Every finding on record at West Oaks Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #27, Resident #50, and Resident #109) reviewed for resident rights.The facility failed to ensure CNA D knocked on Resident #27's door before entering the resident's room.The facility failed to ensure CNA E knocked on Resident #109's door before entering the resident's room.The facility failed to ensure Resident #50's catheter bag had a privacy cover on.These failures could place residents at risk of feeling like their privacy was invaded or cause psychosocial harm and emotional distress.Findings include:1. Record review of Resident #27's face sheet, dated 02/24/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #27 had diagnoses which included reduced mobility, unsteadiness on feet, dementia (memory, thinking, difficulty), cognitive communication deficit (problems with communication), muscle weakness, cerebral infraction (long term effects of a stroke), Schizophrenia (mental disorder that affects a person's ability to think, feel and behave clearly), and peripheral vascular disease (abnormal narrowing of arteries),Record review of Resident #27's quarterly MDS assessment, dated 01/30/2026, revealed Resident #27 had a BIMS score of 0, which indicated severe cognitive impairment.During an observation of 100-hall on 02/23/2026 at 12:26 p.m., revealed CNA D did not knock on Resident #9's door before entering.During an attempted interview with Resident #27 on 02/23/2026 at 9:53 a.m., revealed she was lying in her bed but would not respond to the state surveyor.2. Record review of Resident #50's face sheet, dated 02/24/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included muscle wasting, neuromuscular dysfunction of bladder (lack of bladder control), hyperthyroidism (excessive production of thyroid hormones), hypertension (high blood pressure), pulmonary embolism without acute cor pulmonale (blood clot in the lungs without difficulty breathing) and tracheostomy status (an incision in the front of the neck to create a direct airway into the trachea.).Record review of Resident #50's quarterly MDS assessment, dated 02/16/2026, revealed Resident #50 had a BIMS score of 0, which indicated severe cognitive impairment.Record review of Resident #50's care plan, dated 02/16/2026, revealed [Resident #50] has a catheter r/t neurogenic bladder. Position catheter bag and tubing below the level of the bladder and away from entrance room door.Record review of Resident #50's Physician orders, dated 2/12/2026, revealed Position Privacy bag and tubing below the level of the bladder.During an observation of Resident #50 on 02/23/2026 at 10:22 a.m., revealed the resident was lying in bed. Resident #50 had a catheter bag that did not have a privacy cover on it.During an attempted interview with Resident #50 on 02/23/2026 at 10:23 a.m., revealed the resident could not respond to questions. Resident #50 was lying in bed and had a trach in her neck.During an interview with CNA D on 02/25/2026 at 10:06 a.m., she said the policy for covering catheter bags was that the catheter bag must always be sealed and covered with a blue bag. She said the CNAs were responsible for ensuring the catheter bags had a privacy cover. She said the resident may feel uncomfortable if the catheter bag did not have a privacy cover. She said the CNA's monitored to ensure the residents had a privacy cover on their catheter. She said she did not know why Resident #50 did not have the privacy bag on her catheter. During an interview with the DON on 02/25/2026 at 2:14 p.m., she said the policy for covering catheters was staff must cover the catheter with a privacy. She said the catheter should always have a privacy cover on it. She said all staff were responsible for ensuring the catheter had a privacy cover. She said the resident might not like that their catheter bag did not have a privacy cover. She said all staff should monitor to ensure the catheter bags had privacy covers. She said staff monitored the catheter bags by doing rounds on the residents. She said the only thing she could think of was the resident came from the hospital and they did not change the catheter bag. She said the facility had catheter bags with the built in privacy cover.During an interview with the ADM on 02/25/2026 at 3:06 p.m., he said the policy for covering the catheter bags was all catheter bags must have a privacy cover on them. He said the nurses and aids were responsible for ensuring the catheters bags had a privacy cover over them. He said if the catheter did not have a privacy cover on it the resident may feel embarrassed. He said management monitored to ensure the catheter bags had covers on them. He said management monitored by doing morning rounds. He said he did not know why Resident #50 did not have a privacy cover on her catheter bag.Record review of the facility's Indwelling Urinary Catheter Care Policy, dated 12/2025, revealed It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. Cover the drainage bag with a privacy bag to maintain dignity.3. Record review of Resident #109's face sheet, dated 02/24/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #109 had diagnoses which included parkinsonism (syndrome characterized by tremors and postural instability), dementia (memory, thinking, difficulty), major depressive disorder (mental health disorder characterized by persistent depressed mood), and cognitive communication deficit (problems with communication).Record review of Resident #109's quarterly MDS, dated [DATE], revealed Resident #109 had a BIMS of 14, which indicated intact cognitive response.During an observation of 200-hall on 02/23/2026 at 11:45a.m., revealed CNA E did not knock on resident #109's door before entering.During an interview with Resident #109 on 02/23/2026 at 10:36 a.m., she said the staff did not always knock on the door before entering. She said she would like for staff to knock before entering her room. She said knocking was the right thing to do. She said she did not get upset when staff do not knock.During an interview with CNA D on 02/25/2026 at 10:03 a.m., she said she had been trained on resident rights. She said the policy for knocking on the door was to knock before entering the room. She said the CNAs were responsible for knocking on the residents door. She said if staff did not knock on the door before entering the resident may feel uncomfortable or their privacy was invaded. She said the CNAs monitored to ensure staff knocked on the residents' doors. She said staff monitored by observation. She said she did not knock on Resident #27's door because she was distributing lunch.During an interview with CNA E on 02/25/2026 at 10:19 a.m., he said he had been trained on resident rights. He said the policy for knocking was staff were to knock and announce themselves before entering. He said all staff should knock on the door before entering. He said a resident may feel uncomfortable and feel violated if staff did not knock before entering the room. He said the nurse monitored to ensure staff were knocking. He said the nurses monitored by observations. He said he did not know why he did not knock on Resident #109's door. During an interview with the DON on 02/25/2026 at 2:12 p.m., she said she was trained on resident rights. She said the policy for knocking was staff were to knock before entering any residents' room. She said all staff were responsible for knocking on the resident's door. She said if staff did not knock on the door before entering, the resident could get startled. She said the DON and ADM monitored to ensure staff were knocking on residents' doors. She said the DON and the ADM monitored by doing rounds throughout the day. She said she did not know why staff were not knocking on residents' doors before entering. During an interview with the ADM on 02/25/2026 at 2:18 p.m., he said the policy for knocking was staff were to knock before entering and introduce themselves. He said all staff should knock if wanting to enter the resident's room. He said residents' may feel surprised, and shocked if staff did not knock on the door before entering. He said management monitored to ensure staff were knocking on resident doors. He said management did daily rounds and observed staff walking in resident rooms. He also said if management saw staff not knocking the manager would in-service the staff member immediately . He said he did not know why staff did not knock on Resident #27 and Resident #109's doors before entering. Record review of Resident Rights Dignity Policy dated 07/2025 revealed It is the policy of this facility that all residents be treated with kindness, dignity and respect. The right to privacy.

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 3 of 6 staff ( the DM, CK A and CK B) reviewed for food and nutrition services. The facility failed to ensure the DM, CK A and CK B wore appropriate hairnets so the hair was not exposed. This failure could place residents at risk of having hair in their food as well as ingesting contaminated food leading to illness.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 3 of 6 staff ( the DM, CK A and CK B) reviewed for food and nutrition services. The facility failed to ensure the DM, CK A and CK B wore appropriate hairnets so the hair was not exposed. This failure could place residents at risk of having hair in their food as well as ingesting contaminated food leading to illness. Findings include: Observations on 02/23/26 at 09:00 AM revealed CK A's hairnet was not covering their full hair and hair was exposed while preparing lunch for residents in the kitchen. The front and top was covered while the back was exposed and free. Although CK A's hair was in a bun, the back was hanging to the neck. Observation on 02/23/26 at 11:25 AM revealed CK B in the kitchen without a hair net and full head of hair was exposed. CK B's hair was hanging down past the shoulders. Observation on 02/24/26 at 08:45 AM revealed the DM in the kitchen with her hair not fully covered by her hair net. The front and top were covered while the back of her hair was exposed and free. Although the DM's hair was in a bun, the back was hanging to the neck. In an interview with CK A on 02/23/26 at 09:00 AM, she stated the facility had a policy that stated hair nets were to cover the full head. She stated exposed hair placed residents at risk of hair in their food that could make them sick. She stated she was in-serviced on hair restraints about 2 weeks ago (dates not provided). CK A stated the DM was responsible for ensuring staff wore proper hair restraints. The policy on hair restraints was requested from CK A, but she stated she did not know the location of the policy binder. In an interview with CK B on 02/23/26 at 11:35 AM, she stated according to facility policy, hair nets were supposed to be put on before entering the kitchen. CK B stated exposed hair placed residents at risk of hair in their food and added it was an all-around safety issue. She stated she was trained on hair nets in June 2018 when she started, and again a couple of weeks ago (exact date unknown). She stated training included ensuring staff wore hair restraints properly. CK B stated full head should be covered. In an interview with the DM on 02/23/26 at 11:30 AM, she stated there was a facility policy related to hair restraints. She stated the policy stated hair nets had to cover the full head, to include ears with no hair exposed. She stated she had not conducted an in-service with staff, but added according to staff, an in-service was done about 2 months ago (date not provided) by the Dietitian. The DM stated hair falling into food could cause stomach issues and choking. She stated it was her responsibility to ensure staff wore hair restraints properly. The DM stated Surveyor just walked in and caught her with the hairnet partially on. Record review of the facility's, undated, policy Hair Restraints reflected, (a) Except as provided in subsection (b) of this section, food employees shall wear hair restraints such as hats, hair covering 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 SOM - Appendix PP reflected, Hair Restraints/Jewelry/Nail Policy - According to the current standards of practice such as the Food Code of the FDA, food service staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. According to the Food Code, food service staff must wear hairnets when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad. Record review of facility's in-services for 90 days was conducted and reflected:*02/23/26 Hairnet: Hairnets on before walking into kitchen. Always! 5 of 6 kitchen staff signed the sign-in sheet.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #50, #11, and #99) reviewed for infection control. The facility failed to ensure Resident #50 and Resident #11's catheter drainage bags were positioned correctly and not touching the floor on 02/23/2026 and 02/24/2026.The facility failed to ensure MA performed hand hygiene before preparing medications for Resident #99.The facility failed to ensure the Blood pressure monitor was sanitized after it was picked up from the floor and placed on the medication cart for Resident #99. These failures could place residents at risk for cross contamination and the spread of infection.Findings include: 1. Record review of Resident #50's face sheet, dated 02/24/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included nontraumatic intracerebral hemorrhage in cerebellum (brain bleed), acute respiratory failure with tracheostomy status (surgically created opening in the neck/windpipe to allow air to reach the lungs when normal breathing is impaired), speech and language deficits following cerebral infarction (stroke) and gastrostomy status (feeding tube). Record review of Resident #50's admission MDS Assessment, dated 02/16/2026, reflected no BIMS score because Resident #50 was rarely understood and nonverbal. Resident #50 was completely dependent on all tasks. Resident #50 had an indwelling catheter. Record review of Resident #50's Comprehensive Care Plan, dated 02/11/2026, reflected Resident #50 had a catheter. Interventions included Position catheter bag and tubing below the level of the bladder and away from entrance room door. 2. Record review of Resident # 11's face sheet, dated on 08/21/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #11 had diagnoses which included acute and chronic respiratory failure with hypoxia (low levels of oxygen), tracheostomy status, chronic obstructive pulmonary disease (progressive lung disease), type 2 diabetes mellitus (a condition when the body cannot use insulin correctly and sugar builds up in the blood), lung cancer, and gastrostomy status (feeding tube). Record review of Resident #11's admission MDS Assessment, dated 12/11/2025, reflected Resident #11 had a BIMS score of 14, which indicated his cognition was intact. Resident #11 had an indwelling catheter. Record review of Resident #11's Comprehensive Care Plan, revised 01/13/2026, reflected Resident #11 had a catheter. Interventions included Position catheter bag and tubing below the level of the bladder. During an observation on 02/23/2026 at 12:11 p.m. and 2:56 p.m. revealed Resident #50's catheter drainage bag was hung on the left side of the bed rail with part of the bag touching the floor. During an observation on 02/24/2026 at 8:12 a.m. revealed Resident #11's catheter drainage bag was hung on the left side of the bed rail with the bottom part of the bag touching the floor. During an interview on 02/24/2026 at 8:56 a.m., LVN F stated she had been trained in foley catheter care and infection control. LVN F stated it was important the urine collection bag be placed below the bladder, draining with gravity, and always kept off the floor. LVN F stated if the bag touched the floor, it could cause cross-contamination, cause the tube to be kinked or block urine from getting into the bag, which could cause an injury to the resident. LVN F stated it was everybody's responsibility to check the placement of the catheter bag anytime they rounded, which would be every two hours, or anytime they provided patient care. The CNAs should inform the nurses if they saw a bag touching the floor. During an interview on 02/24/2026 at 9:03 a.m., RN J stated it was her second day at the facility, and she was in training, but as a nurse, she had knowledge about indwelling catheter care and infection control practices. As a nurse, she was aware the urine collection bag should be placed below the bladder, draining with gravity, and always kept off the floor. She stated the urine bag should never touch the floor due to the risk of bacteria, which could cause the resident to get a urinary tract infection. If the bag was on the floor, it might not drain the urine properly and could cause a backflow into the tubing. RN J stated it was everybody's responsibility to check the placement in the bag anytime they entered the room or provided patient care. RN J stated she would expect CNA's to move the bag off the floor and then report it to a charge nurse. During an interview on 02/24/2026 at 9:07 a.m., CNA C stated she was trained on foley catheter care. CNA C stated she emptied the urine collection bags. She stated the urine bag should be hung on the side of the bed, below the bladder, and it should never touch the floor because that could lead to crossing examination, which could give the residents an infection. She stated if she ever saw the bag on the floor, she would move it off the floor and tell the charge nurse. She stated it was everybody's responsibility to check to ensure the bag was not touching the floor. During an interview on 02/25/2026 at 2:27 p.m., the DON stated she was trained in catheter care and infection control prevention and she was the infection control preventionist. The DON stated the urine collection bag should never touch the floor to prevent infection. She stated it was everybody's responsibility to check to ensure the bag was not touching the floor. The DON stated she would expect staff to move the bag if it was on the floor and Resident #11 and Resident #50's urine collection bag touching the floor would not meet her expectations. During an interview on 02/25/2026 at 3:22 p.m., the ADM stated he had not been trained in catheter care as he did not have a clinical background, but he had been trained in infection control prevention measures. The ADM stated the urine collection bag should never touch the floor due to infection control issues, cross contamination, and bacteria which could cause illness. The ADM stated he would expect staff to move the bag if it was on the floor or report it to the nurse. He was unaware Resident #11 and Resident #50's urine collection bag was touching the floor and that would not meet his expectations. Record review of the facility's Indwelling Urinary Catheter Care Policy, dated 05/2007 and revised 12/2025, reflected It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. Record review of the facility's Catheter Drainage Bag Policy, dated 05/2007 and revised 12/2023, reflected Position the drainage bag below the level of the resident's bladder and without resting on the floor. 3. Record review of Resident # 99's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Type 2 diabetes mellitus without complications (chronic high blood sugar where the condition has not yet caused damage to organs, nerves, or blood vessels.), Essential hypertension (chronic elevation of blood pressure without a known, specific cause), and Unspecified dementia (decline in mental abilities). Record review of Resident #99's Quarterly MDS, dated [DATE], reflected a BIMS score of 06, which indicated severe cognitive impairment. Record review of Resident #99's Order Summary Report, dated 05/03/2024, reflected, Amlodipine Besylate Oral Tablet 5 MG Give 1 tablet by mouth one time a day for HTN hold for SBP less than 110 or HR is less than 60 bpm. During observation of medications administration on 02/24/26 at 9:05 a.m. revealed MA prepared to administer medications to Resident #99 on hall 100 (medication cart #100). The MA used the blood pressure monitor on Resident #99 to obtain the resident's blood pressure. The MA dropped the blood pressure monitor on the floor after obtaining Resident 99's blood pressure. The MA picked up the blood pressure monitor from the floor and placed it on the surface of the medication cart without disinfecting it. The MA continued to pull out Resident # 99's medications without performing hand hygiene and proceeded to Resident # 99's room to administer medications. The MA was observed to perform hand hygiene after Resident # 99's medications were administered. During an interview on 02/24/2026 at 9:17 a.m. Resident # 99 stated she was not aware the MA did not sanitize her hands prior to preparing her medications. Resident # 99 stated, It is not good. Not good. During an interview on 02/25/2026 at 2:56 p.m., the MA stated she forgot to disinfect the blood pressure monitor and to perform hand hygiene before administering medications because she was nervous. The MA further stated she received training on infection control. She stated the policy on cleaning reusable equipment (blood pressure monitor) was to sanitize before it was returned to the medication cart. The MA stated this was important because it prevented the spreading of germs between residents. The MA stated the policy on hand hygiene was to perform hand hygiene before preparing medications, before and after administration of medications, this was important to prevent the spread of infections and the negative outcome to residents. During an interview on 02/25/2026 at 3:18 p.m., the DON stated she was trained on infection control and she was the facility's infection preventionist. The DON stated if staff did not conduct proper hand hygiene and disinfect shared equipment before and after it was used. The DON stated failure to do so could cause residents infections. She further stated the nurses and herself monitored to ensure staff followed the infection control procedures. Interview on 02/25/2026 at 3:31 p.m., the ADM stated he was trained on the infection control steps. The ADM stated all management staff expected to monitor staff for proper hand hygiene during all levels of care in the facility. He stated staff members expected to follow the infection control procedures and prevent transmission of infection. The ADM further stated the impact to the residents of not following infection control policies and procedures ultimately was the transmission of germs. Record review of the facility's, Policy and Procedure titled Nursing Clinical, revised on 05/2007 reflected Preparing Non-Unit Dose medications: 1. Wash hands. Record review of the facility's Policy and Procedure titled Infection Control reviewed on 05/2021 reflected It is the policy of this facility that all resident care equipment will be cleaned and decontaminated after use and will be prepared for reuse by the same or another resident. Procedures: Equipment is disinfected with EPA-approved product and returned to storage or resident area, ready for reuse

Based on observation, interview and record reviews the facility failed to ensure residents had a right to organize and participate in resident groups in the facility for 10 of 10 confidential residents reviewed for resident council.The facility failed to provide the Resident Council with a private meeting area to conduct their monthly meetings. This failure could place residents at risk of not being able to exercise their rights to meet as a group in private. Findings include:During a confidential group interview/observation at an undisclosed date and time the group of ten residents stated they wanted to have a meeting where there were no interruptions. The meeting was in held in the activity room. The residents stated staff walked in while they were conducting their monthly council meeting. The residents' said they had to constantly stop their meeting or vote because people would interrupt. During this confidential group interview the meeting was interrupted by residents and staff six times within the hour-long meeting. The residents stated that it upset them, and they felt like they did not have any privacy.During an interview with the Activity Director on 02/25/2026 at 08:55 a.m., she said she was trained on resident rights. She said the policy for resident council was the facility had to provide a private meeting place for the residents to conduct their meeting. She said she was responsible for ensuring the resident council had a private meeting space. She said if the resident council did not have a private meeting space the residents may get upset, angry or disgruntled when they could not meet privately. She said the ADM monitored to ensure the resident council had a private meeting space. She said he monitored by checking with her and checking and ensuring everything was private and secure. She said she did not know why staff and residents kept interrupting the council meeting she said she put a sign on the door. She said placed a sign on the door. She said that was the only place big enough for the council.During an interview with the ADM on 02/25/2026 at 3:08 p.m., he said he was trained on resident rights. He said the policy for resident council was they met once a month and the facility must provide a private area. He said the Activity Director was responsible for providing a private meeting space for the resident council. He said if the resident council did not have a private meeting space the resident may not feel like their rights were respected. He said the ADM monitored to ensure there was a private meeting space for the resident council. He said the ADM monitored by talking to the Activity Director to ensure they were meeting privately. He said he had not had any complaints about the resident council meeting being interrupted and he was not sure why staff and residents were interrupting the council meeting.Record review of the facility's, undated, Resident Rights Policy revealed, it is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. To organize and participate in resident groups in the Nursing Center and have members of Resident's family meet with.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #88) reviewed for care plans. The facility failed to ensure a comprehensive care plan was developed for Resident #88 to include her smoking status when the care plan was completed on 12/03/2025 and revised on 01/30/2026. This deficient practice could place residents at risk of not being provided with the necessary care or services and the implementation of personalized plan of care developed to address their specific needs.The findings include: Record review of Resident #88's face sheet, dated 12/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #88 had diagnoses which included chronic obstructive pulmonary disease (progressive lung disease), end stage renal disease, acute and chronic respiratory failure with hypoxia (insufficient oxygen), asthma, type 2 diabetes mellitus with diabetic nephropathy (damage to kidneys), and hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (paralysis and weakness on right side after stroke). Record review of Resident #88's care plan, dated 12/03/2025 and revised on 01/30/2026, reflected no information on smoking. Record review of Resident #88's admission MDS, dated [DATE], reflected Resident #98 had a BIMS of 14, which indicated intact cognitive response. The MDS also reflected current tobacco use was marked as no. Record review of Resident #88's Smoking Assessment, dated 12/19/2025, reflected Resident #88 had a dexterity problem (problem performing tasks with hands), smoked 3-4 times a day, could not light her own cigarette, and aware of safety associated with smoking. Plan of Care updated to reflect this evaluation was marked yes. During an interview on 02/25/2026 at 1:50 p.m., the SW stated she was trained in completing her portions of the care plan but did not handle the smoking portion, as that was the MDSN responsibility. During an interview on 02/25/2026 at 1:56 p.m., the MDSN stated she was trained in completing care plans and the training covered what should be listed on the care plan and the timeframes for completing the care plan. The MDSN stated anything unusual, including smoking, should be listed on the care plan. The MDS nurse was responsible for ensuring the care plan was accurate and ultimately signed off on the review. The MDSN stated the MDS nurse, the DON, and Resources monitored to ensure care plans were done correctly. The MDSN stated she was not aware Resident #88's care plan did not list smoking, and it should have. She stated whoever completed the smoking assessment, should have put it on Resident #88's care plan. She stated she was the one who completed Resident #88's care plan and she was embarrassed that she missed it. She stated if staff were looking at care plans, they would not know what Resident #88's needs would be regarding safety or interventions while smoking. During an interview on 02/25/2026 at 2:27 p.m., the DON stated she was trained in completing care plans and the training covered what should be listed on the care plan and the timeframes for completing the care plan. The DON stated all staff (the DON, MDS nurses, ADONs, Activity Director, SW, DM, and Resources) were responsible for ensuring the care plans were completed and the MDS nurses were responsible for the accuracy. The IDT was responsible for discussing and updating the care plans. The DON stated anything unusual, including smoking, should be listed on the care plan. The DON stated the SW was responsible for adding smoking to the care plan, but the SW was new; therefore, the MDS nurses would handle that. The DON stated she was not aware Resident #88 was a smoker and was not aware it was not on Resident #88's care plan. The DON stated an accurate care plan was needed to ensure the resident's safety during smoking.During an interview on 02/25/2026 at 3:22 p.m., the ADM stated he had not been trained on care plans, but smoking should be listed on a resident's care plan. The ADM stated if the care plans did not have a resident's smoking status staff would not be able to identify the resident as a smoker. The ADM stated he did not know why Resident #88's smoking status was not on the care plan and failure to do so could lead to some level of potential harm. The ADM stated smoking assessments were completed by nurses, and it would not meet his expectations to not have smoking listed on the care plan. Record review of the facility's policy titled Comprehensive Person-Centered Care Planning, dated 11/2016 and revised 12/2025, reflected It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person centeredcare plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation and interview the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 1 medication rooms reviewed for pharmacy services.The facility failed to ensure expired and/or discontinued medications removed from use for one medication storage room.This failure could place residents at risk of not receiving the intended therapeutic benefits of medication.Findings include:During observation of medication storage room on 02/23/2026 at 3:03 p.m. revealed one bag of the Lactated Ringer's Injection USP (500mL) solution with an expiration date of 11/2025 stored inside of the box along with 5 unexpired bags of solutions. The DON present at the time of the observation, removed the expired packages from the room. The DON stated medications would be disposed of per facility policy.During an interview on 02/25/2026 at 3:18 p.m., the DON stated her expectation was all nurses were to place expired medications in medication destruction bins. The DON could not explain the expired medication found along with the unexpired medications. The DON stated a nurse might place it there by mistake thinking it was a destruction bin. The supply person monitored the expiration dates when supplies restocked. The DON stated expired medications could potentially cause adverse medication reactions on residents or not be effective for their intended purpose.During an interview on 02/25/2026 at 3:31 p.m., the ADM stated expired medication should properly disposed of. He stated the responsibility for monitoring expired medications was mixed audit of the medication room. He stated use of expired medication was not effective and could be unsafe practice. Record review of the facility's, undated, Policy and Procedure titled Care and Treatment reviewed on 05/2007, 07/2015, 07/2017, 07/2019, 7/2020, 7/2021, 7/2022, 7/2023, 7/2024, 06/2025 reflected Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medications destruction and reordered from the pharmacy, if a current order exist.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 5 residents (Resident #88 and Resident #91) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #91's annual MDS, dated [DATE], accurately reflected his smoking status. 2. The facility failed to ensure Resident #88's admission MDS, dated [DATE], accurately reflected her smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment of smoking status. Findings include: 1. Record review of Resident #91's face sheet, dated 02/25/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #91 had diagnoses which included traumatic brain injury with loss of consciousness, muscle weakness, cognitive communication deficit, need for assistance with personal care, and lack of coordination. Record review of Resident #91's annual MDS, dated [DATE], reflected Resident #91 had a BIMS of 15, which indicated intact cognitive response. The MDS also reflected current tobacco use was marked as no. Record review of Resident #91's Smoking Assessment, dated 03/03/2025 and 12/03/2025, reflected Resident #91 smoked 3-4 times a day and was aware of safety associated with smoking.Record review of Resident #91's care plan, revised 02/13/2026, reflected Resident #91 was a smoker with a remote history of suspected of smoking in his room. Interventions were Remind resident of smoking rules and Resident made aware smoking is only to be during designated times.2. Record review of Resident #88's face sheet, dated 12/17/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #88 had diagnoses which included obstructive pulmonary disease (chronic progressive lung disease), end stage renal disease, acute and chronic respiratory failure with hypoxia (insufficient oxygen), asthma ( condition that causes your airways to swell, narrow and fill with mucus), type 2 diabetes mellitus with diabetic nephropathy (damage to kidneys), and hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (paralysis and weakness on right side after stroke). Record review of Resident #88's care plan, dated 12/03/2025 and revised on 01/30/2026, reflected Resident #88 was not a smoker. Record review of Resident #88's admission MDS, dated [DATE], reflected Resident #98 had a BIMS of 14, which indicated intact cognitive response. The MDS also reflected current tobacco use was marked as no. Record review of Resident #88's Smoking Assessment, dated 12/19/2025, reflected Resident #88 had a dexterity problem, smoked 3-4 times a day, could not light her own cigarette, and aware of safety associated with smoking. During an interview on 02/24/2026 at 4:00 p.m., Resident #88 stated she was a smoker. She stated she smoked daily and was able to smoke independently but needed help with pushing her wheelchair out to the smoking area.During an interview on 02/25/2026 at 1:50 p.m., the SW stated she had been trained in completing her portions of the MDS but did not handle the smoking portion as that was the MDSN responsibility. During an interview on 02/25/2026 at 1:56 p.m., the MDSN stated she was trained on the MDS and the MDS nurse was ultimately responsible for completing the MDS. She stated the MDS should be updated quarterly, annually, and if there was a significant change in the residents' condition. She stated she had fourteen days from admission to complete the MDS. She stated Resident #88's smoking status was supposed to be on the MDS and it was coded no in error. She stated if the resident's smoking status was not coded correctly it would not affect the resident's care. The MDSN was not aware, and she did not know why Resident #91's smoking status was not on the MDS. During an interview on 02/25/2026 at 2:27 p.m., the DON stated she was trained on the MDS and would sometimes complete the MDS, but it was the MDS nurse who was ultimately responsible for signing off on the MDS. She stated the MDS should be updated quarterly, annually, and if there was a significant change in the residents' condition. The DON was unaware the smoking status was incorrect on the MDS for Resident #88 and Resident #91 and stated she was not sure a resident's smoking status went on the MDS. The DON stated Resident #88 was new and she was not aware Resident #88 smoked. The DON stated it was the receptionist's responsibility to notify nursing staff if a resident wanted to smoke. The DON stated Resident #91's smoked on and off. The DON could not say how a resident might be affected if the resident's smoking status was not coded correctly on the MDS. During an interview on 02/25/2026 at 3:22 p.m., the ADM stated he had not been trained on MDS's. The ADM stated he did not have a clinical background and he relied on his nursing staff to complete assessments accurately. The ADM stated the MDS nurse was responsible for doing the MDS. The ADM stated incorrect information on the MDS would potentially affect the quality of care and would not reflect an accurate picture of the residents' needs. The ADM stated he was not aware the smoking status for Resident #88 and Resident #91 were incorrect and that would not meet his expectation. Record review of the Smoking Residents list, provided on 02/23/2026, revealed Resident #88 and Resident #91 were smokers.Record review of the facility's Resident Assessment Policy, dated 11/2016 and revised 12/2025, reflected It is the policy of this facility that resident's will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents and hazards. The facility failed to ensure Resident #1's wheelchair brakes were functional. This failure could place residents at risk for injury and decreased quality of life. The findings included: Review of Resident #1's face sheet dated 12/10/25 reflected a [AGE] year old male admitted to the facility on [DATE] with a diagnosis that included need for assistance with personal care, hemiplegia (one sided paralysis or weakness of the face, arm, or leg) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke) affecting the left non-dominant side, unspecified lack of coordination, unsteadiness on feet, cervical disc disorder with myelopathy (spinal cord compression)- cervicothoracic region, and idiopathic peripheral autonomic neuropathy (condition characterized by damage to the peripheral nerves that control involuntary body functions). The face sheet and EMR alerts also indicated Resident #1 was part of the Fall Star program (an initiative aimed at reducing falls with a multidiscipline committee approach to identify residents using a gold star marking on the door or chart).Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Section GG for functional abilities reflected Resident #1 normally used a wheelchair for mobility. Section GG related to transfers (toileting, chair, bed) reflected substantial/ maximal assistance.Review of Resident #1's care plan last revised 11/30/25 reflected a focus Resident #1 has an ADL self-care performance deficit r/t limited mobility, impaired balance, CVA with left sided weakness interventions included toilet transfer; bed mobility; Requires (1) staff participation. Another focus was observed which reflected, Resident #1 is at risk for falls r/t gait/balance problems, incontinence, CVA, with L sided weakness, cervical stenosis; he does not always follow recommendations for appropriate footwear to prevent falls with interventions that included, falling star program, needs safe environment, review information on past falls and attempt to determine cause of falls, record possible root causes, alter remove any potential causes if possible. As well as a focus on Resident #1 has had an actual fall 12/11/23-resident slid from wheelchair to floor while reaching for grab bar in the bathroom- no injury. 01/26/24-resident noted on floor after using the toilet stated that his shoes had no traction, so he fell, no injuries; 02/27/24-Noted sitting on floor in bathroom stated he was trying to get into w/c from the toilet and slid down. No injuries: 10/29/25 fall in bathroom with interventions that included, shoes checked for traction, encouraged to call for assistance before transferring, grab bars inspected by maintenance, education to use call light, therapy consult for strength and mobility. Review of Resident #1's fall risk evaluation assessment dated [DATE] reflected assessment completed due to change of condition, and indicated Resident #1 was medium risk. The assessment included Resident #1 was alert and oriented x3, history of falls (1-2 falls in the last 3 months), balance problems while standing, decreased muscle coordination/jerking movements, changes in gait pattern, and required use of assistive device (i.e. cane, walker, wheelchair) were marked.Review of Resident #1's progress notes and EMR items from 10/29/25 through 12/10/25 reflected no information for a documented wheelchair assessment indicating it was evaluated for functionality or safety. In an observation and interview on 12/10/25 at 11:07 AM with Resident #1 in his room, he stated he had a concern with his wheelchair brakes not being functional. At this time, Resident #1 was in bed and surveyor observed Resident #1's wheelchair at bedside in the locked position. Surveyor observed and tested the brakes on the wheelchair; the brakes on the right side of the wheelchair while engaged had a good grip and prevented the right wheel from moving when putting slight pressure on the chair to move it. The left side of the wheelchair was also tested and with the left brake engaged the chair easily moved revealing that the left brake was not functioning correctly. The break mechanism and handle itself also appeared slightly loose. Resident #1 stated that it has been over a month that the break was non-functional. He stated he alerted 3 staff but could not recall who he notified other than the DOR who he also notified earlier that day 12/10/25, but had not yet been resolved. Resident #1 stated that at times he did self-transfer before assistance arrived, and it scared him to not have functional brakes because the wheelchair could move backwards which could cause him to fall. Resident #1 denied that he had a fall or an injury directly related to the wheelchair break not being operational. In an interview on 12/10/25 at 11:10 AM with CNA A, she stated she did not know Resident #1's wheelchair brake was not functional and she could not recall the last time it was checked. She stated she would assist Resident #1 with transferring from his bed to his wheelchair, but he has been known to do transfers himself before help arrived. She stated that a negative outcome of not having functional brakes would be Resident #1 could have a fall and injure himself. In an interview on 12/10/25 at 12:56 PM with RN B, she stated she was the nurse for Resident #1. She stated she was not aware that Resident #1's wheelchairs brakes were not functional. RN B stated Resident #1 had an unsteady gait, diabetic ulcers, which contributed to the unsteady gait, and was also known to be impatient when asking for assistance; he would frequently do self-transfers. RN B stated Resident #1's weakness is primarily affecting the left side of the body. RN B stated that if a resident is on the falling star program, it means they are at risk for falls. She stated things that could contribute to falls included weakness, behavior, pain, and a non-functional wheelchair could also contribute. RN B stated when they are aware a wheelchair is not functioning they will alert maintenance and PT. RN B denied having any knowledge of the non-functional wheelchair and denied Resident #1 ever alerting her of it. RN B stated it was important for Resident #1 to have a safe and functional wheelchair to prevent a fall on the floor when he completes transfers himself. In an interview on 12/10/25 at 01:23 PM with DOR, she stated the falling star program was used to identify residents who were at risk for falls or have had falls in the past. The DOR stated she worked with Resident #1, and he was a fall risk and has had falls in the past. DOR stated she spoke to Resident #1 that morning and was alerted to his wheelchair brakes not being functional and advised him that she would pass the message along to OT during his appointment later in the day so OT could take a look at the wheelchair. DOR stated the wheelchair Resident #1 was using was a wheelchair that was provided to him by the facility. She stated she did not know the last time it was checked to determine it was fully functional and would have to refer surveyor to OT (OT C specifically). DOR stated that a negative outcome of Resident #1's brakes not working was the potential for him to have a fall if he tried to transfer himself to or from the chair. In an interview on 12/10/25 at 01:42 PM with OT C, stated she worked with Resident #1. She stated she was alerted by DOR that Resident #1 had concerns with his wheelchair brakes, and that he was on schedule to be seen that day at 2pm. OT C stated she had a session with Resident #1 the day before on 12/09/25, and that while doing OT his wheelchair did not shift backwards but stated she did not specifically assess it at the time for functionality. OT C stated Resident #1 had a lot of left sided knee pain, difficulty pivoting, and was a fall risk. OT C stated that equipment is evaluated regularly by the therapy department to ensure it is safe and functional but could not recall the last time Resident #1's wheelchair was evaluated. OT C stated a negative outcome of Resident #1's brakes not working would be that it could contribute to a fall. OT C stated Resident #1 was seen by PT 10/14/25 through 11/25/25 and was being seen by OT presently with 12/10/25 being his fourth visit. She stated she reviewed notes and documentation for that period of time which did not reflect Resident #1's wheelchair had been assessed to ensure the brakes were functional. In an interview on 12/10/25 at 01:57 PM with ADON, she stated the falling star program was for residents who were at risk for falls. ADON stated that it was the responsibility of the therapy department to ensure residents' equipment such as wheelchairs were monitored for safety and functionality. She stated if direct care staff were to notice equipment was not working or brakes were not functional, while working with the resident, it was her expectation that the therapy department was alerted to have it fixed. She stated a negative outcome of Resident #1 not having functional brakes was the potential for him to have a fall if he were to self-transfer. The ADON stated that equipment issues should be addressed immediately once staff has knowledge of it to prevent injury. In an interview on 12/10/25 at 03:39 PM with the ADM, he stated the falling star program is a way for them to be able to identify residents who are at risk for consistent falls; they put a star on the door to alert staff and make them more aware of interventions needed. He stated it was his expectation that when staff see that when doing room checks or working with residents that it brings extra awareness to fall checks and surroundings. The ADM stated Resident #1 tries to be independent, and staff try to be mindful of that. He stated Resident #1 was known for doing things on his own before staff assistance arrived to him. He was known for pushing the button, but still doing self-transfers. The ADM stated his expectation was when a wheelchair is provided, it was checked by the therapy department to ensure it is safe and functional. He stated if there were any issues, PT or maintenance would be the one to resolve the equipment issues. The ADM stated that every month there should be checks on the equipment to ensure it is in working order. He stated a negative outcome to Resident #1's wheelchair brakes not being functional would be the potential for him to slip out of the chair, or he could be doing something like self-transferring which could result in a fall if the wheelchair were to move from the brakes not working. The ADM stated he was not sure what the standard or facility policy was for how often a wheelchair assessment would be documented. Review of the facility's Fall Management System along with the Fall Prevention Program revised 12/2023 reflected: It is the policy of this facility to provide an environment that remains free of accident hazards as possible, It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Falling star:- Identify high risk residents for falls. - Therapy will evaluate wheelchair for appropriateness; wheelchair size; functioning correctly.

Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all routine and emergency drugs and biologicals for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure that Resident #1's hospital discharge orders were followed to prevent rehospitalization due to hypoglycemia. 1. The facility failed to discontinue Resident #1's metformin and glyburide medications. 2. The facility failed to implement blood sugar monitoring for Resident #1. 3. The facility failed to start Resident #1 on the appetite stimulant (Mirtazapine) as ordered. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 02/10/2025 at 5:06 PM and an IJ template was given. While the IJ was removed on 02/11/2025 at 3:45 PM, the facility remained out of compliance at no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of exacerbation and/or deterioration of their health conditions which could result in rehospitalization and/or death. Review of Resident #1's face sheet reflected a [AGE] year-old woman readmitted on [DATE] with initial admitted [DATE] with diagnoses of end stage renal disease (a medical condition where the kidneys have permanently lost their ability to function adequately), type 2 diabetes mellitus with unspecified complications (a diagnosis of type 2 diabetes where the specific complications are not detailed or identified), dysphagia (difficulty swallowing), dependence on renal dialysis (a condition where a person's kidneys have permanently lost their ability to adequately filter waste products from the blood, requiring regular treatments to remove these toxins and maintain life), cognitive communication deficit (a difficulty with communication caused by an impairment in cognitive processes), and other speech and language deficits following cerebral infarction (a range of communication impairments that can occur after a stroke). Review of Resident #1 MDS assessment dated [DATE] reflected a BIMS score of 13 and had an active diagnosis of diabetes mellitus. Review of Resident #1 active orders as of 1/27/2025 reflected resident had order for hemodialysis three times a week with an order date of 01/17/2025. Further review reflected an order for glyburide one time a day for diabetes mellitus and metformin tablet two times a day for diabetes mellitus with a start date of 01/17/2025. Review of Resident #1 progress note dated 01/22/2025 by the DON reflected dialysis center called to notify facility Resident #1 was sent to ER after treatment due to lower blood sugar of 27. Review of Resident #1 progress note dated 01/23/2025 by LVN A reflected Resident #1 returned to facility via ambulance. Progress note reflected Resident has no medications changes, no wounds. Review of Resident #1 progress note dated 01/25/2025 by RN B reflected Resident #1 refused to eat lunch and breakfast, and blood sugar obtained at 112 with no signs or symptoms of hypo/hyperglycemia. Review of Resident #1 hospital discharge instructions with date of 01/23/2025 reflected special instructions to follow up hospitalization for hypoglycemia (condition where the blood glucose level falls below normal) after discharge to SNF. Additional instructions reflected all diabetes medications now discontinued. Monitor blood sugar. Patient started on appetite stimulant. Discharge instructions included discharge medications which reflected metformin and glyburide were not included and mirtazapine was started on 01/22/2025. Review of Resident #1 orders active as of 01/27/2025 reflected no order for blood glucose checks or orders for appetite stimulant. Review of Resident #1 active orders at of 02/10/2025 reflected blood sugar checks before meals and at bedtime with a start date of 02/04/2025 and mirtazapine (appetite stimulant) by mouth at bedtime with a start date of 02/04/2025. Review of Resident #1 MAR reflected glyburide was administered on 1/24/2025, 01/25/2025 and 01/26/2025. Further review reflected metformin was administered once on 01/23/2025, twice on 01/24/2025, and twice on 01/26/2025. Review of Resident #1 change of condition evaluation dated 01/27/2025 reflected Resident #1 displayed altered mental status, abnormal vitals signs and signs of stroke. Resident #1 had a resting heart rate of 48 and blood glucose of 24 mg/dL. Review reflected change of condition was reported to the NP recommended to administer glucagon. Review of Resident #1's hospital notes dated 01/27/2025 reflected Resident #1's metformin and glyburide were discontinued and she was discharged back to the facility. Review reflected that, Resident #1 was found minimally responsive and blood sugar was 24 and did not improve after doses of glucagon. Review of hospital notes also reflected, Resident #1 had continued to receive metformin and glyburide. Review reflected Resident presented back with hypoglycemia, severe lactic acidosis and hyperkalemia. Further review reflected Resident #1 was seen in ICU. Review of Resident #1 hospital notes dated 02/01/2025 with admitted [DATE] reflected Resident #1 was readmitted to hospital on 01/22/2025 with hypoglycemia which was corrected, and she was stopped on metformin and glyburide. Resident #1 was readmitted on [DATE] with hypoglycemia as she was restarted on her metformin and glyburide at the SNF. Further review reflected lactic acidosis (condition where the body builds up too much lactic acid) was felt secondary to metformin. During an interview on 02/10/2025 at 1:24 PM, RN C stated that he was familiar with Resident #1. RN C stated Resident #1 could be forgetful and may not recall everything. RN C stated that Resident #1 does get her blood sugar taken and that the nurse is responsible for taking blood sugar. He stated that her blood sugar that morning (02/10/2025) was 100 and that was within normal range. RN C stated that when residents get readmitted , the facility received a medication list from the hospital, and they call the medications into the on-call service to [NAME] the orders with the NP or MD or if the NP is in the facility, they could review it then. RN C stated if an order was discontinued, a resident should not have received the medication unless it was approved by the NP. RN C stated that the harm of receiving a discontinued medication depended on the type of medication that was received, and that if glyburide or metformin was given, it may lower the resident's blood sugar and could cause hypoglycemia. During a telephonic interview on 02/10/2025 at 1:55 PM, RN D stated she was familiar with Resident #1. RN D stated she was aware that Resident #1 went to the hospital two times, and she was the nurse that sent Resident #1 to the hospital the second time. RN D stated that she could not recall the date that Resident #1 went to the hospital. RN D stated that Resident #1 was unresponsive, and her blood sugar was really low. RN D stated she followed protocol and gave Resident #1 a shot of glucagon IM. RN D stated that she waited with Resident #1 for 15-20 minutes and when Resident #1's blood sugar did not go up, she called 911. RN D stated that when Resident #1 was being evaluated by EMS, her face started to droop. RN D stated that when a resident returns from the hospital, the facility received discharge orders and then they are verified with the NP. RN D stated that NP would clarify whether or not to keep or discontinue the medication. RN D stated she was not sure if Resident #1 received medication that was discontinued. RN D stated that there is not anyone else that verified orders received from the hospital. During a telephonic interview on 02/10/2025 at 2:11 PM, LVN A stated she was familiar with Resident #1. LVN A stated she readmitted Resident #1 on 01/23/2025. LVN A stated she could not recall if there were any medication changes for Resident #1. LVN A stated that at one point Resident #1 came back to the facility from the hospital and did not have any paperwork. LVN A stated she remembered she tried calling the hospital, and was left on hold and the line got disconnected. LVN A stated she went through some of Resident #1's paperwork in her room and looked for medication changes. LVN A stated she asked Resident #1 if they made any changes at the hospital and Resident #1 answered there were no changes. LVN A clarified that Resident #1 did not come back with any paperwork and EMS did not provide LVN A with any paperwork. LVN A stated that normally EMS gave her paperwork. LVN A stated that she asked EMS if there were any changes, and she was told no. LVN A stated she looked and found an envelope in Resident #1's closet and looked through it and did not see that there were any medication changes compared to the list the facility had. LVN A stated she did not recall the title of the paperwork because there were a lot of residents and a lot of things going on. LVN A stated, normally, the facility received paperwork from the paramedics and they would get a brief report and check a medication list that was brought in. LVN A stated that she would then call on-call and let them know a resident was readmitted and would provide medication names and doses. She stated if there were a discrepancy, she would call the hospital and get clarification. LVN A stated that Resident #1 could be forgetful. LVN A stated she left the paperwork with Resident #1 and did not take it with her. LVN A stated that she looked through Resident #1's paperwork because she could be forgetful and she wanted to double check if there were any changes. During an interview on 02/10/2025 at 2:47 PM, the NP stated she was a little familiar with Resident #1 as she was usually out to dialysis. NP stated she received something that there were no changes with Resident #1's medication and that the hospital did not send paperwork back and she resumed her medications. NP stated that Resident #1 then went out to the hospital again and they caught that there was an order to discontinue medication and that they were not discontinued. NP stated she saw Resident #1 when she admitted . NP stated she did not see Resident #1 when she returned from the hospital because she was not at the facility on Fridays and Resident #1 returned on 1/23/2025. NP stated if a resident returns during business hours staff will call her and let her know and they would review the medications. NP stated if a resident return in the evening, the facility staff would have called the on-call person and reviewed medications to the on-call staff. NP stated if a resident returned without a medication list or discharge instructions, she could usually call the doctor because he works at the hospital as well and get the doctor to send the medications. NP stated when she received a call about a resident that was readmitted to the facility, she would ask the facility staff if there were changes to previous medications and the nurse would clarify to resume or not. NP stated she would normally check the resident's admission the following day. NP stated she missed seeing Resident #1 because Resident #1 was either at dialysis or in the hospital. NP stated that Resident #1 was not a good historian and she did have some cognitive deficits. NP stated that glyburide and metformin were long-acting diabetic pills and were meant to lower blood sugar. She stated that if a resident was on an oral medication to control blood sugar, then blood sugar was not checked. NP stated it may be checked the first few days to get a trend and from there it would be checked every three months or if the Resident was symptomatic. NP stated that if Resident #1 was not eating, and with dialysis filtering her blood, it could contribute to her blood sugar lowering. NP stated that she was notified that the facility did not receive paperwork from the hospital and NP was not going to stop all medications just because the paperwork was not received. NP stated that normally, the following day, she would see the resident and reconcile medications, but she was not at the facility on 1/24/2025, and the MD saw her and they are unable to see a resident on the same day. During an interview on 2/10/2025 at 3:12 PM, RN E stated that Resident #1 was sent out from dialysis on 1/22/2025 due to low blood sugar. She stated Resident #1 was sent around 11:13 AM. RN E stated her blood sugar was 42 and did not increase after she was provided glucose gel. During an interview on 2/10/2025 at 3:35 PM, the ED stated that the admission assessment packet was the policy used for readmissions and medication reconciliation during readmissions. During an interview on 2/10/2025 at 3:36 PM, the DON stated the facility was not aware when Resident #1 returned without paperwork from the hospital. She stated LVN A said whoever brought Resident #1 back to the facility stated there were no changes to her medication, and Resident #1 stated she had no paperwork. DON stated LVN A tried to call the hospital because the hospital did not call for report. DON stated after Resident #1 was readmitted , the doctor called and said the medications should have been discontinued. DON stated she spoke with LVN A, and LVN A stated there was no paperwork. DON stated if a resident returned from the hospital with no paperwork, the nurse was supposed to call the ER and try to get a medication list. DON stated LVN A tried to get ahold of the hospital, but she was not able to get through. DON stated that Resident #1 was alert and orientated, and she said there were no changes. DON stated that it was the facility's responsibility to ensure there were no changes. DON stated she would have expected LVN A to document her attempts to try and get the medication list from the hospital, and any information she received that there were no changes. DON stated LVN A took EMS' word because nothing was sent with Resident #1 and assumed nothing had changed. DON stated Resident #1 went out to the hospital again on 1/27/2025 because her blood sugar had dropped again, and the nurse thought she was having a stroke because her heart rate was high and other symptoms. DON stated, initially, Resident #1 went to the hospital from dialysis. DON stated the admission packet was used for new admissions and readmissions after a 72-hour hospital stay. During an interview on 2/10/2025 at 3:51 PM, Resident #1 stated she had returned from dialysis and stated she was tired. Resident #1 stated she had been to the hospital a few times because her blood glucose dropped. Resident #1 stated when that happened, she felt dizzy. Resident #1 was unable to remember if she had paperwork when she returned from the hospital or the nurse that was working. Review of undated admission assessment packet reflected no guidance on medication reconciliation. Review of the facility's policy titled Medication Administration dated June 2022 reflected it is the policy of this facility that medications shall be administered as prescribed by the attending physician. The ED and DON were notified on 2/10/2025 at 5:00 PM that an IJ had been identified. An IJ template was provided and a POR was required. The following POR was approved on 02/11/2025 at 1:09 PM and indicated: Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified, on 2/10/2025. Identification of Others Affected by Alleged Deficient Practice: All admissions and re-admissions have the potential to be affected by this alleged deficient practice. Summary: On 2/10/2025 an abbreviated survey was initiated at [facility]. On 2/10/2025 the surveyor provided an Immediate Jeopardy (IJ) that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy (IJ) states as follows: F755- The facility failed to ensure pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals. The facility failed to ensure that Resident #1's hospital discharge orders were followed to prevent rehospitalization due to hypoglycemia. Action: Medical Director notification Start Date: 2/10/25 Completion Date: 2/10/25 Responsible: Executive Director Action: Audit all admissions/readmissions from 1/23/25 to present to ensure all medications were correctly verified. Start Date: 2/10/25 Completion Date: 2/10/25 Responsible: DON/Designee/Clinical Resource Action: Inservice DON on admission requirements to verify orders. If the sending facility (hospital, SNF, etc.) does not provide discharge summaries or orders: a. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders. b. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting nurse to assist in retrieving discharge summaries/orders. c. These steps will remain in the permanent admission/readmission protocol. Start Date: 2/10/25 Completion Date: 2/10/25 Responsible: Clinical Resource Action: Inservice Nursing and Nursing Leadership staff on admission requirements to verify orders. If the sending facility (hospital, SNF, etc.) does not provide discharge summaries or orders: a. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders. b. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting nurse to assist in retrieving discharge summaries/orders. c. These steps will remain in the permanent admission/readmission protocol. Start Date: 2/10/25 Completion Date: 2/11/25 Responsible: DON/Designee Action: Ad hoc QA1 meeting. Attendees will include ED, DON, Clinical Resource, Cluster Partners, Medical Director. Meeting will include the Plan of Removal and inventions. Start Date: 2/10/25 Completion Date: 2/10/25 Responsible: Executive Director Action: Admissions Coordinator inservice on notification of pharmacy consultant of all admissions/readmissions for medication review. Start Date: 2/11/25 Completion Date: 2/11/25 Responsible: DON Systemic Change to Prevent Re-Occurrence: DON/Designee will ensure admitting nursing staff verify admission/readmission orders. If the sending facility (hospital, SNF, etc.) does not provide discharge summaries or orders: d. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders. e. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting nurse to assist in retrieving discharge summaries/orders. f. These steps will remain in the permanent admission/readmission protocol. Monitoring to Ensure Ongoing Compliance: DON/ Designee will audit order listing report daily to include admissions and readmissions. Will include trends of verification of orders upon admissions during QAPI meeting x 90 days. Surveyor monitored the POR on 2/11/2025 as followed: Review of the facility's in-service training report dated 02/10/2025 and titled admission process verification of medication on admission and readmission reflected it was provided to the DON by Clinical resource. Review of facility in-service titled notification of pharmacy consultant of all admission and readmission for medication review dated 02/11/2025 reflected in-service was provided to admission coordinator. Review of facility in-service dated 02/10/2025 titled Admission/Verification of Meds reflected it was completed with 25 nurses. Review reflected any admission will have medication verification against discharge orders. If a resident did not bring orders, hospital needed to be called and attempts needed to be made to get orders. If unable to do so, documentation needed to be noted in the resident's charge. Notification to DON/ADON/NP was to be made to attempt to get discharge orders and staff should pass along on the 24-hour report. Review of admission medication orders audit for admissions on 1/23/2025 included 23 residents. No discrepancies were listed. Review of QAPI sign-in sheet dated 02/10/2025 reflected a meeting was conducted and included the ADM, DON, NP, and Medical Director. During interviews on 02/11/2025 between 2:27 PM and 3:30 PM, with 2 RNs and 4 LVNs, it was revealed that staff received an in-service either 2/10/2025 or prior to their shift on 2/11/2025 by the DON or Clinical resource. Staff stated that the in-service included to ensure orders were received for any new admission and if the resident did not come with paperwork then the staff should try to contact the hospital and if they are unable to get through then they should notify the DON/ADON. Staff stated this information should be written on the 24-hour report and document all that was done and who was notified in management and attempts made to get the orders. Staff stated the NP should also be called and notified that a patient was sent with no orders. Staff stated if a resident was still at the hospital at midnight then they would be considered a new admission and all orders should have been discontinued and all new orders would be put in as if they were a new patient. Staff stated that if a resident was sent out with low blood sugar, they would want to check the resident's blood sugar when they returned and may ask the NP if they wanted to initial blood sugar checks and felt that was standard nursing care. During an interview on 02/11/2025 at 3:36 PM, the DON stated in-service was provided to her on 02/10/2025 by clinical resource. DON stated nurses were in-serviced prior to beginning their shift of if they were present yesterday (02/10/2025). DON stated the process was updated and for any admission staff was to ensure they received discharge orders. If they were not received, then they should call the sending facility that discharged the residents. DON stated if staff could not get ahold of the facility, then it should be communicated with the DON/ADON/NP and with the oncoming shift. DON/ADON would then attempt to get ahold of the MD to get discharge orders. DON stated if the resident was not back in the facility by midnight, then their medications should be discontinued, and the medications would have to be entered again like a new admission. DON stated that ADONs would pull an order listing from the report daily and cross reference the information with discharge paperwork and what is in PCC. DON stated order listing report will also be discussed during QAPI and during IDT meetings. The ED was notified on 02/11/2025 at 3:45 PM that the IJ had been removed. While the IJ was removed, the facility remained out of compliance at a level of no actual harm that was not immediate jeopardy at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure resident rights for personal privacy for 4 of 15 residents (Resident #23, Resident #52, Resident #78 and Resident #93) residents reviewed for personal privacy. The facility failed to knock on Resident #23, Resident #52, Resident #78 and Resident #93's room when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy is being invaded or the facility is not their home. Findings included: Review of Resident #23 Face Sheet dated 11/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #23's diagnoses included dementia (memory, thinking, difficulty), morbid obesity, insomnia (difficulty sleeping), hypertension (high blood pressure), major depressive disorder, cognitive communication deficit (problems with communication), muscle wasting, heart failure, muscle weakness, gout (swollen arthritis), and need for assistance with personal care. Record review of Resident #23's Quarterly MDS assessment dated [DATE] revealed that Resident #23's BIMS score was 14 which means resident was cognitively intact. Review of Resident #52 Face Sheet dated 11/26/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52's diagnoses included heart disease, hyperlipidemia (high cholesterol), hypertension (high blood pressure), cognitive communication deficit (problems with communication), repeated falls, abnormalities of gait and mobility, unsteadiness on feet, muscle weakness, hyperthyroidism (excessive production of thyroid hormones), dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), and age-related physical debility. Record review of Resident #52's Quarterly MDS dated [DATE] revealed that Resident #52's BIMS score was 12 which means resident was moderately cognitively impaired. Review of Resident #78 Face Sheet dated 11/26/2024 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #52's diagnoses included dementia (memory, thinking, difficulty), hypertension (high blood pressure), depression, difficulty walking, unsteadiness on feet, Parkinson's disease (a progressive disorder that affects the nervous system), Schizophrenia (mental disorder), cognitive communication deficit (problems with communication), muscle weakness, anemia (not enough healthy red blood cells), and anxiety disorder. Record review of Resident #78's Quarterly MDS dated [DATE] revealed that Resident #78's BIMS score was 15 which means resident was cognitively intact. Review of Resident #93 Face Sheet dated 11/26/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #93's diagnoses included cognitive communication deficit (problems with communication), repeated falls, abnormalities of gait and mobility, unsteadiness on feet, muscle weakness, major depressive disorder, insomnia, acute pain due to trauma, hypertension (high blood pressure), hyperlipidemia (high cholesterol and need for assistance with personal care. Record review of Resident #93's Quarterly MDS dated [DATE] revealed that Resident #93's BIMS score was 14 which means resident was cognitively intact. Observation on the 100 hall on 11/24/2024 at 11:10 am revealed that LVN D walked into Resident #23, Resident #52 and Resident #78's room without knocking. Observation on the 300 hall on 11/24/2024 at 01:05 pm revealed that CNA E walked into Resident #93's room without knocking. An interview with Resident #23 on 11/24/2024 at 10:27am revealed that staff do not always knock on her door before entering. She said it did not bother her that staff do not knock. She said she would like staff to knock before entering her room, so she knows someone is coming in. An interview with Resident #78 on 11/24/2024 at 11:10am revealed that staff do not always knock on his door before entering. He said it bothered him at times when staff did not knock on his door. He said he would like staff to knock all the time. An interview with Resident #52 on 11/24/2024 at 11:12am revealed that staff do not always knock on his door before entering. He said it did not bother him that staff does not knock, but he said that he would like staff to knock because he might be changing or something. An interview with LVN D on 11/24/2024 at 2:29 pm revealed she had been trained on resident rights. She stated that staff were supposed to knock on the door before going into the room. She said if staff did not hear anything, they were supposed to knock again. She said staff are supposed to knock always before entering a resident's room even if their door is open. She said that some residents may not be familiar with staff and maybe uncomfortable if staff did not knock. She stated she should have knocked but did not know why she did not knock. An interview with CNA E on 11/26/2024 at 11:12 am revealed that she had been trained on resident rights. She stated that staff were supposed to knock on the resident's door and wait a bit or wait for the resident to tell them to come in. She said staff should even knock on the resident's door when their call light was on. She said residents may not like it if staff just walk in without knocking. She said it was just like someone being at home and not knocking before coming into your house. She said she did not know why she did not knock on the resident's door before entering. An interview with the ADM on 11/26/2024 at 11:26 am revealed he had been trained on resident rights. He stated staff were supposed to knock on the resident's door anytime they were entering a resident's room to get permission to enter. He said that if staff are not knocking the resident may feel like they were losing their privacy and being treated like a patient. He said if staff were not knocking it does not create a homelike environment for the resident. He stated staff may not have knocked due to urgency or being relaxed. An interview with the DON on 11/26/2024 at 11:49 am revealed she had been trained on resident rights. She stated that staff should knock before entering and see if it was okay for them to enter. She said staff should be knocking on the door any time they wanted to enter the resident's room. She said if staff did not knock on the door before entering, the resident may get upset or not like staff just coming in. She said she did not know why staff were not knocking on the door. Record Review of Resident Rights Policy dated 10/04/2016 revealed residents of the nursing facility had the right to a dignified existence and had the right to exercise their rights. The residents also have the right to personal privacy.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administrating of all drugs and biologicals in accordance with currently accepted practices for 1 of 4 (Cart #1,) medication carts reviewed for pharmacy services in that: Medication Cart #1 for the 100 hall was left unattended with the keys in the lock and was not locked. This deficient practice could affect residents and result in a drug diversion causing an allergic reaction or a resident taking medication not prescribed for them due to medications not being properly secured. The findings were: Observation on 11/24/2024 at 10:37 am revealed that LVN D walked away from Cart #1 on the 100 hall and left the keys in the lock and the cart unlocked. Observation on 11/24/2024 at 11:04 a.m. of Medication Cart #1 for the 100 revealed it was not locked and had the keys hanging out the lock when LVN D went into a resident's room to administer medication. Observation on 11/24/2024 at 11:06 a.m. revealed LVN D walked away from Cart #1 and left the keys hanging in the lock and left unlocked when she went down the hall to a resident's room to check on her. The medications were not in sight of LVN D's view. An interview with LVN D on 11/24/2024 at 2:36 pm revealed that she had been trained on medication storage. She said that the medication cart was to always be locked. She also said that all staff were responsible for ensuring the medication carts were locked. She stated if the medication carts were left unlocked, someone could take the medications from it. She stated that she would have to take her cart with her everywhere because she does not recall leaving the keys in the cart and the cart unlocked. An interview with the ADM on 11/26/2024 at 11:30 pm revealed that he and staff had been trained on medication storage . He stated the medication carts were supposed to be locked if staff did not have a hundred percent visibility. He stated the nurses and medication aides were responsible for ensuring the medication carts were always locked. He said that if the carts were left unlocked, it could cause a medication diversion, a resident could come by and take the medications, and someone could use the medication for their personal gain. He said that he thought that LVN D may have thought she was close enough to the medication cart or she was not paying attention. An interview with the DON on 11/26/2024 at 11:52 am revealed she and staff had been trained on medication storage . She stated that the medication carts were supposed to be locked every time staff walk away from it. She stated the charge nurse or whoever was working the cart was responsible for ensuring that the cart was locked. She said if the staff walk away from the cart and leave it unlocked someone could open the cart and take the medications. She said her and the ADM were responsible for ensuring the carts were locked. She said that she would walk around and take the keys if they were left in the cart. She said she did not know why LVN D left the cart unlocked three times. Record Review of Medication Administration: Medication and Treatment Cart Policy revised on May 2007 revealed do not leave the medication or treatment cart unlocked or unattended in the resident care area. The cart must remain in your line of sight when it is not locked.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen and one of one nourishment room and one of one activities room reviewed for sanitation. 1. The facility failed to properly label and date perishable foods. 2. The facility failed to ensure the nourishment room was properly cleaned and items were correctly labeled and dated. 3. The facility failed to ensure employees did not wear jewelry and had removed false nails to best food service standards. 4. The facility failed to ensure employees were practicing proper hand hygiene while cooking and serving foods. 5. The facility failed to ensure meat was properly thawed under cold running water. 6. The facility failed to ensure dishwasher temperature was within standard range for disinfection. 7. The facility failed to ensure the microwave, ice machine, and ice scoop holder were cleaned. 8. The facility failed to ensure the microwave in the nourishment room was cleaned. 9. The facility failed to ensure margarine was kept at the appropriate temperature outside of refrigeration. These failures could place residents who were served from the kitchen at risk for consuming hazardous expired food, developing foodborne illnesses, and a diminished quality of life. Findings included: Observation in the kitchen walk-in refrigerator on [DATE] at 9:04 AM revealed the following items were undated. A bag of bacon A bag of solid block cheese A container of peaches A container of applesauce A box of sandwich bread A bag of shredded lettuce that emitted a foul odor and looked wilted. Observation in the kitchen walk-in refrigerator on [DATE] at 09:04 AM the following expired items: A container labeled Italian pasta salad with the label [DATE]. A large pan labeled orange Jello dated [DATE]. A bottle of mayo labeled [DATE]. A bag of raw sausage labeled [DATE]. An opened container of whipped topping with a label of [DATE]. Observation on [DATE] at 9:05 am a large container with ground beef thawing under hot running water in a sink next to dirty dishes. Observation on [DATE] at 9:05 am dented cans on the can holding cart with non-damaged cans. Observation on [DATE] at 9:07 am an employee's personal sized soda bottle inside the reach in refrigerator containing food for the next meal. Observation on [DATE] at 9:07 am the low temperature dishwasher temperature was at 110 degrees with a stem thermometer in the bottom of the dishwasher. Observation on [DATE] at 9:07 am a black slime substance inside the ice machine near the internal dispenser. Observation on [DATE] at 9:10 am a pink substance splattered inside the walls of the microwave in the kitchen. Observation on [DATE] at 9:11 am a brown liquid at the bottom of the holder for the ice machine scoop. Observation on [DATE] at 10:51 AM a pan with margarine sitting out on stove; not obtaining direct heat. The temperature was 114 F when measured by a stem thermometer by the dietary manager. Observation in the nourishment room on [DATE] at 9:15 am revealed the following items: Dirty dishes were in the sink with clean dishes and a used napkin. The microwave had a red substance splattered inside. The freezer had visible dirt on the bottom and contained ice cream that was unlabeled and undated. Personal cups without names were on top of the refrigerator. Observation in the refrigerator of the activities room on [DATE] at 9:30 am revealed the following items: Bins of drinks containing different sodas and hydration drinks unlabeled and undated. Popsicles in the freezer unlabeled or dated. Observation on [DATE] at 9:59 am revealed the following while the staff making pureed foods. The DM failed to wash her hands before assisting [NAME] J in removing the cover of the food processor. Cook J failed to wash her hands before starting her tasks. She donned gloves and did not change the gloves when she wiped her station or when she washed the food processor bowls and blades. Cook J failed to take the temperature of the meatloaf that had just finished cooking and used it for her meals. Cook J had long (around 2 inches) false nails and was wearing large hoop earrings before beginning purees. Observation on [DATE] at 12:13 pm revealed RN B touch his face while he yawned and then grab a plate holder and the meal slip. He did not sanitize his hands. Observation on [DATE] at 12:20 pm RN B scratch his back under his shirt, then touched a resident's tray, and failed to sanitize his hands . In an interview with [NAME] J on [DATE] at 2:17 pm, she stated that she was only supposed to wear small hoops and was allowed to keep her false nails if she had a scrub brush. She stated that she carries her own scrub brush for her nails. She stated that she needs to wash and sanitize her hands every time she walked away from her prep station, and she should have changed her gloves. She thought they had done a hand hygiene in-service about a month ago. She stated that she did not keep any left-over foods, any food needed to be thrown away after 10 days, and it was a team effort to clean out expired foods. In an interview with RN B on [DATE] at 2:28 pm, he stated that he started a month ago and only had hand hygiene training upon orientation. He had not received training from dietary or nursing staff on how to pass trays. He did not believe it was wrong to touch his face and then touch items on the resident's tray. He did believe cross contamination can happen while passing trays. He stated he was not responsible for ensuring residents receive their same trays. He was responsible for ensuring the accuracy of the trays. In an interview with the DM on [DATE] at 1:34 pm, she stated that their rules follow the Texas Food Establishment Rules (TFER). They did not follow a specific diet manual. She stated the cooks were allowed to have on small hoops and a plain wedding band. She stated the cook should not have had on long false nails. She did not believe there was nail brushes around. She stated that the employees are required to place personal foods in her office and no personal food or cups were allowed in the nourishment room or in the refrigerators. She stated nursing staff was responsible for cleaning out the nourishment room. She stated that the cook was responsible for cleaning the microwave, sweeping, and mopping. She stated she cleaned the ice machine is cleaned monthly and was unsure as to why it was still dirty. She stated that the dishwasher was out of temperature and the correct temperature should have been 120 degrees . She stated the margarine on the stove should have been at 145 degrees or changed every 3 hours. In an interview with the Dietitian on [DATE] at 2:35 pm. she stated that she came that month and came every two weeks . She stated she recently did an in-service on labeling and dating and following alternative diet textures. She stated that they followed the TFER for their storage and handling policies. She stated that she did quality assurance rounds and tried to observe two meals at her last visit. She left notes with the dietary manager for recommended improvements. During an interview with the ADM on [DATE] at 2:35 pm, he stated that the dietary manager was responsible for the cleaning of the entire kitchen expired foods. The dietary manager was to follow the Texas Food Establishment Regulations for food service policies. He believed a hand hygiene in-service was done recently but did not remember the details. He stated the kitchen staff should have been wearing a hair and beard net, no long and loose clothing was allowed, but did not know the policy for jewelry or nails. Review of 2022 Food Code states: ,d+[DATE].16 States: (A) FOOD EMPLOYEES shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. (B) Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. ,d+[DATE].14 States: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S ,d+[DATE].12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (E) After handling soiled EQUIPMENT or UTENSILS. (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD. (H) Before donning gloves to initiate a task that involves working with FOOD; and ,d+[DATE].15 states: (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. ,d+[DATE].13 states: Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (B) Completely submerged under running water (1) At a water temperature of 21C (70F) or below ,d+[DATE].16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S,d+[DATE].19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in ,d+[DATE].11(B) or reheated as specified in ,d+[DATE].11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5 C (41 F) or less.

Based on observation, interview, and record review, the facility failed to treat each resident (resident #93)with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents reviewed for dignity. 1. The facility failed to ensure Resident #93 received her lunch meal on 11/24/2024 in an adequate timeframe. This failure could place residents at risk of diminished dignity and affect their quality of life. Findings included: Review of Resident #93's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] and 08/13/2024 with diagnoses of fracture of T11-T12 Vertebra (a fracture of the spine), Subdural Hemorrhage (a brain bleed), and mild neurocognitive disorder (a change in processing people, speech, and events in real time). Review of Resident #93's Quarterly MDS assessment, dated 11/16/2024 reflected a BIMS score of 14 indicating intact cognition . MDS further reflected resident had a diagnosis of depression. Review of Resident #93's care plan, dated 09/04/2024, reflected resident was at risk for nutritional problems due to neurocognitive disorder. Observation on 11/24/24 at 12:30 PM revealed Resident #93 sitting at a table in the dining room without a meal tray. Observation on 11/24/24 at 12:58 PM revealed Resident #93's table mates received their food. Observation on 11/24/24 at 1:19 PM revealed Resident #93 received a tray of food, but it was sent back immediately. Observation on 11/24/24 at 1:25 PM revealed Resident #93's table mates had finished eating. Observation on 11/24/24 at 1:30 PM revealed Resident 93 left the dining room looking upset. Observation on 11/24/24 at 1:38 PM revealed Resident #93 in her room with a meal of 2 slices of pizza. In an interview on 11/24/24 at 1:17 PM, RN B stated Resident #93 did not get her tray because the staff had lost her meal ticket. In an interview on 11/24/24 at 1:25 PM, Resident #93 said she sent her tray back because she did not like fish. In an interview on 11/24/24 at 1:38 pm Resident #93 said she was happy with her pizza. In an interview on 11/24/24 at 2:35 PM, RN A stated that she was responsible for ensuring people at the same table received their tickets. She stated that table mates should have waited less than a minute for their food. She stated she would have talked to the kitchen directly. She stated it could make the resident's feel neglected if they did not receive their food on-time. In an interview on 11/25/24 at 1:34 PM, the DM stated that residents should be served together and relied on dining room staff to communicate who had not received their trays yet. She stated it would make residents feel bad and frustrated if they had not received their meal with the others. In an interview on 11/26/2024 at 1:30 PM, the ADM stated all trays needed to be distributed within an hour of starting meal service. Resident 93's tray was late because they printed the wrong ticket, and it took too long to get it reprinted. Review of the facility's policy titled, Resident Rights- Dignity and Respect, dated 07/23 revealed, 1) the staff shall display respect for residents when speaking with caring for or talking about them as constant affirmation of their individually [NAME] and dignity as human beings. 2) residence individual preferences regarding things such as menus, clothing, religious activities, friendships, activity programs, and entertainment are elicited and respected by the facility.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 4 residents (Resident #69) reviewed for accidents and supervision. The facility failed to ensure Resident #69 was supervised while eating ice chips according to physician orders. This failure placed resident at risk for choking or aspiration due to lack of supervision. Findings included: Record review of Resident #69's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Dysphagia (difficulty swallowing), flaccid hemiplegia (one side of the body being completely and permanently paralyzed), gastroesophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the esophagus) and gastrostomy status (feeding tube insertion). Record review of Resident #69's quarterly MDS assessment, dated 11/10/2024, reflected a BIMS of 07, indicating severe cognitive impairment. Section GG (Functional Abilities) reflected he was dependent on assistance for eating, (helper does all the effort, resident does none of the effort to complete the activity). Section K (Swallowing/Nutritional Status) reflected the resident did not have a swallowing disorder, received a mechanically altered diet, and had a feeding tube. Review of Resident #69's care plan, revised 11/08/2024, reflected he had a potential nutritional problem due to being fed through a tube and dysphagia. He was to follow the diet as ordered by the physician and have a mechanical soft texture and thin liquids. The goal was the resident would be free of aspiration. Review of Resident #69's physician order , dated 11/06/2024, reflected May have ice chips. Do not leave alone with patient or at bedside d/t risk of aspiration. Every 2 hours as needed for dry mouth. Review of Resident #69's swallow study dated 11/7/2024, reflected based on the swallow test, the following strategies are recommended: small bites/sips, feed slowly and carefully, alternate bites/sips, precautions during PO feeding: small bites/sips, cueing for strategies, allow extra time, minimize distractions. Patient is currently NPO and transitioning to oral feeds. SLP will be performing skilled trials to train strategies before advancement to meals. During an observation and interview on 11/25/2024 at 9:46 AM, Resident #69 was lying in bed after receiving care from LVN F. When the state surveyor asked him how everything was going, he whispered the word ice. It was observed that Resident #69 had a quarter cup of melted ice on his bedside table. LVN F re-entered Resident #69's room with a fresh cup of ice, sat it on Resident 69's bedside table and left the room. During an interview on 11/25/2204 at 2:00 PM, LVN F stated she was not aware Resident #69 had an active physician's order that stated resident was not to be left alone with ice chips. When asked how she would know if a resident was allowed to have certain food or drink items, she stated it would be listed in their chart on the computer. When asked what the risks of leaving an NPO resident alone with ice, could be, she stated aspiration pneumonia and choking. During an interview on 11/25/2024 at 2:05 PM, the MDSN stated that the physician order for supervision with ice was supposed to have been discontinued by the SLP after Resident #69's swallow study on 11/07/2024. During an interview on 11/25/2024 at 3:00 PM, the ADT revealed a swallow study was done on 11/07/2024 for Resident #69 and it had been determined he could be removed from NPO and put on mechanical soft diet. This meant that the ice chip order should have been discontinued in PCC. When asked what the dangers were of residents on an NPO diet order given ice without supervision, she stated that a resident could get aspiration pneumonia or choke. She stated all LVNs should be checking the computer for residents' orders. During an interview on 11/26/2024 at 1:40 PM, the DON was asked what the expectation was for uploading documents into PCC or making changes to care plans, physician's orders, she stated that within 24 hours of a new edit, those things should be uploaded, unless records have not been received. She stated the process for CNAs and other direct care staff to know if residents are allowed certain foods or drinks was to check the binder located in the dining room, check their diets in the system, and/or check with a nurse to see if the resident's diet needed to be changed. When asked what the risks of a resident being left alone with ice chips if they are said to be on an NPO diet, she stated there could be a risk of aspiration or choking. Review of the facility's Documentation and Charting Policy, dated reviewed 7/2022, reflected the following: It is the policy of this facility to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatments. 4. Nursing service personnel with a record of the physical and mental status of the resident. 5. Assistant in the development of a Plan of Care for each resident.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #46) reviewed for indwelling catheter care. CNA G did not remove soiled gloves and conduct hand hygiene after cleansing Resident #46's perineal area, and cleansed the suprapubic catheter with a wipe x 2 during incontinent care. This failure could place residents at risk of the spread of diseases, a decreased quality of life, illness, and hospitalization . Findings included: Review of Resident #46's face sheet dated 11/26/24, reflected a [AGE] year-old male admitted to the facility on [DATE] with admitting diagnoses that include: Dementia, cognitive communication deficit, chronic obstructive pulmonary disease, bradycardia (slower than normal heart rate), chronic pain syndrome, hypertension (elevated blood pressure), obstructive and reflux uropathy (a blockage in one or both ureters), neuromuscular dysfunction of bladder (damage to nerves that control the bladder), and need for personal assistance. Review of Resident #46's MDS assessment dated [DATE] reflected a BIMS score of 8, indicating resident had moderate cognitive impairment. The MDS also reflected in Section H - Bowel and Bladder, Resident #46 had an indwelling catheter, and more specifically, a suprapubic catheter (a device that drains urine from the bladder through the belly button). Review of Resident #46's Care Plan dated 08/29/24 reflected he had a suprapubic foley catheter, and he returned from the hospital on 08/29/24 with a UTI related to the catheter. The goal was for Resident #46 to remain free from catheter-related trauma. There were no relevant interventions related to cleansing the catheter tubing reflected in the Care Plan. Observation on 11/25/24 at 03:34 PM of the suprapubic catheter care and peri-care for Resident #46 with CNA G revealed she did not remove soiled gloves or conduct hand hygiene after cleansing Resident #46's perineal area before moving to Resident #46's suprapubic catheter site. CNA G then cleansed the suprapubic catheter site with a wipe and the catheter tubing with a wipe x 2. Interview on 11/25/24 03:53 PM with CNA G who stated she had forgotten to conduct hand hygiene and change her gloves between conducting peri-care and suprapubic catheter care. CNA G then stated not conducting hand hygiene or a glove change when going from peri-care to conducting suprapubic catheter care, could lead to cross-contamination. CNA G stated she had received training on infection control, hand hygiene, and catheter care when she was hired, and could not recall when she had received training since then. Interview on 11/25/24 at 4:11 PM with LVN D revealed the removal of soiled gloves, conducting hand hygiene, and donning clean gloves when going from dirty to clean during resident care was to prevent cross-contamination. LVN D stated she received a recent in-servicing on infection control and hand hygiene, and had also been trained throughout the past year. Interview on 11/26/24 at 11:01 AM with the DON revealed she currently was the ICPC for the facility, as the Infection Preventionist had left facility about one month ago. The DON stated her expectation was for staff to make sure they were following all the steps in preventing the spread of infection when providing care to the residents. The DON further stated she expected her staff to practice hand hygiene and glove changes when going from clean to dirty during all resident care. The DON stated it was important to practice good hand hygiene and follow infection control protocols to prevent residents from getting infections and cross-contamination, and she would be conducting in-services on these topics with her staff. Interview on 11/26/24 at 01:34 PM with the ADM revealed the DON was responsible for infection control oversight. The ADM stated they were in the process of hiring another ADON, as the ADON with ICPC qualifications had left the position recently. The ADM stated not conducting good hand hygiene when providing resident care, could ultimately lead to an infectious situation that could lead to bigger medical issues for the residents, as well as staff contaminating themselves and other staff members. The ADM further stated his expectations were for all staff to follow the appropriate protocols for infection control to reduce the spread of infection, and he stated the facility regularly conducted a skills fair and required every nurse and aide to participate and pass to provide resident care. Review of In-Service Training Report dated 09/13/24 on Sanitizing Hands - Hands need to be sanitized before patient care and when coming out of a room, was signed by CNA G. Review of policy Hand Hygiene dated revision 10.2022 revealed the following relevant information: 1. Wash hands with soap and water when hands are visibly soiled (e.g., blood, body fluids). 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non- antimicrobial) and water for the following situations: e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites), h. before moving from a contaminated body site to a clean body site during resident care, and m. after removing gloves. Review of policy IPCP Standard and Transmission-Based Precautions dated revision 10.2022 revealed: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Review of policy Infection Prevention and Control Program dated revision 10.2022 revealed: The infection prevention and control program are a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance management program. Further it revealed the goals were to: decrease the risk of infection to residents and personnel, recognize infection control practices while providing care, identify and correct problems related to infection control, ensure compliance with state and federal regulations related to infection control and promote individual residents' rights and wellbeing while trying to prevent and control the spread of infection.

Based on observation, interviews, and record reviews, the facility failed to 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 (Resident #1) of 6 residents reviewed for comprehensive care plans. The facility failed to have a fall mat at Resident #1's bedside while he was lying in his bed. This deficient practice could place residents at risk of not receiving the care and services noted in their care plans. Findings include: Record review of Resident #1's Admission Record, dated 05/09/24, revealed he was initially admitted on [DATE], readmitted [DATE], was his own RP, and diagnosed with diffuse traumatic brain injury without loss of consciousness, conversion disorder with seizures or convulsions, unspecified bipolar disorder, need for assistance with personal care, cognitive communication deficit, repeated falls, and generalized muscle weakness. Record review of Resident #1's Comprehensive MDS Assessment, dated 03/22/24, revealed he had a BIMS score of 00, which indicated he had severe cognitive impairment. Resident #1 had no fall history since admission or readmission. Resident #1 was dependent on staff for assistance with toileting, bed mobility, and transfers. Record review of Resident #1's Care Plan revealed the following note, [Resident #1] had an actual fall 03/30/24 - Resident noted on floor beside bed, 2 red areas to left FH. Resident #1 had one of the following interventions assigned to nursing staff, 3/30/24-Floor mat at bedside. Record review of Resident #1's Fall Risk Evaluation, dated 05/07/24 at 2:01 p.m., revealed he was at high risk for falls because he was disoriented, regularly incontinent, had 3 or more falls in the past 3 months, poor vision, balance problem while standing/walking, 1-2 predisposing conditions, and took 1-2 high risk medications and/or within the last 7 days. An observation and interview on 05/09/24 at 10:00 a.m., revealed Resident #1 was lying in his bed. Resident #1's fall mat was not at bedside. The fall mat was on the ground and across from Resident #1's bed. During an interview, Resident #1 stated the fall mat had been left in the position the surveyor observed, he did not know how long the fall mat been in the position the surveyor observed, he did not know why the fall mat was in the position the surveyor observed, he knew the fall mat was supposed to be at bedside, and he did not notify staff about the fall mat position. Resident #1 also stated he fell daily, and staff would leave him on the ground and not help him. Resident #1 did not elaborate on occurrences in which staff left him on the ground and did not help him. An observation on 05/09/24 at 10:08 a.m., revealed Resident #1 pressed his call light. An observation on 05/09/24 at 10:11 a.m., revealed CNA A answered Resident #1's call light. CNA A repositioned Resident #1's fall mat to his bedside. During an interview on 05/09/24 at 10:12 a.m., CNA A revealed she checked on residents every one or two hours and fall risk residents every two hours. CNA A stated she documented completing all her rounds at the end of her shift in residents' POC. CNA A stated she was responsible for checking on residents who resided in rooms in the first half of the hallway in which Resident #1 resided on. CNA A stated she last checked on Resident #1 at 9:00 a.m. CNA A stated she did not know Resident #1's fall mat was away from his bed. CNA A explained Therapy staff put Resident #1 in bed after his therapy session. CNA A stated she was trained and in-serviced on falls. CNA A stated she was trained on falls last week by one of the two ADONs, which she learned how to respond when a resident falls and ensuring fall mats were next to residents' beds when residents were lying in bed. CNA A stated residents' health and safety could be affected if residents were at risk of falling, lying in bed and did not have a fall mat next to their bed. During an interview on 05/09/24 at 10:24 a.m., CNA B revealed she checked on residents every two hours and constantly and fall risk residents every hour. CNA B stated she documented completing all her rounds throughout her shift in residents' POC. CNA B stated she was responsible for checking on residents who resided in rooms in the second half of the hallway in which Resident #1 resided on. CNA B stated she last checked on residents at 9:30 a.m. CNA B stated she did not check on Resident #1 because she did not work on the first half of the hallway in which Resident #1 resided on. CNA B stated she was trained and in-serviced on falls. CNA B stated residents' health and safety could be affected if residents were at risk of falling, lying in bed and did not have a fall mat next to their bed because they could hurt themselves. During an interview on 05/09/24 at 10:44 a.m., RN C revealed she checked on residents and fall risk residents every hour. RN C stated she worked on two hallways, one of which was the hallway Resident #1 resided on. RN C stated she documented assessments she completed on residents throughout her shift. RN C stated residents' health and safety could be affected if residents were at risk of falling, lying in bed and did not have a fall mat next to their bed. RN C stated nurse staff were responsible for ensuring fall risk residents' fall mats were next to residents' beds if residents were lying down. RN C stated she did not know Resident #1's fall mat was away from his bed. RN C stated she last checked on residents at 9:00 a.m. RN C stated she was trained and in-serviced on falls. During an interview on 05/09/24 at 12:24 p.m., PT D revealed Resident #1 had physical therapy on 05/09/24 between 9:00 a.m. through 10:00 a.m. PT D stated when therapy staff brought Resident #1 back into his room, Resident #1's fall mat was next to his bed. During an interview on 05/09/24 at 12:40 p.m., ADON E revealed she, ADON F, and the DON in-serviced staff on falls. ADON E stated staff were in-serviced weekly. ADON E stated staff were in-serviced on falls within last week, which specifically discussed lowering beds and fall mat placement. ADON E stated residents' fall mats should be next to the bed if residents were lying in their beds. ADON E stated she expected staff to check and ensure residents' fall mats were next to their beds. ADON E stated residents' health and safety could be affected if residents were at risk of falling, lying in bed and did not have a fall mat next to their bed. ADON E stated staff checked on residents every two hours. ADON E stated CNAs documented checking on residents in POC and nurses documented in the administration record and nurse's notes. ADON E stated she was responsible for two halls, one of which was a hall that Resident #1 resided on. ADON E stated she did not know Resident #1's fall mat was not next to his bed because she recently changed to being responsible for two halls in which Resident #1 did not reside on. ADON E stated ADON F worked with Resident #1 a lot. During an interview on 05/09/24 at 2:10 p.m., ADON F revealed she trained and in-serviced staff on falls. ADON F stated staff were in-serviced on falls two weeks ago, which covered fall mat placement on floor and repositioning. ADON F stated she expected staff to check on residents every two hours. ADON F stated CNAs documented checking on residents in POC and nurses documented in POC and nurse's notes. ADON F stated she expected staff to check and ensure residents' fall preventative devices were properly placed on the floor. ADON F stated residents' fall mats should be next to their beds when residents were lying in their beds. Residents' health and safety could be affected if residents were at risk of falling, lying in bed and did not have a fall mat next to their bed. During an interview on 05/09/24 at 2:40 p.m., DON revealed she trained and in-serviced staff on falls. DON stated she expected nursing staff to check on residents throughout their shifts and every two hours, which was best practice. DON stated nursing staff documented in POC whenever they provided a care or service to a resident. DON stated she expected staff to ensure fall risk residents' beds were low and fall mats were placed at bedside. DON stated residents' fall mats should be at bedside if they were lying in bed. DON stated residents' health and safety could be affected if residents were at risk of falling, lying in bed and did not have a fall mat next to their bed. During an interview on 05/09/24 at 3:55 p.m., ADON F revealed there was no policy and procedure for rounding on residents. During an interview on 05/09/24 at 3:56 p.m., MDS G revealed she was trained and in-serviced on falls. MDS G stated residents' health and safety could be affected if residents were at risk of falling, lying in bed and did not have a fall mat next to their bed according to their care plan, which was not following the care plan. During an interview on 05/09/24 at 4:33 p.m., ADM revealed he expected residents who were at risk for falls and lying in bed to have floor mats on the ground next to their beds. During an interview on 05/13/24 at 1:53 p.m., LVN H revealed she checked on residents every hour. LVN H stated residents' fall mats should be next to their beds if residents were lying in their beds. LVN H stated residents' health and safety could be affected if residents were at risk of falling, lying in bed and did not have a fall mat next to their bed. Record review of Resident #1's Kardex Report, dated 05/09/24, revealed staff were required to place floor mat at bedside as of 03/30/24 for Resident #1's safety. Record review of the facility's Incident Log, dated 05/09/24, revealed Resident #1 had a fall on 03/30/24 at 7:07 a.m., 04/09/24 at 12:55 p.m., 04/18/24 at 5:35 p.m., 04/24/24 at 10:02 a.m., and 04/26/24 at 2:46 a.m. Record review of the facility's In-Services Training Reports, from 04/01/24 through 05/13/24 revealed staff did not have any trainings related to implementing care plan interventions and falls. Record review of the facility's Comprehensive Person-Centered Care Planning Policy and Procedure, revised 12/2023, revealed the following, The facility IDT will develop and implement a comprehensive person-centered, culturally-competent, and trauma-informed care plan for each resident within seven days of completion of the MDS and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and resident's goals and desired outcomes, preferences for future discharge and discharge plan. Record review of the facility's Nursing Services - ADLs Policy and Procedure, revised 05/2007, revealed the following, Each resident receives or is provided the necessary care and services enabling him/her to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehension assessment and plan of care. Each resident receives adequate supervision and assistive devices as needed.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #3 reviewed for medication administration. The facility failed to ensure Resident #3 received his 08:00 AM medications (Norco, Baclofen, Cozaar, and Cipro) on time for 7 of 10 days between 04/01/24 and 04/10/24. This failure placed residents at risk of not receiving the therapeutic benefit of their medications. Findings included : Review of the undated face sheet for Resident #3 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included multiple sclerosis, chronic pain syndrome, muscle weakness, stage 4 pressure ulcer of left buttock, major depressive disorder, and high blood pressure. Review of the quarterly MDS assessment for Resident #3, dated 03/05/24, reflected a BIMS score of 15, indicating intact cognition. It also reflected Resident # 1 was completely dependent on a helper to execute all ADLs, including bed mobility, transfer, dressing, eating, ambulation, bathing, and personal hygiene. It reflected that he received a scheduled regimen for pain, received non-pharmacological interventions for pain, had experienced pain in the five days leading up to the assessment, and was taking an opioid medication for pain. Review of the care plan for Resident #3, dated 02/08/24, reflected the following: is at risk for pain r/t disease process. Will voice a level of comfort of through the review date. Able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain). Follow pain scale to medicate as ordered. Pain assessment every shift. Therapy evaluation and treatment per physician orders. Review of physician orders for Resident #3 on 04/10/24 reflected the following: Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth four times a day for chronic pain related to MULTIPLE SCLEROSIS (G35) with a start date of 02/01/24. Administration times were listed as 12:00 AM (midnight), 04:00 AM, 08:00 AM, 12:00 PM (noon), 04:00 PM, and 08:00 PM. Cozaar Oral Tablet 50 MG (Losartan Potassium) Give 1 tablet by mouth one time a day for HTN hold for SBP <110 or HR <60 bpm with a start date of 02/02/24 and administration time 08:00 AM Baclofen Oral Tablet (Baclofen) Give 20 mg by mouth five times a day for muscle relaxant related to MULTIPLE SCLEROSIS (G35) with a start date of 02/01/24 and administration times of 04:00 AM, 08:00 AM, 12:00 PM (noon), 04:00 PM, and 08:00 PM. Cipro Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth two times a day for infection for 7 Days with a start date 04/05/2024 and administration times at 08:00 AM and 02:00 PM Review of the April 2024 MAR for Resident #3 reflected the following administration times: 04/01/24 Norco administered at 09:32 AM; Baclofen administered at 09:39 AM; Cozaar administered at 09:39 AM 04/04/24 Norco administered at 09:13 AM; Baclofen administered at 09:12 AM; Cozaar administered at 09:12 AM 04/05/24 Norco administered at 09:42 AM; Baclofen administered at 09:42 AM; Cozaar administered at 09:42 AM 04/06/24 Norco administered at 09:59 AM; Baclofen administered at 09:59 AM; Cozaar administered at 09:59 AM; Cipro administered at 11:53 AM 04/07/24 Norco administered at 09:36 AM; Baclofen administered at 09:35 AM; Cozaar administered at 09:36 AM; Cipro administered at 09:35 AM 04/08/24 Norco administered at 09:23 AM; Baclofen administered at 09:23 AM; Cozaar administered at 09:27 AM; Cipro administered at 09:23 AM 04/10/24 Norco administered at 09:25 AM; Baclofen administered at 09:24 AM; Cozaar administered at 09:25 AM; Cipro administered at 09:25 AM Observation and interview on 04/10/24 at 11:53 AM revealed Resident #3 lying flat in his bed with his overbed table pushed up over his chest and a flosser he placed his teeth and used to press television remote buttons. Resident #1 stated he was scared to death that the facility would take his medications away from him, and every morning when he waited for his morning dose of Norco, he became even more scared. Resident #3 stated he took Norco every four hours, and he stayed up at night, because he was afraid if he went to sleep, he would not get his morning Norco on time. Resident #3 stated his 08:00 AM administration was late every day, and that was why he was scared. He stated he always had pain even with his Norco, but he needed his medication on time to stay on top of the worst of the pain. Resident #3 stated all his morning medications were late, not just the pain medications. During an interview on 04/10/24 at 02:33 PM, MA B stated she passed medications to Resident #3 five days a week. She stated she had been slower than usual, and she did not know exactly why. MA B stated the documentation times in the MAR audit were correct, and she did give the morning meds to Resident #3 late often. MA B stated she was trained to pass medications one hour before or one hour after their administration times. MA B stated she was used to passing medications to a lot of residents and had come from a different facility that had more residents, so the problem was not that she had too much work to do to get it all done. She stated she was occasionally asked to help with things other than passing medications, like getting water, changing the television channel, or putting a blanket over a resident. MA B stated Resident #3 had not complained to her about getting his medication late. MA B stated Resident #1 was always awake in the morning when his medications were due, but he had not said anything about it. During an interview on 04/10/24 at 02:58 PM, the DON stated the entire nurse management team was responsible for overseeing the medication administration system to ensure that medications were given on time. She stated she had not looked at the medication audit sheet for Resident #3 since the surveyor requested to view it, so she was not aware of any late administrations for him. She stated Resident #3 was very aware of when he should have received his medication, especially his Norco. She stated he usually woke up to get each of his doses even when he was sleeping. The DON stated the policy on how late a scheduled medication could be administered was one hour before to one hour after it was scheduled. The DON stated she would have to investigate why the medication aides were administering the 08:00 AM doses so late. The DON stated Resident #1 should not have gone so long without his morning dose of Norco. She stated he was able to voice if he was in pain, so the potential outcome of intolerable pain was unlikely. The DON stated she was not aware of any grievances filed by Resident #1 or complaints about getting his morning medications late. The DON stated they obviously had to put a system into place to ensure the medications were administered on time. During an interview on 04/10/24 at 04:04 PM, the ADM stated the DON was the ultimate person responsible for ensuring medications are administered on time according to policy and regulations. He stated she delegated some of those tasks to ADONs, but he was not sure exactly what the details were. The ADM stated he knew they did audits on the MARs and TARs, and he had been privy to the DON pulling the reports and talking through things on occasion and had participated in conversations after the fact but had not participated in the actual auditing process. The ADM stated Resident #3 had multiple grievances, but none of them were about medication, and the ADM was not aware of any issue with pain management. The ADM stated a potential negative outcome of not receiving scheduled pain medication in a timely manner was not only the possibility of breakthrough pain, but just generally having a poor experience in the facility. The ADM the failure could also bring about other health conditions due to the stress and anxiety of not receiving his medication on time. A policy on medication administration times was requested from the ADM but not provided prior to exit.

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #3 reviewed for pain management. The facility failed to ensure Resident #3 received his 08:00 AM scheduled Norco on time for 7 of 10 days between 04/01/24 and 04/10/24. This failure placed residents at risk of increased pain and decreased quality of life. Findings included: Review of the undated face sheet for Resident #3 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included multiple sclerosis , chronic pain syndrome, muscle weakness, stage 4 pressure ulcer of left buttock, major depressive disorder, and high blood pressure. Review of the quarterly MDS assessment for Resident #3, dated 03/05/24, reflected a BIMS score of 15, indicating intact cognition. It also reflected Resident # 1 was completely dependent on a helper to execute all ADLs, including bed mobility, transfer, dressing, eating, ambulation, bathing, and personal hygiene. It reflected that he received a scheduled regimen for pain, received non-pharmacological interventions for pain, had experienced pain in the five days leading up to the assessment, and was taking an opioid medication for pain. Review of the care plan for Resident #3, dated 02/08/24, reflected the following: is at risk for pain r/t disease process. Will voice a level of comfort of through the review date. Able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain) . Follow pain scale to medicate as ordered. Pain assessment every shift. Therapy evaluation and treatment per physician orders. Review of physician orders for Resident #3 on 04/10/24 reflected the following: Norco Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen ) Give 1 tablet by mouth four times a day for chronic pain related to MULTIPLE SCLEROSIS with a start date of 02/01/24. Administration times were listed as 12:00 AM (midnight), 04:00 AM, 08:00 AM, 12:00 PM (noon), 04:00 PM, and 08:00 PM. Baclofen Oral Tablet (Baclofen) Give 20 mg by mouth five times a day for muscle relaxant related to MULTIPLE SCLEROSIS with a start date of 02/01/24 and administration times of 04:00 AM, 08:00 AM, 12:00 PM (noon), 04:00 PM, and 08:00 PM. Review of the April 2024 MAR for Resident #3 reflected the following administration times: 04/01/24 Norco administered at 09:32 AM; Baclofen administered at 09:39 AM 04/04/24 Norco administered at 09:13 AM; Baclofen administered at 09:12 AM 04/05/24 Norco administered at 09:42 AM; Baclofen administered at 09:42 AM 04/06/24 Norco administered at 09:59 AM; Baclofen administered at 09:59 AM 04/07/24 Norco administered at 09:36 AM; Baclofen administered at 09:35 AM 04/08/24 Norco administered at 09:23 AM; Baclofen administered at 09:23 AM 04/10/24 Norco administered at 09:25 AM; Baclofen administered at 09:24 AM Review of pain assessments (0-10 scale, with zero being the least amount of pain and 10 the most) for Resident #3 reflected 0 for each day shift from 04/01/24 to 04/07/24 and 04/09/24 and a level 6 on 04/08/24. Observation and interview on 04/10/24 at 11:53 AM revealed Resident #3 lying flat in his bed with his overbed table pushed up over his chest and a flosser he placed his teeth and used to press television remote buttons . Resident #3 stated he was scared to death that the facility would take his medications away from him, and every morning when he waited for his morning dose of Norco, he became even more scared. Resident #3 stated he took Norco every four hours, and he stayed up at night, because he was afraid if he went to sleep, he would not get his morning Norco on time. Resident #3 stated his 08:00 AM administration was late every day, and that was why he was scared. He stated he always had pain even with his Norco, but he needed his medication on time to stay on top of the worst of the pain. During an interview on 04/10/24 at 02:33 PM, MA B stated she passed medications to Resident #3 five days a week. She stated she had been slower than usual, and she did not know exactly why. MA B stated the documentation times in the MAR audit were correct, and she did give the morning meds to Resident #3 late often. MA B stated she was trained to pass medications one hour before or one hour after their administration times. MA B stated she was used to passing medications to a lot of residents and had come from a different facility that had more residents, so the problem was not that she had too much work to do to get it all done. She stated she was occasionally asked to help with things other than passing medications, like getting water, changing the television channel, or putting a blanket over a resident. MA B stated Resident #3 had not complained to her about getting his medication late. MA B stated Resident #3 was always awake in the morning when his medications were due, but he had not said anything about it. She stated he was sometimes in some pain throughout the day, but she did not think it was because his medications were given late, and she had never seen him in a lot of pain. During an interview on 04/10/24 at 02:58 PM, the DON stated the entire nurse management team was responsible for overseeing the medication administration system to ensure that medications were given on time. She stated she had not looked at the medication audit sheet for Resident #3 since the surveyor requested to view it, so she was not aware of any late administrations for him. She stated Resident #3 was very aware of when he should have received his medication, especially his Norco. She stated he usually woke up to get each of his doses even when he was sleeping. The DON stated the policy on how late a scheduled medication could be administered was one hour before to one hour after it was scheduled. The DON stated she would have to investigate why the medication aides were administering the 08:00 AM doses so late. The DON stated Resident #3 should not have gone so long without his morning dose of Norco. She stated he was able to voice if he was in pain, so the potential outcome of intolerable pain was unlikely. The DON stated she was not aware of any grievances filed by Resident #3 or complaints about getting his morning Norco late. The DON stated they obviously had to put a system into place to ensure the medications were not administered late. During an interview on 04/10/24 at 04:04 PM, the ADM stated the DON was the ultimate person responsible for ensuring medications are administered on time according to policy and regulations. He stated she delegated some of those tasks to ADONs, but he was not sure exactly what the details were. The ADM stated he knew they did audits on the MARs and TAR s, and he had been privy to the DON pulling the reports and talking through things on occasion and had participated in conversations after the fact but had not participated in the actual auditing process. The ADM stated Resident #3 had multiple grievances, but none of them were about medication, and the ADM was not aware of any issue with pain management. The ADM stated a potential negative outcome of not receiving scheduled pain medication in a timely manner was not only the possibility of breakthrough pain, but just generally having a poor experience in the facility. The ADM said the failure could also bring about other health conditions due to the stress and anxiety of not receiving his medication on time. Review of facility policy, dated 07/17, and titled Recognition and Management of Pain reflected the following: It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to a dignified existence for 2 of 11 residents reviewed for dignity. 1. The facility failed to ensure that PTA A maintained Resident #1's dignity when speaking with her in a public area. 2. The facility failed to ensure Resident #2's back and incontinence brief area were not exposed in a public area while she waited for a shower. This failure placed residents at risk of embarrassment and diminished quality of life. Findings included: 1. Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction (brain damage due to lack of blood and/or oxygen), cognitive communication deficit (difficulty communicating that is caused by a problem with thinking), aphasia (speech difficulties) following cerebral infarction, age-related physical debility, and need for assistance with personal care. Review of the quarterly MDS assessment for Resident #1, dated 02/13/24, reflected a BIMS score of 00, indicating severe cognitive impairment. Review of the care plan for Resident #1, dated 11/17/22, reflected the following: [Resident #1] is at risk for impaired thought process r/t CVA. Will be able to communicate basic needs on a daily basis through the review date. COMMUNICATION: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. [Resident #1] has a communication problem r/t CVA and hearing deficit. Will be able to make basic needs known on a daily basis through the review date. Use communication techniques which enhance interaction: Allow adequate time to respond, Repeat as necessary, Do not rush, Request feedback/clarification from the resident to ensure understanding,Turn off TV/radio as needed to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and picture. The care plan also reflected the following item: [Resident #1] is taking medication, Chlorophyllin for controlling odor. Nullo is a dietary supplement which customers have found to be effective to reduce personal odors related to body odor, perspiration, incontinence, fecal odor, and adult diaper odor. Observation on 04/10/24 at 11:02 AM revealed PTA A in the 100 hall speaking loudly enough to be heard from another room on the hall. PTA A stated, Do you need some more pull ups? You know, like a diaper that goes on a baby? Do you need more of those? Don't you usually wear those? Upon exiting the other room on the hall, the surveyor observed PTA A was speaking to Resident #1 out in the hallway two doors down from Resident #1's room. During observation and interview on 04/10/24 at 11:25 AM, Resident #1 was in her bathroom tying up a used incontinence brief in a wastebasket bag and tidying her bathroom. She made eye contact and smiled when addressed but did not respond verbally and did not indicate she understood any questions being asked of her. 2. Review of the undated face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included left-sided hemiplegia and hemiparesis (paralysis of one side of the body), chronic pain syndrome, attention and concentration deficit following cerebral infarction (brain damage due to lack of blood and/or oxygen), need for assistance with personal care, aphasia (speech difficulties) following cerebral infarction, reduced mobility, cognitive communication deficit (difficulty communicating that is caused by a problem with thinking), age-related physical debility, anxiety disorder, and bipolar disorder (a serious mental illness characterized by extreme mood swings). Review of the quarterly MDS assessment for Resident #2, dated 02/22/24, reflected a BIMS score of 10, indicating moderate cognitive impairment. It also reflected Resident #2 required partial/moderate assistance in the activity of bathing and she was independent with ambulation in her wheelchair. Review of the care plan for Resident #2, dated 01/10/23, reflected the following: [Resident #2] has an ADL Self Care Performance Deficit r/t left sided Hemiparesis, debility, and weakness secondary to CVA history. Will maintain current level of function in ADLs through the review date. BATHING: Is able to: wash chest area and prefers to wash part of her hair with her right hand as able, requires total assist to complete bathing of body and washing of hair. DRESSING: Requires extensive staff participation to dress. Observation on 04/10/24 at 11:04 AM revealed Resident #2 in her wheelchair in front of the shower room in a hospital gown leaning forward to touch something in a shower caddy which was sitting in front of her. PTA A came up behind Resident #2, greeted her, and walked away. Resident #2 leaned forward again to move items in her shower caddy, and her hospital gown was completely open in the back, revealing her naked back, sacral area, and the upper portion of her incontinence brief. During an interview on 04/10/24 at 11:15 AM Resident #2 stated the staff did this to her all the time. She stated she wore the hospital gown to bed, and she would get into clean clothes after her shower, but they often left her sitting in front of the shower room for a long time while she waited to be showered. Resident #2 stated she went to the shower room door herself, but none of the staff cared what state she was in while she sat and waited. Resident #2 stated she did not want the whole hallway of residents and visitors to see her exposed back and brief, but they did not care. During an interview on 04/10/24 at 01:00 PM, PTA A stated she had worked at the facility for a year and had not received any training from the facility specifically about speaking to residents in a way that maintained their dignity. PTA A stated she saw Resident #1 looking in the linen cart the CNAs used and had been trying to figure out if Resident #1 needed a pull-up. PTA A stated Resident #1 had a hard time communicating and was hard of hearing, so sometimes it was difficult to ascertain what she wanted. PTA A stated she had come down the hall to invite residents to a group exercise activity, and she saw Resident #1 out of her room, not using her wheelchair, and was trying to intervene. PTA A stated Resident #1 had a wheelchair but was often noncompliant with it. PTA A stated a possible negative outcome of speaking to a resident the way she did to Resident #1 in a public was the resident might be embarrassed, but PTA A was trying to help Resident #1. PTA A stated Resident #2 was always anxious about her showers and often waited outside the shower room on those days. PTA A stated she had just stopped to say hello to Resident #2 and did not really notice she was exposed. During an interview on 04/10/24 at 02:58 PM, the DON stated they included the therapy staff in in-services about some topics, and she thought the therapists would have participated in trainings about Resident Rights. The DON stated she was not sure who was responsible for ensuring the therapists and therapy assistants spoke to residents in a way that maintained their dignity. The DON stated she would not like to be spoken to the way PTA A spoke to Resident #1 in the hall, and it also may have been a HIPAA violation. The DON stated she would not like everyone to know she wore a brief or a pull up. The DON stated Resident #2 often waited outside the shower room because she felt like she would not get a shower and she took a whole hour for her shower. The DON stated Resident #2 usually wore a hospital gown while sitting outside the shower room, and that was her choice. The DON stated she did not know if that had been care planned. The DON stated they had talked to Resident #2 about her back and brief being exposed, but Resident #2 did not like to be told anything. The DON stated the staff could have offered to cover her up. During an interview on 04/10/24 at 04:04 PM, the ADM stated he monitored to ensure that residents are treated with dignity by having weekly huddles and talking about customer service. He stated facility staff needed to treat residents like they were valued people who had earned the right to be respected at this point in their lives. The ADM stated PTA A told the DOR what had happened with Resident #1, but he had not heard she said anything about wearing diapers like a baby. He stated that was not the way they should have ever spoken to residents. He stated if they needed to be that direct with residents about incontinence, it needed to happen privately, inside the resident's room. The ADM stated Resident #2 was adamant about her shower time and was willing to come and wait by the shower door for a long time. The ADM stated he had not witnessed her sitting in an open gown and hoped someone would have covered her back for her. He stated he did not want her to have to be exposed in the hall, and they would need to find a solution. A policy on Resident Rights was requested from the ADM, but the policy provided was for Notice of Resident Rights and Responsibilities and did not contain any information pertinent to the above failure.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #2) of three residents reviewed for accidents and hazards, in that: The facility failed to ensure Resident #2 (who was a high-elopement risk) did not elope from the facility on 03/26/24 at 12:50 PM when the Receptionist used her remote-control door opener to unlock the front door. He was located over 24 hours later at a bus stop approximately 12 miles from the facility. The noncompliance was identified as PNC. The IJ began on 03/26/24 and ended on 03/27/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization . Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), hypertension (high blood pressure), type II diabetes, and frontal lobe and executive function deficit following cerebral infarction. Review of Resident #2's admission MDS assessment, dated 03/06/24, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected he ambulated independently. Section P (Restraints and Alarms) reflected he required no physical restraints or alarms. Review of Resident #2's admission care plan, dated 02/26/24, reflected he was an elopement risk/wanderer related to impaired safety awareness with an intervention of providing structured activities. Review of Resident #2's Elopement/Wandering Evaluation, dated 02/27/24, reflected he was a high risk for elopement. Review of Resident #2's nursing progress notes, dated 03/26/24 at 7:35 PM and documented by LVN C, reflected the following : [Resident #2] reported missing to charge nurse around 5PM charge nurse was on 200 hall. [Resident #2] is aox2-3 and has a hx of attempting to elope. [Resident #2] usually goes to smoke break at regular intervals. Informed DON, ADMIN, ADON. All staff began searching entire facility for [Resident #2] . police called. Review of Resident #2's nursing progress notes, dated 03/27/24 at 9:50 PM and documented by LVN C, reflected the following : [Resident #2] brought back to facility via private vehicle with staff member. No new orders given from hospital . Sitter at bedside. During an interview on 03/28/24 at 9:32 AM with the ADM and DON, the ADM stated around 5:00 PM on 03/26/24, a MA notified the charge nurse that he could not find Resident #2 when he went to administer his medication. The ADM stated upon review of the video footage, Resident #2 attempted to push the front door open around 12:50 PM and the alarm went off. The ADM stated the Receptionist looked up and immediately pressed the button that turns the alarm off and unlocks the door. The ADM stated Resident #2 then pushed open the door and walked out. He stated his expectations were that all staff, including the Receptionist, were to verify residents before allowing them to exit the facility. The ADM stated the Receptionist was fully aware Resident #2 was an elopement risk and he was even in the elopement binder that was kept at the Receptionist's desk and the nurses' station. The ADM stated all residents that were a high risk of wandering/eloping had their picture in the binder, along with their face sheet, and the elopement process. The ADM stated the Receptionist had been suspended and would not be returning. The ADM stated they had more than 20 people searching for Resident 32 around the clock and he was found at a bus station around 4:22 PM on 03/27/24 by a sister facility's ADM. The ADM stated they took him to the hospital for an evaluation and other than mild dehydration, he had a good bill of health and was taken back to the facility. The ADM stated he did not remember what he did the day before but was now on 1:1 around-the-clock until they found alternate placement. On 03/28/24 at 10:40 AM, a telephone call was made to the Receptionist. A return call was not received prior to exiting. During an observation and interview on 03/28/24 at 11:53 AM, revealed Resident #2 was in his bed sleeping. HSK B was sitting in his room. She stated she worked in the housekeeping department but today was sitting with Resident #2 due to his elopement incident. She stated he had not exhibited any exit-seeking behaviors and when she asked him what he did yesterday (03/27/24), he stated he went to the store for groceries. She stated before her shift she was in-serviced on the elopement policy, exit-seeking behaviors, and about verifying residents in the elopement binders at the front desk and nurses' station before every letting a resident leave. During an interview on 03/28/24 at 11:59 AM, LVN C stated she was in-serviced before working her shift on elopements, the elopement binders, checking the binders if a resident was trying to leave, and ensuring you put eyes on each of their residents at the beginning of their shift, frequently, and end of their shift. During an interview on 03/28/24 at 12:08 PM, the MDSC stated she had been in-serviced the day Resident #2 eloped. She stated the in-services included their elopement policy, the elopement binders, and exit-seeking behaviors. She stated at every morning meeting she was told if someone was a high-elopement risk she was responsible for ensuring their care plan had interventions in place. During an interview on 03/28/24 at 12:59 PM, the SC stated she had been in-serviced on the elopement binders, if a resident was a high-risk of elopement and wanted to go outside, to go out with them and ensure to bring them back inside. She stated she was also in-serviced on redirecting residents that wandered. During an interview on 03/28/24 at 1:06 PM, CNA A stated she was in-serviced before her shift the day before, 03/27/24. She stated the in-services were about elopements, the elopement binder, knowing residents that were a high-risk of eloping, who to notify, and to check on the residents every two hours and ensure you lay eyes on them. During a telephone interview on 03/28/24 at 1:18 PM, CNA D stated she worked on Resident #2's hall on the day he eloped. She stated when she made her initial rounds at 2:00 PM, he was not in his room, but that was not unusual for him because he was rarely in his room as he liked to walk around the facility and sit in the dining room or living room area. She stated she knew she had made a mistake. She stated she had been in-serviced on ensuring they lay your eyes on your residents at the start of each shift and every two hours. She stated there were elopement binders at the front desk and the nurses' stations which identified residents that were high risk. Observation on 03/28/24 from 1:57 PM - 2:04 PM revealed three staff members getting in-serviced by the DON and taking a written elopement quiz in the front lobby before clocking in for their shifts. During an interview on 03/28/24 at 2:08 PM, the new Receptionist stated if a resident wanted to leave the facility, she would first check the elopement binder to ensure they were not a high elopement risk. Review of the facility's Suspension document, dated 03/26/24, reflected the Receptionist was suspended pending the full investigation. Review of the facility's Elopement Timeline for Resident #2, from 03/26/24 - 03/27/24, reflected the following: [Resident #2] (Elopement) 3/26/24 Timeline: 5:15 PM- Med Aide, looked to provide meds to resident and saw they were not in their room. Resident often would sit in other resident's rooms or be in other places of the building, but upon looking for him, it was determined resident may be missing. 5:45 PM- ED and DON were notified that resident was not able to be found after staff had searched the facility and other resident rooms. Immediate code was called to search for the resident. Reviewed Cameras: 12:45 PM- It was observed that [Resident #2] left his room and per his roommate's statement was going to go and purchase or find some cigarettes. 12:50 PM- [Resident #2] approached front door and attempted to open the door. The door alarm sounded, and the resident pulled back from the door. Receptionist looked and noticed someone wanting to exit and pushed the button to release the door alarm and [Resident #2] was able to leave the facility. 6:28 PM- Notified cluster and market to create search party in the local area- reaching out to hospitals, potential places resident may have gone to, metro bus routes were contacted, reached out to point of contacts. POC on file has not had any contact with him and asked that we stop reaching out as he does not want involvement with the resident. 7:10 PM- Police were called after initial search and resident not returned. Case #240861143- Officer [name] #8755. 7:00 PM-11:00 PM- Search parties drove surrounding neighborhoods, called hospitals every couple hours, spoke with local patrons of convenient stores/gas stations/stores providing pictures of the resident. 3/27/24 6:30 AM- Searching began again: 6:30 AM- Local Hospitals called. 7:22 AM- All bus stops from (street) to (street) 7:27 AM- (homeless shelter) searched 7:32 AM- (two major retailers), 2 Homeless [NAME] near (major highway) 8:04 AM- Parks and Churches in area around facility 8:27 AM- Gas stations from (street) to (street) 8:27 AM- (fast-food restaurant) on (intersection) stated they would review their cameras for us this morning 8:34 AM- (apartment complex) just west of the facility 8:38 AM- (neighborhood) east of facility 8:58 AM- (neighborhood) cleared 9:00 AM- (DON from sister facility) contacted (bus) company to ask for any sign on bus routes. From 4PM 3/26 to 4 AM 3/27, there were not sightings of the resident. 9:13 AM- (public park) cleared 9:17 AM- (fast-food restaurant) stated they would review cameras for us and get back to us later 9:47 AM- (neighborhood) 10:20 AM- (grocery store) 10:24 AM- (ED from sister facility) spoke with police department to see if they can trace bank information, they are unable to do that due to time to do that and not being next of kin, but did identify a [family member] that we can try and contact but did not have contact information 11:33 AM- Calls to hospitals and transits again 11:54 AM- (fast-food restaurant) staff member saw the silver alert and would look out 12:07 PM- (transit company) searched as well as (nearby church) 12:15 PM- (grocery store) at (intersection) searched again 12:22 PM- (fast-food restaurant) confirmed they did not see him on Camera 12:23 PM- two gas stations searched 12:35 PM- (three retailers) 12:55 PM- All hospitals called again 1:09 PM- Flyer created based on silver alert to provide to vendors, stations, community 2:00 PM- Huddle with staff- in-serviced staff on Elopement Risk, Elopement Policy, Resident Monitoring and Residents walking along driveway 2:30 PM- Regrouped- Mapped out more regions and sent teams to additional grids of [city name]- some interviewed current residents to see if they would have additional insight to where he may go- one resident made recommendations more into downtown [city name] 3:50 PM- Security company across from facility shared that they had video of resident from prior day heading east towards (major highway) 4:22 PM- [Resident #2] was found at a bus stop- was willing to go with (two EDs from sister facilities), who took him to (hospital) evaluation 4:48 PM- Called Police Department to give update on resident being located 5:23 PM- Submitted Self Report to HHSC 5:30 PM- QAPI Meeting completed with IDT and Medical Director regarding elopement risk, root cause and interventions and next steps 6:00 PM- Present- Continue inservicing staff Review of an in-service entitled Elopement Process, from 03/26/24 - 03/27/24, reflected staff from all shifts were in-serviced on the following: Where are the elopement binders? Who is in the binders? Elopement Policy and Procedure Review of the facility's Interdisciplinary Committee Meeting (QAPI) agenda, dated 03/27/24, reflected the MD, DON, ADM, MDSC, SW, SC, BOM, and other corporate individuals were in attendance. The problem areas discussed reflected the following: Ad hoc QAPI meeting discussing elopement, process and procedure during an elopement, RCA and training going forward. Searches and grids were created and were searched in a 5-mile radius. [Resident #2] mentioned to roommate the was wanting some cigarettes. Searching places triggered gas stations. Different people were assigned in searching on 3/26 and this morning. [Resident #2] was found. Interventions: elopement risk assessments completed at 100%, in-serviced started on #1 elopement assessments, #2 notifying leadership team when someone is noted leaving the facility, #3 monitoring of residents upon start of shift, #4 no one is to be outside unsupervised if they are in the elopement binder. Elopement drill completed. Self-report submitted this afternoon. Care plan for elopements interviewed [sic]. We will continue to monitor for completion of in-services. Review of the elopement binder at the Receptionist's desk, on 03/28/24, reflected residents with a high-elopement risk had a face sheet and picture in the binder. Resident #2's information was included in the binder. Review of the facility's Elopement/Unsafe Wandering Policy, revised 12/2023, reflected the following: It is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintain the least restrictive manner for those at risk of elopement.

Based on observations, interviews, and record reviews the facility failed to ensure the resident(s) environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 4 residents (Resident #72) reviewed for accident hazards and supervision, in that; 1.Resident #72 had 2 unauthorized, unchaperoned elopement events on 10/03/2022 and 01/03/2023, without the facility providing adequate safety interventions to prevent further elopement risks. An IJ was identified on 09/01/2023. The IJ template was provided to the facility on [DATE] at 05:30 PM. While the IJ was removed on 09/03/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on elopement risk residents. The findings included: A record review of Resident #72's admission record, dated 08/31/2023, revealed an admitted [DATE] with diagnoses which included Alzheimer's disease [a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment] and cognitive communication deficit [a difficulty with thinking and how someone uses language]. A record review of Resident #72's quarterly MDS, dated [DATE], revealed Resident #72 was a [AGE] year-old female admitted for long term care. Further review revealed Resident #72 needed supervision and or touching assistance while walking outdoors., Functional Abilities and Goals .mobility .Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel .1 step (curb): The ability to go up and down a curb and/or up and down one step .Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #72's IDT-BIMS assessment, dated 10/04/2022, revealed a score of 04 out of a possible 15, which indicated severe cognitive impairment. A record review of Resident #72's care plan dated 08/31/2023, revealed Resident #72 had eloped on 10/03/2022, at risk for elopement related to her independence in mobility and her dementia .[Resident #72] will be safe while ambulating about the facility and around the facility . reorient her to the facility and the surroundings .encourage her to tell staff when she is going for a walk . continue with stop alarm at exit doors . continue to have door alarm on at all times . complete elopement assessment . assess for any changes . activity program set up through speech therapy and activities to go on assisted walks. A record review of Resident #72's nursing progress note dated 10/03/2022 authored by LVN H at 06:07 PM, revealed Resident #72 was seen walking 0.7 miles away down a busy 5 lane road by a person who was familiar with Resident #72. The note reflected, pt [Resident #72] noted wandering off of the property. pt [Resident #72] was noted walking down the highway towards [named] grocery store. nurse and cna left property and noted pt [Resident #72] walking back toward property. pt [Resident #72] stated that she just wanted to go for a walk and see the people. pt's [Resident #72] [family member] has been notified. MD .has been notified. pt [Resident #72] has been fully assessed and has no s/s of distress no c/o pain no injuries noted. 135/82/118-20-98.2-96% room air. pt [Resident #72] is in dining area at this time ax0 2-3 eating dinner. A record review of Resident #72's nursing progress note dated 01/03/2023 authored by LVN I at 02:34 AM, revealed Resident #72 eloped and was returned to the facility by a kind stranger, around 06:00 PM, who discovered Resident #72 0.8 miles away at a convenience store. The note reflected At 1839 [06:38 PM], resident [#72] was returned to facility. The gentleman that brought resident back to facility states she was at [named] corner store. DON and NP aware of elopement. DON attempted to call [family member] X2 and left message, no return call this noc [nocturnal / night]. Q 1hr checks per order. Labs ordered. WCTM. A record review of the google maps website, https://www.google.com/maps/place/3200+W+Slaughter+Ln,+Austin,+TX+78748/@30.1828935,7.8431987,17z/data=!3m1!4b1!4m6!3m5!1s0x865b4c68be837171:0x9764e07399760efb!8m2!3d30.1828889!4d-97.8406238!16s%2Fg%2F11bw3ybj_j?entry=ttu , accessed August 31, 2023, revealed the facility had a 1000-foot driveway from the 5 lane road where the facility was located. Further review revealed a convenience store 0.8 miles away from the facility accessed only by crossing the 5-lane road. Further review revealed the grocery store was located 0.7 miles away from the facility. During multiple observations from 08/29/2023 through 09/03/2023 of the route from the facility to the convenience store and the grocery store revealed the facility had a 1000-foot driveway before reaching the road, several isolated wooded areas, numerous commercial businesses, and an apartment complex. The route was adjacent to a 5-6 lane road with a 45 mile an hour speed limit. During an interview on 08/31/2023 at 10:02 AM LVN H stated she was on working the evening on October 03, 2022, and was responsible for Resident #72's care when she received a telephone call, around 06:00 PM, from a person who was familiar with Resident #72 and the facility. The person stated Resident #72 was seen walking to the local grocery store along the busy road. LVN H stated she immediately alerted the staff to the elopement and initiated the elopement protocol. LVN H stated she and a fell ow CNA went in their vehicles and searched for Resident #72. LVN H stated she had observed Resident #72 walking back to the facility. LVN H stated she had assessed the resident without any injuries, alerted the previous DON, reported the elopement to the doctor, and made a nursing note . During an interview on 08/31/2023 at 05:32 PM the facility's Community Liason [CL] stated she, by chance, had been outside of the facility's front door on 08/30/2023 when she observed Resident #72 walking out of the front door behind a visitor who was exiting the facility. The CL stated she redirected Resident #72 back into the facility. The CL stated she recognized Resident #72 maybe should not be outdoors due to her own experience and had not received any training to identify residents who were elopement risks. During an interview on 9/1/2023 at 10:37 AM the Administrator stated he began as the Administrator in January of 2023 and had not received a report from the previous Administrator and/or the previous DON [CSC RN] of any elopement events for any residents. The Administrator stated Resident #72 had eloped on 01/03/2023 however he believed the elopement was the first elopement and without any previous history of elopements. The Administrator stated had he known that was her second elopement he may have explored a discharge for Resident #72 to a facility which had more infrastructure for residents who were elopement risks. The Administrator stated the IDT met in January 2023 and implemented elopement risk interventions for Resident #72, to include staff to monitor Resident #72's elopement seeking, documentation of elopement seeking, and interventions for Resident #72 to have the opportunity to walk outside with staff and family. The Administrator stated Resident #72 had several attempts for elopement and has been redirected back into the facility due to staff monitoring Resident #72. During an interview on 09/01/2023 at 11:46 AM the DON stated she had been the DON since December 2022 and had not received any report for elopements for any residents. The DON stated she had received a report from the facility nurses on 01/03/2023 that Resident #72 had eloped and was returned to the facility by a person who discovered her at the convenience store down the road from the facility. The DON stated she had no clear idea how long Resident #72 was gone or how she eloped. The DON stated she had reported the elopement to the Administrator and the elopement resulted in an IDT meeting where the elopement was reviewed. The DON stated Resident #72 had since been redirected from elopement seeking by staff who utilized the facility's all alarmed doors secured by access codes and electromagnetic locks. The DON stated the risk to Resident #72's elopement could have been severe injury. The DON stated if she had been aware that the elopement had been the second time the interventions could have been more intense to include a discharge to a facility which could meet her needs for elopement risk. The DON stated the facility was not equipped for wander guards used for residents who were elopement risks. During an interview on 09/01/2023 at 04:38 PM the CSC RN stated she was the previous DON from October 2022 up to December 2022 when the current DON accepted the position. The CSC RN stated she recalled Resident #72 had a practice of safely ambulating outside of the facility unsupervised and unchaperoned and in early October 2022 she was discovered to have eloped. The CSC RN stated at the time she did not recognize the event as an elopement due to her regular practice of walking outdoors around the facility to include her walks to the store. The CSC RN stated staff were still learning the residents since the facility recently accepted ownership of the facility. The Surveyor reminded the CSC RN Resident #72's BIMS was a 4 at the time of the elopement in October 2022, the facility's driveway was 1000 feet long, the main road at the end of the driveway leading to the grocery store was a 5-6 lane busy road. The Surveyor asked again if the CSC RN still believed the event was not an elopement and the CSC RN stated Resident #72 had that practice and she had not recognized the event as an elopement . A record review of the facility's Elopement / Unsafe Wandering policy, dated June 2018, revealed, It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Wandering is defined as random or repetitive locomotion and can be either goal directed or non-goal directed/aimless. Elopement is when a resident leaves the facility premises or a safe area without authorization; an order for discharge or leave of absence, and or any necessary supervision to do so. This was determined to be an Immediate Jeopardy (IJ) on 09/01/2023 at 05:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/01/2023. The following Plan of Removal verification was accepted on 09/03/2023 at 01:17 PM. Removal of Immediacy Plan: Wandering and Elopement Date/Time presented to Surveyors: 09/01/23, 08:00 PM Identified here are the steps and immediate actions [The Facility] will take to address the non-compliance and provide residents with proper assessments to meet resident needs and safety concerns. IMMEDIATE ACTION The Medical Director was notified of immediate jeopardy. 1. Resident #72 a. On 9/1/23, Resident #72 was assessed by a nurse with head-to-toe assessment for injury. b. On 8/30/23 at 10 am Resident #72 was placed on one-on-one line-of-sight supervision. Supervision will continue until [a] safe transition to a secure healthcare facility. c. On 09/01/23 Family/RP and physician were notified of elopement and elopement risk. 2. All other Residents a. On 9/1/23, elopement assessments [were] completed on all Residents. b. By 09/02/23, all Residents at high risk of elopement will be reviewed by [the] IDT to ensure a safe environment. Care plans will be updated to reflect elopement risk and person-centered care interventions. c. On 9/1/23, DON or designee placed all high-risk Residents in an elopement binder. 3. In-servicing/audits a. DON or designee will in-service licensed nurses on completing elopement assessments accurately. In-servicing started on 9/1/23 of [with] licensed nursing staff on completing the elopement assessment at admission, quarterly, and at change of condition. Staff re-educated to notify DON or designee when a Resident triggers high risk for elopement. All nurses will receive this in-servicing prior to next shift worked at the facility. DON or designee will check weekly to ensure assessments are being completed. b. In-servicing started on 9/1/23 of all staff on elopement policy and procedure. In-services to be completed for each staff prior to the next shift worked. c. On 9/1/23 all exit doors checked for integrity + proper functionality. 4. The abuse coordinator will provide a summary of elopement incidents and Residents at high risk for elopement to monthly QAPI meeting. Submitted by: The Administrator Plan of Removal Verification Plan of Removal Verification 09/02/2023 Removal of Immediacy Plan: Wandering and Elopement Date/Time presented to Surveyors: 09/01/23, 08:00 PM Identified here are the steps and immediate actions [The Facility] will take to address the non-compliance and provide residents with proper assessments to meet resident needs and safety concerns. IMMEDIATE ACTION The Medical Director was notified of immediate jeopardy. Interview: A phone interview with the Medical Director on 09/2/2023, at 12:15 PM, revealed he was notified of immediate jeopardy on 09/01/23 at 05:00 PM. Record review of the facility POR binder dated 09/01/23 revealed that the medical director was notified of IJ elopement on 09/01/23 and 4 residents were assessed as at a high risk for elopement (Resident #72, Resident #80, Resident #34, and Resident #141.) 1. Resident #72 a. On 9/1/23, Resident #72 was assessed by a nurse with head-to-toe assessment for injury. i. Record review of resident #72's electronic medical record revealed a progress noted dated 09/02/23 revealed a head to assessment was completed on 09/01/2023 with no injuries noted. b. On 8/30/23 at 10 am Resident #72 was placed on one-on-one line-of-sight supervision. Supervision will continue until [a] safe transition to a secure healthcare facility. i. Observation on 09/02/23 at 12:22 p.m. of resident #72 at the entrance of 300 hall revealed she was sitting next to her family member, reminiscing about how they met. ii. Interview on 09/02/2023 at 12:28 p.m. with Staffing Coordinator A assigned to 1:1 with Resident #72. She stated she was assigned to 1:1 and hanging out with resident, ensuring she did not elope. Staffing coordinator A confirmed she was in-serviced on elopement this morning prior to starting her shift. c. On 09/01/23 Family/RP and physician were notified of elopement and elopement risk. i. Record review of Resident #72's electronic medical record dated 09/01/23 at 4:11 p.m. revealed that the family member was made aware that resident #72 was an elopement risk, and he agreed to seek placement due to safety. ii. During an interview on 09/02/2023 at 12:15 PM the Medical Director stated that the Interdisciplinary committee recommended Resident #72 be discharged to a facility that could meet her needs. 2. All other Residents a. On 9/1/23, elopement assessments [were] completed on all residents. i. During an interview on 09/02/2023 at 10:29 a.m., the DON stated all elopement risk assessments were completed by nurses assigned to corresponding residents on 09/01/2023. ii. All census, 97 residents, were reviewed for elopement risk assessments. Record review of all 97 residents electronic medical records on 09/02/23 revealed elopement risk assessments had been completed on 09/01/23. iii. A sample of 10 were selected for the document record review. iv. Record review of Resident #76; revealed an elopement risk assessment was completed on 09/01/23. v. Record review of Resident #65; revealed an elopement risk assessment was completed on 09/01/23. vi. Record review of Resident #75; revealed an elopement risk assessment was completed on 09/01/23. vii. Record review of Resident #32; revealed an elopement risk assessment was completed on 09/01/23. viii. Record review of Resident #87; revealed an elopement risk assessment was completed on 09/01/23. ix. Record review of Resident #84; revealed an elopement risk assessment was completed on 09/01/23. x. Record review of Resident #72; revealed an elopement risk assessment was completed on 09/01/23. [NAME]. Record review of Resident #37; revealed an elopement risk assessment was completed on 09/01/23. xii. Record review of Resident #61; revealed an elopement risk assessment was completed on 09/01/23. xiii. Record review of Resident #49; revealed an elopement risk was completed on 09/01/23. b. By 09/02/23, all residents at high risk of elopement would be reviewed by [the] IDT to ensure a safe environment. Care plans would be updated to reflect elopement risk and person-centered care interventions. i. During an interview on 09/02/2023 at 10:29 AM, the DON stated all residents who were assessed as a high risk of elopement had been reviewed by IDT to ensure a safe environment. Care plans were updated to reflect elopement risks and person-centered care interventions. ii. The facility identified four residents (Residents #72, #34, #80 and #141) as elopement risks. iii. Record review of Resident #72's care plan, dated 08/31/2023, revealed an intervention see elopement binder at the nurse's station, dated 08/31/2023 iv. Record review of Resident #34's care plan dated 09/01/2023 revealed an intervention: 09/01/23 IDT team met MDS resource, CNA, DON, Clinical resource, ED, on residents' high risk for elopement. currently resident wanders around facility aimlessly but is not exit seeking. v. Record review of Resident #80's care plan dated 09/01/2023 revealed an intervention: 09/01/23 IDT team met MDS resource, CNA, DON, Clinical resource, ED, on residents' high risk for elopement. currently resident wanders around facility aimlessly but is not exit seeking. vi. Record review of Resident #141's care plan dated 09/01/2023 revealed an intervention: 09/01/23 IDT team met MDS resource, CNA, DON, Clinical resource, ED, on residents' high risk for elopement. currently resident wanders around facility aimlessly but is not exit seeking. c. On 9/1/23, DON or designee placed all high-risk Residents in an elopement binder. i. Record review of the facility's elopement binder, located at the nurse's station on 09/02/2023 revealed the elopement policy, pictures and face sheets for the four residents (Residents #72, #80, # 34, and #141) identified as high risk for elopement. 3. In-servicing/audits a. The DON or designee will in-service licensed nurses on completing elopement assessments accurately. In-servicing started on 9/1/23 of [with] licensed nursing staff on completing the elopement assessment at admission, quarterly, and at change of condition. Staff re-educated to notify the DON or designee when a resident triggers high risk for elopement. All nurses will receive this in-servicing prior to next shift worked at the facility. The DON or designee will check weekly to ensure assessments are being completed. i. A record review of the facility's nursing roster dated 09/01/2023 revealed 1 DON and 1 ADON and an additional 18 nurses and 44 CNA's. As of 09/03/2023 the DON and the ADON and 13 of the 18 nurses and 34 of the 44 CNA's were interviewed. ii. A record review of the facility's elopement in-service records dated 09/01/2023 and 09/02/2023 revealed the DON, the ADON and the additional 18 nurses received the elopement in-service training. Further review of the training records revealed 30 of the 44 CNA's received the elopement in-service training. iii. During an interview on 09/03/2023 at 11:30 AM the Administrator stated the DON and himself would monitor all shifts and ensure any staff member that had not received the in-service training would not be allowed to accept CNA duties prior to receiving the elopement in-service with a return demonstration of the understanding of the training. iv. A record review of the facility's in-service, Elopement and Unsafe Wandering dated 09/01/2023, revealed, the regional clinical RN and the DON provided the training. The in-service revealed, It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Wandering is defined as random or repetitive locomotion and can be either goal directed, or non-goal directed or angle. Elopement is when a resident leaves the facility premises or a safe area without and or any necessary supervision to do so . procedures . residents with high risk factors identified on an elopement wandering evaluation are considered at risk and will have an individualized care plan developed that includes measurable objectives and time frames . staff shall promptly report any resident who is trying to leave the premises or suspected of being missing to the charge nurse or supervisor to elevate the need for further interventions. If a resident is missing it is a facility wide emergency. The missing resident procedures will be initiated . if the resident is unaccounted for after a thorough search of the building and grounds immediately notify, the Administrator . v. During an interview on 09/02/2023 at 04:09 PM RN C stated her shift was the 06:00 AM to 02:00 PM shift. RN C stated on 09/01/2023 and again on 09/02/2023, received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. RN C stated she had received her training from the DON. vi. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed RN C had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. vii. During an interview on 09/02/2023 at 05:28 PM CNA D stated her shift was the 06:00 AM to 02:00 PM shift. CNA D stated she received an in-person and computerized training. CNA D stated the training included the implementation of an Elopement Binder which she could refer to, to identify residents who were a high risk for elopement. She stated the binder was kept at the nurse's station. CNA D stated she had received the training from the DON. viii. Record review of the facility's elopement assessment in-service dated 09/01/2023, revealed CNA D had received the elopement assessment and prevention training. ix. During an interview on 09/02/2023 at 05:25 PM CNA E stated her shift was the 06:00 AM to 02:00 PM shift. CNA D stated she received an in-person and computerized training. CNA D stated the training included the implementation of an Elopement Binder which she could refer to, to identify residents who were a high risk for elopement. She stated the binder was kept at the nurse's station. x. Record review of the facility's elopement assessment in-service dated 09/01/2023, revealed CNA E had received the elopement assessment and prevention training and prevention training and completed the computerized elopement prevention and safety protocol training. [NAME]. During an interview on 09/02/2023 at 05:38 PM LVN J stated her shift was the 06:00 AM to 06:00 PM shift. LVN J stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. LVN J stated she had received her training from the DON. xii. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed LVN J had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xiii. During an interview on 09/02/2023 at 01:58 PM LVN E stated her shift was the 02:00 PM to 10:00 PM shift. LVN E stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. LVN E stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed an elopement risk and had a need for safety. LVN E stated she had received her training from the DON. xiv. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed LVN E had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xv. During an interview on 09/02/2023 at 02:38 PM CNA K stated her shift was the 02:00 PM to 10:00 PM shift. CNA K stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. CNA K stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed as an elopement risk and had a need for safety. CNA K stated she had received her training from the DON. xvi. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed CNA K had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xvii. During an interview on 09/02/2023 at 02:13 PM CNA L stated his shift was the 02:00 PM to 10:00 PM shift. CNA L stated on 09/01/2023 and again on 09/02/2023, he received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. CNA L stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed aa an elopement risk and had a need for safety. CNA L stated he had received his training from the DON. xviii. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed CNA L had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xix. During an interview on 09/02/2023 at 05:27 PM LVN M stated her shift was the 06:00 PM to 06:00 AM shift. LVN M stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. LVN M stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed as an elopement risk and had a need for safety. LVN M stated she had received her training from the DON. xx. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed LVN M had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xxi. During an interview on 09/02/2023 at 04:19 PM LVN N stated her shift was the 06:00 PM to 06:00 AM shift. LVN J stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. LVN N stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed as an elopement risk and had a need for safety. LVN N stated she had received her training from the DON. xxii. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed LVN N had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xxiii. During an interview on 09/02/2023 at 05:26 PM CNA O stated her shift was the 06:00 PM to 06:00 AM shift. CNA O stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who had been assessed as elopement risks, elopement prevention and elopement safety protocols. CNA O stated an Elopement Safety binder was implemented to assist staff recognize residents who were assessed a elopement risk and had a need for safety. CNA O stated she had received her training from the DON. xxiv. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed CNA O had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xxv. During an interview on 09/02/2023 at 04:46 PM CNA P stated her shift was the 06:00 PM to 06:00 AM shift. CNA P stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. CNA P stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed as an elopement risk and had a need for safety. CNA P stated she had received her training from the DON. xxvi. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed CNA P had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. b. In-servicing started on 9/1/23 of all staff on elopement policy and procedure. In-services to be completed for each staff prior to the next shift worked. i. During an interview on 09/03/2023 at 11:30 AM the Administrator stated the DON and himself would monitor all shifts and ensure any staff member that had not received the in-service training would not be allowed to accept CNA duties prior to receiving the elopement in-service with a return demonstration of the understanding of the training. c. On 9/1/23 all exit doors were checked for integrity and proper functionality. i. During an interview on 09/02/2023 at 2:27 PM, the Administrator stated he had checked all exit doors on 09/01/2023. ii. Record review of a report provided by the Administrator, located in the facility's POR binder revealed on 09/01/2023 the seven exit doors had been checked for integrity and proper functioning. 4. The abuse coordinator will provide a summary of elopement incidents and Residents at high risk for elopement to monthly QAPI meeting. i. During an interview on 09/02/2023 at 2:15 pm the Administrator stated QAPI meetings were held the last two days (09/01/2023 and 09/02/2023) to review residents at risk for elopement. ii. Record review of sign in sheets from Ad Hoc QAPI meetings with the Medical Director in attendance, dated 09/01/2023 and 09/02/2023. Further review of Problem Areas Discussed revealed the four residents (#34, #72, #80 and #141), identified as high risk for elopement were discussed and arrangements made for transitions to memory care units for Resident #72 and Resident #141. Submitted by: The Administrator The Administrator was informed the Immediate Jeopardy was removed on 09/03/2023 at 01:17 PM. While the IJ was removed the facility remained ou [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of 15 residents reviewed for resident-to-resident abuse. The facility failed to prevent Resident #2, who had a history of hypersexual behaviors, from touching Resident #1 in a sexually inappropriate manner on 12/04/2022. LVN B failed to identify Resident #2's unwanted touching of Resident #1's breast area as sexual abuse. The facility failed to protect Resident #1, who had a history of sexual assault as a child, from being sexually abused by Resident #2. These failures placed Resident #1 at serious risk of reliving trauma, mental anguish, decreased psychosocial well-being and mental health, and increased anxiety. On 12/09/2022 at 5:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/11/2022, the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: A record review of the facility's abuse and neglect prohibition policy dated 7/10/2019 and provided on 12/08/2022 at 10:01 a.m. reflected the following: Long-Term Care Regulatory Provider Letter Number: PL 19-17 (Replaces PL 17-18) Title: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC) Provider Types: Nursing Facility (NF) Date Issued: July 10, 2019 1.0 Subject and Purpose This letter provides guidance for reporting incidents to HHSC and: o Adds Attachment 1, describing reporting requirements and providing examples to help determine what constitutes a reportable incident. o Adds Attachment 2, a flow chart to assist in decisions about making reports. o Deletes guidance on resident-resident sexual activity and incorporates that guidance into the flow chart in Attachment 2. 2.0 Policy Details & Provider Responsibilities 2.1 Incidents that a NF Must Report to HHSC and the Time Frames for Reporting A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: o Abuse A review of PL 19-17 reflected abuse (with or without serious bodily injury) was a type of incident that needed to be reported immediately, but not later than two hours after the incident occurred or was suspected. Attachment 1 of PL 19-17 reflected what HHSC rules defined abuse as, which reflected sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code S21.08 (indecent exposure) or [NAME] Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Attachment 1 of PL 19-17 reflected CMS's definition of abuse which reflected that instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. Attachment 2 of PL 19-17 reflected a flowchart with guidance on reporting resident-resident sexual activity. The flowchart reflected the following: The facility becomes aware of, or receives, and allegation of suspected abuse, neglect, exploitation or another reportable incident --> Does it involve resident-to-resident sexual activity? --> YES --> Take immediate action to prevent further potential ANE pending investigation --> Can all residents involved in the sexual activity consent to participation? --> NO --> Report the incident within two hours --> Complete an internal investigation of the incident --> Take appropriate corrective action --> Report the investigation findings within 5 working days from the initial report to HHSC on Form 3613-A --> Maintain evidence demonstrating results of all incidents for no less than three years after the reported allegation A record review of the facility's policy on abuse and neglect prohibition dated 11/28/2016 and provided on 12/10/2022 at 4:22 p.m. reflected the following: Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representative, families, friends, or other individuals. Prevention - The employees of our facility will take action to protect and prevent abuse and neglect from occurring within the facility by: Staff has knowledge of the individual residents' care needs Supervision of staff to identify inappropriate behaviors (i.e., derogatory language, rough handling, ignoring residents while giving care. Etc.) Assess, care plan, and monitor residents with history of aggressive behaviors, behaviors such as entering other residents'' rooms, self-injurious behavior, communication disorders, totally dependent on staff Identification of Abuse - Identify events, such as but not limited to, suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction for the investigation. 2. Episodes of resident to resident altercation, willful or accidental, with or without injury. 3. Occurrences, patterns and trends will be assessed by Licensed staff and/or Interdisciplinary Team to determine the direction of the investigation. Protection - If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, this facility will take the following steps to prevent further potential abuse while the investigation is in progress; 1. If the suspected perpetrator is another resident: a. Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined b. If a room change is appropriate, advise residents'' families of the change and room location Reporting/Response - All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow-up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days. The facility will analyze occurrences and determine what change are needed, if any, to the policies and procedures to prevent further occurrences. Definitions - 483.13(b) and (c) To assist the facility's staff members in recognizing incidents of abuse, the following definitions are provided o Abuse - willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse - is non-consensual sexual contact of any type with a resident. A record review of Resident #1's undated face sheet reflected an [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior), hypertension (high blood pressure), peripheral vascular disease (condition affecting blood vessels), hyperlipidemia (high cholesterol), generalized anxiety disorder, recurrent depressive disorders (depression), and unspecified dementia. A record review of Resident #1's care plan last revised on 12/06/2022 reflected Resident #1 had impaired thought process related to Alzheimer's Disease and had potential for psychosocial well-being problem related to recent resident to resident interaction. Interventions included that staff were to allow the resident time to express feelings and emotions as needed, anticipate and meeting her needs and redirect as necessary, assess for any changes in behavior, encourage residing to sit in common areas and socialize with her peers as able, and provide comfort and reassurance. Resident #1's care plan did not reflect any history of sexual assault or trauma. Resident #1's care plan reflected a diagnosis of anxiety, however, this was not listed as a focus area no interventions for anxiety were reflected. A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severe cognitive impairment. A review of Section G (Functional Status) reflected Resident #1 required extensive assistance and one person physical assist with bed mobility and transfers. Section G also reflected Resident #1 required a wheelchair and was only able to stabilize with staff assistance when moving from seated to standing, moving on and off toilet, and transferring from bed to wheelchair. Resident #1's face sheet reflected she resided in room [ROOM NUMBER]-A. A record review of Resident #2's undated face sheet reflected an [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia, type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), chronic obstructive pulmonary disease (trouble breathing). Resident #2's face sheet reflected he resided in room [ROOM NUMBER]-A. A record review of Resident #2's care plan created by MDS Resource and revised on 10/11/2022 reflected he had a behavior problem including hypersexual tendencies related to cognitive impairment. Interventions for this behavior reflected that staff were to educate family and/or caregivers on successful coping and interaction strategies, administer medications as ordered, discuss resident's behavior and explain/reinforce why behavior was inappropriate and/or unacceptable to the resident, stop and talk with resident when passing by, and intervene as necessary to protect the rights and safety of others. A record review of Resident #2's MDS assessment dated [DATE] reflected a BIMS score of 6, which indicated severe cognitive impairment. A review of Section G (Functional Status) reflected Resident #1 required only supervision and set up help with bed mobility and transfers. Section G also reflected Resident #1 required a wheelchair but could stabilize without staff assistance when moving from seated to standing, moving on and off toilet, and transferring from bed to wheelchair. This indicated Resident #2 had higher functional ability than Resident #1. A record review of Resident #3's undated face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of major depressive disorder (depression), hyperlipidemia (high cholesterol), cognitive communication deficit (difficulties with communication), dementia, and anxiety. Resident #3's face sheet reflected she resided in room [ROOM NUMBER]-B. A record review of Resident #3's care plan revised on 11/08/2022 reflected she was at risk for psychosocial well-being related to the pandemic. A record review of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severe cognitive impairment. During an observation on 12/08/2022 at 10:58 a.m., Resident #1 was observed in her wheelchair rolling down the 400-hall saying, I am so confused. During an observation and interview translated by and HHSC employee on 12/08/2022 beginning at 11:21 a.m., Resident #2 was observed sitting in a wheelchair in his room. When asked if he had touched Resident #1, Resident #2 stated I have not touched her anymore. Resident #2 stated one of the ladies at the front of the facility told him not to touch Resident #1. Resident #2 stated the ladies asked him to come over there but he would not do that anymore. Upon exiting Resident #2's room, Resident #2 pointed to HK A and stated, she knows. In an interview on 12/08/2022 at 11:37 a.m., DON stated HK A saw Resident #1 with a napkin on her chest and saw Resident #2 take the napkin off and put his hand back on her chest. In an interview translated by an HHSC employee on 12/08/2022 at 11:47 a.m., HK A stated she was working in the 400 hall when she observed Resident #1 in her room with Resident #2. HK A stated Resident #1 was wearing a clothing protector and Resident #2 took off Resident #1's clothing protector and started touching Resident #1 under over and under her shirt. HK A stated the incident between Resident #1 and Resident #2 had occurred the weekend prior just before 2:00 p.m. HK A stated she reported the incident to LVN B. HK A stated that Resident #2 had touched a different female resident, Resident #3, about one or two months ago in the dining room. HK A stated Resident #3 was not cognitively intact. HK A stated the previous company did not do anything to prevent incidents like that from happening but stated since the incident on 12/04/2022, staff had been keeping an eye on Resident #2. In a confidential resident interview, a cognitively intact female resident stated Resident #2 went for women that wanted a lot of attention. When asked if women he went for understood what he was going for, the resident stated no. The resident stated Resident #2 had been going for her roommate and she had seen Resident #2 touching her roommate's arm but never her breast area. The resident stated Resident #2 thought he was god's gift to women, preyed on weak and older women, and stated she did not trust him at all. In an interview on 12/09/2022 at 9:26 a.m., Resident #2's family stated the facility notified her of the incident between Resident #2 and Resident #1. Resident #2's family stated Resident #2 had never done anything indecent prior to being admitted but that was the second time someone at the facility had seen him sticking his hand in another lady's shirt. In an interview on 12/09/2022 at 10:03 a.m., DON stated Resident #2 came to the DON's office after Resident #2's psychologist appointment on 12/06/2022 and they discussed the plan for him to not go into ladies' rooms and touch them. The DON stated an incident like that had never happened before. The DON stated Resident #2 took Depakote for behaviors. In an interview on 12/09/2022 at 10:45 a.m., Resident #1's family stated DON had called her to explain what had happened. Resident #1's family stated DON stated to her that Resident #1 went back to her room with a napkin and Resident #2 pulled it off and put his hand down Resident #1's shirt. Resident #1's family stated DON told her Resident #2 had dementia, but not to Resident #1's extent. Resident #1's family stated DON told her the facility would do a full investigation. Resident #1's family stated DON did not tell her how they planned to keep Resident #1 and other residents safe. Resident #1's family stated she could not recall DON saying they planned to move either Resident #1 or Resident #2 to a different room in order to keep them separated. Resident #1's family member stated Resident #1 had a history of sexual assault as a child, stating Resident #1 told her that Resident #1's uncle used to touch Resident #1 all the time down there and do things when Resident #1 was five years old. After this, Resident #1's family stated Resident #1 did not speak for an entire year after the assault. Resident #1's family stated she learned about this when Resident #1's dementia came out, stating she was blown away and had no idea Resident #1 had PTSD. Resident #1's family stated it all made sense since Resident #1 was always a worrier, always stressed, and had so much anxiety about that. In an interview on 12/09/2022 at 11:05 a.m., when asked why she had revised Resident #2's care plan to reflect hypersexual behaviors, the MDS Resource stated honestly I don't remember. It would have been something communicated to me from nursing staff. The MDS Resource stated information in the care plan comes from the MDS assessment or from nursing, and if nurses were busy she would enter information for them. The MDS Resource stated she did not remember which nurse had communicated to her the hypersexual behaviors and she just typed up care plans using information from nursing. In interviews on 12/09/2022 from 10:56 a.m.-11:30 a.m., LVN B stated HK A had made a remark to her on 12/04/2022, stating she had seen Resident #2 touching Resident #1 inappropriately by putting his hand down Resident #1's shirt. LVN B stated at that point, she went down the 400 hall and saw both residents in their own room. LVN B stated she looked down Resident#1's blouse and did not see anything so she came back to the nurses station because she did not see any evidence that Resident #2 had been close to Resident #1. When asked if there was anyone she reported this incident to on that Sunday, LVN B stated, that day, I did not. LVN B stated it was reported to DON Monday. When asked if she had reported it to DON, LVN B stated no. When asked what the facility's policy was on reporting alleged abuse, LVN B stated, we have to report it immediately to someone in charge. When asked if in that instance, she reported it immediately, LVN B stated, I did not. In that instance I did not see anything I felt was abuse. When asked about Resident #2's hypersexual behaviors, LVN B stated LVN C had reported to her a prior incident in which Resident #2 had touched another female resident on the 300 hall. LVN B stated she did not remember when this was. In an interview on 12/09/2022 at 12:00 p.m., LVN C stated there was a previous incident reported to her by two CNAs on her hall who saw Resident #2 touching Resident #3 inappropriately. LVN C stated the incident was sometime before October of 2022 and that she had reported it to the prior administrator. LVN C stated the new company took over the facility on 10/01/2022. In an interview on 12/09/2022 at 12:40 p.m., DON stated the incident between Resident #1 and Resident #2 was reported to her Monday morning (12/05/2022) by the Housekeeping Supervisor. In an interview on 12/09/2022 at 12:06 p.m., Resident #1's other family member stated, I want to make sure that this person is not near my mother again. Resident #1's other family member stated she hoped Resident #1 and Resident #2 were not still on the same hallway. In an interview on 12/09/2022 at 12:41 p.m., the Housekeeping Supervisor stated HK A had told her she witnessed Resident #2 removing a napkin or clothing protector from Resident #1 and at first HK A thought Resident #2 was trying to help Resident #1 but then HK A saw Resident #2 put his hand inside Resident #1's shirt. The Housekeeping Supervisor stated that since the incident occurred on 12/04/2022, and DON did not become aware of it until 12/05/2022, she thought that meant LVN B had not reported it to the DON. The Housekeeping Supervisor stated that nurses were supposed to check with residents, ensure they were not in danger, and ensure they were not being abused. When asked what LVN B did as a result of HK A reporting the incident to her on 12/04/2022, the Housekeeping Supervisor stated she heard that LVN B did an incident report. In an interview on 12/09/2022 at 1:50 p.m., when asked how the facility would ensure continuity of care during changes in the facility's leadership, DON stated some staff were from the previous company including the MDS nurses, and when she started at the facility in October 2022 she received a report from the previous DON with residents' care plans and a summary of what was going on with residents. DON stated she was not aware of any other residents with hypersexual behaviors. DON stated the facility would protect Resident #1 by ensuring staff were aware of Resident #1 and Resident #2, were observant of them, and knew to redirect them when seen together. DON stated this was communicated to staff one on one and in the nurses shift change report. DON clarified that this was a verbal training in which staff were instructed to redirect Resident #1 and Resident #2. When asked if this training was documented, DON referred to an in-service, with no written text and only signatures from staff, dated 12/06/2022 and titled care of resident in room [ROOM NUMBER]A. When asked if these interventions were documented in PCC, DON stated interventions would be documented in residents' care plans. When asked if this was documented in either Resident #1's or Resident #2's care plans, DON stated, I believe so because we had a discussion as a team. DON stated it can be anyone's responsibility to document in care plans. When asked how staff knew who they needed to protect and who they needed to monitor, DON stated to me, I believe it is documented in the care plan and in Kardex. In his chart it is documented and we are observant. Resident #2's care plan was pulled up and DON observed it had not been revised since the incident on 12/04/2022. DON then stated upon reviewing his care plan earlier that week, she believed Resident #2's current interventions were appropriate and thus, his care plan did not need to be revised. DON stated Resident #1 and Resident #2's care plans were reviewed during morning meetings and during the facility's high risk meeting earlier that week on Monday or Tuesday but could not specify an exact date or who participated in the care plan review. Resident #1's care plan was pulled up and DON pointed out that her care plan had been updated on 12/06/2022 to include potential for a psychosocial well-being problem related to recent resident to resident interaction. When asked how the facility would ensure residents were protected int eh future with changes in management, DON stated, we have care plans and Kardex where it is documented and this is used by staff and CNAs. In an interview on 12/09/2022 at 4:19 p.m., DON stated she reviewed the facility's incidents/accidents for the past six months and did not see any reportable event involving Resident #2 and Resident #3. DON stated they had no record of any previous incident involving Resident #2. In an interview on 12/09/2022 at 2:45 p.m., CNA G stated she had received an in-service training that week about Resident #2 but did not recall that it addressed Resident #1. In an interview on 12/09/2022 at 2:46 p.m., LVN E stated she received training that week on abuse, inappropriate behavior, and redirecting residents who looked confused and were about to go in other residents' rooms. LVN E did not recall whether the in-service pertained to Resident #2 or not. In an interview on 12/09/2022 at 4:46 p.m., DON stated the facility had no record of any previous incidents of inappropriate behavior involving Resident #2. DON stated that after reviewing their incidents and accident log for the past six months, she did not see any reportable event involving Resident #2 and Resident #3. DON stated the facility's incident reports were QA protected and could not be shared. In an interview on 12/09/2022 at 5:06 p.m., DON stated the facility prevented abuse by educating staff and completing background checks on staff. DON stated this process was monitored via rounding with residents and completing safe surveys after an incident had occurred. When asked if and how the facility prevented abuse proactively rather than reactively, DON stated through rounding with residents and talking to staff. DON stated Resident #1 was protected by ensuring staff redirected patients and made sure Resident #2 was not going into Resident #1's room. DON stated she discussed with Resident #2 about his behavior being unacceptable. When asked if there was any potential for a negative resident outcome if residents were not protected from abuse, the DON stated, I don't understand what you're asking because I think residents were protected. In an interview on 12/09/2022 at 5:24 p.m., the Administrator stated the facility's policy on protecting residents from abuse included monitoring patients, in-servicing staff, doing rounds, interdisciplinary meetings, and high risk meetings. The Administrator stated herself, DON, and charge nurses monitored this as a team but it was mostly herself and DON who monitored this policy. The Administrator stated incidents were put onto Kardex to ensure staff monitored and all staff had been in-serviced on Kardex. When asked if staff had been trained on preventing abuse, the Administrator stated, if we see it starting to happen, we intervene to prevent it from happening and redirect. The Administrator stated staff had been in-serviced on that process. The Administrator stated there was monitoring after the event between Resident #1 and Resident #2 so there was not harm and she did not see that Resident #1 was at risk. In an interview on 12/10/2022 at 1:42 p.m., LVN D stated the facility's Kardex system told staff about ADLs and other particular things about residents. Observed LVN D pull up Resident #2's Kardex on his computer. When asked if he could find where Resident #2's Kardex had been updated on 12/05/2022, as the facility's PIR for the incident reflected it had been, LVN D could not find any update on that day. In an interview and record review on 12/10/2022 at 2:00 p.m., the Administrator stated the facility had a paper Kardex system which was just an Excel spreadsheet that got updated daily as needed. The Administrator stated the updates in Kardex were not dated. The Administrator provided a paper copy of an undated document titled C.N.A 400 Hall Kardex which reflected Resident #2 had special care needs that included redirecting him if found in another room. In an interview on 12/10/2022 at 4:18 p.m., RN I stated she had checked the previous company's QAPI binder and did not find anything regarding a prior incident of inappropriate touching with Resident #2. In an interview on 12/11/2022 at 12:24 p.m., Resident #2's Psychologist stated she had met with Resident #2 that day and made it clear to him that he was not to go into other residents' rooms. The Psychologist's meeting with Resident #2 was translated by RN H, the facility's DON in training. The Psychologist stated Resident #2 seemed more stressed during this meeting as compared to last week's meeting and was concerned that they were going to meet again. The Psychologist stated Resident #2 had denied any inappropriate behavior and stated cultural norms about touching and personal space were different for him. The Psychologist stated she acknowledged his cultural outlook but reiterated to Resident #2 that he was not to touch other residents. During an observation and interview on 12/11/2022 beginning at 1:07 p.m., Resident #3 was observed walking to her room. Resident #3 appeared very confused, stated she was going home, and was not able to answer whether or not she had been inappropriately touched in the past. An interview with Resident #3's family was attempted on 12/12/2022 at 12:12 p.m. but Resident #3's family did not answer the phone so a voicemail message was left. In an interview on 12/12/2022 at 11:44 a.m., Resident #1's family stated she had mentioned to the facility many times the fact that Resident #1 had a history of sexual assault. Resident #1's family stated they had brought it up at the beginning, when Resident #1 was admitted , because of Resident #1's anxiety. Resident #1's family stated they made the facility aware of this through care plan meetings, discussions with the psych NP, and through one-on-one meetings with facility staff. Resident #1's family stated her other family member and herself had made it really known during care plan meetings that that was why Resident #1 had anxiety. Resident #1's family could not recall exactly when she notified the psych NP of this history or the names of staff members she notified. Resident #1's family stated, if there is no documentation about that, that is absolutely crazy to me, stating Resident #1 had terrible anxiety and that was their biggest concern. In an interview on 12/12/2022 at 11:49 a.m., Resident #1's other family member stated they had communicated Resident #1's history of sexual assault several times, and it was discussed during care plan meetings. Resident #1's other family member could not recall the names of staff she spoke to about this. In an interview on 12/12/2022 at 12:15 p.m., DON stated Resident #1's history of sexual assault was never mentioned to her and she was not aware. When asked what would be put in place to protect residents with a history of sexual assault, DON stated, in general, we would have a care plan for the patient and we would make sure staff were aware of whether the resident needed female only caregivers or whatever their needs were. If they were not cognitive we would contact family. The DON stated it depend on what the circumstance weas but the care plan would reflect any history of sexual assault. DON stated interventions would include monitoring, educating staff, and redirecting. In an interview on 12/12/2022 at 12:26 p.m., DON stated she did not see any record in Resident #1's chart that reflected a history of assault. DON stated yes, if the facility knew there was a history, then it should be in Resident #1's chart. In an interview on 12/12/2022 at 12:36 p.m., LVN F stated she had worked in the facility for ten years and was not aware of Resident #1's history of sexual assault. LVN F stated the reason why psych services were initiated for Resident #2 was because someone had observed him in the dining room touching Resident #3. LVN F stated that was in September of 2022. LVN F stated she was not part of the investigation, did not know how the facility investigated the incident, and that she was just asked to do a psych referral and update Resident #2's care plan. LVN F stated she would think the facility would have an interdisciplinary meeting to discuss Resident #1 and decide whether her history of sexual assault needed to be care planned or not. LVN F stated things that were active issues were included in the care plan, stating you would potentially not care plan this because it was not an active issue for which interventions and monitoring would need to be in place. LVN F stated sexual assault was part of the big picture but she did not think it was an active issue since Resident #1's memory was impaired. LVN F stated she had never heard Resident #1 voice distress about past issues and never heard she had behaviors related to that. LVN F stated to her knowledge, Resident #1's family had not communicated to the facility that Resident #1 had behaviors related to trauma. LVN F stated whoever was present during discussions with family regarding history of sexual assault or trauma should have notated it in the care plan. LVN F stated if it were a CNA who received that message, it should be reported to their charge nurse, ADON, or DON. When asked how effective she thought Resident #2's interventions were for hypersexual behaviors, LVN F stated she thought they were effective with Resident #3. When asked if she felt Resident #2's interventions for hypersexual behaviors were effective in preventing future incidents, LVN F stated, we did not know whether it happens so I feel like the interventions were still good even though now we have more in place. LVN F stated she had not participated in Resident #1's care plan meetings but stated if staff were aware of any history of trauma or sexual assault, that she expected it to be care planned. LVN F stated the facility did not have a Social Worker at that time but if they did, the Social Worker would document any communications from family. LVN F stated the Social Worker took notes during all care plan meetings but she quit three weeks ago. LVN F stated she did not have access to old care plan meeting minutes but the facility should have those notes. In an interview on 12/12/2022 at 1:00 p.m., DON stated the previous social worker took her care plan notes with her when she quit and the facility did not have access to them. In an interview on 12/12/2022 at 1:36 p.m., the Psychologist stated she was not aware of Resident #1's history of sexual assault and that she had seen Resident #1 in the context of inappropriate touching. The Psychologist stated Resident #1 would not benefit from psychological services because she was not cognitive and could not engage. When asked if she would expect to see this in Resident #[TRUNCATED]

Based on observation interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 70 of 70 residents (Residents #1 - 70) reviewed for infection control. The facility failed to ensure staff was donning and doffing PPE in an area of the facility which had been designated as an isolation wing during an outbreak of COVID-19 virus. Residents who had been symptomatic with COVID-19 like symptoms were placed on droplet isolation in wings of the building that had not been designated as isolation wings, and staff did not adhere to policies and procedures for droplet isolation in these rooms. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as pattern. This failure could place residents at risk for the transmission of COVID-19 and death. Findings included: Review of a facility self-reported incident intake received on [DATE] reflected that one resident had tested positive for COVID-19. Review of a facility self-reported incident intake received on [DATE] reflected that four additional residents had tested positive for COVID-19. Review of a facility self-reported incident intake received on [DATE] reflected that three additional residents had tested positive for COVID-19. Review of a facility self-reported incident intake received on [DATE] reflected that seven additional residents had tested positive for COVID-19. Based on observation interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 70 of 70 residents (Residents #1 - 70) reviewed for infection control. The facility failed to ensure staff was donning and doffing PPE in an area of the facility which had been designated as an isolation wing during an outbreak of COVID-19 virus. Residents who had been symptomatic with COVID-19 like symptoms were placed on droplet isolation in wings of the building that had not been designated as isolation wings, and staff did not adhere to policies and procedures for droplet isolation in these rooms. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a level of actual harm with a scope identified as a pattern. This failure could place residents at risk for the transmission of COVID-19 and death. Findings included: Review of a facility self-reported incident intake received on [DATE] reflected that one resident had tested positive for COVID-19. Review of a facility self-reported incident intake received on [DATE] reflected that four additional residents had tested positive for COVID-19. Review of a facility self-reported incident intake received on [DATE] reflected that three additional residents had tested positive for COVID-19. Review of a facility self-reported incident intake received on [DATE] reflected that seven additional residents had tested positive for COVID-19. The facility investigation report reflected the following provider response: This week the facility identified opportunities to limit spread of infection of COVID-19 with partnership with (local public health agency). Assisted residents to isolation wing. Monitoring continues for those residents. The facility has standing orders to monitor for symptoms of COVID-19 and take temperature of the residents twice daily. The facility is engaged in screening all staff who enter the facility daily. The facility has asked residents to remain in their rooms for this time. The facility took actions for isolation of residents with droplet precautions when necessary. The facility continues with on-going staff meetings and in-services regarding proper hand hygiene/washing, donning and doffing PPE and isolation precaution protocols. Staff utilization of n95 masks for isolation and COVID-19 unit patients. Facility staff utilize face masks and hospital gowns in rooms not identified as COVID-19+/on isolation to assist with minimization of spread. The facility monitored inventory of supplies to ensure adequate amounts. The facility updates the state surveyor and Austin Public Health assigned with updated test results as they came available. The facility infection control specialist maintains a line listing of all residents with symptoms and those that have been tested . The facility met with the Medical Director and held an ad-hoc QAPI meeting. Facility initiation of symptomatic wing and isolation of residents with COVID-1919 symptoms. Ongoing staff re-education. During an email interview on [DATE], the ADM wrote that the total positive COVID-19 resident cases in the facility was 32, with seven of these having expired. During an email interview on [DATE], the ADM wrote that the total positive COVID-19 resident cases in the facility was 35, with 11 of these having expired. Review of a facility census dated [DATE] and provided by the DON with annotations regarding residents who are positive for COVID-19, residents who are presumed positive, and those who had shown symptoms at least once. The census reflected the following: 16 COVID-19 positive residents in the 100 hall; two COVID-19 positive residents and nine presumed positive residents in the 200 hall; three residents presumed positive and three symptomatic on the 300 hall; and one presumed positive, two positive, and five symptomatic on the 400 hall. Review of facility census for [DATE] reflected that one resident remained on hall 300 who had been listed as symptomatic on the [DATE] census (Resident #2), as well as 13 other residents. Additionally, three residents (Residents #3, 4, and 18) who had been listed as symptomatic and one resident who had been listed as presumed positive remained on hall 400, along with 16 other residents. This census reflected that the 100 hall (isolation hall) had 20 residents, the 200 hall (isolation hall) had 17 residents. This census reflected all 70 residents in the building. Review of a spreadsheet reported to the local public health agency on [DATE] reflected that the total positive COVID-19 resident cases in the facility was 60, with 13 of these having expired, and that the total positive COVID-19 staff cases in the facility was 20. The document indicated that these numbers included recovered staff and residents. During an interview on [DATE] at 11:10 a.m. NP A stated the facility has stopped testing residents for COVID-19. She stated the facility is treating all residents as if they had COVID-19, and if residents become symptomatic, she will perform a symptom screening and then treat those symptoms. During a telephone interview on [DATE] at 3:30 p.m., the ADM stated that the test results are taking a week to come back, and instead of testing, they are just treating all residents in the facility as if they were positive. He stated that meant that all residents would be on droplet precautions and be monitored and assessed for symptoms. When asked if he planned to open a second isolation wing for symptomatic residents, he stated they were talking about it and had not decided for sure. He then stated that he thought they would probably do that. During an interview on [DATE] at 9:30 a.m., the ADM stated that the original isolation wing was created on the 100 hall (isolation hall), where the first residents to test positive were moved and cared for by staff who had also been positive but recovered. He stated that PHYS B had decided to test the rest of the symptomatic residents and that someone from the public health agency would be coming to the facility the following day to accomplish this. He stated they would be testing 18 symptomatic residents. Observation on [DATE] at 9:33 a.m. revealed that hall 400 had three rooms with droplet isolation signs on the doors: room [ROOM NUMBER] with door observed open, housed Residents #3 and 15, 411 housed Residents #4 and 16, and room [ROOM NUMBER] was not occupied by any residents. Observation on 300 hall on [DATE] at 10:00 a.m. revealed that there were four more rooms with droplet isolation signs on the doors for rooms 305, 307, 311, and 314. Resident #2 was in room [ROOM NUMBER]. room [ROOM NUMBER] and 314 also housed one resident each. room [ROOM NUMBER] was empty of residents, but resident belongings still filled the room. The doors to all of these four rooms were open. HK A was seen moving in and out of all rooms on the hall including droplet isolation rooms with a housekeeping cart and cleaning inside the rooms. He was wearing a mask but was observed going into room [ROOM NUMBER] without donning gloves, an isolation gown, or a face shield. During an interview on [DATE] at 9:30 a.m., MA A stated she is passing medication on 200 (isolation) and 400 (non-isolation) halls. She stated that she is giving medication to residents in room [ROOM NUMBER] to Resident #3, and she does not know why the resident is on droplet precautions. She stated she had not asked anyone about the droplet precautions. During an interview on [DATE] at 9:40 a.m., NP C stated she is assisting the facility as a CNA. She stated she is a part of PHYS B's practice, and PHYS B brought her and one other NP to give the facility some help today. When asked why the rooms [ROOM NUMBERS] were droplet isolation rooms, she stated that she did not know. She stated that she noticed the droplet precautions signs and asked about it, but she could not say who she asked and did not say what she was told when she asked. She stated she is here just doing CNA work or whatever work is needed. She stated she is assessing residents and taking vital signs. She stated she does not have access to the EMR. When asked where she was recording the vital signs, she stated there was a sheet of paper she was using. She began looking for the sheet and then said she can make another one. Observation on 300 hall on [DATE] at 10:00 a.m. revealed that there were four more rooms with droplet isolation signs on the doors for rooms 305, 307, 311, and 314. Resident #2 was in room [ROOM NUMBER]. room [ROOM NUMBER] and 314 also housed one resident each. room [ROOM NUMBER] was empty of residents, but resident belongings still filled the room. The doors to all of these four rooms were open. HK A was seen moving in and out of all rooms on the hall including droplet isolation rooms with a housekeeping cart and cleaning inside the rooms. He was wearing a mask but was observed going into room [ROOM NUMBER] without donning gloves, an isolation gown, or a face shield. During an interview on [DATE] at 10:04 a.m., HK A stated that he works at a different facility but has been asked to come in and help do deep cleaning of some resident rooms here. He stated he's been asking about the droplet isolation signs, and the people in charge told him the residents have been removed from those rooms. He stated that he has gone into some of these rooms with isolation signs, and there have been residents still in them. He stated he was not told whether he should wear PPE in those rooms or not. During an interview on [DATE] at 10:25 a.m., the RNC stated that the isolation rooms on 300 and 400 are housing residents who have had symptoms once during the last week, and they have been isolated due to an abundance of precaution. She stated that Resident #3 was tested for COVID-19 but came back negative. She stated that this test was performed on [DATE] when the facility tested several residents after their first positive COVID-19 case. She stated she thinks that all the residents with symptoms have been moved off of halls 300 and 400. She stated that the residents in the isolation rooms on 300 and 400 halls have not been tested since [DATE], and they are not symptomatic. She stated she thought the isolation signs were just left on the doors and are no longer applicable. She stated she is not completely sure this is the case and was asked to find out why these residents are on isolation. After checking, she returned to explain that Resident #3 had a cough, so NP B started him on [MEDICATION NAME] and [MEDICATION NAME], and he is not currently symptomatic. She stated that Resident #4 had a dry cough on the [DATE], so she was started on [MEDICATION NAME] and [MEDICATION NAME]. She stated they moved the symptomatic residents on 300, and Resident #2 is the only one on this hall showing symptoms. When asked why Resident #2 had not been moved, she did not have an answer. When asked if the roommates of those symptomatic residents were going to be tested , she stated that would be a question for the ADM. When asked if she thought it was a problem for staff to be working on these halls who did not know why the residents were on droplet precautions, she said she did not think it was a problem, because it was their first day working there. When asked who was responsible for providing orientation for new staff so that they are familiar with the care needs of the residents, she stated that it would be the charge nurse. Review of progress notes for Resident #2 reflected the following note on [DATE]: Resident is currently on droplet/contact isolation for COVID-19(presumably) starting zpack/planquenil per facility protocol. Vitals q8hrs. Resident is afebrile at this time. Alert and oriented to person/place. Review of physician orders [REDACTED]. It also reflected the following two orders: [MEDICATION NAME] Tablet 250 MG Give 500 mg by mouth one time a day for infection for 1 Day started on [DATE] and [MEDICATION NAME] Tablet 250 MG Give 250 mg by mouth one time a day for infection for 4 Days started on [DATE]. Review of progress notes for Resident #3 reflected the following note on [DATE] Awake,responding as usual,denies malaise or sore throat.No SOB,aches ,or nausea.Afebrile.Increased coughing noted,NP notified and the following on [DATE]: Remains on abt/infection([MEDICATION NAME]#,[DATE])and [MEDICATION NAME]#,[DATE] without adverse reactions noted. Hob elevated. A&Ox3. Remains on isolation-droplet precautions. Occ non-prod cough heard. Gave [MEDICATION NAME] cap 1 po with good results. Good po fluid intake. Voice hoarse. O2@2lpm via n/c in use and tolerating well. Resp even and unlabored. Call light within reach. Review of physician orders [REDACTED]. They also reflected the following two orders: [MEDICATION NAME] Tablet 250 MG Give 2 tablet by mouth one time only for URI started on [DATE] and [MEDICATION NAME] Tablet 250 MG Give 1 tablet by mouth one time a day for URI for 4 Days started on [DATE]. During an interview on [DATE] at 9:38 a.m., the DON stated that she was sick with COVID-19 for the last three weeks and recently returned, working on the 100 COVID-19 isolation hall. She stated that since the whole hall is an isolation wing, the residents can come out of their rooms as they please. She stated that staff from other halls are allowed to work on the 100 hall (isolation hall) as long as it is for the second part of their shift. During observation of hall 100 (isolation hall) on [DATE] at 9:42 a.m. revealed staff wearing N95 masks, gowns, and foot protectors. Residents were observed in the hallways and in the makeshift dining room instead of being isolated in their rooms with closed doors. Staff were not observed redirecting residents to their rooms. There were two unidentified CNAs present, one unidentified LVN, and one unidentified RN who were assisting residents, passing medications, and helping residents to their rooms. Biohazard bags full of linens or trash were on the floor in several of the rooms, and a mop was leaning against the wall in one resident's room unattended. All staff were witnessed touching their masks with their hands, and one unidentified CNA had her mask pulled down, leaving her nose uncovered. Most of the rooms occupying residents were found open and signage was posted on only one door reflecting that the resident was on droplet precautions. Observation of the 200 hall (isolation hall) on [DATE] at 10:10 a.m. revealed that there was no designated area to don PPE before entering or doff PPE before exiting the 200 hall (isolation hall). Residents were either in their rooms or in the hallway. The fabric gowns worn by staff were short sleeved. The PPE cart in the hallway contained four isolation gowns. Observation on [DATE] at 2:10 p.m. revealed that the ADMIT was observed on the 200 hall (isolation hall) with only a mask and no other isolation PPE. He was then observed coming out of the 200 hall into the non-isolated area of the building with the same mask without performing any specific decontamination. Observation on [DATE] at 2:13 p.m. revealed that PHYS B came out of the 200 hall (isolation hall) still wearing the same hospital gown and mask she was wearing inside. She was no longer wearing the face shield. She was observed walking through the building, past the nurse's station, the 100 hall entrance (isolation hall), the administrative offices, and out the front door in this isolation gear. Review of facility's Covid Response Plan dated [DATE] reflected the following: Cohort positive cases to 100 hall and any symptomatic PUIs to 100 hallway as above. In doubt, over-react to any infectious concerns and isolate and test patients or staff. Previous policy still applies. No further admissions with new patients until the situation on the ground is better defined and controlled. Allow previous residents in the hospital to come back in. If patient was tested for Covid and negative, they may return to their previous room unless it is on the 100 hall. If patient was tested and positive, they must go to 100 hall until they have recovered from the illness. If the patient was not tested in hospital and not symptomatic, isolate them and test them on arrival and liberate them once the test is negative. Apply high pressure to smokers to stop transit out of their rooms and the facility. If a patient is noncompliant, have me or nurse practitioner see the patient and counsel them and determine if anxiolytics are in order to help them cope. Patients are to isolate in their rooms until further notice. In room dining as you are. Kitchen staff is not to deliver trays. On [DATE] at 12:03 p.m., the ADM was notified the facility had an IJ situation for the above failures. The IJ template was provided to him at 12:28 p.m. The facility's first Plan of Removal (POR) was submitted by the ADM on [DATE] at 2:52 p.m. The following POR was accepted by the survey team on [DATE] at 12:57 p.m. Actions Taken/Plan included: DON / designee will reeducate facility staff regarding DON/DOFF PPE expectations for COVID+ wing, symptomatic wings and any resident on isolation/droplet precautions. DON /designee will demonstrate to staff donning, doffing, and disposal of PPE. Following demonstration, the DON will continue education with ongoing monitoring of staff PPE use. Currently all residents who are symptomatic have been moved to additional isolation wing. All staff working today will be retrained and all staff oncoming retrained prior to the start of their shift or via telephone prior to entering facility. Check off conducted by nurse. The DON / designee will reeducate nursing staff to post See Nurse Prior to Entering Room signage on the doors to alert staff of residents that are on isolation precautions. The facility coordinated with (local public health agency) to have symptomatic residents tested for Covid-19 and samples were obtained today, [DATE]. The survey team monitored the plan of removal from [DATE] through [DATE] as follows: Observation on [DATE] at 2:00 p.m. revealed the staff were changing isolation gowns in between rooms on the 300 hall. Staff were observed donning PPE before going into the rooms and doffing their PPE into the biohazard bins inside the resident rooms. Staff persons were answering call lights and performing hand hygiene in between providing care to different residents. The resident room doors were closed, and no one witnessed in the hallway other than staff members. All rooms were on droplet precautions with door signs indicating as such and plastic drawers of isolation PPE outside each resident room. The hall was a clean, non-cluttered environment and abundant hand sanitizer was available in the hallways of the resident rooms. Observation on [DATE] at 2:27 p.m. revealed that there were ten residents on the 400 hall. All ten of these residents were on droplet precautions, and the doors to their rooms had signs indicating as such. All ten were observed without any symptoms of COVID-19. During an interview on [DATE], the ADON stated that the four residents on the 400 hall were not showing any symptoms of COVID-19 and were presumed not to be positive. During an interview on [DATE] at 3:15 p.m., RN A stated that there were no residents on the 300 hall who were suspected of having COVID-19. She stated that, if a resident was suspected of having COVID-19, she would look for symptoms such as body aches, fever, cough, and changes in breathing. She stated that if a resident were suspected of having COVID-19, she would notify the DON, PHYS A, and the family. She stated that all residents are already on droplet precautions. RN A stated that she was checking the residents twice a day for possible COVID-19 symptoms. Observation on [DATE] at 4:20 p.m. revealed that a clean PPE donning station had been created between the 100 hall (isolation hall) barrier and the 200 hall (isolation hall) entrance. The donning room had supplies including gowns, gloves, and foot protectors. Inside the 200 hall, facility staff persons were observed wearing PPE, including gowns, N95 masks, foot protectors, and face shields. One LVN, two CNAs, and one MA were observed providing care for residents. The resident rooms were shut, and the staff were observed answering call lights. Staff were observed performing hand hygiene and changing their gloves and gowns in between caring for different residents. A PPE doffing and decontamination space had bee created for staff at the end of the hall near the exit. Staff were observed doffing in a safe manner, decontaminating, and exiting the door at the end of the hall. A table was present outside the 200 hall (isolation hall) with a disinfectant spray, wipes, and hand sanitizer. A portable toilet was outside the building at the end of hall 200 (isolation hall). During an interview on [DATE] at 4:55 p.m., LVN B stated that she had been sick with COVID-19 and recovered and returned to work on the 200 hall (isolation hall). She stated there is a new rule implemented that they are wearing the same gown during their shift to conserve PPE, but they change gowns each shift. She stated that the ADON made sure they knew how to don and doff PPE. She stated the biohazard container for doffing PPE is located in the last room on the right before exiting the facility, and this is where facility staff are supposed to take off their PPE before leaving the facility through the back exit door. She stated that she changes her N95 mask each day, and these masks are given out at the entrance of the facility. During an interview on [DATE] at 5:30 p.m. MA B stated that she wears a new disposable gown every day, and they change again if the gown gets soiled. She stated that she doffs and disposes of PPE in a resident room located by the back exit. She stated that she did not have any concerns about running out of PPE. She stated that the ADON had in-serviced her on PPE and had her put it on and take it off in front of her. She stated that the ADON had her wash her hands in front of him. Observation on [DATE] at 10:30 p.m. revealed that the facility was adequately staff, resident needs were being met, and all staff were observant of proper infection control practices. Review of undated in-services on biohazard linens, biohazard trash, meal service hand hygiene, COVID-19 symptom monitoring, proper PPE donning/doffing/disposal/decontamination provided by the ADM on [DATE] reflected that all staff had signed the in-service and completed competencies as performed and demonstrated by the ADON. The ADM was notified on [DATE] at 11:46 p.m. the IJ had been lowered, and that the facility remained out of compliance at a severity of actual harm and a scope identified as pattern due to a need for ongoing monitoring.

Based on observation, interview and record review the facility failed to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of four residents reviewed for IV access device (Resident #1). Resident #1 ' s double lumen central line permacath (access line going into the main vein) was cut by CNA M on 3/29/16. The CNA taped plastic over the permacath prior to a shower. Then CNA M used scissors to remove the plastic and tape, cutting one of the two ports. Resident #1 was transported to the hospital and had to have surgery to replace his permacath. The facility failed to properly monitor CNAs to prevent them from performing skills outside their scope of practice and train LVNs to cover and uncover IV access devices for resident showers. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 04/06/16. While the IJ was removed on 04/07/16, the facility remained out of compliance at an actual harm with a scope identified as isolated. This failure could place three residents, who have IV access catheters, at risk excessive bleeding, infection, surgery, embolism, and death. The Findings Include: Review of Face Sheet dated 04/05/16 for Resident #1 reflected a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Comprehensive MDS assessment dated [DATE] for Resident #1 reflected [DIAGNOSES REDACTED]. Review of the MDS assessment reflected physical help in part of bathing activity. Further review of the MDS assessment showed no identification of any IV access catheter. Review of Care Plan dated 03/21/16 for Resident #1 reflected [MEDICAL TREATMENT] need related to [MEDICAL CONDITION] with the goal of not having any complications from [MEDICAL TREATMENT] and interventions of monitoring and reporting to the physician any signs or symptoms of infection to access site (for permacath). There were no other plans of care related to the Resident #1 ' s permacath. Review of Nursing Progress Note dated 03/18/16 reflected Resident #1 was admitted with an intact permacath to the right upper chest for [MEDICAL TREATMENT] access. The Nursing Note dated 03/23/16 reflected Resident #1 was given a shower on 03/22/16 at about 11:00 a.m. and permacath was covered for shower. The Nursing Note dated 03/29/16 reflected that the shower aide requested help with Resident #1 and informed the nurse that the resident ' s permacath had been cut on accident while removing the plastic covering put on for the shower. Resident #1 was assessed by the nurse and the NP, who was in the office next to the shower room. Resident #1 was sitting on the shower chair with right side of double lumen permacath cut off. Nurse gathered supplies while NP stayed with Resident #1. NP applied occlusive dressing. NP ordered for EMS to be called and then staff transferred Resident #1 to his room. Due to the bleeding, the NP applied manual pressure to the catheter until EMS arrived. Review of an Incident Report dated 3/29/16 at 10:15 a.m. reflected Resident #1 was given a shower by a CNA (CNA M), who tried to remove plastic she had put over his double lumen permacath with scissors and cut one of the ports off. The report reflected that Resident #1 was discharged with EMS to the hospital. The attached investigation reflected CNA M was the one who cut the catheter. The nurse was LVN F. Corrective actions included CNA M being counseled on job duties and told not to cover or uncover dressings. All staff were then in-serviced (03/29/16) that only nurses were to cover and uncover dressings/external tubing. The QA meeting was held with the Medical Director, NP, Administrator and the DON, with the DON making sure that the in-service is followed. There was no documentation of training nurses on covering and uncovering IV access ports for showers. During a telephone interview on 04/05/16 at 10:20 a.m. Resident #1 ' s daughter stated she received a call on the morning of 03/29/16 informing her that the staff were putting an extra cover over her father ' s port for his shower and when they were cutting it off the port was cut. The daughter stated Resident #1 had surgery to replace the port and the doctors said he could have major complications like an embolism or infection. The daughter added that her father was still in the hospital. In a telephone interview on 04/05/16 at 10:42 a.m. Resident #1 stated on 03/29/16, CNA M was going to give him a shower and wrapped his catheter with a plastic bag. Resident #1 stated after his shower, the CNA started trying to take the tape off to remove the plastic bag but was having trouble. The resident stated CNA M pulled a pair of scissors out of her pocket and began cutting the tape and bag. When the bag came off, the CNA said something like Oh no and left the room to get the nurse. He looked down and saw part of the port was missing. The NP who was in the building and the nurse came into the shower room and the NP bandaged the port. The staff took him to his room and the NP plugged the catheter. The ambulance took him to the hospital and he had to have surgery to remove the cut port and put in a new one. Review of Hospital Report dated 03/29/16 for Resident #1 reflected the permacath was cut accidentally with copious bleeding. Procedure required anesthesia and line sutured in place. Lab values reflected a hematocrit of 29.9 with the normal range being 40.5 to 54.0. Report reflected resident had surgery at hospital to have jugular vein access catheter replaced. CT scan was done to check for any embolism due to opening of the jugular vein access catheter. Review of General Note by NP dated 03/31/16 reflected on the morning of 03/29/16 NP was asked to go immediately to the shower room for Resident #1. NP discovered that the shower aide had cut one of the ports for Resident #1 ' s [MEDICAL TREATMENT] catheter. NP said there was nothing covering the catheter when she arrived in the shower room. NP had staff move the resident to from the shower to his bed and after covering it with an occlusive dressing. NP said EMS was called and the [MEDICAL TREATMENT] clinic was notified. NP said she was able to plug the catheter with a 1cc syringe to stop blood loss. Resident #1 was then transported to the hospital emergency room . During a follow-up interview on 04/06/16 at 9:05 a.m. at the hospital Resident #1 stated when he realized what happened he got really scared and started to have a panic attack. The resident stated when he got to the hospital they told him he would have to have surgery that day to replace the port. Resident #1 said he was also informed that there was a risk with the central line being opened up of getting an infection or an embolism. He was told they were going to do a test to check for an embolism and monitor him before and after the surgery. In an interview on 04/05/16 at 1:43 p.m. CNA M stated 03/29/16 was the second time she had showered Resident #1. When she showered him on 03/24/16, she asked LVN F to cover the port but the nurse said she wasn ' t sure how to do that. CNA M stated she told the nurse she could figure it out and she covered and uncovered the port without any problems. On 03/29/16, she didn ' t ask the LVN F but proceeded to cover the port herself. The CNA stated no one ever told her what to do about a resident with a port, but she just guessed it should be covered. CNA M stated she used a small plastic bag and tape to cover the port. CNA M stated she wrapped the plastic and then taped around and over the port before giving Resident #1 his shower. The CNA stated after the shower she tried to remove the tape, but could not get it unstuck. CNA M stated she used her bandage scissors to cut the plastic bag off the port. CNA M stated once she removed the bag, she saw that she had cut one of the catheters on the port so she went to get the nurse who got the NP and both returned to take care of the resident. CNA M stated she turned over the care of Resident #1 to them. After that incident occurred, the facility told her that only nurses can cover or uncover any catheters, ports or bandages. In an interview on 04/05/16 at 3:18 p.m. by phone LVN F stated she does not remember the aide ever asking her to cover Resident #1 ' s permacath for a shower. LVN F stated she was told on a written in-service sheet after the incident that only nurses are to cover and uncover catheters, ports, and bandages for showers. LVN F stated she is not sure how to properly cover a port or catheter and will need someone to show her the first time. The LVN added this it is not a skill she learned in nursing school. LVN F stated she has worked three shifts since Resident #1 went to the hospital. In an interview on 04/05/16 at 1:32 p.m. the NP stated she was working in the facility on 03/29/16 when the nurse asked her to come help Resident #1 in the shower on the same hall as her office. The NP stated she was there within seconds and when she arrived there was no bandage or plastic covering the double access port on the right side of Resident #1 ' s chest. The right port catheter had been cut off. The NP stated at that point the bleeding was minimal and the nurse went to get bandaging supplies. The NP stated when the nurse returned she covered the access port with an occlusive dressing because there was not enough left out of the skin of the one that was cut off to clamp it. The NP stated she ordered the nurse to call EMS. The NP stated the staff took Resident #1 from the shower to his room and put him in bed. The resident was short of breath which was normal for him and she ordered three liters of oxygen be administered by nasal cannula. From moving and coughing, Resident #1 had bled through the occlusive dressing so she removed it and used a 1cc syringe to plug the catheter. The NP stated when a resident with an IV access port is showered, the port should be covered with one sheet of plastic and uncovered after the shower but there should be no reason to cut anything with scissors. During a telephone interview on 04/06/16 at 12:31 p.m. the PCP stated the entry site for an IV access line should be covered by a non-permeable cover such as transaderm but it is not necessary to cover the access tips for a shower. He stated covering and uncovering the IV access line is a nursing skill and should not be done by a CNA. The PCP stated the extruding catheters should not be wrapped. The PCP further added the proper way to cover it is with one sheet of plastic around sealed to the skin around the edges. In an interview on 04/05/16 at 1:03 p.m. CNA N stated there is a clear bandage over the site where a resident has an IV catheter go in, but the whole catheter has to be covered before the resident gets a shower. CNA N stated the aides used to tape up the catheter before giving the resident a shower but now they have to ask the nurse to do that. She said she had covered and uncovered Resident #6 ' s permacath and Resident #7 ' s picc (peripherally inserted central catheter) line before 03/29/16. The new rule started after CNA M accidently cut the catheter on Resident #1 when she was trying to get the plastic and tape off after a shower on 03/29/16. In an interview on 04/05/16 at 2:02 p.m. the DON stated she doesn ' t know of any training CNAs had on caring for a resident with a catheter or port before the incident occurred. The DON stated covering a port is a nursing task and should not be done by a CNA. The DON stated on 03/29/16, she in-serviced CNAs that it is not within their job scope to cover or uncover catheters, ports or bandaged wounds. The DON stated the same day she in-serviced the nurses that it is their responsibility. In an interview on 04/05/16 at 3:45 p.m. RN A stated until the incident on 03/29/16 involving Resident #1 the shower aides covered and uncovered the IV catheters and ports. RN A stated he was told in a written in-service that nurses are now required to perform the task RN A stated he learned how to do this in nursing school when he was becoming a registered nurse but the facility has not provided any training on properly covering and uncovering catheters and ports. In an interview on 04/06/16 at 11:10 a.m. the ADON said he has never thought it was acceptable for a CNA to cover and uncover a port for IV access. The ADON stated when he was a CNA; he would get the nurse to do that because CNA ' s don ' t have the training for that skill. The ADON stated he learned that skill in school training as a registered nurse. In an interview on 04/06/16 at 11:45 a.m. LVN H stated she learned how to properly cover and uncover IV access lines at a sister facility, but did not learn it in vocational nursing school. LVN H does not know of any training she received at this facility. LVN H stated before 03/29/16, the CNAs usually covered and uncovered the IV access lines for showers. Review of Shower History provided by DON on 04/07/16 reflected Resident #7 had three showers between 03/29/16 and 04/05/16. All three showers were assisted by CNA N. Record review of List of Current Residents with IV access lines on 04/06/16 reflected Resident #6 with a right chest area permacath (vascular access tubing), Resident #7 with a picc (peripherally inserted central catheter) line in the right arm, and Resident #8 with a port a cath (Central Venous Access Device just below the skin). In an interview on 04/06/16 at 12:02 p.m. (translated English/Spanish by CNA S) Resident #6 stated he does not know her title, but the same lady who gives him a shower covers and uncovers his central line port. Resident #6 stated he had a shower by that lady on the previous Friday which was 04/01/16. Review of Shower History provided by DON on 04/07/16 reflected Resident #6 had one shower between 03/29/16 and 04/05/16. That shower was assisted by CNA R. In an interview on 04/05/16 at 11:45 a.m. CNA R stated she was covering and uncovering the IV access lines on residents before giving them a shower. CNA R stated the last one she did was last week for Resident #6. She could not remember what day she gave him a shower. CNA R stated she had not been trained to cover and uncover IV access lines, but knew it needed to be covered before going into the shower. Review of Shower Record for 03/18/16 through 04/06/16 for Resident #7 reflected showers on 03/24/16, 03/29/16 and 04/04/16 with all assisted by CNA N. In an interview on 04/05/16 at 1:03 p.m. CNA N stated she had not covered or uncovered any IV access lines since the in-service done on 03/29/16 but had done so prior to the in-service. Review of Nurse Aide Curriculum from the Texas Department of Aging and Disability does not include the skill of covering and uncovering IV access lines for showers. The Administrator, DON and the DOC were notified on 04/06/16 at 12:40 p.m. that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 4/06/16 at 3:35 p.m. The final Plan of Removal was accepted by the Survey Team on 04/06/16 at 5:05 p.m. The facility's Plan of Removal is as follows: On 4/5/16, a complaint survey was initiated at the facility. At approximately 1:15 p.m. on 4/6/16 the surveyor provided verbal notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health and safety. The notification of the alleged immediate jeopardy states as follows: - Quality of Care for a port-o-cath covered and removed by a C.N.A. before and after a shower The following plan of action outlines immediate and previously implemented interventions employed by the Facility to correct any further concerns surrounding the above issue: · Charge Nurse immediately notified NP 3/29/16, 10:15 am · NP assessed & treated resident, 3/29/16, 10:15 am · Orders to send resident to ER, 3/29/16, 10:15 am · Incident Report completed, 3/29/16 · Pain assessment completed, 3/29/16, 10:25 am · Employee counseled and given a final write up, 3/29/16, 2:00 pm · Medical Director notified and aware of incident 3/29/16, 3 pm · Ad-Hoc QA meeting completed 3/29/16 with DON, Medical Director, ADON, Administrator, 3 pm · Nurses, Shower aides, and C.N.A ' s in-serviced initiated on 3/29/16 re: Only nurses to cover and un-cover dressings/external tubing · Proficiencies with return demonstrations initiated on 3/29/16 for Nurses to cover & uncover dressings in place/external tubes · On 4/6/16, initiate education and training for licensed nurses titled, Preparing Residents for Showering that Have Access Devices. The in-service states the nurse will apply and remove the showering shield before and after the shower. See In-service sheet. This education is conducted by the DON and DCO, regional nurse. · On 4/6/16, continuation and completion of C.N.A. in-service regarding the requirement and expectation to have nurses cover and un-cover dressings/external tubing prior to showering care. In the event their nurse is not available or does not assist, the C.N.A.s are to notify the ADON or DON at that time. This task has been added to the C.N.A. documentation under bathing/showering for any resident that has an access device to notify the nurse to apply. This education is conducted by the DON and Director of Staff Development. · On 4/6/16, DON instructed shower aides, C.N.A.s that trained licensed nurses will be responsible for covering access sites prior to showers until in-servicing is completed for licensed nurses. · On 4/6/16, Facility obtained and utilizes Shower Care Bandage Protectors, 100% shower proof designed to block out water and germs in the shower, which completely covers existing bandages. · On 4/6/16 - The Facility updated the new hire orientation and annual competencies to include the training for Showering Residents with Access Devices for C.N.A. and licensed nurses. · Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. · Residents requiring this care have been identified and assessed and will be identified and assessed upon admission. The facility will implement a personalized care plan for these residents for this care and will maintain them on the facility Special Needs sheet, which is reviewed weekly in the interdisciplinary team meeting. · The facility will maintain this plan as part of its internal Quality Assurance committee and monitor compliance with the expectation by random audits conducted by the DON. · The goal date for completion of all the above is 4/8/16. The Investigator monitored the current plan of removal as follows: 1. Reviewed records of staff training for all CNAs, MAs, LVNs and RNs. Records reflected all but CNAs and MAs had been trained and all but 3 nurses had been trained. Staff not already trained will not be allowed to work with residents until trained. a. CNA and MA training to instruct on who is qualified and who is not qualified to cover and uncover IV access lines and bandages for showers. CNAs also trained on new policy that they are not allowed to have scissors. b. LVN and RN training on duties for covering and uncovering IV access lines, demonstration on properly performing this task and return demonstration by staff. Training was directed by DON and Director of Clinical Operations. 2. Surveyor observed training of LVN I by DON. DON performed steps for covering and then uncovering a central line IV access on a mannequin including hand washing and explaining the procedure to the resident. LVN I then performed the steps using the techniques demonstrated by the DON. 3. Surveyor monitored training done of CNAs by having CNA M, CNA N, CNA Q, CNA T, CNA U, CNAV and CNA W explain the training they had received within the previous 24 hours. 4. Surveyor monitored training done of LVNs and RNs by having ADON, RN B, RN C, LVN H and LVN I explain the training received within the last 24 hours including the steps to covering and uncovering IV access lines and bandages. 5. Surveyor reviewed documentation of order placed for large shower shields to be used to cover IV access lines and bandages for showers. Small shower shields were purchased at local pharmacy. 6. Review of Care Plan initiated 04/06/16 for Resident # 6 and Resident #8 (only residents remaining in facility with IV access catheters) reflected CNAs are notified on the computer to get the nurse to cover the site before giving a shower and to have the nurse uncover the site after receiving a shower. Nurses are instructed to document this procedure. On 04/07/16 at 3:15 p.m., the Administrator, DON and Director of Clinical Operations were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as pattern due to the facility requiring additional time to train all staff and monitor their Plan of Removal. A list provided by the DON on 04/06/16 of Residents in the facility with IV access lines named three residents.

Based on interview and record review, the facility failed to provide adequate monitoring to ensure the drug regimen was free from unnecessary drugs for one (1) of five (5) residents (Resident #1) reviewed for medication administration in accordance with professional standards of practice. The facility failed to clarify Resident #1 ' s physician's order [REDACTED].#1 ' s [MEDICAL CONDITION] characteristics and activity. An Immediate Jeopardy (IJ) situation was identified on 03/13/14 at 12:14 p.m. While the IJ was lowered to a non-immediate Jeopardy on 03/17/14 at 3:30 p.m. the facility remained out of compliance at a severity of more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place seven (7) residents who are identified as a [MEDICAL CONDITION] risk and prescribed [MEDICAL CONDITION] medication at risk for neglect, lack of care, being overmedicated, and possible death. Findings include: Review of Resident #1 ' s facesheet reflected a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Admission Nurse ' s Note dated 03/13/13 reflected a [AGE] year old male admitted for respite care. He has a [DIAGNOSES REDACTED]. Recurrent [MEDICAL CONDITION], usual signs of impending [MEDICAL CONDITION] usually look off to left side, has a fixed smile and then shakes his head, may have mild to severe [MEDICAL CONDITION]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected: Section I: Active Diagnoses - I5400. [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION] Review of Resident #1 ' s Comprehensive Care Plan dated 01/27/14 reflected the following problem areas: - Problem: "I have a [DIAGNOSES REDACTED]. The interventions listed are that Resident #1 has frequent [MEDICAL CONDITION], the family and him requested a closed circuit camera be placed in room with the nurse having the monitor to observe in case of a [MEDICAL CONDITION]. - Problem: "I take medications to control my [MEDICAL CONDITION] and am at risk for side effects" with an onset date of 04/12/13 and revised on 12/05/13. The interventions listed are to monitor as much as possible for [MEDICAL CONDITION] activity, notify the doctor of any adverse reactions, to give medications as ordered, the medications put Resident #1 at risk for falls, and to watch for possible side effects which may include dizziness, drowsiness, irritability, weakness, decreased coordination, and new or worsening [MEDICAL CONDITION]. - Problem: " I take Klonopin for [MEDICAL CONDITION] " with an onset date of 04/12/13 and revised on 09/23/13. The interventions listed are to ensure informed consent by resident or Responsible Party (RP) are given, notify doctor of any adverse reactions, to give medication as ordered, and to watch for side effects such as clumsiness, unsteadiness, or behavioral changes. - Problem of "I have severe reflux with high risk for aspiration " with a problem onset date of 04/12/13 and revised on 12/15/13. The interventions listed are to keep the head of bed (HOB) elevated 90 degrees during and after feedings, monitor for side effects of medication, document if present, monitor labs per doctor orders, notify doctor and family of changes in condition, and to administer medications per doctor ' s orders. Review of Resident #1 ' s physician's order [REDACTED]. - Diet: nothing by mouth (NPO) - [MEDICATION NAME] 125 mg/5 milliliters (mL) every 8 hours (Q8H), 5 mL ([MEDICAL CONDITION]) - [MEDICATION NAME] 100 mg/mL G tube, three times a day (TID), 15 mL ([MEDICAL CONDITION]) - Klonopin 0.5 mg G tube, TID: 1 tab ([MEDICAL CONDITION]) - Klonopin 0.25 mg G tube, PRN 1 tab ([MEDICAL CONDITION]), (no additional clarification order) During an interview on 03/12/14 at 4:05 pm, the Director of Nursing (DON) stated the facility nurses administer all of Resident #1 ' s medications and feedings. During an interview on 03/12/14 at 4:10 pm, the ADON A stated there is a video monitor at the nurse ' s station and nurses rely on that to know if Resident #1 has a [MEDICAL CONDITION] or the sitter alerts them. She also stated there is no specific [MEDICAL CONDITION] log but [MEDICAL CONDITION] should be documented in the nurse ' s notes. Resident #1 takes medications post [MEDICAL CONDITION] and he is followed by a Pediatric Neurologist who monitors his [MEDICAL CONDITION] activity and medications. She further stated Resident #1 was initially admitted in 03/2013 for respite care and she did not think the facility could initially care for Resident #1 because of all of his [MEDICAL CONDITION]. She then stated Resident #1 has as many as four to five [MEDICAL CONDITION] a day, then they go away for a while and then come back and he can have them daily. Observation on 03/14/14 at 2:30 pm revealed Resident #1 ' s monitor screen at the nurse ' s station. The screen was black and there was no signal. During an interview on 03/12/14 at 5:00 pm, the DON stated all of Resident #1 ' s [MEDICAL CONDITION] activity is only documented in the nurse notes and nowhere else. She further stated there is no protocol to outline when to document a [MEDICAL CONDITION] but she probably would not document it if it was just a three second [MEDICAL CONDITION] but would if it was a minute to a minute and a half [MEDICAL CONDITION]; it just depends on the length of the [MEDICAL CONDITION]. Review of Resident #1 ' s Physician ' s Progress Note dated 12/10/13 reflected patient was recently treated for [REDACTED]. Further review reflected an assessment/plan of Aspiration Pneumonia treated and resolved and [MEDICAL CONDITION] disorder: continue [MEDICATION NAME] and [MEDICATION NAME] ([MEDICAL CONDITION] medications) deferred to patient ' s neurologist; will continue to monitor for increased activity due to history of aspiration pneumonia that lowers ([MEDICAL CONDITION]) threshold. The NP signed this progress note. Review of Resident #1 ' s Nurse Notes reflected: - 01/10/14: reflected report called from local hospital, resident admitted with pneumonia follow up discharge from Intensive Care Unit (ICU) on 01/07/14 to acute care. Last [MEDICAL CONDITION] activity 01/08/14, discharge orders faxed, medications resumed - 01/22/14, 7:20 am: Had moderate [MEDICAL CONDITION] last approximately 1 ? minutes in bed - caregiver at bedside to safeguard him - no injuries. Had vomited large amount of phlegm, was upright entire time. His father requested AM medications not be given right away and I waited to give them until caregiver told me resident had settled down with no emesis noted. Noted for nasal drainage but no further phlegm emesis, tires easily. Noted for Blood Pressure (BP) up but is talking with his mother his BP tends to go up after a major [MEDICAL CONDITION]. Also at time of [MEDICAL CONDITION] this AM, resident received routine Klonopin. No physician notification documented. - 8:00 pm: 10 second [MEDICAL CONDITION], vomited approximately 150 mL formula and phlegm. Father called facility twice with instructions and request. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 01/23/14 reflected according to nursing, patient had a temperature of 99.4 degrees Fahrenheit (F) with increase nasal drainage last night and a moderate [MEDICAL CONDITION]. Spoke with patient ' s father who is concerned regarding increased [MEDICAL CONDITION] activity; we discussed possible avenues regarding aspiration pneumonia from [MEDICAL CONDITION] Reflux versus allergies [REDACTED]. The NP signed this note. Review of Resident #1 ' s handwritten Admission Physician order [REDACTED]. - Klonopin 0.5 mg PT TID - [MEDICATION NAME] 15 mL PT TID - [MEDICATION NAME] 125 mg, 5 mL PT Q8H - Klonopin 0.25 mg PT PRN Further review of the Admission Administration Record reflected Resident #1 received Klonopin 0.25 mg PRN on 02/07/14 and 02/28/14. It also reflected Nurse Medication notes: 02/28/14 2:45 pm, small [MEDICAL CONDITION] (8 seconds) gave PRN Klonopin 0.25 mg PT. There is no reason listed on the nurses medication notes as to why Klonopin 0.25 mg PRN was given on 02/07/14. Review of Resident #1 ' s Nurse ' s Notes reflected: - 02/06/14, 3:50 pm: patient returned from local hospital via parents ' vehicle, tires easily. Caregiver with patient, family brought back some of his medications but not his Klonopin. Given the medications his dad asked me to give him - didn ' t get at the hospital this afternoon. Had to give his PRN Klonopin and I told his mom - she ' ll check with hospital if she can get back his Klonopin she gave them. No [MEDICAL CONDITION] activity. - 02/07/14, Resident Awake alert, G tube placement verified. 30 second [MEDICAL CONDITION] noted at 8:35 pm, Klonopin 0.25 mg PRN administered per tube. Attendant at side for feedings today, no diarrhea noted. Will continue to monitor. Call to parents, updated on status. No physician notification documented. - 02/28/14, 2:45 pm: Caregiver reported resident had a small [MEDICAL CONDITION] lasted approximately 7 seconds. I gave him PRN Klonopin 0.25 mg PT. No physician notification documented. - 03/04/14, 9:15 pm: Earlier, reported resident had 2 small [MEDICAL CONDITION] today. Call placed to Responsible Party (RP) to notify. No physician notification documented. - 03/05/14, 1:00 pm, Resident sitting in wheelchair in living room area with caregiver. I noted she was assisting him as his head was turning to the side; she was protecting him as he started to move about in chair. She stated it lasted for approximately 20 seconds and he dry heaved once. He was taken to his room and I gave him his anti-[MEDICAL CONDITION] medications via G tube. RP notified. No physician notification documented. - 03/06/14, 1900: small 15 second [MEDICAL CONDITION] reported by caregiver. PRN Klonopin administered, no injuries noted. No physician notification documented. - 03/07/14, 2:15 pm: 30 second [MEDICAL CONDITION] - PRN Klonopin given per family request. No physician notification documented. - 03/11/14, 2:40 pm: Caregiver reported [MEDICAL CONDITION] last approximately 25 seconds, give PRN Klonopin 0.25 mg per tube (PT). No physician notification documented. - 03/11/14, 3:00 pm: Had another [MEDICAL CONDITION] last approximately 10 seconds, give 4.5 [MEDICATION NAME] routine, routine Kepra and Klonopin 0.5 mg PT. Caregiver kept him safe in both instances. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 03/11/14 reflected Resident #1 had a 15 second [MEDICAL CONDITION] according to caregiver on the sixth. Further review reflected an assessment/plan for [MEDICAL CONDITION] disorder to continue current therapy, fair control, occasional breakthrough [MEDICAL CONDITION] deferred to Neurologist. Also, Dysphagia: continue tube feeds, high risk for aspiration. History of aspiration pneumonia, chronic issue, currently asymptomatic. Resident #1 is a high aspiration risk along with increased fall risk due to gait abnormalities, care discussed with nursing and with the patient ' s sitter. The MD signed this note. Review of Resident #1 ' s laboratory value dated 02/14 reflected a [MEDICATION NAME] ([MEDICATION NAME]) level of 17.3 ug/mL. (Reference range: 10.0 - 20.0 micrograms (ug)/mL) Review of Resident #1 ' s Medication Administration Record (MAR) dated March 2014 reflected an order for [REDACTED]. The Klonopin PRN was given on 03/06/14, 03/07/14, and 03/11/14. Further review reflected: 03/07/14, 2:30 pm - Klonopin 0.25 mg PT per family re [MEDICAL CONDITION] activity; 03/11/14 2:40 pm - Klonopin 0.25 mg PT for [MEDICAL CONDITION] approximately 25 seconds. No documentation for reasoning for the PRN Klonopin given on 03/06/14. During an interview on 03/12/14 at 5:10 pm, the NP stated Resident #1 sees a Pediatric Neurologist who prescribes and monitors the [MEDICAL CONDITION] medications and labs. She further stated the facility communicates with her and the Medical Director (MD) about Resident #1 ' s [MEDICAL CONDITION] activity but there is no communication documentation of [MEDICAL CONDITION] activity. She further stated the sitter tells the staff if Resident #1 has any [MEDICAL CONDITION] and they then monitor him if he does. The NP then stated the Klonopin PRN order should be given when a [MEDICAL CONDITION] is happening, and should only be given once per day. During an interview on 03/13/14 at 12:45 the DON stated that Resident #1 has multiple [MEDICAL CONDITION] per day and she expects nurses to document small [MEDICAL CONDITION] that last more than one minute. The DON was then asked how to give Resident #1 ' s PRN order for Klonopin. The DON stated that she would give it however the physician ordered it. The DON then reviewed the order for PRN Klonopin and stated " 0.25 mg for [MEDICAL CONDITION]. " The DON was asked when would she give the PRN Klonpin, she stated " I would have to clarify. " The DON was asked in her nursing judgment when would she give the PRN Klonopin, she stated " I would have to clarify the order. I am not sure if the nurse practitioner wants to give it after every [MEDICAL CONDITION]. " The DON stated that the ADON or the charge nurse would be responsible for clarifying this order. She stated that " the charge nurse gives Resident #1 his medication because he is a tube feeder. " During an interview on 03/13/14 at 12:57 pm, the Neurology LVN stated Resident #1 was a patient and the last phone call they received from the facility about him was on 01/15/14 because of [MEDICAL CONDITION] activity and lab values. They have not contacted the clinic since regarding [MEDICAL CONDITION] activity. She then stated the facility only contacts the Neurology clinic when the resident has significant changes but they do request that all patients alert them of all [MEDICAL CONDITION] to adequately monitor care. She further stated Resident #1 was last in the Neurology clinic on 03/04/14. When asked how often the Klonopin 0.25 mg PRN should be given, she stated it should not be given more than five times per day for Resident #1; three times per routine orders and two PRN doses. During an interview on 03/13/14 at 4:15 pm, the MD stated Resident #1 was admitted to the facility with having about 30 [MEDICAL CONDITION] per month and he does not follow the [MEDICAL CONDITION] medications because the Neurologist does that on a day to day basis. He further stated the Klonopin 0.25 mg PRN should be given after all [MEDICAL CONDITION] and he would rather have it given and Resident #1 not be seizing than for him to have a [MEDICAL CONDITION] and not receive Klonopin 0.25 mg PRN. The MD further stated he expects to be notified of every [MEDICAL CONDITION] and he wants the nursing staff interpretation what a [MEDICAL CONDITION] is when administering the Klonopin 0.25 mg PRN. When asked if it is appropriate to administer routine Klonopin 0.5 mg twenty minutes after receiving the Klonopin 0.25 mg PRN after a [MEDICAL CONDITION], he stated yes. The MD then stated he expects the nursing staff to monitor and document Resident #1's [MEDICAL CONDITION] activity in the nurses ' notes. He further stated he does not know a characteristic [MEDICAL CONDITION] for Resident #1, but he does have a variety, everything from grand mal (features a loss of consciousness and violent muscle contractions) to minor [MEDICAL CONDITION]. In a continued interview on 3/13/14 at 4:15 PM, the MD stated that Resident # 1 ' s condition were exceedingly complex therefore he may not place specifications on the order for how many times a day Resident #1 should get PRN Klonopin. Surveyor asked the PCP how the nurses would know how many times a day to give the medication (Klonopin 0.25 mg PT PRN). The MD stated that he would expect the nurse not to hold back and go ahead and give the Klonopin and then call for further direction. The MD stated that when the nurses call him does a back and forth questioning with the nurse to be able to determine the [MEDICAL CONDITION] activity. The MD stated that he would want them to describe the characteristics of the [MEDICAL CONDITION], rather than diagnosing what kind of [MEDICAL CONDITION] they are. Surveyor asked the MD if he was involved in the care planning process concerning Resident # 1 ' s " complex " medical needs, to ensure that staff are aware of his expectations and to enable the correlation of care. The MD stated that he was not, but that his NP might be he was not sure. During an interview on 03/14/14 at 5:20 pm, the DON stated she expects the nursing staff to assess residents for PRN medications, follow physician orders, and then reassess residents again after a PRN medication is given to monitor effectiveness. She further stated the PRN medication should be documented on the MAR or in Nurse ' s Notes. When asked when nurses should clarify physician orders, the DON stated she expects her staff to clarify it if the order is not clear. She further stated PRN medications usually have the number of tabs and how often it should be administered on the order and she expects her staff to clarify an order if that is not clear. Review of the facility ' s PRN Orders Policy dated April 2008 reflected that PRN orders must clarify the circumstances for offering or giving the medication. When PRN orders are implemented, nursing staff must monitor the use of such medication to determine the nature of the problem and whether it persists, whether additional evaluation is needed or whether the medications could be discontinued. Review of the facility ' s [MEDICAL CONDITION] Management Policy dated 2007 reflected if staff suspect a resident is having a [MEDICAL CONDITION], they will note the time and duration of the [MEDICAL CONDITION] activity, monitor the resident ' s vital signs as ordered by the physician, and notify the physician during or as soon as possible after the [MEDICAL CONDITION], and notify the family of the event subsequently. It further reflected when documenting or reporting a resident ' s [MEDICAL CONDITION] activity to the physician, carefully describe signs and symptoms including: the nature of the activity (where it started, what areas of the body were involved), the duration of the [MEDICAL CONDITION] activity, whether the resident lost consciousness, the resident ' s current level of consciousness, baseline and current cognitive ability, speech, physical function, presence of abnormal motor activity, present of tremors, and overall physical condition. Avoid documenting or reporting just that the individual " had a [MEDICAL CONDITION]. " Instead, provide and document the details. The facility Administrator and DON were notified on 03/13/14 at 12:50 pm that an IJ situation had been identified due to the above failures. The final Plan of Removal was accepted by the surveyor on 03/17/14 at 10:15 am. Removal Plan for Immediate Jeopardy related to Resident #1 ' s [MEDICAL CONDITION] activity. How we will remove the immediacy: I. A clarification order on Resident #1 ' s Klonopin was written. It reads Klonopin 0.25mg give one tablet per tube daily PRN for [MEDICAL CONDITION] activity. If additional dose is needed notify on-call for instructions. II. A nursing in-service on Facility ' s [MEDICAL CONDITION] and [MEDICAL CONDITION] Clinical Protocol will be completed by 3/19/14. The in-service covers Assessment and Recognition, Cause Identification, Treatment/Management and Monitoring. As the policy relates to documentation the in-service include: ? The nature of the activity (where it started, what areas of the body were involved, etc.) ? The duration of the [MEDICAL CONDITION] activity. ? Whether the resident lost consciousness. ? Baseline and current cognitive ability. ? Baseline and current speech. ? Baseline and current physical function. ? Presence of abnormal motor activity. ? Presence of tremors. ? Overall physical condition. III. Facility will communicate Resident #1 ' s [MEDICAL CONDITION] to Resident #1 ' s PCP, or his nurse practitioner, as follows. If Resident #1 ' s [MEDICAL CONDITION] is controlled, meaning the [MEDICAL CONDITION] has stopped, Facility will notify non-emergently. If the [MEDICAL CONDITION] is not controlled, meaning his [MEDICAL CONDITION] continues after the PRN Klonopin is administered, Facility will notify on call. If the physician is not immediately available to discuss the situation Resident #1 will be sent to the emergency room . IV. All nursing staff will be assigned a " Response to [MEDICAL CONDITION] " online course beginning 3/17/14 and will continue until all nursing staff have completed and passed. The steps of the training include: 1. Call the nurse and stay with the patient. 2. Place padding under head and move furniture away from resident (protects resident from injury). 3. Do not restrain the resident or place anything in mouth (any restriction may injury resident during [MEDICAL CONDITION]). 4. Loosen resident ' s clothing especially around neck (prevents injury or choking). 5. After [MEDICAL CONDITION] stops, position patient onto side (allows saliva to drain from mouth so resident doesn ' t choke). 6. Note duration of [MEDICAL CONDITION] and areas involved (provides nurse with necessary information to properly assess resident ' s condition and needs). 7. Perform final steps (i.e. lower bed height and position bed enablers as appropriate, place call light and water within reach, ask resident if anything else is needed, thank resident, wash hands, and document procedure). 8. Assist with documentation according to current nursing practices. V. Resident #1 ' s care plan was updated on 3/16/14 to reflect the characteristics of his [MEDICAL CONDITION]. ? The care plan reads my [MEDICAL CONDITION] can be characterized by: turning head from side to side, raising knees or shaking leg(s), shaking arms. After a [MEDICAL CONDITION] I may be sleepy. Report these symptoms and any other [MEDICAL CONDITION] activity to the charge nurse. During a [MEDICAL CONDITION] keep me safe from injury and do not place anything in my mouth VI. Resident #1 ' s caregivers will communicate with the nurses by using the call light while in Resident #1 ' s room. If outside on community grounds the caregiver will notify the nurse by calling the communities main line via cell phone after ensuring Resident #1 is safe. A [MEDICAL CONDITION] observation log will be developed and by implemented on 3/17/14. The log will allow caregivers to document the length of the [MEDICAL CONDITIONS] observations, recovery observations, and comments (if any are needed). VII. If Resident #1 experiences a [MEDICAL CONDITION] during a community outing the Activity Director, will call 911. VIII. The Private Duty Sitter Authorization Form will completed for all five of Resident #1 ' s private duty sitters. The authorization form will be signed by Resident #1 ' s PCP and The Facility ' s Director of Nursing. IX. Any changes to Resident #1 ' s [MEDICAL CONDITION] medications by his PCP will be faxed to Resident #1 ' s neurologist, for review. Other residents potentially affected. Chart reviews for the other seven residents potentially affected will be conducted. The care plans will be updated to reflect the characteristics of their [MEDICAL CONDITION] as indicated by the chart reviews. The survey team monitored the current plan of removal as follows: Review of Resident #1 ' s physician's order [REDACTED]. If additional dose is needed notify on-call for further instructions. " During an interview on 03/17/14 at 8:30 am, LVN L stated Resident #1 ' s Klonopin PRN was recently changed. She further stated if they need instructions, they would notify the on-call NP. Review of Resident #1 Comprehensive Care Plan reflected: - Problem: I take Klonopin for [MEDICAL CONDITION] with a problem onset date of 04/12/13 and revised on 09/23/13. Interventions listed that were revised on 03/16/14 reflected to watch resident for possible side effects including clumsiness, unsteadiness, constipation, cough, dizziness, drowsiness, dry mouth, headache, loss of appetite, muscle aches, nervousness, severe allergic reactions, behavior changes, blurred vision, change in urination, confusion, fever, chills or sore throat, hallucination, hostility, irregular heartbeat, memory loss, mood changes, new or worsening [MEDICAL CONDITION], shortness of breath, tremor, and unusual bruising or bleeding. - Problem: [MEDICAL CONDITION] disorder [DIAGNOSES REDACTED]. Resident has frequent [MEDICAL CONDITION] with an onset date of 04/12/13 and revised on 03/16/14. Interventions revised on 03/16/14 reflected medical record indicates [MEDICAL CONDITION] are focal, self-limiting, and can turn to tonic-clonic. Further review reflected another intervention revised on 03/16/14 of " [MEDICAL CONDITION]: mine can be characterized by: turning head from side to side, raising knees or shaking leg(s), shaking arms. After a [MEDICAL CONDITION] I may be sleepy. Report these symptoms and any other [MEDICAL CONDITION] activity to the charge nurse. During a [MEDICAL CONDITION] keep me safe from injury and do not place anything in my mouth. " During an interview on 03/17/14 10:05 am, the Activity Director (AD) stated if Resident #1 has a [MEDICAL CONDITION] during an activity in the building, she would immediately get a nurse. If they go on an outing, she stated a CNA and Resident #1 ' s sitter usually come with and she will keep an eye on him. She further stated if he has a [MEDICAL CONDITION] while out, she will make sure he is safe and then call 911. Review of the facility ' s undated Private Duty Sitter Authorization Form reflected " I authorize ________ to provide private duty sitter services for resident ________. " There is a place for the physician and DON to sign and date the form. A facility provided list reflected seven (7) residents who are prescribed [MEDICAL CONDITION] medications.

Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prohibit neglect of residents when: A. The DON failed to supervise and monitor Nurse Management and Nursing staff and failed to implement policies and procedures when: -Nursing staff failed to clarify Resident #1 ' s physician's order [REDACTED].#1 ' s [MEDICAL CONDITION] characteristics and activity. - Nursing staff failed to notify Resident #1's Neurologist and Primary Care Physician after each [MEDICAL CONDITION] - The facility failed to train Resident #1 ' s family-hired sitters in how to properly assess and monitor for a [MEDICAL CONDITION] disorder, put [MEDICAL CONDITION] precautions in place, proper resident care, and include them in his comprehensive plan of care. An Immediate Jeopardy (IJ) situation was identified on 03/13/14 at 12:14 p.m. While the IJ was lowered to a non- immediate Jeopardy on 03/17/14 at 3:30 p.m. the facility remained out of compliance at a severity of more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place seven (7) residents who are identified as a [MEDICAL CONDITION] risk and prescribed [MEDICAL CONDITION] medication at risk for neglect, lack of care, being overmedicated, and possible death. B. The Administrator failed to supervise and monitor the Maintenance Manager and the DON when: - The Maintenance Manager failed to maintain the mechanical lifts in a safe condition. Two mechanical lifts (Mechanical Lift CC and DD) were not functioning safely. The CNAs continued to transfer residents with the mechanical lifts. - The DON failed to ensure that CNAs (CNAs F, G, I, M, J, N, V, BB and CC) were properly transferring residents (Resident #5, #31, #32 and #33) using mechanical lifts. An Immediate Jeopardy (IJ) situation was identified on 03/11/14. While the IJ was lowered to a non-immediate Jeopardy on 03/15/14, the facility remained out of compliance at a severity of more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice placed 21 residents that are transferred with a mechanical lift at risk of discomfort during transfers, falls, hematomas, serious injury and death from malfunctioning equipment. Findings Include: A) Review of Resident #1 ' s face sheet reflected a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Admission Nurse ' s Note dated 03/13/13 reflected a [AGE] year old male admitted for respite care. He has a [DIAGNOSES REDACTED]. Recurrent [MEDICAL CONDITION], usual signs of impending [MEDICAL CONDITION] usually look off to left side, has a fixed smile and then shakes his head, may have mild to severe [MEDICAL CONDITION]. Resident #1 has left sided weakness, he is total assist with feeding and max total assist with rest of Activities of Daily Living (ADLs). He is able to ambulate without device for short distance with minimal assistance with his attendant but is usually wheelchair bound secondary to recurrent [MEDICAL CONDITION]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected: Section G: Functional Status: ADL Assistance - G0110 B. Transfer, 1 person Extensive Assist - G0110 C. Walk in room, 1 person Extensive Assist - G0110 G. Dressing, 1 person Extensive Assist - G0110 I. Toilet Use, 1 person Extensive Assist - G0120. Bathing, Physical Help, Support Provided - G0400. Range of Motion, Impairment in both upper and lower extremities Section H: Bladder and Bowel - H0300: Urinary, frequently incontinent - H0400: Bowel, Always incontinent Section I: Active Diagnoses - I5400. [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION] Review of Resident #1 ' s Comprehensive Care Plan dated 01/27/14 reflected the following problem areas: - Problem: "I have a [DIAGNOSES REDACTED]. The interventions listed are that Resident #1 has frequent [MEDICAL CONDITION], the family and him requested a closed circuit camera be placed in room with the nurse having the monitor to observe in case of a [MEDICAL CONDITION]. - Problem: "I take medications to control my [MEDICAL CONDITION] and am at risk for side effects" with an onset date of 04/12/13 and revised on 12/05/13. The interventions listed are to monitor as much as possible for [MEDICAL CONDITION] activity, notify the doctor of any adverse reactions, to give medications as ordered, the medications put Resident #1 at risk for falls, and to watch for possible side effects which may include dizziness, drowsiness, irritability, weakness, decreased coordination, and new or worsening [MEDICAL CONDITION]. - Problem: " I take Klonopin for [MEDICAL CONDITION] " with an onset date of 04/12/13 and revised on 09/23/13. The interventions listed are to ensure informed consent by resident or Responsible Party (RP) are given, notify doctor of any adverse reactions, to give medication as ordered, and to watch for side effects such as clumsiness, unsteadiness, or behavioral changes. - Problem of "I have severe reflux with high risk for aspiration " with a problem onset date of 04/12/13 and revised on 12/15/13. The interventions listed are to keep the head of bed (HOB) elevated 90 degrees during and after feedings, monitor for side effects of medication, document if present, monitor labs per doctor orders, notify doctor and family of changes in condition, and to administer medications per doctor ' s orders. - Problem of " I have an ADL Self Care Performance Deficit related to Musculoskeletal impairment, disease process [MEDICAL CONDITION] " with an onset date of 04/12/13 and revised on 02/26/14. Interventions listed are: bathing, bed mobility, dressing, personal hygiene, transfer, toilet use: I require one staff participation. The private sitters were not included in his plan of care. Review of Resident #1 ' s physician's order [REDACTED]. - Diet: nothing by mouth (NPO) - [MEDICATION NAME] 125 mg/5 milliliters (mL) every 8 hours (Q8H), 5 mL ([MEDICAL CONDITION]) - [MEDICATION NAME] 100 mg/mL G tube, three times a day (TID), 15 mL ([MEDICAL CONDITION]) - Klonopin 0.5 mg G tube, TID: 1 tab ([MEDICAL CONDITION]) - Klonopin 0.25 mg G tube, PRN 1 tab ([MEDICAL CONDITION]), (no additional clarification order) Resident #1 ' s physician's order [REDACTED]. During an interview on 03/11/14 at 12:35 pm, Resident #1 ' s Sitter AA stated that Resident #1 was in the restroom in his room and he was standing outside waiting for Resident #1 to finish in the bathroom. He further stated that he assists Resident #1 to the bathroom but he can go by himself, and then when he finishes, the Sitter AA helps with wiping. The Sitter AA then stated that Resident #1 can walk but not independently; the Sitter AA steadies Resident #1 as he ambulates. During an interview on 03/12/13 at 11:25 am, CNA D stated that Resident #1 has a family-hired sitter 24 hours per day and they work in shifts. He further stated that the sitters do all ADL care for Resident #1 except for showers, medication administration, and tube feeding. He also stated he was not sure what care was provided for Resident #1 by the facility ' s CNAs. During an interview on 03/12/14 at 11:28 am, CNA E stated she was assigned to the hall Resident #1 lives on and they give Resident #1 ' s sitters supplies like wipes if needed. She then stated they only assist in care if the sitter requests help and the shower aides shower him but that is the only care she knows that the facility ' s CNA ' s provide him. During an interview on 03/12/14 at 11:35 am, LVN L, the charge nurse for Resident #1 ' s hall, stated that Resident #1 has sitters 24 hours a day, seven days a week but sometimes they are not there from 11:00 pm to 7:00 am so the staff care for him when the sitters are not there. She further stated there is a video monitor at the nurse ' s station where they can see Resident #1 in bed and monitor him for [MEDICAL CONDITION] activity. LVN L then stated Resident #1 can walk but not independently so the sitters steady him and no devices are used for assistance. When asked what kind of training the sitters have received from the facility staff, LVN L stated the sitters have not received any that she knows of and she was not sure what the CNA ' s do for Resident #1 because the sitters do most things for him. During an interview on 03/12/14 at 9:25 am, Resident #1 ' s Sitter AA stated that he does all of the care for Resident #1 when he is there but the shower aides shower him. He further stated he helps in the showers to hold Resident #1 ' s head and shampoo his hair to make sure he does not swallow any water in the shower because that can cause pneumonia. When asked if Resident #1 has swallowed water in the shower causing aspiration pneumonia, Sitter AA stated yes, it had happened a few times when he first came to the facility. The Sitter AA then stated Resident #1 has [MEDICAL CONDITION] often and he makes sure there is padding around Resident #1 ' s head for safety because when he has a [MEDICAL CONDITION], his head rotates back and forth. When asked what kind of training he has received from the facility, he stated none because Resident #1 ' s father trained him on how to care for the resident. Sitter AA further stated Resident #1 had two [MEDICAL CONDITION] the previous day (03/11/14). During an interview on 03/12/14 at 12:45 pm, Resident #1 ' s Sitter BB stated she is there to monitor for [MEDICAL CONDITION] and she lets the nurse know if his tube feeding is beeping and helps Resident #1 participate in activities. She further stated Resident #1 cannot walk independently and sitters are there to support him especially because he has [MEDICAL CONDITION] and left sided weakness. When asked what she does when Resident #1 has a [MEDICAL CONDITION], Sitter BB stated it depends on how intense the [MEDICAL CONDITION] is but she mainly tries to keep Resident #1 from hurting himself because he moves arms up and down and his head goes side to side. She then tells the nurses that he had a [MEDICAL CONDITION]. When asked what kind of training she has received from the facility on resident care, Sitter BB stated none because Resident #1 ' s father trained her on how to care for him. She further stated there is a Bowel Movement (BM) log by the door to Resident #1 ' s room and they just log there when he has a BM and staff can just look at that to know when he uses the restroom. Sitter BB then stated Resident #1 may vomit after a [MEDICAL CONDITION] and that can cause Aspiration Pneumonia and he has had that twice since December. She further stated that a fever is Resident #1 ' s first symptom of pneumonia and she monitors for that. She then stated that he was really sick in December and was in the hospital for about four weeks and then again in January for a week and a half for aspiration pneumonia. During an interview on 03/12/14 at 4:05 pm, the DON stated Resident #1 ' s sitters are there to assess and monitor him for [MEDICAL CONDITION] because he has a history of [MEDICAL CONDITION]. She further stated the facility nurses administer all of Resident #1 ' s medications and feedings. The DON also stated there is a facility policy and procedure the sitters have to sign before caring for Resident #1. The signed policy/procedures for the sitters were requested but not provided prior to survey exit 03/17/14. During an interview on 03/12/14 at 4:10 pm, the ADON A stated there is a video monitor at the nurse ' s station and nurses rely on that to know if Resident #1 has a [MEDICAL CONDITION] or the sitter alerts them. She also stated there is no specific [MEDICAL CONDITION] log but [MEDICAL CONDITION] should be documented in the nurse ' s notes. Resident #1 takes medications post [MEDICAL CONDITION] and he is followed by a Pediatric Neurologist who monitors his [MEDICAL CONDITION] activity and medications. She further stated Resident #1 was initially admitted in 03/2013 for respite care and she did not think the facility could initially care for Resident #1 because of all of his [MEDICAL CONDITION]. She then stated Resident #1 has as many as four to five [MEDICAL CONDITION] a day, then they go away for a while and then come back and he can have them daily. Observation on 03/14/14 at 2:30 pm revealed Resident #1 ' s monitor screen at the nurse ' s station. The screen was black and there was no signal. During an interview on 03/12/14 at 5:00 pm, the DON stated all of Resident #1 ' s [MEDICAL CONDITION] activity is only documented in the nurse notes and nowhere else. She further stated there is no protocol to outline when to document a [MEDICAL CONDITION] but she probably would not document it if it was just a three second [MEDICAL CONDITION] but would if it was a minute to a minute and a half [MEDICAL CONDITION]; it just depends on the length of the [MEDICAL CONDITION]. Review of Resident #1 ' s Physician ' s Progress Note dated 12/10/13 reflected patient was recently treated for [REDACTED]. Further review reflected an assessment/plan of Aspiration Pneumonia treated and resolved and [MEDICAL CONDITION] disorder: continue [MEDICATION NAME] and [MEDICATION NAME] ([MEDICAL CONDITION] medications) deferred to patient ' s neurologist; will continue to monitor for increased activity due to history of aspiration pneumonia that lowers ([MEDICAL CONDITION]) threshold. The NP signed this progress note. Review of Resident #1 ' s Nurse Notes reflected: - 01/10/14: reflected report called from local hospital, resident admitted with pneumonia follow up discharge from Intensive Care Unit (ICU) on 01/07/14 to acute care. Last [MEDICAL CONDITION] activity 01/08/14, discharge orders faxed, medications resumed - 01/22/14, 7:20 am: Had moderate [MEDICAL CONDITION] last approximately 1 ? minutes in bed - caregiver at bedside to safeguard him - no injuries. Had vomited large amount of phlegm, was upright entire time. His father requested AM medications not be given right away and I waited to give them until caregiver told me resident had settled down with no emesis noted. Noted for nasal drainage but no further phlegm emesis, tires easily. Noted for Blood Pressure (BP) up but is talking with his mother his BP tends to go up after a major [MEDICAL CONDITION]. Also at time of [MEDICAL CONDITION] this AM, resident received routine Klonopin. No physician notification documented. - 8:00 pm: 10 second [MEDICAL CONDITION], vomited approximately 150 mL formula and phlegm. Father called facility twice with instructions and request. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 01/23/14 reflected according to nursing, patient had a temperature of 99.4 degrees Fahrenheit (F) with increase nasal drainage last night and a moderate [MEDICAL CONDITION]. Spoke with patient ' s father who is concerned regarding increased [MEDICAL CONDITION] activity; we discussed possible avenues regarding aspiration pneumonia from [MEDICAL CONDITION] Reflux versus allergies [REDACTED]. The NP signed this note. Review of Resident #1 ' s handwritten Admission Physician order [REDACTED]. - Klonopin 0.5 mg PT TID - [MEDICATION NAME] 15 mL PT TID - [MEDICATION NAME] 125 mg, 5 mL PT Q8H - Klonopin 0.25 mg PT PRN Further review of the Admission Administration Record reflected Resident #1 received Klonopin 0.25 mg PRN on 02/07/14 and 02/28/14. It also reflected Nurse Medication notes: 02/28/14 2:45 pm, small [MEDICAL CONDITION] (8 seconds) gave PRN Klonopin 0.25 mg PT. There is no reason listed on the nurses medication notes as to why Klonopin 0.25 mg PRN was given on 02/07/14. Review did not reflect orders for sitters to provide assistance with ADLs or for [MEDICAL CONDITION] monitoring. Review of Resident #1 ' s Nurse ' s Notes reflected: - 02/06/14, 3:50 pm: patient returned from local hospital via parents ' vehicle, tires easily. Caregiver with patient, family brought back some of his medications but not his Klonopin. Given the medications his dad asked me to give him - didn ' t get at the hospital this afternoon. Had to give his PRN Klonopin and I told his mom - she ' ll check with hospital if she can get back his Klonopin she gave them. No [MEDICAL CONDITION] activity. - 02/07/14, Resident Awake alert, G tube placement verified. 30 second [MEDICAL CONDITION] noted at 8:35 pm, Klonopin 0.25 mg PRN administered per tube. Attendant at side for feedings today, no diarrhea noted. Will continue to monitor. Call to parents, updated on status. No physician notification documented. - 02/28/14, 2:45 pm: Caregiver reported resident had a small [MEDICAL CONDITION] lasted approximately 7 seconds. I gave him PRN Klonopin 0.25 mg PT. No physician notification documented. - 03/04/14, 9:15 pm: Earlier, reported resident had 2 small [MEDICAL CONDITION] today. Call placed to Responsible Party (RP) to notify. No physician notification documented. - 03/05/14, 1:00 pm, Resident sitting in wheelchair in living room area with caregiver. I noted she was assisting him as his head was turning to the side; she was protecting him as he started to move about in chair. She stated it lasted for approximately 20 seconds and he dry heaved once. He was taken to his room and I gave him his anti-[MEDICAL CONDITION] medications via G tube. RP notified. No physician notification documented. - 03/06/14, 1900: small 15 second [MEDICAL CONDITION] reported by caregiver. PRN Klonopin administered, no injuries noted. No physician notification documented. - 03/07/14, 2:15 pm: 30 second [MEDICAL CONDITION] - PRN Klonopin given per family request. No physician notification documented. - 03/11/14, 2:40 pm: Caregiver reported [MEDICAL CONDITION] last approximately 25 seconds, give PRN Klonopin 0.25 mg per tube (PT). No physician notification documented. - 03/11/14, 3:00 pm: Had another [MEDICAL CONDITION] last approximately 10 seconds, give 4.5 [MEDICATION NAME] routine, routine Kepra and Klonopin 0.5 mg PT. Caregiver kept him safe in both instances. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 03/11/14 reflected Resident #1 had a 15 second [MEDICAL CONDITION] according to caregiver on the sixth. Further review reflected an assessment/plan for [MEDICAL CONDITION] disorder to continue current therapy, fair control, occasional breakthrough [MEDICAL CONDITION] deferred to Neurologist. Also, Dysphagia: continue tube feeds, high risk for aspiration. History of aspiration pneumonia, chronic issue, currently asymptomatic. Resident #1 is a high aspiration risk along with increased fall risk due to gait abnormalities, care discussed with nursing and with the patient ' s sitter. The MD signed this note. Review of Resident #1 ' s laboratory value dated 02/14 reflected a [MEDICATION NAME] ([MEDICATION NAME]) level of 17.3 ug/mL. (Reference range: 10.0 - 20.0 micrograms (ug)/mL) Review of Resident #1 ' s Medication Administration Record (MAR) dated March 2014 reflected an order for [REDACTED]. The Klonopin PRN was given on 03/06/14, 03/07/14, and 03/11/14. Further review reflected: 03/07/14, 2:30 pm - Klonopin 0.25 mg PT per family re [MEDICAL CONDITION] activity; 03/11/14 2:40 pm - Klonopin 0.25 mg PT for [MEDICAL CONDITION] approximately 25 seconds. No documentation for reasoning for the PRN Klonopin given on 03/06/14. During an interview on 03/12/14 at 5:10 pm, the NP stated Resident #1 sees a Pediatric Neurologist who prescribes and monitors the [MEDICAL CONDITION] medications and labs. She further stated the facility communicates with her and the Medical Director (MD) about Resident #1 ' s [MEDICAL CONDITION] activity but there is no communication documentation of [MEDICAL CONDITION] activity. She further stated the sitter tells the staff if Resident #1 has any [MEDICAL CONDITION] and they then monitor him if he does. The NP then stated the Klonopin PRN order should be given when a [MEDICAL CONDITION] is happening, and should only be given once per day. During an interview on 03/13/14 at 12:45 the DON stated that Resident #1 has multiple [MEDICAL CONDITION] per day and she expects nurses to document small [MEDICAL CONDITION] that last more than one minute. The DON was then asked how to give Resident #1 ' s PRN order for Klonopin. The DON stated that she would give it however the physician ordered it. The DON then reviewed the order for PRN Klonopin and stated " 0.25 mg for [MEDICAL CONDITION]. " The DON was asked when would she give the PRN Klonpin, she stated " I would have to clarify. " The DON was asked in her nursing judgment when would she give the PRN Klonopin, she stated " I would have to clarify the order. I am not sure if the nurse practitioner wants to give it after every [MEDICAL CONDITION]. " The DON stated that the ADON or the charge nurse would be responsible for clarifying this order. She stated that " the charge nurse gives Resident #1 his medication because he is a tube feeder. " The DON stated that any change in Resident #1 ' s condition is told to the CNAs by the caregivers, then the CNAs inform the nurses. The DON stated that she expected documentation in the nurses notes of any change of condition, [MEDICAL CONDITION] that lasts 3 minutes, distress, shortness of breath. She stated that Resident #1 has multiple [MEDICAL CONDITION] per day and she expects nurses to document small [MEDICAL CONDITION] that last more than one minute. During an interview on 03/13/14 at 12:57 pm, the Neurology LVN stated Resident #1 was a patient and the last phone call they received from the facility about him was on 01/15/14 because of [MEDICAL CONDITION] activity and lab values. They have not contacted the clinic since regarding [MEDICAL CONDITION] activity. She then stated the facility only contacts the Neurology clinic when the resident has significant changes but they do request that all patients alert them of all [MEDICAL CONDITION] to adequately monitor care. She further stated Resident #1 was last in the Neurology clinic on 03/04/14. When asked how often the Klonopin 0.25 mg PRN should be given, she stated it should not be given more than five times per day for Resident #1; three times per routine orders and two PRN doses. During an interview on 03/13/14 at 4:15 pm, the MD stated Resident #1 was admitted to the facility with having about 30 [MEDICAL CONDITION] per month and he does not follow the [MEDICAL CONDITION] medications because the Neurologist does that on a day to day basis. He further stated the Klonopin 0.25 mg PRN should be given after all [MEDICAL CONDITION] and he would rather have it given and Resident #1 not be seizing than for him to have a [MEDICAL CONDITION] and not receive Klonopin 0.25 mg PRN. The MD further stated he expects to be notified of every [MEDICAL CONDITION] and he wants the nursing staff interpretation what a [MEDICAL CONDITION] is when administering the Klonopin 0.25 mg PRN. When asked if it is appropriate to administer routine Klonopin 0.5 mg twenty minutes after receiving the Klonopin 0.25 mg PRN after a [MEDICAL CONDITION], he stated yes. The MD then stated he expects the nursing staff to monitor and document Resident #1's [MEDICAL CONDITION] activity in the nurses ' notes. He further stated he does not know a characteristic [MEDICAL CONDITION] for Resident #1, but he does have a variety, everything from grand mal (features a loss of consciousness and violent muscle contractions) to minor [MEDICAL CONDITION]. In a continued interview on 3/13/14 at 4:15 PM, the MD stated that Resident # 1 ' s condition were exceedingly complex therefore he may not place specifications on the order for how many times a day Resident #1 should get PRN Klonopin. Surveyor asked the PCP how the nurses would know how many times a day to give the medication (Klonopin 0.25 mg PT PRN). The MD stated that he would expect the nurse not to hold back and go ahead and give the Klonopin and then call for further direction. The MD stated that when the nurses call him does a back and forth questioning with the nurse to be able to determine the [MEDICAL CONDITION] activity. The MD stated that he would want them to describe the characteristics of the [MEDICAL CONDITION], rather than diagnosing what kind of [MEDICAL CONDITION] they are. Surveyor asked the MD if he was involved in the care planning process concerning Resident # 1 ' s " complex " medical needs, to ensure that staff are aware of his expectations and to enable the correlation of care. The MD stated that he was not, but that his NP might be he was not sure. During an interview on 3/13/14 at 4:15 PM Surveyor asked Administrator how the facility communicated to the direct care staff of what Resident # 1 ' s caregivers " can and cannot do " for Resident #1. Administrator stated that these directions in care were not developed until the night of 3/12/14. During an interview on 03/14/14 at 5:20 pm, the DON stated she expects the nursing staff to assess residents for PRN medications, follow physician orders, and then reassess residents again after a PRN medication is given to monitor effectiveness. She further stated the PRN medication should be documented on the MAR or in Nurse ' s Notes. When asked when nurses should clarify physician orders, the DON stated she expects her staff to clarify it if the order is not clear. She further stated PRN medications usually have the number of tabs and how often it should be administered on the order and she expects her staff to clarify an order if that is not clear. The DON stated she was not aware that Resident #1 ' s sitters were providing personal care for him. The DON then said the CNA ' s do the same amount of care for Resident #1 as they do for other residents who are assessed to be minimal assist. Review of the facility ' s PRN Orders Policy dated April 2008 reflected that PRN orders must clarify the circumstances for offering or giving the medication. When PRN orders are implemented, nursing staff must monitor the use of such medication to determine the nature of the problem and whether it persists, whether additional evaluation is needed or whether the medications could be discontinued. Review of the facility ' s [MEDICAL CONDITION] Management Policy dated 2007 reflected if staff suspect a resident is having a [MEDICAL CONDITION], they will note the time and duration of the [MEDICAL CONDITION] activity, monitor the resident ' s vital signs as ordered by the physician, and notify the physician during or as soon as possible after the [MEDICAL CONDITION], and notify the family of the event subsequently. It further reflected when documenting or reporting a resident ' s [MEDICAL CONDITION] activity to the physician, carefully describe signs and symptoms including: the nature of the activity (where it started, what areas of the body were involved), the duration of the [MEDICAL CONDITION] activity, whether the resident lost consciousness, the resident ' s current level of consciousness, baseline and current cognitive ability, speech, physical function, presence of abnormal motor activity, present of tremors, and overall physical condition. Avoid documenting or reporting just that the individual " had a [MEDICAL CONDITION]. " Instead, provide and document the details. Review of the facility ' s Private Duty Sitters Policy dated August 2006 reflected residents/family members desiring the use of private duty sitters must first obtain written approval of the attending physician and the DON. Private duty nursing personnel must follow the facility ' s established nursing care policies and procedures, instructions issued by the Nurse Supervisor/Charge Nurse, and may not administer direct care to the resident unless authorized in writing by the Attending Physician. The facility Administrator and DON were notified on 03/13/14 at 12:50 pm that an IJ situation had been identified due to the above failures. The final Plan of Removal was accepted by the surveyor on 03/17/14 at 10:15 am. Removal Plan for Immediate Jeopardy related to Resident #1 ' s [MEDICAL CONDITION] activity. How we will remove the immediacy: I. A clarification order on Resident #1 ' s Klonopin was written. It reads Klonopin 0.25mg give one tablet per tube daily PRN for [MEDICAL CONDITION] activity. If additional dose is needed notify on-call for instructions. II. A nursing in-service on Facility ' s [MEDICAL CONDITION] and [MEDICAL CONDITION] Clinical Protocol will be completed by 3/19/14. The in-service covers Assessment and Recognition, Cause Identification, Treatment/Management and Monitoring. As the policy relates to documentation the in-service include: ? The nature of the activity (where it started, what areas of the body were involved, etc.) ? The duration of the [MEDICAL CONDITION] activity. ? Whether the resident lost consciousness. ? Baseline and current cognitive ability. ? Baseline and current speech. ? Baseline and current physical function. ? Presence of abnormal motor activity. ? Presence of tremors. ? Overall physical condition. III. Facility will communicate Resident #1 ' s [MEDICAL CONDITION] to Resident #1 ' s PCP, or his nurse practitioner, as follows. If Resident #1 ' s [MEDICAL CONDITION] is controlled, meaning the [MEDICAL CONDITION] has stopped, Facility will notify non- emergently. If the [MEDICAL CONDITION] is not controlled, meaning his [MEDICAL CONDITION] continues after the PRN Klonopin is administered, Facility will notify on call. If the physician is not immediately available to discuss the situation Resident #1 will be sent to the emergency room . IV. All nursing staff will be assigned a " Response to [MEDICAL CONDITION] " online course beginning 3/17/14 and will continue until all nursing staff have completed and passed. The steps of the training include: 1. Call the nurse and stay with the patient. 2. Place padding under head and move furniture away from resident (protects resident from injury). 3. Do not restrain the resident or place anything in mouth (any restriction may injury resident during [MEDICAL CONDITION]). 4. Loosen resident ' s clothing especially around neck (prevents injury or choking). 5. After [MEDICAL CONDITION] stops, position patient onto side (allows saliva to drain from mouth so resident doesn ' t choke). 6. Note duration of [MEDICAL CONDITION] and areas involved (provides nurse with necessary information to properly assess resident ' s condition and needs). 7. Perform final steps (i.e. lower bed height and position bed enablers as appropriate, place call light and water within reach, ask resident if anything else is needed, thank resident, wash hands, and document procedure). 8. Assist with documentation according to current nursing practices. V. Resident #1 ' s care plan was updated on 3/16/14 to reflect the characteristics of his [MEDICAL CONDITION]. ? The care plan reads my [MEDICAL CONDITION] can be characterized by: turning head from side to side, raising knees or shaking leg(s), shaking arms. After a [MEDICAL CONDITION] I may be sleepy. Report these symptoms and any other [MEDICAL CONDITION] activity to the charge nurse. During a [MEDICAL CONDITION] keep me safe from injury and do not place anything in my mouth VI. Resident #1 ' s caregivers will communicate with the nurses by using the call light while in Resident #1 ' s room. If outside on community grounds the caregiver will notify the nurse by calling the communities main line via cell phone after ensuring Resident #1 is safe. A [MEDICAL CONDITION] observation log will be developed and by implemented on 3/17/14. The log will allow caregivers to document the length of the [MEDICAL CONDITIONS] observations, recovery observations, and comments (if any are needed). VII. If Resident #1 experiences a [MEDICAL CONDITION] during a community outing the Activity Director, will call 911. VIII. The Private Duty Sitter Authorization Form will completed for all five of Resident #1 ' s private duty sitters. The authorization form will be signed by Resident #1 ' s PCP and The Facility ' s Director o

Based on observation, interview and record review the facility failed to maintain all patient care equipment in safe operating condition for two (2) of six (6) mechanical lifts (mechanical lift CC and DD) and three (3) of eight (8) wheelchairs identified with anti-tip and anti-roll back safety devices: A. The Maintenance Manager failed to properly maintain two electrical mechanical lifts (mechanical lift CC and DD) that were being used to transfer resident. Electrical Mechanical Lift CC had tape around the boom accelerator (the mechanical and electrical components that control the hydraulic for the lift) housing, holding the housing together. Electrical Mechanical Lift CC's adjustment lever (the lever that locks the legs in an open and closed position) was not locking and the legs would open and close while the lift was being maneuvered. Electrical Mechanical Lift DD's adjustment lever was not attached and could be removed. The adjustment lever was being held to the lift with an orange therapeutic elastic band. An Immediate Jeopardy (IJ) situation was identified on 03/11/14. While the IJ was lowered to a non-immediate Jeopardy on 03/15/14, the facility remained out of compliance at a severity of more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice placed 21 residents that are transferred with a mechanical lift at risk of falls, serious injury and death from malfunctioning equipment. Non-Immediate Jeopardy: B. The Maintenance Manager failed to properly adjust and maintain wheelchair safety devices on three residents wheelchairs (Resident #8, #14 and #16) when anti-tip and anti-roll backs were not properly installed. This deficient practice placed 8 residents that utilize wheelchair safety devices at risk of falls, injuries and a diminished quality of life. Findings included: A. Observation on 3/11/14 at 4:00 PM revealed CNA F and CNA G were performing a mechanical lift CC with Resident # 31 from his bed to his wheelchair. After the transfer the mechanical lift CC was being wheeled into the hallway. The boom [MEDICATION NAME] was wrapped with several layers of a shiny off white colored tape. The tape was breaking loose around edges and had some scattered cracking and appeared to be torn on outer layer. Observation of the mechanical lift on hall 100 on 03/11/14 at 4:50 pm reflected an electric mechanical lift CC parked outside room 115. The mechanical lift had off white tape wrapped multiple times around the housing for the boom [MEDICATION NAME]. The tape was wrapped around the seam of the housing and, in two different locations, around top to bottom of the housing. There was separation between the seams of the housing on the boom [MEDICATION NAME]. Interview on 3/11/14 at 4:55 pm CNA G stated the mechanical lift had been taped up for at least 6 months. CNA G stated that the legs will automatically open up when the lift is pushed forward; the lever in the back of the lift that opened and closes the legs was broken. CNA G stated that the legs do not remain locked open or closed. CNA G stated that she has reported the mechanical lift needed repair and she did not feel safe using it. CNA G could not recall who she reported the mechanical lift needed repair. During an interview on 3/11/14 at 5:25 pm Maintenance Manager stated that he checks the mechanical lifts on a monthly basis and as needed. The Maintenance Manager stated that he uses The Equipment Lifecycle Stems Checklist (TELS) for his monthly checks of equipment. The Maintenance Manager stated that he did not know of any mechanical lift that was in need of repair at that time. The Maintenance Manager stated that he has not received any recent service requests for any of the mechanical lifts. The Maintenance Manager stated that the only repair that he had done recently was to change a switch on one of the mechanical lifts. The Maintenance Manager stated that he came in on a Monday and found a sign on one of the lift that stated " broken " . The Maintenance Manager stated that the boom was stuck in the top most position. After changing out the up and down switch the mechanical lift was fixed. The Maintenance Manager was taken to the mechanical lift with the tape on it. The Maintenance Manager stated the tape has been there since he started in 06/13. The Maintenance Manager stated that the tape is holding the "mechanism housing for the hydraulic " and " mother board " . The Maintenance Manager stated that if the housing were to come open, it would cause a " system failure " and the mechanical lift " would stop working " . The Maintenance Manager stated that he did not know of any mechanical lifts that malfunctioned or broke during a transfer. Review of the TELS report for the mechanical lifts dated 3/11/14 reflected for the months of 12/2013 through 03/2013 there were three noted checks on mechanical lifts (12/19/13, 02/17/14 and 03/03/14). All three were marked as being done on time with two being done late (3 days late and 17 days late). The task description reflected " Resident lifts: inspect mobile lifts as needed." The report does not reflect any comments as to which mechanical lifts were inspected, any problems found or what maintenance needed to be performed on the mechanical lifts. Observation on 3/11/14 at 6:55pm revealed Electric Mechanical Lift DD on hall 300. Electric Mechanical Lift DD had an orange therapeutic elastic band wrapped around the mast and the adjustment lever, holding the adjustment lever to the mast. The facility Administrator was notified on 03/11/14 at 7:50 pm that an IJ situation had been identified due to the above failures. During an interview on 03/11/14 at 7:53pm the Administrator stated that he pulled the mechanical lift with the tape around the boom [MEDICATION NAME] housing off the hall. The Administrator stated that he had called a durable medical equipment company to deliver 3 mechanical lifts. The Administrator stated the manual lift that Resident #27 had a fall in had been shipped out and was replaced with a new manual mechanical lift. A request was made for the inspection of the manual lift and the invoice for the manual lift being shipped out of the facility. Review of the Facility ' s In-service Training Report dated 3/11/14 reflected a topic of " Hoyer lift". The in- service reflected " staff to report any malfunction equipment immediately to managers. For example: hoyer lifts ... wheelchair, walkers ... or any other equipment in the building." Review of signed letter from the Administrator dated 3/12/14 reflected a hydraulic lift was disassembled and disposed of in the communities Texas Disposal System ' s dumpster on 02/04/14. The letter also reflected a new hydraulic lift was put into service on the same day. In an interview on 03/12/14 at 3:07 pm the Administrator stated that he expects malfunctioning equipment to be removed from the floor and put in the maintenance log. He stated that CNAs are to notify the charge nurse the charge nurse is then responsible for pulling the equipment off the floor and putting it in the maintenance log. The Administrator stated that he is responsible for the supervision of the Maintenance Director and they meet daily at 1:45 pm to go over maintenance concerns. The Administrator stated that he was unaware of the mechanical lift being taped up. He stated that he would need to see the manufacturer ' s recommendations to know if the machine was safe to use in that condition. The Administrator stated that he would expect that the lift would be replaced if broken. In an interview on 03/12/14 at 7:20 pm the Administrator stated that he removed two lifts from service, the lift that had been taped (Mechanical Lift CC) and Mechanical Lift DD, as the handle that engaged the stabilizer bars was loose and could pull out from the machine. In an interview on 03/13/14 at 9:50 am the Administrator stated that the new lift that was brought in from the medical equipment company should be the same as the lifts they already have in the building. The Administrator stated that they were not training staff on the different models, mechanical vs. electrical. He stated that ADON Z and ADON X were conducting the plan of removal in-services based on policy and procedure not specific to the lift models that were in the building. Observation on 3/14/14 at 3:40 pm revealed a wheelchair at the end of hall 300 with a written sign on the back of the chair. The sign revealed " arm rest does not come off. Do not use. " Review of the Maintenance Request Log on 03/14/14 at 3:43 pm reflected only one entry on 03/14/14 at 11:30am for a bed that was not working. The Maintenance Request log did not reflect any entry for a wheelchair arm rest on 3/14/14. During an interview on 3/14/14 at 3:50pm LVN P stated that Maintenance Request book is kept at the Nurses ' station for anyone to fill out. LVN P stated the Maintenance book is for equipment that has broken and needs to be fixed. LVN P stated if any equipment is found to be not working, the equipment is placed in the breezeway between hall 200 and the outside, a sign is placed on the equipment stating that it is broken and to let the Maintenance Manager know the equipment is broken. LVN P stated that if the Maintenance Manager is present in the building she would inform him verbally of the equipment being broken. LVN P stated she would fill out the Maintenance Request book if the Maintenance Manager was not in the building. LVN P stated that if a CNA finds equipment not working they are to inform the nurse for the hall of the broken equipment and log the information into the Maintenance Request book. During an interview on 3/14/14 at 3:55pm the ADON W stated that the staff had already been trained on broken equipment. The ADON W stated that the equipment is supposed to be immediately removed from use, placed in the breezeway of the 200 hall and the Maintenance Request Book is to be filled out " right away. " Observation on 03/14/14 at 4:20pm with the ADON W revealed a wheelchair and a walker at the end of hall 300 with a sign on each. The ADON W stated " that is not supposed to happen. " The Plan of Removal for Immediate Jeopardy related to the mechanical lifts was accepted on 03/13/14 at 11:12 am. Review of the Plan of Removal reflected: How we will remove the immediacy: Beginning 3/11/14 at 8:15pm ADON X and ADON Z began in-servicing validating nursing staff skills associated with transfer of a resident. This is a return demonstration validation skills and includes sling placement. The validations will continue until end of the completion date of Thursday, 03/13/14. Beginning 3/11/14 at 9:00pm DON began an all staff in-service on reporting and removing malfunctioning equipment. This in-service will continue through planned completion date of Thursday, 3/13/14. Administrator removed the mechanical lift (Invacare 450 serial # 07FKN 0 RPL 450-1) with the tape around the [MEDICATION NAME]/pump housing from 100 hall and placed out of service. He also inspected the other three mechanical lifts using The Equipment Lifecycle Stems Checklist (TELS) at approximately 8:45pm. The Invacare 450 serial #13FCD 3 was also removed from service because of a loose spreader bar. The Administrator also ordered a new Invacare 450 from McKesson. The new lift should arrive by 3/14/14. The two lifts that were kept in service are the manual Hoyer lift serial # 1312L0047 and the Invacare 450 serial # 12C 047. The Invacare 600 serial # 05E 8 was rented and arrived 3/12/14 and was put into service. This lift was inspected by Corporate Maintenance Manager using the TELS system. The Recovercare lift will be in place indefinitely. Anytime we have a mechanical lift incident: If the staff member is responsible for the incident they will be disciplined up to and including termination. The staff member will perform a return demonstration immediately. The ADON, or designee, will perform spot checks on the staff member for one week after the incident. The spot checks will be documented on a Mechanical/Hydraulic Lift validation form. The Maintenance Manager will check the mechanical lift for any potential safety issues. The survey team monitored the current plan of removal as follows: Observation on 03/15/14 at 10:30 am revealed CNA BB and CNA DD perform a mechanical lift correctly and safely for an unidentified resident according to the manufacturer ' s instructions. Observation on 03/15/14 at 10:55 am revealed CNA J and CNA CC perform a mechanical lift correctly and safely for an unidentified resident according to the manufacturer ' s instructions. Observation on 03/15/14 at 11:50 am revealed CNA D and CNA EE perform a mechanical lift correctly and safely for an unidentified resident according to the manufacturer ' s instructions. During an interview on 03/15/14 at 12:05 pm, CNA FF stated that her last training on how to use a mechanical lift was that morning and she was able to verbalize how to correctly use a mechanical lift per the manufacturer ' s instructions. During an interview on 03/15/14 at 12:15 pm, CNA K stated that his last training on how to use a mechanical lift was the day before and she was able to verbalize how to correctly use a mechanical lift per the manufacturer ' s instructions. He further stated that if he noticed anything wrong with the lift before using it, he would notify the nurse. The Immediate Jeopardy for the mechanical lifts was lifted on 03/15/14 at 2:20 pm. B. Review of Resident #8 ' s face sheet reflected an [AGE] year old male admitted on [DATE] and readmitted on 10/17/2013 with [DIAGNOSES REDACTED]. Review of Resident #8's Care Plan dated 02/19/2014 reflected "Add anti-tip bars to my w/c" related to having a history of falls. Observation on 03/12/14 at 9:45 am revealed the anti-roll back devices on Resident #8 ' s wheelchair were not properly functioning. The anti-roll backs were not correctly positioned around the wheel to clamp to the back of the resident ' s wheels and ensure the wheelchair did not roll back. In an interview on 03/12/14 at 9:55 am Resident #8 stated that the anti-roll backs do not work properly. He further stated that he requested for the staff to fix the anti-roll back device on his wheelchair. Review of the Maintenance Request Book dated 03/12/14 reflected no request to repair the anti-roll backs to Resident #8 ' s wheelchair. Review of Maintenance Supervisor ' s personal notepad dated 07/24/13 reflected that he was notified to repair Resident #8 ' s wheelchair. Review of Resident #14 ' s face sheet reflected an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 03/13/14 at 10:40 am revealed the anti-roll back devices on Resident #14 ' s wheelchair were not properly installed. The anti-roll back bar was missing from the left wheel of her wheelchair. Review of Resident # 14's Care Plan last reviewed on 02/19/14 reflected: an acute care plan for actual falls on 03/14/14, 01/16/14, 01/11/14, 12/08/13, 10/10/13, 09/24/13, 08/08/13, 07/08/13 ... Further review reflected: Risk for falls and have had actual fall in the facility related to unaware of safety needs, deconditioning and confusion. The care plan included an intervention of: wheelchair adaptations: anti-roll backs added on 03/14/14 Review of Resident #16 ' s face sheet reflected an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 03/13/14 at 10:05 am revealed Resident #16 asleep in her bed with her wheel chair at the side of her bed. The wheel chair brakes were not locked. The anti-roll back device on the right side hook portion of the bar was completely away from the tire by 1.5-2 inches; placing it too far away from the wheel to engage the device properly if the wheelchair rolled back. In an interview on 03/13/14 at 10:30 am the Maintenance Manager stated that he checks the maintenance request book twice a day to see if anything needs repair. He also writes in his personal notepad the repair duties for that day. Staff will notify him by via text, verbal, and maintenance request book for any repairs. He further stated he is not sure why the anti-roll backs have not been repaired since 07/24/13. In an interview on 03/13/14 at 10:50 am the Maintenance Manager stated that no Resident #16 ' s anti-roll back device was not in the right place, " yes, both sides should be working and in place correctly. " The Maintenance Manager stated that he reviews one hall per week each month with a general maintenance check. He stated that the last time this hall (400 where Resident #16 lives) was reviewed was February 28th. He stated that he bases this routine maintenance check on the TELS check sheet from the Facility ' s supply company. In an interview on 03/13/14 at 11:30 am - 11:40 am both CNA K and CMA O stated they notify their charge nurses or the maintenance manager on what needs repair. If they don ' t verbally tell the maintenance manager then they put the request in the Maintenance Request Book. In an interview on 03/13/2014 at 12:00 pm the RN A stated she receives information on items that needs repair by the staff. If she notices something that needs repair then she will put it in the Maintenance Request Book. Review of the Work Order Policy, dated December 2004, reflected: In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the Maintenance Director. It will be the responsibility of the department directors to fill out and forward such work orders to the maintenance director. A supply of work orders is maintained at each nurse ' s station. Work order requests should be placed in the appropriate file basket at the nurse ' s station. Work orders are picked up daily. Review of the Care Plan Policy, dated October 2010, reflected the facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The care plan further states, that each resident's comprehensive care plan is designed to aid in preventing or reducing declines in the resident's functional status and/or functional levels. The facility provided a list of 21 residents that are transferred using a mechanical lift. The facility provided a list of 1 resident that was care planned for anti-tips and 7 residents that were care planned for anti-roll backs on their wheelchairs.

Based on Observation, interview and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for seven (7) of 15 residents (Resident #5, #8, #14, #16, #31, #32 and #33) reviewed for accidents/supervision when: A. The facility failed to maintain the mechanical lifts in a safe condition. Two mechanical lifts (Mechanical Lift CC and DD) were not functioning safely. The CNAs continued to transfer residents with the mechanical lifts. B. The facility failed to ensure that CNAs (CNAs F, G, I, M, J, N, V, BB and CC) were properly transferring residents (Resident #5, #31, #32 and #33) using mechanical lifts. An Immediate Jeopardy (IJ) situation was identified on 03/11/14. While the IJ was lowered to a non-immediate Jeopardy on 03/15/14, the facility remained out of compliance at a severity of more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice placed 21 residents that are transferred with a mechanical lift at risk of discomfort during transfers, falls, hematomas, serious injury and death from malfunctioning equipment. Non-Immediate Jeopardy: C. Anti-roll back devices were not correctly positioned around the wheel to clamp to the back of the resident's wheels and ensure the wheelchair did not roll back for Resident #8, #14 and #16. This deficient practice placed 8 residents that utilize wheelchair safety devices at risk of falls, injuries and a diminished quality of life. This deficient practice placed 8 residents that utilize wheelchair safety devices at risk of falls, injuries and a diminished quality of life. Findings included: A. Observation on 3/11/14 at 4:00 PM revealed CNA F and CNA G were performing a mechanical lift CC with Resident # 31 from his bed to his wheelchair. After the transfer the mechanical lift CC was being wheeled into the hallway. The boom actuator (the mechanical and electrical components that control the hydraulic for the lift) housing was wrapped with several layers of a shiny off white colored tape. The tape was breaking loose around edges and had some scattered cracking and appeared to be torn on outer layer. Observation of the mechanical lift on hall 100 on 03/11/14 at 4:50 pm reflected an electric mechanical lift CC parked outside room 115. The mechanical lift had off white tape wrapped multiple times around the housing for the boom actuator. The tape was wrapped around the seam of the housing and, in two different locations, around top to bottom of the housing. There was separation between the seams of the housing on the boom actuator. Interview on 3/11/14 at 4:55 pm CNA G stated the mechanical lift had been taped up for at least 6 months. CNA G stated that the legs will automatically open up when the lift is pushed forward; the lever in the back of the lift that opened and closes the legs was broken. CNA G stated that the legs do not remain locked open or closed. CNA G stated that she has reported the mechanical lift needed repair and she did not feel safe using it. CNA G could not recall who she reported the mechanical lift needed repair to. During an interview on 3/11/14 at 5:25 pm Maintenance Manager stated that he checks the mechanical lifts on a monthly basis and as needed. The Maintenance Manager stated that he uses The Equipment Lifecycle Stems Checklist (TELS) for his monthly checks of equipment. The Maintenance Manager stated that he did not know of any mechanical lift that was in need of repair at that time. The Maintenance Manager stated that he has not received any recent service requests for any of the mechanical lifts. The Maintenance Manager stated that the only repair that he had done recently was to change a switch on one of the mechanical lifts. The Maintenance Manager stated that he came in on a Monday and found a sign on one of the lift that stated " broken " . The Maintenance Manager stated that the boom was stuck in the top most position. After changing out the up and down switch the mechanical lift was fixed. The Maintenance Manager was taken to the mechanical lift with the tape on it. The Maintenance Manager stated the tape has been there since he started in 06/13. The Maintenance Manager stated that the tape is holding the "mechanism housing for the hydraulic " and "mother board". The Maintenance Manager stated that if the housing were to come open, it would cause a "system failure" and the mechanical lift " would stop working " . The Maintenance Manager stated that he did not know of any mechanical lifts that malfunctioned or broke during a transfer. Review of the TELS report for the mechanical lifts dated 3/11/14 reflected for the months of 12/2013 through 03/2013 there were three noted checks on mechanical lifts (12/19/13, 02/17/14 and 03/03/14). All three were marked as being done on time with two being done late (3 days late and 17 days late). The task description reflected " Resident lifts: inspect mobile lifts as needed." The report does not reflect any comments as to which mechanical lifts were inspected, any problems found or what maintenance needed to be performed on the mechanical lifts. Observation on 3/11/14 at 6:55pm revealed Electric Mechanical Lift DD on hall 300. Electric Mechanical Lift DD had an orange therapeutic elastic band wrapped around the mast and the adjustment lever, holding the adjustment lever to the mast. The facility Administrator was notified on 03/11/14 at 7:50 pm that an IJ situation had been identified due to the above failures. During an interview on 03/11/14 at 7:53pm the Administrator stated that he pulled the mechanical lift with the tape around the boom actuator housing off the hall. The Administrator stated that he had called a durable medical equipment company to deliver 3 mechanical lifts. The Administrator stated the manual lift that Resident #27 had a fall in had been shipped out and was replaced with a new manual mechanical lift. A request was made for the inspection of the manual lift and the invoice for the manual lift being shipped out of the facility. Review of the Facility ' s In-service Training Report dated 3/11/14 reflected a topic of " Hoyer lift". The in- service reflected " staff to report any malfunction equipment immediately to managers. For example: hoyer lifts ... wheelchair, walkers ... or any other equipment in the building." Review of signed letter from the Administrator dated 3/12/14 reflected a hydraulic lift was disassembled and disposed of in the communities Texas Disposal System ' s dumpster on 02/04/14. The letter also reflected a new hydraulic lift was put into service on the same day. In an interview on 03/12/14 at 3:07 pm the Administrator stated that he expects malfunctioning equipment to be removed from the floor and put in the maintenance log. He stated that CNAs are to notify the charge nurse the charge nurse is then responsible for pulling the equipment off the floor and putting it in the maintenance log. The Administrator stated that he is responsible for the supervision of the Maintenance Director and they meet daily at 1:45 pm to go over maintenance concerns. The Administrator stated that he was unaware of the mechanical lift being taped up. He stated that he would need to see the manufacturer ' s recommendations to know if the machine was safe to use in that condition. The Administrator stated that he would expect that the lift would be replaced if broken. In an interview on 03/12/14 at 7:20 pm the Administrator stated that he removed two lifts from service, the lift that had been taped (Mechanical Lift CC) and Mechanical Lift DD, as the handle that engaged the stabilizer bars was loose and could pull out from the machine. In an interview on 03/13/14 at 9:50 am the Administrator stated that the new lift that was brought in from the medical equipment company should be the same as the lifts they already have in the building. The Administrator stated that they were not training staff on the different models, mechanical vs. electrical. He stated that ADON Z and ADON X were conducting the plan of removal in-services based on policy and procedure not specific to the lift models that were in the building. Observation on 3/14/14 at 3:40 pm revealed a wheelchair at the end of hall 300 with a written sign on the back of the chair. The sign revealed " arm rest does not come off. Do not use. " Review of the Maintenance Request Log on 03/14/14 at 3:43 pm reflected only one entry on 03/14/14 at 11:30am for a bed that was not working. The Maintenance Request log did not reflect any entry for a wheelchair arm rest on 3/14/14. During an interview on 3/14/14 at 3:50pm LVN P stated that Maintenance Request book is kept at the Nurses ' station for anyone to fill out. LVN P stated the Maintenance book is for equipment that has broken and needs to be fixed. LVN P stated if any equipment is found to be not working, the equipment is placed in the breezeway between hall 200 and the outside, a sign is placed on the equipment stating that it is broken and to let the Maintenance Manager know the equipment is broken. LVN P stated that if the Maintenance Manager is present in the building she would inform him verbally of the equipment being broken. LVN P stated she would fill out the Maintenance Request book if the Maintenance Manager was not in the building. LVN P stated that if a CNA finds equipment not working they are to inform the nurse for the hall of the broken equipment and log the information into the Maintenance Request book. During an interview on 3/14/14 at 3:55pm the ADON W stated that the staff had already been trained on broken equipment. The ADON W stated that the equipment is supposed to be immediately removed from use, placed in the breezeway of the 200 hall and the Maintenance Request Book is to be filled out " right away. " Observation on 03/14/14 at 4:20pm with the ADON W revealed a wheelchair and a walker at the end of hall 300 with a sign on each. The ADON W stated " that is not supposed to happen. " B. Review of Resident # 31's face sheet reflected an [AGE] year old male admitted on [DATE] and readmitted on 1/20/14 with [DIAGNOSES REDACTED]. Review of Resident # 31's Care Plan dated 10/30/13 reflected that Resident # 31 was at risk for falls related to poor strength, balance, and judgment. Observation on 3/11/14 at 4:00 PM revealed CNA F and CNA G were performing a transfer using mechanical lift with Resident # 31 from his bed to his wheelchair. CNA G did not open the legs of the lift as she rolled them under Resident # 31's bed. CNA F and CNA G ensured the sling and attachments were in place and CNA G lifted Resident # 31 off the surface of the bed. CNA G did not open the legs of the lift, once the legs of the lift were pulled out from under the bed, as she turned and rolled Resident # 31 toward his wheelchair (as per the manufacturer ' s user manual). CNA F turned and positioned the wheelchair for Resident # 31, but did not lock the breaks of the wheelchair (as per the manufacturer ' s user manual). CNA G opened the legs of the lift wide to position Resident # 31 directly over the wheelchair seat and began to lower Resident # 31 down into chair. CNA F was standing behind the wheelchair and guided Resident # 31 into the wheelchair. The wheelchair rolls back slightly against CNA F so she placed both of her hands on the push bars of the wheelchair to hold and support it. Observation on 3/11/14 at 4:00 PM revealed the mechanical lift being wheeled into the hallway. On the side of the mechanical lift was a warning label that reflected " Before using the patient lift, Read and Understand the owner ' s manual for proper operation and safety procedures. " The warning also reflected " Do not lock the casters of the patient lift when lifting an individual. Casters must be left unlocked to allow patient lift to stabilize during lifting procedures. " During an interview on 3/11/14 at 7:55 PM CNA G was asked by the surveyor: " What do you have to do when operating the mechanical lift to ensure that there was a wide base of support during a transfer? " CNA G looked at surveyor without responding. Surveyor reviewed the observation made earlier during the transfer with Resident # 31. CNA G stated that they didn't open the bar that opens the legs. Surveyor asked CNA G what kind of training she has received by the facility with mechanical lifts and CNA stated that she had training the first month she started working here and she has worked here six months. CNA G stated that the electric and the manual lifts are shared between all of the halls. CNA G stated that if she saw a problem with a mechanical lift that she would let the charge nurse, the Administrator, and her co-workers know about it. CNA G denied identifying any problems with the lifts she has used. Review of Resident # 33's face sheet reflected an [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 3/14/14 at 3:25 PM revealed CNA M and CNA J were performing a mechanical lift transfer with Resident # 33 from her bed to her reclining wheelchair. CNA M and CNA J ensured the sling and attachments were in place and CNA M lifted Resident # 33 off the surface of the bed. Resident # 33 head was within the sling tucked in the right upper corner and the bottom of the sling covered the buttocks and maybe an inch down the upper thighs. Her legs were stiff and straight out in front of her (positioning in the sling was not performed correctly as per the manufacturer ' s user manual). Resident # 33 was transferred across the room to her wheelchair. CNA J turned and positioned the wheelchair for Resident # 33. CNA M pushed the open legs of the lift under the wheelchair. The mechanical lift faced the left side of Resident # 33 ' s wheelchair. Resident # 33 and her wheelchair were facing the opposite side of the room with both of their backs to the door. Resident # 33 was parallel with and to left side of the wheelchair. Her legs were straight out directly in front of her. CNA M stood beside Resident # 33 facing her left side. CNA M pushed the mechanical lift forward. Resident # 33 was directly over the wheelchair seat and was lowered down into the chair in a supine position while CNA J supported her and stood behind the chair. The wheelchair seat was adjusted by CNA J. Resident # 33 was now in an upright sitting position. Review of Resident # 33's Care Plan dated 1/2/14 reflected that Resident # 33 had fragile bones due to demineralization and a history of fractures and that Resident # 33 needed extra care with handling because her bones were especially fragile. Resident # 33 Care Plan interventions reflected to be cautious in setting me down in a chair or in my bed, and in repositioning me, and in moving my limbs because something as simple as sitting down or rolling over might cause fractures. During an interview on 3/14/14 at 3:25 PM with CNA J stated that they used a full body sling to transfer Resident # 33. CNA J stated it was a one size fits all used on all of the residents for chairs. CNA J stated that they also have a one size fits all that was for showers because it has a hole in the bottom. CNA J stated that his last in- service or training on the mechanical lift was last month. During an interview on 3/14/14 at 3:25 PM with CNA M he was asked by surveyor why he would stand beside Resident # 33 and transfer her from the side of the chair, rather than doing it from the front. CNA M stated "There is a side way and there is a front way depending on the chair. " CNA M stated that his last in-service on the mechanical lift was three days ago and he was checked off on it last week. Review of Resident # 5 ' s face sheet reflected an [AGE] year old male admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 5 ' s Care Plan dated 2/6/14 reflected that Resident # 5 was at risk for falls related to deconditioning and confusion. Observation on 03/13/14 at 9:15 am revealed CNA BB and CNA CC performing a mechanical transfer with Resident #5 from her wheelchair to the bed. CNA BB was operating the lift while CNA CC was guiding Resident #5. CNA BB locked the rear casters of the mechanical lift prior to hooking Resident #5 ' s sling up to the mechanical then proceeded to raise Resident #5 with the rear caster brakes engaged (the rear casters are not to be locked when raising or lowering a resident as per the manufacturer ' s user manual). CNA BB raised Resident #5 to the height that of Resident #5 ' s bed, which was higher than the back of her wheelchair (resident should only be lifted just high enough to clear the surface they are on, as per the manufacturer ' s user manual) . CNA BB closed the legs of the mechanical lift and began to maneuver the lift to Resident #5 ' s bed (legs of the lift are to be opened as soon as possible when transferring a resident as per the manufacturer ' s user manual). CNA BB placed the mechanical lift under Resident #5 ' s bed. CNA BB locked the rear casters of the mechanical lift before lowering Resident #5 in to bed. During an interview on 3/14/14 at 9:30 am CNA BB stated that when lifting and lowering a resident in a mechanical lift the rear casters should be locked, so the lift " will not sway. " CNA BB stated when moving a resident in the mechanical lift the legs of the lift should be closed. CNA BB stated when lifting a resident, the resident should be lifted " high enough to get onto the other surface. " CNA BB stated that she had been in-service on mechanical lifts. During an interview on 3/14/14 at 9:35 am CNA CC stated she had been trained on 03/13/14 on mechanical lifts through the computer. CNA CC stated that when lifting a resident in a mechanical lift the rear casters of the lift needed to be locked. Observation on 3/14/14 at 3:45 PM revealed CNA V and CNA N were performing a mechanical lift with Resident # 5 from her bed to his wheelchair. CNA N did not open the legs of the lift as she rolled them under Resident # 5's bed (legs of the lift are to be in the open position as per the manufacturer ' s user manual). CNA V and CNA N ensured the sling and attachments were in place and CNA N lifted Resident #5 off the surface of the bed. CNA N did not open the legs of the lift, once the legs of the lift were pulled out from under the bed, as she turned and rolled Resident # 5 toward her wheelchair (the legs of the lift are to be open as possible when a resident is being transferred as per the manufacturer ' s user manual). CNA V turned, positioned, and supported the wheelchair for Resident # 5. CNA N opened the legs of the lift wide to position Resident # 5 directly over the wheelchair seat and begins to lower Resident # 5 down into chair. CNA V stood behind the wheelchair and guided Resident # 5 into the chair. During an interview on 3/14/14 at 3:55 PM CNA N stated that she didn ' t notice that she didn't open the legs of the mechanical lift until she reached Resident # 5 ' s wheelchair but stated that it was a mistake on her part. CNA N stated that her last mechanical lift training was a few days ago. CNA N stated that if she had any questions on how to operate mechanical lift that she would ask the ADON. Review of Resident # 32 ' s face sheet reflected a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 3/14/14 at 5:50 pm revealed CNA G and CNA I performing a mechanical lift transfer with Resident #32. CNA G was operating the mechanical lift and CNA I was guiding Resident #32. When Resident #32 was being lifted out of her wheelchair, the wheelchair began to lift off the ground with Resident #32. Resident #32 was lowered back to the ground and re-lifted with CNA I holding onto the chair to prevent the chair from lifting again. Resident #32 was raised to the height of her bed, which was in the highest position for the bed (was lifted too high for transferring the resident as per the manufacturer ' s user manual). Resident #32 was in the mechanical lift sideways while being transported from the wheelchair to the bed (resident should be positioned parallel with the lift as per the manufacturer ' s user manual). Resident #32 did not have to be raised to meet the height of the bed, but was lowered onto the bed. During an interview on 3/14/14 at 6:00 pm CNA I stated that she had not been in-serviced on the mechanical lifts. CNA I stated that her last training on mechanical lifts was computer based around the end of February 2014. CNA I stated that she did not see any problems with the lift of Resident #32. When asked about the wheelchair lifting, CNA I stated that Resident #32 has to wide of hips for her wheelchair and sometimes she sticks. CNA I stated that Resident #32 likes her bed in the high position and when lifting a resident in the mechanical lift, the lift should be " parallel " with the surface you are transferring. During an interview on 3/14/14 at 3:55pm the ADON W stated that she was responsible for the CNAs that were working on her hall. The ADON W stated that she had not seen the training video for the mechanical lifts that was being watched by the CNAs. When asked how could she be responsible for the CNAs performing proper technique if she had not seen the video, ADON W stated that she " needed to watch the video. " Review of the mechanical lift BB, CC, DD, EE and FF ' s user manual reflected: WARNING " (The mechanical lift manufacturer) ... does not recommend locking the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. (The mechanical lift manufacturer) ...does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed or any stationary object. " " The legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position and lock the shifter handle immediately. " 7.2 Lifting/Moving the Patient 1. Pump the lift handle or press the up button to raise the patient above the bed. The patient should be elevated high enough to clear the bed with their weight fully supported by the lift. 2. When the patient is lifted from the bed (with the patient ' s head supported by the sling and/or an assistant), he/she will be raised to a sitting position. 3. When the patient is clear of the bed surface, swing their feet off the bed. 4. Using the steering handle, move the lift away from the bed. 5. When moving the patient lift away from the bed, turn the patient so that he/she faces assistant operating the patient lift. 6. Press the down button (electric) or open the control valve (manual/hydraulic) lowering patient so that his feet rest on the base of the lift, straddling the mast. Close the control valve. 7. Pull the patient lift away from the bed and then push it from behind with both hands firmly on the steering handle. The Plan of Removal for Immediate Jeopardy related to the mechanical lifts was accepted on 03/13/14 at 11:12 am. Review of the Plan of Removal reflected: How we will remove the immediacy: Beginning 3/11/14 at 8:15pm ADON X and ADON Z began in-servicing validating nursing staff skills associated with transfer of a resident. This is a return demonstration validation skills and includes sling placement. The validations will continue until end of the completion date of Thursday, 03/13/14. Beginning 3/11/14 at 9:00pm DON began an all staff in-service on reporting and removing malfunctioning equipment. This in-service will continue through planned completion date of Thursday, 3/13/14. Administrator removed the mechanical lift (Invacare 450 serial # 07FKN 0 RPL 450-1) with the tape around the actuator/pump housing from 100 hall and placed out of service. He also inspected the other three mechanical lifts using The Equipment Lifecycle Stems Checklist (TELS) at approximately 8:45pm. The Invacare 450 serial #13FCD 3 was also removed from service because of a loose spreader bar. The Administrator also ordered a new Invacare 450 from McKesson. The new lift should arrive by 3/14/14. The two lifts that were kept in service are the manual Hoyer lift serial # 1312L0047 and the Invacare 450 serial # 12C 047. The Invacare 600 serial # 05E 8 was rented and arrived 3/12/14 and was put into service. This lift was inspected by Corporate Maintenance Manager using the TELS system. The Recovercare lift will be in place indefinitely. Anytime we have a mechanical lift incident: If the staff member is responsible for the incident they will be disciplined up to and including termination. The staff member will perform a return demonstration immediately. The ADON, or designee, will perform spot checks on the staff member for one week after the incident. The spot checks will be documented on a Mechanical/Hydraulic Lift validation form. The Maintenance Manager will check the mechanical lift for any potential safety issues. The survey team monitored the current plan of removal as follows: Review of the facility ' s In-service Training Report dated 3/13/14 reflected at 11:00 am an in-service training was performed with nursing staff. The in-service topic was lift rear wheel casters. The in-service reflected " do not lock the rear casters of the patient lift when lifting an individual. Locking the rear casters could cause the patient lift to tip and endanger the patient and assistant.... " Review of the facility ' s In-service Training Report dated 3/13/14 and 3/14/14 reflected at 11:00 am an in-service training was performed with nursing staff. The in-service topic was " Joerns Hoyer manual lift video " . The in- service also reflected, " Only one rear caster. Do not lock it during a patient lift. " Review of the facility ' s In-service Training Report dated 3/13/14 and 3/14/14 reflected at 11:00 am an in-service training was performed with nursing staff. The in-service topic was " Difference between Invacare 450 and Invacare 600. " The in-service reflected, " Weight capacity on Invacare 450 is 450 lbs (pounds). The weight capacity on the Invacare 600 is 600 lbs." Review of the facility ' s Return Competency checks for electric mechanical lift on 03/11/14 and 03/12/14 reflected 25 competency checks were performed. 23 of the 25 met all requirements on the return competency form. LVN P was listed in the competency checks, but did not have either any of the 17 performance criteria for the mechanical lift. CNA DD was listed in the competency checks, but did not have either "met " or " not met " checked in 5 of the 17 performance criteria (#13 through #17). Review of the facility ' s Return Competency checks for manual mechanical lift on 03/13/14 reflected 10 competency checks were performed. Nine of the 10 met all requirements on the return competency form. LVN Q was listed in the competency checks, but did not have either " met " or " not met " checked in any of the 17 performance criteria for the manual mechanical lift. In an interview on 03/14/14 at 5:10 PM MA T stated that she had attended a training session on mechanical lifts. She stated that three different types of lifts were used in the facility, 2 electrical and one manual. MA T stated that she had to " show how to do it " during the training. Observation on 03/15/14 at 10:30 am revealed CNA BB and CNA DD perform a mechanical lift correctly and safely for an unidentified resident according to the manufacturer ' s instructions. Observation on 03/15/14 at 10:55 am revealed CNA J and CNA CC perform a mechanical lift correctly and safely for an unidentified resident according to the manufacturer ' s instructions. Observation on 03/15/14 at 11:50 am revealed CNA D and CNA EE perform a mechanical lift correctly and safely for an unidentified resident according to the manufacturer ' s instructions. During an interview on 03/15/14 at 12:05 pm, CNA FF stated that her last training on how to use a mechanical lift was that morning and she was able to verbalize how to correctly use a mechanical lift per the manufacturer ' s instructions. During an interview on 03/15/14 at 12:15 pm, CNA K stated that his last training on how to use a mechanical lift was the day before and she was able to verbalize how to correctly use a mechanical lift per the manufacturer ' s instructions. He further stated that if he noticed anything wrong with the lift before using it, he would notify the nurse. The Immediate Jeopardy for the mechanical lifts was lifted on 03/15/14 at 2:20 pm. C. Review of Resident #8 ' s face sheet reflected an [AGE] year old male admitted on [DATE] and readmitted on 10/17/2013 with [DIAGNOSES REDACTED]. Review of Resident #8's Care Plan dated 02/19/2014 reflected "Add anti-tip bars to my w/c" related to having a history of falls. Observation on 03/12/14 at 9:45 am revealed the anti-roll back devices on Resident #8 ' s wheelchair were not properly functioning. The anti-roll backs were not correctly positioned around the wheel to clamp to the back of the resident ' s wheels and ensure the wheelchair did not roll back. In an interview on 03/12/14 at 9:55 am Resident #8 stated that the anti-roll backs do not work properly. He further stated that he requested for the staff to fix the anti-roll back device on his wheelchair. Review of the Maintenance Request Book dated 03/12/14 reflected no request to repair the anti-roll backs to Resident #8 ' s wheelchair. Review of Maintenance Supervisor ' s personal notepad dated 07/24/13 reflected that he was notified to repair Resident #8 ' s wheelchair. In an interview on 03/13/14 at 10:30 am the Maintenance Manager stated that he checks the maintenance request book twice a day to see if anything needs repair. He also writes in his personal notepad the repair duties for that day. Staff will notify him by via text, verbal, and maintenance request book for any repairs. He further stated he is not sure why the anti-roll backs have not been repaired since 07/24/13. Review of Resident #14 ' s face sheet reflected an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 03/13/14 at 10:40 am revealed the anti-roll back devices on Resident #14 ' s wheelchair were not properly installed. The anti-roll back bar was missing from the left wheel of her wheelchair. Review of Resident # 14 ' s Care Plan last reviewed on 02/19/14 reflected: an acute care plan for actual falls on 03/14/14, 01/16/14, 01/11/14, 12/08/13, 10/10/13, 09/24/13, 08/08/13, 07/08/13 ... Further review reflected: Risk for falls and have had actual fall in the facility related to unaware of safety needs, deconditioning and confusion. The care plan included an intervention of: wheelchair adaptations: anti-roll backs added on 03/14/14. Review of Resident #16 ' s face sheet reflected an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of five (5) residents reviewed for quality of care (Resident #1). The facility failed to train Resident #1 ' s family-hired sitters in how to properly assess and monitor for a [MEDICAL CONDITION] disorder, put [MEDICAL CONDITION] precautions in place, proper resident care, and include them in his comprehensive plan of care. An Immediate Jeopardy (IJ) situation was identified on 03/13/14 at 12:14 p.m. While the IJ was lowered to a non-immediate Jeopardy on 03/17/14 at 3:30 p.m. the facility remained out of compliance at a severity of more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place seven (7) residents who are identified as a [MEDICAL CONDITION] risk and prescribed [MEDICAL CONDITION] medication at risk for neglect, lack of care, being overmedicated, and possible death. Findings include: Review of Resident #1 ' s facesheet reflected a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Admission Nurse ' s Note dated 03/13/13 reflected a [AGE] year old male admitted for respite care. He has a [DIAGNOSES REDACTED]. Recurrent [MEDICAL CONDITION], usual signs of impending [MEDICAL CONDITION] usually look off to left side, has a fixed smile and then shakes his head, may have mild to severe [MEDICAL CONDITION]. Resident #1 has left sided weakness, he is total assist with feeding and max total assist with rest of Activities of Daily Living (ADLs). He is able to ambulate without device for short distance with minimal assistance with his attendant but is usually wheelchair bound secondary to recurrent [MEDICAL CONDITION]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected: Section G: Functional Status: ADL Assistance - G0110 B. Transfer, 1 person Extensive Assist - G0110 C. Walk in room, 1 person Extensive Assist - G0110 G. Dressing, 1 person Extensive Assist - G0110 I. Toilet Use, 1 person Extensive Assist - G0120. Bathing, Physical Help, Support Provided - G0400. Range of Motion, Impairment in both upper and lower extremities Section H: Bladder and Bowel - H0300: Urinary, frequently incontinent - H0400: Bowel, Always incontinent Section I: Active Diagnoses - I5400. [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION] Review of Resident #1 ' s Comprehensive Care Plan dated 01/27/14 reflected the following problem areas: - Problem: "I have a [DIAGNOSES REDACTED]. The interventions listed are that Resident #1 has frequent [MEDICAL CONDITION], the family and him requested a closed circuit camera be placed in room with the nurse having the monitor to observe in case of a [MEDICAL CONDITION]. - Problem: "I take medications to control my [MEDICAL CONDITION] and am at risk for side effects" with an onset date of 04/12/13 and revised on 12/05/13. The interventions listed are to monitor as much as possible for [MEDICAL CONDITION] activity, notify the doctor of any adverse reactions, to give medications as ordered, the medications put Resident #1 at risk for falls, and to watch for possible side effects which may include dizziness, drowsiness, irritability, weakness, decreased coordination, and new or worsening [MEDICAL CONDITION]. - Problem: " I take Klonopin for [MEDICAL CONDITION] " with an onset date of 04/12/13 and revised on 09/23/13. The interventions listed are to ensure informed consent by resident or Responsible Party (RP) are given, notify doctor of any adverse reactions, to give medication as ordered, and to watch for side effects such as clumsiness, unsteadiness, or behavioral changes. - Problem of "I have severe reflux with high risk for aspiration " with a problem onset date of 04/12/13 and revised on 12/15/13. The interventions listed are to keep the head of bed (HOB) elevated 90 degrees during and after feedings, monitor for side effects of medication, document if present, monitor labs per doctor orders, notify doctor and family of changes in condition, and to administer medications per doctor ' s orders. - Problem of " I have an ADL Self Care Performance Deficit related to Musculoskeletal impairment, disease process [MEDICAL CONDITION] " with an onset date of 04/12/13 and revised on 02/26/14. Interventions listed are: bathing, bed mobility, dressing, personal hygiene, transfer, toilet use: I require one staff participation. The private sitters were not included in his plan of care. Review of Resident #1 ' s physician's order [REDACTED]. During an interview on 03/11/14 at 12:35 pm, Resident #1 ' s Sitter AA stated that Resident #1 was in the restroom in his room and he was standing outside waiting for Resident #1 to finish in the bathroom. He further stated that he assists Resident #1 to the bathroom but he can go by himself, and then when he finishes, the Sitter AA helps with wiping. The Sitter AA then stated that Resident #1 can walk but not independently; the Sitter AA steadies Resident #1 as he ambulates. During an interview on 03/12/13 at 11:25 am, CNA D stated that Resident #1 has a family-hired sitter 24 hours per day and they work in shifts. He further stated that the sitters do all ADL care for Resident #1 except for showers, medication administration, and tube feeding. He also stated he was not sure what care was provided for Resident #1 by the facility ' s CNAs. During an interview on 03/12/14 at 11:28 am, CNA E stated she was assigned to the hall Resident #1 lives on and they give Resident #1 ' s sitters supplies like wipes if needed. She then stated they only assist in care if the sitter requests help and the shower aides shower him but that is the only care she knows that the facility ' s CNA ' s provide him. During an interview on 03/12/14 at 11:35 am, LVN L, the charge nurse for Resident #1 ' s hall, stated that Resident #1 has sitters 24 hours a day, seven days a week but sometimes they are not there from 11:00 pm to 7:00 am so the staff care for him when the sitters are not there. She further stated there is a video monitor at the nurse ' s station where they can see Resident #1 in bed and monitor him for [MEDICAL CONDITION] activity. LVN L then stated Resident #1 can walk but not independently so the sitters steady him and no devices are used for assistance. When asked what kind of training the sitters have received from the facility staff, LVN L stated the sitters have not received any that she knows of and she was not sure what the CNA ' s do for Resident #1 because the sitters do most things for him. During an interview on 03/12/14 at 9:25 am, Resident #1 ' s Sitter AA stated that he does all of the care for Resident #1 when he is there but the shower aides shower him. He further stated he helps in the showers to hold Resident #1 ' s head and shampoo his hair to make sure he does not swallow any water in the shower because that can cause pneumonia. When asked if Resident #1 has swallowed water in the shower causing aspiration pneumonia, Sitter AA stated yes, it had happened a few times when he first came to the facility. The Sitter AA then stated Resident #1 has [MEDICAL CONDITION] often and he makes sure there is padding around Resident #1 ' s head for safety because when he has a [MEDICAL CONDITION], his head rotates back and forth. When asked what kind of training he has received from the facility, he stated none because Resident #1 ' s father trained him on how to care for the resident. Sitter AA further stated Resident #1 had two [MEDICAL CONDITION] the previous day (03/11/14). During an interview on 03/12/14 at 12:45 pm, Resident #1 ' s Sitter BB stated she is there to monitor for [MEDICAL CONDITION] and she lets the nurse know if his tube feeding is beeping and helps Resident #1 participate in activities. She further stated Resident #1 cannot walk independently and sitters are there to support him especially because he has [MEDICAL CONDITION] and left sided weakness. When asked what she does when Resident #1 has a [MEDICAL CONDITION], Sitter BB stated it depends on how intense the [MEDICAL CONDITION] is but she mainly tries to keep Resident #1 from hurting himself because he moves arms up and down and his head goes side to side. She then tells the nurses that he had a [MEDICAL CONDITION]. When asked what kind of training she has received from the facility on resident care, Sitter BB stated none because Resident #1 ' s father trained her on how to care for him. She further stated there is a Bowel Movement (BM) log by the door to Resident #1 ' s room and they just log there when he has a BM and staff can just look at that to know when he uses the restroom. Sitter BB then stated Resident #1 may vomit after a [MEDICAL CONDITION] and that can cause Aspiration Pneumonia and he has had that twice since December. She further stated that a fever is Resident #1 ' s first symptom of pneumonia and she monitors for that. She then stated that he was really sick in December and was in the hospital for about four weeks and then again in January for a week and a half for aspiration pneumonia. During an interview on 03/12/14 at 4:05 pm, the DON stated Resident #1 ' s sitters are there to assess and monitor him for [MEDICAL CONDITION] because he has a history of [MEDICAL CONDITION]. She further stated the facility nurses administer all of Resident #1 ' s medications and feedings. The DON also stated there is a facility policy and procedure the sitters have to sign before caring for Resident #1. The signed policy/procedures for the sitters were requested but not provided prior to survey exit 03/17/14. During an interview on 03/12/14 at 4:10 pm, the ADON A stated there is a video monitor at the nurse ' s station and nurses rely on that to know if Resident #1 has a [MEDICAL CONDITION] or the sitter alerts them. She further stated the sitters know to lower Resident #1 to the ground and to call for staff if he has a [MEDICAL CONDITION]. ADON A then stated there are no problems with communication between the nurse ' s and sitters. She stated there has been no facility training for them because Resident #1 ' s father trained the sitters on how to care for Resident #1. She further stated Resident #1 was initially admitted in 03/2013 for respite care and she did not think the facility could initially care for Resident #1 because of all of his [MEDICAL CONDITION]. She then stated Resident #1 has as many as four to five [MEDICAL CONDITION] a day, then they go away for a while and then come back and he can have them daily. Observation on 03/14/14 at 2:30 pm revealed Resident #1 ' s monitor screen at the nurse ' s station. The screen was black and there was no signal. Review of Resident #1 ' s Nurse Notes reflected: - 01/10/14: reflected report called from local hospital, resident admitted with pneumonia follow up discharge from Intensive Care Unit (ICU) on 01/07/14 to acute care. Last [MEDICAL CONDITION] activity 01/08/14, discharge orders faxed, medications resumed - 01/22/14, 7:20 am: Had moderate [MEDICAL CONDITION] last approximately 1 ? minutes in bed - caregiver at bedside to safeguard him - no injuries. Had vomited large amount of phlegm, was upright entire time. His father requested AM medications not be given right away and I waited to give them until caregiver told me resident had settled down with no emesis noted. Noted for nasal drainage but no further phlegm emesis, tires easily. Noted for Blood Pressure (BP) up but is talking with his mother his BP tends to go up after a major [MEDICAL CONDITION]. Also at time of [MEDICAL CONDITION] this AM, resident received routine Klonopin. No physician notification documented. - 8:00 pm: 10 second [MEDICAL CONDITION], vomited approximately 150 mL formula and phlegm. Father called facility twice with instructions and request. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 01/23/14 reflected according to nursing, patient had a temperature of 99.4 degrees Fahrenheit (F) with increase nasal drainage last night and a moderate [MEDICAL CONDITION]. Spoke with patient ' s father who is concerned regarding increased [MEDICAL CONDITION] activity; we discussed possible avenues regarding aspiration pneumonia from [MEDICAL CONDITION] Reflux versus allergies [REDACTED]. The NP signed this note. Review of Resident #1 ' s handwritten Admission Physician order [REDACTED]. Review of Resident #1 ' s Nurse ' s Notes reflected: - 02/06/14, 3:50 pm: patient returned from local hospital via parents ' vehicle, tires easily. Caregiver with patient, family brought back some of his medications but not his Klonopin. Given the medications his dad asked me to give him - didn ' t get at the hospital this afternoon. Had to give his PRN Klonopin and I told his mom - she ' ll check with hospital if she can get back his Klonopin she gave them. No [MEDICAL CONDITION] activity. - 02/07/14, Resident Awake alert, G tube placement verified. 30 second [MEDICAL CONDITION] noted at 8:35 pm, Klonopin 0.25 mg PRN administered per tube. Attendant at side for feedings today, no diarrhea noted. Will continue to monitor. Call to parents, updated on status. No physician notification documented. - 02/28/14, 2:45 pm: Caregiver reported resident had a small [MEDICAL CONDITION] lasted approximately 7 seconds. I gave him PRN Klonopin 0.25 mg PT. No physician notification documented. - 03/04/14, 9:15 pm: Earlier, reported resident had 2 small [MEDICAL CONDITION] today. Call placed to Responsible Party (RP) to notify. No physician notification documented. - 03/05/14, 1:00 pm, Resident sitting in wheelchair in living room area with caregiver. I noted she was assisting him as his head was turning to the side; she was protecting him as he started to move about in chair. She stated it lasted for approximately 20 seconds and he dry heaved once. He was taken to his room and I gave him his anti-[MEDICAL CONDITION] medications via G tube. RP notified. No physician notification documented. - 03/06/14, 1900: small 15 second [MEDICAL CONDITION] reported by caregiver. PRN Klonopin administered, no injuries noted. No physician notification documented. - 03/07/14, 2:15 pm: 30 second [MEDICAL CONDITION] - PRN Klonopin given per family request. No physician notification documented. - 03/11/14, 2:40 pm: Caregiver reported [MEDICAL CONDITION] last approximately 25 seconds, give PRN Klonopin 0.25 mg per tube (PT). No physician notification documented. - 03/11/14, 3:00 pm: Had another [MEDICAL CONDITION] last approximately 10 seconds, give 4.5 [MEDICATION NAME] routine, routine Kepra and Klonopin 0.5 mg PT. Caregiver kept him safe in both instances. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 03/11/14 reflected Resident #1 had a 15 second [MEDICAL CONDITION] according to caregiver on the sixth. Further review reflected an assessment/plan for [MEDICAL CONDITION] disorder to continue current therapy, fair control, occasional breakthrough [MEDICAL CONDITION] deferred to Neurologist. Also, Dysphagia: continue tube feeds, high risk for aspiration. History of aspiration pneumonia, chronic issue, currently asymptomatic. Resident #1 is a high aspiration risk along with increased fall risk due to gait abnormalities, care discussed with nursing and with the patient ' s sitter. The MD signed this note. During an interview on 03/12/14 at 5:10 pm, the NP stated Resident #1 sees a Pediatric Neurologist who prescribes and monitors the [MEDICAL CONDITION] medications and labs. She further stated the facility communicates with her and the Medical Director (MD) about Resident #1 ' s [MEDICAL CONDITION] activity but there is no communication documentation of [MEDICAL CONDITION] activity. She further stated the sitter tells the staff if Resident #1 has any [MEDICAL CONDITION] and they then monitor him if he does. The NP then stated the Klonopin PRN order should be given when a [MEDICAL CONDITION] is happening, and should only be given once per day. During an interview on 03/13/14 at 12:45 the DON stated that any change in Resident #1 ' s condition is told to the CNAs by the caregivers, then the CNAs inform the nurses. The DON stated that she expected documentation in the nurses notes of any change of condition, [MEDICAL CONDITION] that lasts 3 minutes, distress, shortness of breath. She stated that Resident #1 has multiple [MEDICAL CONDITION] per day and she expects nurses to document small [MEDICAL CONDITION] that last more than one minute. During an interview on 03/13/14 at 4:15 pm, the MD stated Resident #1 was admitted to the facility with having about 30 [MEDICAL CONDITION] per month. He further stated he does not know a characteristic [MEDICAL CONDITION] for Resident #1, but he does have a variety, everything from grand mal (features a loss of consciousness and violent muscle contractions) to minor [MEDICAL CONDITION] and he authorized Resident #1 ' s care given by the sitters. Surveyor asked the MD if he was involved in the care planning process concerning Resident # 1 ' s " complex " medical needs, to ensure that staff are aware of his expectations and to enable the correlation of care. The MD stated that he was not, but that his NP might be he was not sure. During an interview on 3/13/14 at 4:15 PM Surveyor asked Administrator how the facility communicated to the direct care staff of what Resident # 1 ' s caregivers " can and cannot do " for Resident #1. Administrator stated that these directions in care were not developed until the night of 3/12/14. During an interview on 03/14/14 at 5:20 pm, the DON stated she was not aware that Resident #1 ' s sitters were providing personal care for him. The DON then said the CNA ' s do the same amount of care for Resident #1 as they do for other residents who are assessed to be minimal assist. Review of the facility ' s Private Duty Sitters Policy dated August 2006 reflected residents/family members desiring the use of private duty sitters must first obtain written approval of the attending physician and the DON. Private duty nursing personnel must follow the facility ' s established nursing care policies and procedures, instructions issued by the Nurse Supervisor/Charge Nurse, and may not administer direct care to the resident unless authorized in writing by the Attending Physician. Review of the facility ' s [MEDICAL CONDITION] Management Policy dated 2007 reflected if staff suspect a resident is having a [MEDICAL CONDITION], they will note the time and duration of the [MEDICAL CONDITION] activity, monitor the resident ' s vital signs as ordered by the physician, and notify the physician during or as soon as possible after the [MEDICAL CONDITION], and notify the family of the event subsequently. It further reflected when documenting or reporting a resident ' s [MEDICAL CONDITION] activity to the physician, carefully describe signs and symptoms including: the nature of the activity (where it started, what areas of the body were involved), the duration of the [MEDICAL CONDITION] activity, whether the resident lost consciousness, the resident ' s current level of consciousness, baseline and current cognitive ability, speech, physical function, presence of abnormal motor activity, present of tremors, and overall physical condition. Avoid documenting or reporting just that the individual " had a [MEDICAL CONDITION]. " Instead, provide and document the details. The facility Administrator and DON were notified on 03/13/14 at 12:50 pm that an IJ situation had been identified due to the above failures. The final Plan of Removal was accepted by the surveyor on 03/17/14 at 10:15 am. Removal Plan for Immediate Jeopardy related to Resident #1 ' s [MEDICAL CONDITION] activity. How we will remove the immediacy: I. A clarification order on Resident #1 ' s Klonopin was written. It reads Klonopin 0.25mg give one tablet per tube daily PRN for [MEDICAL CONDITION] activity. If additional dose is needed notify on-call for instructions. II. A nursing in-service on Facility ' s [MEDICAL CONDITION] and [MEDICAL CONDITION] Clinical Protocol will be completed by 3/19/14. The in-service covers Assessment and Recognition, Cause Identification, Treatment/Management and Monitoring. As the policy relates to documentation the in-service include: ? The nature of the activity (where it started, what areas of the body were involved, etc.) ? The duration of the [MEDICAL CONDITION] activity. ? Whether the resident lost consciousness. ? Baseline and current cognitive ability. ? Baseline and current speech. ? Baseline and current physical function. ? Presence of abnormal motor activity. ? Presence of tremors. ? Overall physical condition. III. Facility will communicate Resident #1 ' s [MEDICAL CONDITION] to Resident #1 ' s PCP, or his nurse practitioner, as follows. If Resident #1 ' s [MEDICAL CONDITION] is controlled, meaning the [MEDICAL CONDITION] has stopped, Facility will notify non-emergently. If the [MEDICAL CONDITION] is not controlled, meaning his [MEDICAL CONDITION] continues after the PRN Klonopin is administered, Facility will notify on call. If the physician is not immediately available to discuss the situation Resident #1 will be sent to the emergency room . IV. All nursing staff will be assigned a " Response to [MEDICAL CONDITION] " online course beginning 3/17/14 and will continue until all nursing staff have completed and passed. The steps of the training include: 1. Call the nurse and stay with the patient. 2. Place padding under head and move furniture away from resident (protects resident from injury). 3. Do not restrain the resident or place anything in mouth (any restriction may injury resident during [MEDICAL CONDITION]). 4. Loosen resident ' s clothing especially around neck (prevents injury or choking). 5. After [MEDICAL CONDITION] stops, position patient onto side (allows saliva to drain from mouth so resident doesn ' t choke). 6. Note duration of [MEDICAL CONDITION] and areas involved (provides nurse with necessary information to properly assess resident ' s condition and needs). 7. Perform final steps (i.e. lower bed height and position bed enablers as appropriate, place call light and water within reach, ask resident if anything else is needed, thank resident, wash hands, and document procedure). 8. Assist with documentation according to current nursing practices. V. Resident #1 ' s care plan was updated on 3/16/14 to reflect the characteristics of his [MEDICAL CONDITION]. ? The care plan reads my [MEDICAL CONDITION] can be characterized by: turning head from side to side, raising knees or shaking leg(s), shaking arms. After a [MEDICAL CONDITION] I may be sleepy. Report these symptoms and any other [MEDICAL CONDITION] activity to the charge nurse. During a [MEDICAL CONDITION] keep me safe from injury and do not place anything in my mouth VI. Resident #1 ' s caregivers will communicate with the nurses by using the call light while in Resident #1 ' s room. If outside on community grounds the caregiver will notify the nurse by calling the communities main line via cell phone after ensuring Resident #1 is safe. A [MEDICAL CONDITION] observation log will be developed and by implemented on 3/17/14. The log will allow caregivers to document the length of the [MEDICAL CONDITIONS] observations, recovery observations, and comments (if any are needed). VII. If Resident #1 experiences a [MEDICAL CONDITION] during a community outing the Activity Director, will call 911. VIII. The Private Duty Sitter Authorization Form will completed for all five of Resident #1 ' s private duty sitters. The authorization form will be signed by Resident #1 ' s PCP and The Facility ' s Director of Nursing. IX. Any changes to Resident #1 ' s [MEDICAL CONDITION] medications by his PCP will be faxed to Resident #1 ' s neurologist, for review. Other residents potentially affected. Chart reviews for the other seven residents potentially affected will be conducted. The care plans will be updated to reflect the characteristics of their [MEDICAL CONDITION] as indicated by the chart reviews. The survey team monitored the current plan of removal as follows: Review of Resident #1 ' s physician's order [REDACTED]. If additional dose is needed notify on-call for further instructions. " During an interview on 03/17/14 at 8:30 am, LVN L stated Resident #1 ' s Klonopin PRN was recently changed. She further stated if they need instructions, they would notify the on-call NP. Review of Resident #1 Comprehensive Care Plan reflected: - Problem: I take Klonopin for [MEDICAL CONDITION] with a problem onset date of 04/12/13 and revised on 09/23/13. Interventions listed that were revised on 03/16/14 reflected to watch resident for possible side effects including clumsiness, unsteadiness, constipation, cough, dizziness, drowsiness, dry mouth, headache, loss of appetite, muscle aches, nervousness, severe allergic reactions, behavior changes, blurred vision, change in urination, confusion, fever, chills or sore throat, hallucination, hostility, irregular heartbeat, memory loss, mood changes, new or worsening [MEDICAL CONDITION], shortness of breath, tremor, and unusual bruising or bleeding. - Problem: [MEDICAL CONDITION] disorder [DIAGNOSES REDACTED]. Resident has frequent [MEDICAL CONDITION] with an onset date of 04/12/13 and revised on 03/16/14. Interventions revised on 03/16/14 reflected medical record indicates [MEDICAL CONDITION] are focal, self-limiting, and can turn to tonic-clonic. Further review reflected another intervention revised on 03/16/14 of " [MEDICAL CONDITION]: mine can be characterized by: turning head from side to side, raising knees or shaking leg(s), shaking arms. After a [MEDICAL CONDITION] I may be sleepy. Report these symptoms and any other [MEDICAL CONDITION] activity to the charge nurse. During a [MEDICAL CONDITION] keep me safe from injury and do not place anything in my mouth. " - Problem: I have an ADL Self Care Performance Deficit related to Musculoskeletal impairment, disease process with an onset date of 04/12/13 and revised on 02/26/14. An intervention listed reflected I have a very specific morning routing. My parents provide a private care/taker/sitter to help me do my morning care, shaving, brushing teeth, and dressing. Transfer: I require stand by assistance (SBA) to Contact Guard Assistance (CBA) (1) staff participation with transfers dated 04/12/13 and revised 03/12/14. Toileting schedule: CNA to assist to toilet at 1:00 am and 4:00 am daily. CNA to assist to toilet every 2-3 (Q2-3) hours when private sitters not available dated 03/16/14. - Problem: I am at risk for further falls because of weakness and impaired balance and because of medications I take with an onset date of 04/12/13. Interventions listed reflected family refused helmet that was recommended by staff for protection from head injury dated 03/16/14. During an interview on 03/17/14 10:05 am, the Activity Director (AD) stated if Resident #1 has a [MEDICAL CONDITION] during an activity in the building, she would immediately get a nurse. If they go on an outing, she stated a CNA and Resident #1 ' s sitter usually come with and she will keep an eye on him. She further stated if he has a [MEDICAL CONDITION] while out, she will make sure he is safe and then call 911. Review of the facility ' s undated Private Duty Sitter Authorization Form reflected " I authorize ________ to provide private duty sitter services for resident ________. " There is a place for the physician and DON to sign and date the form. A facility provided list reflected seven (7) residents who are prescribed [MEDICAL CONDITION] medications.

Based on observation, interview and record review the facility failed to must develop and implement written policies and procedures that prohibit neglect of residents when: A. Nursing staff failed to clarify Resident #1 ' s physician's order [REDACTED].#1 ' s [MEDICAL CONDITION] characteristics and activity. - Nursing staff failed to notify Resident #1's Neurologist and Primary Care Physician after each [MEDICAL CONDITION] - The facility failed to train Resident #1 ' s family-hired sitters in how to properly assess and monitor for a [MEDICAL CONDITION] disorder, put [MEDICAL CONDITION] precautions in place, proper resident care, and include them in his comprehensive plan of care. An Immediate Jeopardy (IJ) situation was identified on 03/13/14 at 12:14 p.m. While the IJ was lowered to a non-immediate Jeopardy on 03/17/14 at 3:30 p.m. the facility remained out of compliance at a severity of more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place seven (7) residents who are identified as a [MEDICAL CONDITION] risk and prescribed [MEDICAL CONDITION] medication at risk for neglect, lack of care, being overmedicated, and possible death. B. The Maintenance Manager failed to maintain the mechanical lifts in a safe condition. Two mechanical lifts (Mechanical Lift CC and DD) were not functioning safely. The CNAs continued to transfer residents with the mechanical lifts. - The DON failed to ensure that CNAs (CNAs F, G, I, M, J, N, V, BB and CC) were properly transferring residents (Resident #5, #31, #32 and #33) using mechanical lifts. An Immediate Jeopardy (IJ) situation was identified on 03/11/14. While the IJ was lowered to a non-immediate Jeopardy on 03/15/14, the facility remained out of compliance at a severity of more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice placed 21 residents that are transferred with a mechanical lift at risk of discomfort during transfers, falls, hematomas, serious injury and death from malfunctioning equipment. Findings included: Review of the facility ' s Abuse and Neglect Prohibition Policies and Procedures dated June 2005 reflected the facility must maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. It further reflected neglect to be a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Also, resident care and treatments shall be monitored by all staff, on an ongoing basis to assure residents are free from abuse, neglect, or mistreatment. It is the responsibility of all staff to provide a safe environment for the residents. A) Review of Resident #1 ' s face sheet reflected a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Admission Nurse ' s Note dated 03/13/13 reflected a [AGE] year old male admitted for respite care. He has a [DIAGNOSES REDACTED]. Recurrent [MEDICAL CONDITION], usual signs of impending [MEDICAL CONDITION] usually look off to left side, has a fixed smile and then shakes his head, may have mild to severe [MEDICAL CONDITION]. Resident #1 has left sided weakness, he is total assist with feeding and max total assist with rest of Activities of Daily Living (ADLs). He is able to ambulate without device for short distance with minimal assistance with his attendant but is usually wheelchair bound secondary to recurrent [MEDICAL CONDITION]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected: Section G: Functional Status: ADL Assistance - G0110 B. Transfer, 1 person Extensive Assist - G0110 C. Walk in room, 1 person Extensive Assist - G0110 G. Dressing, 1 person Extensive Assist - G0110 I. Toilet Use, 1 person Extensive Assist - G0120. Bathing, Physical Help, Support Provided - G0400. Range of Motion, Impairment in both upper and lower extremities Section H: Bladder and Bowel - H0300: Urinary, frequently incontinent - H0400: Bowel, Always incontinent Section I: Active Diagnoses - I5400. [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION] Review of Resident #1 ' s Comprehensive Care Plan dated 01/27/14 reflected the following problem areas: - Problem: "I have a [DIAGNOSES REDACTED]. The interventions listed are that Resident #1 has frequent [MEDICAL CONDITION], the family and him requested a closed circuit camera be placed in room with the nurse having the monitor to observe in case of a [MEDICAL CONDITION]. - Problem: "I take medications to control my [MEDICAL CONDITION] and am at risk for side effects" with an onset date of 04/12/13 and revised on 12/05/13. The interventions listed are to monitor as much as possible for [MEDICAL CONDITION] activity, notify the doctor of any adverse reactions, to give medications as ordered, the medications put Resident #1 at risk for falls, and to watch for possible side effects which may include dizziness, drowsiness, irritability, weakness, decreased coordination, and new or worsening [MEDICAL CONDITION]. - Problem: " I take Klonopin for [MEDICAL CONDITION] " with an onset date of 04/12/13 and revised on 09/23/13. The interventions listed are to ensure informed consent by resident or Responsible Party (RP) are given, notify doctor of any adverse reactions, to give medication as ordered, and to watch for side effects such as clumsiness, unsteadiness, or behavioral changes. - Problem of "I have severe reflux with high risk for aspiration " with a problem onset date of 04/12/13 and revised on 12/15/13. The interventions listed are to keep the head of bed (HOB) elevated 90 degrees during and after feedings, monitor for side effects of medication, document if present, monitor labs per doctor orders, notify doctor and family of changes in condition, and to administer medications per doctor ' s orders. - Problem of " I have an ADL Self Care Performance Deficit related to Musculoskeletal impairment, disease process [MEDICAL CONDITION] " with an onset date of 04/12/13 and revised on 02/26/14. Interventions listed are: bathing, bed mobility, dressing, personal hygiene, transfer, toilet use: I require one staff participation. The private sitters were not included in his plan of care. Review of Resident #1 ' s physician's order [REDACTED]. - Diet: nothing by mouth (NPO) - [MEDICATION NAME] 125 mg/5 milliliters (mL) every 8 hours (Q8H), 5 mL ([MEDICAL CONDITION]) - [MEDICATION NAME] 100 mg/mL G tube, three times a day (TID), 15 mL ([MEDICAL CONDITION]) - Klonopin 0.5 mg G tube, TID: 1 tab ([MEDICAL CONDITION]) - Klonopin 0.25 mg G tube, PRN 1 tab ([MEDICAL CONDITION]), (no additional clarification order) Resident #1 ' s physician's order [REDACTED]. During an interview on 03/11/14 at 12:35 pm, Resident #1 ' s Sitter AA stated that Resident #1 was in the restroom in his room and he was standing outside waiting for Resident #1 to finish in the bathroom. He further stated that he assists Resident #1 to the bathroom but he can go by himself, and then when he finishes, the Sitter AA helps with wiping. The Sitter AA then stated that Resident #1 can walk but not independently; the Sitter AA steadies Resident #1 as he ambulates. During an interview on 03/12/13 at 11:25 am, CNA D stated that Resident #1 has a family-hired sitter 24 hours per day and they work in shifts. He further stated that the sitters do all ADL care for Resident #1 except for showers, medication administration, and tube feeding. He also stated he was not sure what care was provided for Resident #1 by the facility ' s CNAs. During an interview on 03/12/14 at 11:28 am, CNA E stated she was assigned to the hall Resident #1 lives on and they give Resident #1 ' s sitters supplies like wipes if needed. She then stated they only assist in care if the sitter requests help and the shower aides shower him but that is the only care she knows that the facility ' s CNA ' s provide him. During an interview on 03/12/14 at 11:35 am, LVN L, the charge nurse for Resident #1 ' s hall, stated that Resident #1 has sitters 24 hours a day, seven days a week but sometimes they are not there from 11:00 pm to 7:00 am so the staff care for him when the sitters are not there. She further stated there is a video monitor at the nurse ' s station where they can see Resident #1 in bed and monitor him for [MEDICAL CONDITION] activity. LVN L then stated Resident #1 can walk but not independently so the sitters steady him and no devices are used for assistance. When asked what kind of training the sitters have received from the facility staff, LVN L stated the sitters have not received any that she knows of and she was not sure what the CNA ' s do for Resident #1 because the sitters do most things for him. During an interview on 03/12/14 at 9:25 am, Resident #1 ' s Sitter AA stated that he does all of the care for Resident #1 when he is there but the shower aides shower him. He further stated he helps in the showers to hold Resident #1 ' s head and shampoo his hair to make sure he does not swallow any water in the shower because that can cause pneumonia. When asked if Resident #1 has swallowed water in the shower causing aspiration pneumonia, Sitter AA stated yes, it had happened a few times when he first came to the facility. The Sitter AA then stated Resident #1 has [MEDICAL CONDITION] often and he makes sure there is padding around Resident #1 ' s head for safety because when he has a [MEDICAL CONDITION], his head rotates back and forth. When asked what kind of training he has received from the facility, he stated none because Resident #1 ' s father trained him on how to care for the resident. Sitter AA further stated Resident #1 had two [MEDICAL CONDITION] the previous day (03/11/14). During an interview on 03/12/14 at 12:45 pm, Resident #1 ' s Sitter BB stated she is there to monitor for [MEDICAL CONDITION] and she lets the nurse know if his tube feeding is beeping and helps Resident #1 participate in activities. She further stated Resident #1 cannot walk independently and sitters are there to support him especially because he has [MEDICAL CONDITION] and left sided weakness. When asked what she does when Resident #1 has a [MEDICAL CONDITION], Sitter BB stated it depends on how intense the [MEDICAL CONDITION] is but she mainly tries to keep Resident #1 from hurting himself because he moves arms up and down and his head goes side to side. She then tells the nurses that he had a [MEDICAL CONDITION]. When asked what kind of training she has received from the facility on resident care, Sitter BB stated none because Resident #1 ' s father trained her on how to care for him. She further stated there is a Bowel Movement (BM) log by the door to Resident #1 ' s room and they just log there when he has a BM and staff can just look at that to know when he uses the restroom. Sitter BB then stated Resident #1 may vomit after a [MEDICAL CONDITION] and that can cause Aspiration Pneumonia and he has had that twice since December. She further stated that a fever is Resident #1 ' s first symptom of pneumonia and she monitors for that. She then stated that he was really sick in December and was in the hospital for about four weeks and then again in January for a week and a half for aspiration pneumonia. During an interview on 03/12/14 at 4:05 pm, the DON stated Resident #1 ' s sitters are there to assess and monitor him for [MEDICAL CONDITION] because he has a history of [MEDICAL CONDITION]. She further stated the facility nurses administer all of Resident #1 ' s medications and feedings. The DON also stated there is a facility policy and procedure the sitters have to sign before caring for Resident #1. The signed policy/procedures for the sitters were requested but not provided prior to survey exit 03/17/14. During an interview on 03/12/14 at 4:10 pm, the ADON A stated there is a video monitor at the nurse ' s station and nurses rely on that to know if Resident #1 has a [MEDICAL CONDITION] or the sitter alerts them. She also stated there is no specific [MEDICAL CONDITION] log but [MEDICAL CONDITION] should be documented in the nurse ' s notes. Resident #1 takes medications post [MEDICAL CONDITION] and he is followed by a Pediatric Neurologist who monitors his [MEDICAL CONDITION] activity and medications. She further stated Resident #1 was initially admitted in 03/2013 for respite care and she did not think the facility could initially care for Resident #1 because of all of his [MEDICAL CONDITION]. She then stated Resident #1 has as many as four to five [MEDICAL CONDITION] a day, then they go away for a while and then come back and he can have them daily. Observation on 03/14/14 at 2:30 pm revealed Resident #1 ' s monitor screen at the nurse ' s station. The screen was black and there was no signal. During an interview on 03/12/14 at 5:00 pm, the DON stated all of Resident #1 ' s [MEDICAL CONDITION] activity is only documented in the nurse notes and nowhere else. She further stated there is no protocol to outline when to document a [MEDICAL CONDITION] but she probably would not document it if it was just a three second [MEDICAL CONDITION] but would if it was a minute to a minute and a half [MEDICAL CONDITION]; it just depends on the length of the [MEDICAL CONDITION]. Review of Resident #1 ' s Physician ' s Progress Note dated 12/10/13 reflected patient was recently treated for [REDACTED]. Further review reflected an assessment/plan of Aspiration Pneumonia treated and resolved and [MEDICAL CONDITION] disorder: continue [MEDICATION NAME] and [MEDICATION NAME] ([MEDICAL CONDITION] medications) deferred to patient ' s neurologist; will continue to monitor for increased activity due to history of aspiration pneumonia that lowers ([MEDICAL CONDITION]) threshold. The NP signed this progress note. Review of Resident #1 ' s Nurse Notes reflected: - 01/10/14: reflected report called from local hospital, resident admitted with pneumonia follow up discharge from Intensive Care Unit (ICU) on 01/07/14 to acute care. Last [MEDICAL CONDITION] activity 01/08/14, discharge orders faxed, medications resumed - 01/22/14, 7:20 am: Had moderate [MEDICAL CONDITION] last approximately 1 ? minutes in bed - caregiver at bedside to safeguard him - no injuries. Had vomited large amount of phlegm, was upright entire time. His father requested AM medications not be given right away and I waited to give them until caregiver told me resident had settled down with no emesis noted. Noted for nasal drainage but no further phlegm emesis, tires easily. Noted for Blood Pressure (BP) up but is talking with his mother his BP tends to go up after a major [MEDICAL CONDITION]. Also at time of [MEDICAL CONDITION] this AM, resident received routine Klonopin. No physician notification documented. - 8:00 pm: 10 second [MEDICAL CONDITION], vomited approximately 150 mL formula and phlegm. Father called facility twice with instructions and request. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 01/23/14 reflected according to nursing, patient had a temperature of 99.4 degrees Fahrenheit (F) with increase nasal drainage last night and a moderate [MEDICAL CONDITION]. Spoke with patient ' s father who is concerned regarding increased [MEDICAL CONDITION] activity; we discussed possible avenues regarding aspiration pneumonia from [MEDICAL CONDITION] Reflux versus allergies [REDACTED]. The NP signed this note. Review of Resident #1 ' s handwritten Admission Physician order [REDACTED]. - Klonopin 0.5 mg PT TID - [MEDICATION NAME] 15 mL PT TID - [MEDICATION NAME] 125 mg, 5 mL PT Q8H - Klonopin 0.25 mg PT PRN Further review of the Admission Administration Record reflected Resident #1 received Klonopin 0.25 mg PRN on 02/07/14 and 02/28/14. It also reflected Nurse Medication notes: 02/28/14 2:45 pm, small [MEDICAL CONDITION] (8 seconds) gave PRN Klonopin 0.25 mg PT. There is no reason listed on the nurses medication notes as to why Klonopin 0.25 mg PRN was given on 02/07/14. Review did not reflect orders for sitters to provide assistance with ADLs or for [MEDICAL CONDITION] monitoring. Review of Resident #1 ' s Nurse ' s Notes reflected: - 02/06/14, 3:50 pm: patient returned from local hospital via parents ' vehicle, tires easily. Caregiver with patient, family brought back some of his medications but not his Klonopin. Given the medications his dad asked me to give him - didn ' t get at the hospital this afternoon. Had to give his PRN Klonopin and I told his mom - she ' ll check with hospital if she can get back his Klonopin she gave them. No [MEDICAL CONDITION] activity. - 02/07/14, Resident Awake alert, G tube placement verified. 30 second [MEDICAL CONDITION] noted at 8:35 pm, Klonopin 0.25 mg PRN administered per tube. Attendant at side for feedings today, no diarrhea noted. Will continue to monitor. Call to parents, updated on status. No physician notification documented. - 02/28/14, 2:45 pm: Caregiver reported resident had a small [MEDICAL CONDITION] lasted approximately 7 seconds. I gave him PRN Klonopin 0.25 mg PT. No physician notification documented. - 03/04/14, 9:15 pm: Earlier, reported resident had 2 small [MEDICAL CONDITION] today. Call placed to Responsible Party (RP) to notify. No physician notification documented. - 03/05/14, 1:00 pm, Resident sitting in wheelchair in living room area with caregiver. I noted she was assisting him as his head was turning to the side; she was protecting him as he started to move about in chair. She stated it lasted for approximately 20 seconds and he dry heaved once. He was taken to his room and I gave him his anti-[MEDICAL CONDITION] medications via G tube. RP notified. No physician notification documented. - 03/06/14, 1900: small 15 second [MEDICAL CONDITION] reported by caregiver. PRN Klonopin administered, no injuries noted. No physician notification documented. - 03/07/14, 2:15 pm: 30 second [MEDICAL CONDITION] - PRN Klonopin given per family request. No physician notification documented. - 03/11/14, 2:40 pm: Caregiver reported [MEDICAL CONDITION] last approximately 25 seconds, give PRN Klonopin 0.25 mg per tube (PT). No physician notification documented. - 03/11/14, 3:00 pm: Had another [MEDICAL CONDITION] last approximately 10 seconds, give 4.5 [MEDICATION NAME] routine, routine Kepra and Klonopin 0.5 mg PT. Caregiver kept him safe in both instances. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 03/11/14 reflected Resident #1 had a 15 second [MEDICAL CONDITION] according to caregiver on the sixth. Further review reflected an assessment/plan for [MEDICAL CONDITION] disorder to continue current therapy, fair control, occasional breakthrough [MEDICAL CONDITION] deferred to Neurologist. Also, Dysphagia: continue tube feeds, high risk for aspiration. History of aspiration pneumonia, chronic issue, currently asymptomatic. Resident #1 is a high aspiration risk along with increased fall risk due to gait abnormalities, care discussed with nursing and with the patient ' s sitter. The MD signed this note. Review of Resident #1 ' s laboratory value dated 02/14 reflected a [MEDICATION NAME] ([MEDICATION NAME]) level of 17.3 ug/mL. (Reference range: 10.0 - 20.0 micrograms (ug)/mL) Review of Resident #1 ' s Medication Administration Record (MAR) dated March 2014 reflected an order for [REDACTED]. The Klonopin PRN was given on 03/06/14, 03/07/14, and 03/11/14. Further review reflected: 03/07/14, 2:30 pm - Klonopin 0.25 mg PT per family re [MEDICAL CONDITION] activity; 03/11/14 2:40 pm - Klonopin 0.25 mg PT for [MEDICAL CONDITION] approximately 25 seconds. No documentation for reasoning for the PRN Klonopin given on 03/06/14. During an interview on 03/12/14 at 5:10 pm, the NP stated Resident #1 sees a Pediatric Neurologist who prescribes and monitors the [MEDICAL CONDITION] medications and labs. She further stated the facility communicates with her and the Medical Director (MD) about Resident #1 ' s [MEDICAL CONDITION] activity but there is no communication documentation of [MEDICAL CONDITION] activity. She further stated the sitter tells the staff if Resident #1 has any [MEDICAL CONDITION] and they then monitor him if he does. The NP then stated the Klonopin PRN order should be given when a [MEDICAL CONDITION] is happening, and should only be given once per day. During an interview on 03/13/14 at 12:45 the DON stated that Resident #1 has multiple [MEDICAL CONDITION] per day and she expects nurses to document small [MEDICAL CONDITION] that last more than one minute. The DON was then asked how to give Resident #1 ' s PRN order for Klonopin. The DON stated that she would give it however the physician ordered it. The DON then reviewed the order for PRN Klonopin and stated " 0.25 mg for [MEDICAL CONDITION]. " The DON was asked when would she give the PRN Klonpin, she stated " I would have to clarify. " The DON was asked in her nursing judgment when would she give the PRN Klonopin, she stated " I would have to clarify the order. I am not sure if the nurse practitioner wants to give it after every [MEDICAL CONDITION]. " The DON stated that the ADON or the charge nurse would be responsible for clarifying this order. She stated that " the charge nurse gives Resident #1 his medication because he is a tube feeder. " The DON stated that any change in Resident #1 ' s condition is told to the CNAs by the caregivers, then the CNAs inform the nurses. The DON stated that she expected documentation in the nurses notes of any change of condition, [MEDICAL CONDITION] that lasts 3 minutes, distress, shortness of breath. She stated that Resident #1 has multiple [MEDICAL CONDITION] per day and she expects nurses to document small [MEDICAL CONDITION] that last more than one minute. During an interview on 03/13/14 at 12:57 pm, the Neurology LVN stated Resident #1 was a patient and the last phone call they received from the facility about him was on 01/15/14 because of [MEDICAL CONDITION] activity and lab values. They have not contacted the clinic since regarding [MEDICAL CONDITION] activity. She then stated the facility only contacts the Neurology clinic when the resident has significant changes but they do request that all patients alert them of all [MEDICAL CONDITION] to adequately monitor care. She further stated Resident #1 was last in the Neurology clinic on 03/04/14. When asked how often the Klonopin 0.25 mg PRN should be given, she stated it should not be given more than five times per day for Resident #1; three times per routine orders and two PRN doses. During an interview on 03/13/14 at 4:15 pm, the MD stated Resident #1 was admitted to the facility with having about 30 [MEDICAL CONDITION] per month and he does not follow the [MEDICAL CONDITION] medications because the Neurologist does that on a day to day basis. He further stated the Klonopin 0.25 mg PRN should be given after all [MEDICAL CONDITION] and he would rather have it given and Resident #1 not be seizing than for him to have a [MEDICAL CONDITION] and not receive Klonopin 0.25 mg PRN. The MD further stated he expects to be notified of every [MEDICAL CONDITION] and he wants the nursing staff interpretation what a [MEDICAL CONDITION] is when administering the Klonopin 0.25 mg PRN. When asked if it is appropriate to administer routine Klonopin 0.5 mg twenty minutes after receiving the Klonopin 0.25 mg PRN after a [MEDICAL CONDITION], he stated yes. The MD then stated he expects the nursing staff to monitor and document Resident #1's [MEDICAL CONDITION] activity in the nurses ' notes. He further stated he does not know a characteristic [MEDICAL CONDITION] for Resident #1, but he does have a variety, everything from grand mal (features a loss of consciousness and violent muscle contractions) to minor [MEDICAL CONDITION]. In a continued interview on 3/13/14 at 4:15 PM, the MD stated that Resident # 1 ' s condition were exceedingly complex therefore he may not place specifications on the order for how many times a day Resident #1 should get PRN Klonopin. Surveyor asked the PCP how the nurses would know how many times a day to give the medication (Klonopin 0.25 mg PT PRN). The MD stated that he would expect the nurse not to hold back and go ahead and give the Klonopin and then call for further direction. The MD stated that when the nurses call him does a back and forth questioning with the nurse to be able to determine the [MEDICAL CONDITION] activity. The MD stated that he would want them to describe the characteristics of the [MEDICAL CONDITION], rather than diagnosing what kind of [MEDICAL CONDITION] they are. Surveyor asked the MD if he was involved in the care planning process concerning Resident # 1 ' s " complex " medical needs, to ensure that staff are aware of his expectations and to enable the correlation of care. The MD stated that he was not, but that his NP might be he was not sure. During an interview on 3/13/14 at 4:15 PM Surveyor asked Administrator how the facility communicated to the direct care staff of what Resident # 1 ' s caregivers " can and cannot do " for Resident #1. Administrator stated that these directions in care were not developed until the night of 3/12/14. During an interview on 03/14/14 at 5:20 pm, the DON stated she expects the nursing staff to assess residents for PRN medications, follow physician orders, and then reassess residents again after a PRN medication is given to monitor effectiveness. She further stated the PRN medication should be documented on the MAR or in Nurse ' s Notes. When asked when nurses should clarify physician orders, the DON stated she expects her staff to clarify it if the order is not clear. She further stated PRN medications usually have the number of tabs and how often it should be administered on the order and she expects her staff to clarify an order if that is not clear. The DON stated she was not aware that Resident #1 ' s sitters were providing personal care for him. The DON then said the CNA ' s do the same amount of care for Resident #1 as they do for other residents who are assessed to be minimal assist. Review of the facility ' s PRN Orders Policy dated April 2008 reflected that PRN orders must clarify the circumstances for offering or giving the medication. When PRN orders are implemented, nursing staff must monitor the use of such medication to determine the nature of the problem and whether it persists, whether additional evaluation is needed or whether the medications could be discontinued. Review of the facility ' s [MEDICAL CONDITION] Management Policy dated 2007 reflected if staff suspect a resident is having a [MEDICAL CONDITION], they will note the time and duration of the [MEDICAL CONDITION] activity, monitor the resident ' s vital signs as ordered by the physician, and notify the physician during or as soon as possible after the [MEDICAL CONDITION], and notify the family of the event subsequently. It further reflected when documenting or reporting a resident ' s [MEDICAL CONDITION] activity to the physician, carefully describe signs and symptoms including: the nature of the activity (where it started, what areas of the body were involved), the duration of the [MEDICAL CONDITION] activity, whether the resident lost consciousness, the resident ' s current level of consciousness, baseline and current cognitive ability, speech, physical function, presence of abnormal motor activity, present of tremors, and overall physical condition. Avoid documenting or reporting just that the individual " had a [MEDICAL CONDITION]. " Instead, provide and document the details. Review of the facility ' s Private Duty Sitters Policy dated August 2006 reflected residents/family members desiring the use of private duty sitters must first obtain written approval of the attending physician and the DON. Private duty nursing personnel must follow the facility ' s established nursing care policies and procedures, instructions issued by the Nurse Supervisor/Charge Nurse, and may not administer direct care to the resident unless authorized in writing by the Attending Physician. The facility Administrator and DON were notified on 03/13/14 at 12:50 pm that an IJ situation had been identified due to the above failures. The final Plan of Removal was accepted by the surveyor on 03/17/14 at 10:15 am. Removal Plan for Immediate Jeopardy related to Resident #1 ' s [MEDICAL CONDITION] activity. How we will remove the immediacy: I. A clarification order on Resident #1 ' s Klonopin was written. It reads Klonopin 0.25mg give one tablet per tube daily PRN for [MEDICAL CONDITION] activity. If additional dose is needed notify on-call for instructions. II. A nursing in-service on Facility ' s [MEDICAL CONDITION] and [MEDICAL CONDITION] Clinical Protocol will be completed by 3/19/14. The in-service covers Assessment and Recognition, Cause Identification, Treatment/Management and Monitoring. As the policy relates to documentation the in-service include: ? The nature of the activity (where it started, what areas of the body were involved, etc.) ? The duration of the [MEDICAL CONDITION] activity. ? Whether the resident lost consciousness. ? Baseline and current cognitive ability. ? Baseline and current speech. ? Baseline and current physical function. ? Presence of abnormal motor activity. ? Presence of tremors. ? Overall physical condition. III. Facility will communicate Resident #1 ' s [MEDICAL CONDITION] to Resident #1 ' s PCP, or his nurse practitioner, as follows. If Resident #1 ' s [MEDICAL CONDITION] is controlled, meaning the [MEDICAL CONDITION] has stopped, Facility will notify non-emergently. If the [MEDICAL CONDITION] is not controlled, meaning his [MEDICAL CONDITION] continues after the PRN Klonopin is administered, Facility will notify on call. If the physician is not immediately available to discuss the situation Resident #1 will be sent to the emergency room . IV. All nursing staff will be assigned a " Response to [MEDICAL CONDITION] " online course beginning 3/17/14 and will continue until all nursing staff have completed and passed. The steps of the training include: 1. Call the nurse and stay with the patient. 2. Place padding under head and move furniture away from resident (protects resident from injury). 3. Do not restrain the resident or place anything in mouth (any restriction may injury resident during [MEDICAL CONDITION]). 4. Loosen resident ' s clothing especially around neck (prevents injury or choking). 5. After [MEDICAL CONDITION] stops, position patient onto side (allows saliva to drain from mouth so resident doesn ' t choke). 6. Note duration of [MEDICAL CONDITION] and areas involved (provides nurse with necessary information to properly assess resident ' s condition and needs). 7. Perform final steps (i.e. lower bed height and position bed enablers as appropriate, place call light and water within reach, ask resident if anything else is needed, thank resident, wash hands, and document procedure). 8. Assist with documentation according to current nursing practices. V. Resident #1 ' s care plan was updated on 3/16/14 to reflect the characteristics of his [MEDICAL CONDITION]. ? The care plan reads my [MEDICAL CONDITION] can be characterized by: turning head from side to side, raising knees or shaking leg(s), shaking arms. After a [MEDICAL CONDITION] I may be sleepy. Report these symptoms and any other [MEDICAL CONDITION] activity to the charge nurse. During a [MEDICAL CONDITION] keep me safe from injury and do not place anything in my mouth VI. Resident #1 ' s caregivers will communicate with the nurses by using the call light while in Resident #1 ' s room. If outside on community grounds the caregiver will notify the nurse by calling the communities main line via cell phone after ensuring Resident #1 is safe. A [MEDICAL CONDITION] observation log will be developed and by implemented on 3/17/14. The log will allow caregivers to document the length of the [MEDICAL CONDITIONS] observations, recovery observations, and comments (if any are needed). VII. If Resident #1 experiences a [MEDICAL CONDITION] during a community

Based on observation, interview and record review the facility failed to must develop and implement written policies and procedures that prohibit neglect of residents when: A. Nursing staff failed to clarify Resident #1 ' s physician's order [REDACTED].#1 ' s [MEDICAL CONDITION] characteristics and activity. - Nursing staff failed to notify Resident #1's Neurologist and Primary Care Physician after each [MEDICAL CONDITION] - The facility failed to train Resident #1 ' s family-hired sitters in how to properly assess and monitor for a [MEDICAL CONDITION] disorder, put [MEDICAL CONDITION] precautions in place, proper resident care, and include them in his comprehensive plan of care. An Immediate Jeopardy (IJ) situation was identified on 03/13/14 at 12:14 p.m. While the IJ was lowered to a non-immediate Jeopardy on 03/17/14 at 3:30 p.m. the facility remained out of compliance at a severity of more than minimal harm with a scope identified as a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place seven (7) residents who are identified as a [MEDICAL CONDITION] risk and prescribed [MEDICAL CONDITION] medication at risk for neglect, lack of care, being overmedicated, and possible death. B. The Maintenance Manager failed to maintain the mechanical lifts in a safe condition. Two mechanical lifts (Mechanical Lift CC and DD) were not functioning safely. The CNAs continued to transfer residents with the mechanical lifts. - The DON failed to ensure that CNAs (CNAs F, G, I, M, J, N, V, BB and CC) were properly transferring residents (Resident #5, #31, #32 and #33) using mechanical lifts. An Immediate Jeopardy (IJ) situation was identified on 03/11/14. While the IJ was lowered to a non-immediate Jeopardy on 03/15/14, the facility remained out of compliance at a severity of more than minimal harm with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice placed 21 residents that are transferred with a mechanical lift at risk of discomfort during transfers, falls, hematomas, serious injury and death from malfunctioning equipment. Findings included: A) Review of Resident #1 ' s face sheet reflected a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Admission Nurse ' s Note dated 03/13/13 reflected a [AGE] year old male admitted for respite care. He has a [DIAGNOSES REDACTED]. Recurrent [MEDICAL CONDITION], usual signs of impending [MEDICAL CONDITION] usually look off to left side, has a fixed smile and then shakes his head, may have mild to severe [MEDICAL CONDITION]. Resident #1 has left sided weakness, he is total assist with feeding and max total assist with rest of Activities of Daily Living (ADLs). He is able to ambulate without device for short distance with minimal assistance with his attendant but is usually wheelchair bound secondary to recurrent [MEDICAL CONDITION]. Review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] reflected: Section G: Functional Status: ADL Assistance - G0110 B. Transfer, 1 person Extensive Assist - G0110 C. Walk in room, 1 person Extensive Assist - G0110 G. Dressing, 1 person Extensive Assist - G0110 I. Toilet Use, 1 person Extensive Assist - G0120. Bathing, Physical Help, Support Provided - G0400. Range of Motion, Impairment in both upper and lower extremities Section H: Bladder and Bowel - H0300: Urinary, frequently incontinent - H0400: Bowel, Always incontinent Section I: Active Diagnoses - I5400. [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION] Review of Resident #1 ' s Comprehensive Care Plan dated 01/27/14 reflected the following problem areas: - Problem: "I have a [DIAGNOSES REDACTED]. The interventions listed are that Resident #1 has frequent [MEDICAL CONDITION], the family and him requested a closed circuit camera be placed in room with the nurse having the monitor to observe in case of a [MEDICAL CONDITION]. - Problem: "I take medications to control my [MEDICAL CONDITION] and am at risk for side effects" with an onset date of 04/12/13 and revised on 12/05/13. The interventions listed are to monitor as much as possible for [MEDICAL CONDITION] activity, notify the doctor of any adverse reactions, to give medications as ordered, the medications put Resident #1 at risk for falls, and to watch for possible side effects which may include dizziness, drowsiness, irritability, weakness, decreased coordination, and new or worsening [MEDICAL CONDITION]. - Problem: " I take Klonopin for [MEDICAL CONDITION] " with an onset date of 04/12/13 and revised on 09/23/13. The interventions listed are to ensure informed consent by resident or Responsible Party (RP) are given, notify doctor of any adverse reactions, to give medication as ordered, and to watch for side effects such as clumsiness, unsteadiness, or behavioral changes. - Problem of "I have severe reflux with high risk for aspiration " with a problem onset date of 04/12/13 and revised on 12/15/13. The interventions listed are to keep the head of bed (HOB) elevated 90 degrees during and after feedings, monitor for side effects of medication, document if present, monitor labs per doctor orders, notify doctor and family of changes in condition, and to administer medications per doctor ' s orders. - Problem of " I have an ADL Self Care Performance Deficit related to Musculoskeletal impairment, disease process [MEDICAL CONDITION] " with an onset date of 04/12/13 and revised on 02/26/14. Interventions listed are: bathing, bed mobility, dressing, personal hygiene, transfer, toilet use: I require one staff participation. The private sitters were not included in his plan of care. Review of Resident #1 ' s physician's order [REDACTED]. - Diet: nothing by mouth (NPO) - [MEDICATION NAME] 125 mg/5 milliliters (mL) every 8 hours (Q8H), 5 mL ([MEDICAL CONDITION]) - [MEDICATION NAME] 100 mg/mL G tube, three times a day (TID), 15 mL ([MEDICAL CONDITION]) - Klonopin 0.5 mg G tube, TID: 1 tab ([MEDICAL CONDITION]) - Klonopin 0.25 mg G tube, PRN 1 tab ([MEDICAL CONDITION]), (no additional clarification order) Resident #1 ' s physician's order [REDACTED]. During an interview on 03/11/14 at 12:35 pm, Resident #1 ' s Sitter AA stated that Resident #1 was in the restroom in his room and he was standing outside waiting for Resident #1 to finish in the bathroom. He further stated that he assists Resident #1 to the bathroom but he can go by himself, and then when he finishes, the Sitter AA helps with wiping. The Sitter AA then stated that Resident #1 can walk but not independently; the Sitter AA steadies Resident #1 as he ambulates. During an interview on 03/12/13 at 11:25 am, CNA D stated that Resident #1 has a family-hired sitter 24 hours per day and they work in shifts. He further stated that the sitters do all ADL care for Resident #1 except for showers, medication administration, and tube feeding. He also stated he was not sure what care was provided for Resident #1 by the facility ' s CNAs. During an interview on 03/12/14 at 11:28 am, CNA E stated she was assigned to the hall Resident #1 lives on and they give Resident #1 ' s sitters supplies like wipes if needed. She then stated they only assist in care if the sitter requests help and the shower aides shower him but that is the only care she knows that the facility ' s CNA ' s provide him. During an interview on 03/12/14 at 11:35 am, LVN L, the charge nurse for Resident #1 ' s hall, stated that Resident #1 has sitters 24 hours a day, seven days a week but sometimes they are not there from 11:00 pm to 7:00 am so the staff care for him when the sitters are not there. She further stated there is a video monitor at the nurse ' s station where they can see Resident #1 in bed and monitor him for [MEDICAL CONDITION] activity. LVN L then stated Resident #1 can walk but not independently so the sitters steady him and no devices are used for assistance. When asked what kind of training the sitters have received from the facility staff, LVN L stated the sitters have not received any that she knows of and she was not sure what the CNA ' s do for Resident #1 because the sitters do most things for him. During an interview on 03/12/14 at 9:25 am, Resident #1 ' s Sitter AA stated that he does all of the care for Resident #1 when he is there but the shower aides shower him. He further stated he helps in the showers to hold Resident #1 ' s head and shampoo his hair to make sure he does not swallow any water in the shower because that can cause pneumonia. When asked if Resident #1 has swallowed water in the shower causing aspiration pneumonia, Sitter AA stated yes, it had happened a few times when he first came to the facility. The Sitter AA then stated Resident #1 has [MEDICAL CONDITION] often and he makes sure there is padding around Resident #1 ' s head for safety because when he has a [MEDICAL CONDITION], his head rotates back and forth. When asked what kind of training he has received from the facility, he stated none because Resident #1 ' s father trained him on how to care for the resident. Sitter AA further stated Resident #1 had two [MEDICAL CONDITION] the previous day (03/11/14). During an interview on 03/12/14 at 12:45 pm, Resident #1 ' s Sitter BB stated she is there to monitor for [MEDICAL CONDITION] and she lets the nurse know if his tube feeding is beeping and helps Resident #1 participate in activities. She further stated Resident #1 cannot walk independently and sitters are there to support him especially because he has [MEDICAL CONDITION] and left sided weakness. When asked what she does when Resident #1 has a [MEDICAL CONDITION], Sitter BB stated it depends on how intense the [MEDICAL CONDITION] is but she mainly tries to keep Resident #1 from hurting himself because he moves arms up and down and his head goes side to side. She then tells the nurses that he had a [MEDICAL CONDITION]. When asked what kind of training she has received from the facility on resident care, Sitter BB stated none because Resident #1 ' s father trained her on how to care for him. She further stated there is a Bowel Movement (BM) log by the door to Resident #1 ' s room and they just log there when he has a BM and staff can just look at that to know when he uses the restroom. Sitter BB then stated Resident #1 may vomit after a [MEDICAL CONDITION] and that can cause Aspiration Pneumonia and he has had that twice since December. She further stated that a fever is Resident #1 ' s first symptom of pneumonia and she monitors for that. She then stated that he was really sick in December and was in the hospital for about four weeks and then again in January for a week and a half for aspiration pneumonia. During an interview on 03/12/14 at 4:05 pm, the DON stated Resident #1 ' s sitters are there to assess and monitor him for [MEDICAL CONDITION] because he has a history of [MEDICAL CONDITION]. She further stated the facility nurses administer all of Resident #1 ' s medications and feedings. The DON also stated there is a facility policy and procedure the sitters have to sign before caring for Resident #1. The signed policy/procedures for the sitters were requested but not provided prior to survey exit 03/17/14. During an interview on 03/12/14 at 4:10 pm, the ADON A stated there is a video monitor at the nurse ' s station and nurses rely on that to know if Resident #1 has a [MEDICAL CONDITION] or the sitter alerts them. She also stated there is no specific [MEDICAL CONDITION] log but [MEDICAL CONDITION] should be documented in the nurse ' s notes. Resident #1 takes medications post [MEDICAL CONDITION] and he is followed by a Pediatric Neurologist who monitors his [MEDICAL CONDITION] activity and medications. She further stated Resident #1 was initially admitted in 03/2013 for respite care and she did not think the facility could initially care for Resident #1 because of all of his [MEDICAL CONDITION]. She then stated Resident #1 has as many as four to five [MEDICAL CONDITION] a day, then they go away for a while and then come back and he can have them daily. Observation on 03/14/14 at 2:30 pm revealed Resident #1 ' s monitor screen at the nurse ' s station. The screen was black and there was no signal. During an interview on 03/12/14 at 5:00 pm, the DON stated all of Resident #1 ' s [MEDICAL CONDITION] activity is only documented in the nurse notes and nowhere else. She further stated there is no protocol to outline when to document a [MEDICAL CONDITION] but she probably would not document it if it was just a three second [MEDICAL CONDITION] but would if it was a minute to a minute and a half [MEDICAL CONDITION]; it just depends on the length of the [MEDICAL CONDITION]. Review of Resident #1 ' s Physician ' s Progress Note dated 12/10/13 reflected patient was recently treated for [REDACTED]. Further review reflected an assessment/plan of Aspiration Pneumonia treated and resolved and [MEDICAL CONDITION] disorder: continue [MEDICATION NAME] and [MEDICATION NAME] ([MEDICAL CONDITION] medications) deferred to patient ' s neurologist; will continue to monitor for increased activity due to history of aspiration pneumonia that lowers ([MEDICAL CONDITION]) threshold. The NP signed this progress note. Review of Resident #1 ' s Nurse Notes reflected: - 01/10/14: reflected report called from local hospital, resident admitted with pneumonia follow up discharge from Intensive Care Unit (ICU) on 01/07/14 to acute care. Last [MEDICAL CONDITION] activity 01/08/14, discharge orders faxed, medications resumed - 01/22/14, 7:20 am: Had moderate [MEDICAL CONDITION] last approximately 1 ? minutes in bed - caregiver at bedside to safeguard him - no injuries. Had vomited large amount of phlegm, was upright entire time. His father requested AM medications not be given right away and I waited to give them until caregiver told me resident had settled down with no emesis noted. Noted for nasal drainage but no further phlegm emesis, tires easily. Noted for Blood Pressure (BP) up but is talking with his mother his BP tends to go up after a major [MEDICAL CONDITION]. Also at time of [MEDICAL CONDITION] this AM, resident received routine Klonopin. No physician notification documented. - 8:00 pm: 10 second [MEDICAL CONDITION], vomited approximately 150 mL formula and phlegm. Father called facility twice with instructions and request. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 01/23/14 reflected according to nursing, patient had a temperature of 99.4 degrees Fahrenheit (F) with increase nasal drainage last night and a moderate [MEDICAL CONDITION]. Spoke with patient ' s father who is concerned regarding increased [MEDICAL CONDITION] activity; we discussed possible avenues regarding aspiration pneumonia from [MEDICAL CONDITION] Reflux versus allergies [REDACTED]. The NP signed this note. Review of Resident #1 ' s handwritten Admission Physician order [REDACTED]. - Klonopin 0.5 mg PT TID - [MEDICATION NAME] 15 mL PT TID - [MEDICATION NAME] 125 mg, 5 mL PT Q8H - Klonopin 0.25 mg PT PRN Further review of the Admission Administration Record reflected Resident #1 received Klonopin 0.25 mg PRN on 02/07/14 and 02/28/14. It also reflected Nurse Medication notes: 02/28/14 2:45 pm, small [MEDICAL CONDITION] (8 seconds) gave PRN Klonopin 0.25 mg PT. There is no reason listed on the nurses medication notes as to why Klonopin 0.25 mg PRN was given on 02/07/14. Review did not reflect orders for sitters to provide assistance with ADLs or for [MEDICAL CONDITION] monitoring. Review of Resident #1 ' s Nurse ' s Notes reflected: - 02/06/14, 3:50 pm: patient returned from local hospital via parents ' vehicle, tires easily. Caregiver with patient, family brought back some of his medications but not his Klonopin. Given the medications his dad asked me to give him - didn ' t get at the hospital this afternoon. Had to give his PRN Klonopin and I told his mom - she ' ll check with hospital if she can get back his Klonopin she gave them. No [MEDICAL CONDITION] activity. - 02/07/14, Resident Awake alert, G tube placement verified. 30 second [MEDICAL CONDITION] noted at 8:35 pm, Klonopin 0.25 mg PRN administered per tube. Attendant at side for feedings today, no diarrhea noted. Will continue to monitor. Call to parents, updated on status. No physician notification documented. - 02/28/14, 2:45 pm: Caregiver reported resident had a small [MEDICAL CONDITION] lasted approximately 7 seconds. I gave him PRN Klonopin 0.25 mg PT. No physician notification documented. - 03/04/14, 9:15 pm: Earlier, reported resident had 2 small [MEDICAL CONDITION] today. Call placed to Responsible Party (RP) to notify. No physician notification documented. - 03/05/14, 1:00 pm, Resident sitting in wheelchair in living room area with caregiver. I noted she was assisting him as his head was turning to the side; she was protecting him as he started to move about in chair. She stated it lasted for approximately 20 seconds and he dry heaved once. He was taken to his room and I gave him his anti-[MEDICAL CONDITION] medications via G tube. RP notified. No physician notification documented. - 03/06/14, 1900: small 15 second [MEDICAL CONDITION] reported by caregiver. PRN Klonopin administered, no injuries noted. No physician notification documented. - 03/07/14, 2:15 pm: 30 second [MEDICAL CONDITION] - PRN Klonopin given per family request. No physician notification documented. - 03/11/14, 2:40 pm: Caregiver reported [MEDICAL CONDITION] last approximately 25 seconds, give PRN Klonopin 0.25 mg per tube (PT). No physician notification documented. - 03/11/14, 3:00 pm: Had another [MEDICAL CONDITION] last approximately 10 seconds, give 4.5 [MEDICATION NAME] routine, routine Kepra and Klonopin 0.5 mg PT. Caregiver kept him safe in both instances. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 03/11/14 reflected Resident #1 had a 15 second [MEDICAL CONDITION] according to caregiver on the sixth. Further review reflected an assessment/plan for [MEDICAL CONDITION] disorder to continue current therapy, fair control, occasional breakthrough [MEDICAL CONDITION] deferred to Neurologist. Also, Dysphagia: continue tube feeds, high risk for aspiration. History of aspiration pneumonia, chronic issue, currently asymptomatic. Resident #1 is a high aspiration risk along with increased fall risk due to gait abnormalities, care discussed with nursing and with the patient ' s sitter. The MD signed this note. Review of Resident #1 ' s laboratory value dated 02/14 reflected a [MEDICATION NAME] ([MEDICATION NAME]) level of 17.3 ug/mL. (Reference range: 10.0 - 20.0 micrograms (ug)/mL) Review of Resident #1 ' s Medication Administration Record (MAR) dated March 2014 reflected an order for [REDACTED]. The Klonopin PRN was given on 03/06/14, 03/07/14, and 03/11/14. Further review reflected: 03/07/14, 2:30 pm - Klonopin 0.25 mg PT per family re [MEDICAL CONDITION] activity; 03/11/14 2:40 pm - Klonopin 0.25 mg PT for [MEDICAL CONDITION] approximately 25 seconds. No documentation for reasoning for the PRN Klonopin given on 03/06/14. During an interview on 03/12/14 at 5:10 pm, the NP stated Resident #1 sees a Pediatric Neurologist who prescribes and monitors the [MEDICAL CONDITION] medications and labs. She further stated the facility communicates with her and the Medical Director (MD) about Resident #1 ' s [MEDICAL CONDITION] activity but there is no communication documentation of [MEDICAL CONDITION] activity. She further stated the sitter tells the staff if Resident #1 has any [MEDICAL CONDITION] and they then monitor him if he does. The NP then stated the Klonopin PRN order should be given when a [MEDICAL CONDITION] is happening, and should only be given once per day. During an interview on 03/13/14 at 12:45 the DON stated that Resident #1 has multiple [MEDICAL CONDITION] per day and she expects nurses to document small [MEDICAL CONDITION] that last more than one minute. The DON was then asked how to give Resident #1 ' s PRN order for Klonopin. The DON stated that she would give it however the physician ordered it. The DON then reviewed the order for PRN Klonopin and stated " 0.25 mg for [MEDICAL CONDITION]. " The DON was asked when would she give the PRN Klonpin, she stated " I would have to clarify. " The DON was asked in her nursing judgment when would she give the PRN Klonopin, she stated " I would have to clarify the order. I am not sure if the nurse practitioner wants to give it after every [MEDICAL CONDITION]. " The DON stated that the ADON or the charge nurse would be responsible for clarifying this order. She stated that " the charge nurse gives Resident #1 his medication because he is a tube feeder. " The DON stated that any change in Resident #1 ' s condition is told to the CNAs by the caregivers, then the CNAs inform the nurses. The DON stated that she expected documentation in the nurses notes of any change of condition, [MEDICAL CONDITION] that lasts 3 minutes, distress, shortness of breath. She stated that Resident #1 has multiple [MEDICAL CONDITION] per day and she expects nurses to document small [MEDICAL CONDITION] that last more than one minute. During an interview on 03/13/14 at 12:57 pm, the Neurology LVN stated Resident #1 was a patient and the last phone call they received from the facility about him was on 01/15/14 because of [MEDICAL CONDITION] activity and lab values. They have not contacted the clinic since regarding [MEDICAL CONDITION] activity. She then stated the facility only contacts the Neurology clinic when the resident has significant changes but they do request that all patients alert them of all [MEDICAL CONDITION] to adequately monitor care. She further stated Resident #1 was last in the Neurology clinic on 03/04/14. When asked how often the Klonopin 0.25 mg PRN should be given, she stated it should not be given more than five times per day for Resident #1; three times per routine orders and two PRN doses. During an interview on 03/13/14 at 4:15 pm, the MD stated Resident #1 was admitted to the facility with having about 30 [MEDICAL CONDITION] per month and he does not follow the [MEDICAL CONDITION] medications because the Neurologist does that on a day to day basis. He further stated the Klonopin 0.25 mg PRN should be given after all [MEDICAL CONDITION] and he would rather have it given and Resident #1 not be seizing than for him to have a [MEDICAL CONDITION] and not receive Klonopin 0.25 mg PRN. The MD further stated he expects to be notified of every [MEDICAL CONDITION] and he wants the nursing staff interpretation what a [MEDICAL CONDITION] is when administering the Klonopin 0.25 mg PRN. When asked if it is appropriate to administer routine Klonopin 0.5 mg twenty minutes after receiving the Klonopin 0.25 mg PRN after a [MEDICAL CONDITION], he stated yes. The MD then stated he expects the nursing staff to monitor and document Resident #1's [MEDICAL CONDITION] activity in the nurses ' notes. He further stated he does not know a characteristic [MEDICAL CONDITION] for Resident #1, but he does have a variety, everything from grand mal (features a loss of consciousness and violent muscle contractions) to minor [MEDICAL CONDITION]. In a continued interview on 3/13/14 at 4:15 PM, the MD stated that Resident # 1 ' s condition were exceedingly complex therefore he may not place specifications on the order for how many times a day Resident #1 should get PRN Klonopin. Surveyor asked the PCP how the nurses would know how many times a day to give the medication (Klonopin 0.25 mg PT PRN). The MD stated that he would expect the nurse not to hold back and go ahead and give the Klonopin and then call for further direction. The MD stated that when the nurses call him does a back and forth questioning with the nurse to be able to determine the [MEDICAL CONDITION] activity. The MD stated that he would want them to describe the characteristics of the [MEDICAL CONDITION], rather than diagnosing what kind of [MEDICAL CONDITION] they are. Surveyor asked the MD if he was involved in the care planning process concerning Resident # 1 ' s " complex " medical needs, to ensure that staff are aware of his expectations and to enable the correlation of care. The MD stated that he was not, but that his NP might be he was not sure. During an interview on 3/13/14 at 4:15 PM Surveyor asked Administrator how the facility communicated to the direct care staff of what Resident # 1 ' s caregivers " can and cannot do " for Resident #1. Administrator stated that these directions in care were not developed until the night of 3/12/14. During an interview on 03/14/14 at 5:20 pm, the DON stated she expects the nursing staff to assess residents for PRN medications, follow physician orders, and then reassess residents again after a PRN medication is given to monitor effectiveness. She further stated the PRN medication should be documented on the MAR or in Nurse ' s Notes. When asked when nurses should clarify physician orders, the DON stated she expects her staff to clarify it if the order is not clear. She further stated PRN medications usually have the number of tabs and how often it should be administered on the order and she expects her staff to clarify an order if that is not clear. The DON stated she was not aware that Resident #1 ' s sitters were providing personal care for him. The DON then said the CNA ' s do the same amount of care for Resident #1 as they do for other residents who are assessed to be minimal assist. Review of the facility ' s PRN Orders Policy dated April 2008 reflected that PRN orders must clarify the circumstances for offering or giving the medication. When PRN orders are implemented, nursing staff must monitor the use of such medication to determine the nature of the problem and whether it persists, whether additional evaluation is needed or whether the medications could be discontinued. Review of the facility ' s [MEDICAL CONDITION] Management Policy dated 2007 reflected if staff suspect a resident is having a [MEDICAL CONDITION], they will note the time and duration of the [MEDICAL CONDITION] activity, monitor the resident ' s vital signs as ordered by the physician, and notify the physician during or as soon as possible after the [MEDICAL CONDITION], and notify the family of the event subsequently. It further reflected when documenting or reporting a resident ' s [MEDICAL CONDITION] activity to the physician, carefully describe signs and symptoms including: the nature of the activity (where it started, what areas of the body were involved), the duration of the [MEDICAL CONDITION] activity, whether the resident lost consciousness, the resident ' s current level of consciousness, baseline and current cognitive ability, speech, physical function, presence of abnormal motor activity, present of tremors, and overall physical condition. Avoid documenting or reporting just that the individual " had a [MEDICAL CONDITION]. " Instead, provide and document the details. Review of the facility ' s Private Duty Sitters Policy dated August 2006 reflected residents/family members desiring the use of private duty sitters must first obtain written approval of the attending physician and the DON. Private duty nursing personnel must follow the facility ' s established nursing care policies and procedures, instructions issued by the Nurse Supervisor/Charge Nurse, and may not administer direct care to the resident unless authorized in writing by the Attending Physician. The facility Administrator and DON were notified on 03/13/14 at 12:50 pm that an IJ situation had been identified due to the above failures. The final Plan of Removal was accepted by the surveyor on 03/17/14 at 10:15 am. Removal Plan for Immediate Jeopardy related to Resident #1 ' s [MEDICAL CONDITION] activity. How we will remove the immediacy: I. A clarification order on Resident #1 ' s Klonopin was written. It reads Klonopin 0.25mg give one tablet per tube daily PRN for [MEDICAL CONDITION] activity. If additional dose is needed notify on-call for instructions. II. A nursing in-service on Facility ' s [MEDICAL CONDITION] and [MEDICAL CONDITION] Clinical Protocol will be completed by 3/19/14. The in-service covers Assessment and Recognition, Cause Identification, Treatment/Management and Monitoring. As the policy relates to documentation the in-service include: ? The nature of the activity (where it started, what areas of the body were involved, etc.) ? The duration of the [MEDICAL CONDITION] activity. ? Whether the resident lost consciousness. ? Baseline and current cognitive ability. ? Baseline and current speech. ? Baseline and current physical function. ? Presence of abnormal motor activity. ? Presence of tremors. ? Overall physical condition. III. Facility will communicate Resident #1 ' s [MEDICAL CONDITION] to Resident #1 ' s PCP, or his nurse practitioner, as follows. If Resident #1 ' s [MEDICAL CONDITION] is controlled, meaning the [MEDICAL CONDITION] has stopped, Facility will notify non-emergently. If the [MEDICAL CONDITION] is not controlled, meaning his [MEDICAL CONDITION] continues after the PRN Klonopin is administered, Facility will notify on call. If the physician is not immediately available to discuss the situation Resident #1 will be sent to the emergency room . IV. All nursing staff will be assigned a " Response to [MEDICAL CONDITION] " online course beginning 3/17/14 and will continue until all nursing staff have completed and passed. The steps of the training include: 1. Call the nurse and stay with the patient. 2. Place padding under head and move furniture away from resident (protects resident from injury). 3. Do not restrain the resident or place anything in mouth (any restriction may injury resident during [MEDICAL CONDITION]). 4. Loosen resident ' s clothing especially around neck (prevents injury or choking). 5. After [MEDICAL CONDITION] stops, position patient onto side (allows saliva to drain from mouth so resident doesn ' t choke). 6. Note duration of [MEDICAL CONDITION] and areas involved (provides nurse with necessary information to properly assess resident ' s condition and needs). 7. Perform final steps (i.e. lower bed height and position bed enablers as appropriate, place call light and water within reach, ask resident if anything else is needed, thank resident, wash hands, and document procedure). 8. Assist with documentation according to current nursing practices. V. Resident #1 ' s care plan was updated on 3/16/14 to reflect the characteristics of his [MEDICAL CONDITION]. ? The care plan reads my [MEDICAL CONDITION] can be characterized by: turning head from side to side, raising knees or shaking leg(s), shaking arms. After a [MEDICAL CONDITION] I may be sleepy. Report these symptoms and any other [MEDICAL CONDITION] activity to the charge nurse. During a [MEDICAL CONDITION] keep me safe from injury and do not place anything in my mouth VI. Resident #1 ' s caregivers will communicate with the nurses by using the call light while in Resident #1 ' s room. If outside on community grounds the caregiver will notify the nurse by calling the communities main line via cell phone after ensuring Resident #1 is safe. A [MEDICAL CONDITION] observation log will be developed and by implemented on 3/17/14. The log will allow caregivers to document the length of the [MEDICAL CONDITIONS] observations, recovery observations, and comments (if any are needed). VII. If Resident #1 experiences a [MEDICAL CONDITION] during a community outing the Activity Director, will call 911. VIII. The Private Duty Sitter Authorization Form will completed for all five of Resident #1 ' s private duty sitters. The authorization form will be signed by Resident #1 ' s PCP and The Facility ' s Director of Nursing. IX. Any changes to Resident #1 ' s [MEDICAL CONDITION] medications by his PCP will be faxed to Resident #1 ' s neurologist, for review. Other residents potentially affected. Chart reviews for the other seven residents potentially affected will be conducted. The care plans will be updated to reflect the characteristics of their [MEDICAL CONDITION] as indicated by the chart reviews. The survey team monitored the current plan of

Based on interview and record review, the facility failed to consult with the resident ' s physician when a need to alter treatment significantly occurred for one (1) of five (5) residents (Resident #1) reviewed for physicians being consulted of changes in resident's treatment when: The facility failed to notify Resident #1's Neurologist and Primary Care Physician after each [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) situation was identified on 03/13/14 at 12:14 p.m. While the IJ was lowered to a non-immediate Jeopardy on 03/17/14 at 3:30 p.m. the facility remained out of compliance at a severity of more than minimal harm with a scope identified as a pattern with potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place seven (7) residents who are identified as a [MEDICAL CONDITION] risk and prescribed [MEDICAL CONDITION] medication at risk for neglect, lack of care, being overmedicated, and possible death. Findings include: Review of Resident #1's facesheet reflected a [AGE] year old male admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Nurse's Note dated 03/13/13 reflected a [AGE] year old male admitted for respite care. He has a [DIAGNOSES REDACTED]. Recurrent [MEDICAL CONDITION], usual signs of impending [MEDICAL CONDITION] usually look off to left side, has a fixed smile and then shakes his head, may have mild to severe [MEDICAL CONDITION]. Review of Resident #1's Minimum Data Set ((MDS) dated [DATE] reflected: Section I: Active Diagnoses - I5400. [MEDICAL CONDITION] Disorder or [MEDICAL CONDITION] Review of Resident #1 ' s Physician's Progress Note dated 12/10/13 reflected patient was recently treated for [REDACTED]. Further review reflected an assessment/plan of Aspiration Pneumonia (inflammation of the lungs and [MEDICATION NAME] tubes, occurs after you inhale foreign matter such as vomit, food, or liquids) treated and resolved and [MEDICAL CONDITION] disorder: continue [MEDICATION NAME] and [MEDICATION NAME] ([MEDICAL CONDITION] medications) deferred to patient ' s neurologist; will continue to monitor for increased activity due to history of aspiration pneumonia that lowers ([MEDICAL CONDITION]) threshold. The NP signed this progress note. Review of Resident #1 ' s Nurse Notes reflected: - 01/10/14: reflected report called from local hospital, resident admitted with pneumonia follow up discharge from Intensive Care Unit (ICU) on 01/07/14 to acute care. Last [MEDICAL CONDITION] activity 01/08/14, discharge orders faxed, medications resumed - 01/22/14, 7:20 am: Had moderate [MEDICAL CONDITION] last approximately 1 ? minutes in bed - caregiver at bedside to safeguard him - no injuries. Had vomited large amount of phlegm, was upright entire time. His father requested AM medications not be given right away and I waited to give them until caregiver told me resident had settled down with no emesis noted. Noted for nasal drainage but no further phlegm emesis, tires easily. Noted for Blood Pressure (BP) up but is talking with his mother his BP tends to go up after a major [MEDICAL CONDITION]. Also at time of [MEDICAL CONDITION] this AM, resident received routine Klonopin. No physician notification documented. - 8:00 pm: 10 second [MEDICAL CONDITION], vomited approximately 150 mL formula and phlegm. Father called facility twice with instructions and request. No physician notification documented. Review of Resident #1 ' s Physician ' s Progress Note dated 01/23/14 reflected according to nursing, patient had a temperature of 99.4 degrees Fahrenheit (F) with increase nasal drainage last night and a moderate [MEDICAL CONDITION]. Spoke with patient ' s father who is concerned regarding increased [MEDICAL CONDITION] activity; we discussed possible avenues regarding aspiration pneumonia from [MEDICAL CONDITION] Reflux versus allergies [REDACTED]. The NP signed this note. Review of Resident #1 ' s handwritten Admission Physician order [REDACTED]. - Klonopin 0.25 mg PT PRN - Klonopin 0.5 mg PT TID - [MEDICATION NAME] 15 mL PT TID - [MEDICATION NAME] 125 mg, 5 mL PT Q8H Further review of the Admission Administration Record reflected Resident #1 received Klonopin 0.25 mg PRN on 02/07/14 and 02/28/14. It also reflected Nurse Medication notes: 02/28/14 2:45 pm, small [MEDICAL CONDITION] (8 seconds) gave PRN Klonopin 0.25 mg PT. There is no reason listed on the nurses medication notes as to why Klonopin 0.25 mg PRN was given on 02/07/14. Review of Resident #1 ' s Nurse ' s Notes reflected: - 02/06/14, 3:50 pm: patient returned from local hospital via parents ' vehicle, tires easily. Caregiver with patient, family brought back some of his medications but not his Klonopin. Given the medications his dad asked me to give him - didn ' t get at the hospital this afternoon. Had to give his PRN Klonopin and I told his mom - she ' ll check with hospital if she can get back his Klonopin she gave them. No [MEDICAL CONDITION] activity. - 02/07/14, Resident Awake alert, G tube placement verified. 30 second [MEDICAL CONDITION] noted at 8:35 pm, Klonopin 0.25 mg PRN administered per tube. Attendant at side for feedings today, no diarrhea noted. Will continue to monitor. Call to parents, updated on status. No physician notification documented. - 02/28/14, 2:45 pm: Caregiver reported resident had a small [MEDICAL CONDITION] lasted approximately 7 seconds. I gave him PRN Klonopin 0.25 mg PT. No physician notification documented. - 03/04/14, 9:15 pm: Earlier, reported resident had 2 small [MEDICAL CONDITION] today. Call placed to Responsible Party (RP) to notify. No physician notification documented. - 03/05/14, 1:00 pm, Resident sitting in wheelchair in living room area with caregiver. I noted she was assisting him as his head was turning to the side; she was protecting him as he started to move about in chair. She stated it lasted for approximately 20 seconds and he dry heaved once. He was taken to his room and I gave him his anti-[MEDICAL CONDITION] medications via G tube. RP notified. No physician notification documented. - 03/06/14, 1900: small 15 second [MEDICAL CONDITION] reported by caregiver. PRN Klonopin administered, no injuries noted. No physician notification documented. - 03/07/14, 2:15 pm: 30 second [MEDICAL CONDITION] - PRN Klonopin given per family request. No physician notification documented. - 03/11/14, 2:40 pm: Caregiver reported [MEDICAL CONDITION] last approximately 25 seconds, give PRN Klonopin 0.25 mg per tube (PT). No physician notification documented. - 03/11/14, 3:00 pm: Had another [MEDICAL CONDITION] last approximately 10 seconds, give 4.5 [MEDICATION NAME] routine, routine Kepra and Klonopin 0.5 mg PT. Caregiver kept him safe in both instances. No physician notification documented. Review of Resident #1's Physician ' s Progress Note dated 03/11/14 reflected Resident #1 had a 15 second [MEDICAL CONDITION] according to caregiver on the sixth. Further review reflected an assessment/plan for [MEDICAL CONDITION] disorder to continue current therapy, fair control, occasional breakthrough [MEDICAL CONDITION] deferred to Neurologist. Also, Dysphagia: continue tube feeds, high risk for aspiration. History of aspiration pneumonia, chronic issue, currently asymptomatic. Resident #1 is a high aspiration risk along with increased fall risk due to gait abnormalities, care discussed with nursing and with the patient ' s sitter. The MD signed this note. Review of Resident #1's laboratory value dated 02/14 reflected a [MEDICATION NAME] ([MEDICATION NAME]) level of 17.3 ug/mL. (Reference range: 10.0 - 20.0 micrograms (ug)/mL) Review of Resident #1 ' s Medication Administration Record (MAR) dated March 2014 reflected an order for [REDACTED]. The Klonopin PRN was given on 03/06/14, 03/07/14, and 03/11/14. Further review reflected: 03/07/14, 2:30 pm - Klonopin 0.25 mg PT per family re [MEDICAL CONDITION] activity; 03/11/14 2:40 pm - Klonopin 0.25 mg PT for [MEDICAL CONDITION] approximately 25 seconds. No documentation for reason given for the PRN Klonopin given on 03/06/14. Review of Resident #1 ' s Comprehensive Care Plan dated 01/27/14 reflected the following problem areas: - Problem: "I have a [DIAGNOSES REDACTED]. The interventions listed are that Resident #1 has frequent [MEDICAL CONDITION], the family and him requested a closed circuit camera be placed in room with the nurse having the monitor to observe in case of a [MEDICAL CONDITION]. - Problem: "I take medications to control my [MEDICAL CONDITION] and am at risk for side effects" with an onset date of 04/12/13 and revised on 12/05/13. The interventions listed are to monitor as much as possible for [MEDICAL CONDITION] activity, notify the doctor of any adverse reactions, to give medications as ordered, the medications put Resident #1 at risk for falls, and to watch for possible side effects which may include dizziness, drowsiness, irritability, weakness, decreased coordination, and new or worsening [MEDICAL CONDITION]. - Problem: " I take Klonopin for [MEDICAL CONDITION] " with an onset date of 04/12/13 and revised on 09/23/13. The interventions listed are to ensure informed consent by resident or Responsible Party (RP) are given, notify doctor of any adverse reactions, to give medication as ordered, and to watch for side effects such as clumsiness, unsteadiness, or behavioral changes. - Problem of "I have severe reflux with high risk for aspiration " with a problem onset date of 04/12/13 and revised on 12/15/13. The interventions listed are to keep the head of bed (HOB) elevated 90 degrees during and after feedings, monitor for side effects of medication, document if present, monitor labs per doctor orders, notify doctor and family of changes in condition, and to administer medications per doctor ' s orders. Review of Resident #1 ' s physician's order [REDACTED]. -Diet: nothing by mouth (NPO) -[MEDICATION NAME] 125 mg/5 milliliters (mL) every 8 hours (Q8H), 5 mL ([MEDICAL CONDITION]) -[MEDICATION NAME] 100 mg/mL G tube, three times a day (TID), 15 mL ([MEDICAL CONDITION]) -Klonopin 0.5 mg G tube, TID: 1 tab ([MEDICAL CONDITION]) -Klonopin 0.25 mg G tube, PRN 1 tab ([MEDICAL CONDITION]), (no additional clarification written on order) During an interview on 03/12/14 at 4:10 pm, the ADON A stated there is a video monitor at the nurse ' s station and nurses rely on that to know if Resident #1 has a [MEDICAL CONDITION] or the sitter alerts them. She also stated there is no specific [MEDICAL CONDITION] log but [MEDICAL CONDITION] should be documented in the nurse's notes. Resident #1 takes medications post [MEDICAL CONDITION] and he is followed by a Pediatric Neurologist who monitors his [MEDICAL CONDITION] activity and medications. ADON A then stated there are no problems with communication between the nurse's and sitters. She further stated Resident #1 was initially admitted in 03/2013 for respite care and she did not think the facility could initially care for Resident #1 because of all of his [MEDICAL CONDITION]. She then stated Resident #1 has as many as four to five [MEDICAL CONDITION] a day, then they go away for a while and then come back and he can have them daily. Observation on 03/14/14 at 2:30 pm revealed Resident #1's monitor screen at the nurse ' s station. The screen was black and there was no signal. During an interview on 03/12/14 at 5:00 pm, the DON stated all of Resident #1 ' s [MEDICAL CONDITION] activity is only documented in the nurse notes and nowhere else. She further stated there is no protocol to outline when to document a [MEDICAL CONDITION] but she probably would not document it if it was just a three second [MEDICAL CONDITION] but would if it was a minute to a minute and a half [MEDICAL CONDITION]; it just depends on the length of the [MEDICAL CONDITION]. During an interview on 03/12/14 at 5:10 pm, the NP stated Resident #1 sees a Pediatric Neurologist who prescribes and monitors the [MEDICAL CONDITION] medications and labs. She further stated the facility communicates with her and the Medical Director (MD) about Resident #1 ' s [MEDICAL CONDITION] activity but there is no communication documentation of [MEDICAL CONDITION] activity. She further stated the sitter tells the staff if Resident #1 has any [MEDICAL CONDITION] and they then monitor him if he does. The NP then stated the Klonopin PRN order should be given when a [MEDICAL CONDITION] is happening, and should only be given once per day. During an interview on 03/13/14 at 12:45 the DON stated that any change in Resident #1 ' s condition is told to the CNAs by the caregivers, then the CNAs inform the nurses. The DON stated that she expected documentation in the nurses ' notes of any change of condition, [MEDICAL CONDITION] that lasts 3 minutes, distress, shortness of breath. She stated that Resident #1 has multiple [MEDICAL CONDITION] per day and she expects nurses to document small [MEDICAL CONDITION] that last more than one minute. The DON was then asked how to give Resident #1 ' s PRN order for Klonopin. The DON stated that she would give it however the physician ordered it. The DON then reviewed the order for PRN Klonopin and stated " 0.25 mg for [MEDICAL CONDITION]. " The DON was asked when would she give the PRN Klonopin, she stated " I would have to clarify. " The DON was asked in her nursing judgment when would she give the PRN Klonopin, she stated " I would have to clarify the order. I am not sure if the nurse practitioner wants to give it after every [MEDICAL CONDITION]. " The DON stated that the ADON or the charge nurse would be responsible for clarifying this order. She stated that " the charge nurse gives Resident #1 his medication because he is a tube feeder. " During an interview on 03/13/14 at 12:57 pm, the Neurology LVN stated Resident #1 was a patient and the last phone call they received from the facility about him was on 01/15/14 because of [MEDICAL CONDITION] activity and lab values. They have not contacted the clinic since regarding [MEDICAL CONDITION] activity. She then stated the facility only contacts the Neurology clinic when the resident has significant changes but they do request that all patients alert them of all [MEDICAL CONDITION] to adequately monitor care. She further stated Resident #1 was last seen in the Neurology clinic on 03/04/14. When asked how often the Klonopin 0.25 mg PRN should be given, she stated it should not be given more than five times per day for Resident #1; three times per routine orders and two PRN doses. Resident #1's Neurologist was contacted numerous times but did not return the call. During an interview on 03/13/14 at 4:15 pm, the MD stated Resident #1 was admitted to the facility with having about 30 [MEDICAL CONDITION] per month and he does not follow the [MEDICAL CONDITION] medications because the Neurologist does that on a day to day basis. He further stated the Klonopin 0.25 mg PRN should be given after all [MEDICAL CONDITION] and he would rather have it given and Resident #1 not be seizing than for him to have a [MEDICAL CONDITION] and not receive Klonopin 0.25 mg PRN. The MD further stated he expects to be notified of every [MEDICAL CONDITION] and he wants the nursing staff interpretation what a [MEDICAL CONDITION] is when administering the Klonopin 0.25 mg PRN. When asked if it is appropriate to administer routine Klonopin 0.5 mg twenty minutes after receiving the Klonopin 0.25 mg PRN after a [MEDICAL CONDITION], he stated yes. The MD then stated he expects the nursing staff to monitor and document Resident #1's [MEDICAL CONDITION] activity in the nurses ' notes. He further stated he does not know a characteristic [MEDICAL CONDITION] for Resident #1, but he does have a variety, everything from grand mal (features a loss of consciousness and violent muscle contractions) to minor [MEDICAL CONDITION]. In a continued interview on 3/13/14 at 4:15 PM, the MD stated that Resident # 1 ' s condition were exceedingly complex therefore he may not place specifications on the order for how many times a day Resident #1 should get PRN Klonopin. Surveyor asked the PCP how the nurses would know how many times a day to give the medication (Klonopin 0.25 mg PT PRN). The MD stated that he would expect the nurse not to hold back and go ahead and give the Klonopin and then call for further direction. The MD stated that when the nurses call him does a back and forth questioning with the nurse to be able to determine the [MEDICAL CONDITION] activity. The MD stated that he would want them to describe the characteristics of the [MEDICAL CONDITION], rather than diagnosing what kind of [MEDICAL CONDITION] they are. Surveyor asked the MD if he was involved in the care planning process concerning Resident # 1 ' s " complex " medical needs, to ensure that staff are aware of his expectations and to enable the correlation of care. The MD stated that he was not, but that his NP might be he was not sure. During an interview on 03/14/14 at 5:20 pm, the DON stated she expects the nursing staff to assess residents for PRN medications, follow physician orders, and then reassess residents again after a PRN medication is given to monitor effectiveness. She further stated the PRN medication should be documented on the MAR or in Nurse ' s Notes. When asked when nurses should clarify physician orders, the DON stated she expects her staff to clarify it if the order is not clear. She further stated PRN medications usually have the number of tabs and how often it should be administered on the order and she expects her staff to clarify an order if that is not clear. The DON then stated they only notify the physician for any change in condition not normal to a resident. She further stated she was not aware that Resident #1 ' s sitters were providing personal care for him. The DON then said the CNA ' s do the same amount of care for Resident #1 as they do for other residents who are assessed to be minimal assist. Review of the facility ' s [MEDICAL CONDITION] Management Policy, dated 2007, reflected if staff suspect a resident is having a [MEDICAL CONDITION], they will note the time and duration of the [MEDICAL CONDITION] activity, monitor the resident ' s vital signs as ordered by the physician, and notify the physician during or as soon as possible after the [MEDICAL CONDITION], and notify the family of the event subsequently. It further reflected when documenting or reporting a resident ' s [MEDICAL CONDITION] activity to the physician, carefully describe signs and symptoms including: the nature of the activity (where it started, what areas of the body were involved), the duration of the [MEDICAL CONDITION] activity, whether the resident lost consciousness, the resident ' s current level of consciousness, baseline and current cognitive ability, speech, physical function, presence of abnormal motor activity, present of tremors, and overall physical condition. Avoid documenting or reporting just that the individual " had a [MEDICAL CONDITION]. " Instead, provide and document the details. Review of the facility ' s PRN Orders Policy dated April 2008 reflected that PRN orders must clarify the circumstances for offering or giving the medication. When PRN orders are implemented, nursing staff must monitor the use of such medication to determine the nature of the problem and whether it persists, whether additional evaluation is needed or whether the medications could be discontinued. The facility Administrator and DON were notified on 03/13/14 at 12:50 pm that an IJ situation had been identified due to the above failures. The final Plan of Removal was accepted by the surveyor on 03/17/14 at 10:15 am. Removal Plan for Immediate Jeopardy related to Resident #1 ' s [MEDICAL CONDITION] activity. How we will remove the immediacy: I. A clarification order on Resident #1 ' s Klonopin was written. It reads Klonopin 0.25mg give one tablet per tube daily PRN for [MEDICAL CONDITION] activity. If additional dose is needed notify on-call for instructions. II. A nursing in-service on Facility ' s [MEDICAL CONDITION] and [MEDICAL CONDITION] Clinical Protocol will be completed by 3/19/14. The in-service covers Assessment and Recognition, Cause Identification, Treatment/Management and Monitoring. As the policy relates to documentation the in-service include: ? The nature of the activity (where it started, what areas of the body were involved, etc.) ? The duration of the [MEDICAL CONDITION] activity. ? Whether the resident lost consciousness. ? Baseline and current cognitive ability. ? Baseline and current speech. ? Baseline and current physical function. ? Presence of abnormal motor activity. ? Presence of tremors. ? Overall physical condition. III. Facility will communicate Resident #1 ' s [MEDICAL CONDITION] to Resident #1 ' s PCP, or his nurse practitioner, as follows. If Resident #1 ' s [MEDICAL CONDITION] is controlled, meaning the [MEDICAL CONDITION] has stopped, Facility will notify non-emergently. If the [MEDICAL CONDITION] is not controlled, meaning his [MEDICAL CONDITION] continues after the PRN Klonopin is administered, Facility will notify on call. If the physician is not immediately available to discuss the situation Resident #1 will be sent to the emergency room . IV. All nursing staff will be assigned a " Response to [MEDICAL CONDITION] " online course beginning 3/17/14 and will continue until all nursing staff have completed and passed. The steps of the training include: 1. Call the nurse and stay with the patient. 2. Place padding under head and move furniture away from resident (protects resident from injury). 3. Do not restrain the resident or place anything in mouth (any restriction may injury resident during [MEDICAL CONDITION]). 4. Loosen resident ' s clothing especially around neck (prevents injury or choking). 5. After [MEDICAL CONDITION] stops, position patient onto side (allows saliva to drain from mouth so resident doesn ' t choke). 6. Note duration of [MEDICAL CONDITION] and areas involved (provides nurse with necessary information to properly assess resident ' s condition and needs). 7. Perform final steps (i.e. lower bed height and position bed enablers as appropriate, place call light and water within reach, ask resident if anything else is needed, thank resident, wash hands, and document procedure). 8. Assist with documentation according to current nursing practices. V. Resident #1 ' s care plan was updated on 3/16/14 to reflect the characteristics of his [MEDICAL CONDITION]. ? The care plan reads my [MEDICAL CONDITION] can be characterized by: turning head from side to side, raising knees or shaking leg(s), shaking arms. After a [MEDICAL CONDITION] I may be sleepy. Report these symptoms and any other [MEDICAL CONDITION] activity to the charge nurse. During a [MEDICAL CONDITION] keep me safe from injury and do not place anything in my mouth VI. Resident #1 ' s caregivers will communicate with the nurses by using the call light while in Resident #1 ' s room. If outside on community grounds the caregiver will notify the nurse by calling the communities main line via cell phone after ensuring Resident #1 is safe. A [MEDICAL CONDITION] observation log will be developed and by implemented on 3/17/14. The log will allow caregivers to document the length of the [MEDICAL CONDITIONS] observations, recovery observations, and comments (if any are needed). VII. If Resident #1 experiences a [MEDICAL CONDITION] during a community outing the Activity Director, will call 911. VIII. The Private Duty Sitter Authorization Form will completed for all five of Resident #1 ' s private duty sitters. The authorization form will be signed by Resident #1 ' s PCP and The Facility ' s Director of Nursing. IX. Any changes to Resident #1 ' s [MEDICAL CONDITION] medications by his PCP will be faxed to Resident #1 ' s neurologist, for review. Other residents potentially affected. Chart reviews for the other seven residents potentially affected will be conducted. The care plans will be updated to reflect the characteristics of their [MEDICAL CONDITION] as indicated by the chart reviews. The survey team monitored the current plan of removal as follows: Review of Resident #1 ' s physician's order [REDACTED]. If additional dose is needed notify on-call for further instructions. " During an interview on 03/17/14 at 8:30 am, LVN L stated Resident #1 ' s Klonopin PRN was recently changed. She further stated if they need instructions, they would notify the on-call NP. Review of Resident #1 Comprehensive Care Plan reflected: - Problem: I take Klonopin for [MEDICAL CONDITION] with a problem onset date of 04/12/13 and revised on 09/23/13. Interventions listed that were revised on 03/16/14 reflected to watch resident for possible side effects including clumsiness, unsteadiness, constipation, cough, dizziness, drowsiness, dry mouth, headache, loss of appetite, muscle aches, nervousness, severe allergic reactions, behavior changes, blurred vision, change in urination, confusion, fever, chills or sore throat, hallucination, hostility, irregular heartbeat, memory loss, mood changes, new or worsening [MEDICAL CONDITION], shortness of breath, tremor, and unusual bruising or bleeding. - Problem: [MEDICAL CONDITION] disorder [DIAGNOSES REDACTED]. Resident has frequent [MEDICAL CONDITION] with an onset date of 04/12/13 and revised on 03/16/14. Interventions revised on 03/16/14 reflected medical record indicates [MEDICAL CONDITION] are focal, self-limiting, and can turn to tonic-clonic. Further review reflected another intervention revised on 03/16/14 of " [MEDICAL CONDITION]: mine can be characterized by: turning head from side to side, raising knees or shaking leg(s), shaking arms. After a [MEDICAL CONDITION] I may be sleepy. Report these symptoms and any other [MEDICAL CONDITION] activity to the charge nurse. During a [MEDICAL CONDITION] keep me safe from injury and do not place anything in my mouth. " During an interview on 03/17/14 10:05 am, the Activity Director (AD) stated if Resident #1 has a [MEDICAL CONDITION] during an activity in the building, she would immediately get a nurse. If they go on an outing, she stated a CNA and Resident #1 ' s sitter usually come with and she will keep an eye on him. She further stated if he has a [MEDICAL CONDITION] while out, she will make sure he is safe and then call 911. Review of the facility ' s undated Private Duty Sitter Authorization Form reflected " I authorize ________ to provide private duty sitter services for resident ________. " There is a place for the physician and DON to sign and date the form. A facility provided list reflected seven (7) residents who are prescribed [MEDICAL CONDITION] medications.