Every finding on record at Uvalde Healthcare and Rehabilitation Center

Based on observations, interviews, and record reviews, the facility failed to ensure that at the time each resident was admitted , the facility must have physician orders for the resident's immediate care, for 1 of 8 residents (Resident #31) reviewed for isolation contact precautions and intravenous line maintenance orders. Resident #31 was admitted on [DATE] with an immediate need for isolation contact precautions (essential measures in healthcare settings to prevent the spread of infections, particularly those that can be transmitted through direct or indirect contact with patients or their environment) and intravenous access maintenance, which he did not receive for 4 days until 5/26/2026. These failures could place residents at risk for delayed care and the spread of infectious disease.The Findings included: A record review of Resident #31's admission record dated 6/8/2026 revealed an admission date of 5/22/2026 with diagnoses which included klebsiella pneumoniae (a bacterium naturally found in the human gut and respiratory tract) and urinary tract infection (UTI; an infection that occurs when bacteria enter any part of the urinary system.) A record review of Resident #31's hospital clinical record dated 5/21/2026 revealed Resident #31 was diagnosed with a multi-drug-resistant organism UTI and treated with IV antibiotics which he received through a PICC line and was cared for under isolation contact precautions. A record review of Resident #31's admission MDS dated [DATE] revealed Resident #31 was an [AGE] year-old male admitted for recovery care after a hospitalization. Resident #31 was assessed with the ability to understand others and make himself understood. Resident #31 was assessed with a BIMS score of 11 out of a possible 15 which indicated moderate cognitive impairment. Resident #31 was assessed with an indwelling urinary catheter, had intravenous access, and a multi-drug-resistant organism. A record review of Resident #31's admission Report Form dated 5/22/2026 revealed LVN B documented a report she received from Resident #31's hospital RN. LVN B documented Resident #31 had a need for contact isolation precautions and intravenous antibiotic meropenem. A record review of Resident #31's nursing Progress notes revealed LVN A documented on 5/23/2026 at 12:03 AM that Resident #31 was admitted the evening of 5/22/2026 with an indwelling PICC line, PICC line present to right AC sic[ante-cubital, the space in between the forearm and the upper arm, above the elbow]. A record review of Resident #31's physician's orders, dated 6/10/2026, revealed the physician prescribed for Resident #31 to receive medications and therapies as follows:- On 5/26/2026, contact precautions due to bacteremia klebsiella (the presence of viable bacteria in the bloodstream), every shift.- On 5/26/2026, meropenem (a powerful, broad-spectrum carbapenem antibiotic used to treat severe and multi-drug-resistant bacterial infections), 1 gram intravenous every 8 hours for 2 weeks.- On 5/26/2026, sodium chloride 0.9% (a normal saline flush) syringe, flush PICC line with 10ml normal saline before and after medications.- On 5/26/2026, Monitor for signs of PICC complications including infiltration, occlusion, leaking, . catheter displacement.- On 5/26/2026, Secure PICC line appropriately to reduce risk of accidental dislodgement. Maintain infection prevention practices including hand hygiene and proper use drain line care. A record review of Resident #31's care plan dated 6/8/2026 revealed Resident #31 has an infection and a PICC line (Peripherally Inserted Central Catheter, is a thin, flexible tube inserted into a peripheral vein in the arm and threaded through to a larger vein near the heart), start date 5/26/2026; Resident is on antibiotics for urosepsis, multidrug-resistant organism, and is at risk for adverse reactions. Follow universal standard precautions to prevent cross contamination and spread of infection. Resident has a PICC line for an administration of medications, IV therapy, fluids, antibiotics, . and is at risk for infection, occlusion, . complications associated with central line use. Notify physician promptly of signs of infection, inability to flush line, . swelling, pain, . During an interview on 6/8/2026 at 12:15 PM, Resident #31 stated he was admitted [DATE] from the hospital where he was treated for an infection. Resident #31 stated he received antibiotics which he received through his PICC line on his right arm. Resident #31 stated he was treated in an isolation room at the hospital, and the staff wore gowns and gloves. During an interview on 6/9/2026 at 5:20 PM, LVN C stated she worked as the charge nurse on 5/26/2026 from 6:00 AM to 6:00 PM and recognized Resident #31 was a newly admitted Resident who was admitted on [DATE]. LVN C stated she assessed Resident #31 with a PICC line but had no orders to maintain the PICC line patent, had a diagnosis of Klebsiella Pneumoniae of the urine without antibiotics to control the infection, or infection prevention or control contact precautions in place. LVN C stated she assessed Resident #31 with no decline in health status and gave a report to the physician. LVN C stated that the physician gave new orders for contact isolation precautions, IV meropenem, and PICC line care. LVN C stated she had received reports from previous nurses that Resident #31 had a need for contact precautions, but Resident #31 did not have any signage to indicate he was under isolation contact precautions. LVN C stated she had developed and implemented the contact isolation precautions and PPE supplies at the resident's door side on 5/26/2026. LVN C stated she had reported the new orders and contact isolation to her superior, the DON. During an interview on 6/10/2026 at 4:01 PM, RN D stated she was the facility's admissions coordinator, and, in that capacity, she had coordinated with the hospital case manager to receive Resident #31 as a new admission. RN D stated Resident #31 was being discharged from the hospital with the need for a contact isolation room, a PICC line and an indwelling Foley catheter. RN D stated Resident #31 had a need for isolation contact precautions because Resident #31 was diagnosed with a multi drug resistant organism, Klebsiella pneumoniae of the urine. RN D stated she had reviewed the new admission with the IDT and planned to receive Resident #31 on the evening of 5/22/2026 and gave a report to LVN B that afternoon. RN D recalled LVN B, on 5/22/2026, had received a report from the hospital RN who was discharging Resident #31 who was cared for with a PICC line and under isolation contact precautions. During an interview on 6/10/2026 at 4:20 PM LVN B stated she was the charge nurse on 5/22/2020 from 6:00 AM to 6:00 PM and at 6:00 PM she gave report to LVN A. LVN B stated she had received report from RN D and the hospital RN with care details for Resident #31. LVN B stated she documented on an admissions report worksheet that Resident #31 had an infection of the urine which needed contact isolation, a need for meropenem (a drug which cannot be given other than by intravenous access; meropenem cannot be given orally. It is exclusively administered via intravenous (IV) infusion), and a Foley catheter. LVN B stated she shared the worksheet with LVN A when she gave a report to LVN A during the change of shift nurse-to-nurse report on 5/22/2026 around 6 pm. During an interview on 6/10/2026 at 5:42 PM LVN A stated she could not recall the events of 5/22/2026 and stated any documentation she made regarding residents specifically Resident #31 was accurate. LVN A stated standard practice was for a nurse to secure orders for newly admitted residents to meet their basic immediate needs within 24 hrs. LVN A was informed that she documented on 5/23/2026 at 12:03 AM that Resident #31 had a PICC line and a record review of Resident #31's baseline care plan did not reflect the PICC line. LVN A stated a PICC line would have been an immediate need for flushing to keep the line patent (in nursing and medical jargon, patent [pronounced PAY-tent] means that a tubular anatomical structure, passage, or airway is open, unobstructed, and clear) with orders for flushes. LVN A did not recall receiving a report from LVN B, but that the report would have been standard practice with information about expectant new residents. LVN A stated she worked the 6:00 PM to 6:00 AM shift and she believed Resident #31 may have arrived on 5/22/2026 sometime between 6:00 PM and 11:00 PM 5/22/2026 evidencing her note on 5/23/2026 at 12:03 AM. LVN A stated the potential risk for residents who did not have their physician orders to meet their immediate needs was that they may not have received the immediate care to meet their basic needs. During an interview on 6/11/2026 at 4:10 PM the DON stated she had recognized that Resident #31 was admitted on [DATE] and had gone 4 days without orders for his isolation contact precautions, antibiotic IV medication, and PICC line care orders. The DON stated the expectation was for newly admitted residents to receive immediate care with their basic needs supported by physicians orders upon their admission. Specific to Resident #31 the orders would include PICC line care, isolation contact precautions, and IV antibiotics. The DON stated that the care was developed and implemented with the coordination of the IDT which included the continuity of care between the admissions coordinator and the floor nurses. The DON stated each member of the IDT had their own unique role and responsibility to ensure each resident received their immediate care needs and LVN A had a unique role in that she was the admissions nurse responsible for assessing Resident #31 with a need for isolation contact precautions, PICC line care, and IV antibiotic medications, for which she was expected to report to the physician and support the physician's orders for the care. The DON stated the failure could place residents at risk for potential lack of care and the spread of infection by cross contamination. The DON stated she had reviewed the facility's infection prevention and control surveillance for the period 5/22/2026 through 6/11/2026 which revealed zero incidents of infections throughout the facility with Klebsiella Pneumoniae. A record review of the United States of America's Centers for Disease Prevention and Control's website: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings updated September 2024, accessed 6/16/2026, revealed, Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. A record review of the facility's undated, untitled, quality of care policy revealed, Purpose: To ensure that each resident receives the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with comprehensive assessments, individualized care plans, professional standards of practice, and applicable federal and state regulations. Policy: The facility shall provide care and services consistent with each resident's needs, preferences, goals, and rights. Care shall be person centered, evidence based, and designed to promote optimal quality of life, prevent avoidable decline, and achieve the best possible outcomes. The facility will comply with all applicable Federal and state requirements, including those outlined under F-tags related to quality of care and will maintain systems to monitor, evaluate, and improve the quality of services provided.

Based on interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission; include the minimum healthcare information necessary to properly care for a resident, for 1 of 8 residents (Resident #31) reviewed for care plans for immediate needs. Resident #31 was admitted on [DATE] with immediate needs for care with an intravenous device, a PICC line (Peripherally Inserted Central Catheter, is a thin, flexible tube inserted into a peripheral vein in the arm and threaded through to a larger vein near the heart) and a need for isolation contact precautions (essential measures in healthcare settings to prevent the spread of infections, particularly those that can be transmitted through direct or indirect contact with patients or their environment) without care plans to support his immediate needs. These failures could place residents at risk for an PICC line (when the intravenous (IV) catheter has developed a blockage or obstruction) and the spread of infectious diseases.The findings included: A record review of Resident #31's admission record dated 6/8/2026 revealed an admission date of 5/22/2026 with diagnoses which included klebsiella pneumoniae (a bacterium naturally found in the human gut and respiratory tract) and urinary tract infection (UTI; an infection that occurs when bacteria enter any part of the urinary system). A record review of Resident #31's hospital clinical record dated 5/21/2026 revealed Resident #31 was diagnosed with a multi-drug-resistant organism UTI and treated with IV antibiotics which he received through a PICC line and was cared for under isolation contact precautions. A record review of Resident #31's admission MDS dated [DATE] revealed Resident #31 was an [AGE] year-old male admitted for recovery care after a hospitalization. Resident #31 was assessed with the ability to understand others and make himself understood. Resident #31 was assessed with a BIMS score of 11 out of a possible 15 which indicated moderate cognitive impairment. Resident #31 was assessed with an indwelling urinary catheter, had intravenous access (a PICC line), and a multi-drug-resistant organism. A record review of Resident #31's admission Report Form dated 5/22/2026 revealed LVN B documented a report she received from Resident #31's hospital RN. LVN B documented Resident #31 had a need for contact isolation precautions and intravenous antibiotic meropenem (a powerful, broad-spectrum carbapenem antibiotic used in hospitals to treat severe and multi-drug-resistant bacterial infections.) A record review of Resident #31's nursing Progress notes revealed LVN A documented on 5/23/2026 at 12:03 AM that Resident #31 was admitted the evening of 5/22/2026 with an indwelling PICC line, PICC line present to right AC sic[ante-cubital, the space in between the forearm and the upper arm, above the elbow]. A record review of Resident #31's baseline care plan dated 5/22/2026 revealed that LVN A documented immediate care needs for Resident #31 which did not include his need for a PICC line nor infection control isolation contact precautions. During an interview on 6/8/2026 at 12:15 PM Resident #31 stated he was admitted [DATE] from the hospital where he was treated for an infection. Resident #31 stated he received antibiotics which he received through his PICC line on his right arm. Resident #31 stated he was treated in an isolation room at the hospital, and the staff wore gowns and gloves. During an interview on 6/10/2026 at 4:01 PM RN D stated she was the facility's admissions coordinator, and, in that capacity, she had coordinated with the hospital case manager to receive Resident #31 as a new admission. RN D stated Resident #31 was being discharged from the hospital with the need for a contact isolation room, a PICC line and an indwelling [NAME] catheter. RN D stated Resident #31 had a need for isolation contact precautions because Resident #31 was diagnosed with a multi drug resistant organism, Klebsiella pneumoniae of the urine. RN D stated she had reviewed the new admission with the IDT and planned to receive Resident #31 on the evening of 5/22/2026 and gave a report to LVN B that afternoon. RN D recalled LVN B, on 5/22/2026, had received a report from the hospital RN who was discharging Resident #31 who was cared for with a PICC line and under isolation contact precautions. During an interview on 6/10/2026 at 4:20 PM LVN B stated she was the charge nurse on 5/22/2020 from 6:00 AM to 6:00 PM and at 6:00 PM she gave report to LVN A. LVN B stated she had received report from RN D and the hospital RN with care details for Resident #31. LVN B stated she documented on an admissions report worksheet that Resident #31 had an infection of the urine which needed contact isolation, a need for meropenem (a drug which cannot be given other than by intravenous access; meropenem cannot be given orally. It is exclusively administered via intravenous (IV) infusion), and a Foley catheter. LVN B stated she shared the worksheet with LVN A when she gave a report to LVN A during the change of shift nurse-to-nurse report on 5/22/2026 around 6 pm. During an interview on 6/10/2026 at 5:42 PM LVN A stated she could not recall the events of 5/22/2026 and stated any documentation she made regarding residents specifically Resident #31 was accurate. LVN A stated standard practice was for a nurse to develop a baseline care plan for newly admitted residents to meet their basic immediate needs within 24 hrs. LVN A was informed that she documented on 5/23/2026 at 12:03 AM that Resident #31 had a PICC line and a record review of Resident #31's baseline care plan did not reflect the PICC line. LVN A stated a PICC line would have been an immediate need for flushing to keep the line patent (in nursing and medical jargon, patent [pronounced PAY-tent] means that a tubular anatomical structure, passage, or airway is open, unobstructed, and clear) with orders for flushes. LVN A did not recall receiving a report from LVN B, but if she had received the report, it would have been a standard practice with information about expectant new residents. LVN A stated she worked the 6:00 PM to 6:00 AM shift and she believed Resident #31 may have arrived on 5/22/2026 sometime between 6:00 PM and 11:00 PM 5/22/2026 evidencing her note on 5/23/2026 at 12:03 AM. LVN A stated the potential risk for residents who did not have their baseline care plan fully completed was that they may not have received the immediate care needed to meet their basic needs. During an interview on 6/11/2026 at 4:10 PM the DON stated due to the state's investigation, she had recognized that Resident #31 had no baseline care plan. The DON stated the expectation was for newly admitted residents to receive immediate care with their basic needs with a baseline care plan which was to be developed and implemented within 24 hours of their admission. The DON stated that the baseline care plan was developed and implemented with the coordination of the IDT which included the continuity of care between the admissions coordinator and the floor nurses. The DON stated that each member of the IDT had their own unique role and responsibility to ensure each resident received their immediate care needs. The DON stated the potential risk for residents who did not have their immediate needs care planned could be they would not receive their immediate care needs. A record review of the facility's undated, untitled, care plan policy revealed, Purpose:To ensure that each resident receives individualized, coordinated care based on assessed needs, preferences, goals, and clinical condition.Policy Statement:The facility will develop and maintain a comprehensive, person-centered care plan for each resident. Care plans will be created, reviewed, and revised by an interdisciplinary team and will reflect the resident's physical, psychosocial, emotional, and functional needs.Procedure:1. Assessmento A comprehensive assessment will be completed upon admission and as required thereafter.o Assessment findings will identify resident strengths, needs, risks, preferences, and goals.2. Care Plan Developmento An individualized care plan will be developed within the timeframe required by applicable regulations.o The care plan will include: Identified problems and needs Measurable goals and expected outcomes Interventions and services to be provided Responsible disciplines and staff.4. Interdisciplinary Team Involvemento The care plan will be developed and reviewed by the interdisciplinary team, including nursing, therapy, dietary, social services, activities, and other relevant disciplines.5. Implementationo Staff will provide care according to the documented care plan.o Care plan interventions will be communicated to all appropriate staff. This policy will comply with all applicable federal, state, and local regulations governing long-term care services.

Based on interviews and record review, the facility failed to ensure 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 and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 (4) residents in that: Resident #4's Care Plan did not include his diagnosis of PTSD and interventions. This could affect all residents with care plans and could result in a decrease in care. The Findings: Record review of Resident #4's face sheet dated 6/10/206 revealed his admit date was on 9/5/2025, re-admitted on [DATE] with diagnoses of PTSD (post-traumatic stress disorder). Record review of Resident #4's Physician visit dated 5/22/2026 revealed his diagnosis included PTSD. Record review of Resident #4's Quarterly MDS dated [DATE] revealed his BIMS was 15/15 (cognitively intact), and active diagnosis included PTSD. Record review of Resident #4's Physician visit dated 5/22/2026 revealed his diagnosis included PTSD. Record review of Resident #4's care plan dated 4/22/206 revealed it did not include his diagnosis of PTSD. Interview on 6/10/2026 at 4:48 PM the DON stated she did not see PTSD in Resident #4's care plans. The DON stated it was important to have the diagnosis PTSD in Resident #4's care plan for staff to show interventions, such as avoiding certain triggers. Thes DON stated she was responsible for ensuring the resident's diagnoses and care were in the care plans. Record review of the policy, PTSD Management in Long-Term Care no date, Purpose: To provide guidelines for the identification, assessment, treatment, and support of residents with PTSD while promoting dignity, safety, trauma informed care, and psychological well-being. Policy, the facility shall provide person centered trauma informed care for residents with a diagnosis or history of PTSD. Definitions, PTSD; a mental health condition that may develop following exposure to traumatic events. Trauma informed care; cares that recognizes the impact of trauma and seeks to avoid re traumatization. Procedures; 2. Care planning; Develop individualized interventions and document resident preferences and triggers. Record review of the policy, Care Plan (no date) revealed, To ensure that each resident receives individualized, coordinated care based on assessed needs, preferences, goals and clinical condition. Policy Statement: The facility will develop and maintain a comprehensive, person-centered care plan for each resident. Care Plans will be created, reviewed, and revised by an interdisciplinary team and will reflect the residents' physical, psychological, emotional, and functioning needs. Procedure: 1. Assessment, Assessment findings will identify resident strengths, needs, risk, preferences, and goals. 2. The Care plan will include: identified problems and needs, Measurable goals and expected outcomes, interventions and services to be provided and responsible disciplines and staff. Interdisciplinary Team Involvement: The care plan will be developed and received by the interdisciplinary team, including nursing, therapy, dietary, social services, activities, and other relevant disciplines. 5. Implementation, staff will provide care according to their documented care plan, care plans interventions will be communicated to all appropriate staff. 6. Review and revision; Care plans will be reviewed regularly, and revised when: The residence conditions changes, Goals are achieved or no longer appropriate, new needs or risk are identified, regulatory review schedules require updates. 7. Care plan development, reviews, revisions, and resident participation will be documented in the medical record.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 8 residents (Resident #31) reviewed for continuity of care. CNA E entered Resident #31's isolation contact precautions room without personal protection equipment (PPE). This failure could place residents at risk of the spread of infectious diseases.The findings included: A record review of Resident #31's admission record dated 6/8/2026 revealed an admission date of 5/22/2026 with diagnoses which included klebsiella pneumoniae (a bacterium naturally found in the human gut and respiratory tract) and urinary tract infection (UTI; an infection that occurs when bacteria enter any part of the urinary system.) A record review of Resident #31's hospital clinical record dated 5/21/2026 revealed Resident #31 was diagnosed with a multi-drug-resistant organism UTI and treated with IV antibiotics which he received through a PICC line and was cared for under isolation contact precautions. A record review of Resident #31's admission MDS dated [DATE] revealed Resident #31 was an [AGE] year-old male admitted for recovery care after a hospitalization. Resident #31 was assessed with adequate vision. Resident #31 was assessed with the ability to understand others and make himself understood. Resident #31 was assessed with a BIMS score of 11 out of a possible 15 which indicated moderate cognitive impairment. Resident #31 was assessed with an indwelling urinary catheter, had intravenous access, and a multi-drug-resistant organism. A record review of Resident #31's admission Report Form dated 5/22/2026 revealed LVN B documented a report she received from Resident #31's hospital RN. LVN B documented Resident #31 had a need for contact isolation precautions and intravenous antibiotic meropenem. A record review of Resident #31's physician's orders revealed the physician prescribed for Resident #31 to receive medications and therapies as follows:- On 5/26/2026, contact precautions due to bacteremia klebsiella (the presence of viable bacteria in the bloodstream), every shift. A record review of Resident #31's care plan dated 6/8/2026 revealed Resident #31 has an infection, start date 5/26/2026; Resident is on antibiotics for urosepsis, multidrug-resistant organism, and is at risk for adverse reactions. Follow universal standard precautions to prevent cross contamination and spread of infection. During an observation on 6/8/2026 at 11:15 AM, revealed Resident #31's room with signage which reflected, Stop Contact Precautions Everyone Must: Clean their hands including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment clean and disinfect reusable equipment before use on another person. During an observation on 6/8/2026 at 11:20 AM, revealed CNA E answered Resident #31's call light without putting on any PPE. During an interview on 6/8/2026 at 12:58 PM, Resident #31 stated he was admitted [DATE] from the hospital where he was treated for an infection. Resident #31 stated he was treated in his room under isolation, and the staff sometimes wore gowns and gloves. Resident #31 stated he had just been visited by the CNA who answered his call light for repositioning care. Resident #31 stated the CNA had not worn PPE, and sometimes staff don't wear the gowns. During an interview on 6/8/2026 at 2:10 PM CNA E she had entered Resident #31's room to answer call lights without putting on any PPE. CNA E stated Resident #31 had an infection of the urine and an indwelling urinary catheter. CNA E stated she would wear PPE when she provided any urinary catheter care but did not need to wear PPE if she was not providing catheter care. During an interview on 6/9/2026 at 4:20 PM LVN C stated she was Resident #31's charge nurse and Resident #31 was cared for under isolation contact precautions. LVN C stated on 5/26/2026 she had developed and implemented the contact isolation precautions and PPE supplies at Resident #31's door side. LVN C stated CNA E was her CNA and cared for Resident #31. LVN C stated CNA E had been trained to wear PPE whenever she entered Resident #31's room. LVN C stated she would re-educate CNA E for compliance. LVN C stated the potential risk for residents if staff failed to wear PPE in isolation contact rooms was the spread of infections. During an interview on 6/11/2026 at 4:10 PM the DON stated her expectation was for all staff who entered a contact isolation room to provide hand hygiene, don a gown, and gloves prior to entering the room and to remove the PPE prior to exiting the room. The DON stated if staff did not wear PPE in isolation contact precaution rooms the potential risk for residents could be the spread of infections. A record review of the facility's undated, untitled, quality of care policy revealed, Purpose: To ensure that each resident receives the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being in accordance with comprehensive assessments, individualized care plans, professional standards of practice, and applicable federal and state regulations. Policy: The facility shall provide care and services consistent with each resident's needs, preferences, goals, and rights. Care shall be person centered, evidence based, and designed to promote optimal quality of life, prevent avoidable decline, and achieve the best possible outcomes. The facility will comply with all applicable Federal and state requirements, including those outlined under F-tags related to quality of care and will maintain systems to monitor, evaluate, and improve the quality of services provided. Infection Prevention and Control; staff shall: Follow standard precautions and transmission based precautions; perform hand hygiene according to established guidelines; personal protective equipment; . A record review of the United States of America's Centers for Disease Prevention and Control's website: https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings updated September 2024, accessed 6/16/2026, revealed, Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.

Based on observations and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, for 1 of 1 laundry departments reviewed for laundry equipment. 1 of the 2 commercial washing machines was inoperable for longer than 8 months. This failure could place residents at risk for not having timely laundry service.The findings included: During an observation and interview on 6/8/2026 at 1:00 PM revealed the facility's laundry department had 2 commercial washers of which only 1 functioned. Laundry Aide F stated she was the laundry staff for the day and used the 1 functioning commercial washer. LA F stated she was able to keep up timely laundry services with the 1 washer but at times keeping up with timely laundry services was challenging with only 1 washer for all the residents. LA F stated the broken washer had been out of service for longer than 8 months. During an observation and interview on 6/10/2026 at 3:00 PM revealed the facility's laundry department had 2 commercial washers of which only 1 functioned. Laundry Aide G stated she was the laundry staff for the day and used the 1 functioning commercial washer. LA G stated she was able to keep up timely laundry services with the 1 washer but at times keeping up with timely laundry services was challenging with only 1 washer for all the residents. LA G stated the broken washer had been out of service for longer than 8 months. During an interview on 6/11/2026 at 4:10 PM the Administrator stated she and the facility's Owner had become aware that 1 of the 2 facility commercial washers was not working and the washer was under the manufactures' warranty; however, the facility was unsuccessful in securing service from the vendor for the past 8 months. The Administrator stated that for the time being the laundry department was able to keep up timely laundry services. The Administrator stated she would follow up with the facility's Owner and explore alternate options for repairing the washing machine. A policy was requested (and as of 6/17/2026) a policy had not been provided. The Administrator stated the facility followed HHSC guidelines.

Based on observations, interviews and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 (1 hair salon, 1 kitchen) facility in that: The kitchen drains on floor, near the dish machine, did not have a grate on it.Hair salon was not sanitary, including 3 brushes with hair, hair on several hair curlers and the sink drain filter had a glob of hair.These failures could place residents at risk by residents' germs being spread, that use the hair salon and could allow pests to enter the facility through the kitchen floor open drain. The Finding: 1.Observation on 6/09/2026 at 8:08 AM in the kitchen, with the FSM near the dish machine, revealed an open drain on the floor with no grate. Interview on 6/09/2026 at 8:08 AM in the kitchen, with the FSM confirmed an open drain on the floor with no grate. The FSM stated she was not sure how long the open drain did not have a grate. The FSM stated they had no pests and they were waiting for the Maintenance supervisor to start working at the facility to let him know about it. Interview on 6/09/2026 at 4:19 PM the FSM stated she had told the MS a week or 2 weeks ago, but she had discussed with the new MS, he started Monday, 6/8/2026. The FSM stated the former MS left the position on Friday, 6/5/2026. Record review of the policy, Drain cover (no date) revealed, Purpose, to maintain a safe, sanitary, and complaint food service department by ensuring that all floor drains in the dietary department are equipped with property fitting properly or covers all times. Policy statement, all floor drains located within the dietary department shall have securely fitted grades or drain covers in place during operation and where the area is not in use. Drain grades help prevent pest entry, reduce the risk of foreign material entering the drainage system, minimize slip and trip hazards, and support infection prevention and sanitation standards. Responsibilities: dietary staff; conduct routine inspections and report deficiencies. Dietary Manager: [NAME] compliance and ensure corrective actions are taken. 2. Observation on 6/11/2026 at 11:07AM in the Hair Salon room, with the Activity Director, revealed in the sink drain a glob of hair in the sink filter. Also, 3 brushes in a cabinet had hair and a box of hair curlers with hair on them. Interview on 6/11/2026 at 11:07AM in the Hair Salon room, the Activity Director confirmed the sink drain had a glob of hair in the sink filter and the 3 brushes in a cabinet that had hair and a box of hair curlers with hair on them. The Activity Director (AD) stated the Housekeeping Department was in charge of cleaning the Hair Salon sink. The AD stated the beautician came to visit on Tuesday, 6/9/2026.Interview on 6/11/2026 at 11:10 AM in the Hair Salon room, with the Housekeeping Supervisor (HS) confirmed the sink drain had a glob of hair in the sink filter. The HS stated she might have forgotten to clean the Hair Salon after the beautician visited this week. Interview on 6/11/2026 at 11:30 AM with the ADM, discussed the Hair Salon and kitchen drain findings and she did not have any comments. Record review of the policy, dated August 2019 revealed Cleaning and disinfection of environmental surfaces. Policy statement, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of health care facilities and the OSHA bloodborne pathogen standard. Policy interpretation and implementation. 9. Housekeeping surfaces will be cleaned on a regular basis, the spills occur, and when these surfaces are visibly soiled.Record review of the policy, Beauty shop cleaning policy, (no date) revealed, Purpose, To ensure the hair salon within the facility is maintained in a clean, safe, and sanitary condition to protect residents, staff, and visitors from infection, injury, and environmental hazards. Policy statement, The facility shall maintain the hair salon in a clean and sanitary condition at all times. Cleaning and disinfection practices will be performed routinely and between resident appointments in accordance with infection prevention standards and applicable regulations. Procedure, General Housekeeping, the salon should be kept clean, organized, and free of clutter. Hair flipping shall be removed promptly from floors, chairs, countertops and equipment. 2. Cleaning and Disinfection of Equipment, Combs, brushes, clips, rollers, and other reusable equipment shall be cleaned and disinfected after each use. Responsibilities, Environmental Services: Provide routine housekeeping support as assigned. Department Manager: Monitor compliance and address deficiencies.

Based on observation, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. The findings include: During an observation and interview on 04/10/2025 at 06:07 a.m., revealed a live roach on the floor in the clean pots and pan storage room. This observation was pointed out to DA A, who immediately got a broom, swept the roach up, and removed it from the kitchen. DA A stated the roach was alive. DA A stated he knew that someone came and sprayed the kitchen twice a month for bugs. During an interview on 04/10/2025 at 02:39 p.m., the DS stated she was told about the water roach seen this morning. She stated that the facility kitchen did have stragglers but did not know how the water roach got in. She stated the kitchen had pest control treatment every month. During an interview on 04/10/2025 at 02:57 p.m., the Maint Dir stated the facility had monthly pest control services. He stated that the facility had recently changed pest control companies due to a concern that the prior company's chemical spray was not strong enough. He stated that the new company appeared to be working better for the facility's needs. He stated the new company had been treating the kitchen with a new chemical that seemed to be working. He stated he believed the small bug found that morning possibly entered the kitchen due to a clean out area that had flooded during the night by the kitchen grease trap. He stated that the clean out area and flooding were addressed and fixed that same morning. During an interview on 04/10/2025 at 04:05 p.m., the ADMIN stated the facility changed pest control companies recently due to a concern brought by the maintenance department regarding the prior company's solution not having been effective. The ADMIN stated the facility had not had pest control concerns reported since the change in companies. She stated pests in the kitchen would be an infection control concern and the bug found that morning was brought to her attention. She stated it was due to a backing up of the drainage system, which did not occur very often. She stated the facility maintenance and dietary department do regular rounds to check the environment and would report any concerns they found. Record review of Pest Control Service Proposal, dated as signed 03/18/2025, revealed: PESTS TO BE CONTROLLED: Ants, Centipedes, American Roaches, Silverfish, Pill Bugs Earwigs, Millipedes, [NAME] Bugs, Spiders and Scorpions. NOTE: Rodents including Mice & Rats, [NAME]/Ticks, [NAME] Destroying Insects, Flying Insects, Bed Bugs, German Roaches and Lawn Treatments require different procedures and are not covered by this agreement. [Pest Control Company Name] will provide all materials and labor to perform Monthly Pest Control Service at the above location . Roach Clean-Out Control (2 services 30 days apart) . Monthly Commercial Pest Control Charge (Includes roach bating). Record review of Pest Control Invoice, dated 03/19/2025, revealed the following service, ROACH CLEAN OUT (1 of 2 trips) NO WARRANTY FOR SERVICE. Under Target Pest: American Roach, Ant, German Roach, and Spider were marked. Remarks: German Roaches in the Dietary was noted on the invoice document. Record review of Pest Control Invoice, dated 03/25/2025, revealed the following service, MONTHLY COMMERCIAL SERVICE. Under Target Pest: American Roach, Ant, and Spider were marked. Remarks: German Roaches in the Dietary was noted on the invoice document. Record review of facility policy, Pest Control, dated as revised May 2008, revealed under Policy Statement, Our facility shall maintain an effective pest control program. Under Policy Interpretation and Implementation, 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

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 2 of 8 residents (Resident #1 and Resident #21) reviewed for infection control: 1. The facility failed to ensure CNA A and another unidentified CNA wore the proper PPE while transferring Resident #21 who was on EBP. 2. The facility failed to ensure LVN C did not touch the sink handle in Resident #1's bathroom with her bare hands after washing her hands. 3. The facility failed to ensure laundry aide E did not have food and drinks in the laundry room on the laundry folding table. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #21's face sheet, dated 4/4/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acquired absence of other right toe, infection following a procedure deep surgical site, methicillin resistant staphylococcus aureus infection, and atherosclerosis of native arteries (the buildup of fats, cholesterol, and other substances in and on the artery walls. This buildup is called plaque. The plaque can cause arteries to narrow, blocking blood flow.) of right leg with ulceration (ulcer or break in skin) of other part of foot. Record review of Resident #21's quarterly MDS assessment, dated 3/4/25, revealed Resident #21's cognition was moderately impaired for daily decision making. Section M revealed Resident #21 had 1 arterial ulcer (painful injuries in the skin caused by poor circulation) present. Record review of Resident #21's Care Plan, dated 4/2/25, last revised 4/1/25 revealed he had an arterial wound of the right posttrial (sic) heel and was at high risk for infection and/or pain/discomfort. Approaches included assess the arterial ulcer for stage, size (length, width, and depth), exudate (the material composed of serum (an amber-colored, protein-rich liquid that separates out when blood coagulates), fibrin (an insoluble protein formed from fibrinogen during the clotting of blood), and white blood cells that escapes from blood vessels into a superficial lesion or area of inflammation), necrotic tissue (premature death of body tissue), presence/absence of granulation tissue and epithelization (regenerating the epidermis (skin) over a partial-thickness wound surface or the formation of scar tissues on a full-thickness wound), and condition of surrounding skin weekly and as needed. The care plan did not reflect the resident was on EBP. Record review of Resident #21's physician orders, dated 4/4/25, revealed orders for: - Arterial wound to right posterior heel. Cleanse wound with hypochlorous acid solution, pat dry, moleculight (handheld imaging device that uses fluorescence imaging to help detect bacterial presence in wounds. It is often used to guide wound cleaning), apply cadexomer iodine (antimicrobial gel) to wound cover with border gauze foam dressing 3 times a week, as needed, or when dislodged or soiled. Once a day on Monday, Wednesday, Thursday, with a start date of 2/8/25, and no end date. -Enhanced Barrier Precautions based on open draining wound to right foot, with a start date of 12/1/24, and no end date. During an observation on 4/1/25 at 4:22 p.m. Resident #21's room did not have any signage for EBP or PPE supply carts nearby. During an observation on 4/3/25 at 10:32 a.m. CNA A and another unidentified CNA were helping Resident #21 transfer to bed after bathing him. CNA A and the unidentified CNA did not have on a PPE gown. During an interview on 4/3/25 at 4:00 p.m. CNA A stated she had assisted Resident #21 back to bed earlier that day after she and another aide gave him a shower. CNA A stated Resident #21 was not on any type of precautions. During an interview on 4/3/25 at 5:06 p.m. LVN C stated Resident #21 was not on any type of precautions. LVN C stated residents with wounds would be on EBP. LVN C stated staff would know if residents were on EBP because there would be a sign and a PPE supply cart outside the residents' room. LVN C stated nurses such as her would be responsible for placing the sign and PPE supply cart if there was an order for EBP. LVN C stated she did not think Resident #21 had an active order for EBP and needed to check if it was discontinued. During an interview on 4/3/25 at 5:12 p.m. the DON stated Resident #21 should be on EBP. The DON stated Resident #21's wound was contained and not draining. The DON stated when Resident #21 was showered his wound was covered so staff did not need a PPE gown. The DON stated staff only needed a PPE gown for transferring Resident #21 if the wound was not contained. The DON stated if there was no EBP signage staff would not know the resident was on EBP and he could be exposed to infection. During an interview on 4/4/25 at 10:35 a.m. the MDS nurse stated the care plan should contain EBP under the wound on Resident #21's care plan. The MDS nurse stated EBP was a precaution for draining wounds to protect the resident as well as preventing infections from spreading around the building. 2. During an observation on 4/3/25 at 10:37 a.m. LVN C planned to check Resident #1 blood sugar and administer insulin. LVN C washed her hands at the sink in Resident #1's room. LVN C used her bare hand to turn off the water and touched the handle. LVN C did not use a clean paper towel to turn off the water. During an interview on 4/3/25 at 10:48 a.m. LVN C stated she should have used a paper towel to turn off the sink faucet. LVN C stated she got her hands dirty again by touching the handle with her bare hand and there was risk of infection to the resident. During an interview on 4/3/25 at 12:11 p.m. the DON stated there was a risk of infection control if staff did not use a paper towel to turn off the sink faucet. The DON stated the sink handle could be dirty and you would contaminate your hands if you touched if after washing them. 3. During an observation on 4/2/25 at 3:39 p.m. in the laundry room there was a can soda, open cup of fresh ice and soda, a fast-food plastic cup with a brown liquid in it, and a bowl of food with a spoon and napkin on the folding table. The room smelled like food. Laundry Aide E appeared to still be chewing food. During an interview on 4/2/25 at 3:40 p.m. Laundry Aide E stated she was done with the bowl of food and took it outside and threw it in the trash. Laundry Aide E stated she should not be eating in the laundry room. During an interview on 4/3/25 at 12:16 p.m. the DON stated staff should not be eating or drinking in the laundry room and they had a break room they could eat in. The DON stated laundry staff was dealing with clean linens, then if they eat and touch linens after they are not washing their hands and it could cross contaminate clean linens for the residents. Record review of the facility's policy titled Enhanced Barrier Precautions, dated 2001, revised 12/24, stated Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation. 1. Enhanced barrier precautions (EBPs) refer infection prevention and control intervention designed to reduce the transmission of multi drug resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when .b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and c. Contact precautions do not otherwise apply . 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care); . wound care (any skin opening requiring a dressing) . 11. Outside the resident's room, EBPs are indicated when anticipating close physical contact, including performing transfers or assisting during bathing in a shared/common shower room and when working with residents in the therapy gym. 12. Enhanced barrier precautions are in place for the duration of the resident's stay or until resolution of the wound or until discontinuation of the underlying medical device that place that higher risk .16. Staff are trained prior to caring for residents on EBPs. 17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. 18. Personal protective equipment and alcohol-based hand-rub are readily accessible to staff . Record review of the facility's policy titled Handwashing/ Hand Hygiene, dated 2001, revised 8/19, stated .this facility considers hand hygiene the primary means to prevent the spread of infection . Washing hands .3. Raise hands with water and dry thoroughly with a disposable towel. 4. Use a towel to turn off the faucet . Record review of the facility's policy titled Departmental (Environmental Services)- Laundry and Linen, dated 2001, revised 12/14, stated The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . washing linen and other soiled items .7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering linen carts .

Based on interviews and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 6 (1/18/25, 1/19/25, 1/25/25, 1/26/25, 2/8/25, and 2/9/25) of 90 days reviewed for RN hours reviewed, for the months January 1st, 2025, through March 31st, 2025. The facility failed to have RN coverage for 6 days on Saturday 1/18/25, Sunday 1/19/25, Saturday 1/25/25, Sunday 1/26/25, Saturday 2/8/25, and Sunday 2/9/25. This failure could place residents at risk for harm by denying residents the advanced critical thinking skills a registered nurse could provide. The findings were: Review of the facility's RN timesheets, no date, revealed there were no RN hours for Saturday 1/18/25, Sunday 1/19/25, Saturday 1/25/25, Sunday 1/26/25, Saturday 2/8/25, and Sunday 2/9/25. During an interview on 4/3/25 at 2:45 p.m. the BOM stated there were gaps on the weekend where they did not have RN coverage. During a joint interview on 4/3/25 at 4:07 p.m. the DON and Administrator stated it was difficult to find RNs. They stated they now had an RN who was working weekends and the DON filled in when needed. They stated the DON was working weekends previously when there was no RN but did not clock in to document those days. They stated no resident went without care on the times no RN hours were logged. They both stated the facility did not have a policy for RN coverage and went by CMS guidelines.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 6.67% based on 2 out of 30 opportunities, which involved 2 of 3 Residents (Resident #1 and Resident #35) reviewed for medication administration, in that: 1. The facility failed to ensure LVN C administered Resident #1's insulin lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) correctly. 2. The facility failed to ensure MA B administered the full dose of Resident #35's polyethylene glycol 3350 (osmotic laxative that attracts water into the colon to ease, hydrate, and soften stool). These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: 1. Record review of Resident #1's Admission Record, dated 4/4/25, revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood) with diabetic chronic kidney disease, wheezing, cough, end stage renal disease, and atherosclerotic heart disease native coronary artery (accumulation of plaque within the arterial walls, leading to narrowed or blocked arteries) without angina pectoris (chest pain that comes and goes). Record review of Resident #1's Annual MDS assessment, dated 1/2/25, revealed the resident's cognition was moderately impaired for daily decision making. Record review of Resident #1's care plan, dated 4/4/25, revised 4/1/25 revealed the resident was at risk for S&A of hyper/hypoglycemia [refer to blood sugar levels that are too low or too high] related to diagnosis of diabetes mellitus with approaches to monitor blood sugar as ordered by the MD. Record review of Resident #1's physician order summary, dated 4/3/25, revealed an order for insulin lispro pen, 100 unit/mL, amount 10 units, subcutaneous. Hold if blood sugar less than 100 mg/dL before meals at 7:00 a.m., 11:00 a.m., and 4:00 p.m., with a start date of 7/11/24, and no end date. During an observation on 4/3/25 at 10:37 a.m. LVN C cleaned Resident #1's insulin pen with an alcohol swab, turned the pen to 10 units, placed the needle on the pen, went into the resident's room, removed the needle cover, and administered the insulin into the resident right side of his abdomen. LVN C did not prime the insulin pen prior to administration. During an interview on 4/3/25 at 10:44 a.m. LVN C stated she did not prime the insulin pen prior to administering the insulin to the resident. LVN C stated she had not had any training on using insulin pens and was not aware they needed to be primed. During an interview on 4/3/25 at 12:11 p.m. the DON stated it was recommended staff prefill or prime an insulin pen prior to administering it. The DON stated she had not gone over any training with nursing staff because she was waiting on new training books to come in and had not had an opportunity to use them yet. The DON stated they did not have a specific policy for insulin pen administration. 2. Record review of Resident #35's Admission Record, dated 4/4/25, revealed an [AGE] year-old male admitted on [DATE] with diagnoses of dementia, other lack of coordination, and chronic pain. Record review of Resident #35's Quarterly MDS assessment, dated 3/10/25, revealed the resident's cognition was moderately impaired for daily decision making. Record review of Resident #35's MAR, dated 4/3/25, revealed an order for 1 cap or 17 grams of polyethylene glycol once a day. During an observation on 4/3/25 at 8:03 a.m. MA B pour the polyethylene glycol for Resident #35 into a cap from the bottle. The cap had one line halfway and a second line at the top of the cap for 17 grams. MA B pour to the first line in the cap and only poured half the dose. MA B then mixed the polyethylene glycol with water and administered it to the resident. During an interview on 4/3/25 at 9:01 a.m. MA B stated she thought she poured a cap full. MA B stated she should pour to the top of the white cap to ensure the resident gets the full dose of medication so he can have normal bowels. During an interview on 4/3/25 at 12:07 p.m. the DON stated aides could use a graduated cup to measure the medication amount. The DON stated if staff only pour half the dose, they would not be administering the full amount for full effect, so they would need to notify the doctor and follow any recommendations. Record review of the facility's policy titled Administering medications, dated 2001, revised 4/19, stated medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame . Record review of manufacturer instructions for (insulin lispro) Instructions for Use, dated 8/2023, stated .Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the needle, and repeat priming steps 6 to 8. Small air bubbles are normal and will not affect your dose .

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 8 residents (Resident #21) reviewed for care plans: The facility failed to ensure Residents #21's Care Plan reflected he was on EBP (Enhanced Barrier Precautions). 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 #21's face sheet, dated 4/4/25, revealed a [AGE] year-old male resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acquired absence of other right toe, infection following a procedure deep surgical site, methicillin resistant staphylococcus aureus infection, and atherosclerosis of native arteries (the buildup of fats, cholesterol, and other substances in and on the artery walls. This buildup is called plaque. The plaque can cause arteries to narrow, blocking blood flow.) of right leg with ulceration (ulcer or break in skin) of other part of foot. Record review of Resident #21's quarterly MDS assessment, dated 3/4/25, revealed Resident #21's cognition was moderately impaired for daily decision making. Section M revealed Resident #21 had 1 arterial ulcer (painful injuries in the skin caused by poor circulation) present. Record review of Resident #21's Care Plan, dated 4/2/25, last revised 4/1/25 revealed he had an arterial wound of the right posttrial (sic) heel and was at high risk for infection and/or pain/discomfort. Approaches included assess the arterial ulcer for stage, size (length, width, and depth), exudate (the material composed of serum (an amber-colored, protein-rich liquid that separates out when blood coagulates), fibrin (an insoluble protein formed from fibrinogen during the clotting of blood), and white blood cells that escapes from blood vessels into a superficial lesion or area of inflammation), necrotic tissue (premature death of body tissue), presence/absence of granulation tissue and epithelization (regenerating the epidermis (skin) over a partial-thickness wound surface or the formation of scar tissues on a full-thickness wound), and condition of surrounding skin weekly and as needed. The care plan did not reflect the resident was on EBP. Record review of Resident #21's physician orders, dated 4/4/25, revealed orders for: - Arterial wound to right posterior heel. Cleanse wound with hypochlorous acid solution, pat dry, moleculight (handheld imaging device that uses fluorescence imaging to help detect bacterial presence in wounds. It is often used to guide wound cleaning), apply cadexomer iodine (antimicrobial gel) to wound cover with border gauze foam dressing 3 times a week, as needed, or when dislodged or soiled. Once a day on Monday, Wednesday, Thursday, with a start date of 2/8/25, and no end date. -Enhanced Barrier Precautions based on open draining wound to right foot, with a start date of 12/1/24, and no end date. During an observation on 4/1/25 at 4:22 p.m. Resident #21's room did not have any signage for EBP or PPE supply carts nearby. During an observation on 4/3/25 at 10:32 a.m. CNA A and another unidentified CNA were helping Resident #21 transfer to bed after bathing him. CNA A and the unidentified CNA did not have on a PPE gown. During an interview on 4/3/25 at 4:00 p.m. CNA A stated she had assisted Resident #21 back to bed earlier that day after she and another aide gave him a shower. CNA A stated Resident #21 was not on any type of precautions. During an interview on 4/3/25 at 5:06 p.m. LVN C stated Resident #21 was not on any type of precautions. LVN C stated residents with wounds would be on EBP. LVN C stated staff would know if residents were on EBP because there would be a sign and a PPE supply cart outside the residents' room. LVN C stated nurses such as her would be responsible for placing the sign and PPE supply cart if there was an order for EBP. LVN C stated she did not think Resident #21 had an active order for EBP and needed to check if it was discontinued. During an interview on 4/3/25 at 5:12 p.m. the DON stated Resident #21 should be on EBP. The DON stated Resident #21's wound was contained and not draining. The DON stated when Resident #21 was showered his wound was covered so staff did not need a PPE gown. The DON stated staff only needed a PPE gown for transferring Resident #21 if the wound was not contained. The DON stated if there was no EBP signage staff would not know the resident was on EBP and he could be exposed to infection. During an interview on 4/4/25 at 10:35 a.m. the MDS nurse stated the care plan should contain EBP under the wound on Resident #21's care plan. The MDS nurse stated EBP was not on the care plan because she thought she added it but forgot. The MDS nurse stated EBP was a precaution for draining wounds to protect the resident as well as preventing infections from spreading around the building. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 2001, revised 3/22, stated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .7. The comprehensive, person-centered care plan: a. Includes measurable objectives and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, psychosocial well-being .e. Reflects currently organized standards of practice for problem areas and conditions .9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 of 6 (Resident #1) residents reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen concentrator filter was cleaned and free of debris. This deficient practice could place residents at risk for an increase in respiratory complications. The findings included: Record review of Resident #1's Admission Record, dated 4/4/25, revealed a [AGE] year-old male admitted on [DATE] with diagnoses wheezing, cough, end stage renal disease, and atherosclerotic heart disease native coronary artery (accumulation of plaque within the arterial walls, leading to narrowed or blocked arteries) without angina pectoris (chest pain that comes and goes). Record review of Resident #1's Annual MDS assessment, dated 1/2/25, revealed the resident's cognition was moderately impaired for daily decision making. Record review of Resident #1's care plan, dated 4/4/25, revised 4/1/25 revealed the resident was at risk for ineffective breathing related to congestion to lung fields with approach to notify MD of shortness of breath (SOB) not relieved by oxygen, nebulizers, or medications. Record review of Resident #1's physician order summary, dated 4/3/25, revealed an order for oxygen at 2-3 liters per minute via nasal cannula as needed for SOB/Dyspnea, with an order date of 6/23/24, and no end date. During an observation on 4/1/25 at 12:00 p.m. Resident #1 had an oxygen concentrator in his room. A layer of built-up lint/dust was noted on the filter. During an interview on 4/1/25 at 12:01 p.m. Resident #1 stated he used the oxygen sometimes and had never seen anyone clean it. During an interview on 4/3/25 at 4:55 p.m. LVN C stated there was dust on the oxygen concentrator filter in Resident #1's room. LVN C stated she was unsure if maintenance or housekeeping was responsible for cleaning the oxygen filters. During an interview on 4/3/25 at 4:59 p.m. the Housekeeping Supervisor stated housekeeping staff was expected to clean the oxygen filters daily when they cleaned the resident rooms. The Housekeeping Supervisor stated the filter on Resident #1's concentrator looked dirty and looked like it had not been cleaned recently. The Housekeeping Supervisor stated the resident could breathe in the dust and have breathing issues from it. During an interview on 4/3/25 at 5:12 p.m. the DON stated nursing staff should be checking the oxygen concentrators and can clean them. The DON stated a resident is at risk for a respiratory infection if they do not keep the filters clean. Record review of the facility's policy titled Departmental (Respiratory Therapy)- Prevention of Infection, dated 2001, revised 11/2011, stated The Purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff . Steps in the Procedure .9. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry .

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #20) reviewed for dialysis: The facility failed to fully complete the dialysis communication forms for Resident #20 on 3/24/25 and 3/31/25. This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings included: Record review of Resident #20's face sheet, dated 4/4/25, revealed a [AGE] year-old female resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anoxic (lack of oxygen) brain injury, end stage renal disease (ESRD) (your kidneys can no longer support your body's needs), and type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood) with diabetic neuropathy (nerve damage that affects people with diabetes. The most common type is peripheral neuropathy, which often affects your feet.). Record review of Resident #20's quarterly MDS assessment, dated 1/22/25, revealed Resident #20's cognition was moderately impaired for daily decision making. Section O revealed Resident #20 received dialysis. Record review of the Resident #20's Care Plan, dated 4/3/25, last revised 4/1/25 revealed she required dialysis related to ESRD with approaches to obtain vital signs/weight as needed. Report significant changes in pulse, respiration, and blood pressure immediately. Record review of Resident #20's physician orders, dated 4/3/25, revealed orders for: - [dialysis center] .chair time 11:15 a.m.once a day on Monday, Wednesday, and Friday, with a start date of 12/17/24, and no end date. -Left AV (arteriovenous fistula) shunt (a passage or anastomosis between two natural channels, especially between blood vessels): Monitor for +bruit (the abnormal sound generated by turbulent flow of blood in an artery due to either an area of partial obstruction or a localized high rate of blood flow through an unobstructed artery) and thrill (An abnormal vibration that is felt on the skin overlying a loud cardiac murmur or an arteriovenous fistula.) every shift day and night, with a start date of 4/29/23, and no end date. Record review of Resident #20's dialysis communication forms revealed: -On 3/24/25 the post dialysis section did not have vitals and a line was drawn through the area for vitals. The section was signed by LVN D. -On 3/31/25 the post dialysis section to be completed by the nursing facility was blank. There was no vitals, assessment for presence of bruit or thrill, assessment for infection or bleeding, and assessment of the dressing. There was no nurse signature. Record review of Resident #20's vitals, dated 4/3/25, revealed vitals from the previous 30 days. No vitals were found for dates 3/24/25 and 3/31/25 at the time the resident returned from dialysis in the afternoon. During an interview on 4/4/25 at 10:26 a.m. LVN D stated he worked the 6 a.m. shift to 6 p.m. shift. LVN D stated he would assess residents before dialysis and upon return from dialysis which included assess for thrill, bruit, assesses the access site, and obtaining vitals. LVN D stated the dialysis center would let the nursing facility know if there was a change in status for the resident during dialysis. LVN D stated he should also take the residents vitals upon return from dialysis to see there was no changed in the residents status. LVN D stated he forgot to mark the vitals on the communication form from 3/24/25. LVN D stated it was important to assess the resident upon return from dialysis to make sure the resident was stable. During an interview on 4/4/25 at 10:32 a.m. the DON stated nursing staff should take vitals before a resident goes to dialysis and upon return and document it on the dialysis communication form. The DON stated they assess the resident and take vitals to make sure their blood pressure if not dropping and to see how they feel after. Record review of the facility's policy titled Hemodialysis Catheters- Access and Care of, dated 2001, revised 2/23, stated Purpose Hemodialysis catheters will only be accessed by medical staff who have received training and demonstrated clinical competency regarding use of this catheter. Guidelines .Care of AVFs .3. Care involves the primary goals of preventing infection and maintaining patency of the catheter (preventing clots). 4. To prevent infection and/ or clotting .d. check for signs of infection (warmth, redness, tenderness, or edema) at the access site when performing routine care and at regular intervals .g. Check the color and temperature of the fingers, and the radial pulse of the access arm when performing routine care and at regular intervals. h. Check patency of the site at regular intervals. Palpate the site to feel the thrill or use a stethoscope to hear the whoosh or bruit of blood flow through the access .Documentation. The nurse should document in the resident's medical records every shift as follows: 1. Location of the catheter. 2. The condition addressing (interventions if needed). 3. If dialysis is done during shift. 4. Any part of the report from dialysis nurse post dialysis being given. 5. Observations post dialysis.

Based on observation, interview and record review revealed the facility failed to ensure correct use of bed rails including but not limited to the following elements. Assess the resident for risk of entrapment from bed rails prior to installation and obtain informed consent prior to installation for 1 of 8 Residents (Resident #20) whose records were reviewed for bed rails. The facility failed to ensure staff obtained informed consent (the facility has explained to the resident or RP the risk and benefits of using bedrails) for the use of 1/4 bed rails for Resident #20. These deficient practices could affect residents who used bed rails and could put the residents at risk for potential injuries. Findings Included: Record review of Resident #20's face sheet, dated 4/4/25, revealed a [AGE] year-old female resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including anoxic (lack of oxygen) brain injury, muscle weakness, and rheumatoid arthritis (chronic, condition that causes pain, swelling and irritation, called inflammation, in the joints). Record review of Resident #20's quarterly MDS assessment, dated 1/22/25, revealed Resident #20's cognition was moderately impaired for daily decision making. Section P revealed Resident #20 used bed rails. Record review of the Resident #20's Care Plan, dated 4/3/25, last revised 4/1/25 revealed she used side rails and was at risk for injury with approach assess for the use of side rails quarterly and as needed. Record review of Resident #20's physician orders, dated 4/3/25, revealed an orders for 1/4 rails x2 to promote independence, aid in repositioning. Special instructions: 1/4 rails x2 to promote independence with repositioning, with a start date of 10/31/24, and no end date. Record review of Resident #20's side rails assessment and consent, dated 4/27/21 showed the side rails were not in use and had no resident or family signature for consent. During an observation on 4/1/25 at 12:33 p.m. Resident #20's bed had 1/4 rails on it. During an interview on 4/4/25 at 11:22 a.m. the MDS nurse stated nursing staff would normally fill out a consent form at the time the side rail order was initiated. The MDS nurse stated there should be a consent for Resident #20's side rails. The MDS nurse stated it was important to obtain a consent to show the family and resident were aware of the risk of using side rails. Record review of the facility's policy titled Bed Safety and Bed Rails, dated 2001, revised 8/22, stated use of bed rails is prohibited unless the criteria for use of bed rails have been met .The Use of Bed Rails .8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with use of bed rails; b. The resident's risk from the use of bed rails and how these will be mitigated .

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The DM did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: During an interview and record review with the Dietary Manager on 04/03/25 at 12:30 pm, the Dietary Manager was asked about her certification as a Dietary Manager. The DM stated she had started a course that was being paid for by an employer a couple of years ago when she was working as a Dietary Manager but then quit her job and did not continue school. When she was hired for this job, she was told she would have to pay for her own course so she said she had begun making payments and once she had the course paid for she could take the classes. The DM provided her information from her previously started school which was an online course from University F. The document showed an enrollment date of 02/28/2022. There was no evidence provided that the DM was currently enrolled in the required coursework. The DM stated they do have a Dietician who comes in once a month but the DM is in charge of the overall kitchen duties. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen: 1. The facility failed to store, label and date food items properly in 3 of 3 reach in freezers. 2. The DS, Cook, and Dietary Aide C were not wearing hair restraints properly during food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation and interview with the DS on 10/1/24 at 11:09 a.m. revealed the following: -Reach in Freezer #1 contained 6, gallon size bags of frozen biscuits with no date indicating a use by date. The DS stated they had just received the shipment early in the morning, maybe between 5:30 a.m. and 6:00 a.m. and should have been labeled prior to being placed in the freezer. The DS stated the dietary staff were responsible for labeling the items and the label should identify when the item was received and the date it should be discarded. -Reach in Freezer #2 a gallon bag of a frozen food item that could not be identified with no date indicating a use by date. -The temperature logs for reach in Freezer #1 and reach in Freezer #2 was missing documentation of the temperatures on 9/28, 9/29, 9/30, and 10/1. -A large, opened box of jars of jelly were on the floor between reach in Freezer #1 and reach in Freezer #2. The DS stated the box of jelly should not have been on the floor because it was considered cross contamination. -Reach in Freezer #3 had one medium metal container with cooked beans loosely covered in foil with no date indicating a use by date. One large metal container was observed with cooking oil with food particles that appeared to be old cooking oil was loosely covered in foil with no date indicating a use by date. The DS stated, I don't know why anybody would put that in the refrigerator. One large zip lock bag was observed with 4 frozen Salisbury steaks, with expiration date 9/15/24. One large zip lock bag with frozen bacon was observed with expiration date 9/18/24. 2. Observation on 10/1/24 at 12:19 p.m. revealed the [NAME] in the kitchen, leaning on the stove, wearing a baseball cap and his goatee which was approximately 1/4 inch in length, was not properly restrained. During an interview on 10/1/24 at 12:25 p.m., the [NAME] stated he realized he was not wearing a hair restraint or a beard cover because he had forgotten. The [NAME] stated he was supposed to wear a hair restraint in case hair falls into the food. Observation during the lunch service on 10/3/24 at 11:32 a.m., revealed the [NAME] was not wearing a beard cover while preparing the lunch trays. Further observation revealed the DS was next to the steam table with the [NAME] and her hair, made up in a braid, was not tucked into the hair restraint. The DS's braid was approximately 3 inches in length. DA C was observed taking the assembled trays from the [NAME] and placed beverages and utensils on the trays. DA C's hair restraint did not cover her head entirely and was observed with approximately 1/4 hair protruding from her temples and behind her neck. During an interview on 10/3/24 at 12:38 p.m., DA C stated she was not aware she had hair sticking out of the hair restraint and stated any hair sticking out of the restraint could end up in the food. During an interview on 10/3/24 at 12:43 p.m., the DS stated, she was not aware her hair was not fully tucked and covered by the hair restraint. The DS stated it was not supposed to be that way because hair could fall into the food and it was considered cross contamination. Record review of the facility policy and procedure titled, Employee Information, undated, revealed in part, .Hair nets or hair restraints must be worn at all times in the kitchen. All hair must be under the hair net. Employees with facial hair must wear beard guards or hair nets to restrain the facial hair at all times in the kitchen . Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 3-305.1, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements: The DS did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: During an interview on 10/1/24 at 2:10 p.m., the DS stated she was in training, was not certified and had registered for the CDM course two weeks ago but had been too busy in the kitchen working as the cook, dietary aide, washing dishes and being the supervisor. The DS stated she did not have an associate's or higher degree in food service management and had not been a dietary manager in a long-term care facility. The DS stated she worked in the facility previously as the cook. During a follow up interview on 10/2/24 at 7:50 a.m., the DS stated she was offered the position of DM late August of 2024 and further stated, as of today I am not actually taking the course for CDM. During an interview on 10/3/24 at 1:34 p.m., the Administrator stated the DM, or the DS had to have certain credentials to be the DM and stated the facility did not have a DM. The Administrator stated she had only been the administrator in the facility for just over a week and was aware the facility did not have a DM and was working on the DS getting certified. During a telephone interview on 10/4/24 at 9:51 a.m., the RD stated he came to the facility on ce a month and had last visited in September 2024. The RD stated he believed the DM was the DS, and she was in control of the meal prep. The RD stated he provided the sanitation report, dining, and the kitchen observation but was not involved in the DS's training or involved in any DM active duties. During an interview on 10/4/24 at 11:01 a.m., the BOM stated she was responsible for hiring and background checks on potential employee new hires. The BOM stated the DS was hired by the facility as a dietary aide on 8/9/24 and assumed the position of DS shortly after that. The BOM stated, the DS did not have the credentials to be considered DM and had not even started the training courses. The BOM stated, when the DM left, the owner of the facility had conversations with the DS about getting her certification but the problems with turnover in the kitchen did not give her any time to get the certification. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meal reviewed for food and nutrition services in that: The facility failed to ensure Resident #1 received a health shake with his lunch meal on 10/3/24. This failure could place residents at risk for dissatisfaction, poor intake, weight loss, and diminished quality of life. The findings included: Record review of Resident #1's face sheet, dated 10/3/24 revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute gastritis (sudden inflammation or swelling of the stomach lining causing acid to irritate and inflame the lining) with bleeding, esophageal obstruction (blockage or narrowing of the esophagus, the tube that carries food and liquids from the mouth to the stomach), heartburn (burning sensation or discomfort in the chest or throat often caused by acid reflux), gastro-esophageal reflux disease (backward flow of stomach acid or contents into the esophagus), abnormal weight loss, and protein-calorie malnutrition (condition caused by a deficiency of both protein and calories in the diet leading to a range of health issues). Record review of Resident #1's most recent annual MDS assessment, dated 7/30/24 revealed the resident was moderately cognitively intact for daily decision-making skills, was diagnosed with malnutrition and received a mechanically altered diet texture. Record review of Resident #1's Physician Order Report, dated 8/1/24 to 10/3/24 revealed the following: -Diet: LCS/Pureed diet/Thin liquids, Special Instructions: HOUSE SHAKES WITH MEALS [DX: Esophageal obstruction] Three Times A Day; 0800 AM, 12:00 PM, 05:00 PM, with order date 8/6/24 and no stop date Record review of Resident #1's comprehensive care plan, with review date 8/27/24 revealed the resident was on a planned weight gain program related to history of significant weight loss and low BMI, with approaches that included to Provide supplements: house shakes with meals and TID. During an observation on 10/3/24 at 11:32 a.m., during the lunch meal, revealed the [NAME] and Dietary Aide C preparing the lunch trays. Dietary Aide C was overheard saying, we just got the shakes delivered this morning, but won't get to serve them at lunch because they are still frozen. During an interview on 10/3/24 at 11:58 a.m., Dietary Aide C revealed, Resident #1 would be getting two cartons of milk and a serving of apple sauce instead of the milk shakes he was supposed to get because they ran out of milk shakes last night. Dietary Aide C further stated the shipment of milk shakes were delivered to the facility earlier that morning but would not be served because they were frozen. During an observation and interview on 10/3/24 at 12:15 p.m., revealed Resident #1 sitting up in bed eating his lunch and there were no milk shakes on the tray. Resident #1's meal ticket revealed he received a regular, pureed diet and supplements that included 1 carton of vanilla milk shake, and a note that stated, HOUSE SHAKE WITH EVERY MEAL. Further review of the meal ticket revealed 2 milk was handwritten with a black marker. Resident #1 stated he did not get a house shake, they ain't got none. The last time I got a shake maybe day before last. They're out of shakes and I get 2 with every meal. During an interview on 10/3/24 at 12:43 p.m., the DS stated Resident #1 always asked for 2 milk shakes and 2 milks. The DS stated, We can give him an extra milk and at dinner he will be served his house shake. The DS stated the facility received a delivery earlier that morning that included the house shakes but because they were delivered frozen, they were not served to the resident at lunch, but he will get it at dinner because it should be thawed by then. The DS stated the facility ran out of house shakes the night before and was not served during dinner. During an interview on 10/3/24 at 1:31 p.m., LVN D revealed she had checked Resident #1's lunch tray and was aware the resident was supposed to receive a house shake with meals, but confirmed the resident received a carton of milk instead. LVN D stated since the resident did not have a milk shake on the lunch tray when she checked it, she assumed the kitchen didn't have any, so I didn't ask them. LVN D stated, I wouldn't call the doctor about getting a substitution for the milk shake, that would be up to the kitchen staff. During an interview on 10/3/24 at 1:45 p.m., the DON revealed Resident #1 had a physician's order for a house shake with every meal. The DON further stated the kitchen staff could offer an alternative, but it was ultimately up to the physician to order a substitute if the resident did not receive it because it was not available, then the doctor should have been notified. Record review of the facility policy and procedure titled, Food Preparation and Food Service, undated, revealed in part, .The primary purpose of the dietary department of this facility is to prepare and serve meals in a way to ensure that the food and nutrition service is operating in a safe, sanitary and efficient matter. The menus are prepared in accordance with the physician's orders and to meet the Recommended Dietary Allowance of the Food and Nutrition Board, National Research Council .

Based on interviews, and record reviews the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 residents (Resident #1) reviewed in that: CNA A failed to follow the plan of care which required a 2 person assist to transfer Resident #1 with the Hoyer Lift (a mechanical lift that uses a sling attached to a hoist to transfer a person from a bed to a wheelchair) on 03/23/24. This failure resulted in the identification of Immediate Jeopardy (IJ) on 3/23/24 at 6:53 p.m. While the immediacy was removed on 3/28/24 at 3:42 p.m., the facility remained out of compliance at scope of isolated and a severity with actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure placed residents at the facility who required the mechanical lift for transfers at risk for pain or injuries. Findings included: Record review of Resident #1's undated face sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes (sustained high blood sugar levels and can increase risk of damage to eyes, nerves, heart and cause delayed wound healing), morbid obesity (severe form of excess body weight), contracture of the left knee (gradual shortening of muscles, tendons, and skin that causes the joints to shorten and prevent normal movement), hemiplegia (paralysis of one side of the body) and high blood pressure. Record review of Resident #1's electronic physician's orders revealed an order for ADL - transfer by 2 staff with mechanical lift, with a start date of 09/09/23. Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 11 out of 15 which indicated his cognitive skills for daily decision making were moderately impaired; he had functional limitation in range of motion on 1 side of his upper and lower extremities (legs and arms), used a wheelchair, and was dependent on staff assistance of 2 or more helpers with transfer from chair/bed-to-chair. Record review of Resident #1's Care Plan for the problem of Alteration in ADL self-performance and mobility related to weakness, left sided hemiparesis, contractures to left upper extremity, revealed under Approaches with a start date of 11/09/22 was Requires assist x 2 staff with Hoyer [mechanical lift] with transfer tasks. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:00 PM by LVN B revealed Called to resident room - upon entry resident sitting up in wheelchair alert awake and active forgetful and anxious - CNA A reports resident had light on and asked to put him up for dining-he asked to move to the chair for dinner - she informed him she would go find someone to help - was unable to find assistance - was then transferring resident to wheelchair using Hoyer [mechanical] lift and while put him in wheelchair the back of the wheelchair . reclined quickly and then CNA C came into the room at about 3:30 PM and saw he was in chair. Resident says he fell on the floor while being transferred to wheelchair - resident says he was put in sling and CNA A went to get some help - came back and was trying to put him in wheelchair when he fell to floor - denies pain or loc [loss of consciousness] at this time. Record review of a handwritten, signed statement from CNA A, dated 3/23/24, revealed Resident #1 hes [sic] call light was on. He asked to put him up for dining he asked to move to the chair for dinner. I told him I was going to go find someone. I couldn't find anyone. I went to move him to the chair, his chair reclined back. He did fall. He was placed in the chair. CNA C walked in about 3:35 PM and saw he was in his chair. Record review of a handwritten, signed statement from CNA C, dated 3/24/24, revealed March 23, 2024 about 3-4 PM I heard CNA A's voice. I went to room check if she needed any help only to find she was attempting to transfer Resident #1 to his chair alone, she already had him over his chair but the back of the chair was reclined to [sic] far. I guided him so he was placed in the chair . In an interview on 03/25/24 at 10:33 AM, Resident #1 stated on 3/23/24, around 4 PM, CNA A came into his room to transfer him from his bed to his wheelchair per the resident's request. Resident #1 said CNA A placed the mechanical lift sling underneath him, then she told Resident #1 that he might have to help her because the other CNAs were working. Resident #1 stated he asked CNA A if she could wait until the other aides finished their work to assist her. Resident #1 said CNA A left the room and came back about five minutes later, said she could not find anyone and moved the mechanical lift over to the bed, attached the lift sling that was under him, grabbed the lift remote control and asked Resident #1 if he was ready. Resident #1 stated he responded, Yes, I'm ready, just don't drop me on the floor. Resident #1 stated when CNA A moved him from his bed to the wheelchair with the mechanical lift by herself, she could not bring him to the chair, and he fell . Resident #1 stated another CNA (CNA C) came into the room, and assisted CNA A. In an interview on 03/25/24 at 2:53 PM, CNA C stated on 3/23/24 when she entered Resident #1's room, the back part of his chair had reclined back all the way, and he was a bit crooked in the chair, holding onto the right arm rest with his right arm and Resident #1 stated he fell . CNA C said she asked CNA A why she was doing it by herself, and CNA A said she could not find anyone to help her. CNA C said she assisted CNA A with positioning Resident #1 in his chair correctly, the sling that was under him was crooked, so they fixed the sling, sat him upright, unhooked the straps of the lift sling from the mechanical lift. In a telephone interview on 03/25/24 at 4:38 PM to 4:54 PM, CNA A stated when the mechanical lift was used to move a resident there must be 2 employees present to operate the lift and there could be a lot of damage to the resident if one person transferred a resident by themselves with the lift. CNA A stated she was the shower aide but on 3/23/24 she was working as a CNA and there were 3 other CNAs for a total of 4 CNAs. CNA A stated on 3/23/24 was the first time she cared for Resident #1, but she was aware the aides would use a mechanical lift with the assistance of two staff to move Resident #1. CNA A stated on 3/23/24 Resident #1 insisted on getting out of bed into his chair. CNA A said she told Resident #1 to wait while she went to find assistance. CNA A stated she could not find anyone and came back into Resident #1's room and Resident #1 insisted that he be moved from the bed to his chair. CNA A stated she moved Resident #1 into his wheelchair with the mechanical lift by herself and as she placed him into his wheelchair, the back of the chair reclined, and he got scared. CNA A said Resident #1 stated that he fell but she told him he did not fall, his chair just reclined back. CNA A said then another CNA (CNA C) came into the room, saw Resident #1 in the chair, together they repositioned the resident in his wheelchair. CNA A stated the reason why she did the transfer by herself was because she could not find anyone else to assist her. In an interview on 03/27/24 at 10:50 AM, LVN B stated on 03/23/24 around 4 PM CNA C told her to go see Resident #1. LVN B said when she entered Resident #1's room, he was in his wheelchair and told her he fell when CNA A dropped him to the floor. LVN B stated CNA A then entered the room and said she was getting him ready to take him to the dining room, Resident #1 was in his bed, and she (CNA A) transferred him to his wheelchair with the mechanical lift. CNA A told LVN B the back of Resident #1's wheelchair reclined abruptly, and Resident #1 said his foot hurt; then CNA C walked into the room and assisted CNA A with repositioning Resident #1 into his wheelchair. LVN B said CNA A denied Resident #1 fell to the floor. LVN B stated she expects CNAs to always have 2 people transferring a resident with a mechanical lift and if they cannot find another person, the CNA should wait until they can get assistance. LVN B said a resident could fall, get injured or die because of being transferred with a mechanical lift that was done by only one person. LVN B stated it was important to follow a resident's plan of care because the care plan specifically addressed the resident's needs. In an interview on 03/27/24 at 2:00 PM, RN D stated the DON was on leave, she was the DON Designee in her absence and had worked in the facility for less than one month. RN D stated staff were expected to have 2 CNAs or nurses in the room when they transfer a resident with the mechanical lift, and they should not do the transfer until 2 people are present. RN D stated the harm of transferring a resident with only 1 person operating a mechanical lift instead of 2 people could cause falls, serious injuries, head injuries, broken bones or cause psychological harm. In an interview on 03/25/24 at 6:43 PM, the Assistant Administrator stated the risk of 1 person transferring a resident with a mechanical lift instead of 2 people could result in the resident falling, slipping out of the sling, or a plethora of things could happen. The Assistant Administrator stated CNA A told him she was not able to find anyone right away to assist her, the resident was getting impatient, and she did it right away by herself instead of waiting for assistance. In an interview on 3/25/24 at 3:40 PM, RN D stated an in-service had been completed on use of a mechanical lift in January 2023 and she could not find any other in-service trainings on use of a mechanical lift. Record review of an Employee In-Service Attendance Record, dated 01/15/24, revealed CNA A was in-serviced on mechanical lift transfers. Record review of the facility's policy Safe Lifting and Movement of Residents, revised July 2017, revealed In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Record review of the facility's policy Care Planning - Interdisciplinary Team, revised September 2013, revealed Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident .2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team . This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 6:53 PM. The facility Assistant Administrator was notified. The Assistant Administrator was provided with the IJ template on 03/25/24 at 6:53 PM. On 03/26/24 the facility provided a plan of removal titled: Plan of Removal. The plan of removal was accepted on 03/26/2024 at 7:49 PM. It is documented as follows: Plan of Removal Problem: Failure to prevent accidents allegation Interventions: -CNA A was suspended, and terminated as of 03/26/24 -In the course of investigation, it was reported that CNA A stated Resident #1's foot hit the floor hard. A written statement from CNA A contradicted this, and there was no mention of resident hitting his foot on the floor. -CNA A also admitted that she transferred Resident #1 with no assistance, which is against company policies and procedures -In-service nursing staff on Mechanical Lift Transfer with two staff members at all times, starting on 3/24/24. New in-servicing regarding proper sling placement, and the wear and tear of a sling, as well as the steps to be taken if no other staff members are available at the time of transfer, will begin on 3/26/24. Staff not present on 03/25/24 will be in-serviced prior to attempting to transfer a resident with a mechanical lift. -Abuse and neglect in-service for all staff started on 03/24/24 -Inspection of all lift slings, with removal from service any sling that is frayed or torn, will be conducted on 03/26/24. -Maintenance supervisor to visually inspect both mechanical lifts to ensure that they are in proper working order, and that there is no damage that would prevent the safety of patient transfers Monitoring -The DON and/or Designee will monitor at least 5 lift transfers per week, observing for proper technique and staff assistance, and maintain a running log of said transfers. -The DON/Designee will observe and log that all slings are in good working order at least once a week -The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed The facility's POR Verification was as follows: In an interview on 03/27/24 at 2:30 PM, the Assistant Administrator stated CNA A was terminated from employment on 3/26/24. In an interview on 03/27/24 at 2:00 PM, the DON Designee, RN D, said she had a list of two employees who had not received the education and would not schedule them to work until they received the in-service training. In an interview on 03/27/24 at 3:00 PM, the Assistant Administrator stated the DON Designee had identified employees who had not received education at that time and the employees were not scheduled to work until they have received the education. The Assistant Administrator stated the facility had a QAPI meeting on 03/27/24 and discussed the findings of the deficient practice and the plan of removal. The Administrator said the findings of the audits would be brought to the monthly QAPI meetings and reviewed. He stated the information would be used to determine if the interventions in place were effective or if they need to make changes to their systems. In an interview on 3/27/24 at 3:05 PM, the Maintenance Director stated he inspected both mechanical lifts on 3/26/24 and the lifts were functioning properly. He stated the mechanical lifts were inspected weekly and kept an inspection log in a binder and if there was a concern with a mechanical lift, it would be removed from service and be repaired and notify the DON and the Assistant Administrator. In a group interview on 03/28/24 at 11:15 AM with the Assistant Administrator and the DON Designee, RN D stated an audit log was created to document observations of mechanical lift transfers. RN D stated she or the DON would observe 5 mechanical lift transfers weekly; and two observations were completed on 3/27/24 at 4:45 PM and on 3/28/24 at 8:30 AM. RN D stated there were no concerns with the mechanical lift, technique used by staff or the sling that was used for the transfer. RN D stated she observed the mechanical lift slings used during the transfer and the slings were in good condition. The Administrator stated the log would be reviewed and facility would track the findings and use the information to determine if further education was needed or if staff performed the transfers correctly. The Assistant Administrator stated the audit information would be brought to QAPI meeting monthly and the information would be reviewed to determine effectiveness and if changes needed to be made to the system, policy, or procedure. The Assistant Administrator stated the Housekeeping Supervisor completed a sling audit on 03/27/24 at 4 PM that revealed 9 slings in use were in good working condition. He stated the slings will be observed weekly by the Housekeeping Supervisor and would be recorded on the audit log. He stated any slings with holes, tears or frays would be removed from service. He stated the audit information will be reviewed and used to track the condition of the sling supply and determine when new slings should be purchased. In an interview on 03/28/24 at 1:35 PM, the housekeeping Supervisor stated she completed the sling audit on 03/27/24, there were 9 slings in use, and they were in good condition. She stated if a sling was found with worn, torn, or frayed material she would remove it from service, log the information on the audit log and place an order to replace the sling. Interviews with 23 of 29 direct care staff from different shifts was completed on 03/27/24 and 03/28/24 which consisted of 13 direct care staff from day shift (6 AM-6 PM) and 10 direct care staff from night shift (6 PM-6 AM). All 23 staff members reported there were educated and trained on the use of mechanical lifts. Interviews on 03/27/24 and 03/28/24 with 50 of 66 facility staff from different shifts revealed staff have received education on abuse and neglect. Observations on 03/27/24 and 03/28/24 of resident and staff interactions revealed no signs of abuse or neglect. Observations on 03/26/24 of 5 resident slings and on 03/27/24 of 4 resident slings revealed no holes, tears, or frays on the slings. Record Review of CNA A's termination paperwork dated 3/26/24 revealed she was terminated on 03/26/24 for operating a mechanical lift without 2 people; the document was signed by the Assistant Administrator, and he noted CNA A refused to sign the document. Record review of education sign in sheet, dated 03/24/24, revealed 48 staff received education on proper techniques of a mechanical lift transfer which always included the use of 2 persons for mechanical lift transfers. Record review of education sign in sheet, dated 03/26/24, revealed 66 staff received education on using 2 people to perform a safe mechanical lift transfer. Record review of education sign in sheet, dated 03/26/24, revealed 66 staff received education on reporting incidents of abuse and neglect immediately to the Assistant Administrator, DON, and Charge Nurse. Record Review of the facility sling audit tool dated 03/27/24 revealed documentation 9 slings were in use and in good condition. Record Review of an inspection check off list completed on 3/26/24 for two facility mechanical lifts showed no concerns with the mechanical lifts. Record review of an audit form reflecting a mechanical lift observation was done on 03/27/2024 at 4:45 PM by CNA G and CNA H, who performed a mechanical lift of a resident revealed no concerns were noted. Record Review of the QAPI meeting Sign-in Sheet revealed a QAPI meeting was held on 03/26/24 at 8:30 AM and in attendance was the Administrator, Medical Director, RN Designee-RN D, Director of Marketing, Director of Rehab and 9 other department managers. On 03/28/24 at 3:42 PM, the Assistant Administrator was notified the immediacy was lifted on 03/28/24 at 3:42 PM but the facility remained out of compliance at scope of isolated and a severity with actual harm due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, and supervision in that: CNA A failed to follow Resident #1's physician order and plan of care which required a 2-person assist to transfer Resident #1 with a Mechanical Lift (a mechanical lift with a sling attached to a hoist to transfer a person from a bed to a wheelchair) on 03/23/24, which resulted in the back of Resident #1's wheelchair to recline as he was placed in it and caused an injury to his right foot when his foot hit the floor. Resident #1 was transferred to a local hospital and was diagnosed with a fracture of the right 5th metatarsal bone (break in the little toe). This failure resulted in the identification of Immediate Jeopardy (IJ) on 3/23/24 at 6:53 p.m. While the immediacy was removed on 3/28/24 at 3:42 p.m., the facility remained out of compliance at scope of isolated and a severity with actual harm due to the facility's need to monitor the implementation of the plan of removal. The failure placed residents at the facility who required the mechanical lift for transfers at risk for pain or serious injuries. Findings included: Record review of Resident #1's undated face sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included diabetes (sustained high blood sugar levels and can increase risk of damage to eyes, nerves, heart and cause delayed wound healing), morbid obesity (severe form of excess body weight), contracture of the left knee (gradual shortening of muscles, tendons, and skin that causes the joints to shorten and prevent normal movement), hemiplegia (paralysis of one side of the body) and high blood pressure. Record review of Resident #1's electronic physician's orders revealed an order for ADL - transfer by 2 staff with mechanical lift, with a start date of 09/09/23. Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 11 out of 15 which indicated his cognitive skills for daily decision making were moderately impaired; he had functional limitation in range of motion on 1 side of his upper and lower extremities (legs and arms), used a wheelchair, and was dependent on staff assistance of 2 or more helpers with transfer from chair/bed-to-chair. Record review of Resident #1's Care Plan for the problem of Alteration in ADL self-performance and mobility related to weakness, left sided hemiparesis, contractures to left upper extremity, revealed under Approaches with a start date of 11/09/22 was Requires assist x 2 staff with Hoyer (mechanical lift] with transfer tasks. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:00 PM by LVN B revealed Called to resident room - upon entry resident sitting up in wheelchair alert awake and active forgetful and anxious - CNA A reports resident had light on and asked to put him up for dining-he asked to move to the chair for dinner - she informed him she would go find someone to help - was unable to find assistance - was then transferring resident to wheelchair using Hoyer [mechanical] lift and while put him in wheelchair the back of the wheelchair . reclined quickly and then CNA C came into the room at about 3:30 PM and saw he was in chair. Resident says he fell on the floor while being transferred to wheelchair - resident says he was put in sling and CNA A went to get some help - came back and was trying to put him in wheelchair when he fell to floor - denies pain or loc [loss of consciousness] at this time. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:10 PM by LVN B revealed Resident now begins to c/o [complain of] pain to outer right foot - small bump to area palpated with c/o pain - no discoloration noted - foot is warm/dry - capillary refill [assessment done to determine blood flow to the toes/fingers] less than three seconds pedal [foot] pulse present - this writer asked if his body hurt in any way and he now begins to c/o some back pain. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:16 PM by LVN B revealed contact made with RN D - informed her of occurrence she and I [LVN B] connect via phone with Assistant Administrator and notified him of the occurrence. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:25 PM by LVN B revealed Resident #1's family member contacted informed her - verbalizes understanding. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:29 PM by LVN B revealed physician made aware, order to send to ER to eval and treat. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:40 PM by LVN B revealed report called to nurse at Hospital E's emergency room , 911 called pending arrival. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 4:42 PM by LVN B revealed neuro checks [special assessment done to determine if there is injury to the brain or nervous system] initiated - Resident #1 remains alert awake and active continues to c/o slight pain to back and to outer right foot - denies loc - no change in neuro status noted pending EMS to arrive. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 5:00 PM by LVN B revealed no change in neuro status is alert awake and active forgetful and confused at times .continues to c/o slight pain to right outer foot and to back will continue to monitor. EMS here - patient report and patient care turned over. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 9:15 PM by LVN F revealed received report from nurse at Hospital E's emergency room , Resident #1 ready to be discharged back to facility .diagnoses: right foot sprain, contusion [bruising] to lower back, fracture of 5th metatarsal [little toe] bone .Assistant Administrator notified, RN D/Weekend Supervisor notified of above. Record review of Resident #1's Nurse's Note, dated 3/23/24 at 9:30 PM by LVN F revealed resident returned to facility via EMS accompanied by 2 EMTs, x3 assist to transfer resident back to bed, and made comfortable - Resident #1 c/o back pain administered, pain medication was administered at ER prior to leaving, discoloration noted to right lower extremity [lower leg], resident wearing post-op shoe, no physical sign of distress noted . Record review of Resident #1's Hospital E's emergency room Patient Visit Information sheet, dated 3/23/24, revealed he was seen for contusion of lower back, right foot sprain, and fracture of right fifth metatarsal bone and discharge instructions were sent for the foot fracture. Record review of Resident #1's Hospital E's emergency room Discharge Instructions for Foot Fracture, dated 3/23/24, revealed A foot fracture is a break in any of the 26 bones in the foot. It may take 3 to 10 weeks to heal . Record review of Resident #1's Event [Incident] Report dated 3/23/24 revealed the resident had a fall in his room, complained of pain to his back and outer right foot, resident was sent to the ER for evaluation and treatment, the physician was notified on 3/23/24 at 4:29 PM and gave order to send to ER to evaluate and treat, Resident #1's family member was notified and would meet Resident #1 at the ER. Record review of a handwritten, signed statement from CNA A, dated 3/23/24, revealed Resident #1 hes [sic] call light was on. He asked to put him up for dining he asked to move to the chair for dinner. I told him I was going to go find someone. I couldn't find anyone. I went to move him to the chair, his chair reclined back. He did fall. He was placed in the chair. CNA C walked in about 3:35 PM and saw he was in his chair. Record review of a handwritten, signed statement from CNA C, dated 3/24/24, revealed March 23, 2024 about 3-4 PM I heard CNA A's voice. I went to room check if she needed any help only to find she was attempting to transfer Resident #1 to his chair alone, she already had him over his chair but the back of the chair was reclined to [sic] far. I guided him so he was placed in the chair but he was not correct. As we adjusted him, he stated to me that 'he fell '. I asked him what he meant, and he stated that he fell to the floor. CNA A said 'no' that as she placed him to the chair, that the back dropped as she lowered him, he got scared but he never fell to the floor. He then stated that his right foot hurt I asked what part? He said the outside his toe's. I asked why? He said he hit something when she was transferring him. I told him not to worry we will figure it out. They both told the story until CNA A left the room. Then I asked again if anything hurt he said just his foot. I asked did you drop to the floor. He said 'yes', he was on the floor. I told him to give me a minute that I had to talk to LVN B about what to do next. In an interview on 03/25/24 at 10:33 AM, Resident #1 stated on 3/23/24, around 4 PM, CNA A came into his room to transfer him from his bed to his wheelchair per the resident's request. Resident #1 said CNA A placed the mechanical lift sling underneath him, then she told Resident #1 that he might have to help her because the other CNAs were working. Resident #1 stated he asked CNA A if she could wait until the other aides finished their work to assist her. Resident #1 said CNA A left the room and came back about five minutes later, said she could not find anyone and moved the mechanical lift over to the bed, attached the lift sling that was under him, grabbed the lift remote control and asked Resident #1 if he was ready. Resident #1 stated he responded, Yes, I'm ready, just don't drop me on the floor. Resident #1 stated when CNA A moved him from his bed to the wheelchair with the mechanical lift by herself, she could not bring him to the chair, and he fell . Resident #1 stated another CNA (CNA C) came into the room, asked him if anything hurt and he told her his back and his right foot hurt. Resident #1 stated LVN B came into the room and asked him if he was alright, and he told her his back and his right foot hurt. Resident #1 stated LVN B came back into the room, told him she called his family member to let her know he fell , and his family member was going to meet him at the hospital. Resident #1 stated then the ambulance came and took him to the hospital, and he did not return from the hospital until after 10 PM because the hospital needed the x-ray results. Resident #1 stated he did get out of bed yesterday (3/24/24) and today (3/25/24) he was still a little bit sore, his right foot still hurt, and he received Tylenol for his foot pain which helped. In an interview on 03/25/24 at 2:53 PM, CNA C stated on 3/23/24 when she entered Resident #1's room, the back part of his chair had reclined back all the way, and he was a bit crooked in the chair, holding onto the right arm rest with his right arm and Resident #1 stated he fell . CNA C said she asked CNA A why she was doing it by herself, and CNA A said she could not find anyone to help her. CNA C said she assisted CNA A with positioning Resident #1 in his chair correctly, the sling that was under him was crooked, so they fixed the sling, sat him upright, unhooked the straps of the lift sling from the mechanical lift. CNA C stated when the sling was removed from the lift, Resident #1 stated to her again that he fell . CNA C said she asked Resident #1 what he meant, and the resident said he fell . CNA A told CNA C that Resident #1 did not fall but the back of the chair reclined back and stated again that Resident #1 did not fall. CNA C said Resident #1 told her his foot hurt, so she reassured him, and left the room to notify LVN B of the situation. CNA C stated as LVN B assessed Resident #1 told LVN B the same story of what happened. In a telephone interview on 03/25/24 at 4:38 PM to 4:54 PM, CNA A stated when the mechanical lift was used to move a resident there must be 2 employees present to operate the lift and there could be a lot of damage to the resident if one person transferred a resident by themselves with the lift. CNA A stated she was the shower aide but on 3/23/24 she was working as a CNA and there were 3 other CNAs for a total of 4 CNAs. CNA A stated on 3/23/24 was the first time she cared for Resident #1, but she was aware the aides would use a mechanical lift with the assistance of two staff to move Resident #1. CNA A stated on 3/23/24 Resident #1 insisted on getting out of bed into his chair. CNA A said she told Resident #1 to wait while she went to find assistance. CNA A stated she could not find anyone and came back into Resident #1's room and Resident #1 insisted that he be moved from the bed to his chair. CNA A stated she moved Resident #1 into his wheelchair with the mechanical lift by herself and as she placed him into his wheelchair, the back of the chair reclined, and he got scared. CNA A said Resident #1 stated that he fell but she told him he did not fall, his chair just reclined back. CNA A said then another CNA (CNA C) came into the room, saw Resident #1 in the chair, together they repositioned the resident in his wheelchair and Resident #1 complained that his foot hurt so the nurse was informed who assessed the resident. CNA A stated when the wheelchair back reclined back, Resident #1's foot hit the floor hard. She stated the reason why she did the transfer by herself was because she could not find anyone else to assist her. CNA A stated she received verbal training on how to use the mechanical lift about a month ago and was not in-serviced on 3/23/24 or on 3/24/24 on use of the mechanical lift. In an interview on 03/27/24 at 10:50 AM, LVN B stated on 03/23/24 around 4 PM CNA C told her to go see Resident #1. LVN B said when she entered Resident #1's room, he was in his wheelchair and told her he fell when CNA A dropped him to the floor. LVN B stated CNA A then entered the room and said she was getting him ready to take him to the dining room, Resident #1 was in his bed, and she (CNA A) transferred him to his wheelchair with the mechanical lift. CNA A told LVN B the back of Resident #1's wheelchair reclined abruptly, and the Resident #1 said his foot hurt; then CNA C walked into the room and assisted CNA A with repositioning Resident #1 into his wheelchair. LVN B said CNA A denied Resident #1 fell to the floor. LVN B stated she assessed Resident #1, felt his foot, and felt a bump on his foot which the resident stated he had a lot of pain, and when she assessed his back Resident #1 stated it hurt. LVN B said she notified the RN on duty (RN D), the Assistant Administrator and Resident #1's physician who gave orders to send the resident to the hospital. LVN B stated she expects CNAs to always have 2 people transferring a resident with a mechanical lift and if they cannot find another person, the CNA should wait until they can get assistance. LVN B said a resident could fall, get injured or die because of being transferred with a mechanical lift that was done by only one person. In an interview on 03/27/24 at 2:00 PM, RN D stated the DON was on leave, she was the DON Designee in her absence and had worked in the facility for less than one month. RN D stated staff were expected to have 2 CNAs or nurses in the room when they transfer a resident with the mechanical lift, and they should not do the transfer until 2 people are present. RN D stated the harm of transferring a resident with only 1 person operating a mechanical lift instead of 2 people could cause falls, serious injuries, head injuries, broken bones or cause psychological harm. In an interview on 03/25/24 at 6:43 PM, the Assistant Administrator stated the risk of 1 person transferring a resident with a mechanical lift instead of 2 people could result in the resident falling, slipping out of the sling, or a plethora of things could happen. The Assistant Administrator stated CNA A told him she was not able to find anyone right away to assist her, the resident was getting impatient, and she did it right away by herself instead of waiting for assistance. In an interview on 3/25/24 at 3:40 PM, RN D stated an in-service had been completed on use of a mechanical lift in January 2024 and she could not find any other in-service trainings on use of a mechanical lift. Record review of an Employee In-Service Attendance Record, dated 01/15/24, revealed CNA A was in-serviced on mechanical lift transfers. Record review of the facility's policy on Safe Lifting and Movement of Residents, revised July 2017, revealed In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 6:53 PM. The facility Assistant Administrator was notified. The Assistant Administrator was provided with the IJ template on 03/25/24 at 6:53 PM. On 03/26/24 the facility provided a plan of removal titled: Plan of Removal. The plan of removal was accepted on 03/26/2024 at 7:49 PM. It is documented as follows: Plan of Removal Problem: F689 Failure to prevent accidents allegation Interventions: -CNA A was suspended, and terminated as of 03/26/24 -In the course of investigation, it was reported that CNA A stated Resident #1's foot hit the floor hard. A written statement from CNA A contradicted this, and there was no mention of resident hitting his foot on the floor. -CNA A also admitted that she transferred Resident #1 with no assistance, which is against company policies and procedures -In-service nursing staff on Mechanical Lift Transfer with two staff members at all times, starting on 3/24/24. New in-servicing regarding proper sling placement, and the wear and tear of a sling, as well as the steps to be taken if no other staff members are available at the time of transfer, will begin on 3/26/24. Staff not present on 03/25/24 will be in-serviced prior to attempting to transfer a resident with a mechanical lift. -Abuse and neglect in-service for all staff started on 03/24/24 -Inspection of all lift slings, with removal from service any sling that is frayed or torn, will be conducted on 03/26/24. -Maintenance supervisor to visually inspect both mechanical lifts to ensure that they are in proper working order, and that there is no damage that would prevent the safety of patient transfers Monitoring -The DON and/or Designee will monitor at least 5 lift transfers per week, observing for proper technique and staff assistance, and maintain a running log of said transfers. -The DON/Designee will observe and log that all slings are in good working order at least once a week -The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed The facility's POR Verification was as follows: In an interview on 03/27/24 at 2:30 PM, the Assistant Administrator stated CNA A was terminated from employment on 3/26/24. In an interview on 03/27/24 at 2:00 PM, the DON Designee, RN D, said she had a list of two employees who had not received the education and would not schedule them to work until they received the in-service training. In an interview on 03/27/24 at 3:00 PM, the Assistant Administrator stated the DON Designee had identified employees who had not received education at that time and the employees were not scheduled to work until they have received the education. The Assistant Administrator stated the facility had a QAPI meeting on 03/27/24 and discussed the findings of the deficient practice and the plan of removal. The Administrator said the findings of the audits would be brought to the monthly QAPI meetings and reviewed. He stated the information would be used to determine if the interventions in place were effective or if they need to make changes to their systems. In an interview on 3/27/24 at 3:05 PM, the Maintenance Director stated he inspected both mechanical lifts on 3/26/24 and the lifts were functioning properly. He stated the mechanical lifts were inspected weekly and kept an inspection log in a binder and if there was a concern with a mechanical lift, it would be removed from service and be repaired and notify the DON and the Assistant Administrator. In a group interview on 03/28/24 at 11:15 AM with the Assistant Administrator and the DON Designee, RN D stated an audit log was created to document observations of mechanical lift transfers. RN D stated she or the DON would observe 5 mechanical lift transfers weekly; and two observations were completed on 3/27/24 at 4:45 PM and on 3/28/24 at 8:30 AM. RN D stated there were no concerns with the mechanical lift, technique used by staff or the sling that was used for the transfer. RN D stated she observed the mechanical lift slings used during the transfer and the slings were in good condition. The Administrator stated the log would be reviewed and facility would track the findings and use the information to determine if further education was needed or if staff performed the transfers correctly. The Assistant Administrator stated the audit information would be brought to QAPI meeting monthly and the information would be reviewed to determine effectiveness and if changes needed to be made to the system, policy, or procedure. The Assistant Administrator stated the Housekeeping Supervisor completed a sling audit on 03/27/24 at 4 PM that revealed 9 slings in use were in good working condition. He stated the slings will be observed weekly by the Housekeeping Supervisor and would be recorded on the audit log. He stated any slings with holes, tears or frays would be removed from service. He stated the audit information will be reviewed and used to track the condition of the sling supply and determine when new slings should be purchased. In an interview on 03/28/24 at 1:35 PM, the housekeeping Supervisor stated she completed the sling audit on 03/27/24, there were 9 slings in use, and they were in good condition. She stated if a sling was found with worn, torn, or frayed material she would remove it from service, log the information on the audit log and place an order to replace the sling. Interviews with 23 of 29 direct care staff from different shifts was completed on 03/27/24 and 03/28/24 which consisted of 13 direct care staff from day shift (6 AM-6 PM) and 10 direct care staff from night shift (6 PM-6 AM). All 23 staff members reported there were educated and trained on the use of mechanical lifts. Interviews on 03/27/24 and 03/28/24 with 50 of 66 facility staff from different shifts revealed staff have received education on abuse and neglect. Observations on 03/27/24 and 03/28/24 of resident and staff interactions revealed no signs of abuse or neglect. Observations on 03/26/24 of 5 resident slings and on 03/27/24 of 4 resident slings revealed no holes, tears, or frays on the slings. Record Review of CNA A's termination paperwork dated 3/26/24 revealed she was terminated on 03/26/24 for operating a mechanical lift without 2 people; the document was signed by the Assistant Administrator, and he noted CNA A refused to sign the document. Record review of education sign in sheet, dated 03/24/24, revealed 48 staff received education on proper techniques of a mechanical lift transfer which always included the use of 2 persons for mechanical lift transfers. Record review of education sign in sheet, dated 03/26/24, revealed 66 staff received education on using 2 people to perform a safe mechanical lift transfer. Record review of education sign in sheet, dated 03/26/24, revealed 66 staff received education on reporting incidents of abuse and neglect immediately to the Assistant Administrator, DON, and Charge Nurse. Record Review of the facility sling audit tool dated 03/27/24 revealed documentation 9 slings were in use and in good condition. Record Review of an inspection check off list completed on 3/26/24 for two facility mechanical lifts showed no concerns with the mechanical lifts. Record review of an audit form reflecting a mechanical lift observation was done on 03/27/2024 at 4:45 PM by CNA G and CNA H, who performed a mechanical lift of a resident revealed no concerns were noted. Record Review of the QAPI meeting Sign-in Sheet revealed a QAPI meeting was held on 03/26/24 at 8:30 AM and in attendance was the Administrator, Medical Director, RN Designee-RN D, Director of Marketing, Director of Rehab and 9 other department managers. On 03/28/24 at 3:42 PM, the Assistant Administrator was notified the immediacy was lifted on 03/28/24 at 3:42 PM but the facility remained out of compliance at scope of isolated and a severity with actual harm due to the facility's need to monitor the implementation and effectiveness of its POR.

Based on interviews and record reviews the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 2 of 18 residents (Residents #14 and #23) reviewed for physician notification of changes. 1 . The facility failed to inform Resident #14's physician when Resident #14 made sexual lewd comments towards female residents and entered Resident #23's shower room while she was showering on 02/06/2024 and again on 03/12/2024 and unsuccessfully attempted to enter Resident #23's shower room on 02/15/2024. 2. The facility failed to inform Resident #23's physician when Resident #14 entered Resident #23's shower room while she was showering on 02/06/2024, again on 03/12/2024, and unsuccessfully attempted to enter Resident #23's shower room on 02/15/2024. An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions. This failure denied residents and their physicians accurate and timely assessments so the physician could intervene with care. The findings included : 1. A record review of Resident #14's admission record dated 03/14/2024, revealed an admitted [DATE] with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. Resident #14's admission record revealed Resident #14 had two representatives. A record review of Resident #14' quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment . A record review of Resident #14's care plan dated 03/14/2024 revealed, Resident has episodes of inappropriate behaviors AEB (As Evidenced By) disrobes in public areas, sexual innuendos/gestures .Problem Start Date: 06/26/2023 . Behavioral episodes will be reduced to less than daily over the next 90 days . Monitor and chart behaviors and report to MD . A record review of Resident #14's nursing progress notes revealed LVN A documented on 06/07/2023, Resident urinated in shower room. Redirected resident to room and told resident that was not appropriate. Resident resting in bed . we'll continue to monitor. A record review of Resident #14's nursing progress notes revealed the DON documented on 08/18/2023, Resident sitting in dining room having non-alcoholic beverage. Activity director states that he was having a behavior issue earlier. He kept signaling to female resident to go to shower with him to shower . asked him to stop, he replied she wants to. Resident was redirected and asked to stop behavior . A record review of Resident #14's nursing progress note dated 08/28/2023 revealed LVN A documented, . resident had sexual behaviors this evening was blowing kisses and saying I love you to this writer when providing care - when resident started rubbing his private area through shorts, he was told that was inappropriate and this writer lowered the bed, close the curtain, and stepped out of room. call light within reach. A record review of Resident #14's nursing progress note dated 09/19/2023 revealed LVN AA documented, resident is showing sexual behaviors with aides, continues to tell aides to touch him down there, stating that he likes it, and throws kisses, blinking his eye. A record review of Resident #14's nursing progress note dated 02/06/2024 revealed LVN A documented, this writer was paged to station 1 where this resident was standing in the middle of the shower room while there was already a female resident using it (Resident #23). This resident refused to leave the Shower room after being told several times there was a female showering. The resident did not leave until an aide agreed to shower him in a different room once she was done with her round. A record review of Resident #14's nursing progress note dated 02/15/2024 revealed LVN A documented, resident came to station one and started calling this writer a 'pendeja' ([NAME] -a derogatory name in Spanish ) and demanding that this writer take him into the shower (in Spanish) writer told resident to go back to his room and would let his nurse know. Difficult to redirect. resident kept shaking shower door handle on station 1 after being told several times there was a female resident using the shower. this is not the first-time resident becomes aggressive. resident does not belong to station one but will still come to this station to yell and demand to be showered. A record review of Resident #14's nursing progress note dated 03/12/2024 revealed LVN A documented, ad 0015 (15 minutes past midnight) Resident (#14) walked into station one shower while a female Resident (Resident #23) was using it and refused to leave. Resident (#14) became angry when asked to leave and walked to 700 hall and started opening several rooms - Resident (#14) kept stating he wanted to leave the facility (Spanish speaking). Resident (#14) was cussing and doing sexual gestures to staff. Resident (#14) was repeatedly told that was inappropriate and to stop. Resident (#14) replied I don't give a F*** I'm leaving (Spanish speaking). Resident (#14) walked to front hallway and started shaking door handles and running shoulder into door to force it open. Resident (#14) went to front door and pushed it open - this writer and CNA we're trying to hold it closed as resident repeatedly pushed on it. This writer called [Resident #14] representative and she was able to talk resident down. Resident stated to representative he wanted to be showered - [Resident #14's] representative was told tomorrow is Resident's shower day. [Resident #14's] representative was still on the phone while Resident (#14) was making sexual gestures to staff and was made aware. [Resident #14's] representative told Resident (#14) she would come to facility tomorrow to speak with him . attempted to call the DON and the ADON no answer. called the administrator made aware. A record review of Resident #14's medical record, on 03/14/2024, revealed no evidence for providing the physician with reports where Resident #14 had increased sexual harassment behaviors towards residents since June 2023. During an interview on 03/13/24 at 04:15 PM the BOM stated Resident #23 had complained in early February about Resident #14 trying to get into her shower room. The BOM stated the previous DON reported Resident #14 attempted to enter the room and was unsuccessful and redirected, I did not know [Resident #14] entered [Resident #23's] shower room. During an interview on 3/14/24 at 03:00 PM, Dr. Y stated he was the primary care physician for Resident #14 and, over the span of several months, had received multiple reports Resident #14 was sexually inappropriate with staff . Dr. Y stated he continued with resident #14's drug regiment to allow time for the therapies to progress. Dr. Y stated he had not received any reports Resident #14 was sexually inappropriate toward any resident. Dr. Y stated, I would have recalled a report of him getting in a female resident's shower. Dr. Y stated, if he had received such a report, he would have ordered for a 1 to 1 staff level of supervision for Resident #14 and ordered a psychiatric evaluation. The medical director stated he had received reports of Resident #14's inappropriate sexual behaviors however the reports were limited to staff harassment and not resident harassment. The reports were incomplete and lacking the scope of Resident #14's behaviors towards female residents. Dr. Y stated he was concerned for the behavior towards residents and would have considered further interventions for Resident #14's safety and the safety of residents. During an interview on 03/15/2024 at 09:30 AM Resident #14 stated he was wanting beer, a dance party, and a sexual partner. He stated, I have not been drunk, had sex in a long time .there are no dances here and they only have church! Resident #14 stated he enjoyed female CNAs assisting him with showers and they didn't shower him when he demanded. Resident #14 denied he was in any females shower room. 2. A record review of Resident #23's admission record, dated 03/14/2024, revealed an admitted [DATE] with diagnoses of dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance and anxiety. A record review of Resident #23's quarterly MDS assessment, dated 02/12/2024, revealed Resident #23 was an [AGE] year-old female admitted for long term care assessed with a BIMS score of 10 which indicated moderate cognitive impairment. A record review of Resident #23's care plan, dated 03/14/2024, revealed Resident #23 had a history of rejecting care and or limited permission for assessments and therapies. Further review revealed interventions avoidance of over-stimulation and avoidance of aggressive peer residents. During an interview on 03/13/2024 at 02:30 PM Resident #23 stated she felt unsafe due to Resident #14's sexual harassment behaviors (attempts to get in the shower with her) and now wished to avoid showers and stay in her room. During an interview on 03/13/24 at 04:30 PM Resident #23 stated on several occasions a man got into the shower with her, to which she would yell and scream at him until staff intervened and re-directed him away. Resident #23 stated she had increased anxiety and insomnia due to the fear of resident #14 entering her room and or shower. A record review of Resident #23's medical record, on 03/14/2024, revealed no evidence for providing the physician with reports where Resident #14 had increased sexual harassment behaviors towards Resident #23 since February 2024. During an interview on 03/14/24 at 08:28 AM the Medical Director stated he was unsure if he received a report from the nursing staff that Resident #23 was involuntary secluded in the shower. The medical Director stated if he had he could have assessed resident for psychiatric evaluation. During an interview on 03/15/2024 at 02:00 PM the Medical Director stated he was Resident #23's physician, and he was unaware Resident #14 had on 2 occasions entered Resident #23's shower room. The Medical Director stated had he known he may have assessed Resident #23 for anxiety and may have intervened with a psychiatric evaluation. The physician stated at a minimum he would have expected a report from nursing for Resident #14's sexual harassment behaviors and Resident #23's potential anxiety and fear. During an interview on 03/18/24 at 03:50 PM the MDS Nurse stated a review of Resident #14's medical record revealed no evidence for reports to the physician that Resident #14 was having sexual harassment behaviors towards residents . During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for nursing staff to timely report to Resident's physicians any changes in residents' health status to include increased and or decreased behaviors and or responses to therapies. The Administrator stated nursing staff should have reported to the physician and himself Resident #14's sexual harassment episodes towards residents. The Administrator stated nursing staff had not reported Resident #14 had made sexual harassment behaviors towards residents. During an interview on 03/18/2024 at 05:31 PM the ADON stated a review of Resident #14's and Resident #23's medical record revealed no evidence for reports to the residents' physicians for any of Resident #14's sexual harassment episodes towards residents and or Resident #23. A record review of the facility's Accidents and Incidents - Investigating and Reporting, dated July 2017, revealed, all accidents or incidents involving residents, employees, visitors, vendors, etcetera, occurring on our premises shall be investigated and reported to the Administrator .the following data, as applicable, shall be included on the report of incident accident form; the date and time the accident or incident took place; the nature of the injury illness; where the accident or incident took place; the names of witnesses and their accounts of the accident or incident; the injured person's account of the accident or incident; the time the injured person's attending physician was notified, as well as the time the position responded and his or her instruction . An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 08:05 PM and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM. Plan of Removal Verification Problem: F580 Notification of physicians and responsible parties Interventions: o Responsible parties of both Resident #14 and Resident #23 notified of incident as of 3/16/2024. Record review of Resident #23's progress note dated 3/15/2024 at 11:43 AM, made by the Worker reflected, SW spoke with resident today, via a Spanish translator, and asked if she had any lingering emotional distress or anxiety related to the 2/6/24 incident and if so does she want to be seen by psych. services/counseling. Resident stated she is o.k. and did not want any type of counseling/psych. services. SW also had a conversation with her MPOA regarding the incident on 2/6/24 and asked if she wanted resident to have counseling/psych. services and she stated no she doesn't want that for resident at this time as resident seems fine. SW let her know that counseling/psych. services is available if she ever changes her mind and that she may always speak to SW as needed. Record review of a progress note dated 3/15/2024 at 6:21 PM reflected the Social Worker, and Administrator spoke with Resident #14's RP of the resident's incidents. Interview on 3/18/2024 at 1:10 PM, the Administrator stated that each incident was discussed with Resident #14's responsible parties. The Administrator then confirmed Resident #23's responsible party had been notified of the incidents. The Administrator also confirmed the medication and its adverse effects were discussed with Resident #14's responsible parties. Record review of Resident #14's Progress Note, dated 3/17/2024 at 1:12 PM and written by the MDS Coordinator reflected that education was provided to the RP of risks vs benefits of taking the medication medroxyprogesterone and went on to list risks and benefits. o Evidence of deficiencies in notification of physicians and responsible parties was found to exist in the facility. Interview on 3/18/2024 at 10:55 AM, the Administrator stated that the evidence of deficiencies in notification were found during the survey process and no other evidence of deficiencies in notification were found during the facilities audit after notification of the initial deficiencies. o The following in-services were initiated on 3/14-16/2024: All available staff will begin being in serviced on 3/15/2024, to be completed on or before 3/16/2024. Any staff member not present or in-serviced by this time will not be allowed to assume their duties until they have been in serviced. Administrator/Designee to ensure that in-service training has been done for all staff. O All Staff o Abuse/Neglect o Incident reporting, to include behaviors, to Admin/Physicians o The importance of reporting events to physicians and responsible parties A record review of the facility's all discipline employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 71, were interviewed to confirm receiving in-services for IJ F580 Reporting Change of Condition to Physician. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F580 Reporting Change of Condition to Physician. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F580 Reporting Change of Condition to Physician. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed all disciplines, 46 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator stated that not all staff report to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers and reporting to nursing staff. Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported. Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect, changes in conditions, and when to notify family and physicians. Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents' complaints were recognized and grievances were filed. Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to. Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors, as well as reporting to physicians. Monitoring o DON/Designee will perform a weekly audit of EMR (electronic medical record) to ensure that physicians and responsible parties are being notified with regard to any scenarios outlined in, but not limited to, CMS F580, to include medication changes, changes in condition, and critical labs. Record review reflected a facility activity report, detailing each residents' EMR, signed as Reviewed by the Administrator and DON on 3/16/2024. Interview on 3/18/2024 at 10:36 AM, the Administrator stated that the DON will be performing a weekly audit of the EMR. o Facility will be monitoring this by weekly EMR audits. Nurses will chart items in progress notes, and flagged on 24 hour report which will be discussed Monday - Friday by IDT. Interview on 3/18/2024 at 10:36 AM, the Administrator stated that they will be discussing the 24-hour report during the morning meeting to see if there need to be any changes made to any care for the residents based on what is on the 24 hour report. o The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they followed a template relating to the deficiencies and discussed any changes or suggestions related to any changes in care for residents with all members of the QAPI committee. An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions.

Based on observations, interviews, and record reviews the facility failed to ensure that Residents environments remained as free from accident and hazards as possible, and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 16 residents (Residents #14 and #23) reviewed for environments free from accident and hazards. 1. The facility failed to check a shower room prior to turning off the shower room lights and locking the door; Resident #23 was in the shower room and left alone in a dark with the door locked and fell . 2. The facility failed to ensure storage rooms containing equipment to draw blood for lab work, such as needles and syringes, were secured. This failure could place residents at risk for involuntary seclusion and injuries as well as injuries from syringe needles. An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. While the IJ was removed on 03/18/2024 at 07:26 PM, the facility remained out of compliance at a scope of isolated with potential harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. The findings included: 1. A record review of Resident #23's admission record, dated 03/14/2024, revealed an admitted [DATE] with diagnoses of dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance, anxiety, and Onchocerciasis with glaucoma (a disease where a parasite destroyed parts of the eye). A record review of Resident #23's quarterly MDS assessment, dated 02/12/2024, revealed Resident #23 was an [AGE] year-old female admitted for long term care assessed with a BIMS score of 10 which indicated moderate cognitive impairment. A record review of Resident #23's care plan, dated 03/14/2024, revealed Resident #23 had a history of rejecting care and or limited permission for assessments and therapies. Further review revealed interventions for avoidance of over-stimulation and avoidance of aggressive peer residents and, Problem Start Date: 07/17/2020 .ADLs (activities of daily life) . Presents with alteration in ADL self-performance & mobility R/T hx (related to history) of Rhabdomyolysis (damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death) & failure to thrive, Dementia, stiff left shoulder, muscle weakness, lack of coordination, muscle wasting and atrophy AEB (as evidenced by) requires staff assistance with all ADL's . Approach Start Date: 01/21/202 1; Resident requires supervision and set up by staff with showers. A record review of Resident #14's admission record dated 03/14/2024, revealed an admitted [DATE] with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. A record review of Resident #14's quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment. A record review of Resident #23's nursing notes revealed LVN K documented on 02/06/2024 at 01:12 AM, an incident where Resident #23 was in the shower room bathing alone. LVN K documented she heard screams and shouts and discovered Resident #23 in the darkened shower room and on the floor. LVN K also documented Resident #23 was locked in the shower by another LVN (LVN A) who was re-directing Resident #14 from entering the shower room, while unknowing Resident #14 was in the shower, resident (#23) propel self in wheelchair to shower room. Another Resident (#14) wanting to take a shower and kept wanting to go in shower. Staff (LVN A) unknowing that resident was in shower turned light off and locked door so that other resident would not go into the shower by himself. Resident (#23) calling for help from the shower room and was sitting on the floor. asst. x2 to wheelchair. moving all extremities, refused writer to take vitals and/or check head. resident wanted to be left alone so that she could take her shower. Resident (#23) upset because she could hear other Resident (#14) wanting to go into shower. took other Resident to 200 hall shower room and showered. A record review of the facility's incident reports from June 2023 to March 2024 revealed no evidence for the incident on 02/06/2024 where Resident #23 was showering and Resident #14 trespassed and intruded in her privacy and safety while bathing. During an interview on 03/13/2024 at 02:30 PM Resident #23 stated she felt unsafe due to Resident #14's sexual harassment behaviors (attempts to get in the shower with her). During an interview on 03/13/24 at 04:30 PM Resident #23 stated on several occasions a man got into the shower with her, to which she would, pull the shower curtain closed, yell and scream at him until staff intervened and re-directed him away. During an interview on 03/13/24 at 02:29 PM LVN K stated she and LVN A were the charge nurses on 02/06/2024 from 06:00 PM to 06:00 AM. LVN K stated Resident #23 had a preference to bathe herself in the shower room early in the mornings around midnight to 01:00 AM. LVN K stated Resident #23's routine was she would gather her clothes and bathing supplies and self-ambulate in her wheelchair to the shower room. LVN K stated on 02/06/2024 around 01:00 AM screams and shouting were heard coming from the shower room. LVN K stated she ran to the shower room and discovered Resident #23 in the dark on the floor. Resident #23 was upset and claimed she was locked in the shower with the lights off. LVN K stated Resident #23 stated she fell in the dark attempting to get out of her wheelchair trying to get to the light switch or door. LVN K stated she spoke with LVN A and learned Resident #14 was attempting to get into the shower room with Resident #23. LVN A redirected Resident #14 away and LVN A did not recognize Resident #23 was in the shower room. LVN A turned off the light and locked the shower room door to prevent Resident #14 from entering. LVN K stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents. During an interview on 03/15/24 at 10:59 AM LVN A stated on the early morning of 02/06/2024 around midnight Resident #14 entered the shower room while Resident #23 was showering; although LVN A did not know Resident #23 was in the shower room. LVN A stated she heard Resident #23 in the shower room and entered and redirected him out and away from the shower room and turned off the shower room light and locked the door. LVN A stated she and LVN B spoke and concluded the chain of events. LVN A stated she did not check for other residents in the shower room and did not see Resident #23 possibly due to the shower curtain was pulled shut. LVN A stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents. 2. Observation and interview on 3/11/2024 at 10:55 AM revealed the storage room behind Nurses Station 1 was unlocked and the door was open. Further observation revealed phlebotomy products in the storage room to include needles, syringes, and empty vials for collecting blood. The Administrator approached at this time, and stated to surveyor that the door should be closed and was unsure if the door should be locked. LVN K then approached and stated she was not sure whether the door should be closed or locked. During an observation and interview on 3/13/2024 at 02:45 PM revealed the storage room behind Nurses Station 2 was unlocked and the door was open. Further observation revealed phlebotomy products in the storage room to include needles, syringes, and empty vials for collecting blood. LVN N stated that she was not sure if the door should be locked, and that she had been told that day to ensure the door was closed. LVN N also stated that the needles and other phlebotomy equipment have always been in the storage room with the door opened and unlocked. During an observation on 03/14/2024 at 12:30 PM, the medical equipment storage room behind Nurses Station 1 was observed to have the door open with phlebotomy equipment visible from the hallway. There were no staff present for approximately 15 minutes while the surveyor observed. During an interview on 03/15/2024 at 05:15 PM, the DON stated the storage room doors behind each nursing station should be closed and was unsure if they should be locked. The DON stated the risk could include residents getting into storage rooms and hurting themselves. Record review of facility policy titled Storage of Medications stated, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. A record review of the facility's Accidents and Incidents - Investigating and Reporting, dated July 2017, revealed, All accidents or incidents involving residents, employees, visitors, vendors, etcetera, occurring on our premises shall be investigated and reported to the Administrator .the following data, as applicable, shall be included on the report of incident accident form; the date and time the accident or incident took place; the nature of the injury illness; where the accident or incident took place; the names of witnesses and their accounts of the accident or incident; the injured person's account of the accident or incident; the time the injured person's attending physician was notified, as well as the time the position responded and his or her instruction . An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 08:05 PM and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM. Plan of Removal Problem: F689 Inadequate supervision to prevent accidents allegation Interventions: Resident #23 insists on having her privacy during shower times; staff is to assist in setting up resident for self-showering to include, but not limited to, assisting with transfers to and from wheelchair to shower chairs. Record review of care plan dated 3/16/2024 for Resident #23 revealed Problem: [Resident #23] desires privacy/modesty during showers. With interventions including Staff monitoring showers will be stationed outside the shower room door in order to provide for residents desire for modesty and privacy., and Staff monitoring shower will provide security from any intrusion by other staff or residents seeking entrance to shower room. Further review of the care plan revealed, staff is to assist in setting up resident for self-showering to include but not limited to transferring to and from wheelchair to shower chair. Interview on 3/17/2024 at 5:03 PM, CNA L stated she works overnight shifts and was informed that during Resident #23's shower, she would need to assist the resident with anything she may need in setting up her showers. Interview on 3/18/2024 at 12:55 PM, the Administrator stated that they put in place measures to ensure resident #23's privacy during her showers to include a nursing staff member ensuring no one enters the room, assists the resident as necessary, and monitor. Resident #23's shower time will be monitored by a dedicated nursing staff member at all times while she is showering. Interview on 3/17/2024 at 5:03 PM, CNA L stated she works overnight shifts and was informed that during Resident #23's shower, she or another nursing staff member would be required to monitor during Resident #23's shower. Interview on 3/18/2024 at 12:55 PM, the Administrator stated that they put in place measures to ensure resident #23's privacy during her showers to include a nursing staff member monitoring during all times in which the resident is showering. Staff monitoring showers will be stationed outside the shower room door in order to provide for resident #23's desire for modesty and privacy. Interview on 3/17/2024 at 5:03 PM, CNA L stated she worked overnight shifts and was informed that during Resident #23's shower, she or another nursing staff member would be required to monitor by standing outside the shower room door while the resident was showering to provide privacy to the resident. Interview on 3/18/2024 at 12:55 PM, the Administrator stated that they put in place measures to ensure resident #23's privacy during her showers to include a nursing staff member stationed outside the shower room door. Staff monitoring Resident #23's showers will provide security from any intrusion by other staff or residents seeking entrance to shower room. Interview on 3/17/2024 at 5:03 PM, CNA L stated she worked overnight shifts and was informed that during Resident #23's shower, she or another nursing staff member would be required stand outside the shower room door while the resident was showering to provide privacy to the resident and ensure no other residents enter the shower room. Interview on 3/18/2024 at 12:55 PM, the Administrator stated that they put in place measures to ensure resident #23's privacy during her showers to include a nursing staff member stationed outside the shower room door. We have changed out the doorknobs to the showers, and they are now classroom style locks, which automatically lock from the outside, and cannot be locked from the inside. Residents do not have access to the keys to these locks. Resident #23 will not be able to enter the shower area without a staff member opening the door for her. Observation of Shower room near Nurses Station 1 (of 2) on 3/16/2024 at 5:02 PM revealed doorknobs to the shower room automatically lock from the outside. Further observation revealed the door cannot be locked from the inside. Observation on 3/16/2024 at 5:15 PM revealed Shower Room in 200 hall had doorknobs to the shower room that automatically lock from the outside. Further observation revealed that the doors cannot be locked from the inside. Observation on 3/16/2024 at 5:25 PM revealed all shower room doors at the facility no longer have keys that unlock the shower room door visible or available to residents. These tasks will be added to staff's ADL Flow Chart/POC, which will in turn be monitored by DON/ Designee Record review of Order, start date 3/17/2024 with no end date reflected Ensure Privacy during shower time as follows: 1. Dedicated nursing staff member to monitor and be stationed outside shower room door in order to provide modesty/privacy. 2. Ensure security from any intrusion by other staff or residents seeking entrance to shower room on Monday, Wednesday, and Friday between 6:00 PM and 6:00 AM. Record review of Medication Administration Record, dated 3/18/2024, reflected the above order, once daily on Monday, Wednesday, and Friday between 6:00 PM and 6:00 AM with a start date of 3/17/2024. All shower rooms to have LED night lights installed on 3/15/2024. Observation on 3/16/2024 at 5:07 PM of Shower Room near Nurses Station 1 (of 2) revealed night light mounted near shower that activates when absence of light is detected through a sensor in the light. Observation on 3/16/2024 at 5:16 PM of Shower Room in 200 hall revealed night lights mounted in the shower room that activate when the absence of light is detected through a sensor in the light. Interview on 3/16/2024 at 5:29 PM, the Maintenance Director revealed the LED night lights installed in both shower rooms contain an internal battery, so if the power to them fails or is disrupted, they will remain on so long as the battery is charged. The following in-services were initiated on 3/14-16/2024: All available staff will be in-serviced by close of 3/15/2024 mandatory staff meeting, to be held at 1400 . Any staff member not present or in-serviced at close of mandatory meeting, will not be allowed to assume their duties until in-serviced. Administrator will ensure that trainings have been completed by keeping an in-service log that spells out the names of the staff members who have had trainings and have signed off on their attendance of said trainings. oAll Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to Incident reporting to Admin/Physicians Importance of staff checking shower rooms for residents before turning off lights and locking doors A record review of the facility's employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F689. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F689. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F689. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed 46 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that not all staff report to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers and reporting to nursing staff . Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported and checking shower rooms for residents. Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect, changes in conditions, and when to notify family and physicians. Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents' complaints were recognized and grievances were filed. Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to. Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors, as well as reporting to physicians. Monitoring Psychiatric services to be offered to Resident #23 in order to provide for any mental or emotional anguish created by being left in shower room with lights off. Record review of progress note dated 3/16/2024 at 4:29 PM, LVN K spoke with Resident #23's RP regarding the incident on 2/6/2024 as well as the incident on 3/12/2024. Record review of progress note dated 3/15/2024 at 11:43 AM revealed the Social Worker, spoke with Resident #23 who declined psychiatric services. Further review of the progress note revealed the Social Worker spoke with the MPOA regarding the incident on 2/6/2024 and the MPOA stated she did not want the resident to receive psychiatric services at this time. The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed. Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they will follow a template relating to the deficiencies and discuss any changes or suggestions relating to any changes in care for residents with all members of the QAPI committee. DON to ensure care plans have been updated for resident #23 to reflect that she will have staff monitoring her during shower times. Record review of care plan dated 3/16/2024 for Resident #23 revealed Problem: [Resident #23] desires privacy/modesty during showers. With interventions including Staff monitoring showers will be stationed outside the shower room door in order to provide for residents desire for modesty and privacy., and Staff monitoring shower will provide security from any intrusion by other staff or residents seeking entrance to shower room. Further review of the care plan revealed, staff is to assist in setting up resident for self-showering to include but not limited to transferring to and from wheelchair to shower chair. An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. While the IJ was removed on 03/18/2024 at 07:26 PM, the facility remained out of compliance at a scope of isolated with risk for potential harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.

Based on interviews, and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 16 residents (Resident #14) reviewed for advance education for medication benefits versus risks. The facility administered medroxyprogesterone, a type of hormone (progestin), from June 2023 to March 2024 to Resident #14 without Resident #14 and/or Resident #14's representative receiving education on the rationale for the prescription, the benefits vs. the risks of medroxyprogesterone and offered options for treatment. An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions. This failure denied the resident their right to participate in their care and treatment and placed other residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed. The findings included : A review of Resident #14's admission record dated 03/14/2024, revealed an admitted [DATE] with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. The admission record revealed Resident #14 had two representatives. A record review of Resident #14' quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment . A record review of Resident #14's physicians orders, dated 03/14/2024, revealed the physician prescribed medroxyprogesterone (a hormone which help other hormones start and stop the menstrual cycle) 10 mg once a day at bedtime. A review of Resident #14's medication Administration Records for June, July, August, September, October, November, December 2023, and January, February, March 2024 revealed Resident #14 was receiving medroxyprogesterone daily. Record review of Resident #14's medical record revealed no evidence Resident #14 and or his representatives received any education on the rationale for the prescription, benefits vs risks, or potential adverse reactions of the prescribed medroxyprogesterone. A record review of the National Library of Medicine's website, https://www.ncbi.nlm.nih.gov/books/NBK559192/ , Medroxyprogesterone .Last Update: June 30, 2022 revealed, Continuing Education Activity: This article highlights medroxyprogesterone .This activity discusses the mechanism of action, adverse effects, monitoring, and contraindications for medroxyprogesterone. Also, it highlights the important role that providers play in administering medroxyprogesterone and regularly monitoring patients for side effects . Off-Label Indications: Paraphilia/hypersexuality . Both genders reported experiencing changes in breast and sexual function . Patients currently using medroxyprogesterone for paraphilia/hypersexuality, LFTs (liver function tests), CBC (complete blood count), serum testosterone (male hormone), LH, FSH (a lab for decreased functional activity of the gonads (ovaries or testes)), and glucose require regular monitoring. Also, if serum testosterone shows a marked decrease, consider an annual bone scan. A record review of Resident #14's medical records revealed no evidence Resident #14 received monitoring and or lab studies for the potential adverse effects of the female hormone medroxyprogesterone he was prescribed and administered for 9.5 months. During an interview on 03/13/24 at 02:29 PM LVN K stated she had been the charge nurse for Resident #14. LVN K stated Resident #14 had a history of aggressive sexual harassment behaviors towards staff and Resident s. LVN K stated Resident #14 had been prescribed medroxyprogesterone. LVN K stated the medication aide had administered Resident #14's medroxyprogesterone. LVN K stated there had been no monitoring measures for testosterone levels or breast tenderness . During an interview on 03/14/2024 at 03:00 PM Dr. Y stated he was the primary care physician for Resident #14. Dr. Y stated he had received reports from nursing staff, in June of 2023, that Resident #14 was developing unwanted sexual behaviors towards staff, and he prescribed medroxyprogesterone, a hormone prescribed to reduce Resident #14's unwanted sexual harassment behaviors. Dr. Y stated he had trust and faith the nursing staff would have advised Resident #14 and his representatives of the new medication to include rationale for the prescription, risks versus benefits, and potential adverse reactions. Dr. Y stated since June 2023 he had not received any reports from the nursing staff for any signs and or symptoms of adverse effects from the medroxyprogesterone . During an interview on 03/15/2024 at 02:44 PM Resident #14's 2 representatives stated Resident #14 occasionally had behaviors where he would become upset and would be calmed by the facility when offered non-alcoholic beer, he doesn't know the difference, and the representatives would call and further calm Resident #14. Resident #14's representatives stated Resident #14 was not able to receive education on the rationale, benefits vs risks of any prescribed medications. Resident #14's representatives stated they were unaware of Resident #14's inappropriate sexual behaviors towards female residents. Resident #14's representatives stated they were not informed Resident #14 was prescribed and administered a hormone to reduce his sexual inappropriate behaviors. Resident #14's representatives stated they had not received any education on the rationale, benefits vs risks of the prescribed medroxyprogesterone, and stated We have no idea what the drug is and what it does. The facility called us today to schedule a meeting next week, but they did not report to us any information on any drugs and or past sexual behaviors. During an interview on 03/18/24 at 02:20 PM LVN N stated she was the charge nurse who reported in June 2023 Resident #14's sexual harassment behaviors and received from Dr. Y the order for medroxyprogesterone. LVN N stated she had not clarified Resident #14's medroxyprogesterone order for monitoring for adverse effects of the medroxyprogesterone, breast tenderness and or laboratory test for monitoring Resident #14's testosterone blood levels, because it did not occur to her. LVN N stated she had not consulted with Resident #14 and or his representatives to provided informed consent to include the rationale for the medroxyprogesterone, the benefits versus the risk, and the potential adverse effects of the medroxyprogesterone prior to the administration of the medroxyprogesterone. LVN N stated not having provided Resident #14 the opportunity to receive education for benefits vs risks of medroxyprogesterone would deny him his right to participate in his plan of care and to consent or refuse the care. During an interview on 03/18/24 at 03:50 PM the MDS Nurse stated a review of Resident #14's medical record revealed no evidence for laboratory studies for testosterone, no monitoring for adverse effects medroxyprogesterone, no evidence for education for benefits vs risks of medroxyprogesterone, no care plan summaries to reveal Resident #14 and or the representatives received education for benefits vs risks of medroxyprogesterone. The MDS Nurse stated not having provided Resident #14 the opportunity to receive education for benefits vs risks of medroxyprogesterone would deny him his right to participate in his plan of care and to consent or refuse the care. During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for residents to receive informed consent prior to the initial dose of any medication and or treatment. The Administrator stated going forward he would ensure residents received from the physician and or nursing staff the rational for the new prescription and or treatment, the risks versus benefits, and potential adverse reactions. The Administrator stated not having provided Resident #14, or any resident, the opportunity to receive education for benefits vs risks of a medication and or treatment would deny their rights to participate in their plan of care and to consent or refuse the care. During an interview on 03/18/2024 at 05:31 PM the ADON stated a review of Resident #14's medical record revealed no evidence for laboratory studies for testosterone, no monitoring for adverse effects medroxyprogesterone, no evidence for education for benefits vs risks of medroxyprogesterone, no care plan summaries to reveal Resident #14 and or representatives received education for benefits vs risks of medroxyprogesterone. The ADON stated not having provided Resident #14 the opportunity to receive education for benefits vs risks of medroxyprogesterone would deny him his right to participate in his plan of care and to consent or refuse the care. A record review of the facility's Resident Participation - Assessment/Care Plans policy dated February 2021, revealed, the Resident/representatives right to participate in the development and implementation of his or her plan of care includes the right to: participate in the planning process; identify individuals to be included in the planning process; request meetings; request revisions to the plan of care; participate in the establishing his or her goals and expected outcomes of care; participate in the type, amount, frequency, and duration of care; receive the services and or items included in the care plan; be informed, in advance, of changes to the plan of care; refuse, request changes to and or discontinued care or treatment offered or proposed; be informed, in advance by the physician more professionals, of the risks and benefits of the care or treatment proposed . The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM. POR Verification Problem: F552 Failure to ensure resident had the right to be informed of, and participate in, his or her treatment Interventions: o Resident #14's Responsible Party was notified, according to progress notes, again of orders for Resident #14 to be prescribed medroxyprogesterone. Record review of progress note, dated 03/17/2024 at 1:12 PM, reflected that the MDS Coordinator, spoke with Resident #14's responsible parties to include educating on risk vs benefits of medroxyprogesterone. The progress notes further revealed that the responsible party voiced their understanding of the medication and its side effects and agreed that it was beneficial for the resident to remain on the medication. Interview on 3/18/2024 at 1:06 PM, the Administrator stated that Resident #14's responsible party was notified of the orders for medroxyprogesterone on 3/17/2024. o Resident #14's care plan was updated to reflect responsible party's notification of the medication being prescribed. Record review of the care plan, dated 3/15/2024, reflected Problem: Resident #14 is taking hormone medroxyprogesterone with Approach: Education provided to family as to risk vs benefit of medication. o Any new medication or treatment that Resident #14 (or any other resident) is prescribed will be assessed by nurse staff for a minimum of 72 hours. Record review of Resident #14 progress notes reflected an assessment of adverse reactions by nursing staff on medications. Interview on 3/18/2024 at 1:09 PM, the Administrator stated the assessments of adverse reactions of the new medication or treatments for Resident #14 were in the progress notes. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift , were interviewed to confirm receiving in-services and training on recognizing the side effects of the medication Medroxyprogesterone. o The need for education regarding adverse effects, risks vs. benefits, etc. of treatment before treatment begins, was identified, and in-servicing has begun by administrator; in-servicing will be completed by the end of business on 3/17/2024. This in-service is to include all nurses, and any nurse not in-serviced will not be allowed to perform duties until they are in-serviced. Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that nursing staff who had not been in-serviced would be allowed to perform duties until they had been in-serviced. Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff as having completed the in-service. o The following in-services were initiated on 3/14-16/2024: All available nursing staff will begin being in-serviced on 3/15/2024. Any nursing staff member not present or in-serviced, will not be allowed to assume their duties until in-serviced. Administrator/Designee to ensure that in service training has been done for all nurse staff. o AII Nurse Staff) nurses, CNA, MA) o Abuse/Neglect o The importance of reporting events to physicians and responsible parties A record review of the facility's employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F552 The Right to Participate in Their Care. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F552 The Right to Participate in Their Care. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F552 The Right to Participate in Their Care. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed 46 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that not all staff reported to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. Record review of a document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers and reporting to nursing staff. Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported. Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect, changes in conditions, and when to notify family and physicians. Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents' complaints were recognized and grievances were filed. Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to. Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors, as well as reporting to physicians. Monitoring: o DON/Designee will perform a weekly audit of EMR to ensure that resident and/or responsible parties are being notified and educated with regard to any treatment changes, including but not limited to, any possible adverse effects, risks and benefits, or any alternative treatments that might be available BEFORE any changes are made Record review reflected a facility activity report, detailing each residents EMR, signed as Reviewed by the Administrator and DON on 3/16/2024. Interview on 3/18/2024 at 10:36 AM, the Administrator stated that the DON would be performing a weekly audit of the EMR. o This weekly audit will be monitored on an ongoing weekly basis, to be integrated into the normal work routine of the nurse management team. Initial audit to be performed on 3/16/2024 by DON/Designee. Interview on 3/18/2024 at 10:36 AM, the Administrator stated that the DON will be performing a weekly audit of the EMR. Record review reflected a facility activity report, detailing each residents EMR, signed as Reviewed by the Administrator and DON on 3/16/2024. o The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they will follow a template relating to the deficiencies and discuss any changes or suggestions relating to any changes in care for residents with all members of the QAPI committee. An Immediate Jeopardy (IJ) was identified on 03/15/2024. The IJ was provided to the facility on [DATE] at 08:05 PM. While the IJ was removed on 03/18/2024, the facility remained out of compliance at a scope of isolated with a severity level of potential harm because of the facility's need to evaluate the effectiveness of their corrective actions.

Based on observations, interviews, and record reviews, the facility failed to ensure Residents had the right to be free from abuse, neglect, and involuntary seclusion for 3 (Resident #23, #43, and #1) of 16 residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #23 was not neglected when she was left in a dark, locked, shower room alone. 2. The facility failed to protect Resident #23 from abuse by allowing a male resident access to her while in the shower. 3. The facility failed to protect Resident #1 when she wandered into Resident #43's room and Resident #43 hit her (Resident #1) on the head. An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. While the IJ was removed on 03/18/2024 at 07:26 PM, the facility remained out of compliance at a scope of isolated with potential harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. This failure denied residents their rights for freedom from abuse, neglect, and involuntary seclusion. The findings included: A record review of Resident #23's admission record, dated 03/14/2024, revealed an admitted [DATE] with diagnoses of dementia (not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), mood disturbance, anxiety, and Onchocerciasis with glaucoma (a disease where a parasite destroyed parts of the eye). A record review of Resident #23's quarterly MDS assessment, dated 02/12/2024, revealed Resident #23 was an [AGE] year-old female admitted for long term care assessed with a BIMS score of 10 which indicated moderate cognitive impairment. Section G of the MDS assessment revealed resident #23 used a wc independently and was Setup or clean-up assistance - for transfers and showers. A record review of Resident #23's care plan, dated 03/14/2024, revealed Resident #23 had a history of rejecting care and or limited permission for assessments and therapies. Further review revealed interventions for avoidance of over-stimulation and avoidance of aggressive peer residents and, Problem Start Date: 07/17/2020 .ADLs (activities of daily life) . Presents with alteration in ADL self-performance & mobility R/T hx (related to history) of Rhabdomyolysis (damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death) & failure to thrive, Dementia, stiff left shoulder, muscle weakness, lack of coordination, muscle wasting and atrophy AEB (as evidenced by) requires staff assistance with all ADL's . Approach Start Date: 01/21/202 1; Resident requires supervision and set up by staff with showers. A record review of Resident #23's nursing notes revealed LVN K documented on 02/06/2024 at 01:12 AM, an incident where Resident #23 was in the shower room bathing alone. LVN K documented she heard screams and shouts and discovered Resident #23 in the darkened shower room and on the floor. LVN K also documented Resident #23 was locked in the shower by another LVN (LVN A) who was re-directing Resident #14 from entering the shower room, while unknowing Resident #14 was in the shower, resident (#23) propel self in wheelchair to shower room. Another Resident (#14) wanting to take a shower and kept wanting to go in shower. Staff (LVN A) unknowing that resident was in shower turned light off and locked door so that other resident would not go into the shower by himself. Resident (#23) calling for help from the shower room and was sitting on the floor. asst. x2 to wheelchair. moving all extremities, refused writer to take vitals and/or check head. resident wanted to be left alone so that she could take her shower. Resident (#23) upset because she could hear other Resident (#14) wanting to go into shower. took other Resident to 200 hall shower room and showered. A record review of the facility's incident reports from June 2023 to March 2024 revealed no evidence for the incident on 02/06/2024 where Resident #23 was showering and Resident #14 attempting to enter the shower room while Resident #23 was bathing. During an interview on 03/13/2024 at 02:30 PM Resident #23 stated she felt unsafe due to Resident #14's sexual harassment behaviors (attempts to get in the shower with her). During an interview on 03/13/24 at 04:30 PM Resident #23 stated on several occasions a man got into the shower with her, to which she would, pull the shower curtain closed, yell and scream at him until staff intervened and re-directed him away. During an interview on 03/13/24 at 02:29 PM LVN K stated she and LVN A were the charge nurses on 02/06/2024 from 06:00 PM to 06:00 AM. LVN K stated Resident #23 had a preference to bathe herself in the shower room early in the mornings around midnight to 01:00 AM. LVN K stated Resident #23's routine was she would gather her clothes and bathing supplies and self-ambulate in her wheelchair to the shower room. LVN K stated on 02/06/2024 around 01:00 AM screams and shouting were heard coming from the shower room. LVN K stated she ran to the shower room and discovered Resident #23 in the dark on the floor. Resident #23 was upset and claimed she was locked in the shower with the lights off. LVN K stated Resident #23 stated she fell in the dark attempting to get out of her wheelchair trying to get to the light switch or door. LVN K stated she spoke with LVN A and learned Resident #14 was attempting to get into the shower room with Resident #23 when LVN A redirected Resident #14 away and LVN A did not recognize Resident #23 was in the shower room. LVN A turned off the light and locked the shower room door to prevent Resident #14 from entering. LVN K stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents. During an interview on 03/15/24 at 10:59 AM LVN A stated on the early morning of 02/06/2024 around midnight Resident #14 entered the shower room while Resident #23 was showering; although LVN A did not know Resident #23 was in the shower room. LVN A stated she heard Resident #23 in the shower room and entered and redirected him out and away from the shower room and turned off the shower room light and locked the door. LVN A stated she did not check for other residents in the shower room and did not see Resident #23 possibly due to the shower curtain was pulled shut. LVN A stated she had not initiated an incident report for any of Resident #14's sexual harassment incidents towards peer Residents, did not document on the 24 hour reports the sexual harassment behaviors towards peer residents. A record review of Resident #14's admission record dated 03/14/2024, revealed an admitted [DATE] with diagnoses which included dementia, psychotic disturbance, mood disturbance, anxiety, and alcohol use. A record review of Resident #14's quarterly MDS assessment revealed Resident #14 was a [AGE] year-old male admitted for long term care assessed with a BIMS score of 5 which indicated severe cognitive impairment. During an interview on 03/18/2024 at 05:20 PM the Administrator stated the policy and expectation was for facility staff to ensure residents were supported in their rights to be free from abuse and or neglect, including Resident #23's rights for safety. The Administrator stated he expected a report for all incidents involving resident #23 being secluded and harassed by resident #14 in her shower room. The Administrator stated not having provided any Resident, supports for ensuring their rights could have placed residents at risk for abuse, neglect, exploitation, and or mistreatment. 3. A record review of Resident #43's admission record dated 03/15/2024 revealed an admitted [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.). A record review of Resident #43's quarterly MDS assessment, dated 02/21/2024, revealed Resident #43 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 05 out of a possible 15 which indicated severe cognitive impairment . A record review of Resident #43's care plan dated 03/15/2024 revealed Resident #43 had a history of physical aggression towards staff and peer residents in areas of increased stimulation. Resident #43's care plan revealed interventions for monitoring for early signs of aggression and encouragement to attend social activities. A record review of Resident #1's admission record revealed an admitted [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.). A record review of Resident #1's quarterly MDS assessment, dated 02/06/2024, revealed Resident #1 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 99 which indicated Resident #1 could not participate in the assessment and may be severely cognitively impaired . A record review of Resident #1's care plan dated 03/15/2024 revealed Resident #1 had a history of unsafely wandering in her wheelchair. Further review revealed interventions which included, .Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents) . Remove resident from other resident's rooms and unsafe situations . A record review of Resident #43's nursing progress notes revealed LVN N documented on 01/01/2024 at 10:35 AM, Resident (#43) in his room watching television (Resident #1) wandered into his room via wheelchair was asked to leave she did not - then he hit her in head just above left ear - resident is forgetful at times - and does not like people going into his room re-educated on importance of not hitting people and keeping his hands to himself - verbalized understanding stated she shouldn't be in my room. A record review of Resident #1's nursing progress notes revealed LVN N documented on 01/01/2024 at 10:32 AM, Resident (#1) propelling self in and out of other residents room went into room (Resident #43's room) was in room and she would not leave and (Resident #42) hit in head just above left ear - no apparent injuries noted resident moved from area and placed in main dining room to participate in activities. A record review of the Texas Unified Licensure Information Portal on 03/18/2024 revealed no evidence for reporting the alleged incident of abuse on 01/01/2024 between Residents #43 and #1. A record review of the facility's incidents and accidents log for the review dates of June 2023 through March 2024 revealed no reporting for the 01/01/2024 alleged peer to peer physical abuse between Resident #1 and Resident #43. During an interview on 03/12/2024 at 10:10 AM LVN N stated on 01/01/2024 at around 10:00 am Resident #1, who was pleasant and confused wandered into Resident #43's room when he began yelling at Resident #1 to get out of his room. LVN N stated she received a report from the CNA who saw Resident #43 hit Resident #1 on the side of the head. LVN N stated she assessed both residents for injuries and or pain and none were evidenced. Resident #43 was counseled and redirected to not hit anyone and Resident #1 was redirected to the living room to participate in activities. LVN N stated she had not generated an incident report, nor documented the incident on the 24-hour report but had documented the incident on the residents nursing progress notes. LVN N stated she had not reported the incident to the physician since there was no injuries . During an interview on 03/15/24 at 10:10 AM the DON stated the facility policy and her expectations were for all allegations of abuse, neglect, exploitation and or mistreatment were to be reported to the abuse, neglect, and exploitation prevention coordinator, the Administrator, herself (the DON), and document on the facility's incident report, and the 24-hour report. The DON stated record reviews of the incident reports and 24-hour reports failed to evidence the allegation of abuse on 01/01/204 for Resident #43's aggressive behavior towards Resident #1 therefore the facility leadership was unaware of the incident and failed to report and investigate the incident . During an interview on 03/15/24 at 11:00 AM the Administrator stated the facility policy, and his expectations were for all allegations of abuse, neglect, exploitation and or mistreatment were to be reported to the abuse, neglect, and exploitation prevention coordinator, (himself), and documented on the facility's incident report, and the 24-hour report. The Administrator stated record reviews of the incident reports and 24-hour reports failed to evidence the allegation of abuse on 01/01/204 for Resident #43 aggressive behavior towards Resident #1 therefore the facility leadership was unaware of the incident and failed to report and investigate the incident . A record review of the facility's Abuse / Neglect policy dated 01/08/2003, revealed, The Resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents should not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff, of other agencies serving the Resident, family members or legal guardians, friends, or other Residents .the facility will provide and ensure the promotion and protection of Resident rights. It is each individuals' responsibility to recognize, report, and promptly follow-up abuse or neglect allegations, suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any Resident in the facility . An Immediate Jeopardy (IJ) was identified on 03/15/2024 at 08:05 PM and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 03/17/2024 at 07:08 AM. Plan of Removal Verification Problem: F600 Sexual Inappropriateness allegation Interventions: Resident #14 placed in 1:1 observation and continues currently Record review of Resident #14's Orders reflected, One on one care d/t behaviors. with a start date of 3/14/2024. Observation and interview on 03/16/2024 at 11:25 AM revealed CNA M was assigned to monitor Resident #14 and has monitored him most of the day. She stated she must document on a sheet of paper every 15 minutes. During an observation on 03/16/2024 at 04:00 PM revealed Resident #14 was asleep in his bedroom while CNA M monitored Resident #14 for safety. Observation on 03/16/2024 at 5:10 PM revealed resident #14 in the dining room being observed by staff while eating a meal. Record review of Resident #14's 1 to 1 documentation sheet, dated 03/16/2024, revealed Resident #14 was continuously monitored for safety and documented every 15 minutes. Interview on 3/18/2024 at 12:49 PM, the Administrator stated that Resident #14 is on 1:1 observation and will continue to be pending further evaluation by physician for effectiveness and necessity. Immediate psychiatric services via telehealth initiated on 3/14/2024 Record review of psychiatric evaluation dated 3/14/2024 at 06:06 PM. Record review of consolidated orders dated March 2023 revealed to be evaluated and treated by Psychiatric Services as needed, dated 3/14/2024. Record review of revealed Resident #14 RP verbally consented over the phone on 3/14/2024 to resident receiving psychiatric services. Interview on 3/18/2024 at 10:59 AM, the Administrator stated that Resident #14 had been seen by psychiatric services. Record review of Progress Note, dated 3/14/2024, reflected that Resident #14 was seen by a psychiatric NP with plan based on residents' diagnosis. STAT CBC, CMP, BMP, TSH, Ammonia level, and UA ordered by Primary Care Provider on 3/14/2024 Record review of Resident #14's orders reflected STAT CBC, CMP, UA ordered by the resident's physician on 3/14/2024. Record review of Resident #14's orders reflected Draw blood for TSH and Ammonia level ordered by the resident's physician on 3/15/2024. Record review of Resident #14's lab drawn on 3/14/2024 reflected CBC UA CMP, TSH and Ammonia with no recommendations signed Administrator/DON on 3/17/2024. New order for Sertraline, ordered by psychiatric services NP on 3/14/2024 Record review of telephone order dated 3/14/2024, start date for 3/22/2024 Sertraline 50 mg, 1 tablet once a day, oral for insomnia, ordered by the resident's PCP. Record review of telephone order dated 3/14/2024, start date 3/14/2024, end date 3/21/2024 for Sertraline 25 mg 1 tablet once a day by mouth with diagnosis of insomnia, ordered by the resident's PCP. Record review of telephone order dated 3/16/2024, start date 3/16/2024, with no end date for Risperidone 1 mg 1 tablet twice a day by mouth with diagnosis of anxiety disorder. Record review of telephone order dated 3/16/2024, start date 3/16/2024, with no end date for Melatonin 5 mg 2 tablets once daily at bedtime with diagnosis of insomnia. Psychiatric services to be offered to Resident #23 in order to provide for any mental or emotional anguish created by any interactions with Resident #14 Record review of progress note dated 3/16/2024 at 4:29 PM, LVN K spoke with Resident #23's RP regarding the incident on 2/6/2024 as well as the incident on 3/12/2024. Record review of progress note dated 3/15/2024 at 11:43 AM revealed the Social Worker, spoke with Resident #23 who declined psychiatric services. Further review of the progress note revealed the Social Worker spoke with the MPOA regarding the incident on 2/6/2024 and the MPOA stated she did not want the resident to receive psychiatric services at this time. Abuse and Neglect prevention in-service for all facility staff initiated and completed by Admin/DON/Compliance Nurse on 3/14/2024 A record review of the facility's employee roster dated, 03/16/2024 revealed 74 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F600. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 74 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 74 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600. Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. Interview on 3/18/2024 at 12:54 PM, the Administrator stated most staff have been in-serviced and those who have not will be in-serviced before resuming duties. The following in-services were initiated on 3/14/2024: All available staff will be in-serviced by close of 3/15/2024 mandatory staff meeting, to be held at 1400 . Any staff member not present or in-serviced at close of mandatory meeting, will not be allowed to assume their duties until in-serviced. Administrator/Designee to ensure that in-service training has been done for all staff. oAll Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to Incident reporting, to include behaviors, to Admin/Physicians. A record review of the facility's employee roster dated, 03/16/2024 revealed 71 employees. 57% of employees, 44 of the 74, were interviewed to confirm receiving in-services for IJ F600, Prevention and Reporting of Abuse, Neglect, and Exploitation. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees, 10 were nurses. A sample of 8 nurses, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600, Prevention and Reporting of Abuse, Neglect, and Exploitation. A record review of the facility's employee roster dated, 03/16/2024 revealed of the 71 employees 17 were CNAs. A sample of 8 CNAs, 5 on day shift and 3 on night shift, were interviewed to confirm receiving in-services for IJ F600, Prevention and Reporting of Abuse, Neglect, and Exploitation. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Abuse/Neglect Inservice revealed 46 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 3:15 PM, the MDS Coordinator revealed that not all staff report to physicians or emergency contacts, and that only 11 nurses would be responsible with reporting any events to physicians and emergency contacts. Record review of document titled In-Service Training, dated 3/15/2024, with the topic The Importance of Reporting Events to Physicians and Emergency Contacts revealed 7 of 11 nursing staff signed off as having completed the in-service. Record review of document titled Staff in-service, dated 3/15/2024, with the topic Any staff who is turning off the lights and shutting the doors to any room shall check the room for any other persons prior to turning off the lights and shutting the door. Further review of this in-service revealed 49 of 71 staff signed off as having completed the in-service. Interview on 3/17/2024 at 12:30 PM, LVN N revealed that the in-service consisted of abuse and neglect prevention, complaints, when and where to file grievances and who to report grievances to. Interview on 3/17/2024 at 12:33 PM, CNA J stated that the in-service consisted of ensuring no residents are locked in shower rooms and monitoring showers. Interview on 3/17/2024 at 12:34 PM, CNA I stated that the in-service she received detailed ensuring that grievances are recognized and reported. Interview on 3/17/2024 at 1:35 PM, CNA P stated the in-service detailed abuse, neglect, exploitation, and discussing any of these concerns with the administrator. Interview on 3/17/2024 at 2:04 PM, LVN K stated her most recent in-service consisted of abuse and neglect training, to include specifics about what is abuse and neglect. Interview on 3/17/2024 at 3:00 PM, LVN R stated the in-service she had most recently consisted of ensuring residents complaints were recognized and grievances were filed. Interview on 3/17/2024 at 4:13 PM, CNA O stated the in-service they completed on 3/15/2024 consisted of reporting grievances and who to give them to. Interview on 3/17/2024 at 4:23 PM, LVN T stated the most recent in-service was about abuse and neglect and reporting any abuse or neglect to supervisors. Interview on 3/18/2024 at 12:54 PM, the Administrator stated most staff have been in-serviced and those who have not will be in-serviced before resuming duties. Monitoring Administrator/DON to review findings of psychiatric NP and ensure implementation of treatment plan if found to be necessary. DON to ensure care plans have been updated for resident #14 as well as resident #23. Record review of Progress Note, dated 3/14/2024, reflected that Resident #14 was seen by a psychiatric NP. Further review reveals the DON and Administrator signed the document as Reviewed on 3/14/2024. Interview on 3/18/2024 at 10:59 AM, the Administrator stated that Resident #14 had seen the psychiatric NP and that he and the DON had reviewed the findings. He further stated that he, along with the DON, reviewed the psychiatric services progress note and will continue to do so after any psychiatric services appointment. Administrator will work with social services to develop a plan of action to find suitable placement for resident #14 in order to provide a better, more appropriate level of care, to provide a safer environment for resident #14 as well as all others residing in the facility Interview on 3/18/2024 at 12:58 PM, the Administrator stated that the social worker has put in referrals for 3 places and continues to search for placement. The residents RP's have declined some placements for the resident. Record review of Resident #14's care plan revealed, Problem: Administrator issued 30 Day Discharge Notice has been issued effective from 3/15/24. with interventions of Social services to send referrals to facilities that will meet Resident #14's needs. Thirty-Day Notice of discharge to be issued to resident #14, resident #14's representative, and representative of long-term care ombudsman program on 3/15/2024 Record review of document titled 30 Day Discharge Notice reflected a 30 day discharge notification provided to the residents representative on 3/15/2024. Record review of email to Ombudsman reflected notification of 30-day discharge notice on 3/15/2024. Record review of Resident #14's care plan revealed, Problem: Administrator issued 30 Day Discharge Notice has been issued effective from 3/15/24. with interventions of Social services to send referrals to facilities that will meet Resident #14 's needs. Interview on 3/18/2024 at 1:04 PM, the Administrator stated the family was provided with a 30-day notice to Resident #14, and the ombudsman was provided with the 30-day notice as well. The QAPI committee will review findings monthly for no less than 90 days and makes changes as needed Interview on 3/18/2024 at 10:36 AM, the Administrator stated that during QAPI they will follow a template relating to the deficiencies and discuss any changes or suggestions relating to any changes in care for residents with all members of the QAPI committee. An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. While the IJ was removed on 03/18/2024 at 07:26 PM, the facility remained out of compliance at a scope of isolated with potential harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions.

Based on interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being in accordance with the care plan for 1 of 7 residents (#7) whose care was reviewed. RN A did not immediately activate the EMS/911 for assistance until approximately 17 minutes after she assessed Resident #7 as having no pulse or respirations and requiring CPR. RN A was unsure of actions to be taken for Resident #7. LVN B did not act to notify 911 immediately. RN A was incharge of the residents residing in station A, and LVN B was incharge of the residents residing in station B. Resident #7 was pronounced dead by the Justice of the Peace at 4:28 a.m. on [DATE]. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the DON not completing in-service training to all nursing staff on response to CPR emergencies nor evaluating the effectiveness of training.. These failures resulted in CPR not provided for Resident #7 and could result in death and could affect 28 residents in the facility who were a Full Code status. Findings: Review of Resident #7's admission orders [REDACTED]'s Medical Dictionary, 27th Ed., the condition of weighing 2 or 3 times ideal body weight and resulting in serious, life threatening conditions). Resident #7's CPR Status was documented as "Yes" indicating Full Code. Review of Resident #7's Monthly Record Weights, undated, revealed his admitting weight was documented as 566 pounds on [DATE]. In an interview on [DATE] at 10:55 a.m., CNA C said she took care of Resident #7, whose room was on the 800 Hall, during the night shift that started at 10:00 p.m. on [DATE]. CNA C said staff working during that shift included RN A incharge of Station II, LVN B in charge of Station I, and CNAs D and E. CNA C said she answered Resident #7's call light at 2:00 a.m. on [DATE]. CNA C said Resident #7 told her he had not activated the call light and wanted to sleep. CNA C said she looked in on Resident #7 at either 2:30 or 3:15 a.m. and found him sleeping. CNA C was not sure which was the correct time but said she could tell Resident #7 was sleeping because he always lay on his left side with his right hand resting on his right hip. CNA C said that at 3:45 a.m. on [DATE], she entered Resdient #7's room to empty the garbage can. As she bent over to pick up the garbage can, CNA C said she glanced over at Resident #7's bed and saw his right hand was hanging over the side of the bed. CNA C said she walked over to Resident #7's bed and shook him. When Resident #7 did not respond, CNA C said she turned on the light and saw Resident #7's face, hands, and feet were blue to black in color. CNA C said she attempted to turn Resident #7 over unsuccessfully. CNA C said she left Resident #7's room and notified RN A immediately after finding him unresponsive at 3:45 a.m. CNA C said that on the way to Resident #7's room, she and RN A saw CNA D. CNA C said all 3 staff members went to the resident's room. CNA C said shortly after she and RN A arrived at Resident #7's room, LVN B also entered the room. CNA C said RN A and LVN B attempted to turn Resident #7 over but could not. CNA C said RN A was not sure if Resident #7 was a Full Code or whether she should call 911. CNA C said RN A tried to call the DON and then called 911. In an interview on [DATE] at 11:25 a.m., RN A said she took care of Resident #7 during the shift that started at 6:00 p.m. on [DATE]. RN A said she had a conversation with Resident #7 at 12:15 a.m. until approximately 1:00 a.m. RN A said she was sitting at the nurses' desk on Station II of the facility charting when she noted Resident #7's call light was on. RN A said she instructed CNAs C and D to answer the resident's light. RN A said that after answering the call light, CNA C told her Resident #7 said he wanted to sleep. RN A said at approximately 3:45 a.m., CNA C told her Resident #7 was "gone." RN A said she and CNA C returned to Resident #7's room and found him lying on his left side with his right hand hanging off the the side of the bed. RN A said she told CNA C to "call everyone" (staff in the facility). RN A said she assessed Resident #7 and found: -no movement of the chest -no radial (wrist) pulse -he was cold to touch -his hands and face were blue in color and there were dark patches on his hands and arms -upon listening with a stethoscope, he had no apical (apex of the heart) pulse or lung sounds -there were blood tinged secretions from his mouth RN A said she left the room with CNA C to call all staff. RN A said she, LVN B, CNAs C, D, and E combined to try and turn Resident #7 onto his back but were unsuccessful. RN A said she tried to deliver chest compressions to Resident #7 while he was lying on his left side. RN A said she left Resident #7's room to call the DON for help but was unable to reach her. RN A said she then called 911 for assistance. RN A said the time was: -approximately 3:48 a.m. when she entered Resident #7's room with CNA C -approximately 4:00 a.m. when she tried to call the DON -approximately 4:05 a.m. when she called 911 RN A was not sure of exact times events occurred. RN A said she did not know Resident #7's code status upon entering his room and that LVN B checked his chart but could not find his code status. RN A said she and LVN B then assumed Resident #7 was a Full Code. RN A listed the steps followed for CPR as establishing responsiveness, checking breathing, calling 911, and starting (chest) compressions. RN A said she did not follow the steps for administering CPR. RN A said she did not know how long Resident #7 had been unresponsive, with no pulse or respirations. RN A said she did not remember actions to be taken if a resident was found without a pulse or respirations and time of such condition was unknown. RN A said she tried to get help by calling the DON. RN A said she was nervous, did not know what to do, and called the DON before calling 911. RN A said her orientation upon hire to the facility was 3 days long. RN A said she was not provided training by the facility on responding to emergencies like CPR. Review of RN A's CPR certification card revealed her certification expired in July, 2013. In an interview on [DATE] at 12:55 p.m., CNA D said she saw Resident #7 at 2:00 a.m. with CNA C when they answered his call light. CNA D said Resident #7 told them he wanted to sleep. CNA D said she started to make rounds to check on residents in the 300 Hall at 3:45 a.m. on [DATE] when CNA C was looking for RN A and told her Resident #7 was "gone." CNA D said she accompanied CNA C and RN A to the resident's room. CNA D said upon entry to Resident #7's room, they found him lying in bed with his arms over the side of the bed. CNA D said Resident #7's face, hands, and feet were black. CNA D said RN A was "just kind of there, she didn't know his code status." CNA D said RN A walked over to Resident #7's bed and checked his pulse. CNA D said, at this point, she turned and left the room to find LVN B. CNA D said she found LVN B in the copy room and both proceeded to Resident #7's room. CNA D said upon entry to Resident #7's room, LVN B and RN A both looked at the resident. CNA D said the nurses left Resident #7's room and stood in the hall. CNA D said RN A looked at her phone and said she did not know what to do. CNA D said LVN B told RN A to look in Resident #7's chart. CNA D said the time was 4:15 a.m. CNA D said RN A then tried to call the DON, left a message for the DON, and then called 911. CNA D said she was not sure what time 911 was called. CNA D said RN A and LVN B decided to return to Resident #7's room and, along with CNAs C, D, and E tried to reposiiton the resident. CNA D said she was not sure what time EMS arrived. CNA D said that prior to [DATE], she had not received any training at the facility regarding response to CPR emergencies. In an interview on [DATE] at 1:16 p.m., CNA E said she was called at approximately 3:55 a.m. on [DATE] to help RN A, LVN B, and CNAs C and D try to reposition Resident #7. CNA E said she did not know if CPR was done for Resident #7. CNA E said the DON was called at approximately 4:00 a.m. and EMS/911 was called at approximately 4:02 a.m. CNA E said EMS arrived at the facility at approximately 4:20 a.m. CNA E said she then returned to her duty hall. CNA E said that prior to [DATE], she had not received any training at the facility regarding response to CPR emergencies. In an interview on [DATE] at 2:30 p.m., LVN B said she was in the facility copy room at 3:50 a.m. on [DATE] when CNA D approached her saying she thought Resident #7 was dead. LVN B said when she arrived at Resident #7's room, RN A was assessing him and told her the resident had no pulse. LVN B said Resident #7 was "blue in the face," his mouth was open, there was a pool of saliva at his mouth, and his limbs were blotchy. LVN B said staff tried to turn him over unsuccessfully. LVN B said she tried to help RN A and went to get Resident #7's chart. LVN B said she and RN A could not find information regarding Resident #7's code status. LVN B said she and RN A tried to call DON G and then called 911. LVN B was not sure of times that events took place. LVN B listed steps for CPR as feeling for a pulse, calling 911, rolling the patient over, and starting chest compressions. LVN B acknowledged 911 should have been called when it was determined Resident #7 had no pulse. LVN B said she did not act sooner to call 911 because "he (Resident #7) wasn't my resident." LVN B said she felt more responsible to help RN A and did not feel she had direct responsibility for Resident #7. LVN B said that prior to [DATE], she had not received training at the facility regarding response to CPR emergencies. LVN B said she understood training was to be conducted regarding response to CPR emergencies after [DATE] but she had not yet seen any posted information regarding proposed training. LVN B said she received CPR training and certification in August, 2012 for LVN school. In an interview on [DATE] at 3:10 p.m., the DON said actions taken after the CPR emergency involving Resident #7 on [DATE] included investigation of the event and plans for an in-service to staff regarding CPR response. The DON said RN A was suspended pending outcome of the facility investigation and that RN A submitted her resignation on [DATE]. The DON said she spoke to LVN B and counseled her on steps to take in an emergency. The DON said she planned to start the in-services to staff the next day, [DATE]. The DON said she was also arranging classes in CPR certification for nursing staff. In an interview on [DATE] at 3:15 p.m., the Administrator and the DON asked if LVN B should have also been disciplined about not acting to call 911 immedicately. In an interview on [DATE] at 7:46 a.m., the Administrator said the DON would be investigating LVN B's actions of [DATE]. In a telephone interview on [DATE] at 9:07 a.m., the Medical Director said Resident #7's medical conditions could have caused CPR to be ineffective. The Medical Director acknowledged that EMS/911 should have been called for Resident #7 before attempting to call the administrative staff. Review of RN A's documentation in Resident #7's Nurse Notes dated [DATE], revealed: -at 2:00 a.m. Resident #7's call light was on and he told CNA C he wanted to sleep -at 3:45 a.m. Resident #7 was found without a pulse and attempts were made to move him -at 4:05 a.m. EMS/911 was called -at 4:15 a.m. the Administrator was called -at 4:30 a.m. EMS arrived and confirmed death -at 4:45 a.m. the Justice of the Peace (JP) and police arrived -at 5:00 a.m. the funeral home personnel arrived to transport Resident #7's body Review of RN A's witness statement dated [DATE] revealed: -at 4:00 a.m. on [DATE], she called the DON after attempts to position Resident #7 onto his back were unsuccessful. Purpose of the call was to request guidance and counseling from the DON -EMS arrived at 4:15 a.m. -JP arrived at 4:30 a.m. Review of the EMS Patient Care Report dated [DATE] revealed: -call to EMS was received at 4:18 a.m. -EMS unit was dispatched at 4:20 a.m. -EMS unit was en route to the facility at 4:21 a.m. -EMS unit was at the facility at 4:23 a.m. -EMS personnel were at Resident #7's room at 4:24 a.m. -the Justice of the Peace pronounced Resident #7 dead at 4:28 a.m. Review of facility policy and procedure Cardiopulmonary Resuscitation dated [DATE] revealed: -"assess for unresponsiveness." -"when the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue." -"all staff members will receive education regarding the facility's CPR protocols and identification systems upon hire and at least annually thereafter." Review of the facility's licensed nurse skills check list, Licensed Nurse Proficiency Audit, undated revealed: -knowledge of Emergency Management included CPR Review of RN A's personnel file revealed no Licensed Nurse Proficiency Audit check list. Review of LVN B's personnel file revealed a Licensed Nurse Proficiency Audit check list was placed in the file but was blank. The form had no documentation regarding skills reviewed with LVN B. In an interview on [DATE] at 8:07 a.m., the Administrator said the Licensed Nurse Proficiency Audit check list should have been filled in for the nurses and placed in their respective personnel files. The Administrator said the former DON may or may not have reviewed the skills with nurses or may not have placed the Licensed Nurse Proficiency Audits in the nurses' personnel files. Review of the facility Job Description for Charge Nurse dated 2010, revealed knowledge base included: -"ability to organize work flow, respond to emergencies and note detail." Review of the facility policy and procedure Abuse/Neglect dated [DATE] revealed: -The Definition: "Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other." -"The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect." The facility Administrator was notified on [DATE] at 4:30 p.m., that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on [DATE] and accepted by the Program Manager on [DATE] at 2:03 p.m. The facility took the following actions to remove the IJ: -all licensed staff would be trained in identifying an emergency -training would be provided to all staff regarding CPR emergency response -the facility was scheduling CPR classes to assure licensed staff with expired CPR certifications would be recertified -CPR classes would be offered at the facility annually -mock code drills would be conducted on [DATE] and [DATE] -residents' code status information would be displayed prominently in each resident's clinical record and lists of residents with their code status would be placed in the CNAs' ADL binder at each of the 2 nurses' desks and in a folder on the crash cart All licensed nursing staff had received training in responding to CPR emergencies, either one-to-one or group in-service, by [DATE] at 6:30 p.m. Mock code drills were performed on [DATE] at 10:05 p.m., [DATE] at 6:20 a.m., and [DATE] at 2:58 p.m. CPR classes were held on [DATE] at 8:00 a.m. and [DATE] at 2:00 p.m. All licensed nursing staff whose CPR certification had expired attended and were re-certified. Interviews with facility nurses and CNAs on [DATE] from 5:38 p.m. to 7:42 p.m. revealed nurses and CNAs had received training in responding to CPR emergencies and in locations of residents' code status information. Nurses also listed steps to be taken immediately when residents are found to have no pulse and/or respirations. On [DATE] at 2:05 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff training and evaluate effectiveness of training. In an interview on [DATE] at 8:07 a.m., the Administrator said the DON had initiated disciplinary action for LVN B. The Administrator said the facility expectation was that licensed nurses would handle residents' medical emergencies. The Administrator acknowledged either RN A or LVN B should have called 911 immediately after finding he had no pulse or respirations. According to a list provided by the facility on [DATE], there were 28 residents in the facility who were a Full Code status.

Based on interview and record review, the facility failed to provide services that met professional standards of quality for 1 of 7 residents (#7) whose care was reviewed. RN A called the DON for instructions/guidance before calling EMS/911 when she determined Resident #7 required administration of CPR. RN A was unsure of actions to be taken for Resident #7. LVN B did not act to notify 911 immediately. Resident #7 was pronounced dead by the Justice of the Peace at 4:28 a.m. on [DATE]. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of actual harm. These failures resulted in CPR not provided for Resident #7 and could result in death and could affect 28 residents in the facility who were a Full Code status. Findings: Review of the Texas Administrative Code, Title 22, Part 11, Chaper 217, Rule 217.11 Standards of Nursing Practice, (1) and (M) revealed: "(1) Standards applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications;" Review of the facility policy and procedure Abuse/Neglect dated [DATE] revealed: -The Definition: "Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other." -"The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect." Review of facility policy and procedure Cardiopulmonary Resuscitation dated [DATE] revealed: -"assess for unresponsiveness." -"when the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue." Review of the facility Job Description for Charge Nurse dated 2010, revealed knowledge base included: -"ability to organize work flow, respond to emergencies and note detail." Review of Resident #7's admission orders [REDACTED]'s Medical Dictionary, 27th Ed., the condition of weighing 2 or 3 times ideal body weight and resulting in serious, life threatening conditions). Resident #7's CPR Status was documented as "Yes" indicating Full Code. Review of Resident #7's Monthly Record Weights, undated, revealed his admitting weight was documented as 566 pounds on [DATE]. In an interview on [DATE] at 11:25 a.m., RN A said she took care of Resident #7 during the shift that started at 6:00 p.m. on [DATE]. RN A said she spoke with Resident #7 at 12:15 a.m. until approximately 1:00 a.m. regarding his request for pain medication and her own career plans. RN A said she was sitting at the nurses' desk on Station II of the facility charting when she noted Resident #7's call light was on. RN A said she instructed CNAs C and D to answer the resident's light. RN A said that after answering the call light, CNA C told her Resident #7 said he wanted to sleep. RN A said at approximately 3:45 a.m., CNA C told her Resident #7 was "gone." RN A said she and CNA C returned to Resident #7's room and found him laying on his left side with his right hand hanging off the the side of the bed. RN A said she told CNA C to "call everyone" (staff in the facility). RN A said she assessed Resident #7 and found: -no movement of the chest -no radial (wrist) pulse -he was cold to touch -his hands and face were blue in color and there were dark patches on his hands and arms -upon listening with a stethoscope, he had no apical (apex of the heart) pulse or lung sounds -there were blood tinged secretions from his mouth RN A said she left the room with CNA C to call all staff. RN A said she, LVN B, CNAs C, D, and E combined to try and turn Resident #7 onto his back but were unsuccessful. RN A said she tried to deliver chest compressions to Resident #7 while he was laying on his left side. RN A said she left Resident #7's room to call the DON for help but was unable to reach her. RN A said she then called 911 for assistance. RN A said the time was: -approximately 3:48 a.m. when she entered Resident #7's room with CNA C -approximately 4:00 a.m. when she tried to call the DON -approximately 4:05 a.m. when she called 911 RN A was not sure of exact times events occurred. RN A said she did not know Resident #7's code status upon entering his room and that LVN B checked his chart but could not find his code status. RN A said she and LVN B then assumed Resident #7 was a Full Code. RN A listed the steps followed for CPR as establishing responsiveness, checking breathing, calling 911, and starting (chest) compressions. RN A said she did not follow the steps for administering CPR. RN A said she did not know how long Resident #7 had been unresponsive, with no pulse or respirations. RN A said she did not remember actions to be taken if a resident was found without a pulse or respirations and time of such condtion was unknown. RN A said she tried to get help by calling the DON. RN A said she was nervous, did not know what to do, and called the DON before calling 911. RN A said her orientation upon hire to the facility was 3 days long. RN A said she was not provided training by the facility on responding to emergencies like CPR. Review of RN A's CPR certification card revealed her certification expired in July, 2013. In an interview on [DATE] at 2:30 p.m., LVN B said she was in the facility copy room at 3:50 a.m. on [DATE] when CNA D approached her saying she thought Resident #7 was dead. LVN B said when she arrived at Resident #7's room, RN A was assessing him and told her the resident had no pulse. LVN B said Resident #7 was "blue in the face," his mouth was open, there was a pool of saliva at his mouth, and his limbs were blotchy. LVN B said staff tried to turn him over unsuccessfully. LVN B said she tried to help RN A and went to get Resident #7's chart. LVN B said she and RN A could not find information regarding Resident #7's code status. LVN B said she and RN A tried to call the DON and then called 911. LVN B was not sure of times that events took place. LVN B listed steps for CPR as feeling for a pulse, calling 911, rolling the patient over, and starting chest compressions. LVN B acknowledged 911 should have been called when it was determined Resident #7 had no pulse. LVN B said she did not act sooner to call 911 because "he (Resident #7) wasn't my resident." LVN B said she felt more responsible to help RN A and did not feel she had direct responsibility for Resident #7. LVN B said that prior to [DATE], she had not received training at the facility regarding response to CPR emergencies. LVN B said she understood training was to be conducted regarding response to CPR emergencies after [DATE] but she had not yet seen any posted information regarding proposed training. LVN B said she received CPR training and certification in August, 2012 for LVN school. In an interview on [DATE] at 3:10 p.m., the DON said disciplinary action had been initiated against RN A after Resident #7's CPR emergency. The DON said RN A resigned employment at the facility on [DATE]. In a telephone interview on [DATE] at 9:07 a.m., the Medical Director said Resident #7's medical conditions could have caused CPR to be ineffective. The Medical Director acknowledged that EMS/911 should have been called for Resident #7 before attempting to call the administrative staff. The facility Administrator was notified on [DATE] at 4:30 p.m., that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on [DATE] and accepted by the Program Manager on [DATE] at 2:03 p.m. The facility took the following actions to remove the IJ: -all licensed staff would be trained in identifying an emergency -training would be provided to all staff regarding CPR emergency response -the facility was scheduling CPR classes to assure licensed staff with expired CPR certifications would be recertified -CPR classes would be offered at the facility annually -mock code drills would be conducted on [DATE] and [DATE] -residents' code status information would be displayed prominently in each resident's clinical record and lists of residents with their code status would be placed in the CNAs' ADL binder at each of the 2 nurses' desks and in a folder on the crash cart All licensed nursing staff had received training in responding to CPR emergencies, either one-to-one or group in-service, by [DATE] at 6:30 p.m. Mock code drills were performed on [DATE] at 10:05 p.m., [DATE] at 6:20 a.m., and [DATE] at 2:58 p.m. CPR classes were held on [DATE] at 8:00 a.m. and [DATE] at 2:00 p.m. All licensed nursing staff whose CPR certification had expired attended and were re-certified. Interviews with facility nurses and CNAs on [DATE] from 5:38 p.m. to 7:42 p.m. revealed nurses and CNAs had received training in responding to CPR emergencies and in locations of residents' code status information. Nurses also listed steps to be taken immediately when residents are found to have no pulse and/or respirations. On [DATE] at 2:05 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff training and evaluate effectiveness of training. In an interview on [DATE] at 8:07 a.m., the Administrator said the DON had initiated disciplinary action against LVN B. The Administrator said the facility expectation was that licensed nurses would handle residents' medical emergencies. The Administrator acknowledged either RN A or LVN B should have called 911 immediately after finding he had no pulse or respirations. According to a list provided by the facility on [DATE], there were 28 residents in the facility who were a Full Code status.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect of residents for 1 of 7 residents (#7) whose care was reviewed for neglect. RN A did not immediately activate the EMS/911 for assistance until approximately 17 minutes after she assessed Resident #7 as having no pulse or respirations and requiring CPR. RN A was unsure of actions to be taken for Resident #7. LVN B did not act to notify 911 immediately. RN A was incharge of the residents residing in station A, and LVN B was incharge of the residents residing in station B. Resident #7 was pronounced dead by the Justice of the Peace at 4:28 a.m. on [DATE]. The Administrator and the DON investigated RN A's actions as possible neglect but did not investigate the actions of LVN B for possible neglect. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the DON not completing in-service training to all nursing staff on response to CPR emergencies nor evaluating the effectiveness of training. . These failures resulted in CPR not provided for Resident #7 and in a nurse whose actions were not investigated for possible neglect continuing to be available for provision of care to residents and could result in death that could affect 28 residents in the facility who were a Full Code status. Findings: Review of Resident #7's admission orders [REDACTED]'s Medical Dictionary, 27th Ed., the condition of weighing 2 or 3 times ideal body weight and resulting in serious, life threatening conditions). Resident #7's CPR Status was documented as "Yes" indicating Full Code. Review of Resident #7's Monthly Record Weights, undated, revealed his admitting weight was documented as 566 pounds on [DATE]. In an interview on [DATE] at 10:55 a.m., CNA C said she took care of Resident #7, whose room was on the 800 Hall, during the night shift that started at 10:00 p.m. on [DATE]. CNA C said staff working during that shift included RN A in charge of Station II, LVN B in charge of Station I, and CNAs D and E. CNA C said she answered Resident #7's call light at 2:00 a.m. on [DATE]. CNA C said Resident #7 told her he had not activated the call light and wanted to sleep. CNA C said she looked in on Resident #7 at either 2:30 or 3:15 a.m. and found him sleeping. CNA C was not sure which was the correct time but said she could tell Resident #7 was sleeping because he always lay on his left side with his right hand resting on his right hip. CNA C said that at 3:45 a.m. on [DATE], she entered Resdient #7's room to empty the garbage can. As she bent over to pick up the garbage can, CNA C said she glanced over at Resident #7's bed and saw his right hand was hanging over the side of the bed. CNA C said she walked over to Resident #7's bed and shook him. When Resident #7 did not respond, CNA C said she turned on the light and saw Resident #7's face, hands, and feet were blue to black in color. CNA C said she attempted to turn Resident #7 over unsuccessfully. CNA C said she left Resident #7's room and notified RN A immediately after finding him unresponsive at 3:45 a.m. CNA C said that on the way to Resident #7's room, she and RN A saw CNA D. CNA C said all 3 staff members went to the resident's room. CNA C said shortly after she and RN A arrived at Resident #7's room, LVN B also entered the room. CNA C said RNA and LVN B attempted to turn Resident #7 over but could not. CNA C said RN A was not sure if Resident #7 was a Full Code or whether she should call 911. CNA C said RN A tried to call the DON and then called 911. In an interview on [DATE] at 11:25 a.m., RN A said she took care of Resident #7 during the shift that started at 6:00 p.m. on [DATE]. RN A said she spoke with Resident #7 at 12:15 a.m. until approximately 1:00 a.m. regarding his request for pain medication and her own career plans. RN A said she was sitting at the nurses' desk on Station II of the facility charting when she noted Resident #7's call light was on. RN A said she instructed CNAs C and D to answer the resident's light. RN A said that after answering the call light, CNA C told her Resident #7 said he wanted to sleep. RN A said at approximately 3:45 a.m., CNA C told her Resident #7 was "gone." RN A said she and CNA C returned to Resident #7's room and found him laying on his left side with his right hand hanging off the the side of the bed. RN A said she told CNA C to "call everyone" (staff in the facility). RN A said she assessed Resident #7 and found: -no movement of the chest -no radial (wrist) pulse -he was cold to touch -his hands and face were blue in color and there were dark patches on his hands and arms -upon listening with a stethoscope, he had no apical (apex of the heart) pulse or lung sounds -there were blood tinged secretions from his mouth RN A said she left the room with CNA C to call all staff. RN A said she, LVN B, CNAs C, D, and E combined to try and turn Resident #7 onto his back but were unsuccessful. RN A said she tried to deliver chest compressions to Resident #7 while he was laying on his left side. RN A said she left Resident #7's room to call the DON for help but was unable to reach her. RN A said she then called 911 for assistance. RN A said the time was: -approximately 3:48 a.m. when she entered Resident #7's room with CNA C -approximately 4:00 a.m. when she tried to call the DON -approximately 4:05 a.m. when she called 911 RN A was not sure of exact times events occurred. RN A said she did not know Resident #7's code status upon entering his room and that LVN B checked his chart but could not find his code status. RN A said she and LVN B then assumed Resident #7 was a Full Code. RN A listed the steps followed for CPR as establishing responsiveness, checking breathing, calling 911, and starting (chest) compressions. RN A said she did not follow the steps for administering CPR. RN A said she did not know how long Resident #7 had been unresponsive, with no pulse or respirations. RN A said she did not remember actions to be taken if a resident was found without a pulse or respirations and time of such condtion was unknown. RN A said she tried to get help by calling DON G. RN A said she was nervous, did not know what to do, and called the DON before calling 911. RN A said her orientation upon hire to the facility was 3 days long. RN A said she was not provided training by the facility on responding to emergencies like CPR. Review of RN A's CPR certification card revealed her certification expired in July, 2013. In an interview on [DATE] at 12:55 p.m., CNA D said she saw Resident #7 at 2:00 a.m. with CNA C when they answered his call light. CNA D said Resident #7 told them he wanted to sleep. CNA D said she started to make rounds to check on residents in the 300 Hall at 3:45 a.m. on [DATE] when CNA C was looking for RN A and told her Resident #7 was "gone." CNA D said she accompanied CNA C and RN A to the resident's room. CNA D said upon entry to Resident #7's room, they found him laying in bed with his arms over the side of the bed. CNA D said Resident #7's face, hands, and feet were black. CNA D said RN A was "just kind of there, she didn't know his code status." CNA D said RN A walked over to Resident #7's bed and checked his pulse. CNA D said, at this point, she turned and left the room to find LVN B. CNA D said she found LVN B in the copy room and both proceeded to Resident #7's room. CNA D said upon entry to Resident #7's room, LVN B and RN A both looked at the resident. CNA D said the nurses left Resident #7's room and stood in the hall. CNA D said RN A looked at her phone and said she did not know what to do. CNA D said LVN B told RN A to look in Resident #7's chart. CNA D said the time was 4:15 a.m. CNA D said RN A then tried to call the DON, left a message for the DON, and then called 911. CNA D said she was not sure what time 911 was called. CNA D said RN A and LVN B decided to return to Resident #7's room and, along with CNAs C, D, and E tried to reposiiton the resident. CNA D said she was not sure what time EMS arrived. CNA D said that prior to [DATE], she had not received any training at the facility regarding response to CPR emergencies. In an interview on [DATE] at 1:16 p.m., CNA E said she was called at approximately 3:55 a.m. on [DATE] to help RN A, LVN B, and CNAs C and D try to reposition Resident #7. CNA E said she did not know if CPR was done for Resident #7. CNA E said the DON was called at approximately 4:00 a.m. and EMS/911 was called at approximately 4:02 a.m. CNA E said EMS arrived at the facility at approximately 4:20 a.m. CNA E said she then returned to her duty hall. CNA E said that prior to [DATE], she had not received any training at the facility regarding response to CPR emergencies. In an interview on [DATE] at 2:30 p.m., LVN B said she was in the facility copy room at 3:50 a.m. on [DATE] when CNA D approached her saying she thought Resident #7 was dead. LVN B said when she arrived at Resident #7's room, RN A was assessing him and told her the resident had no pulse. LVN B said Resident #7 was "blue in the face," his mouth was open, there was a pool of saliva at his mouth, and his limbs were blotchy. LVN B said staff tried to turn him over unsuccessfully. LVN B said she tried to help RN A and went to get Resident #7's chart. LVN B said she and RN A could not find information regarding Resident #7's code status. LVN B said she and RN A tried to call the DON and then called 911. LVN B was not sure of times that events took place. LVN B listed steps for CPR as feeling for a pulse, calling 911, rolling the patient over, and starting chest compressions. LVN B acknowledged 911 should have been called when it was determined Resident #7 had no pulse. LVN B said she did not act sooner to call 911 because "he (Resident #7) wasn't my resident." LVN B said she felt more responsible to help RN A and did not feel she had direct responsibility for Resident #7. LVN B said that prior to [DATE], she had not received training at the facility regarding response to CPR emergencies. LVN B said she understood training was to be conducted regarding response to CPR emergencies after [DATE] but she had not yet seen any posted information regarding proposed training. LVN B said she received CPR training and certification in August, 2012 for LVN school. In an interview on [DATE] at 3:10 p.m., the DON said actions taken after the CPR emergency involving Resident #7 on [DATE] included investigation of the event and plans for an in-service to staff regarding CPR response. The DON said RN A was suspended pending outcome of the facility investigation and that RN A submitted her resignation on [DATE]. The DON said she spoke to LVN B and counseled her on steps to take in an emergency. The DON said she planned to start the in-services to staff the next day, [DATE]. The DON said she was also arranging classes in CPR certification for nursing staff. In an interview on [DATE] at 3:15 p.m., both the Administrator and the DON asked if LVN B should have also been disciplined for her actions in not calling 911 immediately for Resident #7. In an interview on [DATE] at 7:46 a.m., the Administrator said the DON would be investigating LVN B's actions of [DATE]. In a telephone interview on [DATE] at 9:07 a.m., the Medical Director said Resident #7's medical conditions could have caused CPR to be ineffective. The Medical Director acknowledged that EMS/911 should have been called for Resident #7 before attempting to call the administrative staff. Review of RN A's documentation in Resident #7's Nurse Notes dated [DATE], revealed: -at 2:00 a.m. Resident #7's call light was on and he told CNA C he wanted to sleep -at 3:45 a.m. Resident #7 was found without a pulse and attempts were made to move him' -at 4:05 a.m. EMS/911 was called -at 4:15 a.m. the Administrator was called -at 4:30 a.m. EMS arrived and confirmed death -at 4:45 a.m. the Justice of the Peace (JP) and police arrived -at 5:00 a.m. the funeral home personnel arrived to transport Resident #7's body Review of RN A's witness statement dated [DATE] revealed: -at 4:00 a.m. on [DATE], she called the DON after attempts to position Resident #7 onto his back were unsuccessful. Purpose of the call was to request guidance and counseling from the DON -EMS arrived at 4:15 a.m. -JP arrived at 4:30 a.m. Review of the EMS Patient Care Report dated [DATE] revealed: -call to EMS was received at 4:18 a.m. -EMS unit was dispatched at 4:20 a.m. -EMS unit was en route to the facility at 4:21 a.m. -EMS unit was at the facility at 4:23 a.m. -EMS personnel were at Resident #7's room at 4:24 a.m. -the Justice of the Peace pronounced Resident #7 dead at 4:28 a.m. Review of facility policy and procedure Cardiopulmonary Resuscitation dated [DATE] revealed: -"assess for unresponsiveness." -"when the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue." -"all staff members will receive education regarding the facility's CPR protocols and identification systems upon hire and at least annually thereafter." Review of the facility Job Description for Charge Nurse dated 2010, revealed knowledge base included: -"ability to organize work flow, respond to emergencies and note detail." Review of the facility policy and procedure Abuse/Neglect dated [DATE] revealed: -The Definition: "Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other." -"The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect." -"With an allegation of abuse or neglect, the employee(s) will immediately be suspended pending an investigation." The facility Administrator was notified on [DATE] at 4:30 p.m., that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on [DATE] and accepted by the Program Manager on [DATE] at 2:03 p.m. The facility took the following actions to remove the IJ: -all licensed staff would be trained in identifying an emergency -training would be provided to all staff regarding CPR emergency response -the facility was scheduling CPR classes to assure licensed staff with expired CPR certifications would be recertified -CPR classes would be offered at the facility annually -mock code drills would be conducted on [DATE] and [DATE] -residents' code status information would be displayed prominently in each resident's clinical record and lists of residents with their code status would be placed in the CNAs' ADL binder at each of the 2 nurses' desks and in a folder on the crash cart All licensed nursing staff had received training in responding to CPR emergencies, either one-to-one or group in-service, by [DATE] at 6:30 p.m. Mock code drills were performed on [DATE] at 10:05 p.m., [DATE] at 6:20 a.m., and [DATE] at 2:58 p.m. CPR classes were held on [DATE] at 8:00 a.m. and [DATE] at 2:00 p.m. All licensed nursing staff whose CPR certification had expired attended and were re-certified. Interviews with facility nurses and CNAs on [DATE] from 5:38 p.m. to 7:42 p.m. revealed nurses and CNAs had received training in responding to CPR emergencies and in locations of residents' code status information. Nurses also listed steps to be taken immediately when residents are found to have no pulse and/or respirations. On [DATE] at 2:05 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff training and evaluate effectiveness of training. In an interview on [DATE] at 8:07 a.m., the Administrator said the DON had initiated disciplinary action for LVN B. The Administrator said the facility expectation was that licensed nurses would handle residents' medical emergencies. The Administrator acknowledged either RN A or LVN B should have called 911 immediately after finding Resident #7 had no pulse or respirations. According to a list provided by the facility on [DATE], there were 28 residents in the facility who were a Full Code status.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit neglect for 1 of 7 residents (#7) whose care was reviewed for neglect. RN A did not immediately activate the EMS/ 911 for assistance until approximately 17 minutes after she assessed Resident #7 as having no pulse or respirations and requiring CPR. RN A was unsure of actions to be taken for Resident #7. LVN B did not act to notify 911 immediately. RN A was incharge of the residents residing in station A, and LVN B was incharge of the residents residing in station B. Resident #7 was pronounced dead by the Justice of the Peace at 4:28 a.m. on [DATE]. The Administrator and DON G investigated RN A's actions as possible neglect but did not investigate the actions of LVN B for possible neglect. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the DON not completing in-service training to all nursing staff on response to CPR emergencies nor evaluating the effectiveness of training.. These failures resulted in CPR not provided for Resident #7 and in a nurse whose actions were not investigated for possible neglect continuing to be available for provision of care to residents and could result in death that could affect 28 residents in the facility who were a Full Code status. Findings: Review of the facility policy and procedure Abuse/Neglect dated [DATE] revealed: -The Definition: "Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other." -"The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect." -"With an allegation of abuse or neglect, the employee(s) will immedicately be suspended pending an investigation." Review of the facility Job Description for Charge Nurse dated 2010, revealed knowledge base included: -"ability to organize work flow, respond to emergencies and note detail." Review of facility policy and procedure Cardiopulmonary Resuscitation dated [DATE] revealed: -"assess for unresponsiveness." -"when the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue." Review of Resident #7's admission orders [REDACTED]'s Medical Dictionary, 27th Ed., the condition of weighing 2 or 3 times ideal body weight and resulting in serious, life threatening conditions). Resident #7's CPR Status was documented as "Yes" indicating Full Code. Review of Resident #7's Monthly Record Weights, undated, revealed his admitting weight was documented as 566 pounds on [DATE]. In an interview on [DATE] at 10:55 a.m., CNA C said she took care of Resident #7, whose room was on the 800 Hall, during the night shift that started at 10:00 p.m. on [DATE]. CNA C said staff working during that shift included RN A in charge of Station II, LVN B in charge of Station I, and CNAs D and E. CNA C said she answered Resident #7's call light at 2:00 a.m. on [DATE]. CNA C said Resident #7 told her he had not activated the call light and wanted to sleep. CNA C said she looked in on Resident #7 at either 2:30 or 3:15 a.m. and found him sleeping. CNA C was not sure which was the correct time but said she could tell Resident #7 was sleeping because he always lay on his left side with his right hand resting on his right hip. CNA C said that at 3:45 a.m. on [DATE], she entered Resdient #7's room to empty the garbage can. As she bent over to pick up the garbage can, CNA C said she glanced over at Resident #7's bed and saw his right hand was hanging over the side of the bed. CNA C said she walked over to Resident #7's bed and shook him. When Resident #7 did not respond, CNA C said she turned on the light and saw Resident #7's face, hands, and feet were blue to black in color. CNA C said she attempted to turn Resident #7 over unsuccessfully. CNA C said she left Resident #7's room and notified RN A immediately after finding him unresponsive at 3:45 a.m. CNA C said that on the way to Resident #7's room, she and RN A saw CNA D. CNA C said all 3 staff members went to the resident's room. CNA C said shortly after she and RN A arrived at Resident #7's room, LVN B also entered the room. CNA C said RNA and LVN B attempted to turn Resident #7 over but could not. CNA C said RN A was not sure if Resident #7 was a Full Code or whether she should call 911. CNA C said RN A tried to call the DON and then called 911. In an interview on [DATE] at 11:25 a.m., RN A said she took care of Resident #7 during the shift that started at 6:00 p.m. on [DATE]. RN A said she spoke with Resident #7 at 12:15 a.m. until approximately 1:00 a.m. regarding his request for pain medication and her own career plans. RN A said she was sitting at the nurses' desk on Station II of the facility charting when she noted Resident #7's call light was on. RN A said she instructed CNAs C and D to answer the resident's light. RN A said that after answering the call light, CNA C told her Resident #7 said he wanted to sleep. RN A said at approximately 3:45 a.m., CNA C told her Resident #7 was "gone." RN A said she and CNA C returned to Resident #7's room and found him laying on his left side with his right hand hanging off the the side of the bed. RN A said she told CNA C to "call everyone" (staff in the facility). RN A said she assessed Resident #7 and found: -no movement of the chest -no radial (wrist) pulse -he was cold to touch -his hands and face were blue in color and there were dark patches on his hands and arms -upon listening with a stethoscope, he had no apical (apex of the heart) pulse or lung sounds -there were blood tinged secretions from his mouth RN A said she left the room with CNA C to call all staff. RN A said she, LVN B, CNAs C, D, and E combined to try and turn Resident #7 onto his back but were unsuccessful. RN A said she tried to deliver chest compressions to Resident #7 while he was laying on his left side. RN A said she left Resident #7's room to call the DON for help but was unable to reach her. RN A said she then called 911 for assistance. RN A said the time was: -approximately 3:48 a.m. when she entered Resident #7's room with CNA C -approximately 4:00 a.m. when she tried to call the DON -approximately 4:05 a.m. when she called 911 RN A was not sure of exact times events occurred. RN A said she did not know Resident #7's code status upon entering his room and that LVN B checked his chart but could not find his code status. RN A said she and LVN B then assumed Resident #7 was a Full Code. RN A listed the steps followed for CPR as establishing responsiveness, checking breathing, calling 911, and starting (chest) compressions. RN A said she did not follow the steps for administering CPR. RN A said she did not know how long Resident #7 had been unresponsive, with no pulse or respirations. RN A said she did not remember actions to be taken if a resident was found without a pulse or respirations and time of such condtion was unknown. RN A said she tried to get help by calling the DON . RN A said she was nervous, did not know what to do, and called the DON before calling 911. RN A said her orientation upon hire to the facility was 3 days long. RN A said she was not provided training by the facility on responding to emergencies like CPR. Review of RN A's CPR certification card revealed her certification expired in July, 2013. In an interview on [DATE] at 12:55 p.m., CNA D said she saw Resident #7 at 2:00 a.m. with CNA C when they answered his call light. CNA D said Resident #7 told them he wanted to sleep. CNA D said she started to make rounds to check on residents in the 300 Hall at 3:45 a.m. on [DATE] when CNA C was looking for RN A and told her Resident #7 was "gone." CNA D said she accompanied CNA C and RN A to the resident's room. CNA D said upon entry to Resident #7's room, they found him laying in bed with his arms over the side of the bed. CNA D said Resident #7's face, hands, and feet were black. CNA D said RN A was "just kind of there, she didn't know his code status." CNA D said RN A walked over to Resident #7's bed and checked his pulse. CNA D said, at this point, she turned and left the room to find LVN B. CNA D said she found LVN B in the copy room and both proceeded to Resident #7's room. CNA D said upon entry to Resident #7's room, LVN B and RN A both looked at the resident. CNA D said the nurses left Resident #7's room and stood in the hall. CNA D said RN A looked at her phone and said she did not know what to do. CNA D said LVN B told RN A to look in Resident #7's chart. CNA D said the time was 4:15 a.m. CNA D said RN A then tried to call the DON, left a message for the DON, and then called 911. CNA D said she was not sure what time 911 was called. CNA D said RN A and LVN B decided to return to Resident #7's room and, along with CNAs C, D, and E tried to reposiiton the resident. CNA D said she was not sure what time EMS arrived. CNA D said that prior to [DATE], she had not received any training at the facility regarding response to CPR emergencies. In an interview on [DATE] at 1:16 p.m., CNA E said she was called at approximately 3:55 a.m. on [DATE] to help RN A, LVN B, and CNAs C and D try to reposition Resident #7. CNA E said she did not know if CPR was done for Resident #7. CNA E said the DON was called at approximately 4:00 a.m. and EMS/911 was called at approximately 4:02 a.m. CNA E said EMS arrived at the facility at approximately 4:20 a.m. CNA E said she then returned to her duty hall. CNA E said that prior to [DATE], she had not received any training at the facility regarding response to CPR emergencies. In an interview on [DATE] at 2:30 p.m., LVN B said she was in the facility copy room at 3:50 a.m. on [DATE] when CNA D approached her saying she thought Resident #7 was dead. LVN B said when she arrived at Resident #7's room, RN A was assessing him and told her the resident had no pulse. LVN B said Resident #7 was "blue in the face," his mouth was open, there was a pool of saliva at his mouth, and his limbs were blotchy. LVN B said staff tried to turn him over unsuccessfully. LVN B said she tried to help RN A and went to get Resident #7's chart. LVN B said she and RN A could not find information regarding Resident #7's code status. LVN B said she and RN A tried to call the DON and then called 911. LVN B was not sure of times that events took place. LVN B listed steps for CPR as feeling for a pulse, calling 911, rolling the patient over, and starting chest compressions. LVN B acknowledged 911 should have been called when it was determined Resident #7 had no pulse. LVN B said she did not act sooner to call 911 because "he (Resident #7) wasn't my resident." LVN B said she felt more responsible to help RN A and did not feel she had direct responsibility for Resident #7. LVN B said that prior to [DATE], she had not received training at the facility regarding response to CPR emergencies. LVN B said she understood training was to be conducted regarding response to CPR emergencies after [DATE] but she had not yet seen any posted information regarding proposed training. LVN B said she received CPR training and certification in August, 2012 for LVN school. In an interview on [DATE] at 3:10 p.m., the DON said actions taken after the CPR emergency involving Resident #7 on [DATE] included investigation of the event and plans for an in-service to staff regarding CPR response. The DONsaid RN A was suspended pending outcome of the facility investigation and that RN A submitted her resignation on [DATE]. The DON said she spoke to LVN B and counseled her on steps to take in an emergency. The DON said she planned to start the in-services to staff the next day, [DATE]. The DON said she was also arranging classes in CPR certification for nursing staff. In an interview on [DATE] at 3:15 p.m., the Administrator and the DON asked if LVN B should have also been disciplined for not immediately calling 911 for Resident #7. In an interview on [DATE] at 7:46 a.m., the Administrator said the DON would be investigating LVN B's actions of [DATE]. In a telephone interview on [DATE] at 9:07 a.m., the Medical Director said Resident #7's medical conditions could have caused CPR to be ineffective. The Medical Director acknowledged that EMS/911 should have been called for Resident #7 before attempting to call the administrative staff. Review of RN A's documentation in Resident #7's Nurse Notes dated [DATE], revealed: -at 2:00 a.m. Resident #7's call light was on and he told CNA C he wanted to sleep -at 3:45 a.m. Resident #7 was found without a pulse and attempts were made to move him' -at 4:05 a.m. EMS/911 was called -at 4:15 a.m. the Administrator was called -at 4:30 a.m. EMS arrived and confirmed death -at 4:45 a.m. the Justice of the Peace (JP) and police arrived -at 5:00 a.m. the funeral home personnel arrived to transport Resident #7's body Review of RN A's witness statement dated [DATE] revealed: -at 4:00 a.m. on [DATE], she called the DON after attempts to position Resident #7 onto his back were unsuccessful. Purpose of the call was to request guidance and counseling from the DON -EMS arrived at 4:15 a.m. -JP arrived at 4:30 a.m. Review of the EMS Patient Care Report dated [DATE] revealed: -call to EMS was received at 4:18 a.m. -EMS unit was dispatched at 4:20 a.m. -EMS unit was en route to the facility at 4:21 a.m. -EMS unit was at the facility at 4:23 a.m. -EMS personnel were at Resident #7's room at 4:24 a.m. -the Justice of the Peace pronounced Resident #7 dead at 4:28 a.m. The facility Administrator was notified on [DATE] at 4:30 p.m., that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on [DATE] and accepted by the Program Manager on [DATE] at 2:03 p.m. The facility took the following actions to remove the IJ: -all licensed staff would be trained in identifying an emergency -training would be provided to all staff regarding CPR emergency response -the facility was scheduling CPR classes to assure licensed staff with expired CPR certifications would be recertified -CPR classes would be offered at the facility annually -mock code drills would be conducted on [DATE] and [DATE] -residents' code status information would be displayed prominently in each resident's clinical record and lists of residents with their code status would be placed in the CNAs' ADL binder at each of the 2 nurses' desks and in a folder on the crash cart All licensed nursing staff had received training in responding to CPR emergencies, either one-to-one or group in-service, by [DATE] at 6:30 p.m. Mock code drills were performed on [DATE] at 10:05 p.m., [DATE] at 6:20 a.m., and [DATE] at 2:58 p.m. CPR classes were held on [DATE] at 8:00 a.m. and [DATE] at 2:00 p.m. All licensed nursing staff whose CPR certification had expired attended and were re-certified. Interviews with facility nurses and CNAs on [DATE] from 5:38 p.m. to 7:42 p.m. revealed nurses and CNAs had received training in responding to CPR emergencies and in locations of residents' code status information. Nurses also listed steps to be taken immediately when residents are found to have no pulse and/or respirations. On [DATE] at 2:05 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff training and evaluate effectiveness of training. In an interview on [DATE] at 8:07 a.m., the Administrator said the DON had initiated disciplinary action for LVN B. The Administrator said the facility expectation was that licensed nurses would handle residents' medical emergencies. The Administrator acknowledged either RN A or LVN B should have called 911 immediately after finding Resident #7 had no pulse or respirations. According to a list provided by the facility on [DATE], there were 28 residents in the facility who were a Full Code status.

Based on interview and record review, the Administrator and Director of Nurses failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable well-being for 1 of 7 residents (#7) whose care was reviewed. The DON did not determine or monitor that staff nurses were competent in responding to CPR emergencies. The Administrator who was the Abuse Prevention Coordinator did not investigate the actions of LVN B as possible neglect for not notifying 911 immediately when Resident #7 required CPR. Resident #7 had a cardiopulmonary arrest, did not receive CPR, and was pronounced dead by the Justice of the Peace approximately 40 minutes after he was found unresponsive by RN A. These failures resulted in identification of an IJ (Immediate Jeopardy) and Substandard Quality of Care (SQC) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the DON not completing in-service training to all nursing staff on response to CPR emergencies or evaluating the effectiveness of training. These failures resulted in CPR not provided for Resident #7 and in a nurse whose actions were not investigated for possible neglect continuing to be available for provision of care to residents and could result in death that could affect 28 residents in the facility who were a Full Code status. Findings: Review of Resident #7's admission orders [REDACTED]'s Medical Dictionary, 27th Ed., the condition of weighing 2 or 3 times ideal body weight and resulting in serious, life threatening conditions). Resident #7's CPR Status was documented as "Yes" indicating Full Code. Review of Resident #7's Monthly Record Weights, undated, revealed his admitting weight was documented as 566 pounds. In an interview on [DATE] at 11:25 a.m., RN A said she took care of Resident #7 during the shift that started at 6:00 p.m. on [DATE]. RN A said she had a conversation with Resident #7 from 12:15 a.m. until approximately 1:00 a.m. RN A said she was sitting at the nurses' desk on Station II of the facility charting when she noted Resident #7's call light was on. RN A said she instructed CNAs C and D to answer the resident's light. RN A said that after answering the call light, CNA C told her Resident #7 said he wanted to sleep. RN A said at approximately 3:45 a.m., CNA C told her Resident #7 was "gone." RN A said she and CNA C returned to Resident #7's room and found him laying on his left side with his right hand hanging off the the side of the bed. RN A said she told CNA C to "call everyone" (staff in the facility). RN A said she assessed Resident #7 and found: -no movement of the chest -no radial (wrist) pulse -he was cold to touch -his hands and face were blue in color and there were dark patches on his hands and arms -upon listening with a stethoscope, he had no apical (apex of the heart) pulse or lung sounds -there were blood tinged secretions from his mouth RN A said she left the room with CNA C to call all staff. RN A said she, LVN B, CNAs C, D, and E combined to try and turn Resident #7 onto his back but were unsuccessful. RN A said she tried to deliver chest compressions to Resident #7 while he was laying on his left side. RN A said she left Resident #7's room to call the DON for help but was unable to reach her. RN A said she then called 911 for assistance. RN A said the time was: -approximately 3:48 a.m. when she entered Resident #7's room with CNA C -approximately 4:00 a.m. when she tried to call the DON -approximately 4:05 a.m. when she called 911 RN A was not sure of exact times events occurred. RN A said she did not know Resident #7's code status upon entering his room and that LVN B checked his chart but could not find his code status. RN A said she and LVN B then assumed Resident #7 was a Full Code. RN A listed the steps followed for CPR as establishing responsiveness, checking breathing, calling 911, and starting (chest) compressions. RN A said she did not follow the steps for administering CPR. RN A said she did not know how long Resident #7 had been unresponsive, with no pulse or respirations. RN A said she did not remember actions to be taken if a resident was found without a pulse or respirations and time of such condtion was unknown. RN A said she tried to get help by calling the DON. RN A said she was nervous, did not know what to do, and called the DON before calling 911. RN A said her orientation upon hire to the facility was 3 days long. RN A said she was not provided training by the facility on responding to emergencies like CPR. RN A said she started working at the facility in December, 2012. Review of RN A's CPR certification card revealed her certification expired in July, 2013. Review of the EMS Patient Care Report dated [DATE] revealed: -the Justice of the Peace pronounced Resident #7 dead at 4:28 a.m. In an interview on [DATE] at 12:55 p.m., CNA D, who was on duty on [DATE] when Resident #7 experienced the CPR emergency, said she had worked at the facility since May, 2013. CNA D said she had not received any training at the facility on responding to CPR emergencies. In an interview on [DATE] at 1:16 p.m., CNA E, who was on duty on [DATE] when Resident #7 experienced the CPR emergency, said she had worked at the facility approximately 1 year. CNA E said she had not received any training in responding to CPR emergencies. In an interview on [DATE] at 2:30 p.m., LVN B said she was in the facility copy room at 3:50 a.m. on [DATE] when CNA D approached her saying she thought Resident #7 was dead. LVN B said when she arrived at Resident #7's room, RN A was assessing him and told her the resident had no pulse. LVN B said Resident #7 was "blue in the face," his mouth was open, there was a pool of saliva at his mouth, and his limbs were blotchy. LVN B said staff tried to turn him over unsuccessfully. LVN B said she tried to help RN A and went to get Resident #7's chart. LVN B said she and RN A could not find information regarding Resident #7's code status. LVN B said she and RN A tried to call the DON and then called 911. LVN B was not sure of times that events took place. LVN B listed steps for CPR as feeling for a pulse, calling 911, rolling the patient over, and starting chest compressions. LVN B acknowledged 911 should have been called when it was determined Resident #7 had no pulse. LVN B said she did not act sooner to call 911 because "he (Resident #7) wasn't my resident." LVN B said she felt more responsible to help RN A and did not feel she had direct responsibility for Resident #7. LVN B said that prior to [DATE], she had not received training at the facility regarding response to CPR emergencies. LVN B said she understood training was to be conducted regarding response to CPR emergencies after [DATE] but she had not yet seen any posted information regarding proposed training. LVN B said she received CPR training and certification in August, 2012 for LVN school. LVN B said she started working at the facility on [DATE]. In an interview on [DATE] at 3:10 p.m., the DON said actions taken after the CPR emergency involving Resident #7 on [DATE] included investigation of the event and plans for an in-service to staff regarding CPR response. The DON said RN A was suspended pending outcome of the facility investigation and that RN A submitted her resignation on [DATE]. The DON said she spoke to LVN B and counseled her on steps to take in an emergency. The DON said she planned to start the in-services to staff the next day, [DATE]. The DON said she was also arranging classes in CPR certification for nursing staff. In an interview on [DATE] at 3:15 p.m., the Administrator and DON asked if LVN B should have also been disciplined about not acting to call 911 immediately. In an interview on [DATE] at 6:54 p.m., the Administrator and DON said the former DON left employment at the facility on [DATE]. The Administrator and DON said they had not been able to locate personnel files and Quality Assurance information that the former DON had kept in her office. In an interview on [DATE] at 7:46 a.m., the Administrator said the DON would be investigating LVN B's actions of [DATE]. In an interview on [DATE] at 8:07 a.m., the Administrator said her supervision of the former DON providing training to nursing staff involved observation of the former DON talking to staff about how to handle medical emergencies. The Administrator said she did not remember dates of observed training by the former DON to staff. In reviewing documentation regarding in-services provided to staff since July, 2012, the Administrator could not locate any training that specified CPR emergencies. The Administrator said she found sign in sheets with a topic listed such as "Risk Management", given on [DATE], but no outline of subjects covered. The Administrator said the facility provided Respiratory training on [DATE]. In reviewing the Respiratory training outline in the facility manual, the Administrator said content did not include respiratory arrest. The Administrator said she told the former DON to place original copies of in-service trainings in the Administrator's office, but the former DON had not done so. In an interview on [DATE] at 10:49 a.m., LVN F said she helped orient LVN B to the facility. LVN F said she showed LVN B where the emergency/crash cart was. LVN F said she did not orient LVN B to any emergency procedures. LVN F said she did not cover CPR emergencies with LVN B because "they (LVN B} had that in school." LVN F said she did not remember when she last received training in the facility on responding to medical emergencies. LVN F said she had worked at the facility for [AGE] years. Review of facility policy and procedure Cardiopulmonary Resuscitation dated [DATE] revealed: -"assess for unresponsiveness." -"when the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue." -"all staff members will receive education regarding the facility's CPR protocols and identification systems upon hire and at least annually thereafter." Review of the facility's licensed nurse skills check list, Licensed Nurse Proficiency Audit, undated, revealed: -knowledge of Emergency Management included CPR Review of RN A's personnel file revealed no Licensed Nurse Proficiency Audit check list. Review of LVN B's personnel file revealed a Licensed Nurse Proficiency Audit check list was placed in the file but was blank except for LVN B's name and license number. The form had no documentation regarding skills reviewed with LVN B. In an interview on [DATE] at 8:07 a.m., the Administrator said the Licensed Nurse Proficiency Audit check list should have been filled in for the nurses and placed in their respective personnel files. The Administrator said the former DON may or may not have reviewed the skills with nurses or may not have placed the Licensed Nurse Proficiency Audits in the nurses' personnel files. Review of the facility Job Description for Charge Nurse dated 2010, revealed knowledge base included: -"ability to organize work flow, respond to emergencies and note detail." Review of the facility policy and procedure Abuse/Neglect dated [DATE] revealed: -The Definition: "Neglect: Failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other." -"The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect." Review of the facility Job Description Administrator dated 2010, revealed the job functions of the Administrator included: -Accountable for total operation of the assigned nursing home in complicance with Standards of Operations and applicable local, state, and federal regulations." Review of the facility Job Description Director of Nursing dated 2010, revealed the job functions of the Director of Nursing included: -"Manage nursing staff through appropriate hiring, training, evaluation, assignment and delegation of duties, within budget and resident census regulations." "Train and develop nursing staff to achieve positive resident outcome." The facility Administrator was notified on [DATE] at 4:30 p.m., that an IJ situation had been identified due to the above failures. Facility Plan of Removal was provided by the Administrator on [DATE] and accepted by the Program Manager on [DATE] at 2:03 p.m. The facility took the following actions to remove the IJ: -all licensed staff would be trained in identifying an emergency -training would be provided to all staff regarding CPR emergency response -the facility was scheduling CPR classes to assure licensed staff with expired CPR certifications would be recertified -CPR classes would be oferred at the facility annually -mock code drills would be conducted on [DATE] and [DATE] -residents' code status information would be displayed prominently in each resident's clinical record and lists of residents with their code status would be placed in the CNAs' ADL binder at each of the 2 nurses' desks and in a folder on the crash cart All licensed nursing staff had received training in responding to CPR emergencies, either one-to-one or group in-service, by [DATE] at 6:30 p.m. Mock code drills were performed on [DATE] at 10:05 p.m., [DATE] at 6:20 a.m., and [DATE] at 2:58 p.m. CPR classes were held on [DATE] at 8:00 a.m. and [DATE] at 2:00 p.m. All licensed nursing staff whose CPR certification had expired attended and were re-certified. Interviews with facility nurses and CNAs on [DATE] from 5:38 p.m. to 7:42 p.m. revealed nurses and CNAs had received training in responding to CPR emergencies and in locations of residents' code status information. Nurses also listed steps to be taken immediately when residents are found to have no pulse and/or respirations. On [DATE] at 2:05 p.m., the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity level of actual harm with a scope of pattern due to the facility not having sufficient time to complete staff training and evaluate effectiveness of training. In an interview on [DATE] at 8:07 a.m., the Administrator said the DON had initiated disciplinary action for LVN B. The Administrator said the facility expectation was that licensed nurses would handle residents' medical emergencies. The Administrator acknowledged either RN A or LVN B should have called 911 immediately after finding Resident #7 had no pulse or respirations. According to a list provided by the facility on [DATE], there were 28 residents in the facility who were a Full Code status.