium 02/09/2021 [8:00p.m.] (blank) - potassium 02/11/2021 [8:24p.m.] on order - potassium 02/15/2021 [8:36p.m.] on order - potassium 02/19/2021 [8:06p.m.] on order - potassium 02/21/2021 [7:23p.m.] on order Record review on 06/06/2021 of pharmacy delivery logs from January 2021 through June 2021 revealed 30 tablets of [MEDICATION(S)] were delivered for Resident #3 on 01/19/2021 and 04/14/2021. Ninety tablets of [MEDICATION(S)] were delivered for Resident #3 on 01/04/2021, 02/04/2021, and 03/20/2021. No pharmacy logs were presented for [MEDICATION(S)], potassium or [MEDICATION(S)]. Calamine lotion and [MEDICATION(S)] cream were available in the facility's central supply and over the counter for purchase. (Medications in central supply were over-the-counter and did not require delivery from a pharmacy. These types of medications can be purchased from any supermarket or drug store.) Record review on 06/06/2021 of the facility's e-kit from January 2021 through June 2021 revealed that eight doses of 40mg [MEDICATION(S)] and eight doses of 20mg [MEDICATION(S)] were available. There was no evidence that these medications were signed out of the e-kit for this resident. 2.Record review of Resident #5's face sheet, dated 06/03/2021, revealed an admitted [DATE] with diagnoses that included [CONDITION(S)] and [CONDITION(S)] following cerebral infarction, polyosteoarthritis, chronic obstructive pulmonary disease, heart failure, [CONDITION(S)] disorder, and post-traumatic stress disorder. Record review of Resident #5's Quarterly MDS, dated [DATE], revealed a BIMS score of 13, which indicated the resident was cognitively intact. Record review of Resident #5's physician orders, dated 06/04/2021, revealed an order for Miconazole [MEDICATION(S)] Cream 2%. Apply to peri area topically every day and evening shift for cutaneous candidiasis, with a start date of 10/09/2020. Record review of Resident #5's MAR from January to June 2021 revealed that the number nine was utilized to indicate there was a corresponding nurse's note in the resident's chart for further information regarding the medication administration. The key on each MAR indicated, 9 = other/see nurse's note. Resident #5 did not receive Miconazole [MEDICATION(S)] Cream as ordered on 05/04/2021 at 3:20p.m. with a corresponding nurse's note that read, Pending receipt from pharmacy. A record review on 06/07/2021 of pharmacy delivery logs from January 2021 through June 2021 did not reveal any deliveries of Miconazole [MEDICATION(S)] Cream for Resident #5 and the medication is not stocked in the facility's e-kit. 3. Record review of Resident #8's face sheet, dated 06/03/2021, revealed an admitted [DATE] with diagnoses that included dementia, polyosteoarthritis, hypertension, and [CONDITION(S)]. Record review of Resident #8's Quarterly MDS, dated [DATE], revealed a BIMS score of 0, which indicated the resident was severely cognitively impaired. Record review of Resident #8's physician orders, dated 06/04/2021, revealed the following orders: - [MEDICATION(S)] tablet delayed release 125mg. Give one tablet by mouth at bedtime for [CONDITION(S)] with a start date of 07/14/2020. - [MEDICATION(S)] Sodium tablet 112mcg. Give one tablet by mouth one time a day for [CONDITION(S)] with a start date of 07/15/2020. - [MEDICATION(S)] Cream 10%. Insert one gram vaginally at bedtime every Monday, Wednesday, and Friday for vaginal dryness with a start date of 07/15/2020. - [MEDICATION(S)] Tablet 100mg. Give one tablet by mouth one time a day for type 2 diabetes mellitus with a start date of 07/14/2020. - [MEDICATION(S)] 0.5mg. Give 0.5mg by mouth two times a day for anxiety disorder with a start date of 07/14/2020. Record review of Resident #8's MAR from January to June 2021 revealed that the number nine was utilized to indicate there was a corresponding nurse's note in the resident's chart for further information regarding the medication administration. The key on each MAR indicated, 9 = other/see nurse's note. Resident #8 did not receive the following medications and indicated the corresponding nurse note: - [MEDICATION(S)] 04/30/2021 [9:48p.m.]: on order - [MEDICATION(S)] 05/18/2021 [10:012p.m.]: not available - [MEDICATION(S)] 05/19/2021 [9:58p.m.]: not available - [MEDICATION(S)] 04/29/2021 [6:00a.m.] (blank) - [MEDICATION(S)] 05/18/2021 [4:44a.m.]: not available - [MEDICATION(S)] cream 04/23/2021 [8:00p.m.] (blank) - [MEDICATION(S)] cream 04/26/2021 [8:35p.m.]: on order - [MEDICATION(S)] cream 04/28/2021 [10:46p.m.]: not available - [MEDICATION(S)] cream 04/30/2021 [9:36p.m.]: not available - [MEDICATION(S)] cream 05/03/2021 [10:05p.m.]: not available - [MEDICATION(S)] cream 05/07/2021 [10:15p.m.]: on order - [MEDICATION(S)] cream 05/12/2021 [10:43p.m.]: not available - [MEDICATION(S)] cream 05/17/2021 [7:49p.m.]: on order - [MEDICATION(S)] 04/15/2021 [7:00p.m.] (blank) - [MEDICATION(S)] 04/19/2021 [6:00p.m.] Pending delivery from pharmacy - [MEDICATION(S)] 01/20/2021 [7:54p.m.]: med not available Record review on 06/06/2021 of pharmacy delivery logs from January 2021 through June 2021 revealed 30 tablets of [MEDICATION(S)] were delivered for Resident #8 on 05/15/2021 and 14 tablets of [MEDICATION(S)] were delivered on 01/04/2021, 02/01/2021, and 04/26/2021. Thirty-four tablets of [MEDICATION(S)] were delivered on 05/17/2021. Forty-two doses of [MEDICATION(S)] cream were delivered 04/27/2021. Twenty-four doses of [MEDICATION(S)] were delivered for Resident #8 on 01/08/2021. Record review on 06/07/2021 of the facility's e-kit from January 2021 through June 2021 revealed that 16 doses of [MEDICATION(S)] 125mg, 8 doses of [MEDICATION(S)] 100mg, and 24 doses of 0.25mg [MEDICATION(S)] were available. There was no evidence that these medications were signed out of the e-kit for this resident. 4. Record review of Resident #11's face sheet, dated 06/03/2021, revealed an admitted [DATE] with diagnoses that included [CONDITION(S)] and [CONDITION(S)] following cerebral infarction, type II diabetes, generalized [CONDITION(S)], heart failure, Alzheimer's disease, and dementia Record review of Resident #11's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, which indicated the resident was moderately cognitively impaired. Record review of Resident #11's physician orders, dated 06/04/2021, revealed the following orders: - [MEDICATION(S)] ointment 5mg/Gm for eye irritation and drainage with a start date of 05/25/2021 - [MEDICATION(S)] Sodium Tablet 50mcg. Give one tablet by mouth one time a day for [CONDITION(S)] with a start date of 09/01/2019. - Prevachol Tablet 40mg. Give one tablet by mouth at bedtime for [CONDITION(S)] with a start date of 08/31/2019. Record review of Resident #11's MAR from January to June 2021 revealed the number nine was utilized to indicate there was a corresponding nurse's note in the resident's chart for further information regarding the medication administration. The key on each MAR indicated, 9 = other/see nurse's note. Resident #11 did not receive the following medications and indicated the corresponding nurse note: - [MEDICATION(S)] ointment 05/26/2021 [9:00p.m.]: med unavailable - [MEDICATION(S)] ointment 05/27/2021 [9:40p.m.]: med unavailable - [MEDICATION(S)] 05/27/2021 [5:38a.m.]: not available - Prevachol 05/07/2021 [10:42]: not available Record review on 06/06/2021 of pharmacy delivery logs from January 2021 through June 2021 revealed a delivery for Resident #11 of eight doses of [MEDICATION(S)]. There were no delivery logs located for [MEDICATION(S)] ointment or Prevachol. Record review on 06/07/2021 of the facility's e-kit from January 2021 through June 2021 revealed eight doses of [MEDICATION(S)] 50mcg There was no evidence that this medication was signed out of the e-kit for this resident. 5. Record review of Resident #14's face sheet, dated 06/03/2021, revealed an admitted [DATE] with diagnoses that included cognitive communication deficit, dependence on renal [CONDITION(S)], [CONDITION(S)], dementia, type II diabetes, and metabolic [CONDITION(S)]. Record review of Resident #14's Quarterly MDS, dated [DATE], revealed the resident had severe cognitive impairment with a BIMS score of 3. Record review of Resident #14's physician orders, dated 06/04/2021, revealed the following orders: - [MEDICATION(S)] Liquid 15mL. Give 15mL by mouth one time a day for supplement with a start date of 03/03/2021. - [MEDICATION(S)] solution 100mg/mL. Give 2.5mL by mouth two times a day for conversion disorder with seizures or convulsions with a start date of 03/02/2021. - [MEDICATION(S)] Oxalate 10mg. Give one tablet by mouth at bedtime for recurrent depressive disorder with a start date of 03/02/2021. - [MEDICATION(S)] packet 0.8GM. Give two packets by mouth three times a day for [CONDITION(S)] with a start date of 03/02/2021. - [MEDICATION(S)] 2.5mg. Give one tablet by mouth two times a day for [CONDITION(S)] with a start date of 03/02/2021. - [MEDICATION(S)] HCl Tablet 10mg. Give one tablet by mouth at bedtime for recurrent depressive disorder with a start date of 03/02/2021. - Acidophilus capsule. Give one capsule by mouth two times a day for supplement with a start date of 03/02/2021. - [MEDICATION(S)] Tears solution 0.5%. Instill one drop in both eyes two times a day for dry eyes with a start date of 03/02/2021. Record review of Resident #14's MAR from January to June 2021 revealed the number nine was utilized to indicate there was a corresponding nurse's note in the resident's chart for further information regarding the medication administration. The key on each MAR indicated, 9 = other/see nurse's note. Resident #14 did not receive the following medications and indicated the corresponding nurse note: - [MEDICATION(S)] Liquid 04/06/2021 [8:00a.m.]: medication not available - [MEDICATION(S)] Liquid 04/09/2021 [8:00a.m.]: on orders - [MEDICATION(S)] 03/02/2021 [7:54p.m.]: on order - [MEDICATION(S)] 03/17/2021 [7:50p.m.]: on order - [MEDICATION(S)] 03/02/2021 [5:00p.m.] on order from pharmacy - [MEDICATION(S)] 03/03/2021 [11:21a.m.]: on order from pharmacy - [MEDICATION(S)] 03/03/2021 [8:26a.m.]: on order from pharmacy - [MEDICATION(S)] 03/02/2021 [7:52p.m.]: on order from pharmacy - [MEDICATION(S)] 03/03/2021 [8:26a.m.]: on order from pharmacy - [MEDICATION(S)] 03/02/2021 [7:54p.m.]: on order - Acidophilus 03/02/2021 [7:53p.m.]: on order - [MEDICATION(S)] Tears 03/02/2021 [7:53p.m.]: on order Record review on 06/06/2021 of pharmacy delivery logs from January 2021 through June 2021 revealed a delivery for Resident #14 of 70 doses of [MEDICATION(S)] on 03/19/2021, 84 doses of [MEDICATION(S)] on 02/09/2021, 28 doses of [MEDICATION(S)] on 02/02/2021, and 14 doses of [MEDICATION(S)] on 02/08/2021. There were no delivery logs located for [MEDICATION(S)]. [MEDICATION(S)] Liquid, Acidophilus, and [MEDICATION(S)] Tears were available in the facility's central supply and over the counter for purchase. Record review on 06/07/2021 of the facility's e-kit from January 2021 through June 2021 revealed 16 doses of [MEDICATION(S)] 10mg, 16 doses of [MEDICATION(S)] 2.5mg, and 16 doses of 5mg [MEDICATION(S)]. There was no evidence that these medications were signed out of the e-kit for this resident. 6. Record review of Resident #15's face sheet, dated 6/3/2021, revealed Resident #15 was admitted to the facility on [DATE] with diagnosis that included Dementia, Pacemaker, hypertension, [CONDITION(S)], chronic obstructive pulmonary disease and falls. Record review of Resident #15's Quarterly MDS dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #15's Physicians orders, dated 6/03/2021, revealed the following orders: - Klor-Con M10 Tablet Extended Release (potassium chloride crystals) 10 mEq. Give one tablet by mouth at bedtime for unspecified essential hypertension and [CONDITION(S)] with a start date of 06/21/2019. - [MEDICATION(S)] Capsule 50mg. Give one capsule by mouth at bedtime for anxiety disorder with a start date of 06/21/2019. - [MEDICATION(S)] 20mg. Give one tablet by mouth one time a day for heart failure with a start date of 06/21/2019. Record review of Resident #15's MAR from January to June 2021 revealed the number nine was utilized to indicate there was a corresponding nurse's note in the resident's chart for further information regarding the medication administration. The key on each MAR indicated, 9 = other/see nurse's note. Resident #15 did not receive the following medications and indicated the corresponding nurse note: - Klor-Con 04/6/2021 [8:02p.m.]: on order - [MEDICATION(S)] 01/16/2021 [8:50p.m.]: not given. unavailable. on order - [MEDICATION(S)] 01/17/2021 [7:18p.m.]: med still not in , on order - [MEDICATION(S)] 01/18/2021 [7:55p.m.]: on order - [MEDICATION(S)] 02/16/2021 [8:26p.m.]: on order - [MEDICATION(S)] 03/20/2021 [8:20p.m.]: awaiting from pharmacy - [MEDICATION(S)] 03/21/2021 [9:05p.m.]: not available - [MEDICATION(S)] 02/17/2021 [7:43p.m.]: med not available Record review on 06/06/2021 of pharmacy delivery logs from January 2021 through June 2021 revealed a delivery for Resident #15 of 30 doses of Klor-Con on 01/06/2021, 03/01/2021, 04/06/2021, and 05/25/2021, a delivery of 28 doses of [MEDICATION(S)] on 01/20/2021, 30 doses of [MEDICATION(S)] on 02/17/2021 and 03/17/2021. There were no delivery logs located for [MEDICATION(S)]. Record review on 06/07/2021 of the facility's e-kit from January 2021 through June 2021 revealed 24 doses of [MEDICATION(S)] 20mg. There was no evidence that this medication was signed out of the e-kit for this resident. During an interview with Resident #15 on 6/3/2021 at 11:43 a.m., the resident stated, Just like I was talking about yesterday in resident council meeting about them running out of medication, again last night I did not get my potassium. They say it is on order and it bothers me that there seems to be a problem getting my meds. The doctor said the potassium was for my heart and I am afraid of having a heart attack. They are constantly running out of my [MEDICATION(S)] and I itch and cannot sleep when I do not have it. 7. Record review of Resident #27's face sheet, dated 6/3/2021, revealed an admitted [DATE] with diagnoses that include cerebral infarction, [CONDITION(S)], hypertension, convulsions, and contractures. Record review of Resident #27's Quarterly MDS dated [DATE], revealed a BIMS score of 1, which indicated the resident was severely cognitively impaired. Record review of Resident #27's Physicians orders, dated 6/03/2021, revealed the following orders: - [MEDICATION(S)] Sodium100mcg. Give one tablet enterally one time a day for [CONDITION(S)] with a start date of 04/23/2020. - [MEDICATION(S)] Solution 100mg/mL. Give 5mL enterally two times a day for unspecified convulsions with a start date of 04/22/2020. - Multivitamin Liquid 5ml. Give 5mL enterally one time a day for supplement with a start date of 04/22/2020. - [MEDICATION(S)] Tartrate12.5mg. Give 12.5mg enterally at bedtime for hypertensive heart disease with a start date of 04/22/2020. - Mucinex Fast-Max liquid 10-850-400 mg/20mL. Give 600mg enterally two times a day for sore throat and cough with a start date of 01/31/2021. Record review of Resident #27's MAR from January to June 2021 revealed the number nine was utilized to indicate there was a corresponding nurse's note in the resident's chart for further information regarding the medication administration. The key on each MAR indicated, 9 = other/see nurse's note. Resident #27 did not receive the following medications and indicated the corresponding nurse note: - [MEDICATION(S)] 03/23/2021 [5:04a.m.]: on order - [MEDICATION(S)] 03/24/2021 [5:04a.m.]: not on cart - [MEDICATION(S)] 04/29/2021 [5:14a.m.]: not available - [MEDICATION(S)] 05/02/2021 [6:00a.m.] (blank) - [MEDICATION(S)] 05/05/2021 [5:06a.m.]: med not available - [MEDICATION(S)] 05/07/2021 [5:26a.m.]: med not available - [MEDICATION(S)] 05/08/2021 [5:04a.m.]: not available - [MEDICATION(S)] 05/09/2021 [5:09a.m.]: med not available - [MEDICATION(S)] 05/10/2021 [5:21a.m.]: med on order. Not available - [MEDICATION(S)] 05/13/2021 [5:05a.m.]: not available - [MEDICATION(S)] 05/15/2021 [5:26a.m.]: med unavailable - [MEDICATION(S)] 05/17/2021 [5:04a.m.]: not available - [MEDICATION(S)] 05/18/0221 [5:36a.m.]:not available - [MEDICATION(S)] 01/02/2021 [9:04a.m.]: on order - [MEDICATION(S)] 04/24/2021 [10:10p.m.]: on order - Multivitamin liquid 02/01/2021 [9:14a.m.]: not available - Multivitamin liquid 04/02/2021 [7:06a.m.]: on order - Multivitamin liquid 04/07/2021 [7:50a.m.]: on order - Multivitamin liquid 04/10/2021 [7:04a.m.]: on order - [MEDICATION(S)] 03/10/2021 [9:28p.m.]: on order - Mucinex 02/05/2021 [6:52a.m.]: med unavailable Record review on 06/06/2021 of pharmacy delivery logs from January 2021 through June 2021 revealed a delivery for Resident #27 of 14 doses of [MEDICATION(S)] on 03/02/2021 and 05/18/2021. There were no delivery logs located for [MEDICATION(S)] or [MEDICATION(S)]. Multivitamin liquid and Mucinex were available in the facility's central supply and over the counter for purchase. Record review on 06/07/2021 of the facility's e-kit from January 2021 through June 2021 revealed eight doses of [MEDICATION(S)] 100mcg. There was no evidence that this medication was signed out of the e-kit for this resident. During an interview with RN Q on 06/06/2021 at 2:24p.m, she stated she remembers when Resident #27 did not get [MEDICATION(S)] and [MEDICATION(S)]. She stated, I remember that. I had passed that along to [an LVN] on day shift. Something happened with the pharmacy that [the resident] wasn't in their system anymore. When asked why she didn't pull the medication from the e-kit, she stated, I'm an agency nurse and agency nurses aren't allowed to pull meds from the e-kit at this facility. 8. Record review of Resident #30's face sheet, dated 6/3/2021, revealed an admitted [DATE] with diagnoses that include [CONDITION(S)] disorder, [CONDITION(S)], type II diabetes, heart failure, hypertensive heart disease, metabolic [CONDITION(S)], and hypertension. Record review of Resident #30's Quarterly MDS dated [DATE], revealed a BIMS score of 0, which indicated the resident was severely cognitively impaired. Record review of Resident #30's Physicians orders, dated 6/03/2021, revealed the following orders: - [MEDICATION(S)] [MEDICATION(S)] Suspension Reconstituted ER 25mg. Inject 25mg intramuscularly one time a day every two weeks on Wednesday for [CONDITION(S)] disorder with a start date of 03/03/2021. - Prevachol Tablet 20mg. Give 20mg by mouth at bedtime for [CONDITION(S)] with a start date of 03/27/2018. Record review of Resident #30's MAR from January to June 2021 revealed the number nine was utilized to indicate there was a corresponding nurse's note in the resident's chart for further information regarding the medication administration. The key on each MAR indicated, 9 = other/see nurse's note. Resident #30 did not receive the following medications and indicated the corresponding nurse note: - Prevachol 03/12/2021 [9:18p.m.]: on order Record review on 06/06/2021 of pharmacy delivery logs from January 2021 through June 2021 revealed no record of delivery of Prevachol for Resident #30. Record review of the resident's chart also revealed a change from PO [MEDICATION(S)] once a day to IM [MEDICATION(S)] once every two weeks due to the resident's tendency to refuse PO medications. This indicated that a missed dose of IM [MEDICATION(S)] would result in the resident not receiving any [MEDICATION(S)]

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 56 of 138 Residents (Residents #1-#50, #56, #57, #58, #62, #70, and #71) observed for infection control, in that: 1. The facility did not prevent staff who tested positive for COVID-19 from returning to work and exposing residents and staff who had tested negative while providing care to residents. The facility did not follow return to work criteria provided by the epidemiologist and based on current CDC guidelines. 2. Staff did not wear appropriate PPE while providing care to residents and did not wear PPE appropriately while in the facility which was under droplet precautions for COVID-19 positive residents and staff. 3. The facility did not clearly mark mitigation zones and did not ensure isolation signs were used to identify which residents were under droplet isolation precautions. 4. The facility did not establish infection control precautions and procedures for housekeeping services to prevent the spread of COVID-19 5. The facility did not implement CDC guidelines for prevention of spread of COVID-19 by failing to ensure Residents #70 and #71 social distanced during a meal service. These failures resulted in identification of Immediate Jeopardy (IJ) on 07/19/2020. While the IJ was removed 07/26/ 0, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place to ensure residents were being monitored and assessed for signs and symptoms of COVID-19. These deficient practices affected all residents and placed residents who were positive for COVID-19 at risk for a decline in health and/or death. The findings were: Record review of a facility provider report sent to HHSC on 07/15/2020 at 8:43 PM by the Administrator revealed: on 7/11/20 and on 7/14/20 the facility received the results of the facility wide COVID-19 testing which resulted in 50 positive residents and 40 positive staff members. 1. Record review of a facility In-Service given to Housekeeping Staff, with no other departments listed and dated 06/25/2020, revealed: COVID absences-If employee has: a positive COVID test, signs and symptoms of COVID, confirmed primary exposure (direct contact with someone who tested positive for COVID), doctor note telling them to quarantine for 14 days. The employee will be sent home and paid their regularly scheduled hours for 14 days . Employee must report daily any symptoms and temperature. If employee fails to report symptoms or temperature it is considered a NCNS (no call no show). This is for the facility to track anyone sick or potentially sick. We are obligated to track and report this information to the state as requested. It is the employee's responsibility to report this information to the facility daily. Record review of an email dated 07/19/2020 sent to the DON from the Health Department Epidemiologist revealed: Thank you for reaching out to me today with your request for details on previous guidance and communication between your facility and the Health Department. Upon notification of your first positive resident, not affiliated to an outside the facility exposure, your facility was encouraged to place the entire facility on droplet precautions until exposure extent could be established. Guidance was provided on: critical staffing measures, cohorting positive cases (hot zone), isolation and monitoring of all exposed populations and return to work criteria for healthcare workers following acute infection. Record review of a facility document (undated) of COVID-19 positive staff members provided by the DON after surveyors requested a list of positive staff who had continued to work after testing positive for COVID revealed: - On 07/15/2020, LVN K, LVN H, and CNA JJ worked in a cold zone with COVID-19 negative residents, and CNA HH worked on a warm zone with COVID-19 negative residents. - On 07/16/2020, CNA JJ worked in a cold zone with COVID-19 negative residents - On 07/17/2020, Dietary Aide N worked on the cold zone kitchen preparing food for COVID-19 negative residents. - On 07/18/2020, Dietary Aide N worked on the cold zone kitchen preparing food for COVID-19 negative residents. - On 07/19/2020, Dietary Aide N worked on the cold zone kitchen preparing food for COVID-19 negative residents. - On 07/20/2020, Dietary Aide N worked on the cold zone kitchen preparing food for COVID-19 negative residents, and CNA L worked on a warm zone with COVID-19 negative residents. - On 07/21/2020, CNA L worked on a warm zone with COVID-19 negative residents. Observation in the warm zone on hallway E at 07/18/2020 at 11:49 AM revealed room Resident #56's room door revealed a sign typed on an 8 x 11 piece of copy paper that stated, change PPE after each use. Further observation revealed Resident #56's room door did not have any other signs to indicate the resident was on droplet or isolation precautions. Further observation revealed the door did not have PPE hanging on or near the resident's door to indicate isolation precautions. During an interview with the DON on 07/17/2020 at 5:30 PM, the DON stated COVID-19 positive staff was working in the facility but only with COVID-19 positive residents. During an interview with the Staffing Coordinator LVN WW on 07/18/2020 at 8:00 AM, the Staffing Coordinator LVN WW stated staff was divided into either hot or cold zones. Staffing Coordinator LVN WW stated some COVID-19 positive staff were working in the facility but only with COVID-19 positive residents. Staffing Coordinator LVN WW stated there were no gaps in staffing at this time and they had been able to fill the available shifts. During an interview with LVN JJJ on 07/19/2020 at 5:39 AM, LVN JJJ confirmed there were three nurses during the night shift to work four hallways, and only two CNAs for all four hallways. LVN JJJ further confirmed shared staffing worked on all hallways without regard for residents' COVID-19 status. During an interview with CNA III on 07/19/2020 at 5:59 AM, CNA III confirmed she had been only 1 of 2 CNAs assigned for four hallways during the night shift. CNA III further confirmed she still did not have the results of her COVID-19 test, so she did not know if she was positive or negative for COVID-19. CNA III confirmed she was assigned to residents on the cold and warm zones worked with both residents who were negative for COVID-19 and those on isolation/quarantine with COVID-19 symptoms. During an interview with MA FFF on 07/19/2020 at 6:45 AM, MA FFF confirmed she was assigned to work on both C and E hallway warm zones with both COVID-19 symptomatic and asymptotic residents. MA FFF confirmed she wore the same gown for all residents except residents with signs to change PPE. During an interview with NA TT on 07/19/2020 at 7:33 AM, NA TT stated the residents on the E wing warm zone were not COVID-19 symptomatic and had been quarantined because they went out of the facility to doctor visits. During an interview with CNA ZZ on 07/19/2020 at 8:23 AM, CNA ZZ confirmed she was assigned to work with all residents on the C hallway warm zone including residents who were COVID-19 symptomatic and those who were COVID-19 asymptomatic and under observation. During an interview with LVN OO on 07/19/2020 at 8:25 AM, LVN OO confirmed she was assigned to work with both COVID-19 asymptomatic and symptomatic residents on the C and E hallways (both warm zones). LVN OO confirmed staff wore the same gown between resident contacts except when a resident was COVID-19 symptomatic. LVN OO stated there were no dedicated staff for COVID-19 symptomatic residents. LVN OO stated both COVID-19 symptomatic and asymptomatic residents could have their doors open. During an interview with Staffing Coordinator LVN WW on 07/19/2020 at 8:40 AM, Staffing Coordinator LVN WW confirmed there were several staff members who were refusing to come to work because they were fearful. Staffing Coordinator LVN WW stated she was utilizing COVID-19 positive staff to work with COVID-19 positive residents. Staffing Coordinator LVN WW stated the facility did not pull staff from sister facilities and did not have any agency staff working at the facility. Staffing Coordinator LVN WW stated some management was working on the floor with residents and added she had communicated the scheduling and staffing needs to the DON. Staffing Coordinator LVN WW further stated, She (the DON) is aware. During an interview with the DON on 07/19/2020 at 8:43 AM, the DON confirmed the facility was on Stage 1 of 3 stages of emergency staffing. The DON stated Stage 1 was management working on the floor which was already occurring, Stage 2 was staffing from sister facilities which had not been done, and Stage 3 was utilizing a staffing agency for additional staff. The DON stated the facility did not have any contracts with a staffing agency that she was aware of but would confirm with the Administrator. During an interview with the DON on 07/21/2020 at 1:20 PM, the DON stated the building was in crisis mode and COVID-19 positive staff could care for negative residents. The DON stated as a last resort this was acceptable. The DON further stated she did not believe any positive staff was working with negative residents but she was not sure, she needed to check with the Staffing Coordinator. The DON stated they were currently on Stage 1 of staffing per their emergency response manual. The DON state Stage 1 indicated management stepped in to assist, and Stage 2 was requesting assistance from sister facilities. The DON stated Corporate took care of Stage 2. The DON stated Stage 3 was assistance from agency staffing. The DON stated she only knew the COVID-19 status and working status of nursing staffing and not ancillary staff and indicated each department manager took care of their own staffing. During an interview with the DON on 07/21/2020 at 4:55 PM, the DON confirmed she received the facility's list of COVID-19 positive staff and residents on 07/15/2020. The DON further confirmed one dietary staff member worked in the cold zone kitchen preparing food for COVID-19 negative residents from 07/15/2020 to 07/20/2020. The DON confirmed she was aware of the only one staff member who had tested positive for COVID-19 continuing to work, and stated the staff was wearing gloves and a mask. During an interview with the DON on 07/21/2020 at 5:18 PM, the DON confirmed she had previously informed surveyors the facility was on Stage 1 of their emergency staffing plan. The DON stated the facility was currently in crisis staffing which meant COVID-19 positive staff could take care of COVID-19 positive residents if the staff member was asymptomatic. The DON further stated that if an asymptomatic staff stated they had a cough and the staff thought the cough could be just allergies [REDACTED]. The DON stated the facility could put COVID-19 positive staff with negative residents as a last resort. The DON confirmed that on Sunday, 07/19/2020, for night shift she had opened up the staffing to any staff, COVID-19 positive or negative, who was willing to come to work and staff could work with any resident. The DON stated the Staffing Coordinator was not intentionally putting positive staff with negative residents but at this point staff could work on any unit. The DON confirmed she felt like sister facilities were already aware of what was going on with this facility due to daily corporate conference calls which included other facility staff and if their sister facilities had the staff to offer they would have already done so. During an interview with Dietary Aide O on 07/27/2020 at 1:50 PM, Dietary Aide O confirmed he was positive for COVID-19 and continued to work at the facility despite the diagnosis. Dietary Aide O stated he was asymptomatic except for headaches and had not missed work since the [DIAGNOSES REDACTED]. Dietary Aide O confirmed he was assigned to work in the cold zone kitchen where his main duty was washing dishes. Dietary Aide O confirmed his duties include handling clean dishes that were used for residents who did not have COVID-19. During an interview with Dietary Aide N on 07/27/2020 at 6:35 PM, Dietary Aide N confirmed she was positive for COVID-19, was asymptomatic, and the facility was aware of her COVID-19 status. Dietary Aide N confirmed she had continued working in the facility and had not missed any work despite her positive COVID-19 status. Dietary Aide N stated her schedule was four days on and two days off. Dietary Aide N stated she had only been assigned to work in the cold zone where food preparation was performed for negative residents. Dietary Aide N stated the kitchen was, very understaffed. Dietary Aide N confirmed she prepared food for all residents in the facility including those residents who do not have COVID-19. Dietary Aide N stated she received no special or specific instructions about returning to work with COVID-19 other than to wash her hands frequently and wear proper PPE. Record review of an email sent to the DON on 07/27/2020 at 11:16 AM from surveyors revealed a request for a copy of the staff and resident COVID-19 test results. On 07/27/2020 at 12:01 PM the DON replied, I have forwarded this to the Administrator. She has this information and will reply. No response was received from the Administrator prior to exit. During an interview with the Local Health Department Epidemiologist on 07/21/2020 at 10:55 AM, the Local Health Department Epidemiologist stated she had discussed with the facility return to work for positive staff members which included: isolation/quarantine for 14 days from test date, complete resolution of symptoms and then when staff returns to work they should not be placed with severely immunocompromised residents. Staff should follow strict PPE usage including no less than N95 mask. Ideally, they should not return to work until 2 negative tests. The Epidemiologist stated she did discuss return to work for staff to include a minimum 10 days from testing who were afebrile for minimum of 3 days and had a complete resolution of symptoms. The Epidemiologist recommended positive staff should not return to work unless the facility was inoperable without this staff. And then this staff should only work with positive resident to provide patient care only. Not housekeeping or dietary services. The Epidemiologist confirmed she sent several emails to the facility with information to included: return to work criteria and resolution of COVID-19 symptoms. Record review of an email dated 07/21/2020 at 6:21 PM from the Epidemiologist to the DON confirmed that it was her directive to put the facility on droplet precautions. The Epidemiologist confirmed she had given recommendation of how to allow staff to return to work after a positive COVID-19 test. The Epidemiologist confirmed that she had discussed with the facility, hot zone, isolation and return to work. Record review of a document titled Return to Work Criteria, undated, from the Local Health Department revealed: 1. Symptomatic HCP for COVID-19 with or without positive test a. symptoms-based strategy: exclude from work until: i. At least 3 days (72 hours) since symptoms have resolved and ii. At least 10 days have passed since symptoms first appeared b. Test based strategy: exclude from work unit: i: resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms and negative test results from an FDA approved COVID-19 PCR test from a minimum of two consecutive respiratory specimens. These specimens should be collected at least 24 hours apart so that there are a total of two negative tests. 2. Asymptomatic HCP with positive COVID-19 PCR test: a. time-based strategy-exclude from work until the follow are met: i. 10 days have passed since the date of their first positive COVID-19 diagnostic test (with no further symptoms) Note: if HCP develops symptoms you must follow one of the two strategies in 1. a. b. test-based strategy i. negative results of an FDA approved COVID-19 PCR test from a minimum of two consecutive respiratory specimens. These specimens should be collected at least 24 hours apart so that there are a total of two negative test. 3. Strategies to Mitigate HCP shortages: Maintaining appropriate staffing is essential to providing a safe work environment for Resident and HCP. It is important to prepare for shortages. As part of this, asymptomatic HCP with a recognized COVID-19 exposure might be permitted to work in a crisis capacity strategy to address staffing shortages if they wear a facemask for source control for 14 days after the exposure. 2. Observation on 07/17/2020 at 10:02 AM revealed HK T was cleaning resident rooms on the 200 hallway which was designated as a hot zone with COVID-19 positive residents with her eye protection resting on top of her head and not covering her eyes. Further observation revealed HK T was not wearing gloves while cleaning resident rooms. During an interview with HK Ton 07/17/2020 at 10:50 AM, HK T confirmed she was not wearing eye protection or gloves while cleaning resident rooms. HK T stated she had not received training on how to wear PPE. HK T stated there was no schedule for cleaning high touch surfaces. Observation on 07/17/2020 at 10:26 AM revealed ADON RN RR was observed without eye protection on both the 100 and 200 Halls which were designated as hot zones with COVID-19 positive staff and residents. During an interview with ADON RN RR on 07/17/2020 at 10:26 AM, ADON RN RR confirmed she was not wearing eye protection while on the 100 and 200 Halls. Observation on 07/17/2020 at 10:56 AM revealed Activity Director/CNA D and two other staff entered an unidentified resident's room on the 200 hallway hot zone while the resident was in the room seated in a wheelchair. Further observation revealed Activity Director/CNA D's eye protection were on the top of his head and not covering his eyes while he was in the resident's room. During an interview with Activity Director/CNA D on 07/17/2020 at 10:56 AM, Activity Director/CNA D confirmed he was not wearing eye protection while in a resident room. Activity Director/CNA D stated his goggles fogged up and that why he did not have them on. Observation on 07/17/2020 at 11:43 AM revealed CNA X entered and then exited a resident room with her goggles on top of her head and with the sleeves of her isolation gown pulled up to her elbows exposing skin below the elbow to the wrist. During an interview with CNA X on 07/17/2020 at 11:43 AM, CNA X confirmed she had rolled up the sleeves to the isolation gown and was not wearing eye protection while performing resident care. Observation on 07/17/2020 at 3:25 PM revealed HK VV was cleaning resident rooms while residents were present in the rooms without eye protection. During an interview with HK VV on 07/17/2020 at 3:25 PM, HK VV confirmed she was not wearing eye protection while cleaning resident rooms. During an interview with MDS Coordinator LVN GGG on 07/19/2020 at 7:05 AM, MDS Coordinator LVN GGG stated she was a member of the management team and was assigned to do whatever needed to be done. MDS Coordinator LVN GGG stated staff expectations included wearing a face shield/eye protection when in direct contact with a resident who was symptomatic for COVID-19 such as a cough in which [MEDICAL CONDITION] particles could be spread. MDS Coordinator LVN GGG stated staff did not need to wear face shield or eye protection at the nurses station or on the cold zone hallways. Observation on 07/19/2020 at 7:15 AM revealed the Admissions Coordinator (COVID-19 positive staff) walking thru the building in the cold zone with her mask not on all the way. Further observation revealed the bottom straps were not on her head and were observed hanging down in front of her face and her face shield was in her hands. Further observation revealed the Admissions Coordinator walked over to the doffing station located near the exit door even though she was not exiting the building and secured her face mask and put on her face shield. During an interview with the Admissions Coordinator on 07/19/2020 at 7:15 AM, the Admissions Coordinator confirmed she did not have her face mask all the way on and had left the bottom strap hanging down in front of her face and also did not have her face shield on. Observation on 07/19/2020 at 9:18 AM in the laundry room revealed Laundry Staff NNN and Laundry Staff OOO were together inside of the laundry building. Further observation revealed Laundry Staff OOO's face mask was completely removed and sitting on a shelf in the laundry area. During an interview with Laundry Staff OOO on 07/19/2020 at 9:18 AM, Laundry Staff OOO confirmed she was not wearing a face mask. Laundry Staff OOO stated she had just come out of the bathroom and had taken her face mask off when she went into the bathroom and would put it back on after she exited the bathroom area. Further interview with Laundry Staff OOO indicated she had been instructed to wear the face mask in the building. Observation on 07/19/2020 at 9:35 AM revealed the Administrator and DON were in the DON's office with their face masks off and less than 6 feet away from one another, as observed through a window. Observation on 07/19/2020 at 10:31 AM of kitchen area in hot zone revealed Dietary Aide R (COVID positive staff) was preparing food in the kitchenette. Further observation revealed Dietary Aide R had her N95 mask pulled down with her nose exposed while preparing sandwiches. Further observation revealed the 2 kitchen doors had been propped open. One door entered into the hot zone resident hallway, the other door opened onto a hot zone common area. During an interview with Dietary Aide R on 07/19/2020 at 10:35 AM, Dietary Aide R confirmed her N95 mask was pulled down underneath her nose. Dietary Aide R stated the mask had slipped down and she wasn't allowed to touch her face. Dietary Aide R stated she had not received any training on proper mask usage and had not been fit tested . Dietary Aide R confirmed she had tested positive for COVID. Observation on 07/19/2020 at 12:15 PM revealed the Administrator and DON were in the DON's office together with their face masks off. Further observation revealed the Administrator and DON were sitting across from one another at the nurses' desk approximately 3-4 feet apart. Observation on 07/19/2020 at 6:30 PM revealed the Administrator and DON were in the DON's office together with their face masks off. Further observation revealed the Administrator and DON were sitting across from one another at the nurses' desk approximately 3-4 feet apart. Observation on 07/21/2020 at 6:38 PM revealed ADON RN RR was performing medication pass on the 100 Hall, which was a designated a hot zone with COVID-19 positive residents and staff. Further observation revealed ADON RN RR was not wearing eye protection. During an interview with ADON RN RR on 07/21/2020 at 6:38 PM, ADON RN RR confirmed she was not wearing her face shield (eye protection), and stated she was not wearing it because it made her feel sweaty. ADON RN RR confirmed she was supposed to be wearing her face shield. During an interview with the DON on 07/26/2020 at 11:14 AM, the DON confirmed the facility policy was for all staff to wear a mask in the facility at all times. The DON confirmed the Administrative offices, including the DON's office, was located in the hot zone. The DON stated she felt like if they were in her office and socially distancing that droplet precautions were appropriate and wearing a mask was not necessary. During an interview with the Local Health Department Epidemiologist on 07/21/2020 at 10:55 AM, the Local Health Department Epidemiologist stated her recommendations included: All residents should be placed on droplet precautions which included all staff wearing all PPE all the time in the facility. Proper donning and doffing of a gown between every resident use. The Epidemiologist stated she did not recommend conservation of PPE and had helped the facility secure addition PPE including gowns. 3. Record review of a facility map provided by the Administrator after surveyors entrance into the facility showed cold (negative COVID-19 status), warm (residents under observation and residents with symptoms for COVID-19 without a positive test) and hot zones (COVID-19 positive). Record review of Resident #56's face sheet, dated 07/27/2020, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #56's Quarterly MDS, dated [DATE], revealed a BIMS score of 4, which indicated the resident was severely cognitively impaired. Record review of Resident #56's progress notes, dated 07/17/2020, revealed, NP informed Resident #56 had a non-productive harsh cough today. Resident is afebrile and had no other symptoms. NP informed resident tested negative for COVID on 7/11/20. Record review of Resident #56's progress noted, dated 07/24/2020, revealed: COVID result is positive. Will need to move over to COVID area. Record review of Resident #57's face sheet, dated 07/27/2020, revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #57's Quarterly MDS, dated [DATE], revealed a BIMS score of 7, which indicated the resident was severely cognitively impaired. Review of Resident #57's progress notes, dated 07/18/2020, revealed, Resident was moved to (warm zone) due to cough/congestion and a temp of 99.3. Observation on 07/17/2020 at 9:30 AM revealed the facility entrance into the hot zone did not have any signage to notify visitors the facility was a hot zone that contained residents and staff with active COVID-19 infection. Further observation revealed the signs posted on the outside of the locked entry door included cough etiquette and a notice that visitors were restricted. Further observation revealed the facility map given to surveyors upon entrance was not posted on the door or entrance of the facility. Observation on 07/17/2020 at 9:40 AM revealed upon entrance to the facility visitors were screened and then instructed to proceed to a donning station. Further observation revealed there was no signage located at the donning station to indicate which isolation precautions were necessary, which zone visitors had entered and no signage indicating which protective equipment to don or which zone was entered. During an interview with Receptionist UU on 07/17/2020 at 9:40 AM, Receptionist UU confirmed she did not know which protective equipment was required to wear on the hot zone, and stated visitors should wear whatever equipment was in the box. Observation on 07/17/2020 at 10:12 AM revealed resident Rooms 200, 202, 204, 205, 206, and 207 located in the hot mitigation zone with active COVID-19 cases did not have signage indicating the residents were under any isolation precautions. Further observation revealed there were no over the door hangers or containers with PPE to indicate the residents in these rooms were under isolation precautions or which PPE should be worn while entering the resident rooms. There was no signage to indicate the area was a hot zone. Observation on 07/17/2020 at 11:18 AM revealed the D hallway (separated hot zone on the designated cold side of the building) did not have any signs indicating what PPE was required on this hallway or what mitigation zone was being entered. Observations on 07/17/2020 at 11:20 AM revealed residents in Rooms 1, 3, 4, 5, 6, 7, 8, 9, 10, 13, and 15 on the D hallway did not have a sign that indicated the residents in these rooms were on droplet isolation precautions. Further observation revealed there were no over the door hangers with PPE or any other indication of what PPE were required to be worn in the resident rooms. Observation on 07/17/2020 at 3:00 PM revealed Resident #56 (confirmed positive 07/24/2020) was outside of the resident room on the E hallway (warm zone) with a mask on. Further observation revealed staff did not redirect the resident at this time. Further observation revealed all resident room doors were open. There were no signs indicating which mitigation zone the hallway had been designated. Resident #56's and #59's room door had a sign that read, change PPE after each use. There were no signs on any of resident doors to indicate if any of the residents were under isolation precautions or that droplet precautions were in place. Observation on 07/17/2020 at 3:05 PM revealed LVN OO was entering and exiting several residents' rooms on the warm zone without changing her gown. During an interview with LVN OO on 07/17/2020 at 3:18 PM, LVN OO confirmed Residents in warm zone include resident with symptoms who do not have a positive COVID-19 test and residents who are asymptomatic. The LVN confirmed residents could come out of their rooms in warm zone but with masks on. Observation on 07/17/2020 at 3:20 PM on the C Hallway (warm zone) revealed there were no isolation signs on the doors to indicate the residents were under isolation precautions. Observation in the warm zone on hallway C at 07/18/2020 at 10:48 AM revealed there was no signs to indicate which mitigation zone the C hallway was designated. Further observation revealed residents on this hallway did not have signs to indicate the residents were under observation/quarantine and there were no signs to indicate any isolation precautions. Observation in the warm zone on hallway E at 07/18/2020 at 11:15 AM revealed occupied resident Rooms 1, 2, 3, 9, 11, and 12 had their door open and there were no signs to indicate these residents were under observation or quarantine and no signs to indicate if any isolations precautions were in place. Further observation revealed none of these resident rooms had PPE hanging on the door. Observation on 07/18/2020 at 11:19 AM revealed one small paper sized 8 x 11 sign to side of the entrance to hallway E stated, warm zone. Designated staff only beyond this point. Further observation revealed there were no other signs or directions on what PPE should be worn in the area. Observation in the warm zone on hallway E at 07/18/2020 at 11:49 AM revealed room Resident #56's room door revealed a sign typed on an 8 x 11 piece of copy paper that stated, change PPE after each use. Further observation revealed Resident #56's room door did not have any other signs to indicate the resident was on droplet or isolation precautions. Further observation revealed the door did not have PPE hanging on or near the resident's door to indicate isolation precautions. Observation in the warm zone on hallway E at 07/18/2020 at 11:51 AM of Resident #60's room revealed the door was open with the resident inside of the room. Further observation revealed there were no isolation signs, no quarantine signs, and no signs to change to, change PPE after each use. Observation on 07/18/2020 at 5:39 PM revealed resident Rooms 101, 102, 103, and 109 in the COVID-19 positive area hot zone had a sign to indicated contact precaution should be followed instead of a droplet precaution sign. Further observation revealed rooms [ROOM NUMBERS] did not have any sign indicating any type of precautions were in place. Observation on 07/19/2020 at 7:40 AM-8:25 AM revealed LVN OO performed med pass and CNA ZZ entered multiple reside (TRUNCATED)