Every finding on record at West Side Campus of Care

Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 medication carts reviewed for medical waste and for 2 of 3 halls reviewed. 1.The facility failed to perform appropriate disposal of medical waste. 2. The facility failed to ensure medical waste container was covered on the medication cart located on secure unit These failures could place residents at risk of cross-contamination, increased risk of infection, and the spread of infection. The findings include: Durning an observation on 03/26/2026 at 9:38 AM revealed alcohol wipe on the floor with blood stain located on the floor in the hallway of the secure unit. During an observation on 03/26/2026 at 09:52 AM revealed, on the secure unit the lid on the medical waste container was open and unsecured. During an interview on 03/26/2026 at 9:44 AM with LVN B stated she was responsible for conducting a capillary blood glucose test (fingerstick blood glucose check) for residents on the secure unit. She stated that when the test was completed, the alcohol wipe should be disposed of in the medical waste bin located on the side of the medication cart. The risk of not properly disposingdisposing of the alcohol wipe was possible for infection transfer because it had blood on it. Durning an interview on 03/26/2026 at 9:52 AM, MA C stated the risk of having the side trash open was the resident could get into the trash and would be at risk for cross-contamination or infection if they met medical waste. The lid should be closed after use. Durning an interview on 03/26/2026 at 1:15 PM with the DON stated the expectation was for those (medical waste) things to be discarded appropriately in the trash. The risk of not properly discarding medical waste was infection and cross-contamination. The DON said after you place the medical waste in the trash, close the lid to ensure that the residents are not getting in them. Record Review of policy titled Medical Waste Management Program revised: December 01, 2017 revealed; D. Disposable items soiled with visible blood (or feces from a resident with a disease transmitted through feces) are placed in designated medical waste containers. A. Medical waste containers are located throughout the Facility and are kept covered at all times.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure that eight 64-ounce pitchers of dark brown liquid were labeled and dated. 2. The facility failed to ensure that four 4-ounce canned food items were free of dents. These failures had the potential to affect residents by placing them at risk for cross-contamination and foodborne intoxication. Findings included: Observation on 03/24/26 at 7:31 AM, upon entry to the kitchen, reflected that eight 64-ounce pitchers of dark brown liquid were on the beverage station counter without labels or use-by dates. Observation on 03/24/26 at 7:46 AM of the dry food storage area reflected a 4-ounce dented can labeled apple slices, a 4-ounce dented can labeled mandarins, and two 4-ounce dented cans labeled grape jelly stored with the regular stock of canned goods. In an interview on 03/25/26 at 12:50 PM, [NAME] Z stated that it was not okay to store dented canned goods with the regular stock of canned goods. [NAME] Z stated that all staff were responsible for making sure dented canned goods were not stored with the regular stock of canned goods. [NAME] Z stated that the dented cans had been mixed in with the regular canned goods because the vendors had not thoroughly checked the cans when they stocked them. [NAME] Z stated that the dented cans were supposed to be placed in a separate area so they could be discarded. [NAME] Z stated that dented canned goods were stored at the bottom of the shelf when first walking into the dry food storage area. [NAME] Z stated that the risk of having dented canned goods with the regular stock of canned goods was that there could be lead or residue in the dented cans if they were served to residents. [NAME] Z stated that this could be prevented in the future by checking all the cans to make sure there were none mixed in and by placing dented cans where they should have been stored on the bottom shelf to be discarded. [NAME] Z stated that the liquid that were in the eight 64-ounce pitchers were tea. [NAME] Z stated that the tea pitchers should have been labeled and dated with the name and use-by date. [NAME] Z stated that [NAME] D had filled the tea pitchers but was not working that day. [NAME] Z stated that the person responsible for labeling and dating the pitchers was the person who filled them. [NAME] Z stated that the risk of the pitchers of tea not being labeled or dated with a use-by date was that residents could feel the beverages were not fresh or were old. In an interview on 03/25/26 at 1:05 PM, [NAME] Y stated that she had been working in the kitchen for 2 years. [NAME] Y stated that all cooks were responsible for checking labels and dates on beverages. [NAME] Y stated that once staff filled the drink pitchers, they were supposed to place the date the beverage was made and the expiration date on the label. [NAME] Y stated that she could not say why the pitchers were not labeled or dated because she was not sure but [NAME] D had filled the pitchers that day. [NAME] Y stated that the policy required beverages to be labeled with the name of the drink and dated, and she stated that dietary staff changed the drinks every morning. [NAME] Y stated that the risk of not labeling and dating beverages was that residents would not know if the beverages were fresh. [NAME] Y stated that staff had an in-service on March 19th and discussed labeling and dating, making sure products were placed in the correct spot in the kitchen, and ensuring everything was correct on the tickets when serving trays. [NAME] Y stated that this could be prevented next time by double-checking to make sure all beverages were labeled and dated with the use-by date. [NAME] Y stated that all cooks were also responsible for checking all canned goods to ensure there were no dented canned goods. [NAME] Y stated that dented canned goods were stored in the dry storage room on the bottom shelf with a sign that said dented cans. [NAME] Y stated that the dented canned goods had not been removed from the regular stock of canned goods because they had not gotten to that task yet. [NAME] Y stated that the policy for dented canned goods was that staff were supposed to inspect canned goods when first received from the vendor, and if the canned goods were dented, they were supposed to place them at the bottom of the shelf with the other dented canned goods, and they would eventually be discarded. [NAME] Y stated that the risk of dented canned goods being served to a resident was that it could cause the resident to get sick. [NAME] Y stated that next time this could be prevented by slowing down and double-checking to see if there were any dented canned goods and, if so, removing them immediately when found. In an interview on 03/25/26 at 1:21 PM, [NAME] X stated that she had been working in the kitchen since 2013. [NAME] X stated that all dietary staff had been in-serviced earlier that month and discussed labeling and dating, how to serve food and drinks to residents, what temperatures food should have been tempted at, and resident rights. [NAME] X stated that labels and dates were supposed to have been on all beverages. [NAME] X stated that all cooks, the Dietary Manager, and whoever filled the beverages were responsible for making sure the drinks were labeled with the name of the drink and dated with the use-by date. [NAME] X stated that she was not sure why the pitchers of tea were not labeled and dated, but she was aware that everything should have been labeled and dated. [NAME] X stated that [NAME] D had filled the tea pitchers and was not working that day. [NAME] X stated that the risk of not putting labels and dates on the beverages was that staff would not have been sure when the tea pitchers were made, and it was a health problem if served to someone. [NAME] X stated that all dietary staff were responsible for checking to see if any dented cans were with the regular stock of canned goods and, if found, they were supposed to be removed immediately. [NAME] X stated that dented canned goods being stocked with the regular canned goods were not okay. [NAME] X stated that dented canned goods were kept on the left side of the dry food storage area at the bottom of a shelf. [NAME] X stated that their policy was that when a can was dented, it was supposed to be placed at the bottom of the shelf and then discarded. [NAME] X stated that when the vendor delivered products, staff were supposed to check for dented canned goods, and sometimes the vendor would take the canned goods back or throw them away. [NAME] X stated that the risk of keeping dented canned goods with the regular canned goods was that, if served to a resident, it could cause food poisoning. [NAME] X stated that next time this could be prevented by all dietary staff by checking canned goods and removing dented canned goods immediately. In an interview on 03/25/26 at 1:47 PM, the Dietary Manager stated that she had conducted an in-service yesterday on 03/24/26 and they discussed removing dented cans and labeling and dating items in the kitchen. The Dietary Manager stated that all staff were responsible for making sure all beverages were labeled and dated with the use-by date. The Dietary Manager stated that staff were expected to ensure all beverages were labeled and dated when they were opened, and pretty much as soon as staff were done with the item it needed to be labeled and dated with the use-by date. The Dietary Manager stated that [NAME] D had filled the tea pitchers on the morning of 03/24/26 and was not at work on 03/25/26. The Dietary Manager stated that the risk of beverages not being labeled and dated was that if something was not labeled and dated, it posed a potential risk that a resident could become sick. The Dietary Manager stated that all dented canned goods needed to be removed from the regular stock of canned goods and placed with the dented cans so the facility could receive credit from the vendor when the dented canned goods were returned. The Dietary Manager stated that all kitchen staff were responsible for removing dented canned goods from the regular stock of canned goods. The Dietary Manager stated that the risk of having dented canned goods with the regular stock of canned goods was that a resident could get sick if served, especially if something was growing inside the dented canned goods and staff were unaware of it. In an interview on 03/26/26 at 2:35 PM, the administrator stated that the expectation of dietary staff was that they should have been following policy for the dented canned goods and the pitchers of tea that were found. The administrator stated that the policy for dented canned goods was that they had to be separated and, if dented, they could not be used. The administrator stated that the policy for labeling and dating was that all dietary staff had to label and date all items in the kitchen. The administrator stated that the risk of the pitchers of tea not being labeled and dated was that staff would not know what was in the pitcher, and the contents could be given to a resident who was not supposed to have it. The administrator stated that the risk of dented canned goods being with the regular stock of canned goods was that it could affect the contents of the food, which might not have been safe for consumption if staff used the dented canned goods. Record review of the facility's policy titled Food Storage, dated 12/2020, reflected in part: Purpose: To establish guidelines for storing, thawing, and preparing food. Policy: Food items would be stored, thawed, and prepared in accordance with good sanitary practice. C. Dented or bulging cans should have been placed in a separate storage area and returned for credit. H. Products should have been labeled and dated.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #179) of 6 residents reviewed for baseline care plans. The facility failed to develop a baseline care plan for Resident #179 within 48 hours of admission. This failure had the potential to place newly admitted residents at risk of not receiving effective, person-centered care.Findings included:Record review of Resident #179's face sheet, dated 03/26/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the bladder (bladder cancer), acute ischemic heart disease (reduced blood flow of the heart), orthostatic hypotension (a sudden drop in blood pressure), hypercalcemia (abnormally high calcium levels in the blood), anemia (low levels of healthy red blood cells), Type 2 diabetes, insomnia (difficulty falling asleep), hypertension (high blood pressure), extrarenal uremia (buildup of waste products in the blood), adult failure to thrive, cachexia (wasting syndrome), and systemic inflammatory response syndrome (inflammation throughout the whole body).Record review of Resident #179's MDS assessment dated [DATE], reflected a BIMS score of 10.Record review of Resident #179's EHR under the assessments tab reflected no baseline care plan, and the baseline care plan was shown in red with the date 03/14/26.In an observation on 03/24/26 at 9:21 AM, Resident #179 was lying down in bed asleep he was observed breathing but he was not alerted to be interviewed. In an interview on 03/24/26 at 9:25 AM, the ADON stated Resident #179 was a new admit and he had come from the hospital. The ADON stated that she was unsure how many days he had left to live but Resident #179 was dying due to the diagnosis of bladder cancer. In an interview on 03/26/26 at 10:35 AM, LVN E stated that she had been working for the facility since November 2024. LVN E stated that the RN was responsible for making sure all baseline care plans were completed. LVN E stated that the baseline care plan was supposed to have been entered into the EHR within 24 hours of a resident being admitted . LVN E stated that the baseline care plan was located under the assessments tab in PCC and would not have been anywhere else in the system. LVN E stated that if the baseline care plan was not in PCC and appeared in red, it meant it was overdue. LVN E stated that the risk of a resident not having a baseline care plan was that the resident would not have been able to receive proper care.In an interview on 03/26/26 at 10:48 AM, RN F stated that she had been working for the facility since May 2021. RN F stated that the DON was responsible for making sure baseline care plans were completed and entered into PCC. RN F stated that baseline care plans were supposed to have been entered into PCC within 24 hours of discussing the plan with the family after reaching an agreement. RN F stated that the risk of a resident not having a baseline care plan was that the resident might not have received the correct treatment or could have experienced delayed care.In an interview on 03/26/26 at 1:08 PM, LVN G stated that she had been working for the facility for a year. LVN G stated that the IDT was responsible for completing baseline care plans and entering them into the EHR system. LVN G stated that the ADON, the DON, therapy nurses, treatment nurse, MDS, and even the kitchen staff were all part of the IDT. LVN G stated that baseline care plans should have been completed right after the resident was admitted or within 48 hours. LVN G stated that there was only a risk if a nurse did not know what was going on. LVN G stated that the policy for completing a baseline care plan was that it should not have exceeded 48 hours.In an interview on 03/26/26 at 1:32 PM, the MDS Coordinator stated that the baseline care plan was a user-defined assessment and automatically opened in PCC when a resident was admitted , and the IDT was supposed to go in and edit the assessment. The MDS Coordinator stated that if the baseline care plan was in red in PCC, that meant it was overdue. The MDS Coordinator stated that the baseline care plan was supposed to be completed within 72 hours. The MDS Coordinator stated that she did not believe the baseline care plan not being in PCC posed a risk because they discussed every morning what needed to be done for the residents. She then stated that it could have posed a risk if the baseline care plan was not in PCC. She stated that she would have had to look at the policy on baseline care plans to know what it said, but she presumed it stated the baseline care plan had to be in PCC within 72 hours.In an interview on 03/26/26 at 1:44 PM, the Social Worker stated that the IDT was responsible for making sure baseline care plans were completed and entered in PCC. The Social Worker stated that the baseline care plan was supposed to have been completed within 24 to 48 hours of a resident being admitted . The Social Worker stated that if the baseline care plan was in red in PCC, that could have indicated that the care plan was not completed. The Social Worker stated that a resident could have been at risk for unmet needs because the care plan was missing, and staff could not have fully identified the resident's needs. The Social Worker stated that the IDT had completed the baseline care plan on 03/13/26, but there was a failure to enter the plan into the system. The Social Worker stated that the baseline care plan was supposed to have been entered into the system the same day the plan was completed with the IDT team. The Social Worker stated that they had an in-service on 03/26/26 due to the baseline care plan not being entered into the system for Resident #179.In an interview on 03/26/26 at 2:10 PM, the DON stated that all nurses were responsible for completing the baseline care plan, and it was usually the admitting nurse who was supposed to make sure it was completed and entered in PCC. The DON stated that the baseline care plan should be completed within 48 hours of admission. The DON stated that she was unsure why the baseline care plan was not in PCC, but that it had been completed. The DON stated that the baseline care plan should have been entered into PCC within 48 hours and on the same day the meeting was held. The DON stated that social services audited the charts to ensure the baseline care plan was completed. The DON stated that she also typically audited the charts to ensure the baseline care plan was completed. The DON stated that the risk of the baseline care plan not being in PCC was that the information would not have been shared with the rest of the team. The DON stated that they had completed a refresher in-service on baseline care plans on 03/26/26. In an interview on 03/26/26 at 2:35 PM, the administrator stated that staff should have been following policy with baseline care plans and that it should have been completed within 48 hours unless it was a weekend, which could have caused a delay when staff were not around. The administrator stated that the expectation of staff was that they should had completed the baseline care plan as soon as possible. The administrator stated that ideally the baseline care plan should be entered into PCC as soon as the meeting with the IDT was completed. The administrator stated that the risk of the baseline care plan not being completed and entered in PCC was that resident care could be affected.Record review of the facility policy titled Care Planning, dated 06/2020 reflected the following, in part:Purpose: To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs.Policy: I. The Facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines.II. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs.III. A Licensed Nurse will initiate the Care Plan.Procedure: I. The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission.

Based on observations, interviews, and record review, the facility failed to accommodate resident's allergies for 1 of 6 (Resident #180) residents reviewed for food allergies. The facility failed to ensure Resident #180 did not receive two ketchup packets on his lunch tray which were listed as a food allergy in his medical record. This failure could cause an allergic reaction, a decrease in resident choices, and a diminished interest in meals placing him at risk for contributing to poor intake and/or weight loss. Findings included: Record review of Resident #180's quarterly MDS, dated [DATE], reflected he was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #180 was diagnosed with malnutrition (deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients), bipolar disorder (chronic mental health condition characterized by intense fluctuating mood shifts between high energy [mania or hypomania] and low energy [depression], and complication of diabetes (chronic metabolic disorder characterized by insulin resistance and relative insulin deficiency, leading to high blood sugar) that affects the eyes by causing damage to the blood vessels. Record review of the quarterly MDS also reflected a BIMS score was 15 which indicated he was cognitively intact. Record review of Resident #180's admission Record, dated 03/26/26, reflected Resident #180 had an allergy to tomato, neutral red, and red dye. Record review of Resident #180's Food and Nutrition Profile, dated 03/26/26, reflected Resident #180 had allergies to tomato, neutral red, and red dye. Record review of Resident #180's care plan, dated 1/1/26, reflected: Focus: Allergic to Tomato, Neutral Red, Red Dye Goal: Will not receive Tomato, Neutral Red, Red Dye Interventions/Tasks: Do not administer and/or come in contact with allergen, Inform MD if the allergen is ordered, Make note on chart of all allergies, Notify MD and family of any changes. Observation on 03/26/26 at 12:32 PM of Resident #180's tray revealed two tomato ketchup packets on Resident #180's lunch tray. Observation of Resident #180's tray ticket, dated 03/26/26, reflected: Allergies: Red Food Color; Tomatoes. Interview on 03/26/26 at 12:35 PM revealed Resident #180 had received his lunch tray with the ketchup packets on the tray. Resident #180 stated that the kitchen had put the ketchup on the tray. Resident #180 stated he would not eat the ketchup because he was allergic to it. Resident #180 stated that if he ate the ketchup, he would begin to itch all over his body, and his throat would begin to close. Resident #180 said that he must take an antihistamine to relieve the symptoms. Resident #180 stated that these symptoms were uncomfortable, and he did not want to experience these types of symptoms. Resident #180 also stated that he had informed the nursing staff on multiple occasions that he was allergic to these types of foods, but the types of foods continued to be put on his tray and served to him. Resident #180 stated that he would usually send his tray back if an item like tomatoes was on his plate and requested an alternative. And due to the length of time it took to get a new tray, he would normally not end up eating his meal. Interview and observation on 03/26/26 at 1:05 PM with LVN A revealed that nurses should check their residents' trays before they are given to their residents. LVN A stated that when the nurses checked the residents' trays, they should check to verify the residents' meal ticket order versus what was served from the kitchen. LVN A said that the nurses should check the residents' allergies that are listed on their meal tickets. LVN A stated that she was Resident #180's nurse, but she did not check Resident #180's tray on 03/26/26. LVN A stated that Resident #180 was cognitive and aware of his allergies. LVN A revealed that Resident #180 knew not to use ketchup due to his allergy to tomatoes. LVN A stated she would have served him the tray the way it came from the kitchen and would not have removed the ketchup packets on Resident #180's tray because of his high cognition. LVN A stated that if a resident had low cognition, she would remove any item they were allergic to when checking their trays before serving them. LVN A stated that when Resident #180 ate food that he was allergic to, he would get a rash that irritated him. LVN A said that Resident #180 did not require an epinephrine injector (a prescription auto-injector device used for immediate self-administration of epinephrine to treat life-threatening, emergency allergic reactions) if he ate tomato or ketchup. LVN A stated that she would notify the DON, dietary manager, and physician if a resident experienced a negative allergic reaction from eating an item that should not have been on their tray during a meal. LVN A was observed by the surveyor discussing the incident with the dietary manager immediately after the interview. Interview on 03/26/26 at 1:16 PM with the Dietary Manager revealed that she had just been informed by LVN A that her staff served Resident #180, who has an allergy to tomatoes, his lunch tray with ketchup packets. The Dietary Manager stated that when a resident has a food allergy, that allergy should be printed on their meal tickets to alert staff of the allergy and remind them not to include those items on the resident's tray. The Dietary Manager said the serving staff was responsible for ensuring that nothing with that product was placed on the tray. The Dietary Manager revealed that the resident's nurse should check the resident's tray before it was served to the resident to ensure that there was no item on the plate that could cause an allergic reaction. The Dietary Manager also stated residents could get sick from the allergic reaction to the food they ate served on their tray. The Dietary Manager said that she would in-service her staff immediately to look closer at residents' tickets to ensure they were following the tray tickets when plating residents' meals. Interview on 03/26/26 at 1:23 PM with the Certified Registered Dietician revealed that residents' allergies were obtained through the facility electronic health record system and then put into the facility dining electronic system. The Certified Registered Dietician revealed that this process ensures that residents' allergies are printed on all their tickets. The Certified Registered Dietitian said that the staff who were responsible for preparing the tray should refer to the ticket to ensure that no item that could cause an allergic reaction was placed on the tray. She stated that once the tray gets to the floor, the nursing staff should look at the tray to ensure that the allergy printed on the ticket was not on the tray before given to the resident. The Certified Registered Dietician revealed this was important to prevent an allergic reaction which could cause harm to the residents. She stated the dietary department would in-service their staff to check their tickets when preparing residents' trays. Interview on 03/26/26 at 2:20 PM with the DON revealed that she expected each resident to receive a tray with their correct order including no items they could cause an allergic reaction. The DON stated that the kitchen staff should check each resident's ticket in the kitchen while they prepare the resident's tray. The DON then stated that residents' charge nurses should check their residents' trays before they were passed to verify that residents' ticket orders match their trays to ensure there were no foods on their trays that conflict with their allergy orders. The DON stated that if this process was not followed, a resident could eat something they were allergic to causing anaphylactic shock (severe potentially life-threatening allergic reaction) or some other adverse event. The DON revealed that since she learned about the error on the resident's lunch tray, she began in-servicing her nursing staff. The DON also said that if a resident ate something that caused an allergic reaction, she would notify the resident's physician, responsible party, the administrator, and her regional nurse consultant. Record review of the facility policy, Nutrition/Hydration Management dated 06/20, reflected, Purpose: To Ensure that each resident maintains acceptable parameters of nutritional status, such as body weight, and protein levels, unless the resident's clinical condition demonstrates that this is not possible based on the resident's comprehensive assessment. To ensure that a resident receives a therapeutic diet when there is a nutritional problem.A registered dietician completes a thorough nutritional assessment providing a more detailed profile of the resident's overall nutritional status within 14 days.Key data points to gather include but are not necessarily limited to: C. Food allergies.

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 that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Residents #1) of 6 residents reviewed for dignity. CNA A failed to ensure Resident #1 was provided with a dignified dining experience, when she stood over him as she was assisting him in eating his lunch in the dining room on 12/11/25. This failure could affect the residents by placing them at risk of not having a home-like dining experience and decreased self-esteem. Finding included: Record review of Resident #1's Face Sheet, dated 12/11/25, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included Spastic Quadriplegic cerebral palsy (this is a condition which causes severe muscle stiffness of all limbs, trunk, and face), Unspecified intellectual disability, and major depression disorder (this is a mental health condition that significantly affects how you feel, think and behave). Record review of Resident #1's quarterly MDS assessment, dated 12/04/25, revealed a BIMS score of 00 indicating severe cognitive impairment. The MDS functional abilities reflected, Resident #1 was dependent on staff to eat; the helper does all the effort. Record review of Resident #1's Physician orders for December 2025 reflected:- Regular diet, puree texture, mildly thick consistency. Record review of Resident #1's care plan initiated on 07/01/25 reflected a focus of risk for potential nutritional problems related to contractures and diagnosis of CP, requires staff assistance of one for all meal in-take. Resident #1 was unable to sit up or bend at the waist and therefore must remain in a supine position (laying on back), this increases his risk for choking and aspiration (this is when food or liquid goes into the lungs) when consuming food or fluids. The goal was for Resident #1 to maintain adequate nutritional status as evidenced by no significant weight changes. Interventions included: Diet was regular puree with mildly thickened liquids and to educate, explain and reinforce to the residents the potential for choking and aspiration (food/liquids go into the lungs) and the consequences involved with his chosen positioning for meals. During dining room observation on 12/11/25 from 12:20PM to 12:44 pm of the lunch meal service, revealed CNA A was feeding Resident #1. CNA A was in a standing position with the dining table that had the food and drink behind her while assisting Resident #1 with the meal service. Resident#1 was in a reclined position in his wheelchair. CNA A picked up the plate of food that was behind her on the table and gave him a few bites of food. She then slightly turned and placed the plate back on the table behind her and gave Resident #1 a drink, then gave him a few more bites of his food while standing over him. Interview with CNA A on 12/11/25 at 2:13 PM revealed she had been helping Resident #1 eat his meals since his admission. CNA A said that Resident #1 was always in a flat reclined position during his meal and because of his condition (Cerebral Palsy) which prevented him from bending to sit upright in his chair. She said she always sat down when assisting him eat. She said she was looking for a chair to sit on but did not see one that was clean. She said that Resident #1 got restless when he was not fed on time and she gave him a few bites while she waited for a coworker to look her way so that she could signal them to bring her a clean chair to sit on. She said that everyone was too busy but, she eventually got a chair herself and sat down. She said the risk of standing over the resident during mealtimes was loss of a dignified dining experience. Interview with DON on 12/11/25 at 3:00 PM, revealed that she expected the staff feeding residents to sit down to help promote the residents' dignity. The DON said CNA A told her that because of Resident #1's supine reclined position in his chair, it made her nervous to sit down while she was feeding him. The DON stated it was important to be at the same eye level to help the residents feel comfortable and to feel free to communicate their needs while assisting them to eat. She said sitting down during meal assistance promoted a respectful environment and dignity. In an interview with the Administrator on 12/11/25 at 4:06 PM, it was revealed he told CNA A to get a chair to sit when he saw her standing in the dining room while she helped Resident #1 to eat. He said the expectation was for residents to feel at home. He said the reclined position of Resident# 1 could make it a challenge to sit. He said the risk was not homelike dining experience. Record review of the facility policy titled, Resident Rights, revised 08/2020, reflected, All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. The Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Facility will protect and promote.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to be free from abuse for one resident (Resident #1) of ten residents reviewed for abuse. -The facility failed to ensure that Resident #1 was free from physical abuse when he alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for Methadone for which he did not have an order for. Resident #1 was transported to the local hospital on 4/30/25 and diagnosed with hypoxia (low oxygen) likely due to acute-on-chronic systolic heart failure. An Immediate Jeopardy (IJ) was identified on 5/07/25 at 1:56 PM and an IJ Template was provided to the Administrator at 3:00 PM. While the IJ was removed on 5/08/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for abuse. Findings included: Record review of Resident #1's face sheet, dated 5/08/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute systolic (congestive) heart failure, unspecified sequelae of cerebral infarction (stroke), major depressive disorder (mood disorder), and hx of cocaine and alcohol abuse. Record review of Resident #1's quarterly MDS assessment, dated 04/21/25, reflected his BIMS score was 12, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required moderate to maximal assistance with most ADLs and used a motorized wheelchair. The MDS Assessment under Section N-Medications, reflected Resident #1 was prescribed medication under the high-risk drug class that included and opioid. Record review of Resident #1's care plan, revised 5/05/25, reflected the resident required pain management r/t to generalized pain that included Gabapentin and Norco. Interventions included: administering analgesia (pain reliever) as ordered, anticipating the resident's need for pain relief immediately to any complaint of pain, monitoring/recording/reporting to nurse any s/sx of non-verbal pain, monitoring/recording/reporting to nurse loss of appetite, refusal to eat, and weight loss, monitoring/recording/reporting to nurse complaints of pain or requests for pain treatment, and observing and reporting changes in usual routine. Further review of this document reflected it was revised on 5/05/25 to reflect that Resident #1 had a history of drug abuse prior to admission to facility. Resident #1 had gone out to hospital and noted to have non prescribed narcotic medication in his system. Interventions included: Drug abuse policy was given to resident with education and signature, Narcan (medication to reverse opioid/narcotic overdose) provided PRN, psychiatric medication management NP to see resident, referral to psychiatric services, resident was offered rehabilitation services and declined, and resident was seen by psychologist. Record review of Resident #1's active consolidated physician orders, dated 5/08/25, reflected in part the following: -HYDROcodone-Acetaminophen oral tablet 5-325 MG (for pain relief) - give 1 tablet by mouth every 6 hours as needed for pain. Hold medication if drowsy and notify MD. -Gabapentin oral capsule 300 MG (for pain relief) - give 1 capsule by mouth three times a day for pain. Hold medication if drowsy and notify MD. Further review of this document revealed there was not an order for Methadone. Record review of Resident #1's hospital records, dated 4/30/25, reflected in part the following: HPI: 64 [sic] y.o. male with a past medical history of GERD, hyperlipidemia, hypertension, diabetes mellitus stroke, seizure disorder who was brought into ER from nursing home because of respiratory distress. During my encounter [Resident #1] was on BiPAP and poor historian so history is taken from ER notes. As per ER [Resident #1] is on opioid outpatient in likely took more than dysuria of narcotics and later on was found to be short of breath and drowsy for which EMS was called. On arrival to ER [Resident #1] was found to be drowsy and was given Narcan, [Resident #1] responded very well to Narcan however got very anxious for which morphine was administer after my suspicion of an opioid withdrawal. ABGs: PH 7.25 (normal range 7.35-7.45), pC02 58.7 (normal range 32.0-45.0 mmHg), P02 98 (normal range 83.0-108.0 mmHg). [Resident #1] was on non-rebreather mask initially and was later on placed on BiPAP. CTA chest negative for PE or pleural effusions. Troponin 122 (normal range 38.73-80.22 ng/L), BNP 125 (normal range less than 100 pg/mL). [Resident #1] was given Lasix 100 mg IV once and breathing treatment as well. Review of system is limited as [Resident #1] is on BiPAP and lethargic during my encounter. . Labs: Specimen: Clean Catch; Urine Methadone- Positive Opiate- Positive . Hospital Course/Long LOS Summary: [Resident #1] is a [AGE] year-old male with past medical history of systolic heart failure, diabetes, hypertension, sleep apnea, and chronic pain who presented to the emergency room for altered mental status and shortness of breath. [Resident #1] was admitted for acute hypoxic respiratory failure requiring supplemental O2 and BiPAP to maintain O2 saturation >92%. Likely related to acute on chronic systolic heart failure versus community acquired or aspiration pneumonia. [Resident #1] was started on IV Lasix (water pill) with good urine output. Discharge plan pending clinical improvement. . Record review of Resident #1's progress note, dated 4/30/25 at 9:30 AM by LVN A, reflected the following: [Resident #1] not alert and SOB noted. [Resident #1] responsive only to sternal rub. b/p 142/90 p137 r22 o2 sat 47% on RA. Applied o2 via mask rebreather at 15l. o2 sat 92%. EMS called and [Resident #1] transferred to [name] ED. Record review of a document titled Resident Out on Pass Log, dated 4/20/25-5/07/25, reflected Resident #1 had not signed out to leave the facility. Record review of Resident #1's EHR reflected the resident was seen by a psychologist to address his s/sx of depression on 5/05/25. The recommendations reflected the following: -Psychological consultation is recommended to assist staff in developing and implementing behavior plans to reduce [Resident 1's] affective and/or cognitive symptoms. -Individual therapy to reduce [Resident 1's] affective and/or cognitive symptoms. -Referral for medication evaluation. Record review of an in-service titled Abuse and Neglect, dated 5/01/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Resident Drug and Alcohol Abuse, dated 5/05/25, reflected all staff were educated on the facility's policy on drugs and alcohol. Record review of an in-service titled Intoxicated Residents, dated 5/05/25, reflected all staff were educated on recognizing s/sx of an intoxicated resident and who to notify. Record review of an in-service titled Naloxone Administration, dated 5/06/25, reflected all nurses were educated on the protocol for administering Naloxone to a resident suspected of an overdose. In an interview and observation on 5/06/25 at 11:42 AM, Resident #1 was sitting in his wheelchair in his room. He was dressed and well-groomed with no s/sx of distress. Observation of the room revealed it was clean with no evidence of drugs, alcohol, or paraphernalia. Resident #1 immediately asked if I was from social services and if he was in trouble. This state investigator stated No and asked Resident #1 about his recent hospital stay. Resident #1 stated he was transported to the hospital for what he thought was another stroke. Resident #1 stated he could not recall what happened but was told that he was found unresponsive in his room. Resident #1 looked concerned, then proceeded to state that he did not want to be in trouble or get anyone else in trouble; however, he became sick after taking Methadone that he received from a staff member. Resident #1 refused to identify the staff. He stated he must have taken too much, and it caused him to pass out. Resident #1 did not recall exactly when he took the drug or how much he consumed. Resident #1 stated he was sad about his mother, who was sick at a different nursing facility, and he needed something to take his mind off it. Resident #1 refused to provide any additional information. In an interview on 5/06/25 at 12:20 PM, LVN A stated she worked at the facility for about 6 months. She stated she worked with Resident #1 on 4/30/25 when he was transported to the ER. LVN A stated she entered Resident #1's room to check his blood sugar at approximately 7:30 AM and found the resident less responsive than usual and exhibited respiratory distress. LVN A stated she immediately called for help while checking Resident #1's vitals. She stated she was unable to get an O2 reading and put the resident on oxygen. LVN A stated EMTs had already been called and arrived at the facility to transfer Resident #1 to the local hospital. LVN A stated initially she was unsure what caused Resident #1's change in condition, but later found it appeared to be from a drug overdose based on clinical records. LVN A stated she was aware Resident #1 had a hx of drug use. She stated she had not ever seen the resident have possession of nonprescription drugs or use them at the facility. LVN A stated she had never seen any staff members or other residents with nonprescription drugs. She stated the staff were in-serviced on the facility's drug policy on 5/05/25. In an interview on 5/06/25 at 1:10 PM, RN B stated she worked at the facility since 2019. She stated she worked with Resident #1 during the incident on 4/30/25. RN B stated the nurses were checking blood sugars on the hall when LVN A called for her help in Resident #1's room. RN B stated LVN A informed that she was unable to obtain an O2 reading from Resident #1, and he was unresponsive. RN B stated when she entered the room, she found that Resident #1 was breathing but was not responding normally. She stated after calling his name loudly a few times, Resident #1 opened his eyes and said Yes then went back to sleep. RN B stated Resident #1 needed constant engagement to stay alert. RN B stated she remained in the room with Resident #1 until EMTs arrived. In an interview on 5/06/25 at 1:54 PM with the DON and Administrator, the DON stated on 04/30/25 she was alerted by LVN A that Resident #1 was in respiratory distress and needed to be sent out to the hospital. This state investigator informed them that Resident #1 admitted he received the Methadone from a staff member that he refused to identify. The DON stated Resident #1 returned to the facility during the weekend on 5/3/25 and the clinicals showed that Methadone was found in his system. The DON stated the MD and pain management team was notified. The DON stated a care plan meeting with Resident #1 was held on 5/05/25 and during an interview with the resident he denied using any drugs and did not report receiving any drug from staff. The DON stated Resident #1 only stated he was depressed about his mother. The DON stated a referral was sent for psychiatric services and Resident #1 was able to talk with a psychologist on 5/05/25. The Administrator stated staff were in-serviced on the facility's drug policy, s/sx of intoxicated residents, and abuse and neglect. He also stated a Resident Council meeting was scheduled to discuss the facility's drug policy and to see if there were any concerns. The Administrator and DON stated this was new information and they would need to consult with regional managers on how to move forward. In a further interview on 5/06/25 at 3:00 PM with the DON and Administrator, the Administrator stated the Regional Managers advised them to submit a self-report to the state agency and start a provider investigation regarding the alleged abuse. In an interview on 5/07/25 at 9:42 AM with the DON and Administrator, the Administrator stated the facility submitted a self-report to the stated agency and started the provider investigation. The Administrator stated Resident #1 was interviewed again and still denied any drug use and getting drugs from a staff member. The Administrator stated the police were called out and Resident #1 also denied everything to them. In a further interview on 5/07/25 at 11:50 AM with the DON and Administrator, The DON stated she received and reviewed Resident #1's hospital records on 5/02/25, prior to the resident discharging from the hospital, when it was found that Methadone was in the resident's system. The DON stated Resident #1 did not have an order to take Methadone at the facility and was not receiving any outpatient treatment where he would receive Methadone. The Administrator stated the incident had just happened and they were still gathering information to determine what happened, which is why a self-report was not submitted prior to the state investigator entering the facility. In an interview on 05/07/25 at 3:45 PM with the Regional Nurse Consultant and Regional Director of Operations, the Regional Nurse Consultant stated she was informed by the DON on 5/02/25 that Resident #1's hospital records indicated there was Methadone found in his system and she advised the DON to start an investigation. The Regional Director of Operations stated the facility began reviewing the resident sign-out logs, in-servicing staff, auditing medications in the facility to check for Methadone/narcotics and medication errors, and conducting safe surveys with staff and residents. The Regional Director of Operations stated the investigation continued over the weekend, with the DON doing pop-up visits to check the facility for drugs. Both Regional managers stated they were not sure why the DON and Administrator did not provide this information prior to the Immediate Jeopardy being called. This state investigator informed that the only evidence that was provided prior to the Immediate Jeopardy being called were the staff in-services, Resident #1's psychology assessment note, Resident #1's care plan conference notes, and a scheduled Resident Council Meeting to discuss the facility's drug policy. There was no evidence of medications audits, safe surveys, interviews, IDT notification, or a report to the state agency provided. Review of the facility's policy titled Abuse Prevention and Prohibition Program, revised 08/2020, reflected in part the following: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy: I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. A. Definitions for the meaning of key terms used in this policy. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. IV. This policy also identifies Special Considerations regarding the investigation of injuries of unknown origin, the reporting of suspected rape, and resident-to-resident abuse. Procedure: . IV Prevention A. Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation. B. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring. . VII Investigation A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. . IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. . Review of the facility's policy titled Resident Drug and Alcohol Abuse, revised 08/2020, reflected in part the following: Purpose: To provide a safe and drug-free environment for residents while at the Facility. Policy Statement: I. The Facility will admit a resident who has a history of drug and alcohol abuse as long as their primary diagnosis is suitable for skilled care at this Facility. II. The Facility has a zero-tolerance policy for the use or possession of illegal drugs (including marijuana) or any type of drug apparatus in the Facility or on the grounds of the Facility. All illegal drugs and/or drug paraphernalia will be confiscated from the resident and /or their room. B. The only drugs permissible at the Facility and/or on Facility grounds are those for which there is an Attending Physician order. IV.Any resident found in violation of this policy will be discharged to a more appropriate setting for care (See Policy Transfer and Discharge). . The Administrator and DON were notified of an Immediate Jeopardy (IJ) on 5/07/25 at 2:57 PM, due to the above failures and the IJ Template was provided at 3:00 PM. The facility's Plan of Removal (POR) was accepted on 5/08/25 at 12:30 PM and included: Date: 5/7/25 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes. F600 Free from Abuse On 5/6/25, during a complaint survey at [Nursing Facility]. The facility failed to ensure Resident #1 was free from abuse when he suffered respiratory distress after taking methadone that the resident reported was provided by a staff member. The notification of the alleged immediate jeopardy states as follows: Resident #1 is a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included: hx of stroke, major depressive disorder, and hx of alcohol and cocaine abuse. On 4/29/25 [sic], Resident# l was found to be in respiratory distress and less aroused than usual. He was sent out to the local hospital where he was diagnosed with hypoxia (low oxygen) likely due to acute-on-chronic systolic heart failure with labs that were positive for methadone. Identify residents who could be affected: All Residents have the potential to be affected by this deficiency Identify responsible staff/ what action taken: 1. Alleged employee suspended pending investigation. Last day employee worked was 4/27/25 2. Attending Physicians was notified of the incident involving the resident on 5/2/25 3. Trauma screen was completed on 5/6/25. 4. Police notified on 5/6/25. 5. Resident referred to Deer OAKS for psychological assessment on 5/5/25 6. Care plans updated on 5/5/25 7. Reviewed out on pass for 5/2/25 8. Reviewed advance entry for visitors on 5/2/25 9. Reviewed facility medications for use of methadone 5/2/25 10. Completed care plan conference with residents on 5/5/25 11. Resident seen by psychologist on 5/5/25 12. Drug abuse contract and policy discussed with residents and signed 5/5/25 13. Staff in-service on facility drug policy, identifying intoxicated residents, Narcan administration on 5/7/25, and will be completed on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff who are not in-serviced for any reason will receive it before the start of the shift. 14. Abuse and neglect in-service started on 5/7 /25 and will be completed on 5/8/25. All staff in services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. 15. 1:1 in-service conducted for DON and Administrator on Abuse and Neglect Policy. In-service conducted by RDO and RNC on 5/7/25 16. Staff and resident questionnaires 5/5/25. 17. Safe surveys on 5/2/25 18. Offered drug rehab services to resident 5/5/25 Implementation of Changes: 1. Audit of all residents who have a drug history or potential for drug use and have completed the drug policy acknowledgement form. This started on 5/7/25 and will end on 5/8/25. This will be ongoing to ensure all new admits and changes are made where necessary. This will be conducted by the DON or Designee. 2. Appropriate interventions are being put in place as needed. 3. All staff were re-educated on identifying intoxicated residents and the resident drug and alcohol abuse policy. This started on 5/7/25 and will end on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive then1 before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. 4. Staff (nurses) in-service on facility drug policy, identifying intoxicated residents, Narcan administration, abuse, and neglect started on 5/7/25 and will end on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. Monitoring: The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted on 5/7 /25 and ongoing. The Administrator/DON will review the effectiveness of this daily X 7 days and weekly X 4 weeks, then X 3 monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discove1y. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 5/6/25 and conducted an Ad HOC QAPI regarding resident drug use. The Medical Director was notified about the immediate Jeopardy on 5/7/25, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA: An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 5/7/25. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of Process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 5/7/25. On 5/08/25 the investigator began monitoring (12:30 PM-2:45 PM) to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observation, interview, and record review on 5/08/25, 12:30 PM-1:15 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 revealed no concerns for abuse . Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status. Observations and interviews with residents and/or RPs revealed no concerns for abuse. The residents denied receiving any nonprescription drugs from staff or other residents. They also denied being physically, mentally, or emotionally abused. Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, nurses, CMAs, and CNAs: RN B (1st shift), CNA F (1st shift), LVN L (3rd shift), MDS Nurse/LVN M (1st shift), LVN N (2nd shift), CMA O (2nd shift), CMA P (1st shift), CNA Q (2nd shift), RN R (PRN/all shifts), CNA S (2nd/3rd shift/weekends), RN T (2nd shift), CNA U (3rd shift), and LVN V (2nd shift) indicated they all participated in in-service trainings starting on 5/07/25-5/08/25. All staff were able to state per the facility's policy on drugs and alcohol that the facility was zero tolerance for drugs and alcohol on the premises unless ordered for the residents by the MD. The staff were able to state s/sx of intoxicated residents and who to report it to. The staff were also able to state how to identify and report any suspected or reported abuse. In addition, the nurses were able to state the protocol for identifying and treating residents suspected of an overdose and who to report it to. The Administrator and DON understood that it was their responsibility to implement the interventions and monitor for effectiveness. Record review of an in-service titled Resident Drug and Alcohol Abuse, dated 5/07/25, reflected all staff were re-educated on the facility's policy on drugs and alcohol. Record review of an in-service titled Intoxicated Residents, dated 5/07/25, reflected all staff were re-educated on recognizing s/sx of an intoxicated resident and who to notify. Record review of an in-service titled Abuse and Neglect, dated 5/07/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Naloxone Administration, dated 5/07/25, reflected all nurses were re-educated on the protocol for administering Naloxone to a resident suspected of an overdose. Record review of a document provided by the Administrator titled Drug & Alcohol Abuse Policy Acknowledgement & Consent dated 5/07/25, reflected the DON audited all residents who had a drug history, reviewed the drug and alcohol policy, and signed updated acknowledgement forms. Record review of an in-service titled Abuse and Neglect, dated 5/08/25, reflected the Administrator and DON were educated by the Regional Nurse Consultant and Regional Director of Operations regarding coordinating and implementing the facility's abuse and prevention policy and procedure. On 5/08/25 at 1:57 PM, the Administrator provided documents from an investigation binder that included the following: -Safe survey, dated 5/02/25 - Resident #1's Care Plan Conference notes, dated 5/05/25 - Resident #1's psychology/behavioral note, dated 5/05/25 -Resident #1's signed behavioral contract, dated 5/05/25 -Trauma screening for Resident #1, dated 5/06/25 - Police Report, dated 5/06/25 -Resident Drug and Alcohol Abuse Questionnaire, dated 5/06/25 -Corrective Action Memo for Activity Staff, dated 5/06/25 (which indicated the Activity Staff was suspended pending an investigation of abuse) -Self-report to state agency, dated 5/06/25 An Immediate Jeopardy (IJ) was identified on 5/07/25 at 1:56 PM and an IJ Template was provided to the Administrator at 3:00 PM. While the IJ was removed on 5/08/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for one resident (Resident #1) of ten residents reviewed for abuse. -The facility failed to implement the abuse and neglect policy and procedures to ensure that Resident #1 was free from physical abuse when he alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for Methadone for which he did not have an order for. Resident #1 was transported to the local hospital on 4/30/25 and diagnosed with hypoxia (low oxygen) likely due to acute-on-chronic systolic heart failure. An Immediate Jeopardy (IJ) was identified on 5/07/25 at 1:56 PM and an IJ Template was provided to the Administrator at 3:00 PM. While the IJ was removed on 5/08/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place all residents at an increased risk for abuse and neglect. Findings included: Review of the facility's policy titled Abuse Prevention and Prohibition Program, revised 08/2020, reflected in part the following: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy: I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. A. Definitions for the meaning of key terms used in this policy. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. IV. This policy also identifies Special Considerations regarding the investigation of injuries of unknown origin, the reporting of suspected rape, and resident-to-resident abuse. Procedure: . IV Prevention A. Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation. B. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring. . VII Investigation A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. . IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. . Review of the facility's policy titled Resident Drug and Alcohol Abuse, revised 08/2020, reflected in part the following: Purpose: To provide a safe and drug-free environment for residents while at the Facility. Policy Statement: I. The Facility will admit a resident who has a history of drug and alcohol abuse as long as their primary diagnosis is suitable for skilled care at this Facility. II. The Facility has a zero-tolerance policy for the use or possession of illegal drugs (including marijuana) or any type of drug apparatus in the Facility or on the grounds of the Facility. All illegal drugs and/or drug paraphernalia will be confiscated from the resident and /or their room. B. The only drugs permissible at the Facility and/or on Facility grounds are those for which there is an Attending Physician order. IV.Any resident found in violation of this policy will be discharged to a more appropriate setting for care (See Policy Transfer and Discharge). . Record review of Resident #1's face sheet, dated 5/08/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute systolic (congestive) heart failure, unspecified sequelae of cerebral infarction (stroke), major depressive disorder (mood disorder), and hx of cocaine and alcohol abuse. Record review of Resident #1's quarterly MDS assessment, dated 04/21/25, reflected his BIMS score was 12, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required moderate to maximal assistance with most ADLs and used a motorized wheelchair. The MDS Assessment under Section N-Medications, reflected Resident #1 was prescribed medication under the high-risk drug class that included and opioid. Record review of Resident #1's care plan, revised 5/05/25, reflected the resident required pain management r/t to generalized pain that included Gabapentin and Norco. Interventions included: administering analgesia (pain reliever) as ordered, anticipating the resident's need for pain relief immediately to any complaint of pain, monitoring/recording/reporting to nurse any s/sx of non-verbal pain, monitoring/recording/reporting to nurse loss of appetite, refusal to eat, and weight loss, monitoring/recording/reporting to nurse complaints of pain or requests for pain treatment, and observing and reporting changes in usual routine. Further review of this document reflected it was revised on 5/05/25 to reflect that Resident #1 had a history of drug abuse prior to admission to facility. Resident #1 had gone out to hospital and noted to have non prescribed narcotic medication in his system. Interventions included: Drug abuse policy was given to resident with education and signature, Narcan (medication to reverse opioid/narcotic overdose) provided PRN, psychiatric medication management NP to see resident, referral to psychiatric services, resident was offered rehabilitation services and declined, and resident was seen by psychologist. Record review of Resident #1's active consolidated physician orders, dated 5/08/25, reflected in part the following: -HYDROcodone-Acetaminophen oral tablet 5-325 MG (for pain relief) - give 1 tablet by mouth every 6 hours as needed for pain. Hold medication if drowsy and notify MD. -Gabapentin oral capsule 300 MG (for pain relief) - give 1 capsule by mouth three times a day for pain. Hold medication if drowsy and notify MD. Further review of this document revealed there was not an order for Methadone. Record review of Resident #1's hospital records, dated 4/30/25, reflected in part the following: HPI: 64 [sic] y.o. male with a past medical history of GERD, hyperlipidemia, hypertension, diabetes mellitus stroke, seizure disorder who was brought into ER from nursing home because of respiratory distress. During my encounter [Resident #1] was on BiPAP and poor historian so history is taken from ER notes. As per ER [Resident #1] is on opioid outpatient in likely took more than dysuria of narcotics and later on was found to be short of breath and drowsy for which EMS was called. On arrival to ER [Resident #1] was found to be drowsy and was given Narcan, [Resident #1] responded very well to Narcan however got very anxious for which morphine was administer after my suspicion of an opioid withdrawal. ABGs: PH 7.25 (normal range 7.35-7.45), pC02 58.7 (normal range 32.0-45.0 mmHg), P02 98 (normal range 83.0-108.0 mmHg). [Resident #1] was on non-rebreather mask initially and was later on placed on BiPAP. CTA chest negative for PE or pleural effusions. Troponin 122 (normal range 38.73-80.22 ng/L), BNP 125 (normal range less than 100 pg/mL). [Resident #1] was given Lasix 100 mg IV once and breathing treatment as well. Review of system is limited as [Resident #1] is on BiPAP and lethargic during my encounter. . Labs: Specimen: Clean Catch; Urine Methadone- Positive Opiate- Positive . Hospital Course/Long LOS Summary: [Resident #1] is a [AGE] year-old male with past medical history of systolic heart failure, diabetes, hypertension, sleep apnea, and chronic pain who presented to the emergency room for altered mental status and shortness of breath. [Resident #1] was admitted for acute hypoxic respiratory failure requiring supplemental O2 and BiPAP to maintain O2 saturation >92%. Likely related to acute on chronic systolic heart failure versus community acquired or aspiration pneumonia. [Resident #1] was started on IV Lasix (water pill) with good urine output. Discharge plan pending clinical improvement. . Record review of Resident #1's progress note, dated 4/30/25 at 9:30 AM by LVN A, reflected the following: [Resident #1] not alert and SOB noted. [Resident #1] responsive only to sternal rub. b/p 142/90 p137 r22 o2 sat 47% on RA. Applied o2 via mask rebreather at 15l. o2 sat 92%. EMS called and [Resident #1] transferred to [name] ED. Record review of a document titled Resident Out on Pass Log, dated 4/20/25-5/07/25, reflected Resident #1 had not signed out to leave the facility. Record review of Resident #1's EHR reflected the resident was seen by a psychologist to address his s/sx of depression on 5/05/25. The recommendations reflected the following: -Psychological consultation is recommended to assist staff in developing and implementing behavior plans to reduce [Resident 1's] affective and/or cognitive symptoms. -Individual therapy to reduce [Resident 1's] affective and/or cognitive symptoms. -Referral for medication evaluation. Record review of an in-service titled Abuse and Neglect, dated 5/01/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Resident Drug and Alcohol Abuse, dated 5/05/25, reflected all staff were educated on the facility's policy on drugs and alcohol. Record review of an in-service titled Intoxicated Residents, dated 5/05/25, reflected all staff were educated on recognizing s/sx of an intoxicated resident and who to notify. Record review of an in-service titled Naloxone Administration, dated 5/06/25, reflected all nurses were educated on the protocol for administering Naloxone to a resident suspected of an overdose. In an interview and observation on 5/06/25 at 11:42 AM, Resident #1 was sitting in his wheelchair in his room. He was dressed and well-groomed with no s/sx of distress. Observation of the room revealed it was clean with no evidence of drugs, alcohol, or paraphernalia. Resident #1 immediately asked if I was from social services and if he was in trouble. This state investigator stated No and asked Resident #1 about his recent hospital stay. Resident #1 stated he was transported to the hospital for what he thought was another stroke. Resident #1 stated he could not recall what happened but was told that he was found unresponsive in his room. Resident #1 looked concerned, then proceeded to state that he did not want to be in trouble or get anyone else in trouble; however, he became sick after taking Methadone that he received from a staff member. Resident #1 refused to identify the staff. He stated he must have taken too much, and it caused him to pass out. Resident #1 did not recall exactly when he took the drug or how much he consumed. Resident #1 stated he was sad about his mother, who was sick at a different nursing facility, and he needed something to take his mind off it. Resident #1 refused to provide any additional information. In an interview on 5/06/25 at 12:20 PM, LVN A stated she worked at the facility for about 6 months. She stated she worked with Resident #1 on 4/30/25 when he was transported to the ER. LVN A stated she entered Resident #1's room to check his blood sugar at approximately 7:30 AM and found the resident less responsive than usual and exhibited respiratory distress. LVN A stated she immediately called for help while checking Resident #1's vitals. She stated she was unable to get an O2 reading and put the resident on oxygen. LVN A stated EMTs had already been called and arrived at the facility to transfer Resident #1 to the local hospital. LVN A stated initially she was unsure what caused Resident #1's change in condition, but later found it appeared to be from a drug overdose based on clinical records. LVN A stated she was aware Resident #1 had a hx of drug use. She stated she had not ever seen the resident have possession of nonprescription drugs or use them at the facility. LVN A stated she had never seen any staff members or other residents with nonprescription drugs. She stated the staff were in-serviced on the facility's drug policy on 5/05/25. In an interview on 5/06/25 at 1:10 PM, RN B stated she worked at the facility since 2019. She stated she worked with Resident #1 during the incident on 4/30/25. RN B stated the nurses were checking blood sugars on the hall when LVN A called for her help in Resident #1's room. RN B stated LVN A informed that she was unable to obtain an O2 reading from Resident #1, and he was unresponsive. RN B stated when she entered the room, she found that Resident #1 was breathing but was not responding normally. She stated after calling his name loudly a few times, Resident #1 opened his eyes and said Yes then went back to sleep. RN B stated Resident #1 needed constant engagement to stay alert. RN B stated she remained in the room with Resident #1 until EMTs arrived. In an interview on 5/06/25 at 1:54 PM with the DON and Administrator, the DON stated on 04/30/25 she was alerted by LVN A that Resident #1 was in respiratory distress and needed to be sent out to the hospital. This state investigator informed them that Resident #1 admitted he received the Methadone from a staff member that he refused to identify. The DON stated Resident #1 returned to the facility during the weekend on 5/3/25 and the clinicals showed that Methadone was found in his system. The DON stated the MD and pain management team was notified. The DON stated a care plan meeting with Resident #1 was held on 5/05/25 and during an interview with the resident he denied using any drugs and did not report receiving any drug from staff. The DON stated Resident #1 only stated he was depressed about his mother. The DON stated a referral was sent for psychiatric services and Resident #1 was able to talk with a psychologist on 5/05/25. The Administrator stated staff were in-serviced on the facility's drug policy, s/sx of intoxicated residents, and abuse and neglect. He also stated a Resident Council meeting was scheduled to discuss the facility's drug policy and to see if there were any concerns. The Administrator and DON stated this was new information and they would need to consult with regional managers on how to move forward. In a further interview on 5/06/25 at 3:00 PM with the DON and Administrator, the Administrator stated the Regional Managers advised them to submit a self-report to the state agency and start a provider investigation regarding the alleged abuse. In an interview on 5/07/25 at 9:42 AM with the DON and Administrator, the Administrator stated the facility submitted a self-report to the stated agency and started the provider investigation. The Administrator stated Resident #1 was interviewed again and still denied any drug use and getting drugs from a staff member. The Administrator stated the police were called out and Resident #1 also denied everything to them. In a further interview on 5/07/25 at 11:50 AM with the DON and Administrator, The DON stated she received and reviewed Resident #1's hospital records on 5/02/25, prior to the resident discharging from the hospital, when it was found that Methadone was in the resident's system. The DON stated Resident #1 did not have an order to take Methadone at the facility and was not receiving any outpatient treatment where he would receive Methadone. The Administrator stated the incident had just happened and they were still gathering information to determine what happened, which is why a self-report was not submitted prior to the state investigator entering the facility. In an interview on 05/07/25 at 3:45 PM with the Regional Nurse Consultant and Regional Director of Operations, the Regional Nurse Consultant stated she was informed by the DON on 5/02/25 that Resident #1's hospital records indicated there was Methadone found in his system and she advised the DON to start an investigation. The Regional Director of Operations stated the facility began reviewing the resident sign-out logs, in-servicing staff, auditing medications in the facility to check for Methadone/narcotics and medication errors, and conducting safe surveys with staff and residents. The Regional Director of Operations stated the investigation continued over the weekend, with the DON doing pop-up visits to check the facility for drugs. Both Regional managers stated they were not sure why the DON and Administrator did not provide this information prior to the Immediate Jeopardy being called. This state investigator informed that the only evidence that was provided prior to the Immediate Jeopardy being called were the staff in-services, Resident #1's psychology assessment note, Resident #1's care plan conference notes, and a scheduled Resident Council Meeting to discuss the facility's drug policy. There was no evidence of medications audits, safe surveys, interviews, IDT notification, or a report to the state agency provided. The Administrator and DON were notified of an Immediate Jeopardy (IJ) on 5/07/25 at 2:57 PM, due to the above failures and the IJ Template was provided at 3:00 PM. The facility's Plan of Removal (POR) was accepted on 5/08/25 at 12:30 PM and included: Date: 5/7/25 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes. F600 Free from Abuse On 5/6/25, during a complaint survey at [Nursing Facility]. The facility failed to ensure Resident #1 was free from abuse when he suffered respiratory distress after taking methadone that the resident reported was provided by a staff member. The notification of the alleged immediate jeopardy states as follows: Resident #1 is a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included: hx of stroke, major depressive disorder, and hx of alcohol and cocaine abuse. On 4/29/25 [sic], Resident# l was found to be in respiratory distress and less aroused than usual. He was sent out to the local hospital where he was diagnosed with hypoxia (low oxygen) likely due to acute-on-chronic systolic heart failure with labs that were positive for methadone. Identify residents who could be affected: All Residents have the potential to be affected by this deficiency Identify responsible staff/ what action taken: 1. Alleged employee suspended pending investigation. Last day employee worked was 4/27/25 2. Attending Physicians was notified of the incident involving the resident on 5/2/25 3. Trauma screen was completed on 5/6/25. 4. Police notified on 5/6/25. 5. Resident referred to Deer OAKS for psychological assessment on 5/5/25 6. Care plans updated on 5/5/25 7. Reviewed out on pass for 5/2/25 8. Reviewed advance entry for visitors on 5/2/25 9. Reviewed facility medications for use of methadone 5/2/25 10. Completed care plan conference with residents on 5/5/25 11. Resident seen by psychologist on 5/5/25 12. Drug abuse contract and policy discussed with residents and signed 5/5/25 13. Staff in-service on facility drug policy, identifying intoxicated residents, Narcan administration on 5/7/25, and will be completed on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff who are not in-serviced for any reason will receive it before the start of the shift. 14. Abuse and neglect in-service started on 5/7 /25 and will be completed on 5/8/25. All staff in services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. 15. 1:1 in-service conducted for DON and Administrator on Abuse and Neglect Policy. In-service conducted by RDO and RNC on 5/7/25 16. Staff and resident questionnaires 5/5/25. 17. Safe surveys on 5/2/25 18. Offered drug rehab services to resident 5/5/25 Implementation of Changes: 1. Audit of all residents who have a drug history or potential for drug use and have completed the drug policy acknowledgement form. This started on 5/7/25 and will end on 5/8/25. This will be ongoing to ensure all new admits and changes are made where necessary. This will be conducted by the DON or Designee. 2. Appropriate interventions are being put in place as needed. 3. All staff were re-educated on identifying intoxicated residents and the resident drug and alcohol abuse policy. This started on 5/7/25 and will end on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive then1 before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. 4. Staff (nurses) in-service on facility drug policy, identifying intoxicated residents, Narcan administration, abuse, and neglect started on 5/7/25 and will end on 5/8/25. All staff in-services will be ongoing to ensure all PRN, new staff, and any staff not in-serviced for any reason receive them before the start of the shift. In-service will be conducted by the Administrator/DON or Designee. Monitoring: The Administrator/DON/Designee will be responsible for monitoring the implementation and effectiveness of in-service conducted on 5/7 /25 and ongoing. The Administrator/DON will review the effectiveness of this daily X 7 days and weekly X 4 weeks, then X 3 monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee. All concerns noted will be addressed at the time of discove1y. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 5/6/25 and conducted an Ad HOC QAPI regarding resident drug use. The Medical Director was notified about the immediate Jeopardy on 5/7/25, the Plan of removal was reviewed and accepted by Medical Director. Involvement of QA: An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, to review the plan of removal on 5/7/25. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of Process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 5/7/25. On 5/08/25 the investigator began monitoring (12:30 PM-2:45 PM) to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observation, interview, and record review on 5/08/25, 12:30 PM-1:15 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10 revealed no concerns for abuse. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status. Observations and interviews with residents and/or RPs revealed no concerns for abuse. The residents denied receiving any nonprescription drugs from staff or other residents. They also denied being physically, mentally, or emotionally abused. Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, nurses, CMAs, and CNAs: RN B (1st shift), CNA F (1st shift), LVN L (3rd shift), MDS Nurse/LVN M (1st shift), LVN N (2nd shift), CMA O (2nd shift), CMA P (1st shift), CNA Q (2nd shift), RN R (PRN/all shifts), CNA S (2nd/3rd shift/weekends), RN T (2nd shift), CNA U (3rd shift), and LVN V (2nd shift) indicated they all participated in in-service trainings starting on 5/07/25-5/08/25. All staff were able to state per the facility's policy on drugs and alcohol that the facility was zero tolerance for drugs and alcohol on the premises unless ordered for the residents by the MD. The staff were able to state s/sx of intoxicated residents and who to report it to. The staff were also able to state how to identify and report any suspected or reported abuse. In addition, the nurses were able to state the protocol for identifying and treating residents suspected of an overdose and who to report it to. The Administrator and DON also understood that it was their responsibility to implement the interventions and monitor for effectiveness. The Administrator and DON stated they received 1 on 1 education regarding the facility's abuse and neglect policy and were able to state they were responsible for implementing the policy to ensure all allegations of abuse, neglect, and exploitation were reported and investigated. Record review of the facility's policy titled Abuse Prevention and Prohibition Program, revised 08/2020, reflected in part the following: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. . Record review of an in-service titled Resident Drug and Alcohol Abuse, dated 5/07/25, reflected all staff were re-educated on the facility's policy on drugs and alcohol. Record review of an in-service titled Intoxicated Residents, dated 5/07/25, reflected all staff were re-educated on recognizing s/sx of an intoxicated resident and who to notify. Record review of an in-service titled Abuse and Neglect, dated 5/07/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Naloxone Administration, dated 5/07/25, reflected all nurses were re-educated on the protocol for administering Naloxone to a resident suspected of an overdose. Record review of a document provided by the Administrator titled Drug & Alcohol Abuse Policy Acknowledgement & Consent dated 5/07/25, reflected the DON audited all residents who had a drug history, reviewed the drug and alcohol policy, and signed updated acknowledgement forms. Record review of an in-service titled Abuse and Neglect, dated 5/08/25, reflected the Administrator and DON were educated by the Regional Nurse Consultant and Regional Director of Operations regarding coordinating and implementing the facility's abuse and prevention policy and procedure. On 5/08/25 at 1:57 PM, the Administrator provided documents from an investigation binder that included the following: -Safe survey, dated 5/02/25 - Resident #1's Care Plan Conference notes, dated 5/05/25 - Resident #1's psychology/behavioral note, dated 5/05/25 -Resident #1's signed behavioral contract, dated 5/05/25 -Trauma screening for Resident #1, dated 5/06/25 - Police Report, dated 5/06/25 -Resident Drug and Alcohol Abuse Questionnaire, dated 5/06/25 -Corrective Action Memo for Activity Staff, dated 5/06/25 (which indicated the Activity Staff was suspended pending an investigation of abuse) -Self-report to state agency, dated 5/06/25 An Immediate Jeopardy (IJ) was identified on 5/07/25 at 1:56 PM and an IJ Template was provided to the Administrator at 3:00 PM. While the IJ was removed on 5/08/25, the facility remained out of compliance at a scope of isolated with the severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one resident (Residents #2) of six residents reviewed for respiratory care in that: -The facility failed to ensure that Residents #2, who required continuous oxygen therapy, continued to receive adequate oxygen when her portable oxygen tank ran out of oxygen while the resident was in the community at an appointment on 4/28/2025. Resident #2 was sent to the local hospital by the clinic after running out of oxygen and complaining of SOB and chest pain. The non-compliance was identified as past non-compliance (PNC). The Administrator and DON were notified of the PNC on 05/07/25 at 2:57 PM. The Immediate Jeopardy began on 04/28/25 and ended on 04/28/25. The facility had corrected the non-compliance before the state's investigation began. This failure could affect all residents who receive oxygen therapy by placing them at risk of receiving inadequate oxygen support, which could result in serious harm or death. Findings included: Record review of Resident #2's face sheet, dated 5/08/25, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (lung disease), emphysema (lung disease), chronic respiratory failure, and chronic bronchitis (inflammation of lungs). Record review of Resident 2's quarterly MDS assessment, dated 04/20/25, reflected her BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required setup to supervision assistance with most ADLs and used a manual wheelchair. The MDS Assessment under Section I-Active Diagnoses reflected Resident #2 had a primary medical condition of cardiorespiratory with other comorbidities that included chronic lung disease and respiratory failure. Further review of this document, under Section O-Special Treatments, Procedures, and Programs, reflected Resident #2 received oxygen therapy. Record review of Resident 2's care plan, revised 4/29/25, reflected the resident was on oxygen therapy r/t ineffective gas exchange and respiratory illness. Interventions included: changing respiratory equipment every 7 days, checking O2 sat every shift and PRN, providing extension tubing and portable oxygen apparatus, giving medications as ordered, requiring additional oxygen tank while away from the facility, monitoring for s/sx of respiratory distress and reporting to MD, O2 at 2 lpm, positioning to facilitate ventilation matching, re-directing if nasal canula was off, and suctioning as needed. Record review of Resident #2's consolidated physician orders, dated 05/06/25, reflected in part the following: -O2 at 2 liters per minute via nasal canula-start date: 2/25/25; discontinue date; 5/01/25 Record review of Resident #1's progress notes, dated 04/28/25 at 2:44 PM by LVN C, reflected the following: [Resident #2 went to appt [Surgical Clinic] sent to ER because she ran out of oxygen. Went to appt with a full tank of oxygen. [Resident #2] able to make needs known. Call light in reach. WCTM. Record review of Resident #2's hospital records, dated 04/28/25, reflected in part the following: [AGE] year-old woman history significant COPD on 2 L home oxygen who presents to ED with complaints of dyspnea (shortness of breath), pleuritic chest pain (sharp pain in chest when breathing) after running out of oxygen during an outpatient appointment. [Resident #2] reports she has been feeling unwell for about a day, she endorses increased cough. [Resident #2] is not sure of the home medications. In the ED chest x-ray showed left-sided opacity concerning for pneumonia. [Resident #2] was oxygen saturated 99% on 2 L In an interview and observation on 05/06/25 at 11:30 AM, Resident #2 was sitting on the side of her bed wearing a nasal cannula that was connected to an oxygen concentrator that was set on 2 lpm. Observation of the portable tank on the back of Resident #2's wheelchair revealed it was an e-tank that held 680 liters of oxygen and was full. Resident #2 stated she was not feeling well due having pneumonia. She stated the nurse was giving her abx. Resident #2 stated she went to the hospital about a week ago after she ran out of oxygen while at an appointment. She stated the staff woke her up at about 5:30 that morning to get ready for her appointment and she was so tired that she was fell asleep in her wheelchair while waiting for the Van Driver to come, so she did not see if the nurse checked her portable oxygen tank to make sure it was full like she normally did. Resident #2 stated because of this she felt like it was also her fault for running out of oxygen. Resident #2 stated she knew how to change the setting on her portable oxygen tank, but she did not change it that day. She stated it remained at whatever setting it was last set to, which was usually 2 lpm. Resident #2 stated she had already been feeling bad and while at her appointment her oxygen was running low, and she started feeling worst. Resident #2 stated her chest was hurting and she was short of breath so the 911 was called and after what seemed like an hour, she was transported to the hospital. In an interview on 05/06/25 at 1:54 PM with the DON and Administrator, the DON stated Resident #2's had a consultation for eye surgery at 8:45 AM and she left the facility at approximately 7:30 AM. The DON stated they were only expecting the appointment to last about 45 minutes, but it lasted over 2 hours. She stated they later found that was normal for those type of consultations due to all the testing required. The DON stated at approximately 10:30 AM, CNA D called and informed that Resident #2's oxygen was low, and the surgical center was giving the facility 15 minutes to bring more oxygen, or they were going to call 911. The DON stated the Van Driver was on her way; however, the nursing facility was about 20-25 minutes away and by the time she arrived Resident #2 had already been transported to the hospital. The DON stated Resident #2 was admitted to the hospital after being diagnosed with pneumonia. The DON stated a full oxygen tank at 2 lpm should have lasted 3-4 hours and LVN C stated she checked, and it was full before Resident #2 left. The DON stated the only explanation she could think of was that Resident #2 waited at the nurse's station for a while, using oxygen from her portable tank, before being transported to the appointment. The DON was asked if an oxygen tank with approximately 680 liters of oxygen, running at 2 lpm could last at least 5 hours and she stated it probably could if the settings were not adjusted. The Administrator stated in-servicing immediately began with all staff on 4/28/25 regarding residents on continuous oxygen therapy. He stated the staff were educated on checking the oxygen levels in portable tanks to ensure they were full before a resident left the facility and the updated protocol to send extra oxygen tanks with residents on appointments that would last longer than 2 hours. In an interview on 05/06/25 at 2:26 PM, LVN C stated she worked with Resident #2 on 04/28/25 when she went to the hospital after running low on oxygen while at an appointment. LVN C stated she assisted Resident #2 that morning before she was transported to her appointment, and she remembered checking the portable oxygen tank and it was completely full and set at 2 lpm. LVN C stated Resident #2 had a lot of respiratory issues, so she always made sure to check her oxygen tanks before she left the facility. LVN C stated Resident #2 was dressed and waiting for her appointment at about 7:15 AM and was using her portable oxygen tank because she required continuous oxygen therapy. In an interview on 05/07/25 at 11:00 AM, CNA D stated she worked on 4/28/25 and rode to the appointment with Resident #2. She stated the nurses checked the portable oxygen tanks before residents were transported to appointments, so she did not check it on that day. CNA D stated she did not make it to work until about 7:45 AM and Resident #2 and the Van Driver were already on the van waiting, she got on the van, and they headed to the appointment. CNA D stated when they arrived, they waited in the lobby for about 30 minutes before Resident #2 was called to the back. She stated while waiting, Resident #2 did not complain of shortness of breath or chest pains while being transported and was acting like her normal self. CNA D also stated she did not see Resident #2 change the setting on her portable oxygen tank. CNA D stated after about an hour, the staff from the surgical center came out and told her that Resident #2's oxygen tank was low, and they were giving them 15 minutes to get her another oxygen tank, or they would have to call 911. CNA D stated she called the facility to inform them and while she was still on the phone, the staff called 911 after they overheard her saying the driver was more than 15 minutes away. CNA D stated she saw Resident #2 being taken to the ambulance and she did not appear to be in distress. She stated Resident #2 was talking and trying to drink water but was asked to not drink anything. CNA D stated when she returned to the nursing facility, she was in-serviced on making sure residents had enough oxygen when going on appointments. CNA D stated she now knew that the aides were also responsible for checking the oxygen tanks and not just the nurses; however, only the nurses could hook the oxygen tanks up. Review of the facility's policy titled Oxygen Administration, revised 06/2020, revealed in part the following: Purpose: To prevent or reverse hypoxemia and provide oxygen to the tissues. . A facility's policy on respiratory care regarding portable oxygen tanks was requested from the Administrator on 5/8/25 at 11:46 AM, and he informed that the facility did not have that specific policy. The non-compliance was identified as past non-compliance (PNC). The Administrator and DON were notified of the PNC on 05/07/25 at 2:57 PM. The Immediate Jeopardy began on 04/28/25 and ended on 04/28/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of Residents #2, #6, #7, #8, #9, and #10 EHRs revealed their care plans included interventions to address respiratory needs. Observations on 05/06/25 from 11:30 AM-2:55 PM, revealed Residents #2, #6, #7, #8, #9, and #10 had no s/sx of respiratory distress and they all had oxygen concentrators and full portable oxygen tanks available. Interviews with residents and RPs on 5/06/25 from 11:30 AM-2:55 PM revealed no concerns for respiratory care of any residents running out of oxygen while in the community. Record review on 5/6/25 of in-service titled Portable Oxygen Tanks, dated 4/28/25, reflected all staff were educated by the DON on ensuring that residents on oxygen therapy always had adequate oxygen available and to notify the nurse or clinical staff if portable oxygen tanks were low. Record review on 5/6/25 of in-service titled Oxygen Supply for Appointments, dated 4/28/25, reflected all nurses were in-serviced by the DON regarding appointments for residents who required continuous oxygen therapy to ensure the residents had adequate oxygen while in the community. The nurses were educated on determining the approximate length of time of each appointment, documenting and communicating the information to all staff interacting with the residents and ensuring an extra portable oxygen tank was sent on appointments that would be longer than 2 hours. Record review on 5/6/25 of in-service titled Oxygen Supply for Appointments, dated 4/28/25, reflected all nurses were in-serviced by the DON regarding appointments orders for residents who required continuous oxygen therapy. The nurses were educated on putting orders for appointments by transportation in the EHR 3 days prior to the appointment date, and including information about the approximate length of time for the appointments to ensure the residents are transported with adequate oxygen. Record review on 5/6/25 of in-service titled Portable Oxygen Tanks, dated 4/28/25, reflected LVN C had 1 on 1 education by the DON on ensuring that residents on oxygen therapy always had adequate oxygen available and to switch out low portable oxygen tanks with full ones. Record review on 5/6/25 of in-service titled Portable Oxygen-Appointments, dated 4/28/25, reflected LVN C had 1 on 1 education by the DON on ensuring that residents on continuous oxygen therapy had a full portable oxygen tank before leaving the facility for an appointment and that an extra portable oxygen tank was sent with the residents for all appointments that would be longer than 2 hours. Record review on 5/6/25 of in-service titled Portable Oxygen Tanks, dated 4/28/25, reflected CNA D had 1 on 1 education by the DON on ensuring that residents on oxygen therapy always had adequate oxygen available and to notify the nurse if portable oxygen tanks were low. Record review on 5/6/25 of in-service titled Portable Oxygen-Appointments, dated 4/28/25, reflected CNA D had 1 on 1 education by the DON on ensuring that residents on continuous oxygen therapy had a full portable oxygen tank before leaving the facility for an appointment and that an extra portable oxygen tank was sent with the residents for all appointments that would be longer than 2 hours. Record review on 5/6/25 of in-service titled Portable Oxygen Tanks, dated 4/28/25, reflected the Van Driver had 1 on 1 education by the DON on ensuring that residents on oxygen therapy always had adequate oxygen available and to notify the nurse or clinical staff if portable oxygen tanks were low. Record review on 5/6/25 of in-service titled Portable Oxygen-Appointments, dated 4/28/25, reflected the Van Driver had 1 on 1 education by the DON on ensuring that residents on continuous oxygen therapy had full portable oxygen tanks before being transported to appointments with and extra portable oxygen tank if the appointments would be longer than 2 hours. Interviews from 5/6/25 (12:00 PM-3:30 PM)-5/8/25 (9:30 AM-10:00 AM), conducted with the Administrator, DON, nurses and CNAs: RN B (1st shift), LVN C (1st shift), CNA D (1st shift), CMA E (1st shift), CNA F (1st shift), RN G (2nd shift, weekends), LVN H (2nd/3rd shift weekends), RN I (3rd shift, PRN), LVN J (2nd shift), RN K (2nd shift) indicated they all participated in in-service trainings on 4/28/25. The nurses were able to state they were ultimately responsible for ensuring that residents who required oxygen therapy always had adequate oxygen available, and residents who required continuous oxygen therapy had full portable tanks when leaving the facility. The nurses were also able to state when confirming an appointment for residents on continuous oxygen therapy, they were responsible for determining the approximate length of time of the appointments, documenting it, and ensuring that the residents had 2 full portable oxygen tanks if the appointments were longer than 2 hours. The CNAs were able to state that while providing care to residents with portable oxygen tanks, they were also responsible for checking the tanks to ensure there was adequate oxygen and to immediately notify the nurse if there was not. The Administrator and DON stated the in-services would be ongoing to include new staff, PRN staff, and any other staff who did not receive the in-service prior to the start of their shifts. A document provided by the DON titled Midnight Census Report-Oxygen List, dated 4/28/25, reflected all residents on oxygen therapy were identified and any of those residents with schedule appointments had all information, including length of time, noted. A document provided by the DON titled AD Hoc Quality Assurance and Performance Improvement Plan, dated 4/28/25, reflected a QAPI meeting was held to discuss failure and interventions put in place to prevent failure from occurring again.

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime, abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the suspicion or allegation was made, to a law enforcement entity or State Agency in accordance with State law through established procedures, for one resident (Resident #1) of ten residents reviewed for abuse. -The facility failed to report to law enforcement and the State Agency when Resident #1 alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for Methadone for which he did not have an order for. This failure could place residents at risk for continued abuse due to unreported allegations of abuse. Findings included: Record review of Resident #1's face sheet, dated 5/08/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute systolic (congestive) heart failure, unspecified sequelae of cerebral infarction (stroke), major depressive disorder (mood disorder), and hx of cocaine and alcohol abuse. Record review of Resident #1's quarterly MDS assessment, dated 04/21/25, reflected his BIMS score was 12, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required moderate to maximal assistance with most ADLs and used a motorized wheelchair. The MDS Assessment under Section N-Medications, reflected Resident #1 was prescribed medication under the high-risk drug class that included and opioid. Record review of Resident #1's care plan, revised 5/05/25, reflected the resident required pain management r/t to generalized pain that included Gabapentin and Norco. Interventions included: administering analgesia (pain reliever) as ordered, anticipating the resident's need for pain relief immediately to any complaint of pain, monitoring/recording/reporting to nurse any s/sx of non-verbal pain, monitoring/recording/reporting to nurse loss of appetite, refusal to eat, and weight loss, monitoring/recording/reporting to nurse complaints of pain or requests for pain treatment, and observing and reporting changes in usual routine. Further review of this document reflected it was revised on 5/05/25 to reflect that Resident #1 had a history of drug abuse prior to admission to facility. Resident #1 had gone out to hospital and noted to have non prescribed narcotic medication in his system. Interventions included: Drug abuse policy was given to resident with education and signature, Narcan (medication to reverse opioid/narcotic overdose) provided PRN, psychiatric medication management NP to see resident, referral to psychiatric services, resident was offered rehabilitation services and declined, and resident was seen by psychologist. Record review of Resident #1's active consolidated physician orders, dated 5/08/25, reflected in part the following: -HYDROcodone-Acetaminophen oral tablet 5-325 MG (for pain relief) - give 1 tablet by mouth every 6 hours as needed for pain. Hold medication if drowsy and notify MD. -Gabapentin oral capsule 300 MG (for pain relief) - give 1 capsule by mouth three times a day for pain. Hold medication if drowsy and notify MD. Further review of this document revealed there was not an order for Methadone. Record review of Resident #1's hospital records, dated 4/30/25, reflected in part the following: HPI: 64 [sic] y.o. male with a past medical history of GERD, hyperlipidemia, hypertension, diabetes mellitus stroke, seizure disorder who was brought into ER from nursing home because of respiratory distress. During my encounter [Resident #1] was on BiPAP and poor historian so history is taken from ER notes. As per ER [Resident #1] is on opioid outpatient in likely took more than dysuria of narcotics and later on was found to be short of breath and drowsy for which EMS was called. On arrival to ER [Resident #1] was found to be drowsy and was given Narcan, [Resident #1] responded very well to Narcan however got very anxious for which morphine was administer after my suspicion of an opioid withdrawal. ABGs: PH 7.25 (normal range 7.35-7.45), pC02 58.7 (normal range 32.0-45.0 mmHg), P02 98 (normal range 83.0-108.0 mmHg). [Resident #1] was on non-rebreather mask initially and was later on placed on BiPAP. CTA chest negative for PE or pleural effusions. Troponin 122 (normal range 38.73-80.22 ng/L), BNP 125 (normal range less than 100 pg/mL). [Resident #1] was given Lasix 100 mg IV once and breathing treatment as well. Review of system is limited as [Resident #1] is on BiPAP and lethargic during my encounter. . Labs: Specimen: Clean Catch; Urine Methadone- Positive Opiate- Positive . Hospital Course/Long LOS Summary: [Resident #1] is a [AGE] year-old male with past medical history of systolic heart failure, diabetes, hypertension, sleep apnea, and chronic pain who presented to the emergency room for altered mental status and shortness of breath. [Resident #1] was admitted for acute hypoxic respiratory failure requiring supplemental O2 and BiPAP to maintain O2 saturation >92%. Likely related to acute on chronic systolic heart failure versus community acquired or aspiration pneumonia. [Resident #1] was started on IV Lasix (water pill) with good urine output. Discharge plan pending clinical improvement. . Record review of Resident #1's progress note, dated 4/30/25 at 9:30 AM by LVN A, reflected the following: [Resident #1] not alert and SOB noted. [Resident #1] responsive only to sternal rub. b/p 142/90 p137 r22 o2 sat 47% on RA. Applied o2 via mask rebreather at 15l. o2 sat 92%. EMS called and [Resident #1] transferred to [name] ED. Record review of a document titled Resident Out on Pass Log, dated 4/20/25-5/07/25, reflected Resident #1 had not signed out to leave the facility. Record review of Resident #1's EHR reflected the resident was seen by a psychologist to address his s/sx of depression on 5/05/25. The recommendations reflected the following: -Psychological consultation is recommended to assist staff in developing and implementing behavior plans to reduce [Resident 1's] affective and/or cognitive symptoms. -Individual therapy to reduce [Resident 1's] affective and/or cognitive symptoms. -Referral for medication evaluation. Record review of an in-service titled Abuse and Neglect, dated 5/01/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Resident Drug and Alcohol Abuse, dated 5/05/25, reflected all staff were educated on the facility's policy on drugs and alcohol. Record review of an in-service titled Intoxicated Residents, dated 5/05/25, reflected all staff were educated on recognizing s/sx of an intoxicated resident and who to notify. Record review of an in-service titled Naloxone Administration, dated 5/06/25, reflected all nurses were educated on the protocol for administering Naloxone to a resident suspected of an overdose. In an interview and observation on 5/06/25 at 11:42 AM, Resident #1 was sitting in his wheelchair in his room. He was dressed and well-groomed with no s/sx of distress. Observation of the room revealed it was clean with no evidence of drugs, alcohol, or paraphernalia. Resident #1 immediately asked if I was from social services and if he was in trouble. This state investigator stated No and asked Resident #1 about his recent hospital stay. Resident #1 stated he was transported to the hospital for what he thought was another stroke. Resident #1 stated he could not recall what happened but was told that he was found unresponsive in his room. Resident #1 looked concerned, then proceeded to state that he did not want to be in trouble or get anyone else in trouble; however, he became sick after taking Methadone that he received from a staff member. Resident #1 refused to identify the staff. He stated he must have taken too much, and it caused him to pass out. Resident #1 did not recall exactly when he took the drug or how much he consumed. Resident #1 stated he was sad about his mother, who was sick at a different nursing facility, and he needed something to take his mind off it. Resident #1 refused to provide any additional information. In an interview on 5/06/25 at 12:20 PM, LVN A stated she worked at the facility for about 6 months. She stated she worked with Resident #1 on 4/30/25 when he was transported to the ER. LVN A stated she entered Resident #1's room to check his blood sugar at approximately 7:30 AM and found the resident less responsive than usual and exhibited respiratory distress. LVN A stated she immediately called for help while checking Resident #1's vitals. She stated she was unable to get an O2 reading and put the resident on oxygen. LVN A stated EMTs had already been called and arrived at the facility to transfer Resident #1 to the local hospital. LVN A stated initially she was unsure what caused Resident #1's change in condition, but later found it appeared to be from a drug overdose based on clinical records. LVN A stated she was aware Resident #1 had a hx of drug use. She stated she had not ever seen the resident have possession of nonprescription drugs or use them at the facility. LVN A stated she had never seen any staff members or other residents with nonprescription drugs. She stated the staff were in-serviced on the facility's drug policy on 5/05/25. In an interview on 5/06/25 at 1:10 PM, RN B stated she worked at the facility since 2019. She stated she worked with Resident #1 during the incident on 4/30/25. RN B stated the nurses were checking blood sugars on the hall when LVN A called for her help in Resident #1's room. RN B stated LVN A informed that she was unable to obtain an O2 reading from Resident #1, and he was unresponsive. RN B stated when she entered the room, she found that Resident #1 was breathing but was not responding normally. She stated after calling his name loudly a few times, Resident #1 opened his eyes and said Yes then went back to sleep. RN B stated Resident #1 needed constant engagement to stay alert. RN B stated she remained in the room with Resident #1 until EMTs arrived. In an interview on 5/06/25 at 1:54 PM with the DON and Administrator, the DON stated on 04/30/25 she was alerted by LVN A that Resident #1 was in respiratory distress and needed to be sent out to the hospital. This state investigator informed them that Resident #1 admitted he received the Methadone from a staff member that he refused to identify. The DON stated Resident #1 returned to the facility during the weekend on 5/3/25 and the clinicals showed that Methadone was found in his system. The DON stated the MD and pain management team was notified. The DON stated a care plan meeting with Resident #1 was held on 5/05/25 and during an interview with the resident he denied using any drugs and did not report receiving any drug from staff. The DON stated Resident #1 only stated he was depressed about his mother. The DON stated a referral was sent for psychiatric services and Resident #1 was able to talk with a psychologist on 5/05/25. The Administrator stated staff were in-serviced on the facility's drug policy, s/sx of intoxicated residents, and abuse and neglect. He also stated a Resident Council meeting was scheduled to discuss the facility's drug policy and to see if there were any concerns. The Administrator and DON stated this was new information and they would need to consult with regional managers on how to move forward. In a further interview on 5/06/25 at 3:00 PM with the DON and Administrator, the Administrator stated the Regional Managers advised them to submit a self-report to the state agency and start a provider investigation regarding the alleged abuse. In an interview on 5/07/25 at 9:42 AM with the DON and Administrator, the Administrator stated the facility submitted a self-report to the stated agency and started the provider investigation. The Administrator stated Resident #1 was interviewed again and still denied any drug use and getting drugs from a staff member. The Administrator stated the police were called out and Resident #1 also denied everything to them. In a further interview on 5/07/25 at 11:50 AM with the DON and Administrator, The DON stated she received and reviewed Resident #1's hospital records on 5/02/25, prior to the resident discharging from the hospital, when it was found that Methadone was in the resident's system. The DON stated Resident #1 did not have an order to take Methadone at the facility and was not receiving any outpatient treatment where he would receive Methadone. The Administrator stated the incident had just happened and they were still gathering information to determine what happened, which is why a self-report was not submitted prior to the state investigator entering the facility. In an interview on 05/07/25 at 3:45 PM with the Regional Nurse Consultant and Regional Director of Operations, the Regional Nurse Consultant stated she was informed by the DON on 5/02/25 that Resident #1's hospital records indicated there was Methadone found in his system and she advised the DON to start an investigation. The Regional Director of Operations stated the facility began reviewing the resident sign-out logs, in-servicing staff, auditing medications in the facility to check for Methadone/narcotics and medication errors, and conducting safe surveys with staff and residents. The Regional Director of Operations stated the investigation continued over the weekend, with the DON doing pop-up visits to check the facility for drugs. Both Regional managers stated they were not sure why the DON and Administrator did not provide this information prior to the Immediate Jeopardy being called. This state investigator informed that the only evidence that was provided prior to the Immediate Jeopardy being called were the staff in-services, Resident #1's psychology assessment note, Resident #1's care plan conference notes, and a scheduled Resident Council Meeting to discuss the facility's drug policy. There was no evidence of medications audits, safe surveys, interviews, IDT notification, or a report to the state agency provided. Review of the facility's policy titled Abuse Prevention and Prohibition Program, revised 08/2020, reflected in part the following: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy: I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. A. Definitions for the meaning of key terms used in this policy. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. IV. This policy also identifies Special Considerations regarding the investigation of injuries of unknown origin, the reporting of suspected rape, and resident-to-resident abuse. Procedure: . IV Prevention A. Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation. B. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring. . VII Investigation A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. . IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. . Review of the facility's policy titled Resident Drug and Alcohol Abuse, revised 08/2020, reflected in part the following: Purpose: To provide a safe and drug-free environment for residents while at the Facility. Policy Statement: I. The Facility will admit a resident who has a history of drug and alcohol abuse as long as their primary diagnosis is suitable for skilled care at this Facility. II. The Facility has a zero-tolerance policy for the use or possession of illegal drugs (including marijuana) or any type of drug apparatus in the Facility or on the grounds of the Facility. All illegal drugs and/or drug paraphernalia will be confiscated from the resident and /or their room. B. The only drugs permissible at the Facility and/or on Facility grounds are those for which there is an Attending Physician order. IV.Any resident found in violation of this policy will be discharged to a more appropriate setting for care (See Policy Transfer and Discharge). .

Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress for one resident (Resident #1) of ten residents reviewed for abuse. -The facility failed to implement their abuse, neglect, and exploitation policy and investigate suspected or alleged abuse when Resident #1 alleged he received methadone from a staff member, was found unresponsive, required Narcan, and tested positive for Methadone for which he did not have an order for. This failure could place all residents at an increased risk for abuse and neglect. Findings included: Record review of Resident #1's face sheet, dated 5/08/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute systolic (congestive) heart failure, unspecified sequelae of cerebral infarction (stroke), major depressive disorder (mood disorder), and hx of cocaine and alcohol abuse. Record review of Resident #1's quarterly MDS assessment, dated 04/21/25, reflected his BIMS score was 12, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required moderate to maximal assistance with most ADLs and used a motorized wheelchair. The MDS Assessment under Section N-Medications, reflected Resident #1 was prescribed medication under the high-risk drug class that included and opioid. Record review of Resident #1's care plan, revised 5/05/25, reflected the resident required pain management r/t to generalized pain that included Gabapentin and Norco. Interventions included: administering analgesia (pain reliever) as ordered, anticipating the resident's need for pain relief immediately to any complaint of pain, monitoring/recording/reporting to nurse any s/sx of non-verbal pain, monitoring/recording/reporting to nurse loss of appetite, refusal to eat, and weight loss, monitoring/recording/reporting to nurse complaints of pain or requests for pain treatment, and observing and reporting changes in usual routine. Further review of this document reflected it was revised on 5/05/25 to reflect that Resident #1 had a history of drug abuse prior to admission to facility. Resident #1 had gone out to hospital and noted to have non prescribed narcotic medication in his system. Interventions included: Drug abuse policy was given to resident with education and signature, Narcan (medication to reverse opioid/narcotic overdose) provided PRN, psychiatric medication management NP to see resident, referral to psychiatric services, resident was offered rehabilitation services and declined, and resident was seen by psychologist. Record review of Resident #1's active consolidated physician orders, dated 5/08/25, reflected in part the following: -HYDROcodone-Acetaminophen oral tablet 5-325 MG (for pain relief) - give 1 tablet by mouth every 6 hours as needed for pain. Hold medication if drowsy and notify MD. -Gabapentin oral capsule 300 MG (for pain relief) - give 1 capsule by mouth three times a day for pain. Hold medication if drowsy and notify MD. Further review of this document revealed there was not an order for Methadone. Record review of Resident #1's hospital records, dated 4/30/25, reflected in part the following: HPI: 64 y.o. male with a past medical history of GERD, hyperlipidemia, hypertension, diabetes mellitus stroke, seizure disorder who was brought into ER from nursing home because of respiratory distress. During my encounter [Resident #1] was on BiPAP and poor historian so history is taken from ER notes. As per ER [Resident #1] is on opioid outpatient in likely took more than dysuria of narcotics and later on was found to be short of breath and drowsy for which EMS was called. On arrival to ER [Resident #1] was found to be drowsy and was given Narcan, [Resident #1] responded very well to Narcan however got very anxious for which morphine was administer after my suspicion of an opioid withdrawal. ABGs: PH 7.25 (normal range 7.35-7.45), pC02 58.7 (normal range 32.0-45.0 mmHg), P02 98 (normal range 83.0-108.0 mmHg). [Resident #1] was on non-rebreather mask initially and was later on placed on BiPAP. CTA chest negative for PE or pleural effusions. Troponin 122 (normal range 38.73-80.22 ng/L), BNP 125 (normal range less than 100 pg/mL). [Resident #1] was given Lasix 100 mg IV once and breathing treatment as well. Review of system is limited as [Resident #1] is on BiPAP and lethargic during my encounter. . Labs: Specimen: Clean Catch; Urine Methadone- Positive Opiate- Positive . Hospital Course/Long LOS Summary: [Resident #1] is a [AGE] year-old male with past medical history of systolic heart failure, diabetes, hypertension, sleep apnea, and chronic pain who presented to the emergency room for altered mental status and shortness of breath. [Resident #1] was admitted for acute hypoxic respiratory failure requiring supplemental O2 and BiPAP to maintain O2 saturation >92%. Likely related to acute on chronic systolic heart failure versus community acquired or aspiration pneumonia. [Resident #1] was started on IV Lasix (water pill) with good urine output. Discharge plan pending clinical improvement. . Record review of Resident #1's progress note, dated 4/30/25 at 9:30 AM by LVN A, reflected the following: [Resident #1] not alert and SOB noted. [Resident #1] responsive only to sternal rub. b/p 142/90 p137 r22 o2 sat 47% on RA. Applied o2 via mask rebreather at 15l. o2 sat 92%. EMS called and [Resident #1] transferred to [name] ED. Record review of a document titled Resident Out on Pass Log, dated 4/20/25-5/07/25, reflected Resident #1 had not signed out to leave the facility. Record review of Resident #1's EHR reflected the resident was seen by a psychologist to address his s/sx of depression on 5/05/25. The recommendations reflected the following: -Psychological consultation is recommended to assist staff in developing and implementing behavior plans to reduce [Resident 1's] affective and/or cognitive symptoms. -Individual therapy to reduce [Resident 1's] affective and/or cognitive symptoms. -Referral for medication evaluation. Record review of an in-service titled Abuse and Neglect, dated 5/01/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Resident Drug and Alcohol Abuse, dated 5/05/25, reflected all staff were educated on the facility's policy on drugs and alcohol. Record review of an in-service titled Intoxicated Residents, dated 5/05/25, reflected all staff were educated on recognizing s/sx of an intoxicated resident and who to notify. Record review of an in-service titled Naloxone Administration, dated 5/06/25, reflected all nurses were educated on the protocol for administering Naloxone to a resident suspected of an overdose. In an interview and observation on 5/06/25 at 11:42 AM, Resident #1 was sitting in his wheelchair in his room. He was dressed and well-groomed with no s/sx of distress. Observation of the room revealed it was clean with no evidence of drugs, alcohol, or paraphernalia. Resident #1 immediately asked if I was from social services and if he was in trouble. This state investigator stated No and asked Resident #1 about his recent hospital stay. Resident #1 stated he was transported to the hospital for what he thought was another stroke. Resident #1 stated he could not recall what happened but was told that he was found unresponsive in his room. Resident #1 looked concerned, then proceeded to state that he did not want to be in trouble or get anyone else in trouble; however, he became sick after taking Methadone that he received from a staff member. Resident #1 refused to identify the staff. He stated he must have taken too much, and it caused him to pass out. Resident #1 did not recall exactly when he took the drug or how much he consumed. Resident #1 stated he was sad about his mother, who was sick at a different nursing facility, and he needed something to take his mind off it. Resident #1 refused to provide any additional information. In an interview on 5/06/25 at 12:20 PM, LVN A stated she worked at the facility for about 6 months. She stated she worked with Resident #1 on 4/30/25 when he was transported to the ER. LVN A stated she entered Resident #1's room to check his blood sugar at approximately 7:30 AM and found the resident less responsive than usual and exhibited respiratory distress. LVN A stated she immediately called for help while checking Resident #1's vitals. She stated she was unable to get an O2 reading and put the resident on oxygen. LVN A stated EMTs had already been called and arrived at the facility to transfer Resident #1 to the local hospital. LVN A stated initially she was unsure what caused Resident #1's change in condition, but later found it appeared to be from a drug overdose based on clinical records. LVN A stated she was aware Resident #1 had a hx of drug use. She stated she had not ever seen the resident have possession of nonprescription drugs or use them at the facility. LVN A stated she had never seen any staff members or other residents with nonprescription drugs. She stated the staff were in-serviced on the facility's drug policy on 5/05/25. In an interview on 5/06/25 at 1:10 PM, RN B stated she worked at the facility since 2019. She stated she worked with Resident #1 during the incident on 4/30/25. RN B stated the nurses were checking blood sugars on the hall when LVN A called for her help in Resident #1's room. RN B stated LVN A informed that she was unable to obtain an O2 reading from Resident #1, and he was unresponsive. RN B stated when she entered the room, she found that Resident #1 was breathing but was not responding normally. She stated after calling his name loudly a few times, Resident #1 opened his eyes and said Yes then went back to sleep. RN B stated Resident #1 needed constant engagement to stay alert. RN B stated she remained in the room with Resident #1 until EMTs arrived. In an interview on 5/06/25 at 1:54 PM with the DON and Administrator, the DON stated on 04/30/25 she was alerted by LVN A that Resident #1 was in respiratory distress and needed to be sent out to the hospital. This state investigator informed them that Resident #1 admitted he received the Methadone from a staff member that he refused to identify. The DON stated Resident #1 returned to the facility during the weekend on 5/3/25 and the clinicals showed that Methadone was found in his system. The DON stated the MD and pain management team was notified. The DON stated a care plan meeting with Resident #1 was held on 5/05/25 and during an interview with the resident he denied using any drugs and did not report receiving any drug from staff. The DON stated Resident #1 only stated he was depressed about his mother. The DON stated a referral was sent for psychiatric services and Resident #1 was able to talk with a psychologist on 5/05/25. The Administrator stated staff were in-serviced on the facility's drug policy, s/sx of intoxicated residents, and abuse and neglect. He also stated a Resident Council meeting was scheduled to discuss the facility's drug policy and to see if there were any concerns. The Administrator and DON stated this was new information and they would need to consult with regional managers on how to move forward. In a further interview on 5/06/25 at 3:00 PM with the DON and Administrator, the Administrator stated the Regional Managers advised them to submit a self-report to the state agency and start a provider investigation regarding the alleged abuse. In an interview on 5/07/25 at 9:42 AM with the DON and Administrator, the Administrator stated the facility submitted a self-report to the stated agency and started the provider investigation. The Administrator stated Resident #1 was interviewed again and still denied any drug use and getting drugs from a staff member. The Administrator stated the police were called out and Resident #1 also denied everything to them. In a further interview on 5/07/25 at 11:50 AM with the DON and Administrator, The DON stated she received and reviewed Resident #1's hospital records on 5/02/25, prior to the resident discharging from the hospital, when it was found that Methadone was in the resident's system. The DON stated Resident #1 did not have an order to take Methadone at the facility and was not receiving any outpatient treatment where he would receive Methadone. The Administrator stated the incident had just happened and they were still gathering information to determine what happened, which is why a self-report was not submitted prior to the state investigator entering the facility. In an interview on 05/07/25 at 3:45 PM with the Regional Nurse Consultant and Regional Director of Operations, the Regional Nurse Consultant stated she was informed by the DON on 5/02/25 that Resident #1's hospital records indicated there was Methadone found in his system and she advised the DON to start an investigation. The Regional Director of Operations stated the facility began reviewing the resident sign-out logs, in-servicing staff, auditing medications in the facility to check for Methadone/narcotics and medication errors, and conducting safe surveys with staff and residents. The Regional Director of Operations stated the investigation continued over the weekend, with the DON doing pop-up visits to check the facility for drugs. Both Regional managers stated they were not sure why the DON and Administrator did not provide this information prior to the Immediate Jeopardy being called. This state investigator informed that the only evidence that was provided prior to the Immediate Jeopardy being called were the staff in-services, Resident #1's psychology assessment note, Resident #1's care plan conference notes, and a scheduled Resident Council Meeting to discuss the facility's drug policy. There was no evidence of medications audits, safe surveys, interviews, IDT notification, or a report to the state agency provided. Review of the facility's policy titled Abuse Prevention and Prohibition Program, revised 08/2020, reflected in part the following: Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements. Policy: I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. A. Definitions for the meaning of key terms used in this policy. II. The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. III. The Administrator is responsible for coordinating and implementing the Facility's abuse prevention policies, procedures, training programs, and systems. IV. This policy also identifies Special Considerations regarding the investigation of injuries of unknown origin, the reporting of suspected rape, and resident-to-resident abuse. Procedure: . IV Prevention A. Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation. B. Supervisors shall immediately intervene, correct, and report identified situations where abuse, neglect or misappropriation of resident property is at risk for occurring. . VII Investigation A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. . IX. Reporting/Response A. Facility Staff are Mandatory Reporters i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. . Review of the facility's policy titled Resident Drug and Alcohol Abuse, revised 08/2020, reflected in part the following: Purpose: To provide a safe and drug-free environment for residents while at the Facility. Policy Statement: I. The Facility will admit a resident who has a history of drug and alcohol abuse as long as their primary diagnosis is suitable for skilled care at this Facility. II. The Facility has a zero-tolerance policy for the use or possession of illegal drugs (including marijuana) or any type of drug apparatus in the Facility or on the grounds of the Facility. All illegal drugs and/or drug paraphernalia will be confiscated from the resident and /or their room. B. The only drugs permissible at the Facility and/or on Facility grounds are those for which there is an Attending Physician order. IV.Any resident found in violation of this policy will be discharged to a more appropriate setting for care (See Policy Transfer and Discharge). .

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 4 of 6 residents reviewed for clinical records (Resident #41, Resident #59, Resident #76, and Resident #121) in that: The facility failed to ensure that Resident #41, Resident #59, Resident #76, and Resident #121 use of bed rails/grab bars/mobility bars were documented in their care plans. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care. Findings included: Record Review of Resident #41's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #41 had relevant diagnoses of type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema (areas of swelling of the tiny blood vessels in the retina, caused by the weakening of their structure), unspecified eye; other abnormalities of gait and mobility; type 2 diabetes mellitus without complications (disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels); muscle wasting and atrophy; other lack of coordination; unspecified symptoms and signs involving cognitive functions and awareness; need for assistance with personal care; cortical age-related cataract (when protein fibers in the lens of the eye break down and clump together causing the lens to become cloudy), bilateral; systemic lupus erythematosus (a chronic autoimmune disease that causes the body's immune system to attack healthy tissue); muscle weakness (generalized); other specified arthritis (joint inflammation causing pain, stiffness, and swelling in a joint), multiple sites; and morbid (severe) obesity due to excess calories. Record Review of Resident #41's Quarterly MDS, dated [DATE], reflected a BIMS score of 15 indicating intact cognition. Resident #41's functional limitations in range of motion were listed as impairment for lower extremities on both sides of the body. Resident #41 was noted to use a wheelchair for mobility. Resident #41 was noted to be dependent (need complete assistance) for self-care categories of toileting, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #23 was noted to need substantial/maximal assistance for upper body dressing, while only requiring partial/moderate assistance for personal hygiene. Resident #41 was noted to need substantial/maximal assistance in the mobility categories of roll left and right and sit to lying. Resident #41 was reflected to be dependent for chair/bed-to-chair transfer and tub/shower transfer. Record review of Resident #41's Care Plan, last updated on 01/07/2025, reflected focus areas of potential for pressure ulcer development r/t impaired mobility, requires extensive assist for bed mobility, and at risk for falls related to impaired mobility and requires total assist with any transfers. Resident #41 had a focus area of an ADL Self Care Performance Deficit r/t Limited Mobility, Arthritis, morbid obesity with interventions of BED MOBILITY: Roll left and right: Substantial/Maximal assist, Sit to Lying: Substantial/Maximal assist, Lying to sitting: Not attempted, DRESSING: Upper Body Dressing: Substantial/Maximal assistance, Lower Body Dressing: Dependent, Donning/Doffing shoes: Dependent, EATING: Set-up/Clean UP, TRANSFER: Chair/bed to chair: Dependent X 2 staff and mechanical lift, Sit to stand: does not occur. There was no mention of bed rails/grab bars as a focus area or intervention in the care plan. Observation of Resident #41's room and bed on 1/14/2025 at 10:25 AM revealed grab/mobility bars on both sides of the bed in a raised position with the call light laying over one of the bars. Observation on 1/15/2025 at 8:08 AM revealed the grab/mobility bars in a raised position. Interview with Resident #41 on 1/15/2025 at 8:05 AM revealed that resident utilized the grab/mobility bars for repositioning while in bed and to aid with positioning with personal care. Resident #41 stated she had been at the facility a very long time. Record review of Resident #59's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #59 had relevant diagnoses of metabolic encephalopathy (brain disorder caused by chemical imbalance in the blood), type 1 diabetes mellitus (chronic condition where the pancreas makes little or no insulin, which causes high blood sugar levels)with unspecified diabetic retinopathy without macular edema (medical condition that affects the eyes), bipolar disorder (mental illness that causes extreme shifts in mood, energy, and activity level making it difficult to perform daily tasks), muscle weakness (generalized), other lack of coordination, other reduced mobility, chronic obstructive pulmonary disease with (acute) exacerbation (chronic lung disease that makes it difficult to breathe caused by damage that narrows airways making it harder to move air in and out of the lungs), acute respiratory failure (when lungs are unable to exchange gases properly with blood), unspecified whether with (lack of oxygen) or hypercapnia (too much carbon dioxide in the blood), morbid (severe) obesity due to excess calories, chronic pain syndrome, unspecified lack of coordination, inflammatory polyneuropathy(disease that affects peripheral nerves causing weakness, numbness and pain), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis or severe weakness on one side of the body caused by a stroke), acquired absence of left leg above knee, other cerebrovascular disease (conditions that affect blood flow and blood vessels in the brain). Record review of Resident #59's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated an intact cognition. The Quarterly MDS also showed that Resident #59 utilized a motorized wheelchair for mobility; was dependent for toileting hygiene, showering/bathing, upper and lower body dressing, personal hygiene, sit to lying, rolling right and left, tub/shower/toiler transfers, lying to sitting on side of bed, and chair/bed-to-chair transfers. Observation on 1/14/2025 at 9:55AM of Resident #59 room area and bed revealed that the bed had a bed grab/mobility bar raised on both sides of the bed. The resident was asleep in the bed at the time. The grab/mobility bar were observed again on 1/15/2025 at 8:10 AM in same position. Interview on 1/15/2024 at 1:25 PM with Resident #59 revealed the resident is liking being back at the facility. Resident #59 stated that she used the grab/mobility bars during personal care by aides, to help roll and for repositioning while in bed. Record review of Resident #59's Care Plan, last updated on 12/17/2024, reflected that Resident had ADL self-care performance deficit r/t decreased mobility and required interventions due to being completely dependent for toilet use, transfer, bathing, personal hygiene, upper body dressing, lower body dressing, putting on/taking off footwear and with bed mobility being substantial/maximum assist. The Care Plan had no mention of bed rails or grab bars as an intervention or focus for Resident #59. Record review of Resident #76's Face Sheet reflected a [AGE] year-old male, originally admitted to the facility on [DATE]. Resident #76 had relevant diagnoses including acute respiratory failure with hypoxia (condition where the body does not have enough oxygen), unspecified osteoarthritis (chronic disease that breaks down cartilage and bone in the joints), idiopathic aseptic necrosis of left femur (condition where blood flow to the hip joint is disrupted), morbid (severe) obesity due to excess calories, critical illness myopathy (disease that affects muscles that control voluntary movement), chronic systolic (congestive) heart failure (when the heart's left ventricle weakens and cannot pump enough blood), chronic obstructive pulmonary disease with (acute) lower respiratory infection (when lower respiratory infection worsens COPD symptoms), chronic respiratory failure with hypoxia (long term condition where the body is unable to adequately oxygen and carbon dioxide , leading to persistently low levels of oxygen in the blood), muscle weakness (generalized), difficulty in walking not elsewhere classified, other lack of coordination, abnormal posture, and personal history of pulmonary embolism (blockage in a lung artery caused by a substance that travels from another part of the body). Record review of Resident #76's Quarterly MDS, dated [DATE], reflected a BIMS score of 09, indicating moderate cognitive impairment. Resident #76's functional limitations were listed as dependent for toileting hygiene, shower/bathing self, lower body dressing, putting on/taking off footwear, roll left and right, sit to lying, lying to sitting on side of the bed, chair/bed-to-chair transfer and tub/shower transfer. Resident #76 was listed as substantial/maximal assistance for upper body dressing and personal hygiene. Record review of Resident #76's Care Plan, last updated on 01/02/2025, reflected a focus of ADL self-care performance deficit r/t morbid obesity with copd/chf and interventions of transfer: chair/bed transfer: dependent x 2 and mechanical lift; resident 76 has morbid obesity with recent fracture and requires staff assist due to weight; bed mobility: roll left to right: dependent, sit to lying: dependent, lying to sitting: dependent; bathing: shower three times a week and as needed, is dependent on staff for showering; dressing: encourage resident #76 to choose clothing that is appropriate for season, upper body: dependent, lower body: dependent, shoes: dependent; eating: independent with eating; toilet use: dependent. resident #76'scare plan does not mention bed rails/grab bars/mobility bars as a focus or intervention. Observation on 1/14/2025 at 10:20AM revealed Resident #76 in bed watching television. Resident #76 was in bed watching television; the resident has a trapeze as well as a call light on the trapeze within reach, bed was in a high position. Resident #76 stated that he has not been injured by the bars being on the bed but has noticed things get quickly entangled when cords are draped overbars. On 1/15/2025 Resident #76 was interviewed and revealed that the grab/mobility grab bars were frequently used to reposition himself in bed. Resident #76 showed how he also has a trapeze for repositioning that he also wraps the cord of his call light on to keep within reach. Resident #76 stated that he thinks the staff have spoken with him about safety with the grab/mobility bar. Record review of Resident #121's Face Sheet reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #121 had relevant diagnoses of acute and chronic respiratory failure with hypoxia (condition where the body does not have enough oxygen), polycythemia vera (blood cancer that causes the bone marrow to produce too many red blood cells), type 2 diabetes mellitus (disease where the body does not use insulin properly causing high blood sugar) with unspecified diabetic retinopathy (chronic eye condition that damages the retina due to high blood sugar levels from diabetes) with macular edema (when fluid builds up against the macula the central part of the retina at the back of the eye), morbid (severe) obesity with alveolar hypoventilation (condition where a person does not breathe enough, resulting in too much carbon dioxide in the blood and not enough oxygen), muscle weakness (generalized), acute kidney failure, other abnormalities of gait and mobility, unspecified lack of coordination, and need for assistance with personal care. Record review of Resident #121's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating intact cognition. Resident #121 had identified functional limitations of substantial/maximal assistance with toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. Resident #121 had functional limitations of dependent for chair/bed-to-chair transfer and tub/shower transfer. Record review of Resident #121's Care Plan, last updated on 01/07/2025, reflected a focus area of ADL self-care performance deficit r/t obesity and weakness with interventions of bed mobility: the ability to roll from lying on back to left and right side, and return to lying on back on the bed; upper body dressing: supervision/touching assist, lower body dressing: dependent, put on take off footwear: dependent; eating: setup/cleanup assist; oral hygiene: setup/cleanup assist; personal hygiene: setup/cleanup assist; shower/bathing: partial/mod assist, can bath with assistance from staff to wash her back and perineal areas; toilet hygiene: dependent; transfers: sit to stand: does not occur; bed to chair: dependent with mechanical lift x 2 staff, toilet transfer: does not occur-uses bed pan, tub/shower: dependent x 2 and mechanical lift; wheelchair mobility: setup assist to dependent. resident #121's care plan does not mention bed rails/grab bars/mobility bars as a focus or intervention. Observation of Resident #121's bed on 01/14/2025 at 9:45AM revealed resident in bed asleep, with both grab/mobility bars raised on the bed. Observation of Resident #121's bed on 01/15/2025 at 8:10 AM revealed resident in bed, both grab bars still raised, having breakfast. Resident declined to be interviewed and asked to be left alone; unable to interview this resident about the grab/mobility bars. Interview on 1/16/2024 at 12:02PM with the DON revealed that it was important to have grab/mobility bars documented in the care plan, so staff know how best to perform the care. The DON stated that the safety assessment and consent form also was offered for the resident or responsible party to review and sign explaining risks and benefits. The DON stated the Resident could have been at risk of harm if the evaluation had not been assessed incorrectly. Interview on 1/61/2024 at 12:11 PM with the ADM revealed the IDT will review resident needs including grab/mobility bars on beds and if resident would be safe to use. The ADM stated the nursing department representative is the one who usually enters these items as the care plan. The ADM stated the potential harm to the resident by not documenting on the care plan could be any harm up to death. Record Review of the facility's Nursing Manuals- Nursing Care policy on Bed Rails (Revised June 2020) states the purpose of the policy was to determine the appropriateness of bed rail use for individual residents while the policy was Decisions to use or to discontinue the use of a bed rail will be made in the context of an individualized resident assessment using an Interdisciplinary Team (IDT) and will take into account the resident's medical needs, comfort, and freedom of movement. The policy further states The resident's plan of care will be updated to reflect the use of bed rails. The plan of care should also include documentation of the type of specific direct monitoring and supervision provided during the use of the bed rails and the identification of how needs will be met during the use of bed rails (e.g., repositioning, hydration, etc. Record Review of the facility's Nursing Manual-Nursing Administration Care Planning policy (Revised October 24, 2022) states the purpose is To ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. Relevant sections include: Policy: The facilities Interdisciplinary Team will develop a baseline and/or comprehensive Care Plan for each resident in accordance with OBRA and MDS guidelines. Procedures: VIII: A culturally competent and trauma-informed comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. A. In the event that the Comprehensive Care Plan identified a change in the resident's goals or functioning that was not identified in the Baseline Care Plan, these changes will be incorporated into an updated summary and provided to the resident and/or resident's representative. B. Changes may be made to the Comprehensive Care Plan on an ongoing basis for the duration of the resident's stay. These subsequent changes will not need to be reflected through updates to the Baseline Care Plan IX: Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; B. Any services that would be required, but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment; C. Any specialized services including rehabilitative service as a result of PASARR recommendations. If the Facility disagrees with PASARR findings, rationale will be notated in the resident's medical record;

Based on observations, interviews, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 1 of 1 (Resident # 165) residents reviewed for resident call system. The facility failed to ensure Resident #165's bathroom call light was functioning outside the Resident's room. On 01/14/2025 when the bathroom light was activated, the call light did not turn on in the hallway above Resident #165's door. This failure could place residents at risk of not getting assistance and not having their needs met. Findings included: Record review of Resident #165's Admission Record, dated 01/16/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included fracture of upper and lower end of right fibula (calf bone), Type 2 Diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), and anxiety. Record review of Resident #165's most recent MDS, dated [DATE], revealed a BIMS of 14, indicating intact cognition. Further review of the MDS revealed Resident #165 required extensive one person assist with bed mobility, transfers and was totally dependent on one staff for toilet use. Observation and interview on 01/14/25 at 10:30 AM, Resident #165 was lying in bed and stated the emergency call light in the bathroom does not turn on. Surveyors went into the bathroom and activated the light, but the light did not turn on in the hallway above the door. Interview on 01/14/25 at 10:30 AM, Housekeeper D stated the light was supposed to come on outside the room. She stated she did not know it was not working. She said if she found a call light not working, she would call maintenance. Interview on 01/14/25 at 10:30 AM, LVN F stated the call light should be on outside the room and flashing. Interview on 01/14/25 at 10:56 AM, Maintenance Staff E arrived in Resident #165's room to fix the call light. He stated no one had reported it not working. He said if the call light was not functioning, residents cannot receive a response from the nurse. Maintenance Staff E stated the call light was working at the nurse's station. Interview on 01/16/25 at 01:25 PM, the DON stated her expectation was if the call light was not working staff would report to the nurse or maintenance. She stated Maintenance was responsible to ensure call lights were functioning. Record review of facility policy titled, Communication - Call System revised 06/2020, reflected in part: Purpose. To Provide a mechanism for residents to promptly communicate with nursing staff. The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities .Should the primary call system become inoperable for any reason, the Facility shall provide a bell for each resident room. Additionally, resident safety check rounds shall be conducted at least hourly and documented until the primary call system is operable again .

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for one of eight residents (Resident #370) reviewed for storage of medication. The facility failed to ensure two medications/suppliments Complete mineral complex dietary supplement for professional use only and Advanced multivitamins were not stored on Resident #370's bedside table and failed to ensure they were secured in the medication cart or medication room. This failure could place residents at risk of medication misuse and supplements could interfere with prescribed medications. The findings included: Review of Resident #370's admission record printed on 01/16/25 reveled a [AGE] year-old female who was readmitted to the facility on [DATE] with an initial admission of 11/14/24. Her diagnoses were pedestrian on foot injured in collision with vehicle, acute post hemorrhagic anemia (low blood due to accident), multiple fractures of ribs, shoulder blade, hip, leg and pelvis. Resident #370 was her own responsible party. Review of Resident #370's admission MDS dated [DATE] did not reflect a BIMS score for cognition. Review of Resident #370's physician order dated 1/14/25 reflected the following orders: -Multi-Vitamin/Minerals Oral Tablet (Multiple Vitamins w/ Minerals) Give 1 tablet by mouth one time a day for Wound Healing -Order Date- 01/09/2025. -Orders did not reflect self-medication Administration. Review of Resident #370's physician orders dated 01/16/25 reflected the following: -Multivitamin Women's 50+ Adv Oral Tablet (Multiple Vitamins w/ Minerals). Give 2 tablet by mouth in the afternoon for Wound supplement May use personal vitamins in bottle. -Multivitamin/iron/minerals/calcium/fa/lyc /lut(complete vitamin). Give 2 capsules by mouth in the afternoon for Wound supplement May use personal supplement in bottle. Review of Resident #370's care plan revealed Resident #370 had impaired visual function. The goal was that the resident would show no decline in visual function through the review date 03/02/25. The interventions were to arrange consultation with eye care practitioner as required, to ensure appropriate visual aids prescription glasses are available to support the resident's participation in activities, Review medications for side effects which affect vision. The care plan did not reflect self-administration of medications. Observation on 01/14/25 at 9:35 AM LVN A in Resident #370's room performing wound care. Observation and interview with Resident #370 on 01/14/25 at 10:12 AM, revealed two bottles of medication on the bedside table. Resident #370 stated the facility was aware that she had the medication at bedside. She stated she had a small lock box that only fit her wallet and that the bedside table had no key to lock the medication or any of her personal items. She stated when she left her room, she closed the door, but her room was not locked. Resident #370 stated she liked her own supplements because they did not contain poisonous mercury in them. She stated she had the Supplements since she returned to the facility on [DATE]. Observation on 01/14/25 at 3:35 PM, ADON in Resident #370's room talking to resident. Resident #370 was in her bed with right leg brace open. Medications could be seen on the bedside table. Observation on 01/15/25 at 7:09 AM, medications were still on Resident #370's bedside table. LVN A was notified of the medication by the surveyor watching medications . LVN A went into Resident #370's room and took the medications and she stated she would notify the physician for the medications to be added to Resident# 370's orders. In an interview with LVN A on 01/15/25 at 0:17 AM, she stated she was not aware that Resident #370 had medication in her room. She stated Resident #370 had expressed to her in the past that her friend was going to bring her supplements that did not contain mercury in them for her. LVN A stated Resident #370 was educated that when her friend brought the medications, they would need to be given to the nurse. LVN A stated Resident #370 was not permitted to self-administer and to have medications at the bedside. She stated medications were to be locked in the medication cart. In an interview with MA C on 01/15/25 at 0:46 AM, she stated she was not aware that Resident #370 had medication at the bedside. She stated Resident #370 usually declined the facility multivitamins and other supplements including the house shake. She stated she had reported the issue to LVN A, ADON and DON. She stated the resident stated she had her own supplements, but CMA C had not seen them in her room. She stated the risk was access to medication. In an interview with ADON on 01/16/25 at 11:26 AM, he stated he was not aware that Resident #370 had medication at the bedside. He stated he was not paying attention to his surroundings to notice that Resident #370 had medication in her room when he went to talk to her 01/14/25. He stated he had gone to talk to Resident #370 regarding her concerns with her surgical site. ADON stated he was aware that Resident #370 was refusing supplements that were provided by the facility. He stated when Resident #370 came back from the hospital (01/09/25), Resident #370's friend came to the facility to bring her belonging and it might have been at that time that the friend brought Resident #370 medications. He stated he had educated both Resident #370 and her friend that if they brought the supplements that the resident wanted to take, they would give them to the nurses so that the doctor could approve them. He stated residents were not allowed to keep medication at the bedside unless they had an order to self-administer, they and an assessment for self-medication administration and had a care plan. He stated the risk was that anyone could have access to the medication in her room. In an interview with the DON on 01/16/25 at 3:20 PM, she stated on 01/10/25, the DON stated education was given to both resident and her friend to give the medications to the nurse. The DON stated she was not aware until 01/15/25 about the medications on Resident #370's bedside. She stated she did an in-service about medications at bedside and that they should be turned into the nurse. She stated residents were not permitted to keep medication at the bedside unless they had an order to self-administer, had an assessment to self-administer medication and had a care plan to self-administer medication. She stated the risk was that anyone could have access to the medication in her room. Review of facility policy titled Bedside medication Storage revision date 08/2020 reflected . read in part . Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team (or equivalent) . For residents who self-administer medications, the following conditions are met for bedside storage. to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if unlocked storage is deemed inappropriate. Facility management should have a copy of the key in addition to the resident.

Based on observation, interview, and record review the facility failed to ensure enteral feeding physician orders were followed for two (Resident #111 and Resident #118) of the four residents reviewed for enteral tube feeding, in that: 1.LVN A failed to check G-tube residual to verify G-tube placement verification before administering medication and feedings for Resident #111 on 01/15/25. 2.LVN B failed to check G-tube residual to verify G-tube placement before administering medication and feedings to Resident #118 on 01/15/25. These failures could place residents with G-tubes at risk of aspiration pneumonia, discomfort, malnutrition and a decline in the resident's health. 1 Record review of Resident #111 admission record dated 1/15/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with an initial admitted [DATE]. Her diagnoses included gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), acute respiratory failure with hypoxia (difficulty breathing due to lack of oxygen), cerebral palsy (a congenital disorder of movement, muscle tone, or posture), and quadriplegia (this is a condition that causes partial or total paralysis of the arms, hands, trunk, legs and pelvic organs). Review of Resident #111 quarterly MDS dated [DATE] reflected Resident #111 had a BIMS of zero, indicating sever cognitive impairment. She had no indicators of delirium, depression, or behaviors. Resident #111 had impaired range of motion, both upper and lower body, on both sides of his body, and was completely dependent on staff for all of his ADLs and movement in bed. Resident #111 was always incontinent of bowel and bladder. The document reflected Resident #111 had a feeding tube while a resident of the facility and received 51% or more of her nutrition through the feeding tube. Review of Resident #111 Care plan reflected a care plan initiated 05/06/22, Focus: Resident #111requires gastrostomy tube feeding related to swallowing problem related to diagnoses of Cerebral Palsy. Goal: The resident will remain free of side effects or complications related to tube feeding through review date. The resident will maintain adequate nutritional and hydration status, as evidenced by weight stable, no signs and symptoms of malnutrition or dehydration through review date. Interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. Clean insertion site daily as ordered, monitoring for s/s infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to MD if symptoms arise. Continuous Enteral Feed: Formula: [brand name ]1.5; Rate: 40ml/hr x 22 hours (1320ml) provides 1980 kcal/84g Protein /1003ml free water); Monitor every Shift. and two times a day o every shift Water at 35ml/hr x 22 hours to run concurrently with enteral feeding (provides 660 ml total daily); o Monitor/document/report to MD PRN: Aspiration- fever, shortness of Breath, Tube dislodged (tube comes out), Infection at tube site, Self-extubating (taking tube out by herself), Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. o Provide local care to G-Tube site as ordered and monitor for s/sx of infection. o The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Record Review of Resident #111 Order summary dated 01/15/15 reflected, -Enteral Feed Order every shift Enteral Feed: Residual Volume Check residual before med administration. If residual volume is greater than 60mL, hold feeding and notify physician. Order active 10/17/24. -Enteral Feed Order every shift Continuous Enteral Nutrition: [brand name ] 1.5 at 37ml/hr x 22hrs to provide 1221kcal, 52 g protein and 619 ml water two times a day. -Enteral Feed Order every shift Flush enteral tube with 30 ml water pre/post medication administration and 5-10 mL water between each medication; -MiraLAX Powder 17 GM per SCOOP (Polyethylene Glycol 3350). Give 1 scoop via G-Tube one time a day for Constipation Hold for loose stool, mix with 4-8 oz of water; - Lasix Oral Tablet 20 MG (Furosemide) Give 1 tablet via G-Tube two times a day for Congestive Heart Failure; - Sucralfate 1 GM Tablet Give 1 tablet via PEG-Tube (other name for G-tube) three times a day for GERD (heart Burn); - Keppra Solution 100 MG/ML (levetiracetam). Give 5 ml via PEG-Tube two times a day for Seizure ;5ml = 500mg; dilute with 4-5 oz of water before administration. - Coreg Oral Tablet 3.125 MG (Carvedilol). Give 1 tablet via G-Tube two times a day for Hypertension (High blood pressure). Hold for sbp less than110 or dbp less than 60 - Baclofen Oral Tablet 10 MG (Baclofen) Give 1 tablet via G-Tube three times a day for Muscle spasms; - Famotidine Oral Tablet 20 MG (Famotidine). Give 1 tablet via G-Tube two times a day for Gerd. - Diflucan Oral Tablet 100 MG (Fluconazole). Give 1 tablet via G-Tube one time a day for Spots on tongue for 5 Days. - Bethanechol Chloride 5 MG Tablet. GIVE 1 TABLET VIA PEG-TUBE FOUR TIMES A DAY FOR URINARY RETENTION. - Potassium Chloride Oral Solution 20 MEQ/15ML (10 percent) (Potassium Chloride); Give 15 ml via G-Tube one time a day for Supplement; dilute with 4-5oz of water before giving to reduce its possible stomach-irritation or laxative effect. Observation of g-tube medication administration on 01/15/25 at 07:52 AM, LVN A did not check Resident #111 g-tube placement. LVN A did not aspirate gastric content and or listen for bowel sounds and did not check for abdominal distention before administering water, medications, and enteral feeds to Resident #111. LVN A stated she got nervous being watched and she forgot to check for placement. She stated she knew how to check for placement by checking residual and by listening using a Stethoscope. LVN A stated the risk was that the tube may not be in the correct position. 2. Record review of Resident # 118 admission record dated 1/15/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of head, face, and neck (this is malignant cancer of the head, face, and neck), gastrostomy status, dysphagia (trouble swallowing), and need for assistance with personal care, lack of coordination. Review of Resident #118 quarterly MDS dated [DATE] reflected Resident #118 had a BIMS of 12 out of 15, indicating moderate cognitive impairment. Resident #118 was independent for all ADL's and movement. The document reflected Resident #118 had a feeding tube while a resident of the facility received 51% or more of her nutrition through the feeding tube. Record Review of Resident #118 Order summary dated 01/15/15 reflected the following; - E very shift Flush enteral tube with 30 mLs water before and after medication administration and 5-10 mLs water between each medication; - Enteral Feed, give Five times a day Bolus Feeding: [brand name ] formula 1.5 at 265ml 5 x day to provide 1988 kcal, 85g Protein and 1007 ml water. - Midodrine HCl Tablet 5 MG. Give 1 tablet via G-Tube two times a day for b/p; hold for SBP> 130 If B/P Less than 90/50 notify MD; - Clopidogrel Bisulfate 75 MG Tablet. GIVE 1 TABLET VIA G-TUBE IN THE MORNING FOR HEART; - Aspirin Low Dose Tablet Chewable 81 MG (Aspirin). Give 1 tablet via G-Tube one time a day related to MUSCLE WASTING AND ATROPHY (muscle wasting and dying).; Review of Resident #118 care plan initiated 07/22/22 reflected, Focus: Resident #118 Focus: has been observed putting liquids in his g- tube. He states in writing that he is not hungry or thirsty feeling like he requires additional intake - but rather he can taste the soda he puts in there and enjoys the flavor. Mr. [NAME] was educated on compliance with g-tube enteral feedings/water, dangers and risks associated with putting additional fluids in the-tube, infection. Goal: The Resident will maintain adequate nutritional status as evidenced by maintaining weight within 10 percent of admission baseline through the review dated 01/28/25. Interventions: Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Focus: Resident #118 has impaired visual function and was at risk of falls/injury. Goal: The Resident will show no decline in visual function through the review date. The Resident will maintain optimal quality of life within limitation imposed by visual function through the review date. Interventions: Arrange consultation with eye care practitioner as required. Identify/record factors affecting visual function including Physiological (glaucoma, Crohn's, macular degeneration, cataracts, color discrimination, light sensitivity, dry eyes); Environmental (poor lighting, monochromatic color scheme), Choice (refuses to wear glasses, use mag glass, turn on lights) etc. Monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Review medications for side effects which affect vision. Observation of g-tube medication administration on 01/15/25 at 8:35 AM, LVN B did not check Resident #118 g-tube placement. LVN B did not aspirate gastric content or listen for bowel sounds, she did not check for abdominal distention before Resident #118 administered his own medications, water, and bolus formular feeds. LVN B stated that Resident #118 had always self-administered his own medications and feeds. She stated that she had been told during training (two months ago) that the nurse would cocktail the medications and the resident would administer the medications himself. She stated the nurse would supervise until the resident was finished and then he would administer his own feedings. LVN B stated that she did not check for Resident #118's g-tube placement because she had been caught off guard by a different surveyor watching her in another room prior to her starting Resident#118's medications. LVN B stated that it was important for the nurse to check for placement of the g-tube to make sure that it was still in place, and it had not dislodged. She stated the risk was the g-tube could be out of place, in the wrong place, and infection control. In an interview with the DON on 01/16/25 at 12:58 PM, the DON stated her expectation for staff was to check placement before giving medications or feedings to residents with G-tubes. She stated staff should have looked at Resident #111 and Resident #118's G-tube, aspirated and checked residual to ensure it was placed in the correct place. She stated LVN B should have administered Resident #118's medications. The DON stated she had inserviced staff on G-tubes. Review of facility policy titled, Gastronomy Placement revised 06/2020, reflected in part: I. Prior to the administration of feeding, hydration, and/or medication through a gastrostomy tube, the placement of the tube shall be verified. II. This verification procedure shall be completed by a licensed nurse IV. Access the resident's abdomen for bowel sounds and distention .XI. Aspirate gastric contents to be sure the tube is in the stomach

Based on observations, interviews, and record review, the facility failed to ensure residents were treated in a respectful manner that maintained or enhanced each resident dignity for 1 of 4 residents reviewed for dignity (Resident #114). Resident #114 did not receive his personal clothing for two days (01/11/25 and 01/12/25) which caused him to remain in bed and not engage in preferred activities during the week. This failure could place the resident who required assistance with dressing at risk of feeling disrespected. Findings included: Record review of Resident #114's Admission Record revealed [AGE] year-old male admitted to the facility on [DATE]. Primary diagnoses included: Enterocolitis due to clostridium difficile, recurrent (a complication of a Clostridioides difficile infection (CDI) that occurs when symptoms reappear within 8 weeks of a previous episode.) Record review of Resident #114's care plan date initiated 12/21/2024 reflected the following: -Focus-Resident #114 is dependent on staff for activities, cognitive stimulation, social interaction. Goal- Resident #114 will attend/participate in activities of choice 3x per week. Interventions- invite the resident to scheduled activities. Focus- Resident #114 had an ADL Self Care Performance Deficit related to weakness, impaired mobility, poor safety awareness. Goal- he will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet use and Personal Hygiene. Intervention- Dressing: Encourage resident to choose clothing. Nursing staff to ensure resident is dressed appropriately for season, activity and comfort. Record review of Resident #114's Minimum Data Set (MDS) State assessment dated [DATE] reflected Cognitive Patterns BIMS score of 15 ( indicates that a person's cognition was intact). Record Review of resident #114's Minimum Data Set Nursing Home Comprehensive dated 12/27/2024 reflected, Functional abilities-admission- F. Upper body dressing: 01 Resident was dependent- Helper does ALL of the effort. Resident does none of the effort to completed the activity. Or , the assistance of 2 or more helpers were required for the resident to complete the activity. G. Lower body dressing: 01 Resident was dependent- Helper does ALL of the effort. Resident does none of the effort to completed the activity. Or , the assistance of 2 or more helpers were required for the resident to complete the activity. H. Putting on/taking off footwear: 01 Resident was dependent- Helper does ALL of the effort. Resident does none of the effort to completed the activity. Or , the assistance of 2 or more helpers were required for the resident to complete the activity. Record review of Inventory of Personal Belongings dated 12/26/2024 reflected, Resident #114 Description of Clothes- Clothes were dirty and sent to laundry. Observation and Interview on 01/14/2025 at 10:20 am with Resident #114 reflected, resident was observed in his wheelchair wearing pants, shoes, undershirt, and top shirt. He stated that those were clothes from lost and found because his clothes have been lost for two days. He stated that he was unable to get out of bed over the weekend because staff were unable to locate his clothing. He stated that he likes to get up and participate in group activities around the facility but was unable to during the weekend (Saturday and Sunday) because he did not have clothes. Observation and Interview on 01/15/2025 at 10:07 AM of the laundry room with the Laundry Aide reflected, all facility laundry was washed and sorted in main laundry room. Residents' personal items are washed and sorted by room number. Interview with the Laundry Aide reflected she worked Monday-Friday not on the weekend (Saturday and Sunday). She stated that resident clothing was not distributed on the weekends. She stated that when she came in on Mondays the clothes be piled up and she would do the best she could to get the laundry distributed to the residents. Interview on 01/16/2025 at 1:00 pm with the Environmental Services Supervisor reflected the residents' personal belongings were washed on the weekend but not distributed because in the past there was an issue of lost clothing. The Monday-Friday laundry aide had a knowledge of the residents and their personal belongings, but the weekend laundry aide would place resident belonging in the wrong rooms. Record Review of policy Resident Rights date revised: 8/2020 reflected, All resident have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. M .Retain and use personal possessions to the maximum extent that space and safety permit. III. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including: B. Personal care needs, such as bathing methods, grooming styles, and dress.

Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team had determined that self-administration of medications by a resident was clinically appropriate for 1 of 4 (Resident #118) residents reviewed for resident rights, in that: The facility failed to assess, obtain physician orders, and interdisciplinary team approval for Resident #118 to self-administer his G-tube medications and feedings. LVN B allowed the resident to self-administer his own medications via g-tube on 01/15/25. This failure placed the resident at risk of not receiving the proper medication or the therapeutic benefits of medications. Findings: Record review of Resident # 118 admission record dated 1/15/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of head, face, and neck (this is malignant cancer of the head, face, and neck), gastrostomy status, dysphagia (trouble swallowing), and need for assistance with personal care, lack of coordination. Review of Resident #118 quarterly MDS dated [DATE] reflected Resident #118 had a BIMS of 12 out of 15, indicating moderate cognitive impairment. Resident #118 was independent for all ADL's and movement. The document reflected Resident #118 had a feeding tube while a resident of the facility received 51% or more of her nutrition through the feeding tube. Record Review of Resident #118 Order summary dated 01/15/15 reflected the following; - E very shift Flush enteral tube with 30 mLs water before and after medication administration and 5-10 mLs water between each medication. - Enteral Feed, give Five times a day Bolus Feeding: [brand name ] formula 1.5 at 265ml 5 x day to provide 1988 kcal, 85g Protein and 1007 ml water. - Midodrine HCl Tablet 5 MG. Give 1 tablet via G-Tube two times a day for b/p; hold for SBP> 130 If B/P Less than 90/50 notify MD; - Clopidogrel Bisulfate 75 MG Tablet. GIVE 1 TABLET VIA G-TUBE IN THE MORNING FOR HEART; - Aspirin Low Dose Tablet Chewable 81 MG (Aspirin). Give 1 tablet via G-Tube one time a day related to MUSCLE WASTING AND ATROPHY (muscle wasting and dying). Review of Resident #118 care plan initiated 07/22/22 reflected, Focus: Resident #118 Focus: has been observed putting liquids in his g- tube. He states in writing that he is not hungry or thirsty feeling like he requires additional intake - but rather he can taste the soda he puts in there and enjoys the flavor. Mr. [NAME] was educated on compliance with g-tube enteral feedings/water, dangers and risks associated with putting additional fluids in the-tube, infection. Goal: The Resident will maintain adequate nutritional status as evidenced by maintaining weight within 10 percent of admission baseline through the review dated 01/28/25. Interventions: Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Focus: Resident #118 has impaired visual function and was at risk of falls/injury. Goal: The Resident will show no decline in visual function through the review date. The Resident will maintain optimal quality of life within limitation imposed by visual function through the review date. Interventions: Arrange consultation with eye care practitioner as required. Identify/record factors affecting visual function including Physiological (glaucoma, Crohn's, macular degeneration, cataracts, color discrimination, light sensitivity, dry eyes); Environmental (poor lighting, monochromatic color scheme), Choice (refuses to wear glasses, use mag glass, turn on lights) etc. Monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Review medications for side effects which affect vision. Observation of g-tube medication administration on 01/15/25 at 8:35 AM, LVN B did not check Resident #118 g-tube placement. LVN B did not aspirate gastric content or listen for bowel sounds, she did not check for abdominal distention before Resident #118 administered his own medications, water, and bolus formular feeds. LVN B stated that Resident #118 had always self-administered his own medications and feeds. She stated that she had been told during training (two months ago) that the nurse would cocktail the medications and the resident would administer the medications himself. She stated the nurse would supervise until the resident was finished and then he would administer his own feedings. LVN B stated that she did not check for Resident #118's g-tube placement because she had been caught off guard by a different surveyor watching her in another room prior to her starting Resident#118's medications. LVN B stated that it was important for the nurse to check for placement of the g-tube to make sure that it was still in place, and it had not dislodged. LVN B stated that she should not have allowed Resident #118 to self-administer G-tube medication without an order. She stated the risk was the g-tube could be out of place, in the wrong place, and infection control. In an interview with the DON on 01/16/25 at 12:58 PM, the DON stated her expectation for staff was to check placement before giving medications or feedings to residents with G-tubes. She stated staff should have looked at Resident #111 and Resident #118's G-tube, aspirated and checked residual to ensure it was placed in the correct place. She stated LVN B should have administered Resident #118's medications. The DON stated she had inserviced staff on G-tubes. Review of facility policy titled Bedside medication Storage revision date 08/2020 reflected . read in part . Residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team (or equivalent) .

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for 1 of 2 shower rooms reviewed for environment. The facility failed to ensure station 2's second shower room was clean and free of a black substance on the ceiling and tiles on the wall. This could place residents at risk for respiratory infections and a decrease in quality of life. Findings included: Observation on 07/02/2024 at 5:04 PM, one of station 2's shower rooms revealed a musty, moldy odor. There were different sized round specks of a black substance near the edges and corners on the ceiling directly above the shower. Interview on 07/02/2024 at 5:08 PM, the Housekeeping Supervisor stated when the ceiling was repainted, whoever painted it did not use [Name of primer]. He stated it looks like mold but not was not mold, and it bled back through the paint. When asked if he smelled an odor, he said no it was the soap residents use. He said every night the shower room was cleaned with a disinfectant. He said they were supposed to use primer to cover the ceiling. When asked when it was last painted, he stated that would be Maintenance. Observation and interview on 07/02/2024 at 5:17 PM, revealed CNA A cleaning the second shower room. Observation revealed the tiles on the wall and floor had a brown and black, slimy substance on the grout. Round specks of a black substance were also on the tiles closest to the floor. CNA A stated she gave showers in the room and was cleaning and picking up the towels. She said it should be cleaned every time after a shower and showed the disinfectant bottle they used. She stated she had not noticed the black substance on the tiles or the ceiling before. She said no residents had complained about the black substance before to her. Interview on 07/02/2024 at 5:41 PM, the DON stated she went to the second shower room and did not smell anything but saw the tile. She said it had brown grout, like it needed to be cleaned and some discoloration. She said she did not know how long it had been like that. She stated her expectation was the shower room be clean and disinfected and the room was able to be used to provide ADL care at all times. She said the CNA should clean and disinfect after residents, and deep cleaning was done by housekeeping. The DON stated if it were mold, the risk could be respiratory issues possibly. Interview on 07/02/2024 at 5:59 PM, the Interim Administrator stated he did see black spots on the ceiling. He said immediately maintenance and housekeeping went to clean and scrub the walls and ceiling. He stated they will put an out of order sign and will start a housekeeping schedule for like 3 days a week deep cleaning. He said his expectation was for CNA's to be cleaning the shower room between residents. He said having housekeeping go in after them and having a schedule should take care of it. He stated the risk to residents could be respiratory infection. Record review of the facility policy titled Resident Rooms and Environment date revised 08/2020, reflected in part: The Facility provides residents with a safe, clean, comfortable, and homelike environment. Facility Staff will provide residents with a pleasant environment and person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences . Procedure I. Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order .

Based on interview and record review the facility failed to complete a significant change of condition assessment within 14 days of determining or should have determined that there had been a significant changed in a resident physical or mental condition for 1 (Resident #25) of 3 residents review for significant changes of condition. The facility failed to complete a significant change of condition MDS assessment when Resident #25 attempted to leave the facility on 01/30/24. This failure could affect residents by placing them at risk for not receiving correct care and services leading to deterioration in their condition. Findings included: Record review of Resident#25's face sheet dated 02/12/24 was a [AGE] year-old male admitted on [DATE] with diagnoses including Major depressive disorder (sadness), recurrent, unspecified, Unspecified dementia (cognitive decline), moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety insomnia (difficulty sleeping). Record review of Resident #25's quarterly MDS assessment dated [DATE] reflected a BIMS score of 9 indicating he was moderately impaired cognitively, supervision of 1 person assist with hygiene task. Resident #25's mood, depression, hearing deficit, and dementia was addressed in MDS. Record review of Resident #25's care plan dated 02/14/24, reflected the resident was at risk for wandering/elopement and he has made attempts to exit the facility and has been moved to the secure unit for safety .Interventions include providing clear, simple instructions, Provide re-orientation to surroundings, environment .The resident has impaired cognitive function and short term memory loss r/t Dementia .interventions, Administer meds as ordered, communicate with the family and resident, use resident preferred name, discuss concerns of confusion, disease process report changes to MD. Record review of Resident #25's progress note dated 01/31/24 reflected 1/3 of room change resident alert has no complaints about room or changes. lying in bed with eyes closed will continue to monitor throughout this shift. Record review of Resident #25's progress note dated 01/30/24 by SW reflected Social services spoke with the resident's FM, , to inform them that the resident has tried to exit the facility. Social services re-iterated that when they met with the resident, on Saturday, it was explained to them that the resident would eventually have a roommate due to the resident staying in the facility for LTC. Everyone agreed with that on Saturday, including the resident. Social services explained that the resident received a roommate today and began to exhibit behaviors, not because of the roommate but because the resident does not want a roommate. It was also explained on Saturday that the resident has not been deemed safe to go out on pass independently and does require supervision. The resident's FM verbalized their understanding and agreed that that was discussed on Saturday. Social services informed them that the resident exited the facility from a side door, however, staff got to the resident quickly and re-directed the resident back into the facility, however, due to that the resident will be moving to the secure unit. The resident's FM verbalized their understanding and agreed with moving the resident to the secure unit. Record review of Care Plan Conference and IDT 02/01/24 reflected Resident #25 was a 1-person physical assist pt is hard of hearing . the residents usual performance based on the review of the functional abilities and goals assessments were addressed .room change no complaints of room no signs of distress . will continue to monitor throughout this shift moved to 400 locked unit due to exit seeking. FMs was concerned about confusion and stated she thinks he has Dementia. explained that he does have an actual Dementia Dx. No other concerns, resident to remain LTC. Record review of Resident elopement assessment dated [DATE], indicated he was low risk for elopement scoring a 1 indicating he was not risk for elopement. The assessment did not indicate the author. Record review of Resident #25's psych services assessment reflected a date of service of 02/1/24 Pt is located on locked unit in order to satisfy his desire to have no roommate .Depression: Staff reports current symptoms of sad moods, fatigue and feelings of worthlessness and reports no current symptoms of loss of interest, guilt, psychomotor agitation, psychomotor slowing, decreased concentration, suicidal ideation/intent/plan and appetite change. Staff reports history of sad moods, fatigue and feelings of worthlessness and reports no history of loss of interest, guilt, psychomotor agitation, psychomotor slowing, decreased concentration, suicidal ideation/intent/plan, and appetite change. Severity is level 4 (Moderate) Cognitive Impairment: Staff reports current symptoms of forgetfulness and confusion and reports no current symptoms of sundowning, incoherent speech, aggression towards others, wandering, mood/personality change, hoarding, word-finding difficulties and difficulties with ADLs. Staff reports no history of forgetfulness, confusion, sundowning, incoherent speech, aggression towards others, wandering, mood/personality change, hoarding, word-finding difficulties and difficulties with ADLs. Severity is level 4 (Moderate). In an interview with the SW/AIT on 02/12/24 at 1:15 PM revealed she was notified by ADON of the attempted exit the building after a conversation with his sister regarding room change to long term hall. He asked to return to previous placement. FM explained the need for change, and the resident asked to return to his room. She said approximately 1 hour later Resident #25 attempted to go out the side door on the 300 halls. Resident #25 verbalized understanding of the need for him to be placed on the memory unit. In an interview on 02/12/24 with ADON at 1:22 PM revealed on 01/30/24 duty the day of the incident. She was notified by charge nurse that Resident #25 attempted to exit the south door setting the alarm off upon opening. Nurse redirected resident away from the door and notified ADON. She maintained supervision of Resident #25 until notification to Administrator was completed to move resident to the locked unit for his safety. Resident was educated, assessed for injuries, vitals, family were notified, and he was monitored for 72 hours on the locked unit. In an interview on 02/12/24 at 1:45 PM with MD revealed nursing staff notified him on 01/30/24 of Resident #25's tried to exit the building, and he approved for him to be moved to the secure unit as the resident has an increase in confusion, memory loss. During an interview on 02/12/24 at 2:00 PM with the ADM, revealed that Resident #25's elopement assessment should have been updated to reflect the exit, and rationale for change on the memory unit for increased supervision. ADM stated that failing to reassess Resident #25, could have led other exit incidents and possibly harm. In an interview with the CN-RN corporate nurse on 02/14/24 at 3:35 PM revealed staff all nursing staff were in-serviced 02/12/24 that when a resident has a change in cognition, behaviors of exit seeking, a new assessment must be completed, reported, and interventions implement to prevent further exit attempts. Corporate nurse stated that it was the responsibility for the Charge nurses, ADON, and DON to monitor and audit assessments for accuracy and implementation of interventions to maintain resident's safety. She stated that the DON was out on medical leave, and she was responsible for monitoring. Record review of Inservice dated 02/12/24, 02/13/24 reflected updating of assessments immediately after an incident or attempt, notify abuse coordinator, MD, family once the resident was safe Resident Rights. resident has a right to be treated in a manner that promotes and enhances the quality of life, dignity, respect, and individuality. Record review of facility locked secure unit elopement binder was reviewed and Resident #25 was listed with interventions and precautions for all staff to reference in the event of an elopement. Record review of a facility's policy titled Wandering/Elopement Risk assessment dated ,d+[DATE] reflected The Licensed Nurse, in collaboration with the I interdisciplinary Team (IDT), will assess res idents upon identification of s significant change in condition to determine their risk of wandering/elopement The resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition .IDT may consider interventions listed in Elopement Risk Reduction Approaches for residents identified to be at risk for elopement .Residents with a history of wandering or who IDT have assessed to be at risk for wandering or elopement will have a photograph maintained in their medical record and the Elopement/Wandering Risk Binder .Facility Staff will reinforce proper procedures for leaving the Facility for residents assessed to be at risk of elopement .If Facility Staff observes a resident leaving the premises without having followed proper procedures, he/she may: Try to prevent the departure in a courteous manner; Get help from other Facility Staff in the immediate vicinity, if necessary; and Direct another Facility Staff member to inform the Charge Nurse or Director of Nursing Services that a resident is trying to leave the premises.

Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and home like environment, for daily living for seven showers viewed for environmental concerns. The facility failed to ensure that the residents' showers were ready resident use. The deficient practice could place residents at risk for diminished quality of life and a diminished clean and homelike environment. The findings included: Record review of Resident's #240's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included: Duchenne or [NAME] muscular Dystrophy (forms of muscular dystrophy). Record review of Resident's #240's care plan, undated reflected personal hygiene- Limited assist/one-person physical assist. Record review of Resident's #240's Minimum Data Set (MDS), dated [DATE] reflected BIMS score of 15 . Observation on 12/06/2023 at 1:00 pm of community resident shower used by residents on Hall 100 labeled WEST revealed a strong odor once the door was opened. Observation on 12/07/2023 at 12:02 PM of resident shower #1 next to Nurse station 2 (door not labeled), revealed a pile of white towels with brown stains located inside the shower area. Observation on 12/07/2023 at 12:04 PM of resident community shower #2 for residents on 200 hall next to Nurse station 2 revealed inside the shower two shower chairs blocking access to the shower, two empty bottles of body wash on the floor, cabinet door open, floor unclean, resident clothing on top of the cabinet. Observation on 12/07/2023 at 12:10 PM of resident community Shower #1 for residents on hall 300 next to Nurse Station 3 revealed inside the shower two unopen straws on the floor. Observation on 12/07/2023 at 12:12 PM of resident community shower #2 next to Nurse station 3 revealed out of order sign. Interview on12/05/2023 at 2:56 PM with Resident #240 reveled the shower rooms could be cleaner for resident use. Interview on 12/06/2023 at 1:00 pm with CMA #4 reveled showers have a keypad for entry. Staff stand-by while residents are occupying the shower. Showers labeled East and [NAME] are located on Hall 100, shower area was for all residents on Hall 100. She entered shower labeled WEST; she stated it smelled like sewer. Interview on 12/07/2023 at 12:05 PM with Housekeeping Supervisor reveled, showers should be cleaned after each use by CNAs . The pile of soiled towels should not be left in resident bathroom. Interview on 12/07/2023 at 12:11 PM with DON reveled the expectation was for the bathroom to be cleaned after each use. When the bathroom was not clean the next resident does not have use of the shower. Interview on 12/07/2023 at 4:37 PM with DON revealed the risk of bathrooms not being cleaned after each use can increase the risk for falls and infections. Interview on 12/07/2023 at 5:11 PM with Administrator revealed the risk of unclean showers was infection control. Review of policy titled Resident Rights revised 8/2020 reflected the facility must treat each resident with respect and dignity and care for each resident in a manner, and in an environment, that promotes maintenance or enhancement of this or her quality of life, . Section III. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including: B. Personal care needs, such as bathing methods, grooming styles and dress;

48520 Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #2, #71) of 11 residents observed for infection control. The facility failed to ensure RN A sanitized her hands after feeding Resident # 2, before starting to feed resident #71. The facility failed to ensure RN A washed her hands after cleaning a spill on Resident #71 table. The facility failed to ensure RN A performed standard hand hygiene after touching and pushing Resident #2 wheelchair. The facility failed to ensure RN A performed hand hygiene after she removed and discarded gloves. These failures could place residents at risk of contamination and infectious diseases. Findings included: Review of Resident #2's Admission Record revealed, he was [AGE] year-old male admitted to facility 11/11/21 with diagnoses that included unspecified dementia moderate with other behavioral disturbance, Parkinson's disease (tremors, shaky motions), lack of coordination, generalized muscle weakness, need for assistance with personal care, difficulty swallowing, and difficulty communication and diabetes. Review of Resident # 2's MDS, dated [DATE], revealed a BIMS score of 3 which indicated severe cognitive impairment. His functional status indicated he was an extensive 1 assist for all- Activities of Daily Living (ADLs). His nutritional status indicated that he was at risk for protein and calorie malnutrition. Review of Resident # 2's Care Plan dated 10/17/23, revealed an Activities of Daily Living (ADL) self-care performance deficit due to weakness, Parkinson's disease, and impaired visual function. Goal was to show no decline in visual function and to remain free of further signs and symptoms of complications related to Parkinson's disease. Interventions included praise all efforts of self-care, to set up and supervise meals, encourage resident to fully participate for each interaction. Care plan also revealed potential nutritional problem indicated by body mass index (BMI) and impaired cognition. Goal was to maintain adequate nutritional status. Interventions included monitoring all intakes and recording meals, monitor/document/report to physician signs & symptoms of dysphagia (Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing), refusing to eat, and appearance of concern during meals. Review of Resident #71's Admission Record revealed, she was [AGE] year-old female admitted to facility 02/07/23 with diagnoses that included unspecified dementia severe without other behavioral disturbance, cognitive communication deficit, muscle weakness, angina pectoris (chest pain), unspecified cataract, and osteoarthritis (joint pain & swelling, bone deformation) unspecified site and essential primary hypertension. Review of Resident # 71's MDS, dated [DATE], revealed a BIMS score of 3 which indicated severe cognitive impairment. Her functional status indicated she was partial/moderate assistance for ADLs. Review of Resident # 71's Care Plan dated 11/16/23, revealed an impaired cognitive function or impaired thought process due to dementia, goal was to maintain current level of cognitive function. Interventions included facing the resident when speaking and make eye contact. Reduction of any distractions- turn off TV, radio, close door. Observation of dining room on 12/07/23 at 8:26 AM revealed, RN A stood in front of Resident #71 at the first dining table wearing cream-colored gloves. RN A picked up a spoon, scooped it with oatmeal, and fed it to Resident #71. RN A took another spoonful of oatmeal and fed Resident #71. She then crossed the dining room to the second table and scooped up a spoon of what appeared to be eggs to Resident #2. Wearing the same gloves with no hand hygiene she scooped the spoon again with eggs and fed Resident #2. RN A then walked to the table with Resident # 71 and noticed that Resident #71 had spilled some food on the table. RN A pulled 3 wipes from a medication cart (med cart) and wiped the table. RN A then deposited the soiled wipes in the medication cart bin. She then removed and discarded her gloves in the med cart bin. No hand hygiene performed. RN A proceeded to Resident #71's cup to fill it with water from a water cooler. She returned with cup full of water and assisted Resident # 71 as she took a drink of the water. RN A continued to feed Resident #71 until the resident asked for something to drink. RN A assisted Resident #71 with her water. RN A then turned towards the second table and noticed that Resident #2 was trying to leave by pushing himself from the table in his wheelchair. She asked him to return so he can finish his food. RN A stopped helping Resident #71 and went to help Resident #2 back to the table by pushing Resident #2's wheelchair. RN A did not perform hand hygiene after assisting Resident #71 and before touching and after touching Resident # 2's wheelchair. RN A scoped some food from the plate and fed Resident #2 a spoon full of eggs. An observation on 12/07/23 at 08:42 AM revealed RN A asked CNA B to help Resident # 2 finish eating. CNA B performed hand hygiene with hand sanitizer, she pulled a chair and sat down and began to assist Resident # 2. RN A returned to table with Resident # 71 and helped her finish her oatmeal. No hand hygiene was performed. An observation on 12/07/23 at 08:48 AM revealed RN A was called into room [ROOM NUMBER] near the dining area by another staff member, RN A was observed closing the door. RN A returned a few minutes later and stood in the same spot in front of #71 and helped Resident #71 with her drink again. RN A did not perform hand hygiene after returning from room [ROOM NUMBER]. An observation on 12/07/23 at 09:03 AM revealed RN A retrieving keys with her left hand from her pocket. She opened med cart and took out some tissues and handed it to Resident # 71. No hand hygiene was performed by RN A after touching keys and med cart. Interview with RN A on 12/07/23 at 09:05 AM revealed RN A forgot to wash her hands. She stated that the risk of not performing hand hygiene was contamination and spreading of diseases. Interview with CNA B on 12/07/23 at 09:42 AM revealed that she always performed hand hygiene before and after resident care. She said that she pulled a chair to sit down for residents' dignity and to be at eye level with resident. She said that she was trained to be mindful and respectful when helping residents eat. She stated the risk of not performing hand hygiene was spreading infection and sharing germs to residents and self. Interview on 12/07/23 at 11:15 AM with DON revealed standard hand hygiene practice was required for all staff. She had trained and in served staff over and over about hand hygiene and Personal Protective Equipment (PPE) putting on and taking off She said risk for not performing hand hygiene was a risk of infection. Interview on 12/07/23 at 12:10 pm with ADM revealed all staff members were expected to follow the infection control protocol as indicated. She expected staff to wash hands and to prevent spread of infection. She expected staff to properly wash hands after and before care. She said the risk of staff not washing hands and following standard hand hygiene protocol can cause a spread of infection. Review of the facility policy Infection Prevention and Control Program COVID (Covid is short for Corona Virus Disease-a sever acute respiratory syndrome aka SARS-COV-2), revision date 07/23, reflected . .facility will follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) as well as state and local government guidance . Hand wash policy requested during survey facility did not provide it.

Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for adequate supervision. 1. On 09/28/23 the facility failed to ensure adequate supervision and services were provided to Resident #1, when she was allowed to sign herself out of the facility even though it was known she had impaired cognitive function, impaired thought process, and potential for delirium or acute episodes of confusion, due to dementia. 2. On 09/28/23 the facility failed to notify Resident #1's RP/POA she signed out of the facility, which caused the RP/POA not to know Resident #1's location and if she was safe for approximately 5 hours. Resident #1 was located at a nearby fast-food restaurant in a high-traffic area with a sunburn. An IJ was identified on 10/04/23 at 5:08 PM. The IJ template was provided to the facility's Administrator on 10/04/23 at 5:15 PM. While the IJ was removed on 10/05/23 at 2:00 PM, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures put residents at risk of serious injury, hospitalization , or even death. Findings Include: A record review of Resident #1's Face Sheet, dated 10/03/23, reflected Resident #1 was a 61-year- old female, who originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's FM was listed as RP, POA- Financial, POA- Care. Resident #1 was listed as other. Resident #1's diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), pain, difficulty in walking, need for assistance with personal care, lack of coordination, bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function), and generalized anxiety disorder (mental health disorder that involves a persistent feeling of anxiety or dread that interferes with how you live your life). A record review of Resident #1's Quarterly MDS Assessment, dated 09/22/23, indicated Resident #1's BIMS score was 11, which indicated the resident's cognition was moderately impaired. The MDS indicated Resident #1 required limited one-person physical assistance for transfers, dressing, personal hygiene and toilet use. A record review of Resident #1's Care Plan, dated 07/04/23, reflected she required psychotropic medications due to diagnosis of bipolar, anti-anxiety medication due to diagnosis of anxiety disorder, and antidepressant medication due to diagnosis of depression. The interventions included to administer medications as ordered. The Care Plan reflected Resident #1 had impaired cognitive function or impaired thought process due to dementia and the goal was to maintain current level of cognitive function. The interventions included Administer meds as ordered. Communicate with the resident/family/caregivers) regarding resident's capabilities and needs. Keep the resident's, routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. The Care Plan reflected Resident #1 had potential for delirium or an acute episode of confusion due to dementia diagnosis and the goal included resident will free of s/sx of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness. The interventions included: Consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Discuss with resident/family/caregivers concerns about delirium . Educate the resident/family/caregivers to observe for and report any s/sx of delirium . Monitor/record/report to MD new onset s/sx of delirium: changes in [behaviour ] altered mental status, wide variation in cognitive function through the day, communication decline, disorientation, lethargy, restlessness, and agitation. Altered sleep cycle, dehydration, infection, delusions, hallucinations . Review medical records for a DX or HX of the most common causes of Delirium: Congestive Heart Failure, Infections especially of the Urinary Tract, Upper Respiratory System, or Pneumonia, Diabetes, Dehydration or Electrolyte Imbalance, Chronic Obstructive Pulmonary Disease, Medication Toxicity or Interactions; or Benzodiazepine Withdrawal. The plan reflected Resident #1 had ADL Self Care Performance Deficit due to her diagnosis of bipolar disorder and the goal included she would be neat, clean, well-groomed and appropriately dressed daily. The interventions included staff providing supervision and assist with dressing, personal hygiene routine. The plan reflected Resident #1 had had potential for mood problem due to bipolar, dementia, GAD, and stated she had previously felt ideations of self-harm, she would bite her arm, and had been placed on 1 to 1 monitoring. A record review of Resident #1's Progress Notes, written by LVN A on 08/21/23 at 1:16 PM reflected, ADON reported to this nurse that pt [family member (FM)] had c/o patient was having a hard time forming sentences and putting thoughts in place, nurse assessed patient, alert and oriented X, pt states it is true she is having more of a hard time forming sentences and putting thoughts into words, but is not a new issue [issue] has been a on going problem and appears to be getting worse with time, reported back to ADON and MD. MD gave new order for labs CBC, CMP, Depakote level (test measures the level of acid in a person's blood), lipid panel and UA with C&S. A record review of Resident #1's Progress Notes, written by LVN B on 08/24/23 at 4:34 PM reflected, Telehealth visit conducted and MD provided new verbal orders for Namenda 10mg QD and CT scan to rule out possible stroke. Also to have speech evaluate for cognition. Information given to transportation to schedule. MAR updated and resident pleased with new orders. No other issues present at this time. A record review of Resident #1's Progress Notes, written by LVN A on 09/14/23 at 2:23 PM reflected, PCP here evaluating pt, pt c/o tremors and increase in memory loss, MD gave verbal order to start Primidone 50mg 1 tab QHS and increase Namenda to twice a day, notified [FM] no answer message left for call back. Pt aware of changes and agrees to changes. A record review of Resident #1's Progress Notes, written by LVN A on 09/14/23 at 3:12 PM reflected, [FM] RP in facility, notified of changes to medication, RP declined to start Primidone and/or increase Namenda, requesting to speak with PCP first, PCP notified, medications D/C as requested and Namenda decreased back to once a day as requested, PCP will contact RP. A record review of Resident #1's Progress Notes, written by the DON on 09/15/23 at 10:27 AM reflected, [Resident #1], residents [FM], informed this nurse that her [FM] told her that she threw her phone away because she didn't think she wanted to speak with her. Resident has been seen by psych and will be seen by a neurologist per [FM] request. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 2:42 PM reflected, Resident sitting in lobby with some shorts, slides (sandals), and a gray tunic top on waiting for her ride per her. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 3:07 PM reflected, Staff reported resident was currently next door at a fast-food restaurant, notified sister who was in the parking lot, she thanked staff and drove off. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 3:08 PM reflected, Notified DON of residents were abouts. A record review of Resident #1's Progress Notes, written by the ADON on 09/28/23 at 3:11 PM reflected, Received a call from [police officer] of [police department] that resident had walked away from her [FM] and was requesting to be sent to [hospital]. Police notified ADON that resident was ignoring [FM] and acted as if she didn't know her. MD called and made aware. A record review of Resident #1's Progress Notes, written by LVN C on 09/28/23 at 9:59 PM reflected, Res (Resident) yet to be back to facility so writer reached out to the [FM] who then confirmed that she was admitted in [hospital] for further assessment. Text message sent to the DON. A record review of Resident #1's MAR, dated September 2023, reflected the following: Amlodipine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day for HTN (Hypertension-when the pressure in your blood vessels is too high) Order Date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Atenolol Tablet 25 MG Give 1 tablet by mouth one time a day for HTN Order Date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Gemtesa Tablet 75 MG Give 1 tablet by mouth one time a day for Urinary Order date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Namenda Oral Tablet 10 MG Give 1 tablet by mouth at bedtime related to Dementia Order Date 09/14/23. The MAR reflected the hour for the medication was 9:00 PM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Loratadine Tablet 10 MG Give 1 tablet by mouth one time a day for Allergies Order Date 06/03/22. The MAR reflected the hour for the medication was 9:00 AM. In the box on 09/28/23, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Benztropine Mesylate Tablet 1 MG Give 1 tablet by mouth two times a day related to Dementia. The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the box, which indicated the medication was not given because the resident was away from the facility; Buspirone HCI Oral Tablet 15 MG Give 1 tablet by mouth two times a day related to Bipolar Disorder The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility; Divalproex Dodium Tablet Delayed Release 500 MG Give 1 tablet by mouth two times a day related to Bipolar Disorder The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility; Metformin HCI Tablet 500 MG Give 1 tablet by mouth two times a day for Diabetes. The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility; and Robaxin Tablet 500 MG Give 1 tablet by mouth two times a day for muscle spasms Order date 07/02/23. The MAR reflected the hours for the medication was 9:00 AM and 9:00 PM. In the box on 09/28/23 for 9:00 AM and 9:00 PM, there was a 3 in the boxes, which indicated the medication was not given because the resident was away from the facility. A record review of the facility's Resident Out On Pass Log reflected on 09/28/23 at 7:06 AM, Resident #1 printed her name and in the section that was labeled Accompanied By (Name, Relationship) was written Self. A record review of Resident #1's Medical POA reflected on 01/27/20 Resident #1 signed and gave permission to her FM to act as her Agent to make any and all health care decisions for me. This Medical Power of Attorney takes effect 01/27/2020. Section B of the POA reflected there were no limitations on the decision-making authority of the agent. Section D of the POA reflected I understand that his power of attorney exists indefinitely from the date I execute this document unless I revoke the power of attorney. The POA reflected it was notarized The State of Texas on 01/27/20. A record review of Resident #1's hospital records, dated 09/28/23, reflected the ER patient course notes, dated 09/28/23 at 2:20, reflected Patient is very minimally communicative, she stating that she no longer wants to go back to the nursing home or live with her [FM] that he wants to go to the downtown shelter . we are getting a behavioral health consult and case management consult . 1715 (5:15 PM) . behavioral health wanted to put on detention warrant, but police department did not seemed worried about her, as she end up becoming voluntarily to Behavioral Health unit . Discharge to Behavioral. The ER's final impression/diagnosis was depressive disorder anxiety state. The ER doctor medically cleared Resident #1 and reported she needed a psychiatric evaluation. Resident #1 consented to observations for emergent care in the [psychiatric hospital] and the Psychiatric ER doctor accepted Resident #1 for an evaluation on 09/28/23 at 4:40 PM. HPI notes on 09/28/23 at 6:39 PM reflected . Legal Status: Voluntary due to concern about harm to self . patient is slow to answer triage questions. Patient states, I want to go to the Downtown Shelter . Interview details: . appears confused. oriented, but slow to respond and may be internally preoccupied . Admits that last night she slept in a nursing home but does not want to return to a nursing home, group home, or her [FM]'s home. Adamant that she can go to the shelter. Patient is sunburned. On 09/28/23 at 9:41 PM the Psychiatric doctor noted, Principal Diagnosis: Schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). [Resident #1] is being discharged from Observation Status. [Resident #1] will be admitted for inpatient psychiatric care and treatment. Review of medical record indicates that [Resident #1] did not stabilize for discharge to home during this observation period . [Resident #1]'s continued mental illness requires higher level of care. Psychiatric initial evaluation dated 09/29/23 at 10:10 AM She has prolonged latency (the delay before a transfer of data begins following an instruction for its transfer) but is able to respond to short, simple questions if given enough time to answer. She states she ran away from her nursing home for lots of reason one being that she can not stomach the food there anymore. Patent states she does not want to go back to a NH (nursing home), her [FM]'s house, or a group home because she would just run away and says she doesn't want to be controlled and follow the rules of these homes . She was unable to answer most questions due to it being hard to get her thoughts together. She states she likely wont remember what we have talked about today . In a phone interview on 10/02/23 at 3:27 PM, Resident #1's FM stated when Resident #1 first admitted to the facility she was in MC. The FM stated about one year ago they went to the facility to visit Resident #1 and the facility had removed Resident #1 from Memory Care (MC) to Long Term Care (LTC). The FM stated she asked the DON why was Resident #1 moved and she was told Resident #1's BIMS had gone from 6 to 8, so, she no longer met the criteria for MC. The FM stated the facility never contacted her or discussed it with her in a care plan meeting, and she was Resident #1's POA. The FM stated she preferred Resident #1 to stay in MC because she knew she would eventually run away, just as she did on 09/28/23. The FM stated on 09/28/23 she went to the facility around 11AM to pick up Resident #1 to take her to a doctor's appointment. The FM stated they had already spoken to the DON the previous day and asked that Resident #1 be ready with her paperwork she needed for the doctor's appointment at 12 PM. The FM stated the DON said she would have Resident #1 and the paperwork ready. The FM stated when she arrived one of the nurse's (does not know her name) said to her oh wow you're back already. The FM stated she was confused and told her she was there to pick Resident #1 up for her doctor's appointment. She said the nurse told her that Resident #1 left earlier in the morning for her doctor's appointment. The FM stated she went to Resident #1's room and her roommate (Resident #2) said Resident #1 left early in the morning for a doctor's appointment. The FM said Resident #2 told her that Resident #1 was acting confused that morning because she jumped up really early about 6:45 AM and said she was going to her doctor's appointment and left out of the room. The FM stated Resident #2 told her she did not even change her night clothes or brush her teeth and just left out. The FM stated Resident #2 told her she knew something was not right because the previous night Resident #1 told her the appointment was at 12 PM but let out so early. The FM stated she told the ADON Resident #1 was missing. The FM stated she was crying and upset and the ADON was acting as if she didn't care. The FM stated the ADON told her Resident #1 probably signed out of the facility and left. The FM stated she told the ADON she cannot sign herself out because she has dementia. The FM stated they went to the front and receptionist said Resident #1 said she had a doctor's appointment and signed out. The ADON showed the FM the sign out log. The FM stated the signature did not look like her sisters . The FM stated she told them she was her POA, and she was not able to sign herself out because she has dementia and mental issues. The FM stated the facility did not even call her to let her know she signed herself out. The FM stated the ADON said she was able to sign herself out because of her BIMS score and it was her right. The FM said she told the ADON again, Resident #1 could not herself out with her mental issues. The FM stated she asked the ADON to call the police and the ADON told her she couldn't because she signed herself out and they had to wait a certain time to call the police, due to their policy. The FM stated she left the facility and a few minutes later the ADON called her and said an employee saw her earlier at a fast-food restaurant near the facility. The FM stated she went to the fast-food restaurant and Resident #1 was sitting outside at a table. The FM stated Resident #1 was in her gray nightgown and flip flops. She stated Resident #1's skin looked red and was acting frantic. The FM stated she told Resident #1 she had a doctor's appointment and attempted to get her in the car. She said Resident #1 was pushing away from her and wouldn't talk to her. The FM stated Resident #1 said was not going with her or to the facility. The FM stated a worker from the fast-food restaurant came outside and told her they were just about to call an ambulance because Resident #1 had been there for several hours, and they knew Resident #1 was not acting right. The FM stated Resident #1 started walking off down the busy access road, so she went to stop her and called 911. The FM stated the police came and Resident #1 was still refusing to go with her. She said she told police she cannot be out on her own because of her mental issues and she was her POA. The FM stated Resident #1 told the police she would not go with her, and she would go to the hospital. The FM stated the police asked Resident #1 about going back to the facility and she said no take her to a shelter. The FM stated the police called ambulance, who took her to the hospital. The FM stated the hospital would not discharge Resident #1 because of mental issues and admitted her into the psychiatric hospital. The FM stated in the last month she noticed Resident #1 had become more confused, her memory had gotten worse, and she had a difficult time forming sentences. The FM stated she talked to the facility about her decline and the doctor tried to give Resident #1 more medication. The FM stated she told the facility she did not want to give Resident #1 more medication and she wanted test done because she believed Resident #1could have had a stroke or something else was happening to make her memory get worse. The FM stated she was not able to remember a lot and her speech was getting worse. Stated she started looking around for her and could not find her. In an interview on 10/03/23 at 11:19 AM, Resident #2 stated Resident #1 walked out of the facility. Resident #2 stated a couple days ago Resident #1 got up early, said her FM was taking her to an appointment, walked out of the room, and she never saw her again. Resident #2 stated Resident #1's FM came to the room about 11:30/12:00 and asked where was Resident #1. Resident #2 stated she told the FM she thought Resident #1 was with her. Resident #2 stated she thought Resident #1 got confused because Resident #1 had previously told her the appointment was at 12PM but she left out of the room early at like 6:30/7:00 AM. Resident #2 stated Resident #1 did not get dressed and left out in her nightgown. She stated Resident #1 did not even wash her face or brush her teeth and didn't have on a bra or panties because she did not like to sleep in them. Resident #2 stated she just left out. She stated she spoke to Resident #1's FM later and they did not know where Resident #1 was for five hours. Resident #2 stated Resident #1 seems mentally ok sometimes but lately she seemed to be very confused about things all the time. A record review of Resident #2's Comprehensive MDS, dated [DATE], reflected her BIMS was 15, which indicated her cognition was intact. In an interview on 10/03/23 at 12:31 PM, the ADON stated on 09/28/23 she arrived at the facility about 6:45/7:00 AM and Resident #1 was sitting at the front with another resident. The ADON stated she said to Resident #1, you're up and dressed early and Resident #1 said her sister was coming to take her to a doctor's appointment. The ADON stated approximately 30 minutes later the receptionist contacted the nurse's station and said Resident #1 said her ride was there and she was signing herself out. The ADON said she told the receptionist she was aware that Resident #1 had an appointment. The ADON stated a couple hours later around 12 PM Resident #1's FM came to her asked where was Resident #1. She said she told the FM she thought she was with her because Resident #1 said she had an appointment. The ADON said Resident #1's FM was really upset and said, you just let her walk out. She stated she told the FM she signed herself out and didn't just walk out. The ADON said Resident #1's FM said Resident #1 had a mental disorder, so how did you all let her sign herself out. The ADON stated she went to the receptionist desk, checked the log and saw Resident #1 had signed out. She stated the receptionist said Resident #1 told her that her [FM] was there and signed out. The ADON stated she checked Resident #1's BIMS and she believed it was a 12, which meant she was able to sign herself out. The ADON stated Resident #1's FM got upset and was crying saying Resident #1 was out there alone with no money. The ADON stated Resident #1's FM wanted to call the police to do a missing person's report, but she told her their policy stated they had to wait 72 hours. The ADON stated Resident #1's FM left the facility. She stated a staff member (does not remember who) heard Resident #1's FM talking about the situation and told her they went to a nearby fast-food restaurant for lunch and saw Resident #1. The ADON stated she called Resident #1's FM to tell her were Resident #1 was. The ADON stated [NAME] after that she received a call from a police officer, who asked did Resident #1 live at the facility and if Resident #1's FM was in fact her relative because Resident #1's FM was trying to get Resident #1 in the car, but she refused and was upset. The ADON stated she verified to police that Resident #1's FM was in fact her FM. She said the police officer said Resident #1 refused to go with the FM and said to take her to [hospital], so he called EMS. The ADON stated the resident's BIMS determined if they were able to sign themselves out. She stated she was not exactly sure what the BIMS score had to be, but Resident #1 was cognitive and able to make decisions. The ADON stated Resident #1 normally signed herself out and walked out to her FM's car. She stated she assumed that was what Resident #1 was doing on 09/28/23 when she signed herself out. During a record review and interview on 10/03/23 at 12:59, the DON stated Resident #1 signed herself out and went to a nearby fast-food restaurant. The DON stated Resident #1's FM came to pick her up for an appointment and got upset that she wasn't at the facility. She stated residents had to have a BIMS of 13 to sign themselves out and Resident #1 had a BIMS of 13. The DON stated she had to check PCC because believed Resident #1 had a BIMS of 13. The Investigator informed the DON that Resident #1's current MDS reflected a BIMS of 11 and showed the DON Resident #1's BIMS assessments in PCC, which reflected a BIMS assessment dated [DATE] with score of 11 and BIMS assessment dated [DATE] with a score of 8. The DON stated she thought maybe the assessment was incorrect because she believed Resident #1 had a BIMS of 13. When the Investigator asked the DON if she felt it was safe for Resident #1 to sign herself out, even though her current Care Plan, reflected Resident #1 had impaired cognitive function and thought process and episodes of confusion due to her dementia diagnosis, the DON stated yes, because Resident #1 was cognitive enough to make sound decisions. The DON stated she did not know exactly what the policy was regarding residents being able to sign themselves, but they had been allowing residents with BIMS of 13 or higher to sign themselves out. When the Investigator asked the DON, was Resident #1 allowed to sign herself out even though she was not her own RP, she stated Resident #1 was her own RP. When the Investigator went to show the DON in PCC that Resident #1 was not her own RP, the information had been changed and reflected Resident #1 as her own RP and Resident #1's FM was listed as emergency contact and not RP and the POA information had been removed. The Investigator pointed out to the DON that she had reviewed Resident #1's record when she first entered the facility and took a snippet of the information, which, reflected Resident #1 was listed as other and not RP and her FM was listed as RP and care and financial POA. When the Investigator asked the DON why the information was changed, since she entered the facility, she stated she didn't know and would have to check into, but she had not changed the information. During a record review and interview on 10/03/23 at 1:12 PM, the Regional Director (RD), she stated she was reviewing Resident #1's clinical record in PCC and accidentally changed her information. She stated she went back in PCC and corrected the information. When the Investigator refreshed her tablet, the clinical record reflected Resident #1 as her own RP and her FM as RP and Care and Financial POA. The Investigator pointed out that Resident #1 was now listed as her own RP, which was not listed as such during the initial review, the RD stated oh but did not provide an additional response. In an interview on 10/04/23 at 10:20 AM, LVN A stated she did write the progress noted on 09/14/23 at 3:12 PM. LVN A stated the MD was in the facility and assessed Resident #1, due to complaints of tremors and increased memory loss. She stated after the assessment the MD gave an order for Primidone for the tremors and increased dosage in Namenda. LVN A stated when she called Resident #1's FM about the new orders she stated she did not want her to take more medications. She stated she notified the MD, who d/c the orders. LVN A stated she updated PCC (electronic medical information platform). LVN A stated when residents sign themselves out, the facility receptionist are supposed to review the list and if the resident was highlighted on the list, they were supposed to call the nurses station to verify they could leave. She stated the receptionist always called to verify regardless of if the resident was highlighted or not. LVN A stated if she was covering a hall and was not familiar with the resident, then go to the front to check with SW regarding BIMS and if they were ok to sign out. Stated she was not exactly sure of what the policy was, but she was informed the residents had to be cognitive with BIMS of 13 to sign out by themselves. LVN A stated she did not know Resident #1's BIMS but she was cognitive, and she would not have interjected with her leaving the facility. LVN A stated if the resident was not their own RP, then you must call their RP before allowing them to sign out. LVN A stated before the resident left, you were supposed to check to see if they would be gone during the time their medication was supposed to be administered and if so, they were supposed to offer the residents their medications. In an interview on 10/04/23 at 11:48 AM, CNA D stated she was assigned to Resident 1's hall on 09/28/23 from 6AM-2:00 PM. CNA D stated about 6:45 AM she went to provide care to Resident #2 and Resident #1 was already up and said her FM was picking her up for a doctor's appointment. She stated Resident #1 did say what time her appointment was. CNA D stated she told LVN E, who was the nurse for Resident #1's hall, that she was leaving for an appointment with her FM. She stated about 15-20 minutes later, she saw Resident #1 heading towards the front of the facility to leave. CNA D stated Resident #1 did occasional get confused but for the most part she was ok. CNA D stated Resident #1 did stutter and took a while to get her words out. In an interview on 10/04/23 at 11:57, LVN E stated she was the nurse assigned to Resident #1's hall on 09/28/23 from 6AM-2:00 PM. LVN E stated Resident #1 was up early and dressed. She stated Resident #1 told her she had a doctor's appointment at 12PM. LVN E stated a little while later the receptionist called to the nurse's station and said Resident #1 was leaving out for an appointment with her FM. She stated the receptionist was told they were aware. LVN E stated she knew her appointment was at 12PM but she figured her FM was there early. LVN E stated the residents were required to be cognitive and have a BIMS of 13 to leave by themselves. LVN E stated if the resident was not their own RP, then they you were supposed to call POA/RP. LVN E stated she did not know Resident #1's BIMS score but she knew she was cognitive. LVN E stated she did not know Resident #1 was not her own RP. She stated Resident #1 mostly went out of the facility with her FM, but there had also been times she signed herself out. LVN E stated Resident #1 always returned and was not known to be an elopement risk. LVN E stated the nurses were supposed to offer the resident's medications if they will be out when the medications were supposed to be administered. She stated Resident #1 was not offered her medications on 09/28/23 because she left before they could offer. In an interview on 10/04/25 at 12:45 PM, the DON stated the process they had been using for resident's signing out was the receptionist checked the list at the front before allowing the resident to sign out. The DON stated the list had highlighted names, which meant those residents were not allowed to sign out by themselves and the receptionist had to contact the nurse. She stated the IDT determined whose names were highlighted and they took into consideration the residents' cognition, BIMS, and over all safety. The DON stated Resident #1 was not a highlighted name, which meant she was able to sign herself out. She stated if a resident was not their own RP, they must contact the RP before the resident could [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure quality of care as well as have a effective pest control program for two (Residents #1 and #3) of five residents reviewed for quality of care. The facility failed to ensure that they established and followed procedures/protocols to ensure that there were no potential negative outcomes to a resident's physical, mental, or psychosocial health or well-being. Staff failed to contact the appropriate entities regarding the issue, failed to have the knowledge to follow protocol of removing clothing, showering resident, completing an assessment, moving the resident to another location, failed to properly assess as well as monitor the residents. An Immediate Jeopardy (IJ) was identified on 09/15/21 at 00:00. While the Immediate Jeopardy was removed on 09/16/21, the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. These failures could place residents at risk for itching, pain, serious bodily harm from ant bites, and [MEDICATION(S)] (A severe, potentially life-threatening allergic reaction) . Findings included: Review of Resident #1's Face Sheet (undated) revealed she was an [AGE] year old female admitted to the facility on [DATE] with active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She discharged on [DATE]. Review of Resident #1's admission MDS assessment dated [DATE] revealed she had clear speech and was usually understood. Her BIMS score was not assessed. Her mood score and behavior assessment on the MDS was not completed. Resident #1's functional status indicated she needed two person physical assistance for bed mobility and had range of motion impairment on her upper body on one side. She had no active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #3's admission MDS assessment dated [DATE] revealed she was a [AGE] year old female admitted to the facility on [DATE] with an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She required extensive physical assitance of two staff for bed mobility, had range of motion impairment on both sides of her upper extremities, and used a wheelchair for mobility. An interview with Resident #1's RP on 09/15/21 at 12:24 PM revealed Resident #1 had been admitted to the facility to the COVID-19 unit to recover from COVID and she was paralyzed on her right side and had dementia. The RP said the stay was to be short-term and there was a planned discharge to another facility which occurred on Saturday 09/11/21. The RP believed the ant bites to have occurred during the middle of Friday night on 09/10/21. The RP said she had visited Resident #1 earlier in the day on Friday 09/10/21 and there were no ant bites on her body. However, when the RP went to Resident #1's bathroom, she saw what looked like little fire ants and notified the CNA who said she would talk to the facility about it. When Resident #1 arrived at the new facility on 09/11/21 and the RP came to visit that evening, Resident #1 told her to look at her arm. The RP said there were puss pockets all over Resident #1's arms, her breasts, her neck, her side and her thigh. The RP said the new facility kept asking her what the skin eruptions were and the RP said it looked like ant bites. The RP said Resident #1 told her and the new facility staff she woke up in the middle Friday night (09/10/21) with ants all over her and a CNA at the previous facility looked at her skin and did not see anything. The RP said Resident #1 did not tell her about the ants on her body until she moved to the new facility on 09/11/21 and the pustules started to show up that evening on her body. The RP said Resident #1 was currently at the hospital for a change in condition, she was severely dehydrated and her blood pressure was low and the ER doctor told her that the ant bites were infected and she would need wound care to treat them. She could not say if Resident #1's change in condition was directly related to the ant bites. The RP said, It breaks my heart knowing she had to go through all of this. An interview and observation of Resident #3 on 09/15/21 at 1:50 PM revealed she was awake and lying in bed. She said she remembered being bitten by ants the week prior in the other room she had been in. She said she woke up around 4:00 AM, she did not remember the day, but there were ants biting her neck. Resident #3 said she could not move her arms easily but could see the ants were on her arms and inside her hands. She said she pressed the call light and yelled out help and the staff came immediately and got the ants off her and her sheets. Resident #3 said she could see her sheets had ants on hem as well. She said the staff showered her and moved her to the room where she was at presently. Resident #1 said the ant bites hurt and itched real bad so the doctor had ordered her a topical medication to put on. Resident #3 said that was the only time she had seen ants at the facility. Review of the facility Maintenance Pest Service Requests (handwritten log) on 09/15/21 reflected the following: *07/13/21 ANTS- Exterior, *07/22/21 ANTS- Exterior, * 08/04/21 ANTS- Exterior, *09/13/21 ANTS- Stations 1 West (COVID unit).Review of Work Order dated 09/14/21 reflected, Ants in Room and in Hallway 100. LVN C completed the request and the MD labeled it as medium priority. Review of Work Order dated 09/14/21 reflected, Resident room [ROOM NUMBER]-ants in bathroom and window. MD labeled the request as medium priority. An interview with the MD on 09/15/21at 10:46 AM revealed he thought LVN C was the person who reported there were ants on the COVID-19 isolation unit, inside resident rooms and the hall, so a work order was put in. He said the contracted pest control company came out on Monday 09/13/21 and sprayed outside the facility. He said pest control usually came out on the 1st and 3rd Friday of the months and any time they were needed in between. He said he did not know anything else related to ants on the COVID unit. The MD said he was not present when the pest control provider came out on 09/13/21. The MD was asked to provide evidence of the last three pest control visits. He stated he did not have them available and would have to contact the pest control provider. An interview with MDA on 09/15/21 at 10:49 AM revealed on Monday, 09/13/21, he heard a page overhead at the facility about ants, he did not remember who paged him but he was given a work order for ants. He did not know who wrote the order because it was digitally entered into their online maintenance request system. MDA said after he received the work order on 09/13/21, he went outside to the exterior of the COVID-19 unit by the parking lot. The MDA stated he observed ants on the wall, so he got some ant spray and sprayed the ants and got a ladder and sprayed the gutter because that was where they were going. He said there were tree branches in the gutter. After that, MDA said he got some ant bait and sprinkled it around the building on the same side. The MDA said he did not see a fire ant mound or any ants around the resident windows. He said the only way they could have come into the building would have been through a gap in the window seal. He said he then went inside the COVID-19 unit where he saw regular ants pointed out by Housekeeper D. He said, Outside ants were more of, I guess fire ants, because they were bigger, and on the inside, regular sugar ants, I didn't see any fire ants. He said he saw one ant in room [ROOM NUMBER] and sprayed the whole room and hallway with an ant and roach spray. He said the rooms in question for ants were rooms 118, which he said was an office, and room [ROOM NUMBER], which he said was an empty room. The MDA said he then called the pest control provider on 09/13/21 who came and treated the exterior of the COVID unit that same day. The MDA said he did not meet with pest control when he came out that day because he was busy with a water leak in the facility. He said he had not seen any other ant activity since then. Review of the facility pest control invoices revealed the last three visits were on 07/20/21, 08/23/21 and 09/16/21. Ants were only identified on the 09/16/21 visit and listed the visit as Odd Job/Extra Service and reflected, Treated and inspected for ants for all halls exterior; inspected around all windows. An interview with the pest control provider for the facility on 09/15/21 at 11:05 AM revealed he walked the perimeter on 09/13/21 and he saw ants on the south west corner under a concrete block out, on the COVID unit about two to three feet away from the wall of the unit. He said he used a granule pesticide on the ants and a spray which generally took 30 minutes to start working. He said, It was fire ants, spread out, looked like we had a shower come through and generally they will move to a few feet to an area under the concrete block. The pest control provider stated he also found a few dead tree stumps that termites could habitat and then eventually ants would follow. He said he went on the COVID-19 unit and did not see any ant activity. Review of the facility census cross referenced with the facility floor plan on 09/15/21, showed the following resident rooms on the exterior covid side of the building where the fire ants were found: 118 office 120 EMPTY 122 Resident #2-admitted on [DATE]**(This is where Resident #1 was previously) 124 EMPTY 126 occupied with one resident 130 Resident #3 An interview on 09/15/21 at 12:56 PM with LVN C revealed she worked the 6AM-2PM shifts during the week on the COVID-19 unit. She said last Friday 09/10/21, she came into work at 6:00 AM and she had an agency nurse working with her and she noticed two of the residents had been moved to another room on the unit (Residents #3 and #5). She said the two residents were on the even side of the hall, so she was not assigned to them. She said CNA D told her the unit had ants and Residents #3 and #5 had been moved from room [ROOM NUMBER] to room [ROOM NUMBER]. LVN C said Resident #5 did not have any ant bites, but Resident #3 did have them on her shoulder and on her left elbow. She said the ant bites were being cleaned and monitored. LVN C said a few days later, Resident #3 started to have little pustules on her left arm. LVN said all the residents' skin was assessed for ant bites on the COVID unit. She said the CNAs and the agency nurse and herself looked at the residents' skin and linens and did not see any evidence of ants. She said she did not have any documented evidence that skin assessments were completed that day because they only did a visual check. After the ants were seen overnight on Thursday 09/09/21 in room [ROOM NUMBER] with Residents #3 and #5, the room was shut off on Friday 09/10/21. The room was cleaned by Housekeeper D and maintenance was notified, but she did not believe pest control came out. LVN C said, I don't know what they did I did not pay attention. I know my housekeeper did a deep cleaning. I think the maintenance did some sort of ant spray because it stunk. LVN C said on Monday 09/13/21, when she came in, she saw the ants in COVID office room [ROOM NUMBER] in the windowsill, along the wall going into the bathroom and she saw some [NAME] ones in the hallway. She said pest control came that Monday 09/13/21. She said that was when the night nurse, LVN F, told her about Resident #1. She said, I don't know what kind of ants they were, the annoying red little ants. LVN C said when she came into work on Monday 09/13/21 and saw ants in the COVID office (empty resident room [ROOM NUMBER]), the night nurse (LVN F) told her he had moved Resident #1 over the weekend because he saw ants along her window. LVN C said Resident #1 discharged that weekend so she never got to see her skin. LVN C said LVN F did not say if there were any ant bites on Resident #1 and she did not ask. She said Resident #1 had been staying in room [ROOM NUMBER] B, which was by the window two doors down and she did not have a roommate at the time. Review of Resident #1 and #3's clinical charts reflected no mention of ants found in their rooms or on their skin, ant bites, skin assessments, an incident report, or a clinical nursing progress note. An interview with CNA D on 09/15/21 at 1:11 PM revealed she worked during the weekdays on the 6AM-2PM shift. She said she could not remember the exact day, but the week prior (week of 09/06/21-09/10/21), she was putting Resident #5 in a chair in her room and she saw little black ants on the floor and one on her on her leg. She said she cleaned it up and alerted LVN C. CNA D said she did not look in Resident #5's bathroom but she looked at her and her roommate's (Resident #3) bed linens and there was no sign of ants. CNA D said the next day was when Resident #3 had ants all over her. She said Resident #3 did not have any ant bites, nor did Resident #5. CNA D said she and other staff moved both Resident #3 and #5 to another room that day to 130. CNA D said she did not check the other resident rooms that day for signs of ants in the room or on the residents' bodies. She said she did work with Resident #1 on Friday, 09/10/21 and she did not have any ants in her room or on her skin. An interview with CNA E on 09/15/21 at 1:24 PM revealed she did not work Friday morning on 09/10/21 and was not part of the move of Residents #3 and #5 to a new room after ants were observed. She said she was present on Saturday 09/11/21 and was the CNA who got Resident #1 ready to be discharged and showered her. CNA E said she did not see any skin concerns, except some discoloration on her stomach where the resident said she got insulin. CNA E said there were no observable ant bites. She said when Resident #1's RP arrived at the facility prior to the transfer to another nursing facility, that was when Resident #1 told them there were ants in her bed and the staff had found a pile of them in her bed. Resident #1 told her the staff did not move her from the room, but moved her from the B bed side to the A bed side. An interview with the OT on 09/15/21 at 1:35 PM revealed she saw a line of ants the week prior towards the end of the week (unable to recall exact day) by the COVID unit hallway, outside the rooms of 120 and 122. She said housekeeping came and sprayed and showed her the ants but she did not know what kind of ants they were. The OT said she saw ants again, and thought the housekeeper sprayed more and cleaned them up. Then on Monday, 09/13/21, the OT said she observed ants in the COVID staff office. She said, There were a whole bunch coming through the bottom of the floor under the window and trailed about six feet to the bathroom below the sink next to the trashcan which typically had nothing in it but paper towels. The OT said she reported it when she saw them to LVN C and the ADON and I said we have ants and we got a problem. She said a man came in that day from pest control and sprayed all around the inside of the rooms and the exterior of the COVID unit. An interview with Housekeeper D on 09/15/21 at 1:39 PM revealed she could not remember the day, but she had seen ants in the COVID office restroom and in the corner of the room. She said she did not see ants in the resident rooms, but did see them in the first half of the COVID hallway. She said, It was like a line marching in the hall. I don't know where they were going. They were going in different directions. She said she reported it to the maintenance department and the nurse. She said she saw ants the week prior and the current week. An observation with LVN C on 09/15/21 at 1:45 PM of room [ROOM NUMBER] (where Resident #1 had previously been), revealed a new resident had been placed in that room in Bed A, by the door, on Sunday 09/12/21 (Resident #2). The bedroom window was observed to have the bottom right half open with a crack of approximately ¼ inch. It did not form a seal and the window screen frame was bent and out of frame. An interview with Resident #2 on 09/15/21 at 1: 50 PM revealed he had not seen any ants in his room or on his person. There were no ants observed in the room at the time of the interview. An observation on 09/15/21 at 1:59 PM with LVN C occurred where the exterior of the COVID unit was observed between the facility and the side parking lot. An active ant colony was observed under two cement blocks a few feet outside the window of Resident #3 between her and the room next to her. The ants observed were numerous and the cement block appeared to be covering an open white PVC pipe approximately four inches in diameter. The dirt around the pipe did not have a mound, only dirt. The dirt was aggravated with a kick of the shoe and at that point, ants came pouring out of the dirt. No ants were observed along the wall of the building exterior COVID unit, and there were observable ant granules placed down. The active ant colony was observed to be about three rooms away from the crack in the window in room [ROOM NUMBER]. LVN C confirmed she saw the active ant colony. At that time, the MDA came outside at 2:02 PM. Observation and interview with the MDA on 09/15/21 at 2:12 PM revealed he saw the ant colony and confirmed it was still present and posed a risk. The MDA said he had been notified the week prior there had been ants found in Resident #3 and #5's room so he went and sprayed their room and he sprayed the outside of the window. The MDA said that when he sprayed the room, he did not check any other resident rooms, he was just going off where staff had reported they had seen ants. An interview with LVN C on 09/15/21 at 2:14 PM revealed when ants were seen in one room or one place, housekeeping would be notified and they would come in and do a deep cleaning and maintenance would come and spray. If staff started seeing ants in other places, then they call the MD to have pest control come out. An interview with CNA G on 09/15/21 at 2:15 PM revealed she worked the overnight shift on Thursday 09/09/21 and Friday 09/10/21. She said on 09/09/21, there were no ants observed. She said ants were not seen until that next morning. She said, Basically, me and the other aide saw them because we were doing our rounds together and we let the nurse know. She said, What we saw was the ants just crawling everywhere at that particular time on that person, I have no idea because I did not go into the room, the aide told me they were in there. She said the room was room [ROOM NUMBER] with Residents #3 and #5. She said other staff told her there were also ants in room [ROOM NUMBER], Resident #1's room. She said she was wondering where all the ants were coming from. CNA G said she did not see any ants on Resident #1 but she did see ants on Resident #3 while she was rounding that morning from the 09/09/10 overnight shift. She said there were ants on Resident #3's left side of her neck and arm and on her chest. CNA G said she and the other aide came into Resident #3's room and turned on the light and Resident #3 opened up her eyes and that is when I saw ants on her. She said they looked like black ants. She said Resident #3 did not say if they were stinging her. She said, Once we saw those, my instincts were to knock them off her. Then [LVN F] grabbed the infection stuff, the germicide and started killing them and [CNA H] was cleaning the ants up while I was getting [Resident #3] together. CNA G said LVN F told her to leave Resident #3 there because he did not know which room she would be switched to. She said she did not move Resident #3 before her shift ended but by the time she came back for the overnight shift on Friday 09/10/21, Resident #3 had been moved to a different room. CNA G said she did not know if anyone reported the ants and the ant bites, I didn't. She said the LVN F told her he was going to let the facility know. CNA G said she and the other staff checked the other residents and there were no issues with ants. On the Friday overnight shift, CNA G said Resident #3 and #5 were moved to a new room and their old room [ROOM NUMBER] was emptied and closed off. She said Resident #1 had the room next door to the now emptied room and at the beginning of her shift, there were no observations of ants in her room. She said during the middle of the night check, she did not see anything, but around 5AM, one of the aides, CNA I, noticed ants in Resident #1's room when she was rounding. CNA G said she did not see Resident #1 because she already had a CNA assigned to her. She said once CNA I saw the ants in Resident #1's room, they moved her from the B side (by the window) to the A side (by the door), cleaned up the area and made sure no ants were on her. CNA G said Resident #1 was not moved to another room because she did not know if there was another room available. CNA G said her shift was over by the time Resident #1 woke up on Saturday 09/11/21, so she did not see her skin. An interview with ADON A on 09/15/21 at 2:57 PM revealed she did not discharge Resident #1 on Saturday, 09/11/21, she only started the discharge form in the system and that was why her name was on it. She said she was not present at the facility on the date of discharge and an agency nurse was working that shift on the COVID unit. She said prior to a discharge, the nurse was supposed to complete a skin assessment and document it on the discharge form. ADON A said she was aware ants had been seen on the COVID unit on Monday 9/13/21 by the charge nurse, LVN C. She said LVN C reported the ants to maintenance and pest control had come and sprayed the day before. She said as far as she knew, that was the only time ants had been seen on the COVID unit. She said there were four ADONs in the facility, but she was the ADON over the COVID unit. ADON A said if ants were seen on the COVID unit and in a resident's room and on a resident' body, she should have been notified so she could give staff the direction they would need to go and ensure the proper channels were notified. ADON A said had she been notified of possible ant bites, she would have made the staff shower the affected residents immediately, have the nurse complete a head to toe skin assessment and then move the resident(s) to another room. ADON A denied knowing that Resident #3 had been bitten by ants on the overnight shift of 09/09/21 or that Resident #1 had been bitten on the overnight shift on 09/10/21. She said. I remember ants on Monday and reporting it to maintenance. ADON A said staff should always report any insect sightings, even with one ant, because with one, there is more. ADON A said on Monday 09/13/21, during stand up and throughout the day, no one told her that Resident #1 had ants in her room or any claims she made that she was bitten. A follow up interview with the MD on 09/15/21 at 3:13 PM revealed he remembered there was a work order placed on Friday 09/10/21 that the housekeeper had seen one ant by the window in the COVID unit, so MDA attended to the work order. He said when MDA was done, he reported to the MD, Man .I seen like one little ant. The MD said no one was in the room so he sprayed and cleaned up and checked the perimeter outside and that was that. Then on Monday, 09/13/21 was when there were more reports of ants and that was when he reached out to pest control. He said pest control was not contacted sooner on Friday 09/10/21 when the ants were first seen in the facility's COVID unit because it was only a report of one ant, so they sprayed and placed bait. He said only if there were more ants observed after that, would he have pest control come out because it would be a bigger situation. The MD said no one notified him that Resident #1 had gotten bitten and ants were found on her and in her room over the previous weekend. MD confirmed that he did go out and see that there were still ants outside the COVID unit about an hour ago and had placed more bait down. He said the bait would kill the ants or move them away from the building. The MD said no one told him there was a gap in the bedroom window of room [ROOM NUMBER]. He responded, It's really, with ants, it's like, you know they can get in from anywhere, but definitely, those are little clues and spots that we have to try and catch them. I didn't know there was an opening in the window. No one notified me through a work order. An interview with the DON on 09/15/21 at 3:37 PM revealed she was only made aware of ants on the COVID unit on Monday 09/13/21. She said she was never told that two residents (Residents #3 and #5) had been seen with ants in their room and one of them had ant bites on their body on 09/10/21 and if she would have been notified, she could have assessed the residents and called the corporate nurse to decide if it was a reportable incident to HHSC or not. The DON said once LVN C notified her on Monday 09/13/21 of ants found in resident rooms the week prior, she said do a head to toe assessment, document in the clinical chart and notify maintenance. The DON said had she known on 09/10/21 and 09/11/21 that ants had been found on the COVID unit and bitten Resident #3 and #1, her expectation would be that all their clothes would be taken off, they would be showered, a head to toe assessment completed, personal items packed up and the residents moved to another room, the family, doctor, DON and abuse/neglect coordinator would then be notified. The DON then questioned how could it be proved that the ants found on Resident #1 overnight caused her ant bites found by the receiving facility later the next day, because the CNA who showered her that morning did not see any bites on her skin prior to the discharge. An interview with CNA I on 09/15/21 at 3:58 PM revealed she worked the overnight shift Thursday night 09/09/21 going into Friday night 09/10/21. CNA I said she had known there was a previous issue with ants because Residents #3 and #5 had been moved to another room when some were found on 09/09/21. She said she went into Resident #1's room on Friday overnight shift on 09/10/21 to do care. When she pulled the cover back, the linens were full of ants on the right side of her body from her ankles to her arm and It startled me. She also said it scared her and she called LVN C to come in and he left the room and got some type of bug spray while she sat Resident #1 up on the side of the bed. CNA I then looked in Resident #1's brief and she did not see any other ants. CNA I said she sat Resident #1 in the chair and asked her if she felt anything bite her and Resident #1 responded no. CNA I believed it was because her right arm was paralyzed. CNA I said, I was like oh my god. But it was a bunch. Like more than 50, small ants. And they had a trail going. CNA I said she and LVN F determined the ants were coming in from the outside but they could not determine where. At that point, CNA I said she cleaned Resident #1 up with a wet wipe to remove the ants and moved her to the bed on the A side of the room by the door. She did not know if LVN F checked Resident #1's skin. She said after she got Resident #1 comfortable. She said she did not check any other residents to see if there were ants in there room or on their person. CNA I said when her shift was over on Saturday morning, 09/11/21, she did not let the oncoming 6A-2P staff about the incident with the ants because she had to leave and they had not arrived to work yet. CNA I said she did not know why Resident #1 was not moved to a different room and she asked LVN F about it, but he only told her to move the resident to the other bed, so she did. Several attempts were made to contact LVN F for an interview on 09/15/21 at 4:10 PM, 5:07 PM and 10:15 PM. Voice mail message were let with no return phone call. An interview was conducted on 09/15/21 at 4:39 PM with the social worker from the receiving facility for Resident #1. She said the DON, ADM and ADON had already left for the day but she remembered Resident #1 admitting to their facility on Saturday 09/11/21 because it had been planned. The receiving facility's social worker said she did not work on the weekend so the first time she saw Resident #1 was on Monday morning 09/13/21 when she met with her and her family. She said Resident #1 was covered with what looked like hundreds of pus filled fire ant bites on her right arm. She said Resident #1 told her there were also ant bites on her chest and down her body. The social worker said when she did the care conference with the family, they were distraught. The social worker said what she saw with the ant bites was dangerous and neglectful. She said Resident #1 was sent out on Tuesday 09/14/21 to the hospital when her blood pressure kept dropping. She could not say if her change in condition was related to the fire ants. Attempted interview with the ER nurse and ER doctor on 09/15/21 at 4:37 PM and at 6:18 PM was unsuccessful. A message was left with the ER nurse to return investigator's call. An interview with LVN J on 09/15/21 at 6:04 PM revealed she was an agency nurse who discharged Resident #1 on Saturday 09/11/21 and completed the discharge paperwork, which included a skin assessment. She said when she assessed Resident #1's skin, she observed a small bruise on her right arm, like a skin tear. LVN J said she wiped her skin tear with alcohol and put a bandage on it. LVN J said she gave Resident #1 her morning medications and she was given a shower and she was fine and had no complaints of ant bites. She said there was nothing on Resident #1's arm that would indicate ant bites. LVN J said two days before, she had been told that the staff had to move some residents in the COVID unit because their room had ants. She said when she worked on Saturday 09/11/21, Resident #1 had been moved to a different room on the other side of the hall. She said the night nurse (LVN F) did not report any ant sightings or ant bites when she came on shift, So I didn't know to look for them. LVN J said no one asked her to assess any of the residents' skin on the COVID unit after the ants were discovered. LVN J said had she been told that Resident #1 was found with ants on her body the night before, she would have done things differently. She said, I would have checked all her skin and taken her clothes off and checked totally. What I did was what I could see with her clothes on. An interview with the receiving nursing facility's DON on 09/16/21 at 2:00 PM revealed she was not working when Resident #1 admitted to the facility on [DATE], an agency nurse completed the admission and they did not document anything at that time about her skin. She said on Monday, 09/13/21, a charge nurse documented she had ant bites and the resident reported it was from the previous facility. The DON said she did not get to see Resident #1 prior to being sent to the ER due to low blood pressure, but the wound care nurse saw her. She said the wound care nurse reported there were at least 100 ant bites with pus all over Resident #1's arm. She said she started treating them with an antibiotic ointment on Monday 09/13/21. The DON said she did not know what had caused Resident #1's drop in blood pressure. An interview with the charge nurse from the receiving facility on 09/16/21 at 2:09 PM revealed she saw Resident #1 on Monday 09/13/21 and observed that she had hundreds of ant bites on her right side and right extremities. She said they were leaking and were very angry and aggravated when I saw them. She said she asked Resident #1 if she felt it when the ants bit her at the last facility and she said she had just woken up and they were there on her. The nurse said Resident #1 denied having pain because she could not feel that arm since she was a stoke patient. She said Resident #1 was sent out to the ER because when therapy went to get her up on 09/14/21, she was pale and lethargic and pale. The nurse said she did orthostatic vitals on her but her blood pressure remained low, so the nurse practitioner wanted her sent out for evaluation. She could not say if the numerous ant bites were a cause of her low blood pressure. The nurse said by the time Resident #1 was sent to the ER, her ant bites had turned black. She said she gave the EMT report and let them know the ant bites came from the previous facility. She also called the [TR

Based on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for two (Residents #1 and #3) of five residents reviewed for incidents and accidents related to pests. The facility failed to act promptly to ensure Resident #1's safety when ants were first observed in her room on the COVID unit on 09/10/21-09/11/21 overnight shift. Resident #1 was bitten by the ants on her right arm, chest, and thigh. The facility staff was aware ants were seen on Resident #1's hall earlier that morning as Resident #3 had already been bitten in the adjacent room on her neck and arms. Pest control was not called to come out for three days. On 09/15/21, the COVID unit had an active ant colony observed several feet outside the COVID unit and Resident #1's room window had an open crack about ¼ inch wide which allowed for further fire ant access to residents. An Immediate Jeopardy (IJ) was identified on 09/15/21 at 00:00. While the Immediate Jeopardy was removed on 09/16/21, the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. These failures could place residents at risk for itching, pain, serious bodily harm from ant bites, and [MEDICATION(S)] (A severe, potentially life-threatening allergic reaction) . Findings included: Review of Resident #1's Face Sheet (undated) revealed she was an [AGE] year old female admitted to the facility on [DATE] with active diagnoses of COVID-19 and type 2 diabetes. She discharged on [DATE]. Review of Resident #1's admission MDS assessment dated [DATE] revealed she had clear speech and was usually understood. Her BIMS score was not assessed. Her mood score and behavior assessment on the MDS was not completed. Resident #1's functional status indicated she needed two person physical assistance for bed mobility and had range of motion impairment on her upper body on one side. She had no active diagnoses or skin conditions assessed. Review of Resident #3's admission MDS assessment dated [DATE] revealed she was a [AGE] year old female admitted to the facility on [DATE] with an active diagnosis of COVID-19. She had a BIMS score of 15, which indicated no cognitive impairment. She required extensive physical assitance of two staff for bed mobility, had range of motion impairment on both sides of her upper extremities, and used a wheelchair for mobility. An interview with Resident #1's RP on 09/15/21 at 12:24 PM revealed Resident #1 had been admitted to the facility to the COVID-19 unit to recover from COVID and she was paralyzed on her right side and had dementia. The RP said the stay was to be short-term and there was a planned discharge to another facility which occurred on Saturday 09/11/21. The RP believed the ant bites to have occurred during the middle of Friday night on 09/10/21. The RP said she had visited Resident #1 earlier in the day on Friday 09/10/21 and there were no ant bites on her body. However, when the RP went to Resident #1's bathroom, she saw what looked like little fire ants and notified the CNA who said she would talk to the facility about it. When Resident #1 arrived at the new facility on 09/11/21 and the RP came to visit that evening, Resident #1 told her to look at her arm. The RP said there were puss pockets all over Resident #1's arms, her breasts, her neck, her side and her thigh. The RP said the new facility kept asking her what the skin eruptions were and the RP said it looked like ant bites. The RP said Resident #1 told her and the new facility staff she woke up in the middle Friday night (09/10/21) with ants all over her and a CNA at the previous facility looked at her skin and did not see anything. The RP said Resident #1 did not tell her about the ants on her body until she moved to the new facility on 09/11/21 and the pustules started to show up that evening on her body. The RP said Resident #1 was currently at the hospital for a change in condition, she was severely dehydrated and her blood pressure was low and the ER doctor told her that the ant bites were infected and she would need wound care to treat them. She could not say if Resident #1's change in condition was directly related to the ant bites. The RP said, It breaks my heart knowing she had to go through all of this. An interview and observation of Resident #3 on 09/15/21 at 1:50 PM revealed she was awake and lying in bed. She said she remembered being bitten by ants the week prior in the other room she had been in. She said she woke up around 4:00 AM, she did not remember the day, but there were ants biting her neck. Resident #3 said she could not move her arms easily but could see the ants were on her arms and inside her hands. She said she pressed the call light and yelled out help and the staff came immediately and got the ants off her and her sheets. Resident #3 said she could see her sheets had ants on hem as well. She said the staff showered her and moved her to the room where she was at presently. Resident #1 said the ant bites hurt and itched real bad so the doctor had ordered her a topical medication to put on. Resident #3 said that was the only time she had seen ants at the facility. Review of the facility Maintenance Pest Service Requests (handwritten log) on 09/15/21 reflected the following: *07/13/21 ANTS- Exterior, *07/22/21 ANTS- Exterior, * 08/04/21 ANTS- Exterior, *09/13/21 ANTS- Stations 1 West (COVID unit).Review of Work Order dated 09/14/21 reflected, Ants in Room and in Hallway 100. LVN C completed the request and the MD labeled it as medium priority. Review of Work Order dated 09/14/21 reflected, Resident Room 118-ants in bathroom and window. MD labeled the request as medium priority. An interview with the MD on 09/15/21at 10:46 AM revealed he thought LVN C was the person who reported there were ants on the COVID-19 isolation unit, inside resident rooms and the hall, so a work order was put in. He said the contracted pest control company came out on Monday 09/13/21 and sprayed outside the facility. He said pest control usually came out on the 1st and 3rd Friday of the months and any time they were needed in between. He said he did not know anything else related to ants on the COVID unit. The MD said he was not present when the pest control provider came out on 09/13/21. The MD was asked to provide evidence of the last three pest control visits. He stated he did not have them available and would have to contact the pest control provider. An interview with MDA on 09/15/21 at 10:49 AM revealed on Monday, 09/13/21, he heard a page overhead at the facility about ants, he did not remember who paged him but he was given a work order for ants. He did not know who wrote the order because it was digitally entered into their online maintenance request system. MDA said after he received the work order on 09/13/21, he went outside to the exterior of the COVID-19 unit by the parking lot. The MDA stated he observed ants on the wall, so he got some ant spray and sprayed the ants and got a ladder and sprayed the gutter because that was where they were going. He said there were tree branches in the gutter. After that, MDA said he got some ant bait and sprinkled it around the building on the same side. The MDA said he did not see a fire ant mound or any ants around the resident windows. He said the only way they could have come into the building would have been through a gap in the window seal. He said he then went inside the COVID-19 unit where he saw regular ants pointed out by Housekeeper D. He said, Outside ants were more of, I guess fire ants, because they were bigger, and on the inside, regular sugar ants, I didn't see any fire ants. He said he saw one ant in room 118 and sprayed the whole room and hallway with an ant and roach spray. He said the rooms in question for ants were rooms 118, which he said was an office, and room 120, which he said was an empty room. The MDA said he then called the pest control provider on 09/13/21 who came and treated the exterior of the COVID unit that same day. The MDA said he did not meet with pest control when he came out that day because he was busy with a water leak in the facility. He said he had not seen any other ant activity since then. Review of the facility pest control invoices revealed the last three visits were on 07/20/21, 08/23/21 and 09/16/21. Ants were only identified on the 09/16/21 visit and listed the visit as Odd Job/Extra Service and reflected, Treated and inspected for ants for all halls exterior; inspected around all windows. An interview with the pest control provider for the facility on 09/15/21 at 11:05 AM revealed he walked the perimeter on 09/13/21 and he saw ants on the south west corner under a concrete block out, on the COVID unit about two to three feet away from the wall of the unit. He said he used a granule pesticide on the ants and a spray which generally took 30 minutes to start working. He said, It was fire ants, spread out, looked like we had a shower come through and generally they will move to a few feet to an area under the concrete block. The pest control provider stated he also found a few dead tree stumps that termites could habitat and then eventually ants would follow. He said he went on the COVID-19 unit and did not see any ant activity. Review of the facility census cross referenced with the facility floor plan on 09/15/21, showed the following resident rooms on the exterior covid side of the building where the fire ants were found: 118 office 120 EMPTY 122 Resident #2-admitted on [DATE]**(This is where Resident #1 was previously) 124 EMPTY 126 occupied with one resident 130 Resident #3 An interview on 09/15/21 at 12:56 PM with LVN C revealed she worked the 6AM-2PM shifts during the week on the COVID-19 unit. She said last Friday 09/10/21, she came into work at 6:00 AM and she had an agency nurse working with her and she noticed two of the residents had been moved to another room on the unit (Residents #3 and #5). She said the two residents were on the even side of the hall, so she was not assigned to them. She said CNA D told her the unit had ants and Residents #3 and #5 had been moved from Room 120 to Room 130. LVN C said Resident #5 did not have any ant bites, but Resident #3 did have them on her shoulder and on her left elbow. She said the ant bites were being cleaned and monitored. LVN C said a few days later, Resident #3 started to have little pustules on her left arm. LVN said all the residents' skin was assessed for ant bites on the COVID unit. She said the CNAs and the agency nurse and herself looked at the residents' skin and linens and did not see any evidence of ants. She said she did not have any documented evidence that skin assessments were completed that day because they only did a visual check. After the ants were seen overnight on Thursday 09/09/21 in room 120 with Residents #3 and #5, the room was shut off on Friday 09/10/21. The room was cleaned by Housekeeper D and maintenance was notified, but she did not believe pest control came out. LVN C said, I don't know what they did I did not pay attention. I know my housekeeper did a deep cleaning. I think the maintenance did some sort of ant spray because it stunk. LVN C said on Monday 09/13/21, when she came in, she saw the ants in COVID office room 118 in the windowsill, along the wall going into the bathroom and she saw some [NAME] ones in the hallway. She said pest control came that Monday 09/13/21. She said that was when the night nurse, LVN F, told her about Resident #1. She said, I don't know what kind of ants they were, the annoying red little ants. LVN C said when she came into work on Monday 09/13/21 and saw ants in the COVID office (empty resident room 118), the night nurse (LVN F) told her he had moved Resident #1 over the weekend because he saw ants along her window. LVN C said Resident #1 discharged that weekend so she never got to see her skin. LVN C said LVN F did not say if there were any ant bites on Resident #1 and she did not ask. She said Resident #1 had been staying in room 122 B, which was by the window two doors down and she did not have a roommate at the time. Review of Resident #1 and #3's clinical charts reflected no mention of ants found in their rooms or on their skin, ant bites, skin assessments, an incident report, or a clinical nursing progress note. An interview with CNA D on 09/15/21 at 1:11 PM revealed she worked during the weekdays on the 6AM-2PM shift. She said she could not remember the exact day, but the week prior (week of 09/06/21-09/10/21), she was putting Resident #5 in a chair in her room and she saw little black ants on the floor and one on her on her leg. She said she cleaned it up and alerted LVN C. CNA D said she did not look in Resident #5's bathroom but she looked at her and her roommate's (Resident #3) bed linens and there was no sign of ants. CNA D said the next day was when Resident #3 had ants all over her. She said Resident #3 did not have any ant bites, nor did Resident #5. CNA D said she and other staff moved both Resident #3 and #5 to another room that day to 130. CNA D said she did not check the other resident rooms that day for signs of ants in the room or on the residents' bodies. She said she did work with Resident #1 on Friday, 09/10/21 and she did not have any ants in her room or on her skin. An interview with CNA E on 09/15/21 at 1:24 PM revealed she did not work Friday morning on 09/10/21 and was not part of the move of Residents #3 and #5 to a new room after ants were observed. She said she was present on Saturday 09/11/21 and was the CNA who got Resident #1 ready to be discharged and showered her. CNA E said she did not see any skin concerns, except some discoloration on her stomach where the resident said she got insulin. CNA E said there were no observable ant bites. She said when Resident #1's RP arrived at the facility prior to the transfer to another nursing facility, that was when Resident #1 told them there were ants in her bed and the staff had found a pile of them in her bed. Resident #1 told her the staff did not move her from the room, but moved her from the B bed side to the A bed side. An interview with the OT on 09/15/21 at 1:35 PM revealed she saw a line of ants the week prior towards the end of the week (unable to recall exact day) by the COVID unit hallway, outside the rooms of 120 and 122. She said housekeeping came and sprayed and showed her the ants but she did not know what kind of ants they were. The OT said she saw ants again, and thought the housekeeper sprayed more and cleaned them up. Then on Monday, 09/13/21, the OT said she observed ants in the COVID staff office. She said, There were a whole bunch coming through the bottom of the floor under the window and trailed about six feet to the bathroom below the sink next to the trashcan which typically had nothing in it but paper towels. The OT said she reported it when she saw them to LVN C and the ADON and I said we have ants and we got a problem. She said a man came in that day from pest control and sprayed all around the inside of the rooms and the exterior of the COVID unit. An interview with Housekeeper D on 09/15/21 at 1:39 PM revealed she could not remember the day, but she had seen ants in the COVID office restroom and in the corner of the room. She said she did not see ants in the resident rooms, but did see them in the first half of the COVID hallway. She said, It was like a line marching in the hall. I don't know where they were going. They were going in different directions. She said she reported it to the maintenance department and the nurse. She said she saw ants the week prior and the current week. An observation with LVN C on 09/15/21 at 1:45 PM of Room 122 (where Resident #1 had previously been), revealed a new resident had been placed in that room in Bed A, by the door, on Sunday 09/12/21 (Resident #2). The bedroom window was observed to have the bottom right half open with a crack of approximately ¼ inch. It did not form a seal and the window screen frame was bent and out of frame. An interview with Resident #2 on 09/15/21 at 1: 50 PM revealed he had not seen any ants in his room or on his person. There were no ants observed in the room at the time of the interview. An observation on 09/15/21 at 1:59 PM with LVN C occurred where the exterior of the COVID unit was observed between the facility and the side parking lot. An active ant colony was observed under two cement blocks a few feet outside the window of Resident #3 between her and the room next to her. The ants observed were numerous and the cement block appeared to be covering an open white PVC pipe approximately four inches in diameter. The dirt around the pipe did not have a mound, only dirt. The dirt was aggravated with a kick of the shoe and at that point, ants came pouring out of the dirt. No ants were observed along the wall of the building exterior COVID unit, and there were observable ant granules placed down. The active ant colony was observed to be about three rooms away from the crack in the window in room 122. LVN C confirmed she saw the active ant colony. At that time, the MDA came outside at 2:02 PM. Observation and interview with the MDA on 09/15/21 at 2:12 PM revealed he saw the ant colony and confirmed it was still present and posed a risk. The MDA said he had been notified the week prior there had been ants found in Resident #3 and #5's room so he went and sprayed their room and he sprayed the outside of the window. The MDA said that when he sprayed the room, he did not check any other resident rooms, he was just going off where staff had reported they had seen ants. An interview with LVN C on 09/15/21 at 2:14 PM revealed when ants were seen in one room or one place, housekeeping would be notified and they would come in and do a deep cleaning and maintenance would come and spray. If staff started seeing ants in other places, then they call the MD to have pest control come out. An interview with CNA G on 09/15/21 at 2:15 PM revealed she worked the overnight shift on Thursday 09/09/21 and Friday 09/10/21. She said on 09/09/21, there were no ants observed. She said ants were not seen until that next morning. She said, Basically, me and the other aide saw them because we were doing our rounds together and we let the nurse know. She said, What we saw was the ants just crawling everywhere at that particular time on that person, I have no idea because I did not go into the room, the aide told me they were in there. She said the room was room 120 with Residents #3 and #5. She said other staff told her there were also ants in room 122, Resident #1's room. She said she was wondering where all the ants were coming from. CNA G said she did not see any ants on Resident #1 but she did see ants on Resident #3 while she was rounding that morning from the 09/09/10 overnight shift. She said there were ants on Resident #3's left side of her neck and arm and on her chest. CNA G said she and the other aide came into Resident #3's room and turned on the light and Resident #3 opened up her eyes and that is when I saw ants on her. She said they looked like black ants. She said Resident #3 did not say if they were stinging her. She said, Once we saw those, my instincts were to knock them off her. Then [LVN F] grabbed the infection stuff, the germicide and started killing them and [CNA H] was cleaning the ants up while I was getting [Resident #3] together. CNA G said LVN F told her to leave Resident #3 there because he did not know which room she would be switched to. She said she did not move Resident #3 before her shift ended but by the time she came back for the overnight shift on Friday 09/10/21, Resident #3 had been moved to a different room. CNA G said she did not know if anyone reported the ants and the ant bites, I didn't. She said the LVN F told her he was going to let the facility know. CNA G said she and the other staff checked the other residents and there were no issues with ants. On the Friday overnight shift, CNA G said Resident #3 and #5 were moved to a new room and their old room 120 was emptied and closed off. She said Resident #1 had the room next door to the now emptied room and at the beginning of her shift, there were no observations of ants in her room. She said during the middle of the night check, she did not see anything, but around 5AM, one of the aides, CNA I, noticed ants in Resident #1's room when she was rounding. CNA G said she did not see Resident #1 because she already had a CNA assigned to her. She said once CNA I saw the ants in Resident #1's room, they moved her from the B side (by the window) to the A side (by the door), cleaned up the area and made sure no ants were on her. CNA G said Resident #1 was not moved to another room because she did not know if there was another room available. CNA G said her shift was over by the time Resident #1 woke up on Saturday 09/11/21, so she did not see her skin. An interview with ADON A on 09/15/21 at 2:57 PM revealed she did not discharge Resident #1 on Saturday, 09/11/21, she only started the discharge form in the system and that was why her name was on it. She said she was not present at the facility on the date of discharge and an agency nurse was working that shift on the COVID unit. She said prior to a discharge, the nurse was supposed to complete a skin assessment and document it on the discharge form. ADON A said she was aware ants had been seen on the COVID unit on Monday 9/13/21 by the charge nurse, LVN C. She said LVN C reported the ants to maintenance and pest control had come and sprayed the day before. She said as far as she knew, that was the only time ants had been seen on the COVID unit. She said there were four ADONs in the facility, but she was the ADON over the COVID unit. ADON A said if ants were seen on the COVID unit and in a resident's room and on a resident' body, she should have been notified so she could give staff the direction they would need to go and ensure the proper channels were notified. ADON A said had she been notified of possible ant bites, she would have made the staff shower the affected residents immediately, have the nurse complete a head to toe skin assessment and then move the resident(s) to another room. ADON A denied knowing that Resident #3 had been bitten by ants on the overnight shift of 09/09/21 or that Resident #1 had been bitten on the overnight shift on 09/10/21. She said. I remember ants on Monday and reporting it to maintenance. ADON A said staff should always report any insect sightings, even with one ant, because with one, there is more. ADON A said on Monday 09/13/21, during stand up and throughout the day, no one told her that Resident #1 had ants in her room or any claims she made that she was bitten. A follow up interview with the MD on 09/15/21 at 3:13 PM revealed he remembered there was a work order placed on Friday 09/10/21 that the housekeeper had seen one ant by the window in the COVID unit, so MDA attended to the work order. He said when MDA was done, he reported to the MD, Man .I seen like one little ant. The MD said no one was in the room so he sprayed and cleaned up and checked the perimeter outside and that was that. Then on Monday, 09/13/21 was when there were more reports of ants and that was when he reached out to pest control. He said pest control was not contacted sooner on Friday 09/10/21 when the ants were first seen in the facility's COVID unit because it was only a report of one ant, so they sprayed and placed bait. He said only if there were more ants observed after that, would he have pest control come out because it would be a bigger situation. The MD said no one notified him that Resident #1 had gotten bitten and ants were found on her and in her room over the previous weekend. MD confirmed that he did go out and see that there were still ants outside the COVID unit about an hour ago and had placed more bait down. He said the bait would kill the ants or move them away from the building. The MD said no one told him there was a gap in the bedroom window of Room 122. He responded, It's really, with ants, it's like, you know they can get in from anywhere, but definitely, those are little clues and spots that we have to try and catch them. I didn't know there was an opening in the window. No one notified me through a work order. An interview with the DON on 09/15/21 at 3:37 PM revealed she was only made aware of ants on the COVID unit on Monday 09/13/21. She said she was never told that two residents (Residents #3 and #5) had been seen with ants in their room and one of them had ant bites on their body on 09/10/21 and if she would have been notified, she could have assessed the residents and called the corporate nurse to decide if it was a reportable incident to HHSC or not. The DON said once LVN C notified her on Monday 09/13/21 of ants found in resident rooms the week prior, she said do a head to toe assessment, document in the clinical chart and notify maintenance. The DON said had she known on 09/10/21 and 09/11/21 that ants had been found on the COVID unit and bitten Resident #3 and #1, her expectation would be that all their clothes would be taken off, they would be showered, a head to toe assessment completed, personal items packed up and the residents moved to another room, the family, doctor, DON and abuse/neglect coordinator would then be notified. The DON then questioned how could it be proved that the ants found on Resident #1 overnight caused her ant bites found by the receiving facility later the next day, because the CNA who showered her that morning did not see any bites on her skin prior to the discharge. An interview with CNA I on 09/15/21 at 3:58 PM revealed she worked the overnight shift Thursday night 09/09/21 going into Friday night 09/10/21. CNA I said she had known there was a previous issue with ants because Residents #3 and #5 had been moved to another room when some were found on 09/09/21. She said she went into Resident #1's room on Friday overnight shift on 09/10/21 to do care. When she pulled the cover back, the linens were full of ants on the right side of her body from her ankles to her arm and It startled me. She also said it scared her and she called LVN C to come in and he left the room and got some type of bug spray while she sat Resident #1 up on the side of the bed. CNA I then looked in Resident #1's brief and she did not see any other ants. CNA I said she sat Resident #1 in the chair and asked her if she felt anything bite her and Resident #1 responded no. CNA I believed it was because her right arm was paralyzed. CNA I said, I was like oh my god. But it was a bunch. Like more than 50, small ants. And they had a trail going. CNA I said she and LVN F determined the ants were coming in from the outside but they could not determine where. At that point, CNA I said she cleaned Resident #1 up with a wet wipe to remove the ants and moved her to the bed on the A side of the room by the door. She did not know if LVN F checked Resident #1's skin. She said after she got Resident #1 comfortable. She said she did not check any other residents to see if there were ants in there room or on their person. CNA I said when her shift was over on Saturday morning, 09/11/21, she did not let the oncoming 6A-2P staff about the incident with the ants because she had to leave and they had not arrived to work yet. CNA I said she did not know why Resident #1 was not moved to a different room and she asked LVN F about it, but he only told her to move the resident to the other bed, so she did. Several attempts were made to contact LVN F for an interview on 09/15/21 at 4:10 PM, 5:07 PM and 10:15 PM. Voice mail message were let with no return phone call. An interview was conducted on 09/15/21 at 4:39 PM with the social worker from the receiving facility for Resident #1. She said the DON, ADM and ADON had already left for the day but she remembered Resident #1 admitting to their facility on Saturday 09/11/21 because it had been planned. The receiving facility's social worker said she did not work on the weekend so the first time she saw Resident #1 was on Monday morning 09/13/21 when she met with her and her family. She said Resident #1 was covered with what looked like hundreds of pus filled fire ant bites on her right arm. She said Resident #1 told her there were also ant bites on her chest and down her body. The social worker said when she did the care conference with the family, they were distraught. The social worker said what she saw with the ant bites was dangerous and neglectful. She said Resident #1 was sent out on Tuesday 09/14/21 to the hospital when her blood pressure kept dropping. She could not say if her change in condition was related to the fire ants. Attempted interview with the ER nurse and ER doctor on 09/15/21 at 4:37 PM and at 6:18 PM was unsuccessful. A message was left with the ER nurse to return investigator's call. An interview with LVN J on 09/15/21 at 6:04 PM revealed she was an agency nurse who discharged Resident #1 on Saturday 09/11/21 and completed the discharge paperwork, which included a skin assessment. She said when she assessed Resident #1's skin, she observed a small bruise on her right arm, like a skin tear. LVN J said she wiped her skin tear with alcohol and put a bandage on it. LVN J said she gave Resident #1 her morning medications and she was given a shower and she was fine and had no complaints of ant bites. She said there was nothing on Resident #1's arm that would indicate ant bites. LVN J said two days before, she had been told that the staff had to move some residents in the COVID unit because their room had ants. She said when she worked on Saturday 09/11/21, Resident #1 had been moved to a different room on the other side of the hall. She said the night nurse (LVN F) did not report any ant sightings or ant bites when she came on shift, So I didn't know to look for them. LVN J said no one asked her to assess any of the residents' skin on the COVID unit after the ants were discovered. LVN J said had she been told that Resident #1 was found with ants on her body the night before, she would have done things differently. She said, I would have checked all her skin and taken her clothes off and checked totally. What I did was what I could see with her clothes on. An interview with the receiving nursing facility's DON on 09/16/21 at 2:00 PM revealed she was not working when Resident #1 admitted to the facility on [DATE], an agency nurse completed the admission and they did not document anything at that time about her skin. She said on Monday, 09/13/21, a charge nurse documented she had ant bites and the resident reported it was from the previous facility. The DON said she did not get to see Resident #1 prior to being sent to the ER due to low blood pressure, but the wound care nurse saw her. She said the wound care nurse reported there were at least 100 ant bites with pus all over Resident #1's arm. She said she started treating them with an antibiotic ointment on Monday 09/13/21. The DON said she did not know what had caused Resident #1's drop in blood pressure. An interview with the charge nurse from the receiving facility on 09/16/21 at 2:09 PM revealed she saw Resident #1 on Monday 09/13/21 and observed that she had hundreds of ant bites on her right side and right extremities. She said they were leaking and were very angry and aggravated when I saw them. She said she asked Resident #1 if she felt it when the ants bit her at the last facility and she said she had just woken up and they were there on her. The nurse said Resident #1 denied having pain because she could not feel that arm since she was a stoke patient. She said Resident #1 was sent out to the ER because when therapy went to get her up on 09/14/21, she was pale and lethargic and pale. The nurse said she did orthostatic vitals on her but her blood pressure remained low, so the nurse practitioner wanted her sent out for evaluation. She could not say if the numerous ant bites were a cause of her low blood press [TRUNCATED]

Based on interviews and record reviews the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for one (Resident #1) of seven residents reviewed for accident and injury. CNA A and CNA B did not transfer Resident #1 with a hoyer lift as documented in her care plan and LVN C, LVN E and ADON D failed to assess and report Resident #1 fell and complained of pain from 06/24/19 - 06/25/19 and did not get the resident further evaluation and treatment until 06/26/19. As a result of these failures, Resident #1 experienced significant pain from 06/24/19 to 06/25/19 and on 06/26/19 she received an x-ray that identified bilateral femur fractures. The resident was then sent to the hospital and admitted on [DATE]. An Immediate Jeopardy (IJ) existed from 06/24/19 to 06/27/19. The IJ was removed on 06/27/19 because the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation. These failures placed residents at risk of injury and emotional distress and turmoil. Findings included: Review of Resident #1's face Sheet dated 06/28/19 revealed a [AGE] year-old resident who admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Fall assessment dated [DATE] revealed she had a high-risk score of 10 with intermittent confusion, chair bound and required assist with toileting and takes 1-2 types of sedatives/hypnotic medications. Review of Resident #1's MDS assessment dated [DATE] revealed, Transfer: the resident was not transferred during this assessment period and had range of motion impairment on both sides of her lower extremities and had no issues with pain. Review of Resident #1's Care Plan dated 05/23/19 reflected, ADL self-care performance deficit: Resident #1 requires two staff with hoyer lift participation with transfers but usually refuses to get out of bed .Risk for falls, weakness and dementia unaware of safety needs. In an interview on 06/28/19 at 5:48 PM, CNA A stated on Monday, 06/24/19, she and CNA B went to Resident #1's room, and during Resident #1's transfer from her bed to the shower chair, the resident's legs became weak and she was lowered to the floor. They did not use a hoyer lift, but after the resident fell LVN C assisted with getting a hoyer lift to put the resident into the shower chair then they proceeded to take her to the shower chair and shower her then laid her down to bed. CNA A said LVN C did not assess Resident #1 but said after she laid Resident #1 down, the resident complained of pain she told LVN C, then LVN C gave Resident #1 some pain medication. CNA A said she did not report Resident #1's fall to anyone because LVN C said, She was not going to report it. CNA A said in hindsight she wished she would have said something to someone. In an interview on 06/28/19 at 7:58 PM, CNA A said she was the shower aide and had cared for Resident #1 in the past and always transferred Resident #1 manually with a second person and did not know she required hoyer lift transfers. She said she usually obtained the care information from the care tool in the computer and normally looked to see if the resident was a one or two person assist; however, she did not check it before transferring Resident #1 on Monday, 06/24/19. CNA A said it was four staff in Resident #1's room: CNA B was trying to lift the resident; CNA F was holding the shower chair and LVN C was observing. In an interview on 07/02/19 at 9:38 AM, CNA A said she knew she was wrong for not reporting Resident #1's fall on 06/24/19 to administration but thought LVN C had reported it. In an interview on 06/28/19 at 6:25 PM, CNA B said on Monday, 06/24/19, around 9:30 AM she and CNA B attempted to transfer Resident #1 from her bed to the shower chair, but the resident became weak and was lowered to the floor. They used a hoyer lift to get her into the shower chair and showered the resident before lying her down. CNA B said she did not look at the care system for Resident #1's care plan information because she did not know she needed to and was new to the facility. She said she went by what CNA A said because she had worked at the facility longer. CNA B said she did not know Resident #1 required hoyer lift transfers. CNA B said on Wednesday, 06/26/19, while she was providing Resident #1 incontinence care the resident hollered and said she was hurting, so the nurse gave her some pain medication. CNA B said she did not report Resident #1's fall to anyone because she thought LVN C had reported it. She said LVN C was in the resident's room right after she fell and saw the resident on the floor but did not assess Resident #1. CNA B said she had not had any in services on transferring residents but was in serviced trained on Stop and watch if you find a change in a resident's condition and abuse and neglect. In an interview on 06/28/19 at 6:08 PM, LVN C stated she worked Monday through Friday from 6:00 AM to 2:00 PM. She said CNA A and CNA B said they reported Resident #1's fall to her, but they did not. LVN C said she worked Monday during the dayshift 06/24/19 and when she walked into the room, she did not see Resident #1 on the floor but saw CNA A and CNA B standing next to Resident #1 who was in the hoyer lift. ,. Resident #1 was totally dependent and required total care. LVN C said on 06/24/19 she did not call Resident #1's physician or do a Change in condition assessment but did give her PRN pain medications when she complained of a headache. In an interview on 06/29/19 at 1:41 PM, LVN E said she was unaware Resident #1 fell but she knew the resident was experiencing pain and contacted her physician for an x-ray on 06/26/19. She complained of pain in both of her legs on 06/25/19, so she had given her two Tylenol 325 mg and her pain resolved that day. On Wednesday, 06/26/19, Resident #1's family member said the resident complained of pain, so she did a pain assessment which was an eight (severe pain) out of 10 on the pain scale, so she gave Resident #1 two Tylenol 325 mg and talked to Resident #1's physician to get the x-ray. The x-ray findings were that the resident had right and left femur fractures. LVN E said she called the resident's physician, DON, ADON and family and sent the resident to the hospital. Review of Resident #1's Nurses' note dated 06/26/19 at 3:50 PM and written by LVN E reflected, Resident #1 voiced increased pain to bilateral legs, assessed resident stated, 'I am hurting soo (sic) bad' rated pain 8/10 Doctor notified obtained orders for stat x-ray, family member at bedside and Tylenol 325 mg. 2 tabs administered will continue to monitor. Review of Resident #1's Pain Flow documentation dated from 06/01/19 to 06/26/19: 06/01/19 to 06/23/19 was 0. 06/24/19 at 10:34 AM was a 5 (moderate pain). 06/24/19 at 6:10 PM was a 7 (very severe pain). 06/25/19 at 2:52 PM was a 6 (severe pain). 06/25/19 at 7:58 PM was a 6 (severe pain). Review of Resident #1's Nurses' Note dated 06/26/19 at 10:35 PM revealed, the X-ray Report - Acute fracture involving supra-condylar femur (Thigh bone breaks at the knee), modest angulation and displacement. Resident #'1's physician notified received order to transfer resident to the emergency room , Responsible party notified, DON notified and ADON E aware. Review of Resident #1's Nurses Note dated 06/27/19 at 1:05 AM revealed, Resident transferred to the hospital for further evaluation family aware. Review of Resident #1's Hospital History and physical dated 06/27/19 at 4:12 AM revealed the resident admitted to the hospital 06/27/19 at 2:55 AM due to bilateral distal femoral fractures, supracondylar (thigh bone breaks at the knee) .extremities: She has pain at both distal femurs .Labs: X-rays of both legs showing bilateral distal femur fractures .Radiographs in the emergency department revealed mildly displaced fractures of the distal left and right distal femur metadiaphysis (combined region of a long bone, often used to describe [MEDICAL CONDITION] that span both regions) with no significant angulation .Plan: The patient is demented and does not walk .the risk for surgery outweigh the benefits, I have recommended non-operative treatment the patient will be non-weight bearing on bilateral lower extremities, keep knee immobilizers on at all times .ankles negative for fractures. Resident #1 discharge from the hospital 06/29/19. Review of Resident #1's Hospital Discharge Summary dated 06/29/19 revealed Physician orders [REDACTED]. Observation on 06/29/19 at 4:15 PM, revealed Resident #1 was moved to another hall, laying in bed with her gown on and sheets up to arms with knee mobilizers under her sheets. In an interview on 06/29/19 at 1:17 PM, ADON D said Resident #1's family member came by on Tuesday, 06/25/19, before dinner and told ADON D Resident #1 complained of leg pain and hurting and her pain medication was given. Then on Wednesday 06/26/19 in the afternoon before dinner, the resident's family member said Resident #1 was still complaining of her leg hurting, so ADON D said she got LVN E to call Resident #1's physician to get x-rays. The results came back that Resident #1 had a fracture of both femurs. ADON D said LVN E called the physician and family and Resident #1 was sent to the hospital. ADON D said she did not assess or alert the Resident #1's physician about her leg pain because she had told LVN E to do it`. In an interview on 07/02/19 at 4:56 PM, Resident #1's nursing facility Physician stated neither she or her Nurse Practitioner were aware of Resident #1 falling, and after reviewing her call logs, she stated she did not get any calls about Resident #1 on 06/24/19 and 06/25/19. On 06/26/19 one of the nurses called about Resident #1 complaining of leg pain and saying, I'm hurting so bad, so then her Nurse Practitioner ordered an x-ray which revealed Resident #1 had two femur fractures. Then Resident #1 was sent to the hospital. Resident #1's Physician said Resident #1 had not been on any routine pain medications but took PRN pain medications two days prior to her hospital transfer. Resident #1's physician added if she had known about her issues with pain she would have ordered an x-ray much sooner. In an interview on 06/28/19 at 7:17 PM, the DON said from her investigation, CNA A and CNA B said Resident #1 started losing control and then they lowered the resident to the floor, which is still considered a fall and CNA A said after Resident #1 fell they tried to get her off of the floor, so they got LVN C to assist and they were still unable get her off of the floor and CNA F was passing down the hall and LVN C told CNA F to get the hoyer lift then the three CNA's and the nurse got Resident #1 transferred her in the hoyer lift. After a resident had a fall they were supposed to assess the resident for injury and if the resident had pain to monitor the resident and if the pain didn't get better they were to call the dr. In an interview on 07/01/19 at 3:14 PM, the DON said everything in a resident's care plan went into the facility's care computer tool system. The staff had to go to the computer and look up the residents' name, then it brought up everything about the residents' bed mobility, transfer, mobility on the hall, and whether the residents' were one or two-person hoyer transfers. The DON said CNA A and CNA B knew the care computer process and they said they knew how to access the it but did not use it before transferring Resident #1. The DON said CNA A had told her they just picked the resident up by her arms, then lowered her down, which was considered a fall. After Resident #1's fall the facility completed re-education with the staff on abuse/neglect/reporting, transfer, skills checks, the computer care system, change in condition and pain assessments with the nurses, falls, incident and accidents and when and how to complete forms. The DON said they terminated LVN C, CNA F, CNA B, CNA A and LVN E, she said LVN E was terminated because she failed to report Resident #1's fall on 06/24/19 and ADON D was terminated because she did not follow-up with the family member notifying her about Resident #1's issues of pain and failed to notify her and others in their standup meeting about the resident's pain issue. The DON said the two CNA's should have known what type of transfer she was, they all should have reported the incident immediately to her after Resident #1 fell and the nurses should have assessed the resident and contacted the resident's physician to get X-rays and should have reported the incident to her, but they did not so they were all terminated. In an interview on 07/01/19 at 4:01 PM, the Administrator said during his absence from the facility his DON was the acting Abuse Coordinator and the person who started the investigation into Resident #1's incident. They concluded LVN C was aware of Resident #1's fall, she went into the room shortly after Resident #1 fell . CNA A and CNA B worked with her when the resident fell , and they had called out for LVN C to assist. They then transferred her to the shower chair. CNA A and CNA B had completed an improper transfer. The Administrator said they should have known better because they had care computer tool trainings in the past. The Administrator said the care information was based on the resident's care plan needs and added there was also an issue with Resident #1 not getting a change in condition assessment after she fell . The CNA A and CNA B should have made sure they were doing the right type of transfer and the three CNA's failed to report the incident to the DON (in his absence) and the three nurses failed to assess the resident and report the incident to the DON (in his absence), do a change in condition and call the resident's physician about her issues with pain, but they did not. The Administrator said this was why the staff were terminated because they also did not follow their company's policies. The measures they have in place to prevent this from happening again was by in servicing the Staff about Abuse and neglect, care tool resident transfers with return demonstrations, and skills checks and doing change in conditions and incident/accident reports and reporting alleged abuse or neglect. Review of the facility's Falls policy dated May 2017 revealed, Policy- It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention .Education of staff related to fall prevention: Provident a safe environment for residents, cause and risk factors or falls as well as the interventions to manage risk, safe transferring techniques, use of assistive devices . Review of the facility's Mechanical Lift policy dated May 2017 revealed, Policy- It is the policy of this home to utilize the Hoyer (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition. Review the facility's Change in Condition policy: Observing, reporting and recording, dated May 2017, revealed: Policy: It is the policy of this home to inform the resident, the residents physician and if indicated the residents responsible party of the following. 2. An accident or incident involving a resident which results in injury and has the potential for requiring physician intervention .3. An allegation of abuse or neglect regardless of who reports the allegation or (resident, family, visitor, staff, etc.) . Review of the Texas Administrative Code, Title 22: Part 11: Chapter 217, dated 12/15/07, reflected, Rule §217.11 Standards of Nursing Practice . (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: . (B) Implement measures to promote a safe environment for clients and others; . (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status . Review of the facility's Incident/Accident policy dated May 2017 revealed Policy: It is the policy of this home for staff to report and investigate event accidents, or incidents. Definitions: 1. Any event, accident or incident, which results in an injury or has the potential for injury .Procedure - Resident: The Charge nurse will immediately assess the condition of the resident involved, initiate emergency first aid, and when necessary, transfer to the hospital . Review of the facility's Abuse and Neglect policy dated May 2017 revealed, Policy- It is the policy of the home to prohibit resident abuse or neglect in any form and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse of neglect caused by another person. Definition: Neglect: The facility and its employee are neglectful when a reasonable person would conclude that a deprivation of the omitted goods and services would cause, among other things, emotional distress. On 06/28/19 at 9:05 PM, the Administrator was informed that a Past Non-Compliance Immediate Jeopardy was determined to have existed from 06/24/19 to 06/27/19. Review of the Facility's Provider Investigative Report dated 06/27/19 revealed on 06/24/19 at 9:30 AM, CNA A and CNA B transferred Resident #1 which caused the resident to fall, LVN C, LVN E and ADON D failed to provide the resident an assessment. On 06/26/19 Resident #1's family member told LVN E and ADON D about resident's pain then an x-ray was ordered which revealed acute right femur fracture with modest angulation and displacement and recent left femur fracture with modest angulation and displacement. The CNA's, LVN's and ADON involved were terminated and staff in-services were initiated. Findings: Confirmed. The facility took the following actions to correct the non-compliance prior to the investigation: On 06/28/19 at 7:17 PM, the DON said she started investigating and reported the incident to HHSC on 06 27/19, then started Inservice training staff and skills checks with return demonstrations on hoyer lift transfers and gait belts to all of the nursing staff. In addition, she said the facility also conducted in-service trainings for nursing staff to review the resident's plan of care prior to providing services, abuse and neglect reporting and change in condition and assessments. And added CNA A, CNA B, LVN C, ADON D, LVN E and CNA F were terminated. Interviews were conducted between 06/28/19 to 07/02/19 with LVN G, LVN H, LVN I, LVN J, LVN K, LVN L, LVN M, RN N, MA, CNA O, CNA P, ADON Q, HK and DA representing staff from all three shifts were knowledge on the subjects related to the deficiencies. Record Reviews of the resident's records who required hoyer transfers or on the same hall and other halls, the resident transfer policy, change in condition policy, pain assessment policy, abuse/neglect policy and reporting policy, incident/accident reporting, employee background checks, grievances, resident council minutes, incident/accidents, skills checks, and posttests and no concerns were found. Review of in-service training records revealed the staff had been re-educated with skills checks and post-tests to validate their knowledge and comprehension from 06/27/19 to 06/29/19: falls, change in condition, pain, incident/accident reporting, abuse and neglect, transfers and utilizing the care tool. In an interview on 07/01/19 at 4;04 PM, the Administrator stated the Medical Director agreed with their action plan to prevent similar incidents from re-occurring and by reviewing and monitoring to make sure there no breakdown in systems and to review Resident #1's incident in their Quality Assurance meeting. In an interview on 07/02/19 at 11:06 AM, the Administrator said all of the staff had been re-trained and included in their action plan and none of the staff including PRN staff would be allowed to work until they have been in serviced first. An Immediate Jeopardy (IJ) existed from 06/24/19 to 06/27/19. The IJ was removed on 06/27/19 because the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation.

Based on interviews and record reviews, the facility failed to ensure the resident's rights to be free from neglect for one (Resident #1) of seven residents reviewed for Incidents and accidents. 1. CNA A and CNA B failed to transfer Resident #1 properly and report it to management when the resident had a fall and had to be lowered to the ground on Monday, 06/24/19, and the nurse did not assess the resident or document the incident. 2. LVN C failed to assess Resident #1 or report the incident after the resident fell and had to be lowered to the ground on Monday, 06/24/19 and complained of pain due to an inappropriate transfer. 3. LVN E and ADON D failed to assess Resident #1 after the resident and family member said the resident was experiencing significant pain for two days after she fell . As a result of these failures, Resident #1 experienced significant pain on 06/24/19 and 06/25/19 and on 06/26/19 she received an x-ray that identified two bilateral leg fractures. The resident was then sent to the hospital where she was admitted on [DATE]. An Immediate Jeopardy (IJ) existed from 06/24/19 to 06/27/19. The IJ was determined to be at past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation. These failures placed the residents at risk for serious bodily harm, permanent physical impairment and issues with pain. Findings include: Review of Resident #1's face Sheet dated 06/28/19 revealed a [AGE] year-old resident who admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Fall assessment dated [DATE] revealed she had a high-risk score of 10 with intermittent confusion, chair bound and required assist with toileting and takes 1-2 types of sedatives/hypnotic medications. Review of Resident #1's MDS assessment dated [DATE] revealed, Transfer: the resident was not transferred during this assessment period and had range of motion impairment on both sides of her lower extremities and had no issues with pain. Review of Resident #1's Care Plan dated 05/23/19 reflected, ADL self-care performance deficit: Resident #1 requires two staff with hoyer lift participation with transfers but usually refuses to get out of bed .Risk for falls, weakness and dementia unaware of safety needs. In an interview on 06/28/19 at 5:48 PM, CNA A stated on Monday, 06/24/19, she and CNA B went to Resident #1's room, and during Resident #1's transfer from her bed to the shower chair, the resident's legs became weak and she was lowered to the floor. They did not use a hoyer lift, but after the resident fell LVN C assisted with getting a hoyer lift to put the resident into the shower chair then they proceeded to take her to the shower chair and shower her then laid her down to bed. CNA A said LVN C did not assess Resident #1 but said after she laid Resident #1 down, the resident complained of pain she told LVN C, then LVN C gave Resident #1 some pain medication. CNA A said she did not report Resident #1's fall to anyone because LVN C said, She was not going to report it. CNA A said in hindsight she wished she would have said something to someone. In an interview on 06/28/19 at 7:58 PM, CNA A said she was the shower aide and had cared for Resident #1 in the past and always transferred Resident #1 manually with a second person and did not know she required hoyer lift transfers. She said she usually obtained the care information from the care tool in the computer and normally looked to see if the resident was a one or two person assist; however, she did not check it before transferring Resident #1 on Monday, 06/24/19. CNA A said it was four staff in Resident #1's room: CNA B was trying to lift the resident; CNA F was holding the shower chair and LVN C was observing. In an interview on 07/02/19 at 9:38 AM, CNA A said she knew she was wrong for not reporting Resident #1's fall on 06/24/19 to administration but thought LVN C had reported it and said she believed an example of neglect was a fall or injury not being reported to the Administrator or DON. In an interview on 06/28/19 at 6:25 PM, CNA B said on Monday, 06/24/19, around 9:30 AM she and CNA B attempted to transfer Resident #1 from her bed to the shower chair, but the resident became weak and was lowered to the floor. They used a hoyer lift to get her into the shower chair and showered the resident before lying her down. CNA B said she did not look at the care system for Resident #1's care plan information because she did not know she needed to and was new to the facility. She said she went by what CNA A said because she had worked at the facility longer. CNA B said she did not know Resident #1 required hoyer lift transfers. CNA B said on Wednesday, 06/26/19, while she was providing Resident #1 incontinence care the resident hollered and said she was hurting, so the nurse gave her some pain medication. CNA B said she did not report Resident #1's fall to anyone because she thought LVN C had reported it. She said LVN C was in the resident's room right after she fell and saw the resident on the floor but did not assess Resident #1. CNA B said she had not had any in services on transferring residents but was in serviced trained on Stop and watch if you find a change in a resident's condition and abuse and neglect. In an interview on 07/02/19 at 9:41 AM, CNA B said, Neglect meant not caring for the residents. In an interview on 06/28/19 at 6:08 PM, LVN C stated she worked Monday through Friday from 6:00 AM to 2:00 PM. She said CNA A and CNA B said they reported Resident #1's fall to her, but they did not. LVN C said she worked Monday during the dayshift 06/24/19 and when she walked into the room, she did not see Resident #1 on the floor but saw CNA A and CNA B standing next to Resident #1 who was in the hoyer lift. ,. Resident #1 was totally dependent and required total care. LVN C said on 06/24/19 she did not call Resident #1's physician or do a Change in condition assessment but did give her PRN pain medications when she complained of a headache. In an interview on 06/29/19 at 1:41 PM, LVN E said she was unaware Resident #1 fell but she knew the resident was experiencing pain and contacted her physician for an x-ray on 06/26/19. She complained of pain in both of her legs on 06/25/19, so she had given her two Tylenol 325 mg and her pain resolved that day. On Wednesday, 06/26/19, Resident #1's family member said the resident complained of pain, so she did a pain assessment which was an eight (severe pain) out of 10 on the pain scale, so she gave Resident #1 two Tylenol 325 mg and talked to Resident #1's physician to get the x-ray. The x-ray findings were that the resident had right and left femur fractures. LVN E said she called the resident's physician, DON, ADON and family and sent the resident to the hospital. Review of Resident #1's Nurses' note dated 06/26/19 at 3:50 PM and written by LVN E reflected, Resident #1 voiced increased pain to bilateral legs, assessed resident stated, 'I am hurting soo (sic) bad' rated pain 8/10 Doctor notified obtained orders for stat x-ray, family member at bedside and Tylenol 325 mg. 2 tabs administered will continue to monitor. Review of Resident #1's Pain Flow documentation dated from 06/01/19 to 06/26/19: 06/01/19 to 06/23/19 was 0. 06/24/19 at 10:34 AM was a 5 (moderate pain). 06/24/19 at 6:10 PM was a 7 (very severe pain). 06/25/19 at 2:52 PM was a 6 (severe pain). 06/25/19 at 7:58 PM was a 6 (severe pain). Review of Resident #1's Nurses' Note dated 06/26/19 at 10:35 PM revealed, the X-ray Report - Acute fracture involving supra-condylar femur (Thigh bone breaks at the knee), modest angulation and displacement. Resident #'1's physician notified received order to transfer resident to the emergency room , Responsible party notified, DON notified and ADON E aware. Review of Resident #1's Nurses Note dated 06/27/19 at 1:05 AM revealed, Resident transferred to the hospital for further evaluation family aware. Review of Resident #1's Hospital History and physical dated 06/27/19 at 4:12 AM revealed the resident admitted to the hospital 06/27/19 at 2:55 AM due to bilateral distal femoral fractures, supracondylar (thigh bone breaks at the knee) .extremities: She has pain at both distal femurs .Labs: X-rays of both legs showing bilateral distal femur fractures .Radiographs in the emergency department revealed mildly displaced fractures of the distal left and right distal femur metadiaphysis (combined region of a long bone, often used to describe [MEDICAL CONDITION] that span both regions) with no significant angulation .Plan: The patient is demented and does not walk .the risk for surgery outweigh the benefits, I have recommended non-operative treatment the patient will be non-weight bearing on bilateral lower extremities, keep knee immobilizers on at all times .ankles negative for fractures. Resident #1 discharge from the hospital 06/29/19. Review of Resident #1's Hospital Discharge Summary dated 06/29/19 revealed Physician orders [REDACTED]. Observation on 06/29/19 at 4:15 PM, revealed Resident #1 was moved to another hall, laying in bed with her gown on and sheets up to arms with knee mobilizers under her sheets. In an interview on 06/29/19 at 1:17 PM, ADON D said Resident #1's family member came by on Tuesday, 06/25/19, before dinner and told ADON D Resident #1 complained of leg pain and hurting and her pain medication was given. Then on Wednesday 06/26/19 in the afternoon before dinner, the resident's family member said Resident #1 was still complaining of her leg hurting, so ADON D said she got LVN E to call Resident #1's physician to get x-rays. The results came back that Resident #1 had a fracture of both femurs. ADON D said LVN E called the physician and family and Resident #1 was sent to the hospital. ADON D said she did not assess or alert the Resident #1's physician about her leg pain because she had told LVN E to do it`. In an interview on 07/02/19 at 4:56 PM, Resident #1's nursing facility Physician stated neither she or her Nurse Practitioner were aware of Resident #1 falling, and after reviewing her call logs, she stated she did not get any calls about Resident #1 on 06/24/19 and 06/25/19. On 06/26/19 one of the nurses called about Resident #1 complaining of leg pain and saying, I'm hurting so bad, so then her Nurse Practitioner ordered an x-ray which revealed Resident #1 had two femur fractures. Then Resident #1 was sent to the hospital. Resident #1's Physician said Resident #1 had not been on any routine pain medications but took PRN pain medications two days prior to her hospital transfer. Resident #1's physician added if she had known about her issues with pain she would have ordered an x-ray much sooner. In an interview on 06/28/19 at 7:17 PM, the DON said from her investigation, CNA A and CNA B said Resident #1 started losing control and then they lowered the resident to the floor, which is still considered a fall and CNA A said after Resident #1 fell they tried to get her off of the floor, so they got LVN C to assist and they were still unable get her off of the floor and CNA F was passing down the hall and LVN C told CNA F to get the hoyer lift then the three CNA's and the nurse got Resident #1 transferred her in the hoyer lift. After a resident had a fall they were supposed to assess the resident for injury and if the resident had pain to monitor the resident and if the pain didn't get better they were to call the dr. In an interview on 07/01/19 at 3:14 PM, the DON said everything in a resident's care plan went into the facility's care computer tool system. The staff had to go to the computer and look up the residents' name, then it brought up everything about the residents' bed mobility, transfer, mobility on the hall, and whether the residents' were one or two-person hoyer transfers. The DON said CNA A and CNA B knew the care computer process and they said they knew how to access the it but did not use it before transferring Resident #1. The DON said CNA A had told her they just picked the resident up by her arms, then lowered her down, which was considered a fall. After Resident #1's fall the facility completed re-education with the staff on abuse/neglect/reporting, transfer, skills checks, the computer care system, change in condition and pain assessments with the nurses, falls, incident and accidents and when and how to complete forms. The DON said they terminated LVN C, CNA F, CNA B, CNA A and LVN E, she said LVN E was terminated because she failed to report Resident #1's fall on 06/24/19 and ADON D was terminated because she did not follow-up with the family member notifying her about Resident #1's issues of pain and failed to notify her and others in their standup meeting about the resident's pain issue. The DON said the two CNA's should have known what type of transfer she was, they all should have reported the incident immediately to her after Resident #1 fell and the nurses should have assessed the resident and contacted the resident's physician to get X-rays and should have reported the incident to her, but they did not so they were all terminated. In an interview on 07/01/19 at 4:01 PM, the Administrator said during his absence from the facility his DON was the acting Abuse Coordinator and the person who started the investigation into Resident #1's incident. They concluded LVN C was aware of Resident #1's fall, she went into the room shortly after Resident #1 fell . CNA A and CNA B worked with her when the resident fell , and they had called out for LVN C to assist. They then transferred her to the shower chair. CNA A and CNA B had completed an improper transfer. The Administrator said they should have known better because they had care computer tool trainings in the past. The Administrator said the care information was based on the resident's care plan needs and added there was also an issue with Resident #1 not getting a change in condition assessment after she fell . The CNA A and CNA B should have made sure they were doing the right type of transfer and the three CNA's failed to report the incident to the DON (in his absence) and the three nurses failed to assess the resident and report the incident to the DON (in his absence), do a change in condition assessment and call the resident's physician about her issues with pain, but they did not. The Administrator said this was why the staff were terminated because they also did not follow their company's policies. The measures they have in place to prevent this from happening again was by in servicing the Staff about Abuse and neglect, care tool, resident transfers with return demonstrations, and skills checks and doing change in condition assessment and incident/accident reports and reporting alleged abuse or neglect. Review of the trainings dated and signed by CNA A on 04/17/19 revealed annual trainings for falls, assisting totally dependent residents with dressing, hair combing, proper body mechanics, mechanical lift, assisting residents with transfer to chair or wheelchair and gait belt. Review of the trainings dated and signed by CNA B on 04/18/19 revealed Initial trainings for falls, assisting totally dependent residents with dressing, hair combing, proper body mechanics, mechanical lift, assisting residents with transfer to chair or wheelchair and gait belt. Review of the facility's Falls policy dated May 2017 revealed, Policy- It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention .Education of staff related to fall prevention: Provident a safe environment for residents, cause and risk factors or falls as well as the interventions to manage risk, safe transferring techniques, use of assistive devices . Review of the facility's Mechanical Lift policy dated May 2017 revealed, Policy- It is the policy of this home to utilize the Hoyer (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition. Review the facility's Change in Condition policy: Observing, reporting and recording, dated May 2017, revealed: Policy: It is the policy of this home to inform the resident, the residents physician and if indicated the residents responsible party of the following. 2. An accident or incident involving a resident which results in injury and has the potential for requiring physician intervention .3. An allegation of abuse or neglect regardless of who reports the allegation or (resident, family, visitor, staff, etc.) . Review of the Texas Administrative Code, Title 22: Part 11: Chapter 217, dated 12/15/07, reflected, Rule §217.11 Standards of Nursing Practice . (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: . (B) Implement measures to promote a safe environment for clients and others; . (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status . Review of the facility's Incident/Accident policy dated May 2017 revealed Policy: It is the policy of this home for staff to report and investigate event accidents, or incidents. Definitions: 1. Any event, accident or incident, which results in an injury or has the potential for injury .Procedure - Resident: The Charge nurse will immediately assess the condition of the resident involved, initiate emergency first aid, and when necessary, transfer to the hospital . Review of the facility's Abuse and Neglect policy dated May 2017 revealed, Policy- It is the policy of the home to prohibit resident abuse or neglect in any form and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse of neglect caused by another person. Definition: Neglect: The facility and its employee are neglectful when a reasonable person would conclude that a deprivation of the omitted goods and services would cause, among other things, emotional distress. On 06/28/19 at 9:05 PM, the Administrator was informed that a Past Non-Compliance Immediate Jeopardy was determined to have existed from 06/24/19 to 06/27/19. Review of the Facility's Provider Investigative Report dated 06/27/19 revealed on 06/24/19 at 9:30 AM, CNA A and CNA B transferred Resident #1 which caused the resident to fall, LVN C, LVN E and ADON D failed to provide the resident an assessment. On 06/26/19 Resident #1's family member told LVN E and ADON D about resident's pain then an x-ray was ordered which revealed acute right femur fracture with modest angulation and displacement and recent left femur fracture with modest angulation and displacement. The CNA's, LVN's and ADON involved were terminated and staff in-services were initiated. Findings: Confirmed. The facility took the following actions to correct the non-compliance prior to the investigation: On 06/28/19 at 7:17 PM, the DON said she started investigating and reported the incident to HHSC on 06 27/19, then started Inservice training staff and skills checks with return demonstrations on hoyer lift transfers and gait belts to all of the nursing staff. In addition, she said the facility also conducted in-service trainings for nursing staff to review the resident's plan of care prior to providing services, abuse and neglect reporting and change in condition and assessments. And added CNA A, CNA B, LVN C, ADON D, LVN E and CNA F were terminated. Interviews were conducted between 06/28/19 to 07/02/19 with LVN G, LVN H, LVN I, LVN J, LVN K, LVN L, LVN M, RN N, MA, CNA O, CNA P, ADON Q, HK and DA representing staff from all three shifts were knowledge on the subjects related to the deficiencies. Record Reviews of the resident's records who required hoyer transfers or on the same hall and other halls, the resident transfer policy, change in condition policy, pain assessment policy, abuse/neglect policy and reporting policy, incident/accident reporting, employee background checks, grievances, resident council minutes, incident/accidents, skills checks, and posttests and no concerns were found. Review of in-service training records revealed the staff had been re-educated with skills checks and post-tests to validate their knowledge and comprehension from 06/27/19 to 06/29/19: falls, change in condition, pain, incident/accident reporting, abuse and neglect, transfers and utilizing the care tool. In an interview on 07/01/19 at 4;04 PM, the Administrator stated the Medical Director agreed with their action plan to prevent similar incidents from re-occurring and by reviewing and monitoring to make sure there no breakdown in systems and to review Resident #1's incident in their Quality Assurance meeting. In an interview on 07/02/19 at 11:06 AM, the Administrator said all of the staff had been re-trained and included in their action plan and none of the staff including PRN staff would be allowed to work until they have been in serviced first. An Immediate Jeopardy (IJ) existed from 06/24/19 to 06/27/19. The IJ was removed on 06/27/19 because the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation.

Based on interviews and record reviews the facility failed to implement their written policies and procedures that prohibit and prevent neglect for one (Resident #1) of seven residents reviewed for neglect prevention. 1. CNA A and CNA B failed to transfer Resident #1 properly and report to management when the resident had a fall where she had to be lowered to the ground on Monday, 06/24/19, and the nurse did not assess the resident or document the incident. 2. LVN C failed to assess Resident #1 or report the incident after the resident fell and had to be lowered to the ground on Monday, 06/24/19, and complained of pain due to an inappropriate transfer. 3. LVN E and ADON D failed to assess Resident #1 after the resident and family member said the resident was experiencing significant pain for two days after she fell . As a result of these failures, Resident #1 experienced significant pain on 06/24/19 and 06/25/19 and on 06/26/19 she received an x-ray that identified two bilateral leg fractures. The resident was then sent to the hospital where she was admitted on [DATE]. An Immediate Jeopardy (IJ) existed from 06/24/19 to 06/27/19. The IJ was determined to be at past noncompliance as the facility implemented actions that corrected the noncompliance prior to the beginning of the investigation. These failures placed residents at risk of injury and emotional distress and turmoil. Findings included: Review of Resident #1's face Sheet dated 06/28/19 revealed a [AGE] year-old resident who admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Fall assessment dated [DATE] revealed she had a high-risk score of 10 with intermittent confusion, chair bound and required assist with toileting and takes 1-2 types of sedatives/hypnotic medications. Review of Resident #1's MDS assessment dated [DATE] revealed, Transfer: the resident was not transferred during this assessment period and had range of motion impairment on both sides of her lower extremities and had no issues with pain. Review of Resident #1's Care Plan dated 05/23/19 reflected, ADL self-care performance deficit: Resident #1 requires two staff with hoyer lift participation with transfers but usually refuses to get out of bed .Risk for falls, weakness and dementia unaware of safety needs. In an interview on 06/28/19 at 5:48 PM, CNA A stated on Monday, 06/24/19, she and CNA B went to Resident #1's room, and during Resident #1's transfer from her bed to the shower chair, the resident's legs became weak and she was lowered to the floor. They did not use a hoyer lift, but after the resident fell LVN C assisted with getting a hoyer lift to put the resident into the shower chair then they proceeded to take her to the shower chair and shower her then laid her down to bed. CNA A said LVN C did not assess Resident #1 but said after she laid Resident #1 down, the resident complained of pain she told LVN C, then LVN C gave Resident #1 some pain medication. CNA A said she did not report Resident #1's fall to anyone because LVN C said, She was not going to report it. CNA A said in hindsight she wished she would have said something to someone. In an interview on 06/28/19 at 7:58 PM, CNA A said she was the shower aide and had cared for Resident #1 in the past and always transferred Resident #1 manually with a second person and did not know she required hoyer lift transfers. She said she usually obtained the care information from the care tool in the computer and normally looked to see if the resident was a one or two person assist; however, she did not check it before transferring Resident #1 on Monday, 06/24/19. CNA A said it was four staff in Resident #1's room: CNA B was trying to lift the resident; CNA F was holding the shower chair and LVN C was observing. In an interview on 07/02/19 at 9:38 AM, CNA A said she knew she was wrong for not reporting Resident #1's fall on 06/24/19 to administration but thought LVN C had reported it and said she believed an example of neglect was a fall or injury not being reported to the Administrator or DON. In an interview on 06/28/19 at 6:25 PM, CNA B said on Monday, 06/24/19, around 9:30 AM she and CNA B attempted to transfer Resident #1 from her bed to the shower chair, but the resident became weak and was lowered to the floor. They used a hoyer lift to get her into the shower chair and showered the resident before lying her down. CNA B said she did not look at the care system for Resident #1's care plan information because she did not know she needed to and was new to the facility. She said she went by what CNA A said because she had worked at the facility longer. CNA B said she did not know Resident #1 required hoyer lift transfers. CNA B said on Wednesday, 06/26/19, while she was providing Resident #1 incontinence care the resident hollered and said she was hurting, so the nurse gave her some pain medication. CNA B said she did not report Resident #1's fall to anyone because she thought LVN C had reported it. She said LVN C was in the resident's room right after she fell and saw the resident on the floor but did not assess Resident #1. CNA B said she had not had any in services on transferring residents but was in serviced trained on Stop and watch if you find a change in a resident's condition and abuse and neglect. In an interview on 07/02/19 at 9:41 AM, CNA B said, Neglect meant not caring for the residents. In an interview on 06/28/19 at 6:08 PM, LVN C stated she worked Monday through Friday from 6:00 AM to 2:00 PM. She said CNA A and CNA B said they reported Resident #1's fall to her, but they did not. LVN C said she worked Monday during the dayshift 06/24/19 and when she walked into the room, she did not see Resident #1 on the floor but saw CNA A and CNA B standing next to Resident #1 who was in the hoyer lift. ,. Resident #1 was totally dependent and required total care. LVN C said on 06/24/19 she did not call Resident #1's physician or do a Change in condition assessment but did give her PRN pain medications when she complained of a headache. In an interview on 06/29/19 at 1:41 PM, LVN E said she was unaware Resident #1 fell but she knew the resident was experiencing pain and contacted her physician for an x-ray on 06/26/19. She complained of pain in both of her legs on 06/25/19, so she had given her two Tylenol 325 mg and her pain resolved that day. On Wednesday, 06/26/19, Resident #1's family member said the resident complained of pain, so she did a pain assessment which was an eight (severe pain) out of 10 on the pain scale, so she gave Resident #1 two Tylenol 325 mg and talked to Resident #1's physician to get the x-ray. The x-ray findings were that the resident had right and left femur fractures. LVN E said she called the resident's physician, DON, ADON and family and sent the resident to the hospital. Review of Resident #1's Nurses' note dated 06/26/19 at 3:50 PM and written by LVN E reflected, Resident #1 voiced increased pain to bilateral legs, assessed resident stated, 'I am hurting soo (sic) bad' rated pain 8/10 Doctor notified obtained orders for stat x-ray, family member at bedside and Tylenol 325 mg. 2 tabs administered will continue to monitor. Review of Resident #1's Pain Flow documentation dated from 06/01/19 to 06/26/19: 06/01/19 to 06/23/19 was 0. 06/24/19 at 10:34 AM was a 5 (moderate pain). 06/24/19 at 6:10 PM was a 7 (very severe pain). 06/25/19 at 2:52 PM was a 6 (severe pain). 06/25/19 at 7:58 PM was a 6 (severe pain). Review of Resident #1's Nurses' Note dated 06/26/19 at 10:35 PM revealed, the X-ray Report - Acute fracture involving supra-condylar femur (Thigh bone breaks at the knee), modest angulation and displacement. Resident #'1's physician notified received order to transfer resident to the emergency room , Responsible party notified, DON notified and ADON E aware. Review of Resident #1's Nurses Note dated 06/27/19 at 1:05 AM revealed, Resident transferred to the hospital for further evaluation family aware. Review of Resident #1's Hospital History and physical dated 06/27/19 at 4:12 AM revealed the resident admitted to the hospital 06/27/19 at 2:55 AM due to bilateral distal femoral fractures, supracondylar (thigh bone breaks at the knee) .extremities: She has pain at both distal femurs .Labs: X-rays of both legs showing bilateral distal femur fractures .Radiographs in the emergency department revealed mildly displaced fractures of the distal left and right distal femur metadiaphysis (combined region of a long bone, often used to describe [MEDICAL CONDITION] that span both regions) with no significant angulation .Plan: The patient is demented and does not walk .the risk for surgery outweigh the benefits, I have recommended non-operative treatment the patient will be non-weight bearing on bilateral lower extremities, keep knee immobilizers on at all times .ankles negative for fractures. Resident #1 discharge from the hospital 06/29/19. Review of Resident #1's Hospital Discharge Summary dated 06/29/19 revealed Physician orders [REDACTED]. Observation on 06/29/19 at 4:15 PM, revealed Resident #1 was moved to another hall, laying in bed with her gown on and sheets up to arms with knee mobilizers under her sheets. In an interview on 06/29/19 at 1:17 PM, ADON D said Resident #1's family member came by on Tuesday, 06/25/19, before dinner and told ADON D Resident #1 complained of leg pain and hurting and her pain medication was given. Then on Wednesday 06/26/19 in the afternoon before dinner, the resident's family member said Resident #1 was still complaining of her leg hurting, so ADON D said she got LVN E to call Resident #1's physician to get x-rays. The results came back that Resident #1 had a fracture of both femurs. ADON D said LVN E called the physician and family and Resident #1 was sent to the hospital. ADON D said she did not assess or alert the Resident #1's physician about her leg pain because she had told LVN E to do it`. In an interview on 07/02/19 at 4:56 PM, Resident #1's nursing facility Physician stated neither she or her Nurse Practitioner were aware of Resident #1 falling, and after reviewing her call logs, she stated she did not get any calls about Resident #1 on 06/24/19 and 06/25/19. On 06/26/19 one of the nurses called about Resident #1 complaining of leg pain and saying, I'm hurting so bad, so then her Nurse Practitioner ordered an x-ray which revealed Resident #1 had two femur fractures. Then Resident #1 was sent to the hospital. Resident #1's Physician said Resident #1 had not been on any routine pain medications but took PRN pain medications two days prior to her hospital transfer. Resident #1's physician added if she had known about her issues with pain she would have ordered an x-ray much sooner. In an interview on 06/28/19 at 7:17 PM, the DON said from her investigation, CNA A and CNA B said Resident #1 started losing control and then they lowered the resident to the floor, which is still considered a fall and CNA A said after Resident #1 fell they tried to get her off of the floor, so they got LVN C to assist and they were still unable get her off of the floor and CNA F was passing down the hall and LVN C told CNA F to get the hoyer lift then the three CNA's and the nurse got Resident #1 transferred her in the hoyer lift. After a resident had a fall they were supposed to assess the resident for injury and if the resident had pain to monitor the resident and if the pain didn't get better they were to call the dr. In an interview on 07/01/19 at 3:14 PM, the DON said everything in a resident's care plan went into the facility's care computer tool system. The staff had to go to the computer and look up the residents' name, then it brought up everything about the residents' bed mobility, transfer, mobility on the hall, and whether the residents' were one or two-person hoyer transfers. The DON said CNA A and CNA B knew the care computer process and they said they knew how to access the it but did not use it before transferring Resident #1. The DON said CNA A had told her they just picked the resident up by her arms, then lowered her down, which was considered a fall. After Resident #1's fall the facility completed re-education with the staff on abuse/neglect/reporting, transfer, skills checks, the computer care system, change in condition and pain assessments with the nurses, falls, incident and accidents and when and how to complete forms. The DON said they terminated LVN C, CNA F, CNA B, CNA A and LVN E, she said LVN E was terminated because she failed to report Resident #1's fall on 06/24/19 and ADON D was terminated because she did not follow-up with the family member notifying her about Resident #1's issues of pain and failed to notify her and others in their standup meeting about the resident's pain issue. The DON said the two CNA's should have known what type of transfer she was, they all should have reported the incident immediately to her after Resident #1 fell and the nurses should have assessed the resident and contacted the resident's physician to get X-rays and should have reported the incident to her, but they did not so they were all terminated. In an interview on 07/01/19 at 4:01 PM, the Administrator said during his absence from the facility his DON was the acting Abuse Coordinator and the person who started the investigation into Resident #1's incident. They concluded LVN C was aware of Resident #1's fall, she went into the room shortly after Resident #1 fell . CNA A and CNA B worked with her when the resident fell , and they had called out for LVN C to assist. They then transferred her to the shower chair. CNA A and CNA B had completed an improper transfer. The Administrator said they should have known better because they had care computer tool trainings in the past. The Administrator said the care information was based on the resident's care plan needs and added there was also an issue with Resident #1 not getting a change in condition assessment after she fell . The CNA A and CNA B should have made sure they were doing the right type of transfer and the three CNA's failed to report the incident to the DON (in his absence) and the three nurses failed to assess the resident and report the incident to the DON (in his absence), do a change in condition assessment and call the resident's physician about her issues with pain, but they did not. The Administrator said this was why the staff were terminated because they also did not follow their company's policies. The measures they have in place to prevent this from happening again was by in servicing the Staff about Abuse and neglect, care tool, resident transfers with return demonstrations, and skills checks and doing change in condition assessment and incident/accident reports and reporting alleged abuse or neglect. Review of the trainings dated and signed by CNA A on 04/17/19 revealed annual trainings for falls, assisting totally dependent residents with dressing, hair combing, proper body mechanics, mechanical lift, assisting residents with transfer to chair or wheelchair and gait belt. Review of the trainings dated and signed by CNA B on 04/18/19 revealed Initial trainings for falls, assisting totally dependent residents with dressing, hair combing, proper body mechanics, mechanical lift, assisting residents with transfer to chair or wheelchair and gait belt. Review of the facility's Falls policy dated May 2017 revealed, Policy- It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention .Education of staff related to fall prevention: Provident a safe environment for residents, cause and risk factors or falls as well as the interventions to manage risk, safe transferring techniques, use of assistive devices . Review of the facility's Mechanical Lift policy dated May 2017 revealed, Policy- It is the policy of this home to utilize the Hoyer (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition. Review the facility's Change in Condition policy: Observing, reporting and recording, dated May 2017, revealed: Policy: It is the policy of this home to inform the resident, the residents physician and if indicated the residents responsible party of the following. 2. An accident or incident involving a resident which results in injury and has the potential for requiring physician intervention .3. An allegation of abuse or neglect regardless of who reports the allegation or (resident, family, visitor, staff, etc.) . Review of the Texas Administrative Code, Title 22: Part 11: Chapter 217, dated 12/15/07, reflected, Rule §217.11 Standards of Nursing Practice . (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: . (B) Implement measures to promote a safe environment for clients and others; . (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status . Review of the facility's Incident/Accident policy dated May 2017 revealed Policy: It is the policy of this home for staff to report and investigate event accidents, or incidents. Definitions: 1. Any event, accident or incident, which results in an injury or has the potential for injury .Procedure - Resident: The Charge nurse will immediately assess the condition of the resident involved, initiate emergency first aid, and when necessary, transfer to the hospital . Review of the facility's Abuse and Neglect policy dated May 2017 revealed, Policy- It is the policy of the home to prohibit resident abuse or neglect in any form and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse of neglect caused by another person. Definition: Neglect: The facility and its employee are neglectful when a reasonable person would conclude that a deprivation of the omitted goods and services would cause, among other things, emotional distress. On 06/28/19 at 9:05 PM, the Administrator was informed that a Past Non-Compliance Immediate Jeopardy was determined to have existed from 06/24/19 to 06/27/19. Review of the Facility's Provider Investigative Report dated 06/27/19 revealed on 06/24/19 at 9:30 AM, CNA A and CNA B transferred Resident #1 which caused the resident to fall, LVN C, LVN E and ADON D failed to provide the resident an assessment. On 06/26/19 Resident #1's family member told LVN E and ADON D about resident's pain then an x-ray was ordered which revealed acute right femur fracture with modest angulation and displacement and recent left femur fracture with modest angulation and displacement. The CNA's, LVN's and ADON involved were terminated and staff in-services were initiated. Findings: Confirmed. The facility took the following actions to correct the non-compliance prior to the investigation: On 06/28/19 at 7:17 PM, the DON said she started investigating and reported the incident to HHSC on 06 27/19, then started Inservice training staff and skills checks with return demonstrations on hoyer lift transfers and gait belts to all of the nursing staff. In addition, she said the facility also conducted in-service trainings for nursing staff to review the resident's plan of care prior to providing services, abuse and neglect reporting and change in condition and assessments. And added CNA A, CNA B, LVN C, ADON D, LVN E and CNA F were terminated. Interviews were conducted between 06/28/19 to 07/02/19 with LVN G, LVN H, LVN I, LVN J, LVN K, LVN L, LVN M, RN N, MA, CNA O, CNA P, ADON Q, HK and DA representing staff from all three shifts were knowledge on the subjects related to the deficiencies. Record Reviews of the resident's records who required hoyer transfers or on the same hall and other halls, the resident transfer policy, change in condition policy, pain assessment policy, abuse/neglect policy and reporting policy, incident/accident reporting, employee background checks, grievances, resident council minutes, incident/accidents, skills checks, and posttests and no concerns were found. Review of in-service training records revealed the staff had been re-educated with skills checks and post-tests to validate their knowledge and comprehension from 06/27/19 to 06/29/19: falls, change in condition, pain, incident/accident reporting, abuse and neglect, transfers and utilizing the care tool. In an interview on 07/01/19 at 4;04 PM, the Administrator stated the Medical Director agreed with their action plan to prevent similar incidents from re-occurring and by reviewing and monitoring to make sure there no breakdown in systems and to review Resident #1's incident in their Quality Assurance meeting. In an interview on 07/02/19 at 11:06 AM, the Administrator said all of the staff had been re-trained and included in their action plan and none of the staff including PRN staff would be allowed to work until they have been in serviced first. An Immediate Jeopardy (IJ) existed from 06/24/19 to 06/27/19. The IJ was removed on 06/27/19 because the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation

Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #1) of seven residents reviewed for physician notifications. LVN C, LVN E and ADON D failed to notify Resident #1's physician after she fell on [DATE] and complained of pain for two days (06/24/19 and 06/25/19), despite Resident #1's family member's attempts to get the nursing staff to address the resident's bilateral leg pain, they failed to contact the resident's physician until 06/26/19 for an X-ray. As a result of these failures, Resident #1 experienced significant pain on 06/24/19 and 06/25/19 and on 06/26/19 she received an x-ray that identified two bilateral leg fractures. The resident was then sent to the hospital where she was admitted on [DATE]. An Immediate Jeopardy (IJ) existed from 06/24/19 to 06/27/19. The IJ was removed on 06/27/19 because the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation. These failures placed residents at risk of not receiving the necessary care and services in a timely manner which could result in permanent injury or emotional turmoil. Findings included: Review of Resident #1's face sheet dated 06/28/19 revealed a [AGE] year-old resident who admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed, Transfer: the resident was not transferred during this assessment period and had range of motion impairment on both sides of her lower extremities and had no issues with pain. In an interview on 06/28/19 at 5:48 PM, CNA A stated on Monday, 06/24/19, she went to Resident #1's room because CNA B asked for her assistance getting Resident #1 out of bed. As they proceeded to get Resident #1 up, her legs buckled, and the resident fell to the floor. CNA A said after she reported Resident #1's fall, LVN C said they needed to get the hoyer and they lifted Resident #1 with the hoyer lift to the shower chair. CNA A said after she laid Resident #1 down she complained of pain, so she told LVN C and LVN C gave her pain medication but never assessed the resident and told CNA A and CNA B she was not going to do an incident report. CNA A said it was four staff in Resident #1's room: CNA B was trying to lift the resident; CNA F was holding the shower chair and LVN C was observing. In an interview on 06/28/19 at 6:25 PM, CNA B stated she and CNA A got Resident #1 up for a shower on Monday, 06/24/19 around 9:30 AM. CNA A told her Resident #1 was not a hoyer lift transfer resident. CNA B said Resident #1's feet were touching the floor because she could feel the resident's weight against her body, then noticed Resident #1's legs getting weak and then they lowered the resident to the floor. CNA A retrieved LVN C who came in and helped get Resident #1 into the hoyer lift, then to the shower chair to get her showered, and finally the resident was laid to bed. She said LVN C was in the resident's room right after she fell and saw the resident on the floor but did not assess Resident #1. On Wednesday 06/26/19 while changing Resident #1, the resident hollered and said she was hurting so the LVN gave her pain medication. In an interview on 06/28/19 at 6:08 PM, LVN C stated she worked Monday through Friday from 6:00 AM to 2:00 PM. She said CNA A and CNA B said they reported Resident #1's fall to her, but they did not. LVN C said she worked Monday during the dayshift 06/24/19 and when she walked into the room, she did not see Resident #1 on the floor but saw CNA A and CNA B standing next to Resident #1 who was in the hoyer lift. Resident #1 was totally dependent and required total care. LVN C said on 06/24/19 she did not call Resident #1's physician or do a Change in condition assessment but did give her PRN pain medications when she complained of a headache. In an interview on 06/29/19 at 1:41 PM, LVN E said she was unaware Resident #1 fell but she knew the resident was experiencing pain and contacted her physician for an x-ray on 06/26/19. She complained of pain in both of her legs on 06/25/19, so she had given her two Tylenol 325 mg and her pain resolved that day. On Wednesday, 06/26/19, Resident #1's family member said the resident complained of pain so she did a pain assessment which was an eight (severe pain) out of 10 on the pain scale, so she gave Resident #1 two Tylenol 325 mg and talked to Resident #1's physician to get the x-ray. The x-ray findings were that the resident had right and left femur fractures. LVN E said she called the resident's physician, DON, ADON and family and sent the resident to the hospital. Resident #1's Nurses' note dated 06/24/19 at 10:34 AM, LVN C's documentation revealed Give 2 tablet (sic) by mouth every 6 hours as needed for pain not to exceed 3 grams of [MEDICATION NAME] per 24 hours which did not reflect what kind of pain the resident experienced. Resident #1's Nurses note dated 06/25/19 at 1:52 PM, LVN E's documentation revealed Give 2 tablet (sic) by mouth as needed for pain not to exceed 3 grams of [MEDICATION NAME] per 24 hours, Resident c/o generalized pain Review of Resident #1's Nurses' note dated 06/26/19 at 3:50 PM and written by LVN E reflected, Resident #1 voiced increased pain to bilateral legs, assessed resident stated, 'I am hurting soo (sic) bad' rated pain 8/10 Doctor notified obtained orders for stat x-ray, family member at bedside and Tylenol 325 mg. 2 tabs administered will continue to monitor. Review of Resident #1's Pain Flow documentation dated from: 06/01/19 to 06/23/19 was 0. 06/24/19 at 10:34 AM was a 5 (moderate pain). 06/24/19 at 6:10 PM was a 7 (very severe pain). 06/25/19 at 2:52 PM was a 6 (severe pain). 06/25/19 at 7:58 PM was a 6 (severe pain). Review of Resident #1's Nurses' Note dated 06/26/19 at 10:35 PM revealed, X-ray results reviewed Final results indicate acute fracture involving supra-condylar femur modest angulation and displacement. Resident #'1's physician notified received order to transfer resident to the emergency room , Responsible party notified, DON notified and ADON E aware. Review of Resident #1's Nurses Note dated 06/27/19 at 1:05 AM revealed, Resident transferred to the hospital for further evaluation family aware. Review of Resident #1's Hospital History and physical dated 06/27/19 at 4:12 AM revealed the resident admitted to the hospital 06/27/19 at 2:55 AM due to bilateral distal femoral fractures, supracondylar (thigh bone breaks at the knee) .extremities: She has pain at both distal femurs .Labs: X-rays of both legs showing bilateral distal femur fractures .Radiographs in the emergency department revealed mildly displaced fractures of the distal left and right distal femur metadiaphysis (combined region of a long bone, often used to describe [MEDICAL CONDITION] that span both regions) with no significant angulation .Plan: The patient is demented and does not walk .the risk for surgery outweigh the benefits, I have recommended non-operative treatment the patient will be non-weight bearing on bilateral lower extremities, keep knee immobilizers on at all times .ankles negative for fractures. Resident #1 discharge from the hospital 06/29/19. In an interview on 06/29/19 at 1:17 PM, ADON D said Resident #1's family member came by on Tuesday 06/25/19 before dinner and said Resident #1 complained of leg pain and hurting and her pain medication was given. Then on Wednesday 06/26/19 in the afternoon before dinner, the resident's family member said Resident #1 was still complaining of her leg hurting, so ADON D said she got LVN E to call Resident #1's physician to get x-rays. The results came back that Resident #1 had a fracture of both femurs. ADON D said LVN E called the physician and family and Resident #1 was sent to the hospital. ADON D said she did not think she had to do anymore than what she had done for Resident #1 because she had told LVN E to call the physician. In an interview on 07/02/19 at 4:56 PM, Resident #1's nursing facility Physician stated neither she or her Nurse Practitioner was aware of Resident #1 falling, and after reviewing her call logs, she stated she did not get any calls about Resident #1 on 06/24/19 and 06/25/19. On 06/26/19, one of the nurses called about Resident #1 complaining of leg pain and saying, I'm hurting so bad, so then her Nurse Practitioner ordered an x-ray which revealed Resident #1 had two femur fractures. Then, Resident #1 was sent to the hospital. Resident #1's Physician said Resident #1 had not been on any routine pain medications but took PRN pain medications two days prior to her hospital transfer and she said if she had known about her issues with pain she would have ordered an x-ray much sooner. In an interview on 06/28/19 at 7:17 PM, the DON stated ADON D notified her about Resident #1's right and left femur fractures and her complaints of leg pain were more than usual on 06/26/19. The DON said LVN E's response for not assessing Resident #1 was because she said the resident always complained of pain and gave the resident PRN pain medications instead. The DON said LVN C should have assessed Resident #1 and did a changed in condition assessment and called her Physician Monday, 06/24/19. The DON said LVN E also failed to do a change in condition assessment and contact Resident #1's physician after 06/24/19 when the resident was complaining of pain to both legs. The DON said due to the factors involving Resident #1's fall, they terminated LVN C, CNA F, CNA B, CNA A and LVN E. ADON D was terminated because she failed to follow-up on Resident #1's family member notifying her about Resident #1's pain issue and failed to notify her and others in the standup meeting about Resident #1's pain issues. CNA A and CNA B said CNA F assisted with getting the hoyer lift to the room, but CNA F denied having knowledge of Resident #1 falling or getting the hoyer lift to get the resident off of the floor but said they terminated her also. Review the facility's Change in Condition policy: Observing, reporting and recording, dated May 2017, revealed: Policy: It is the policy of this home to inform the resident, the residents physician and if indicated the residents responsible party of the following. 2. An accident or incident involving a resident which results in injury and has the potential for requiring physician intervention .3. An allegation of abuse or neglect regardless of who reports the allegation or (resident, family, visitor, staff, etc.) . On 06/28/19 at 9:05 PM, the Administrator was informed that a Past Non-Compliance Immediate Jeopardy was determined to have existed from 06/24/19 to 06/27/19. Review of the Facility's Provider Investigative Report dated 06/27/19 revealed on 06/24/19 at 9:30 AM, CNA A and CNA B transferred Resident #1 which caused the resident to fall, LVN C, LVN E and ADON D failed to provide the resident an assessment. On 06/26/19 Resident #1's family member told LVN E and ADON D about resident's pain then an x-ray was ordered which revealed acute right femur fracture with modest angulation and displacement and recent left femur fracture with modest angulation and displacement. The CNA's, LVN's and ADON involved were terminated and staff in-services were initiated. Findings: Confirmed. The facility took the following actions to correct the non-compliance prior to the investigation: On 06/28/19 at 7:17 PM, the DON said she started investigating and reported the incident to HHSC on 06 27/19, then started Inservice training staff and skills checks with return demonstrations on hoyer lift transfers and gait belts to all of the nursing staff. In addition, she said the facility also conducted in-service trainings for nursing staff to review the resident's plan of care prior to providing services, abuse and neglect reporting and change in condition and assessments. And added CNA A, CNA B, LVN C, ADON D, LVN E and CNA F were terminated. Interviews were conducted between 06/28/19 to 07/02/19 with LVN G, LVN H, LVN I, LVN J, LVN K, LVN L, LVN M, RN N, MA, CNA O, CNA P, ADON Q, HK and DA representing staff from all three shifts were knowledge on the subjects related to the deficiencies. Record Reviews of the resident's records who required hoyer transfers or on the same hall and other halls, the resident transfer policy, change in condition policy, pain assessment policy, abuse/neglect policy and reporting policy, incident/accident reporting, employee background checks, grievances, resident council minutes, incident/accidents, skills checks, and posttests and no concerns were found. Review of in-service training records revealed the staff had been re-educated with skills checks and post-tests to validate their knowledge and comprehension from 06/27/19 to 06/29/19: falls, change in condition, pain, incident/accident reporting, abuse and neglect, transfers and utilizing the Care tool. In an interview on 07/01/19 at 4;04 PM, the Administrator stated the Medical Director agreed with their action plan to prevent similar incidents from re-occurring and by reviewing and monitoring to make sure there no breakdown in systems and to review Resident #1's incident in their Quality Assurance meeting. In an interview on 07/02/19 at 11:06 AM, the Administrator said all of the staff had been re-trained and included in their action plan and none of the staff including PRN staff would be allowed to work until they have been in serviced first. An Immediate Jeopardy (IJ) existed from 06/24/19 to 06/27/19. The IJ was removed on 06/27/19 because the facility implemented actions that corrected the noncompliance prior to the beginning of HHSC's investigation.

Based on observation, interview and record review, the facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing for two (Resident #11 and Resident #22) of 16 residents reviewed for pressure ulcers. 1. The facility failed to provide wound care to Resident #11's two pressure ulcers from 07/15/17 (date of admission) through 07/17/17. 2. The facility failed to turn and reposition Resident #11 every two hours and failed to offload his heels. 3. The wound care nurse failed to properly place the clean dressing completely over Resident #11's coccyx wound to help prevent infection. 4. The facility failed to ensure Resident #11's pressure relieving device was on set to the resident's weight. Due to these failures, Resident #11 developed an unstageable pressure ulcer to his left heel and his sacral pressure ulcer was not improving and had a foul odor upon observation of the wound. 5. The wound care nurse failed to completely clean Resident #22's right buttock pressure ulcer before placing a clean bandage. These failures could affect the 16 residents who receive wound care for their pressure ulcers from the wound care nurse and staff who failed to turn and reposition and off load heels of residents by placing them at risk for deterioration of the pressure injury, infections and cross-contamination. Findings Included: 1. Review of Resident #11's facility transfer orders dated 07/12/17 from the hospital reflected the following wound care orders: (DON confirmed these were the orders Resident #11 came with from the hospital and were the orders they were supposed to follow) Wound Vac (vacuum) to coccyx (sacrum) at 125 mm Hg (millimeters of mercury) continuous mode. Change dressing three times per week. Clean wound to right heel with normal saline, apply [MEDICATION NAME] gel to base, cover with [MEDICATION NAME] 4 x (by) 4 border and tape with [MEDICATION NAME] tape. Change every 3 days. Review of the initial pressure ulcer assessment by the wound care nurse dated 07/18/17 reflected the following wounds present upon admission: 1. Unstageable pressure ulcer to the sacrum measuring 7cm x 7.5 cm with moderate amount of bloody clear drainage. 2. Stage 2 pressure ulcer to the left buttock measuring 4 cm x 2 cm x 0.2 cm with light bloody clear drainage. 3. Stage 2 pressure ulcer to the right heel measuring 2 cm x 1.5 cm x 0.2 cm with light bloody clear drainage. Review of Resident #11's face sheet dated 08/17/17 reflected Resident #11 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's MDS assessment dated [DATE] reflected Resident #11 was moderately cognitively impaired. He weighed 185 pounds. Resident #11 required extensive assistance of two people with bed mobility, including moving to and from a lying position, turning side to side, and positioning his body while in bed. The MDS assessment also reflected he had two Stage 2 pressure ulcers and one unstageable pressure ulcer. Review of Resident #11's Comprehensive Care Plan initiated on 07/18/17 and updated on 08/16/17 reflected he had a pressure ulcer to his sacrum and interventions included avoid positioning the resident on sacrum, administer treatments as ordered and monitor for effectiveness, and assess wound healing weekly and report declines to the MD (doctor). Another focus area on the care plan was the pressure ulcer to the right heel with an intervention which included avoid positioning the resident on heels and ensure heels are floated with the use of pillows. Review of Resident #11's admitting skin assessment dated [DATE] reflected the following; peri-area moist, d/t (due to) area to coccyx, left heel wound as well as an area to the right heel. The admitting skin assessment did not include measurements or any descriptions of the wounds. Review of Resident #11's Admission Physician order [REDACTED]. However, there was an order for [REDACTED].>Review of July 2017's treatment record revealed wound care orders were not started until 07/18/17, which was three days after Resident #11 was admitted on [DATE]. Interview with the Wound Care Nurse on 08/15/17 at 10:30 a.m. revealed she knew Resident #11 had come in with an admission order for a wound vac, but she got the order changed when she discussed it with the physician on 07/18/17 after she reviewed the hospital transfer orders. She stated Resident #11 never had a wound vac and since he came in on a weekend, she did not see him until three days later. She stated the charge nurses were responsible for ensuring the wound care orders were transcribed and completed on the weekends. She stated when she had assessed the wounds initially on 07/18/17, they were covered with a dry dressing and there were three pressure ulcers including the one on the sacrum, right heel, and left buttock. Since he had been admitted , they had healed the pressure ulcer on his left buttock and right heel. She stated he did develop an unstageable pressure ulcer to his left heel. Interview with the DON on 08/17/17 at 10:51 a.m. revealed when a resident was admitted on a weekend, it was the expectation that the charge nurse was to provide wound care until the wound care nurse could assess the wound on Monday. She revealed the charge nurse was to follow the hospital orders and ensure they were followed. She stated she did not realize Resident #11 went without wound care for three days when he was admitted and that was concerning. Review of Resident #11's Weekly Pressure Ulcer Assessments for the Resident #11's pressure ulcers reflected the following: Sacrum: 07/25/17: Resident #11 had a 8 cm x 12 cm Stage 3 pressure ulcer to the sacrum with heavy bloody clear drainage and a mild odor. The sacral wound was covered with 50 percent of necrotic (dead) tissue. 08/03/17: Resident #11 had a 6.3 cm x 7.5 cm Unstageable pressure ulcer to the sacrum with moderate amount of bloody clear drainage with a strong odor and covered with 75 percent necrotic tissue. 08/11/17: Resident #11 had a 8.5 cm x 11 cm Stage 4 Pressure Ulcer to the sacrum with moderate amount of bloody clear drainage with a strong odor and covered with 50 percent necrotic tissue. Left Heel: 08/03/17: Resident #11 developed an Unstageable Deep Tissue Injury (DTI) on his left heel, which measured 3.5 cm x 3.6 cm with 100 percent necrotic tissue. A new treatment order for the left heel included wound cleanser and [MEDICATION NAME] to affected area and secure with a dry protective dressing every day. 08/11/17: Resident #11 had a 4.5 cm x 5.5 cm an Unstageable Deep Tissue Injury and the treatment was changed to apply skin prep daily to wound and cover with occlusive dressing. Review of the Wound Care Doctor's treatment notes regarding Resident #11's pressure ulcers reflected the following: 07/21/17: Resident #11 had a 8 cm x 12 cm Stage 4 pressure ulcer to the sacrum with heavy serous (clear) drainage and covered with 40 percent of necrotic tissue. 08/04/17: Resident #11 had a 8.5 x 11 cm Stage 4 pressure ulcer to the sacrum with moderate serous drainage and covered with 40 percent necrotic tissue. The wound care doctor surgically debrided (removed) 37.40 cm of necrotic muscle and tissue from the sacral wound. The resident had a new unstageable pressure ulcer of less than one day duration on his left heel measuring 4.5 cm x 5.5 cm. The pressure ulcer to the right heel was healed on 08/04/17. 08/11/17: Resident #11 had a 8.5 x 6.5 cm Stage 4 pressure ulcer to the sacrum with heavy serous drainage and covered with 40 percent of necrotic tissue. The wound care doctor surgically debrided (removed) 22.10 cm of necrotic muscle and tissue from the sacral wound. The wound care doctor did not change the orders for the sacral wound on his visit on 07/21/17, 08/04/17, and 08/11/17. Observation of Resident #11 on 08/14/17 at 9:15 a.m. revealed the resident in bed lying on his back, directly on the coccyx wound. Observation of the air loss mattress revealed a dial which was to be turned to how much the resident weighed in pounds. Observation of the dial revealed it to be turned to 285 pounds (Note: Resident #11's weight was 183 pounds per the MDS assessment dated [DATE]). Review of NPUAP's (National Pressure Ulcer Advisory Panel) article Quality of Care Regulations Made Easy dated March 2014 and obtained from http://www.npuap.org/wp-content/uploads/2014/03/NPUAP-F-tag-final-March-2014.pdf and accessed on 09/05/17 reflected the following: Pressure redistribution refers to the function or ability to distribute a load over a surface or contact area. Redistribution results in shifting pressure from one area to another and requires attention to all affected areas.an overinflated overlay product (such as an air mattress) is unlikely to effectively reduce the pressure risk. Observation of Resident #11 on 08/14/17 at 11:30 a.m. revealed the resident in bed lying on his back with his heels touching the mattress. CNA D and CNA E performed peri-care on Resident #11 and positioned him on his back once again. Observation of the air mattress revealed it to be was still set at 285 pounds. Observation of Resident #11 on 08/15/17 at 6:20 a.m. revealed Resident #11 to be lying in bed on his back with a pillow under his calves with his heels still touching the bed. The dial on the air mattress was still turned to 285 pounds. Observation of Resident #11 on 08/15/17 at 7:45 a.m. revealed Resident #11 lying on his back with his heels touching the mattress. Observation at that time also revealed the wound care nurse provided pressure ulcer care to Resident #11's sacral pressure ulcer. The sacral wound had a large amount of purulent (pus) drainage and smelled very foul. Once the wound care nurse cleaned and applied the treatment as ordered, she placed a 4x4 dressing. The sticky border of the dressing was put over half of the wound and the bottom of the dressing was not stuck to the skin which left it open to allow foreign materials such as fecal matter to get into the wound. The wound care nurse then with the assistance of CNA E, repositioned Resident #11 back onto his back. She put the pillow back under Resident #11's calves, but his heels were still touching the mattress. The air mattress was still set at 285 pounds. Observation of Resident #11's heels revealed there to be a large necrotic closed wound on his left heel which was uncovered. Interview with the wound care nurse on 08/15/17 at 10:30 a.m. revealed she did not check the air mattress settings. She stated when the company dropped off the air mattress, the rental company would inflate it and she always assumed that it was set at the right setting. She revealed Resident #11's heels should always be off loaded. She stated the charge nurses and CNAs should also be turning and repositioning Resident #11 every two hours. Interview with Resident #11 on 08/15/17 at 10:10 a.m. revealed he was able to answer yes or no questions by nodding or shaking his head. Resident #11 nodded his head yes when asked if his wounds were painful. He shook his head no when asked if the staff ever turned and reposition him. Resident #11 nodded his head yes when asked if he was always lying on his back. Resident #11 nodded his head yes when asked if it hurt his bottom to lie on his back all of the time. Observation of the air mattress at that time revealed it was still set at 285 pounds. Resident #11 was still positioned on his back with his heels touching the mattress. Interview with CNA E who was Resident #11's day shift CNA on 08/15/17 at 10:20 a.m. revealed she did not turn and reposition Resident #11 and he stayed lying on his back because he had an air mattress. CNA E stated she did not mess with the air mattress and if a resident had an air mattress, she did not turn and reposition them. She stated she does put the pillow underneath his heels so they do not touch the mattress. She stated she did not realize when she assisted the wound care nurse earlier that day, that Resident #11's heels were touching the bed and stated she would fix it. Observation of Resident #11 on 08/16/17 at 7:57 a.m. revealed Resident #11 lying on his back with his heels touching the mattress. Observation of Resident #11 on 08/16/17 at 9:50 a.m. revealed Resident #11 lying on his back with his heels still touching the mattress. A pillow was placed underneath his calves. Observation of Resident #11 on 08/16/17 at 11:55 a.m. revealed Resident #11 lying on his back with his heels still touching the mattress. Review of Resident #11's care plan dated 07/19/17 and updated 08/16/17 reflected the following interventions: Avoid positioning the resident on sacrum .Avoid positioning the resident on heels .Ensure heels are floated (not touching mattress or other surface) with the use of pillows . Interview with LVN N on 08/15/17 at 11:35 a.m. revealed she did not feel the need to turn and reposition Resident #11 because he was on an air mattress. She stated Resident #11's heels were to be off-loaded by placing a pillow underneath his feet so his heels were not touching any surface. She stated she expected her CNAs to ensure the heels were offloaded and she would check on Resident #11's heels when she administered his medications. Interview with ADON H on 08/15/17 at 11:45 a.m. revealed the air mattresses came from a rental company and they set up the bed and they put it on a setting. She stated she guessed the charge nurse or herself should ensure the mattresses were at the proper setting, but she never looked before. She confirmed Resident #11's bed was set on 285 pounds and it should actually be set based on his current weight of around 180 pounds. Interview with the DON on 08/17/17 at 10:51 a.m. revealed residents with pressure ulcers should be turned and repositioned every two hours. She stated she believed the rental company who they rented air mattresses from will would put the air mattress on the correct setting. She stated she does did not know who is was in charge of ensuring the mattresses are were inflated correctly. 2. Review of Resident #22's MDS assessment dated [DATE] reflected Resident #22 was a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He required extensive assistance of two people with bed mobility and transfers. He was severely cognitively impaired and had no unhealed pressure ulcers according to his 06/02/17 MDS assessment. Resident #22's care plan dated 01/06/17 reflected Resident #22 had a stage 3 pressure ulcer and interventions included administer treatments as ordered, monitor dressing every shift to ensure it is intact and adhering, and use an air mattress. Review of Resident #22's physician orders [REDACTED]. Observation of the wound care nurse performing wound care on Resident #22's right buttock pressure ulcer revealed she removed Resident #22's brief. Resident #22 had a moderate amount of fecal matter on his buttocks. The wound care nurse did not wipe away or clean the fecal matter away from the wound. She cleaned the wound bed and applied the treatment as ordered. She covered the wound with a 4x4 dressing even though there was fecal matter underneath the dressing. The wound care nurse stated since she did not have any help from another staff member during wound care, she could not do incontinence care too. She stated she did not realize she had put the dressing over any fecal matter and would have to change it later when she had assistance. 3. Review of the Admission of a Resident policy and procedure dated 05/2017 reflected the following: admission orders [REDACTED] .6. Orders for treatment: Specific area to be treated should be clearly stated, prn orders must include reason(s) (no exceptions). Review of the Skin-Treatment Guidelines for Pressure Injuries Policy and Procedure dated 05/2017 reflected the following: Institute the use of air fluidized therapy or low air loss therapy if appropriate .Institute the use of pressure reducing devices for chair and other off-loading devices as necessary .Reposition/turn the resident at least every two (2) hours . The Resident Census and Conditions of Residents, Form CMS-672, signed and dated by the DON on 08/14/17, reflected a total of 16 residents who had pressure ulcers.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free from accident hazards as possible for one (Resident #1) of 15 residents reviewed for accident hazards. The facility failed to put interventions in place, such as staff to assist resident with all hot liquids and providing a coffee cup with a lid, after Resident #1 spilt hot coffee on himself on 03/25/17 and sustained a second degree burn on his right thigh. Resident #1 then spilt hot coffee on himself again on 04/24/17. An Immediate Jeopardy was identified on 04/25/17. While the IJ was removed on 04/26/17, the facility remained out of compliance at severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed 29 residents, who the facility determined were a high risk for injuries from hot liquids, at risk for burns, pain and discomfort. Findings included: Review of Resident #1's face sheet dated 03/28/17 revealed Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #1's MDS dated [DATE] reflected he was cognitively intact. Further review reflected Resident #1 required extensive of one person with eating, transfers, and locomotion on and off the unit. Review of the Provider Investigation Report dated 04/04/17 and signed by the Administrator revealed Resident #1 had a scheduled skin assessment on 03/25/17 where a 7.5 x 15 cm (2.95 x 5.90 in) reddened area was noted on his right posterior thigh by LVN E. Resident #1 stated he had spilt coffee on himself. There was no documentation that LVN E notified Resident #1's doctor about the burn. On 03/27/17, Resident #1 was reassessed by LVN F and she noted the reddened area had turned into a blister and had opened. Review of the nurse's note dated 03/27/17, LVN F notified Resident #1's physician at 4:30 p.m. and a new order for the open blister to the right femur to be cleaned with normal saline and triple antibiotic and a dry dressing was to be applied for ten days. Further review of the Provider Investigation Report revealed the facility's interventions to prevent a future incident included completing a Hot Liquid Safety Evaluation on all the residents who partake in any kind of hot beverage. Review of the Hot Liquids Safety Evaluation tool included in the provider investigation report reflected two sections. The top section listed seven different risk factors: Cognition, mood, behaviors, tremors, contractures, strength, and mobility and if a resident had two or more risk factors they were determined to be at high risk for an injury from a hot liquid. The bottom section listed seven interventions the facility could put in place to prevent injuries from hot liquids if the resident was identified as a high risk. If an intervention was initialed, it indicated the intervention was to be put in place. Review of Resident #1's Hot Liquids Safety Evaluation tool dated 03/28/17 reflected Resident #1 had two risk factors including observed tremors in upper extremities, and weakness in the upper extremities. According to the evaluation, Resident #1 was at risk for injuries from spills of hot liquids. Interventions listed on Resident #1's evaluation dated 03/28/17 included the resident to use a cup with a handle, resident to use dominant hand for drinking, resident to drink hot liquids while sitting at table only, and staff to assist resident with all hot liquids. Review of the coffee temperature log noted the temperature of the coffee on 03/25/17 (the date the resident stated he was burned) was 152 degrees at 7:00 a.m., 146 degrees at 9:00 a.m., 153 degrees at 11:00 a.m., 152 degrees at 1:00 p.m., 150 degrees at 3:00 p.m., and 143 degrees at 5:00 p.m. The coffee temperature log was taped to the wall beside the coffee machine in the kitchen. At the top of the coffee temperature log, reflected the temperature of the coffee is not to exceed 165 degrees. Review of the Resident Safety with Hot Beverages Policy dated 06/24/16 reflected the following: Serve the hot beverages between 150 and 165 degrees. A staff member should pour the hot beverages .fill hot beverage mugs to 75% or less of their capacity .When serving hot liquids to residents with medical conditions that put them at risk for spills-Allow hot liquids to cool before serving .Encourage iced tea or iced coffee. Review of the Hot Liquid Safety Evaluations completed on 03/28/17 revealed 15 residents were identified at risk of injuries from hot liquids. Interventions the facility was to put in place for the residents identified as high risks included providing cups with handles, resident to use non-dominant hand for drinking, encouraging the resident to drink hot liquids while sitting at a table only, staff to assist residents with all hot liquids, and ensuring the temperature of hot liquids not to exceed 130 degrees. Observation of the dining room on 04/25/17 at 9:30 a.m. revealed there was an electric coffee dispenser on a counter which was accessible to all residents. Cook A measured the coffee temperature coming from the coffee dispenser at 150 degrees. No staff were observed to assist residents if they wished to get coffee from the dispenser. Interview with Cook A on 04/25/17 at 9:35 a.m. revealed they measure the coffee temperature in the kitchen prior to putting it in the dining room and he was told by his manager the temperature was not to exceed 165 degrees. He stated they put the temperature on a log which is on the wall next to the coffee machine. Review of the Coffee Temperature Log for March 2017 revealed between 03/21/17 through 03/31/17 the coffee temperatures ranged between 141 and 156 degrees. Review of the Coffee Temperature Log for April 2017 revealed between 04/01/17 through 04/25/17, the coffee temperatures ranged between 142 and 178 degrees. Interview with Resident #1 on 04/25/17 at 11:32 a.m. in the dining room revealed he always gets his coffee from the coffee dispenser in the dining room without any staff help. He stated he had spilled his coffee and burnt himself again yesterday (04/24/17) in the dining room around 11:00 a.m. He stated this was the second time it had happened, but he did not feel much pain because he did not have much feeling in his legs. He stated after the first incident, the facility had never given him a coffee cup with a lid. Resident #1 was at the coffee dispenser holding a coffee cup with no lid and Resident #1's hands were noted to shaking. Observation of the dining room during the interview revealed there to be no staff available to assist the residents with getting coffee. Interview with LVN G on 04/25/17 at 1:03 p.m. revealed she was Resident #1's nurse. She stated she knew he had been burnt a while back, but they were done treating the burn. She stated she was never told about any interventions to be put in place for Resident #1. LVN G stated Resident #1 loves coffee and will go to the dining room and get coffee all day. She stated he does have tremors in his hands. Interview with CNA B on 04/25/17 at 12:58 p.m. revealed she had never been told about any special cups or interventions for Resident #1 regarding hot liquids. She stated he drinks coffee all the time. Observation of Resident #1's right thigh on 04/25/17 at 2:25 p.m. revealed there to be a pink area on his right thigh, but no blisters or open areas were noted at that time. Interview with the DON and Administrator on 04/25/17 at 11:38 a.m. revealed the DON gave the hot liquids evaluation tool to the nursing staff to complete. The DON stated only two residents had triggered as a high risk for injuries from hot liquids. Upon review of the evaluation tools provided to the surveyor, she stated the evaluation tool was completed incorrectly because the nurses were not supposed to mark the intervention parts. She stated she had not reviewed them after they were completed to figure out who was at risk for an injury from hot liquids. The Administrator stated he did not know about the interventions listed on the evaluation tool. The DON stated the only intervention they completed was giving Resident #1 a cup with a lid, but no other interventions were completed for the other residents identified as at risk. This surveyor stated based upon her observations and interview with Resident #1, a cup with a lid which was supposedly provided could not be found. The DON stated Resident #1 should have the cup because she went to the store herself and bought him one. She stated she did not know what happened to the cup. The DON stated she should have reviewed the evaluation tool to determine who was at risk and The DON stated she was not aware Resident #1 had burnt himself again yesterday. Review of the Burns article on https://medlineplus.gov/ency/article/ 0.htm retrieved on 05/01/17 reflected the following: Burns fall into 2 groups .Major burns include third degree burns, second degree burns more than 2 to 3 inches (5 to 7.5 centimeters) wide .adults over 60 have a higher chance of complications and death from severe burns because their skin tends to be the thinner than in other age groups. http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf reflected, .The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed .When the temperature of a hot liquid is increased to 140 (degrees) F/60 (degrees) C it only takes five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 (degrees) F/ 71-82 (degrees) C, resulting in almost instantaneous burns .Since immediate removal of the hot liquid from the skin may lessen severity, splash and spill burns may not be as deep as burns suffered in a bathtub. High risk groups .Older Adults Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults.2 Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids .Time and Temperature Relationship to Severe Burns Water temperature Time for a third degree burn to occur 155 degrees F 1 second 148 degrees F 2 seconds 140 degrees F 5 seconds 133 degrees F 15 seconds 127 degrees F 1 minute 124 degrees F 3 minutes 120 degrees F 5 minutes (Retrieved on 05/04/17) An IJ was identified on 04/25/17 at 10:35 a.m. and the Administrator and DON were informed and a Plan of Removal was requested. The facility's Plan of Removal, accepted on 04/26/17 at 8:24 a.m. reflected: Coffee temperatures at the time DADS checked temperature 04-25-17 was 150 degrees. Effective 4-25-2017 the established Westside Campus of Care hot beverage temperature is between 130-140 F degrees. Immediate Actions taken to prevent recurrence: 1. Coffee has been moved into the kitchen. Kitchen staff, specifically the dietary aide will ensure coffee is proper temperature prior to serving coffee. Clip board will be kept next to coffee pot and when temperature reaches 140 degrees, staff will initial, date and time it. A. Sign will be placed at kitchen door that states Please ask for coffee. B. Resident council president and frequent coffee drinkers will meet with Administrator and DON to discuss plan to move coffee into kitchen for resident safety. C. Dietary staff arrive at approximately 6:30 AM and begin brewing. D. Staff will be in-serviced immediately beginning 04-25-17 and will continue until all staff has been educated that coffee has been moved into the kitchen and it must be requested due to the hazards of burns from hot liquids and the temperature of the coffee should not exceed 140 degrees. E. Dietary staff will be in-serviced by Dietary manager and the Registered Dietician regarding the need to move coffee into kitchen and that it must be available always while kitchen is open. As well as dietary staff cooling coffee to 130-140 F degrees before serving. 2. Residents that can drink coffee (take fluids/nutrition by mouth) will be assessed for safe handling of hot liquids by nurse manager by end of day 04-25-17. Systemic Changes to prevent recurrence included the following measures: A. After completion of assessments, appropriate interventions will be put in place, eg; (cup with lid, cup with handle, encourage resident to drink beverage only at a table, staff to assist resident with hot beverages, wear splint if indicated, resident to wear clothing protector). B. Nurse managers have been on 4-25-2017 in-serviced on the updated assessment form for hot liquids to be performed on admission, re-admission, quarterly and significant change by DON. C. Residents identified at risk will have an alert placed on their Kardex in POC system and a list will be provided of residents at risk to be kept at nurse's station in a binder labeled residents at risk for injury from hot liquids, in the kitchen for dietary staff, and in the dining areas. D. Staff will be in-serviced on the identification of residents at risk and the location of the list for staff that do not have access to POC by DON immediately beginning 04-25-17 and will continue until all staff have been educated. E. A care plan will be developed for residents identified at risk with the specific interventions identified after the assessment is completed. Monitoring the systemic changes include the following measures: A. The Facility Administrator will validate safe temperatures by visualization of the hot beverage log daily for no less than 30 days. The Plan of Removal's Monitoring Plan: Observation of the dining room on 04/26/17 at 9:30 a.m. revealed the coffee dispenser is was no longer in the dining room. A piece of paper on the kitchen door stated for the residents to ask for coffee from the kitchen. A group of residents were gathered around the Administrator as he explained how the coffee will have to be asked from the kitchen to help prevent burns. Interviews with CNA B, CNA C, and LVN D on 04/26/17 between 10:12 a.m. and 10:26 a.m. revealed they had been in-serviced over the hazards of hot liquids and how residents need to request coffee from the kitchen. They also knew the hot liquids are not to exceed 140 degrees. Observation of the dining room and nurse's stations on 04/26/17 at 11:30 a.m. revealed there were folders available to staff which contained the names of residents who were at risk for a hot liquid spill. Review of the in-services completed on 04/25/17 and 04/26/17 revealed the staff had been in-serviced over residents at risk for hot liquid spills are identified and their names are placed in a binder at each nurse's station, dining room, and in the kitchen. Review of the Hot Liquids Safety Evaluations dated 04/25/17 revealed 29 residents were identified as a high risk for injuries from hot liquids. On 04/26/17., the Administrator was informed the IJ was removed. While the IJ was removed on 04/26/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. The Care Plan Item Listing Report provided by the Administrator on 04/26/17 reflected 29 residents were at risk for injury from hot liquids or spills.

Based on observation, interview and record review, the facility failed to ensure the resident was free from neglect for one (Resident #1) of 15 residents reviewed for neglect. The facility failed to put interventions in place, such as staff to assist resident with all hot liquids and providing a coffee cup with a lid, after Resident #1 spilt hot coffee on himself on 03/25/17 and sustained a second degree burn on his right thigh. Resident #1 then spilt hot coffee on himself again on 04/24/17. An Immediate Jeopardy situation was identified on 04/25/17. The Immediate Jeopardy was removed on 04/26/17. The facility remained out of compliance at severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed 29 residents, who the facility determined were a high risk for injuries from hot liquids, at risk for burns, pain and discomfort. Findings included: Review of Resident #1's face sheet dated 03/28/17 revealed Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #1's MDS dated [DATE] reflected he was cognitively intact. Further review reflected Resident #1 required extensive of one person with eating, transfers, and locomotion on and off the unit. Review of the Provider Investigation Report dated 04/04/17 and signed by the Administrator revealed Resident #1 had a scheduled skin assessment on 03/25/17 where a 7.5 x 15 cm (2.95 x 5.90 in) reddened area was noted on his right posterior thigh by LVN E. Resident #1 stated he had spilt coffee on himself. There was no documentation that LVN E notified Resident #1's doctor about the burn. On 03/27/17, Resident #1 was reassessed by LVN F and she noted the reddened area had turned into a blister and had opened. Review of the nurse's note dated 03/27/17, LVN F notified Resident #1's physician at 4:30 p.m. and a new order for the open blister to the right femur to be cleaned with normal saline and triple antibiotic and a dry dressing was to be applied for ten days. Further review of the Provider Investigation Report revealed the facility's interventions to prevent a future incident included completing a Hot Liquid Safety Evaluation on all the residents who partake in any kind of hot beverage. Review of the Hot Liquids Safety Evaluation tool included in the provider investigation report reflected two sections. The top section listed seven different risk factors: Cognition, mood, behaviors, tremors, contractures, strength, and mobility and if a resident had two or more risk factors they were determined to be at high risk for an injury from a hot liquid. The bottom section listed seven interventions the facility could put in place to prevent injuries from hot liquids if the resident was identified as a high risk. If an intervention was initialed, it indicated the intervention was to be put in place. Review of Resident #1's Hot Liquids Safety Evaluation tool dated 03/28/17 reflected Resident #1 had two risk factors including observed tremors in upper extremities, and weakness in the upper extremities. According to the evaluation, Resident #1 was at risk for injuries from spills of hot liquids. Interventions listed on Resident #1's evaluation dated 03/28/17 included the resident to use a cup with a handle, resident to use dominant hand for drinking, resident to drink hot liquids while sitting at table only, and staff to assist resident with all hot liquids. Review of the coffee temperature log noted the temperature of the coffee on 03/25/17 (the date the resident stated he was burned) was 152 degrees at 7:00 a.m., 146 degrees at 9:00 a.m., 153 degrees at 11:00 a.m., 152 degrees at 1:00 p.m., 150 degrees at 3:00 p.m., and 143 degrees at 5:00 p.m. The coffee temperature log was taped to the wall beside the coffee machine in the kitchen. At the top of the coffee temperature log, reflected the temperature of the coffee is not to exceed 165 degrees. Review of the Resident Safety with Hot Beverages Policy dated 06/24/16 reflected the following: Serve the hot beverages between 150 and 165 degrees. A staff member should pour the hot beverages .fill hot beverage mugs to 75% or less of their capacity .When serving hot liquids to residents with medical conditions that put them at risk for spills-Allow hot liquids to cool before serving .Encourage iced tea or iced coffee. Review of the Hot Liquid Safety Evaluations completed on 03/28/17 revealed 15 residents were identified at risk of injuries from hot liquids. Interventions the facility was to put in place for the residents identified as high risks included providing cups with handles, resident to use non-dominant hand for drinking, encouraging the resident to drink hot liquids while sitting at a table only, staff to assist residents with all hot liquids, and ensuring the temperature of hot liquids not to exceed 130 degrees. Observation of the dining room on 04/25/17 at 9:30 a.m. revealed there was an electric coffee dispenser on a counter which was accessible to all residents. Cook A measured the coffee temperature coming from the coffee dispenser at 150 degrees. No staff were observed to assist residents if they wished to get coffee from the dispenser. Interview with Cook A on 04/25/17 at 9:35 a.m. revealed they measure the coffee temperature in the kitchen prior to putting it in the dining room and he was told by his manager the temperature was not to exceed 165 degrees. He stated they put the temperature on a log which is on the wall next to the coffee machine. Review of the Coffee Temperature Log for March 2017 revealed between 03/21/17 through 03/31/17 the coffee temperatures ranged between 141 and 156 degrees. Review of the Coffee Temperature Log for April 2017 revealed between 04/01/17 through 04/25/17, the coffee temperatures ranged between 142 and 178 degrees. Interview with Resident #1 on 04/25/17 at 11:32 a.m. in the dining room revealed he always gets his coffee from the coffee dispenser in the dining room without any staff help. He stated he had spilled his coffee and burnt himself again yesterday (04/24/17) in the dining room around 11:00 a.m. He stated this was the second time it had happened, but he did not feel much pain because he did not have much feeling in his legs. He stated after the first incident, the facility had never given him a coffee cup with a lid. Resident #1 was at the coffee dispenser holding a coffee cup with no lid and Resident #1's hands were noted to shaking. Observation of the dining room during the interview revealed there to be no staff available to assist the residents with getting coffee. Interview with LVN G on 04/25/17 at 1:03 p.m. revealed she was Resident #1's nurse. She stated she knew he had been burnt a while back, but they were done treating the burn. She stated she was never told about any interventions to be put in place for Resident #1. LVN G stated Resident #1 loves coffee and will go to the dining room and get coffee all day. She stated he does have tremors in his hands. Interview with CNA B on 04/25/17 at 12:58 p.m. revealed she had never been told about any special cups or interventions for Resident #1 regarding hot liquids. She stated he drinks coffee all the time. Observation of Resident #1's right thigh on 04/25/17 at 2:25 p.m. revealed there to be a pink area on his right thigh, but no blisters or open areas were noted at that time. Interview with the DON and Administrator on 04/25/17 at 11:38 a.m. revealed the DON gave the hot liquids evaluation tool to the nursing staff to complete. The DON stated only two residents had triggered as a high risk for injuries from hot liquids. Upon review of the evaluation tools provided to the surveyor, she stated the evaluation tool was completed incorrectly because the nurses were not supposed to mark the intervention parts. She stated she had not reviewed them after they were completed to figure out who was at risk for an injury from hot liquids. The Administrator stated he did not know about the interventions listed on the evaluation tool. The DON stated the only intervention they completed was giving Resident #1 a cup with a lid, but no other interventions were completed for the other residents identified as at risk. This surveyor stated based upon her observations and interview with Resident #1, a cup with a lid which was supposedly provided could not be found. The DON stated Resident #1 should have the cup because she went to the store herself and bought him one. She stated she did not know what happened to the cup. The DON stated she should have reviewed the evaluation tool to determine who was at risk and The DON stated she was not aware Resident #1 had burnt himself again yesterday. Review of the Abuse and Neglect - Clinical Protocol dated 04/07 reflected the following: Neglect refers to refusal or failure to fulfill any part of one's obligations or duties to an individual .The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. Review of the Burns article on https://medlineplus.gov/ency/article/ 0.htm retrieved on 05/01/17 reflected the following: Burns fall into 2 groups .[MEDICAL CONDITION] third degree burns, second [MEDICAL CONDITION] than 2 to 3 inches (5 to 7.5 centimeters) wide .adults over 60 have a higher chance of complications and death from [MEDICAL CONDITION] their skin tends to be the thinner than in other age groups. http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf reflected, .The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed .When the temperature of a hot liquid is increased to 140 (degrees) F/60 (degrees) C it only takes five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 (degrees) F/ 71-82 (degrees) C, resulting in almost [MEDICAL CONDITION].Since immediate removal of the hot liquid from the skin may lessen severity, splash and [MEDICAL CONDITION] not be as deep [MEDICAL CONDITION] in a bathtub. High risk groups .Older Adults Older adults, like young children, have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults.2 Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids .Time and Temperature Relationship to Severe Burns Water temperature Time for a third degree burn to occur 155 degrees F 1 second 148 degrees F 2 seconds 140 degrees F 5 seconds 133 degrees F 15 seconds 127 degrees F 1 minute 124 degrees F 3 minutes 120 degrees F 5 minutes (Retrieved on 05/04/17) An IJ was identified on 04/25/17 at 10:35 a.m. and the Administrator and DON were informed and a Plan of Removal was requested. The facility's Plan of Removal, accepted on 04/26/17 at 8:24 a.m. reflected: Coffee temperatures at the time DADS checked temperature 04-25-17 was 150 degrees. Effective 4-25-2017 the established Westside Campus of Care hot beverage temperature is between 130-140 F degrees. Immediate Actions taken to prevent recurrence: 1. Coffee has been moved into the kitchen. Kitchen staff, specifically the dietary aide will ensure coffee is proper temperature prior to serving coffee. Clip board will be kept next to coffee pot and when temperature reaches 140 degrees, staff will initial, date and time it. A. Sign will be placed at kitchen door that states Please ask for coffee. B. Resident council president and frequent coffee drinkers will meet with Administrator and DON to discuss plan to move coffee into kitchen for resident safety. C. Dietary staff arrive at approximately 6:30 AM and begin brewing. D. Staff will be in-serviced immediately beginning 04-25-17 and will continue until all staff has been educated that coffee has been moved into the kitchen and it must be requested due to the hazards [MEDICAL CONDITION] hot liquids and the temperature of the coffee should not exceed 140 degrees. E. Dietary staff will be in-serviced by Dietary manager and the Registered Dietician regarding the need to move coffee into kitchen and that it must be available always while kitchen is open. As well as dietary staff cooling coffee to 130-140 F degrees before serving. 2. Residents that can drink coffee (take fluids/nutrition by mouth) will be assessed for safe handling of hot liquids by nurse manager by end of day 04-25-17. Systemic Changes to prevent recurrence included the following measures: A. After completion of assessments, appropriate interventions will be put in place, eg; (cup with lid, cup with handle, encourage resident to drink beverage only at a table, staff to assist resident with hot beverages, wear splint if indicated, resident to wear clothing protector). B. Nurse managers have been on 4-25-2017 in-serviced on the updated assessment form for hot liquids to be performed on admission, re-admission, quarterly and significant change by DON. C. Residents identified at risk will have an alert placed on their Kardex in POC system and a list will be provided of residents at risk to be kept at nurse's station in a binder labeled residents at risk for injury from hot liquids, in the kitchen for dietary staff, and in the dining areas. D. Staff will be in-serviced on the identification of residents at risk and the location of the list for staff that do not have access to POC by DON immediately beginning 04-25-17 and will continue until all staff have been educated. E. A care plan will be developed for residents identified at risk with the specific interventions identified after the assessment is completed. Monitoring the systemic changes include the following measures: A. The Facility Administrator will validate safe temperatures by visualization of the hot beverage log daily for no less than 30 days. The Plan of Removal's Monitoring Plan: Observation of the dining room on 04/26/17 at 9:30 a.m. revealed the coffee dispenser is was no longer in the dining room. A piece of paper on the kitchen door stated for the residents to ask for coffee from the kitchen. A group of residents were gathered around the Administrator as he explained how the coffee will have to be asked from the kitchen to help prevent burns. Interviews with CNA B, CNA C, and LVN D on 04/26/17 between 10:12 a.m. and 10:26 a.m. revealed they had been in-serviced over the hazards of hot liquids and how residents need to request coffee from the kitchen. They also knew the hot liquids are not to exceed 140 degrees. Observation of the dining room and nurse's stations on 04/26/17 at 11:30 a.m. revealed there were folders available to staff which contained the names of residents who were at risk for a hot liquid spill. Review of the in-services completed on 04/25/17 and 04/26/17 revealed the staff had been in-serviced over residents at risk for hot liquid spills are identified and their names are placed in a binder at each nurse's station, dining room, and in the kitchen. Review of the Hot Liquids Safety Evaluations dated 04/25/17 revealed 29 residents were identified as a high risk for injuries from hot liquids. On 04/26/17., the Administrator was informed the IJ was removed. While the IJ was removed on 04/26/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. The Care Plan Item Listing Report provided by the Administrator on 04/26/17 reflected 29 residents were at risk for injury from hot liquids or spills.

Based on observation, interview and record review, the facility failed to ensure the resident was free from neglect for one (Resident #1) of 15 residents reviewed for neglect. The facility failed to put interventions in place, such as staff to assist resident with all hot liquids and providing a coffee cup with a lid, after Resident #1 spilt hot coffee on himself on 03/25/17 and sustained a second degree burn on his right thigh. Resident #1 then spilt hot coffee on himself again on 04/24/17. An Immediate Jeopardy situation was identified on 04/25/17. The Immediate Jeopardy was removed on 04/26/17. The facility remained out of compliance at severity level of actual harm that is not immediate jeopardy, and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. This failure placed 29 residents, who the facility determined were a high risk for injuries from hot liquids, at risk for burns, pain and discomfort. Findings included: Review of the Abuse and Neglect - Clinical Protocol dated 04/07 reflected the following: Neglect refers to refusal or failure to fulfill any part of one's obligations or duties to an individual .The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. Review of Resident #1's face sheet dated 03/28/17 revealed Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #1's MDS dated [DATE] reflected he was cognitively intact. Further review reflected Resident #1 required extensive of one person with eating, transfers, and locomotion on and off the unit. Review of the Provider Investigation Report dated 04/04/17 and signed by the Administrator revealed Resident #1 had a scheduled skin assessment on 03/25/17 where a 7.5 x 15 cm (2.95 x 5.90 in) reddened area was noted on his right posterior thigh by LVN E. Resident #1 stated he had spilt coffee on himself. There was no documentation that LVN E notified Resident #1's doctor about the burn. On 03/27/17, Resident #1 was reassessed by LVN F and she noted the reddened area had turned into a blister and had opened. Review of the nurse's note dated 03/27/17, LVN F notified Resident #1's physician at 4:30 p.m. and a new order for the open blister to the right femur to be cleaned with normal saline and triple antibiotic and a dry dressing was to be applied for ten days. Further review of the Provider Investigation Report revealed the facility's interventions to prevent a future incident included completing a Hot Liquid Safety Evaluation on all the residents who partake in any kind of hot beverage. Review of the Hot Liquids Safety Evaluation tool included in the provider investigation report reflected two sections. The top section listed seven different risk factors: Cognition, mood, behaviors, tremors, contractures, strength, and mobility and if a resident had two or more risk factors they were determined to be at high risk for an injury from a hot liquid. The bottom section listed seven interventions the facility could put in place to prevent injuries from hot liquids if the resident was identified as a high risk. If an intervention was initialed, it indicated the intervention was to be put in place. Review of Resident #1's Hot Liquids Safety Evaluation tool dated 03/28/17 reflected Resident #1 had two risk factors including observed tremors in upper extremities, and weakness in the upper extremities. According to the evaluation, Resident #1 was at risk for injuries from spills of hot liquids. Interventions listed on Resident #1's evaluation dated 03/28/17 included the resident to use a cup with a handle, resident to use dominant hand for drinking, resident to drink hot liquids while sitting at table only, and staff to assist resident with all hot liquids. Review of the coffee temperature log noted the temperature of the coffee on 03/25/17 (the date the resident stated he was burned) was 152 degrees at 7:00 a.m., 146 degrees at 9:00 a.m., 153 degrees at 11:00 a.m., 152 degrees at 1:00 p.m., 150 degrees at 3:00 p.m., and 143 degrees at 5:00 p.m. The coffee temperature log was taped to the wall beside the coffee machine in the kitchen. At the top of the coffee temperature log, reflected the temperature of the coffee is not to exceed 165 degrees. Review of the Resident Safety with Hot Beverages Policy dated 06/24/16 reflected the following: Serve the hot beverages between 150 and 165 degrees. A staff member should pour the hot beverages .fill hot beverage mugs to 75% or less of their capacity .When serving hot liquids to residents with medical conditions that put them at risk for spills-Allow hot liquids to cool before serving .Encourage iced tea or iced coffee. Review of the Hot Liquid Safety Evaluations completed on 03/28/17 revealed 15 residents were identified at risk of injuries from hot liquids. Interventions the facility was to put in place for the residents identified as high risks included providing cups with handles, resident to use non-dominant hand for drinking, encouraging the resident to drink hot liquids while sitting at a table only, staff to assist residents with all hot liquids, and ensuring the temperature of hot liquids not to exceed 130 degrees. Observation of the dining room on 04/25/17 at 9:30 a.m. revealed there was an electric coffee dispenser on a counter which was accessible to all residents. Cook A measured the coffee temperature coming from the coffee dispenser at 150 degrees. No staff were observed to assist residents if they wished to get coffee from the dispenser. Interview with Cook A on 04/25/17 at 9:35 a.m. revealed they measure the coffee temperature in the kitchen prior to putting it in the dining room and he was told by his manager the temperature was not to exceed 165 degrees. He stated they put the temperature on a log which is on the wall next to the coffee machine. Review of the Coffee Temperature Log for March 2017 revealed between 03/21/17 through 03/31/17 the coffee temperatures ranged between 141 and 156 degrees. Review of the Coffee Temperature Log for April 2017 revealed between 04/01/17 through 04/25/17, the coffee temperatures ranged between 142 and 178 degrees. Interview with Resident #1 on 04/25/17 at 11:32 a.m. in the dining room revealed he always gets his coffee from the coffee dispenser in the dining room without any staff help. He stated he had spilled his coffee and burnt himself again yesterday (04/24/17) in the dining room around 11:00 a.m. He stated this was the second time it had happened, but he did not feel much pain because he did not have much feeling in his legs. He stated after the first incident, the facility had never given him a coffee cup with a lid. Resident #1 was at the coffee dispenser holding a coffee cup with no lid and Resident #1's hands were noted to shaking. Observation of the dining room during the interview revealed there to be no staff available to assist the residents with getting coffee. Interview with LVN G on 04/25/17 at 1:03 p.m. revealed she was Resident #1's nurse. She stated she knew he had been burnt a while back, but they were done treating the burn. She stated she was never told about any interventions to be put in place for Resident #1. LVN G stated Resident #1 loves coffee and will go to the dining room and get coffee all day. She stated he does have tremors in his hands. Interview with CNA B on 04/25/17 at 12:58 p.m. revealed she had never been told about any special cups or interventions for Resident #1 regarding hot liquids. She stated he drinks coffee all the time. Observation of Resident #1's right thigh on 04/25/17 at 2:25 p.m. revealed there to be a pink area on his right thigh, but no blisters or open areas were noted at that time. Interview with the DON and Administrator on 04/25/17 at 11:38 a.m. revealed the DON gave the hot liquids evaluation tool to the nursing staff to complete. The DON stated only two residents had triggered as a high risk for injuries from hot liquids. Upon review of the evaluation tools provided to the surveyor, she stated the evaluation tool was completed incorrectly because the nurses were not supposed to mark the intervention parts. She stated she had not reviewed them after they were completed to figure out who was at risk for an injury from hot liquids. The Administrator stated he did not know about the interventions listed on the evaluation tool. The DON stated the only intervention they completed was giving Resident #1 a cup with a lid, but no other interventions were completed for the other residents identified as at risk. This surveyor stated based upon her observations and interview with Resident #1, a cup with a lid which was supposedly provided could not be found. The DON stated Resident #1 should have the cup because she went to the store herself and bought him one. She stated she did not know what happened to the cup. The DON stated she should have reviewed the evaluation tool to determine who was at risk and The DON stated she was not aware Resident #1 had burnt himself again yesterday. Review of the Burns article on https://medlineplus.gov/ency/article/ 0.htm retrieved on 05/01/17 reflected the following: Burns fall into 2 groups .[MEDICAL CONDITION] third degree burns, second [MEDICAL CONDITION] than 2 to 3 inches (5 to 7.5 centimeters) wide .adults over 60 have a higher chance of complications and death from [MEDICAL CONDITION] their skin tends to be the thinner than in other age groups. http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf reflected, .The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed .When the temperature of a hot liquid is increased to 140 (degrees) F/60 (degrees) C it only takes five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180 (degrees) F/ 71-82 (degrees) C, resulting in almost [MEDICAL CONDITION].Since immediate removal of the hot liquid from the skin may lessen severity, splash and [MEDICAL CONDITION] not be as deep [MEDICAL CONDITION] in a bathtub. High risk groups .Older Adults Older adults, like young children, have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults.2 Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids .Time and Temperature Relationship to Severe Burns Water temperature Time for a third degree burn to occur 155 degrees F 1 second 148 degrees F 2 seconds 140 degrees F 5 seconds 133 degrees F 15 seconds 127 degrees F 1 minute 124 degrees F 3 minutes 120 degrees F 5 minutes (Retrieved on 05/04/17) An IJ was identified on 04/25/17 at 10:35 a.m. and the Administrator and DON were informed and a Plan of Removal was requested. The facility's Plan of Removal, accepted on 04/26/17 at 8:24 a.m. reflected: Coffee temperatures at the time DADS checked temperature 04-25-17 was 150 degrees. Effective 4-25-2017 the established Westside Campus of Care hot beverage temperature is between 130-140 F degrees. Immediate Actions taken to prevent recurrence: 1. Coffee has been moved into the kitchen. Kitchen staff, specifically the dietary aide will ensure coffee is proper temperature prior to serving coffee. Clip board will be kept next to coffee pot and when temperature reaches 140 degrees, staff will initial, date and time it. A. Sign will be placed at kitchen door that states Please ask for coffee. B. Resident council president and frequent coffee drinkers will meet with Administrator and DON to discuss plan to move coffee into kitchen for resident safety. C. Dietary staff arrive at approximately 6:30 AM and begin brewing. D. Staff will be in-serviced immediately beginning 04-25-17 and will continue until all staff has been educated that coffee has been moved into the kitchen and it must be requested due to the hazards [MEDICAL CONDITION] hot liquids and the temperature of the coffee should not exceed 140 degrees. E. Dietary staff will be in-serviced by Dietary manager and the Registered Dietician regarding the need to move coffee into kitchen and that it must be available always while kitchen is open. As well as dietary staff cooling coffee to 130-140 F degrees before serving. 2. Residents that can drink coffee (take fluids/nutrition by mouth) will be assessed for safe handling of hot liquids by nurse manager by end of day 04-25-17. Systemic Changes to prevent recurrence included the following measures: A. After completion of assessments, appropriate interventions will be put in place, eg; (cup with lid, cup with handle, encourage resident to drink beverage only at a table, staff to assist resident with hot beverages, wear splint if indicated, resident to wear clothing protector). B. Nurse managers have been on 4-25-2017 in-serviced on the updated assessment form for hot liquids to be performed on admission, re-admission, quarterly and significant change by DON. C. Residents identified at risk will have an alert placed on their Kardex in POC system and a list will be provided of residents at risk to be kept at nurse's station in a binder labeled residents at risk for injury from hot liquids, in the kitchen for dietary staff, and in the dining areas. D. Staff will be in-serviced on the identification of residents at risk and the location of the list for staff that do not have access to POC by DON immediately beginning 04-25-17 and will continue until all staff have been educated. E. A care plan will be developed for residents identified at risk with the specific interventions identified after the assessment is completed. Monitoring the systemic changes include the following measures: A. The Facility Administrator will validate safe temperatures by visualization of the hot beverage log daily for no less than 30 days. The Plan of Removal's Monitoring Plan: Observation of the dining room on 04/26/17 at 9:30 a.m. revealed the coffee dispenser is was no longer in the dining room. A piece of paper on the kitchen door stated for the residents to ask for coffee from the kitchen. A group of residents were gathered around the Administrator as he explained how the coffee will have to be asked from the kitchen to help prevent burns. Interviews with CNA B, CNA C, and LVN D on 04/26/17 between 10:12 a.m. and 10:26 a.m. revealed they had been in-serviced over the hazards of hot liquids and how residents need to request coffee from the kitchen. They also knew the hot liquids are not to exceed 140 degrees. Observation of the dining room and nurse's stations on 04/26/17 at 11:30 a.m. revealed there were folders available to staff which contained the names of residents who were at risk for a hot liquid spill. Review of the in-services completed on 04/25/17 and 04/26/17 revealed the staff had been in-serviced over residents at risk for hot liquid spills are identified and their names are placed in a binder at each nurse's station, dining room, and in the kitchen. Review of the Hot Liquids Safety Evaluations dated 04/25/17 revealed 29 residents were identified as a high risk for injuries from hot liquids. On 04/26/17., the Administrator was informed the IJ was removed. While the IJ was removed on 04/26/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring the implementation of the Plan of Removal. The Care Plan Item Listing Report provided by the Administrator on 04/26/17 reflected 29 residents were at risk for injury from hot liquids or spills.

Based on observation, interview, and record review, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of three (Resident #1, Resident #6 and Resident #8) of four residents reviewed for neglect. 1. The facility failed to supervise a visit between Resident #1, who was intellectually disabled and autistic, with Resident #1's Family Member, whom the resident accused of touching her inappropriately on 10/05/2016. Resident #1 was left alone with Family Member who required supervised visitations with Resident #1. 2. The facility failed to inform staff that Resident #6 had a restricted visitor 3. The facility failed to have a plan in place if Resident #8's restricted visitor came to the facility. An Immediate Jeopardy (IJ) was identified on 10/14/2016. Although, the IJ was removed on 10/15/2016, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolation due to needing to in-service staff and monitor their implementation of the Plan of Removal (POR). These failures could affect the facility's 157 residents by placing them at risk for abuse, mistreatment, fear and anxiety. Findings Included: Review of Resident #1's Face Sheet, received 10/18/2016 revealed Resident #1 was a 54- year-old, female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 had unclear speech, sometimes made herself understood by others, could sometimes understand others, and had moderately impaired cognition. Resident #1 had physical behaviors, verbal behaviors, and other behaviors not directed toward others and would refuse care. Resident #1 was totally dependent on staff for ADL care and incontinent of bowel and bladder. Review of the facility's Provider Investigation Report dated 10/06/2016 revealed on 10/05/2016 at 8:30 PM two CNAs observed Resident #1's Family Member standing over Resident #1 in her room wearing gloves. Resident #1's Family Member stated he was changing her. Resident #1 was distraught and yelling you are not my brother, you nasty, you touched me, get out of my room. CNA asked Resident #1's Family Member to step out the room so they could provide care. The Provider Investigation Report Provider Response revealed the Medical Director, Administrator, and Director of Nursing (DON) were immediately notified. The local police department (PD) was notified and arrived at the facility at approximately 9:45 PM to interview Resident #1 and staff. Resident #1 was transferred to a local hospital via Emergency Medical Service (EMS) at 9:50 PM. She was examined and returned to the facility on [DATE] at approximately 4:00 AM. Resident #1's Family Member was not notified and would be supervised pending rape kit results. Provider Investigation Report Provider Action Taken Post-Investigation revealed Resident #1 would be supervised while Resident #1's Family Member visited. Observation of Resident #1's clinical chart was reviewed which revealed no documented plan noted in chart indicating what days Resident #1's Family Member could visit the facility, who would supervise the visit, and where the visit would be supervised at. The facility's 24 Hour Report/Change of Condition Report dated 10/05/2016 revealed Resident #1's Family Member in (Resident #1's) room, resident very guarded very suspicion, ADON, DON, Administrator notified, transfer to (local) ER. Resident #1's Nurse's Notes (in chart) there was no note regarding the incident on 10/05/2016 (initial incident), or incident dated 10/08/2016 (Resident #1's Family Member left unsupervised in Resident #1's room). Resident #1's electronic clinical chart revealed no nurse's notes regarding the incident on 10/05/2016 and or 10/08/2016. On 10/14/2016 at 10:32AM an observation and interview with Resident #1 revealed the resident sitting up in geriatric chair with her bedside table pulled up to her with a coloring book and [MEDICATION NAME] on it. Her television was on Sesame Street. Resident #1 stated my name is (Resident #1) Resident #1 was not in any distress at the time of observation; however, when talking about Resident #1 ' s Family Member resident ' s affect changed from conversational to blank. Resident #1 stated she was coloring a fish which was an accurate statement. Resident #1 revealed Resident #1's Family Member bought her things and she liked him but not when he did bad things. When asked what bad things? Resident #1 stated he (Resident #1 ' s Family Member) put something there (pointing at her vagina) and then she started saying no, no that is bad you do not do that stop that then said he stop. Resident #1 pulled the zipper area of her pants and once she pulled down her zipper she had a pink toy (light up ball wand) in her right hand she then started pushing toy handle against her vagina. Resident #1 then started stating ( Resident #1's Family Member) Loves (Resident #1) in a mimic tone., Resident #1 then started saying Do You Love (Resident #1's Family Member), (Resident #1)? in her mimic tone. Resident #1 said (Resident #1) Loves (Resident #1's Family Member) and started pointing in the center of her chest (between her neck and center of her breast bone), Resident #1 stated this is my heart (pointing in the same place). Resident #1 got distracted and went back to looking at the fish in the coloring book. On 10/18/2016 at 1:23PM individual interview was conducted with Administrator, stating that she had not done any interventions regarding Resident #1 nor have she spoken with Resident #1 regarding incident on 10/05/2016 or did she interview Resident #1 on 10/08/2016 regarding resident being unsupervised with Resident #1's Family Member visitor. Administrator stated that she did not interview resident or talk to resident because she did not want to interfere with police investigation When asked was she told by police not to speak with resident she stated that she just did not because she was told resident would be interviewed by an forensic interviewer. Administrator stated that she assumed Resident #1's Family Member would not come back to the facility on [DATE] because law enforcement advised him not to come back to the facility. Administrator stated that she informed Resident #1's Family Member on 10/10/2016 that he was not allowed in the facility until law enforcement investigation is completed she stated that she did not give him much information regarding incident but stated that any questions he have to contact local law enforcement. Administrator stated that on 10/08/2016 she was informed that Resident #1's Family Member was in the building by DON, and the DON told her that Resident #1's Family Member was removed before seeing Resident #1. Administrator stated that she did not do any interviews with residents and or staff regarding incident on 10/08/2016. An interview on 10/14/2016 at 1:51 PM with the DON revealed the Resident #1's Family Member had not been back in the facility since the incident on 10/05/2016. An interview on 10/14/2016 at 2:04 PM with CNA D revealed she provided ADL care for Resident #1 who could respond to questions when asked. CNA D stated Resident #1 is no problem, for the most part. CNA D revealed she was one of the aides who witnessed the Resident #1's Family Member coming into the hallway with gloves on, asking for assistance to change Resident #1 on 10/05/2016. CNA D stated she and another aide went into Resident #1's room and noticed Resident #1 was jumpy and that she started yelling you are nasty, you are not my brother, you touched me (pointed to her brief) CNA D stated that she asked Resident #1's Family Member to leave room so they could provide care to Resident #1. CNA D stated they cleaned her and changed her sheets and after that she and the other aide went and told charge nurse what they had seen. CNA D revealed she had not heard of any restrictions for Resident #1's visitors. She stated she was not aware Resident #1 required supervised visits with Resident #1's Family Member. CNA D stated she had not seen Resident #1's Family Member since the incident on 10/05/2016 and had not heard of any special instructions when dealing with him. CNA D stated Resident #1 had visits from Resident #1's Family Member often. CNA D revealed when she first encountered him for the first time she felt that he was creepy and weird. She said that (Resident #1's Family Member) slapped (Resident #1) on the bottom in an inappropriate way but stated that she never said anything because she did not know the nature of their relationship, and the CNA she was training with did not say anything. CNA D stated that Resident #1's Family Member would refer to Resident #1 as being her dad at times; he would greet Resident #1 as this is your dad. CNA D stated that he would always close the door when he would enter into Resident #1's room. An interview on 10/14/2016 at 2:17 PM with CNA E revealed she provided care for Resident #1 and stated that Resident #1 would refuse incontinent care she would hold on to rails and it would take three CNA ' s to change Resident #1. CNA E stated that when Resident #1 did not want to be changed it was difficult to provide care. CNA E stated that although other aides thought it was weird for AP to want to stay in the room while she provided incontinent care, she did not mind, because he was the only one who could calm her down so she would allow him to stay in the room, while she provided incontinent care. CNA E stated that Resident #1 had visits often and Resident #1's Family Member would visit at least three times a week or more and he would always close the door when he would visit. CNA E stated that Resident #1 did not have any restrictions regarding her visitors nor did she require supervised visits that she was aware of. CNA E revealed the Resident #1's Family Member visited Resident #1 on the day she returned back to work (not sure if it was Saturday or Sunday 10/8/2016 or 10/09/2016) and he was left alone in Resident #1's room with the door closed. CNA E stated she did not do anything, because she was not told of anything to do. She revealed another CNA came to her and they were talking at the nurse's station about the incident that took place on 10/05/2016. CNA E stated that while she and another CNA were talking about the incident, the charge nurse started asking questions about the incident and then checked Resident #1's chart. She stated she did not know what took place but noticed about ten to fifteen minutes later the charge nurse asked the Resident #1's Family Member to leave the facility and to come back Monday to talk with the Administrator. CNA E revealed she had not seen the Resident #1's Family Member since then An interview on 10/15/2016 at 2:06 PM with LVN K revealed on 10/08/2016 between 4-5 PM he was on the hall passing out medications to residents when he saw the Resident #1's Family Member go into Resident #1's room and close the door. LVN K stated he continued his task and when he was finished he went to the nurse's station. While he was at the nurse's station, he overheard two CNAs talking about the incident on 10/05/2016. He said checked Resident #1's chart and started looking for incident information. He stated he did not see anything in Resident #1's chart, so he called the on-call phone number to the supervisor. He said he left a message LVN K stated about ten minutes later he received a call over the intercom system asking him to pick up a call, and he then was instructed by the DON to escort Resident #1's Family Member out the building and if he came back or did not comply to notify local law enforcement. LVN K stated he went to Resident #1's room, opened the door and saw the Resident #1's Family Member putting a DVD into Resident #1's DVD player. He revealed he asked the Resident #1's Family Member to come with him and then told the Resident #1's Family Member he had been instructed to ask him to leave the facility. LVN K said he told the Resident #1's Family Member that he could come back on Monday 10/10/2016 to talk with the administrator for the reason he was asked to leave the facility. LVN K stated the Resident #1's Family Member left the facility. LVN K revealed he was unaware the Resident #1's Family Member should have not been in the facility and or the Resident #1's Family Member should have been supervised while visiting. DON ' s statement dated 10/14/2016 revealed .When I was done speaking with ADON A, I called the facility to speak with LVN G. I told him Resident #1's Family Member was not to be in the facility until further notice. The facility's 24 Hour Report/Change of Condition Report Dated 10/08/2016 did not reveal Resident #1's Family Member was in the facility. The 24 Hour Report/Change of Condition Report Dated 10/09/2016 did not reveal Resident #1's Family Member was in the facility. An interview on 10/17/2016 at 3:25 PM with ADON A revealed she received a voicemail on 10/08/2016 at 4:47 PM asking about Resident #1's visitor. The ADON A stated she was not aware of any visitation restrictions regarding Resident #1 so she called the DON at 5:20 PM asking about Resident #1. ADON said she was told by the DON that she (the DON) would call LVN K herself instructing him on what to do. ADON stated she was unaware of the incident because that side of the building she was not responsible for and as of Friday 10/07/2016 the administrator was still investigating the incident and she had left early that day. ADON revealed on 10/10/2016 Resident #1 Family Member came into her office and she notified the administrator that he was in the building and she was told to bring him to the administrator's office. The Administrator stated that she was only aware of one additional resident with visitor restrictions; post IJ the administrator was able to identify all four residents with visitor restrictions. On 10/15/16 at 3:33 PM, The Administrator was notified the IJ was removed. While the IJ was removed on 10/15/16, the facility remained out of compliance at a severity level of no actual harm that is not an Immediate Jeopardy and a scope of isolated, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan. 2. Review of Resident #8 Face Sheet received on 10/13/2016 revealed Resident #8 was a [AGE] year-old, female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8 MDS assessment dated [DATE] revealed Resident #8 had unclear speech, rarely/never made herself understood by others, could sometimes understand others, and had moderately impaired cognition. Resident #8 did not have behaviors. Resident #8 was totally dependent on staff for ADL care and was incontinent of bowel and bladder. Review of Resident #8's clinical chart reveled that Resident #8 had a court order limiting her husband Visitor #2 from visiting the facility. An interview on 10/14/2016 at 3:14 PM with CNA I revealed she was not aware of any visitors who were restricted from visiting the facility or who required supervision whenever they visited the facility. CNA I cares for Resident #8 On 10/14/2016 at 3:20 PM an interview with RN G revealed he was unaware of any residents who had visitor restrictions. RN G provided care for Resident #8. On 10/14/2016 at 3:34PM interview with LVN H revealed that she was only aware of one resident (Resident #8) who had restricted visitor she stated that Resident #8 required supervised visitations and that Resident #8 visitor was in the facility on 10/07/2016 and she had to inform Resident #8 responsible party that visitor was in the facility and that he was taking pictures (which was not allowed via court order) and she was unsure what she should have done. LVN H stated that responsible party informed her that whenever he comes into the facility and does not comply she should call the police. LVN H stated that Resident #8 underwent a room change and was placed in a room closer to the nurse's station. LVN H stated that Resident #8's visitor had come in the building after 10/07/2016 because her former roommate notified her that visitor was looking for Resident #8 and asking what room she was moved too. LVN H stated that she has not been told of visitors who had restrictions and she only is aware of Resident #8 because it's listed as a legal document in resident ' s chart. 3. Review of Resident #6 Face Sheet revealed Review of Resident #6's Admission Record dated 10/17/16 reflected that she is a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview on 10/16/2016 at 12:50 with Resident #6 revealed that she informed the facility on 10/13/2016 of a Visitor #2 who was a former friend of hers; she stated that she told the facility that she was uncomfortable because he would make sexual gestures (verbally). Resident #6 revealed Visitor #2 was a registered sex offender and she checked after he left the facility, she stated she conducted a background check after he asked her if she would judge him of his past. Resident #6 stated that she gave him her Foodstamp Card to get him to leave her room so she could inform the nurse that she did not want him in her room. She revealed that after he left the room she told the nurse that she did not want him in her room and that he had her card, she sent him to the store to get her a drink so she could inform them of the situation. Review of Resident #6 clinical charts did not reveal any evidence of occurrence of incident involving Resident #6 and Visitor #2. Review of Grievance Complaint Investigation Report dated 10/14/2016 reveled a man she (Resident #6) knew previously, Visitor #2 was coming to her room to visit but she does not feel comfortable around him, she does not want him in her room Review of facility response dated 10/15/2016 revealed Visitor #2 had a previous criminal history and he has been told by the administrator that he is no longer allowed in the building and if he came to the facility local law enforcement would be called. On 10/18/2016 interview with the Administrator revealed that she called Visitor #2 and informed him that he is not allowed in the facility. Administrator stated that he expressed understanding. An interview on 10/15/2016 at 1:20PM with RNC, Regional Nurse Consultant revealed that she was assigned to follow-up on the grievance that was made on 10/13/2016; RNC stated that the facility has 5 days to investigate a grievance and that because Resident #1 did not state Visitor #2 did anything to her but made her uncomfortable and that her story was inconsistent the facility was investigating her concern before any plans were put in place. RNC stated that she conducted a background check to see if Visitor #2 was a registered sex offender; the results revealed that he was convicted and listed as a registered sex offender. An interview on 10/14/2016 at 2:39 PM with CNA F revealed that she provides ADL care to residents on 100 hall and that she's aware of one resident who has visitor restrictions because she was told by the resident herself (Resident #6). CNA F stated that a visitor can gain entrance on her hall and that the code is the same for all three entrance points going in and going out of the facility. CNA F stated that she had to inform Resident #6's visitor to leave the facility on 10/13/2016 around the evening time (exact time unknown). CNA F stated that she has not been made aware from facility staff of any visitors who are restricted from visiting or should be supervised while visiting. CNA F stated that she feels she should be aware for her own safety and the safety of the residents she stated that she was told from Resident #6 that the visitor who has tried to visit her is a registered sex offender. An interview on 10/15/2016 at 11:50AM with CNA A revealed that she provides ADL care to residents on hall 100 and that she was informed on 10/15/2016 of one resident (Resident #1) who has visitor restrictions. CNA A stated that Resident #6 is her resident but she don't know much about her CNA A stated that Resident #6 provides her own ADL's and that resident never pushes her call light or requires much care. CNA A stated that she noticed that Resident #6 has lots of visitors; she revealed that Resident #6 does not have any restrictions with her visitors that she is aware of. Review of the facility's undated policy Restriction of Visitation Privileges revealed, 3. The facility reserves the right to require supervised visitation and/or to restrict visitation to a particular time and area of the building when: a. A visitor's behavior requires intervention by security personnel or by the police department; c. The resident's family member or visitor has been accused of abuse. Review of the facility's policy Protection of Residents during Abuse Investigations revised 06/10/2016, revealed, Our facility will protect residents from harm during investigations of abuse allegations. 1. During abuse investigations, residents will be protected from harm by the following measures: b. If the alleged abuse involves a resident's family member or visitor, such person(s) will not be permitted to have unsupervised visits with the resident . Review of the facility's policy Analyzing Occurrences of Abuse, Neglect, Mistreatment and Theft/Misappropriation of Resident Property, revised 06/10/2016, revealed, 2. Reviews of each occurrence will be made to determine if policies, procedures, training programs or facility systems need to be modified to prevent further incidents of abuse or theft. Review of the facility's policy Recognizing Signs and Symptoms of Abuse/Neglect, revised 06/10/2016 revealed, Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or other designee immediately. b. Signs of or actual physical neglect .Failure to provide privacy; Left alone, but needs supervision . c. Signs/Symptoms of psychological abuse/neglect .Resident clings to abuser/caregiver; Withdrawal . Anger An Immediate Jeopardy was identified on 10/14/2016 The Administrator was notified of the Immediate Jeopardy on 10/14/2016 at 3:52 PM. The Administrator expressed understanding of Immediate Jeopardy and a Plan of Removal was requested. Plan of Removal was accepted on 10/15/2016 at 3:28PM. PLAN OF REMOVAL: When was perpetrator notified? The perpetrator AP; was notified on 10-6-16 by Police. On 10-10-16 by Admin and DON met with perpetrator and notified him again. Resident #8's State Appointed Guardian was notified of Visitor #1's violation of Court Appointed visitation schedule. Resident #9's visitor, Visitor #2 was notified 10-15-16 by Admin and was notified that his visitation to the facility has been restricted. 2. Resident was given SANE test 10-05-16, results are pending. Actions Taken: 1. Adm./DON/Weekend Supervisor and Regional Nurse started in-services for all staff on all shifts, including PRN staff. In-servicing will continue until all staff has received the in-service training regarding Protection of Residents during an Investigation. Nursing will review Prevention of Abuse and Neglect Policy and Procedure including restricted visitor's notification policy and notification of staff. The nurse LVN K has been suspended pending the outcome of the investigation. 2. A description and/or photograph of any visitors not allowed in the facility is now located at each Nurses' Station. AP - brother of Resident #1 Visitor #2 - Friend of Resident #9 Visitor #1 - Husband of Resident #8 3. Visitors identified as a threat to residents or staff will be notified that their visiting privileges are restricted and the specific nature of the restriction. Restricted visitor's names and specific restrictions will be entered on the Point Click Computer Bulletin Board so that Licensed Nurses have access to the information. Nursing, Housekeeping, Activities, Social Services, Maintenance, Therapy, Laundry, Dietary, Administration Staff and Vendors that frequent the facility are being in-serviced to check with their nurse at the beginning of their shift/visit to be informed about restricted visitors. The physical description, or photos, of restricted visitors will be posted at each nurse's station. Who is monitoring the restriction, ensuring perpetrator was not entering the facility? Staff has been in-serviced on P&P and descriptions of Perpetrators. Monitoring staff have been assigned 24/7 to rotate between residents and insure immediate notification of nurse and Administrator if perpetrators are seen. Staff members both nursing assistants and non-nursing department members have been assigned to the three identified residents and is doing monitoring rounds between the three residents continuously each shift. Administrator is not available the DON is designated as the alternate Abuse Prohibition. Interview with various facility staff that work various shifts on 10/18/16 LVN R, LVN S, CNA T, LVN U, CNA V, housekeeper, CNA W, porter, housekeeping supervisor, LVN M, LVN N, LVN O, CNA C, Dietary Aide P, Dietary Aide Q revealed all showed competency regarding in-service over identifying and reporting abuse and neglect and restricted visitors. On 10/15/16 at 3:33 PM, The Administrator was notified the IJ was removed. While the IJ was removed on 10/15/16, the facility remained out of compliance at a severity level of no actual harm that is not an Immediate Jeopardy and a scope of isolated, because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan. CMS 672 dated 10/18/2016 revealed there were 157 residents. Facility bulletin board revealed 4 residents with visitor restrictions.

Based on observation, interview and record review, the facility failed to implement the facility's policies and procedures, which prohibit neglect, for four (Residents #4, #8, #34, and #35) of ten residents reviewed for neglect. 1) The facility failed to implement interventions shen Resident #8 sustained a fall resulting in fractures of the right clavicle (shoulder) and right wrist and a subdural hematoma on [DATE], and required supervision with transfers and ambulation and physical therapy identified her as a fall risk. This failure contributed to Resident #8 falling on [DATE], sustaining a significant facial fracture and subarachnoid hemorrhage, and returning to the facility on [DATE] to be admitted to hospice for continuous care. Resident #8 expired on [DATE]. 2) The facility failed to implement interventions when Resident #34 was identified as requiring extensive assistance with toileting, ambulating during the evening/night, and fell while transferring herself independently to the toilet and sustained multiple pelvic fractures on [DATE]. 3) The facility failed to ensure the Hoyer lift was used to transfer Resident #35 on [DATE] when the resident fell sustaining two fractures of the left leg. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still inservicing staff and monitoring the effectiveness of the Plan of Removal. The facility's failure to provide residents with supervision or implement interventions to assist with the prevention of falls could affect the facility's 149 residents, who required some type of assistance with ambulation, including Residents #34 and #35, and placed them at risk for falls and possible injuries, including fractures and hematoma's resulting in the need for hospital treatment and/or loss of life. Findings included: After Administrative Review, it was determined the visit needed to be reopened for further investigation on [DATE]. 1) Resident #8's Face Sheet printed [DATE] reflected an original admission date of [DATE] with a readmission date of [DATE]. Her discharge date was [DATE], when she expired in the facility. Resident #8's MDS assessment dated [DATE] for Resident #8, a [AGE] year-old female, reflected the resident scored a ,[DATE] on the BIMS, which indicated she was cognitively intact. The MDS assessment reflected she required supervision-oversight/encouragement or cueing for transfers and ambulation, but when support was provided, she required one person's physical assistance to ambulate in room and corridors, for dressing and toileting. The MDS further reflected she was continent of bladder and bowel. Active [DIAGNOSES REDACTED]. Resident #8's care plan dated [DATE] reflected the resident had short and long-term memory problems, had an altered ability to understand others and altered ability to make herself understood, was easily distracted and had disorganized thinking. The goals and approaches/needs for these problems were not changed when the care plan was updated on [DATE] and [DATE]. Resident #8 had a care plan dated [DATE], which identified the problem of sustaining a fall in the last ,[DATE]-180 days and was on a hypnotic medication. The goals were for the resident to have no injuries due to falls in the next 90 days and to consistently use the call light for assistance in the next 90 days. There were no approaches/needs identified to use. This care plan was updated on [DATE] and on [DATE] without any changes being made to the problem, goals or approaches/needs. Resident #8's care plan dated [DATE] addressed the resident's ADLs. The problems included: Needs assist: --Bed mobility - S was circled --Transfer - S was circled --Walk in room - S was circled --Walk in corridor - S was circled --Locomotion on unit - S was circled --Locomotion off unit - S was circled --Toilet use - S and L were circled --Dressing/Personal Hygiene - S and L were circled --Bathing - S and L were circled A key indicated S was for supervision to be provided by staff and L was for Limited physical assistance. The goal on this care plan was for the resident to maintain her current level of function for the next 90 days. Approaches/needs included: The Staff will: --Assist with showers, peri care, dressing and grooming, shaving, cleaning of hands, face, oral care every morning, after meals and prn. --Refer to therapy or restorative nursing as indicated. --Provide active/passive ROM exercises. --Visually check the resident every 2 hours and pr, assuring the call light is in reach. --Remind the resident to use the call light to call for assist. --Answer the call light in timely manner. --Take time to encourage the resident to participate in their own care. --One/two staff to assist with transfers. Written in was "Supervised." --Meals in room. Set-up was indicated. The care plan was updated on [DATE] to continue the plan of care. The care plan was updated on [DATE] with the notation Resident #8 needed more assist at this time due to her fractured clavicle. The resident's fractured right wrist and subdural hematoma were not mentioned. There was no change in any of the approaches/needs to identify the increased assistance to be provided to Resident #8. A Resident Incident Report dated [DATE] reflected Resident #8 had sustained a [MEDICAL CONDITION] clavicle and right wrist as a result of a fall during the night shift on [DATE] at 10:20 p.m. According to the report, the resident was ambulating to the bathroom when she fell , hit her forehead, right shoulder and wrist. Resident #8 also sustained a wound to the right eyebrow, a bruise and a scratch to the right knee. Resident #8's Resident Incident Follow-up Report dated [DATE] reflected the additional fall prevention measure added after the resident's fall was for "frequent monitoring." There was nothing to indicate how "frequent monitoring" was defined: when, where or how often the frequent monitoring would occur. ADON J was queried on [DATE] at 10:45 a.m. about what "frequent monitoring" consisted of as documented on the incident follow-up dated [DATE]. The ADON stated, "That's just every two hours." According to ADON J all residents were provided with every two hour monitoring. The surveyor queried ADON J about every two hours being considered frequent and/or specific for Resident #8. ADON J stated, "I couldn't tell you, I don't have a specific time for frequent monitoring." Resident #8's Daily Skilled Nurse's Note dated [DATE] with an untimed entry reflected the resident had returned from the hospital with a splint on her right wrist and wearing a sling for the right clavicle fracture. A report from the hospital nurse to the facility nurse reflected Resident #8 had also sustained a subdural hematoma, and the resident declined surgery or any life-saving procedures. Resident #8's care plan dated [DATE] reflected the problem as having fallen within the last ,[DATE]-180 days. Further clarification indicated on [DATE], Resident #8 fell while walking to the bathroom and fractured her right clavicle and right wrist. There was nothing about the subdural hematoma. Goals included she would have no injuries due to falls in the next 90 days and Resident #8 would consistently use the call light for assistance in the next 90 days. Approaches/needs included: The staff will: --Keep bed in lowest position. --Keep call light, bed controls within easy reach. --Evaluate medications for possible adjustment or reductions in dose. --Keep room clean and uncluttered. --Encourage to wear non-skid footwear at all times (grippy socks, proper shoes). --Observe for and correct safety hazards. --Refer to therapy as needed. There was nothing individualized for Resident #8 to indicate she might need increased assistance to prevent falls in the next 90 days. "Frequent monitoring," which was the fall prevention measure on the Resident Incident Report dated [DATE], was not included. Resident #8's care plans did not address the resident's potential for falls when she ambulated. Resident #8's Daily Skilled Nurse's Note dated [DATE] reflected the resident was ambulating independently to the bathroom. The most recent fall risk assessment for Resident #8 was dated [DATE] and reflected she was a low risk for falls. The resident was assessed as being a low risk for falls even though she had sustained fractures of the right clavicle and right wrist and had a subdural hematoma from a fall on [DATE]. Resident #8's Daily Skilled Nurse's Note dated [DATE] at 9:00 a.m. reflected the resident continued to ambulate without assistance and was independent with her ADLs. At 6:00 p.m., documentation reflected Resident #8 was able to participate in her ADLs with supervision. Resident #8's Care Plan Conference Summary dated [DATE] reflected the resident was independent with her ADLs and was on fall precautions dated [DATE] for a right collar bone fracture. The summarization included the resident was "out to hospital [DATE] (wrong date entered) broken (right) clavicle D/T Fall." The right wrist fracture and subdural hematoma were not included. Resident #8's Telephone Orders from the physician dated [DATE] reflected an order for [REDACTED]. Review of Resident #8's Physical Therapy Evaluation dated [DATE] revealed the resident would benefit from physical therapy by improving her transfers, gait and balance and possibly begin right arm movement when approved by the physician. Resident #8's Physical Therapy Assistant Weekly Progress Report dated [DATE] reflected the following Clinical Summary: Resident at risk for falling without arm support during gait training. Resident #8's Physical Therapy Assistant Weekly Progress Report dated [DATE] reflected the following Clinical Summary: Resident reports continued pain to right arm and fear of falling. Resident #8's Physical Therapy progress Report dated [DATE] reflected the following precaution: "fall risk," right upper arm in sling, right wrist in brace. Outcome of training: "fair outcome - slow progress...." Resident #8's Physical Therapy progress Report dated [DATE] reflected the following: Resident still has limitations of right arm mobility due to clavicle fracture and wrist sprain (sic). Precautions included: fall risk, right arm sling, right wrist splint. Resident #8's Physical Therapy progress Report dated [DATE] reflected the following: Resident having restriction of right shoulder mobility and right wrist fracture. Precautions included: fall risk, right arm sling, right wrist cast. Resident #8 was observed during initial rounds with the DON on [DATE] at 9:40 a.m. resting in bed. During this time, the DON told the surveyor the resident was ambulatory without assistance and had recently experienced a fall, which resulted in a fracture. The resident was observed with a right arm cast and a sling. Resident #8 was observed on [DATE] at 10:06 a.m. resting in bed and again at 12:30 p.m. eating lunch in her room. On [DATE] at 9:20 a.m., Resident #8's bed was observed to be empty. An interview with Resident #8's roommate at that time revealed Resident #8 was in the hospital. The roommate stated Resident #8 did not see well and had an unsteady gait but she "got up all the time" to walk without assistance. According to the roommate, Resident #8 fell during the night ([DATE]) and was sent to the hospital. On [DATE] at 9:20 a.m., LVN B confirmed Resident #8 was in the hospital as a result of a fall during the night shift on [DATE]. LVN B had no information related to the resident's condition. During this time LVN B was queried about the amount and type of assistance Resident #8 required after her fall on [DATE]. The nurse stated the resident had been able to ambulate and transfer without assistance. The nurse further stated the resident required no supervision and was able to and did ambulate in the hallway. A Resident Incident Report dated [DATE] reflected Resident #8 was found lying on the floor in another resident's room during the night shift on [DATE] at 11:20 p.m. The report further reflected blood was on the resident's face and on the floor. Resident #8 was assessed with [REDACTED]. The resident was transferred to the hospital. An interview with LVN R on [DATE] at 11:30 p.m. revealed she was the charge nurse on duty when Resident #8 fell during the night shift on [DATE]. LVN R stated she heard loud yelling and found the resident on the floor of another resident's room. The nurse further stated the resident was bleeding from the face, unable to explain what happened and a large amount of blood was on the floor. During this interview, LVN R stated Resident #8 often ambulated in the hallways without assistance and held on to the handrails to steady herself even after the fall/fracture on [DATE]. During an interview with ADON J on [DATE] at 10:00 a.m., the ADON stated Resident #8 was heard yelling out for help last p.m. ([DATE]) and was found on the floor in another resident's room. When ADON J was queried about the type and amount of assistance the resident required, ADON J stated the resident was independent with ambulation. Resident #8's Nurse's Notes dated [DATE] at 10:00 p.m. reflected the resident was in bed. Documentation at 11:20 p.m. reflected a noise was heard and "help, help down the hall...." Resident #8 was found on the floor in another resident's room with a "full amount of blood on her nose and face and on floor...." At 11:45 p.m., Resident #8 was sent by ambulance to the hospital for evaluation and was admitted . There were no other notes for Resident #8 during [DATE]. An interview with LVN B on [DATE] at 2:30 p.m. revealed nurses charted by exception, and there were no other notes for Resident #8 for [DATE]. An interview with CNA P on [DATE] at 9:30 a.m. revealed she had provided care for Resident #8. When asked how she knew what care and assistance to provide to the resident, CNA P stated, "We just tell each other." Additionally, CNA P stated Resident #8 was able to ambulate and transfer without assistance. The CNA stated the facility no longer used assignment sheets to ensure staff was aware of care needs for residents. An interview with CNA Q on [DATE] at 10:30 a.m. revealed she had provided care for Resident #8. The CNA stated the resident did not see well and required assistance with meal tray setup but did not require any assistance with ambulation. Additionally, CNA Q stated she had never been informed of a need to monitor, assist and/or supervise Resident #8. According to ADON J on [DATE] at 10:45 a.m., Resident #8 was independent with ambulation. ADON J stated she was not aware of any care plan related to providing Resident #8 with supervision. The ADON further stated if she was not aware of a care plan providing Resident #8 with supervision, she did not expect or think direct care staff (CNAs) would be aware the resident required assistance and supervision with ambulation and transfers. An interview with the Rehab Director (RD) on [DATE] at 1:00 p.m. revealed physical therapy services were being provided to Resident #8. Services included gait training with a cane and contact assist. According to the RD, the resident had an unsteady gait and was fearful of falling. When queried whether the resident was able to ambulate independently in her room and in the hall, the RD said Resident #8 had "maybe" been safe to ambulate in her room but not outside the room. The undated hospital records for Resident #8, which the facility obtained on [DATE], reflected Resident #8 "sustained a significant facial fracture, as well as subarachnoid hemorrhage." The radiology report, dated [DATE], reflected Resident #8 had a subdural hematoma in the right temporal region and extensive facial bone fractures. On [DATE] at 8:20 a.m., the DON stated Resident #8 expired in the facility on [DATE] after coming back from the hospital. She was placed on hospice continuous care. The fall she experienced the night of [DATE] resulted in a subdural hematoma and facial fractures. On [DATE] at approximately 5:30 p.m., the DON was queried about Resident #8 being placed on hospice continuous care (around the clock, one-on-one care). The DON stated the reason Resident #8 was placed on continuous care hospice was because it was obvious she was declining. 2) On [DATE] at 9:08 a.m., Resident #34 was observed awake in bed wearing a gown and a brief. A gold star was observed on her name plate just outside her door. According to the MDS assessment, dated [DATE], Resident #34 was an [AGE] year old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment reflected Resident #34 had short and long term memory problems, was moderately impaired for decision-making, had [MEDICAL CONDITION] with [MEDICAL CONDITION], was occasionally incontinent with bladder and required the extensive assistance of one person with toilet use. The care plan, dated [DATE], reflected Resident #34 required supervised assistance and extensive assistance with "toilet use." A Resident Incident Report, dated [DATE], reflected "Res (Resident #34) in RR (restroom), transferred from toilet to w/c, slid on floor, able to move all extremities, assist x 3 to bed. C/O pain to R (right) hip when touched. Sent out to ER via (ambulance)." The report included a witness statement, dated [DATE], and reflected CNA Q was transferring Resident #34's roommate with another CNA when they heard yelling in the bathroom. The last time they observed Resident #34 was in her room while they were transferring the roommate. CNA Q's statement reflected she did not observe Resident #34 fall. When she heard the resident yelling, she went into the bathroom and found Resident #34 on the floor. An Imaging Report, dated [DATE], reflected Resident #34 had multiple fractures of her pelvis. The hospital's discharge instructions, dated [DATE], reflected Resident #34 had a pelvic fracture. On [DATE] at 11:40 a.m., ADON J stated the CNAs were verbally told how to care for the residents they were assigned to, including Resident #34. She stated nothing was provided to the CNAs in writing. She stated Resident #34 was independent before her fall on [DATE] when she fractured her hip. The surveyor inquired about the [DATE] MDS assessment and [DATE] care plan, which reflected Resident #34 required extensive assistance with toileting. ADON J directed the surveyor to the MDS coordinator. On [DATE] at about 1:00 p.m., MDS Coordinator U confirmed the MDS assessment for Resident #34 reflected she required extensive assistance with "toilet use" even before her fall, which resulted in her [MEDICAL CONDITION]. She stated the expectation of staff, who saw Resident #34 making her way to the bathroom without help, would have been for staff to provide physical assistance. On [DATE] at 11:42 a.m., CNA S stated she cared for Resident #34 before and after her fall, which resulted in a [MEDICAL CONDITION]. She stated before Resident #34's fall, she was independent but now she needed more help. The CNA thought they had a book with instructions for each resident she could access, if for some reason, she forgot the resident's care or if the resident's care had changed and she had been off for a couple of days. However, CNA S could not find a resident instruction book at the nurses station. The CNA then told the surveyor she could just look at the resident and could tell what care they needed. She stated she was also instructed verbally by the staff, who were coming off the previous shift. On [DATE] at 12:37 p.m., CNA T stated she was given verbal instructions regarding care issues for Resident #34 and other residents she was assigned to on her shift. She stated she had 12 residents today ([DATE]), and she remembered what she was told by the charge nurse and CNAs from the previous shift. She said she was not provided any documentation about resident care unless she wrote it down. The ADL sheets were for documenting when and what care they provided. On [DATE] at 3:08 p.m., interview via telephone with CNA Q revealed she was in Resident #34's room assisting the roommate when Resident #34 fell and fractured her pelvis. CNA Q stated Resident #34 was independent and toileted herself, so she did not question Resident #34 when she saw her wheel herself into the bathroom. The minute she heard Resident #34 yelling, she went to her and found Resident #34 on the bathroom floor. She stated Resident #34 now required more care. CNA Q confirmed care instructions were not written anywhere, and they are told by the previous shift what care the residents need. Review of Resident #34's care plans revealed it did not address the resident's tendency to ambulate in the evening and/or night. No interventions were implemented, which would have potentially prevented the resident from getting up during the night or her requirements for extensive assistance from staff. Resident #34's Assessment of Risk for Falls, dated [DATE], reflected a score of "5," which put her at a low risk for falls. A note at the bottom of the assessment reflected, "A low score does not necessarily constitute a low risk. It is simply a guideline. The assessor must still look at the resident and apply clinical judgement...." 3) On [DATE] at 9:15 a.m., Resident #35 was observed awake in bed wearing street clothes and talking on a cell telephone. A [MEDICAL CONDITION] and an indwelling urethral catheter were observed in use. Additionally, a green and gold star was observed on his name plate just outside his door. According to the MDS assessment, dated [DATE], Resident #35 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment reflected Resident #35 was interviewable, had [MEDICAL CONDITION], used an indwelling catheter and ostomy, and required extensive physical assistance of two people with transfers. Resident #35's care plan, dated [DATE], reflected a hand written entry, which reflected, "use hoyer lift all transfers." The care plan also reflected Resident #35 required assistance with transfers and to "evaluate need for assistive devices...." Review of the Resident Incident Report, dated [DATE], reflected the "nurse aide (CNA X) was attempting to transfer resident to bed when she noticed resident was too weak and eased him down to the floor." The facility had obtained a written statement from CNA X on [DATE], which reflected, "I turn his (Resident #35) chair around close to bed, I put gait belt on him, he scooted to end of chair. I counted 123 I helped him up, and he said I'm hurting, and started going down, so I told him I was gonna ease him down to the floor, when I did he said my leg my leg, I moved his leg, lowered him to floor put pillow up under his head, told him I was going to get the nurse... I got him up the way I was showed since I've been working here...." Resident #35's x-ray report dated [DATE] reflected there was a left distal femur fracture (upper leg) and a [MEDICAL CONDITION] fibular shaft (lower leg). On [DATE] at 1:25 p.m., Resident #35 was interviewed. He stated CNA X did not use the Hoyer lift to transfer him the other day, and his leg was fractured in three places. He stated when the CNA sat him down when he was slipping, she sat him on his leg. On [DATE] at 5:30 p.m., CNA W was asked by the surveyor how she transferred Resident #35. She stated she used a Hoyer lift. The surveyor asked her how she knew to use the Hoyer lift. The CNA stated, "I just know to use a Hoyer with (Resident #35) because I was told, but nothing is in writing." CNA W went on to say the different colored stars were recently placed on the residents' name plates just outside their rooms. The green star meant the resident was a Hoyer lift, the gold star meant the resident was a fall risk and a red star meant the resident had experienced a fall. 4) The facility's current p/p related to falls was provided post survey on [DATE] by the Director of Staff Development, RN M. The p/p was dated revised [DATE] and reflected the following: Facility staff would evaluate and document falls, which occurred while the resident resided in the facility. If underlying causes could not be readily identified or corrected, staff would try various relevant interventions based on an assessment of the nature or category of falling, until the resident had fewer falls or stopped falling or until a reason was identified for the continued use of the intervention implemented. The facility's Abuse and Neglect Prevention Policy, provided by the DON and identified as current on [DATE] reflected: "Definitions ...Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care." Policies and Procedures: This policy ...this important aspect of abuse/neglect prevention. It defines abuse and neglect; the organizational response to perceived, actual, or possible abuse/neglect;... Clinical Protocols: These should be utilized when the provider offers clinical care in support of efforts to meet accepatable industy standards. Clinical Outcomes: Clinical outcomes are tracked and assessed to detrmine deviation for industry standards or norms. Associated care paractices are assessed to determine unfavorable outcomes..... Identify: Abuse and neglect are often linked with as combination of psychological, emotional, social, and economic fators....In order to establish a proactive approach to detection and prevention, facility seeks to identify the factors that potentially put resdients at risk for abuse and neglect. Characteristics of Residents: ....They may also be physically a or verbally agresive. Monitoring these risk factors and practices to identify siuations or incidents tha may be precursors to abuse and neglect are ongoing. Mangement staff observed employee stress, track incidents of abuse and neglect, and monitor staff performances. 5) An IJ was identified on [DATE]. The Administrator and DON were notified on [DATE] at 1:45 PM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, dated [DATE], was accepted on [DATE] and reflected: The "(facility) respectfully submits the following plan of removal in response to the Immediate Jeopardy related to: Quality of Care/Administration and Resident Behavior/Facility Practice This immediate jeopardy is related to the lack of an effective fall prevention program including identification of residents at risk for falls/injury and residents who have a fall history with/without injury, interventions to decrease the risk for falls / injury, process for informing the direct and ancillary staff for routine monitoring in resident rooms and in common areas." Residents #8, #34, and #35 sustained falls resulting in significant injury. Resident #8 expired on [DATE]. Resident #34 is an assist of one staff member for transfers and currently utilizes a bed/chair alarm for safety. Resident #35 is a Hoyer transfer with two staff assist. CNAs and Licensed Nurses have access to a comprehensive care guide individualized to the specific needs of Resident #34 and Resident #35 as well as all other residents residing in the facility The lack of an effective fall prevention program puts residents at risk for falls and fall-related injuries. A facility fall prevention system has been developed and implemented to remove the immediate jeopardy and to decrease the risk and potential for other residents in the facility to sustain injury from falls. The following people have been contacted and provided assistance with developing this Plan of Removal: 1. The facility Medical Director and Physician Y, primary physician for Residents #34 and #35, who were identified during the immediate jeopardy investigation 2. The facility Nurse Consultants AAA and ZZ 3. Administrative Nursing Staff including ADON J, the DON, ADON F, Therapy Director BBB, ADON N, MDS Coordinator U, LVN CCC, LVN DDD, RN M, and LVN EEE 4. Therapy Director BBB Plan of Removal: Assessment: 1. Residents at risk for falls/injury are identified with fall risk evaluations to be completed upon admission, quarterly and with significant change. 2. Residents with a history of falls were identified based on the incident log for falls documenting falls with/without injury within the last 30 days. 3. The DON conducted an audit of current Fall Risk Assessments for all residents residing in the Facility on [DATE] from approximately 12:00 PM to 3:00 PM. This audit was generated from a medical records program. Fall Risk Assessments are completed in conjunction with the MDS upon admission, quarterly, with off-cycle quarterly assessments and significant change assessments by the Unit Managers All residents who were identified as being at risk for falls/injury based on their fall risk assessment are identified by a yellow star placed on the name plate of their room door to inform staff that resident is at risk for falls/injury. A YELLOW STAR indicates the resident meets the criteria per their Fall Risk Assessment to be at risk for falls. The facility is placing a yellow bracelet on the right wrist of each resident identified as being at risk to inform staff of their risk for fall/injury when outside of the resident's room. This program is referred to as Look to the Stars. Residents identified as 'at risk for falls' in the facility equals 104. 4. The DON conducted an audit of Incident Reports of Falls from the medical records program for the time period from [DATE] ~ [DATE] to determine which residents have sustained falls with/without injury. The audit was completed between 12:00 PM and 3:00 PM on [DATE]. Residents with a significant history of falls with/without injury within the last 30 calendar days ([DATE] ~ [DATE]) based on the facility incident log for falls with/without injury are identified by a red star on the name plate of their room door to inform staff that resident has a fall history. The facility is placing a red bracelet on each identified resident with a fall history to inform staff of their history of falls when outside of the residents' room. A RED STAR indicates the resident has sustained a fall within the last 30 calendar days, [DATE] ~ [DATE]. This program is referred to as Look to the Stars. Thirty-three residents were identified to have had falls during the time period of [DATE] ~ [DATE]. A total of 137 residents were placed on the Look to the Stars Program, which identified them as having fallen or being at risk for falling. 5. All residents residing in the Facility are at risk for falls/fall related injury due to a lack of staff knowledge regarding transfer status, bed mobility and level of assistance required to maintain their highest practicable well-being. 6. The DON conducted a training for completion of the Fall Risk Assessments from the medical records program Tech on [DATE] for ADON N, ADON J and ADON F. The Unit Manager completed a data set of general resident information, which generates the Falls Risk Assessment. Staff Training: 1. The Nursing Management of the Facility (Director of Staff Development, Unit Managers, Resident Assessment Coordinator Nurses, Therapy Manager and Treatment Nurse) met with the Ad

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls for three (Residents #8, #34, and #35) of seven residents reviewed for falls. 1) The facility failed to implement interventions shen Resident #8 sustained a fall resulting in fractures of the right clavicle (shoulder) and right wrist and a subdural hematoma on [DATE], and required supervision with transfers and ambulation and physical therapy identified her as a fall risk. This failure contributed to Resident #8 falling on [DATE], sustaining a significant facial fracture and subarachnoid hemorrhage, and returning to the facility on [DATE] to be admitted to hospice for continuous care. Resident #8 expired on [DATE]. 2) The facility failed to implement interventions when Resident #34 was identified as requiring extensive assistance with toileting, ambulating during the evening/night, and fell while transferring herself independently to the toilet and sustained multiple pelvic fractures on [DATE]. 3) The facility failed to ensure the Hoyer lift was used to transfer Resident #35 on [DATE] when the resident fell sustaining two fractures of the left leg. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still inservicing staff and monitoring the effectiveness of the Plan of Removal. The facility's failure to provide residents with supervision or implement interventions to assist with the prevention of falls could affect the facility's 149 residents, who required some type of assistance with ambulation, including Residents #34 and #35, and placed them at risk for falls and possible injuries, including fractures and hematoma's resulting in the need for hospital treatment and/or loss of life. Findings included: After Administrative Review, it was determined the visit needed to be reopened for further investigation on [DATE]. 1) Resident #8's Face Sheet printed [DATE] reflected an original admission date of [DATE] with a readmission date of [DATE]. Her discharge date was [DATE], when she expired in the facility. Resident #8's MDS assessment dated [DATE] for Resident #8, a [AGE] year-old female, reflected the resident scored a ,[DATE] on the BIMS, which indicated she was cognitively intact. The MDS assessment reflected she required supervision-oversight/encouragement or cueing for transfers and ambulation, but when support was provided, she required one person's physical assistance to ambulate in room and corridors, for dressing and toileting. The MDS further reflected she was continent of bladder and bowel. Active [DIAGNOSES REDACTED]. Resident #8's care plan dated [DATE] reflected the resident had short and long-term memory problems, had an altered ability to understand others and altered ability to make herself understood, was easily distracted and had disorganized thinking. The goals and approaches/needs for these problems were not changed when the care plan was updated on [DATE] and [DATE]. Resident #8 had a care plan dated [DATE], which identified the problem of sustaining a fall in the last ,[DATE]-180 days and was on a hypnotic medication. The goals were for the resident to have no injuries due to falls in the next 90 days and to consistently use the call light for assistance in the next 90 days. There were no approaches/needs identified to use. This care plan was updated on [DATE] and on [DATE] without any changes being made to the problem, goals or approaches/needs. Resident #8's care plan dated [DATE] addressed the resident's ADLs. The problems included: Needs assist: --Bed mobility - S was circled --Transfer - S was circled --Walk in room - S was circled --Walk in corridor - S was circled --Locomotion on unit - S was circled --Locomotion off unit - S was circled --Toilet use - S and L were circled --Dressing/Personal Hygiene - S and L were circled --Bathing - S and L were circled A key indicated S was for supervision to be provided by staff and L was for Limited physical assistance. The goal on this care plan was for the resident to maintain her current level of function for the next 90 days. Approaches/needs included: The Staff will: --Assist with showers, peri care, dressing and grooming, shaving, cleaning of hands, face, oral care every morning, after meals and prn. --Refer to therapy or restorative nursing as indicated. --Provide active/passive ROM exercises. --Visually check the resident every 2 hours and pr, assuring the call light is in reach. --Remind the resident to use the call light to call for assist. --Answer the call light in timely manner. --Take time to encourage the resident to participate in their own care. --One/two staff to assist with transfers. Written in was "Supervised." --Meals in room. Set-up was indicated. The care plan was updated on [DATE] to continue the plan of care. The care plan was updated on [DATE] with the notation Resident #8 needed more assist at this time due to her fractured clavicle. The resident's fractured right wrist and subdural hematoma were not mentioned. There was no change in any of the approaches/needs to identify the increased assistance to be provided to Resident #8. A Resident Incident Report dated [DATE] reflected Resident #8 had sustained a fracture of the right clavicle and right wrist as a result of a fall during the night shift on [DATE] at 10:20 p.m. According to the report, the resident was ambulating to the bathroom when she fell , hit her forehead, right shoulder and wrist. Resident #8 also sustained a wound to the right eyebrow, a bruise and a scratch to the right knee. Resident #8's Resident Incident Follow-up Report dated [DATE] reflected the additional fall prevention measure added after the resident's fall was for "frequent monitoring." There was nothing to indicate how "frequent monitoring" was defined: when, where or how often the frequent monitoring would occur. ADON J was queried on [DATE] at 10:45 a.m. about what "frequent monitoring" consisted of as documented on the incident follow-up dated [DATE]. The ADON stated, "That's just every two hours." According to ADON J all residents were provided with every two hour monitoring. The surveyor queried ADON J about every two hours being considered frequent and/or specific for Resident #8. ADON J stated, "I couldn't tell you, I don't have a specific time for frequent monitoring." Resident #8's Daily Skilled Nurse's Note dated [DATE] with an untimed entry reflected the resident had returned from the hospital with a splint on her right wrist and wearing a sling for the right clavicle fracture. A report from the hospital nurse to the facility nurse reflected Resident #8 had also sustained a subdural hematoma, and the resident declined surgery or any life-saving procedures. Resident #8's care plan dated [DATE] reflected the problem as having fallen within the last ,[DATE]-180 days. Further clarification indicated on [DATE], Resident #8 fell while walking to the bathroom and fractured her right clavicle and right wrist. There was nothing about the subdural hematoma. Goals included she would have no injuries due to falls in the next 90 days and Resident #8 would consistently use the call light for assistance in the next 90 days. Approaches/needs included: The staff will: --Keep bed in lowest position. --Keep call light, bed controls within easy reach. --Evaluate medications for possible adjustment or reductions in dose. --Keep room clean and uncluttered. --Encourage to wear non-skid footwear at all times (grippy socks, proper shoes). --Observe for and correct safety hazards. --Refer to therapy as needed. There was nothing individualized for Resident #8 to indicate she might need increased assistance to prevent falls in the next 90 days. "Frequent monitoring," which was the fall prevention measure on the Resident Incident Report dated [DATE], was not included. Resident #8's care plans did not address the resident's potential for falls when she ambulated. Resident #8's Daily Skilled Nurse's Note dated [DATE] reflected the resident was ambulating independently to the bathroom. The most recent fall risk assessment for Resident #8 was dated [DATE] and reflected she was a low risk for falls. The resident was assessed as being a low risk for falls even though she had sustained fractures of the right clavicle and right wrist and had a subdural hematoma from a fall on [DATE]. Resident #8's Daily Skilled Nurse's Note dated [DATE] at 9:00 a.m. reflected the resident continued to ambulate without assistance and was independent with her ADLs. At 6:00 p.m., documentation reflected Resident #8 was able to participate in her ADLs with supervision. Resident #8's Care Plan Conference Summary dated [DATE] reflected the resident was independent with her ADLs and was on fall precautions dated [DATE] for a right collar bone fracture. The summarization included the resident was "out to hospital [DATE] (wrong date entered) broken (right) clavicle D/T Fall." The right wrist fracture and subdural hematoma were not included. Resident #8's Telephone Orders from the physician dated [DATE] reflected an order for [REDACTED]. This order was not written until 15 days after the resident's fall when she fractured her right clavicle and right wrist and sustained a subdural hematoma. Review of Resident #8's Physical Therapy Evaluation dated [DATE] revealed the resident would benefit from physical therapy by improving her transfers, gait and balance and possibly begin right arm movement when approved by the physician. Resident #8's Physical Therapy Assistant Weekly Progress Report dated [DATE] reflected the following Clinical Summary: Resident at risk for falling without arm support during gait training. Resident #8's Physical Therapy Assistant Weekly Progress Report dated [DATE] reflected the following Clinical Summary: Resident reports continued pain to right arm and fear of falling. Resident #8's Physical Therapy progress Report dated [DATE] reflected the following precaution: "fall risk," right upper arm in sling, right wrist in brace. Outcome of training: "fair outcome - slow progress...." Resident #8's Physical Therapy progress Report dated [DATE] reflected the following: Resident still has limitations of right arm mobility due to clavicle fracture and wrist sprain (sic). Precautions included: fall risk, right arm sling, right wrist splint. Resident #8's Physical Therapy progress Report dated [DATE] reflected the following: Resident having restriction of right shoulder mobility and right wrist fracture. Precautions included: fall risk, right arm sling, right wrist cast. Resident #8 was observed during initial rounds with the DON on [DATE] at 9:40 a.m. resting in bed. During this time, the DON told the surveyor the resident was ambulatory without assistance and had recently experienced a fall, which resulted in a fracture. The resident was observed with a right arm cast and a sling. Resident #8 was observed on [DATE] at 10:06 a.m. resting in bed and again at 12:30 p.m. eating lunch in her room. On [DATE] at 9:20 a.m., Resident #8's bed was observed to be empty. An interview with Resident #8's roommate at that time revealed Resident #8 was in the hospital. The roommate stated Resident #8 did not see well and had an unsteady gait but she "got up all the time" to walk without assistance. According to the roommate, Resident #8 fell during the night ([DATE]) and was sent to the hospital. On [DATE] at 9:20 a.m., LVN B confirmed Resident #8 was in the hospital as a result of a fall during the night shift on [DATE]. LVN B had no information related to the resident's condition. During this time LVN B was queried about the amount and type of assistance Resident #8 required after her fall on [DATE]. The nurse stated the resident had been able to ambulate and transfer without assistance. The nurse further stated the resident required no supervision and was able to and did ambulate in the hallway. A Resident Incident Report dated [DATE] reflected Resident #8 was found lying on the floor in another resident's room during the night shift on [DATE] at 11:20 p.m. The report further reflected blood was on the resident's face and on the floor. Resident #8 was assessed with [REDACTED]. The resident was transferred to the hospital. An interview with LVN R on [DATE] at 11:30 p.m. revealed she was the charge nurse on duty when Resident #8 fell during the night shift on [DATE]. LVN R stated she heard loud yelling and found the resident on the floor of another resident's room. The nurse further stated the resident was bleeding from the face, unable to explain what happened and a large amount of blood was on the floor. During this interview, LVN R stated Resident #8 often ambulated in the hallways without assistance and held on to the handrails to steady herself even after the fall/fracture on [DATE]. During an interview with ADON J on [DATE] at 10:00 a.m., the ADON stated Resident #8 was heard yelling out for help last p.m. ([DATE]) and was found on the floor in another resident's room. When ADON J was queried about the type and amount of assistance the resident required, ADON J stated the resident was independent with ambulation. Resident #8's Nurse's Notes dated [DATE] at 10:00 p.m. reflected the resident was in bed. Documentation at 11:20 p.m. reflected a noise was heard and "help, help down the hall...." Resident #8 was found on the floor in another resident's room with a "full amount of blood on her nose and face and on floor...." At 11:45 p.m., Resident #8 was sent by ambulance to the hospital for evaluation and was admitted . There were no other notes for Resident #8 during [DATE]. An interview with LVN B on [DATE] at 2:30 p.m. revealed nurses charted by exception, and there were no other notes for Resident #8 for [DATE]. An interview with CNA P on [DATE] at 9:30 a.m. revealed she had provided care for Resident #8. When asked how she knew what care and assistance to provide to the resident, CNA P stated, "We just tell each other." Additionally, CNA P stated Resident #8 was able to ambulate and transfer without assistance. The CNA stated the facility no longer used assignment sheets to ensure staff was aware of care needs for residents. An interview with CNA Q on [DATE] at 10:30 a.m. revealed she had provided care for Resident #8. The CNA stated the resident did not see well and required assistance with meal tray setup but did not require any assistance with ambulation. Additionally, CNA Q stated she had never been informed of a need to monitor, assist and/or supervise Resident #8. According to ADON J on [DATE] at 10:45 a.m., Resident #8 was independent with ambulation. ADON J stated she was not aware of any care plan related to providing Resident #8 with supervision. The ADON further stated if she was not aware of a care plan providing Resident #8 with supervision, she did not expect or think direct care staff (CNAs) would be aware the resident required assistance and supervision with ambulation and transfers. An interview with the Rehab Director (RD) on [DATE] at 1:00 p.m. revealed physical therapy services were being provided to Resident #8. Services included gait training with a cane and contact assist. According to the RD, the resident had an unsteady gait and was fearful of falling. When queried whether the resident was able to ambulate independently in her room and in the hall, the RD said Resident #8 had "maybe" been safe to ambulate in her room but not outside the room. The undated hospital records for Resident #8, which the facility obtained on [DATE], reflected Resident #8 "sustained a significant facial fracture, as well as subarachnoid hemorrhage." The radiology report, dated [DATE], reflected Resident #8 had a subdural hematoma in the right temporal region and extensive facial bone fractures. On [DATE] at 8:20 a.m., the DON stated Resident #8 expired in the facility on [DATE] after coming back from the hospital. She was placed on hospice continuous care. The fall she experienced the night of [DATE] resulted in a subdural hematoma and facial fractures. On [DATE] at approximately 5:30 p.m., the DON was queried about Resident #8 being placed on hospice continuous care (around the clock, one-on-one care). The DON stated the reason Resident #8 was placed on continuous care hospice was because it was obvious she was declining. 2) On [DATE] at 9:08 a.m., Resident #34 was observed awake in bed wearing a gown and a brief. A gold star was observed on her name plate just outside her door. According to the MDS assessment, dated [DATE], Resident #34 was an [AGE] year old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment reflected Resident #34 had short and long term memory problems, was moderately impaired for decision-making, had psychosis with delusions, was occasionally incontinent with bladder and required the extensive assistance of one person with toilet use. The care plan, dated [DATE], reflected Resident #34 required supervised assistance and extensive assistance with "toilet use." A Resident Incident Report, dated [DATE], reflected "Res (Resident #34) in RR (restroom), transferred from toilet to w/c, slid on floor, able to move all extremities, assist x 3 to bed. C/O pain to R (right) hip when touched. Sent out to ER via (ambulance)." The report included a witness statement, dated [DATE], and reflected CNA Q was transferring Resident #34's roommate with another CNA when they heard yelling in the bathroom. The last time they observed Resident #34 was in her room while they were transferring the roommate. CNA Q's statement reflected she did not observe Resident #34 fall. When she heard the resident yelling, she went into the bathroom and found Resident #34 on the floor. An Imaging Report, dated [DATE], reflected Resident #34 had multiple fractures of her pelvis. The hospital's discharge instructions, dated [DATE], reflected Resident #34 had a pelvic fracture. On [DATE] at 11:40 a.m., ADON J stated the CNAs were verbally told how to care for the residents they were assigned to, including Resident #34. She stated nothing was provided to the CNAs in writing. She stated Resident #34 was independent before her fall on [DATE] when she fractured her hip. The surveyor inquired about the [DATE] MDS assessment and [DATE] care plan, which reflected Resident #34 required extensive assistance with toileting. ADON J directed the surveyor to the MDS coordinator. On [DATE] at about 1:00 p.m., MDS Coordinator U confirmed the MDS assessment for Resident #34 reflected she required extensive assistance with "toilet use" even before her fall, which resulted in her hip fracture. She stated the expectation of staff, who saw Resident #34 making her way to the bathroom without help, would have been for staff to provide physical assistance. On [DATE] at 11:42 a.m., CNA S stated she cared for Resident #34 before and after her fall, which resulted in a hip fracture. She stated before Resident #34's fall, she was independent but now she needed more help. The CNA thought they had a book with instructions for each resident she could access, if for some reason, she forgot the resident's care or if the resident's care had changed and she had been off for a couple of days. However, CNA S could not find a resident instruction book at the nurses station. The CNA then told the surveyor she could just look at the resident and could tell what care they needed. She stated she was also instructed verbally by the staff, who were coming off the previous shift. On [DATE] at 12:37 p.m., CNA T stated she was given verbal instructions regarding care issues for Resident #34 and other residents she was assigned to on her shift. She stated she had 12 residents today ([DATE]), and she remembered what she was told by the charge nurse and CNAs from the previous shift. She said she was not provided any documentation about resident care unless she wrote it down. The ADL sheets were for documenting when and what care they provided. On [DATE] at 3:08 p.m., interview via telephone with CNA Q revealed she was in Resident #34's room assisting the roommate when Resident #34 fell and fractured her pelvis. CNA Q stated Resident #34 was independent and toileted herself, so she did not question Resident #34 when she saw her wheel herself into the bathroom. The minute she heard Resident #34 yelling, she went to her and found Resident #34 on the bathroom floor. She stated Resident #34 now required more care. CNA Q confirmed care instructions were not written anywhere, and they are told by the previous shift what care the residents need. Review of Resident #34's care plans revealed it did not address the resident's tendency to ambulate in the evening and/or night. No interventions were implemented, which would have potentially prevented the resident from getting up during the night or her requirements for extensive assistance from staff. Resident #34's Assessment of Risk for Falls, dated [DATE], reflected a score of "5," which put her at a low risk for falls. A note at the bottom of the assessment reflected, "A low score does not necessarily constitute a low risk. It is simply a guideline. The assessor must still look at the resident and apply clinical judgement...." 3) On [DATE] at 9:15 a.m., Resident #35 was observed awake in bed wearing street clothes and talking on a cell telephone. A tracheostomy and an indwelling urethral catheter were observed in use. Additionally, a green and gold star was observed on his name plate just outside his door. According to the MDS assessment, dated [DATE], Resident #35 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment reflected Resident #35 was interviewable, had psychosis, used an indwelling catheter and ostomy, and required extensive physical assistance of two people with transfers. Resident #35's care plan, dated [DATE], reflected a hand written entry, which reflected, "use hoyer lift all transfers." The care plan also reflected Resident #35 required assistance with transfers and to "evaluate need for assistive devices...." Review of the Resident Incident Report, dated [DATE], reflected the "nurse aide (CNA X) was attempting to transfer resident to bed when she noticed resident was too weak and eased him down to the floor." The facility had obtained a written statement from CNA X on [DATE], which reflected, "I turn his (Resident #35) chair around close to bed, I put gait belt on him, he scooted to end of chair. I counted 123 I helped him up, and he said I'm hurting, and started going down, so I told him I was gonna ease him down to the floor, when I did he said my leg my leg, I moved his leg, lowered him to floor put pillow up under his head, told him I was going to get the nurse... I got him up the way I was showed since I've been working here...." Resident #35's x-ray report dated [DATE] reflected there was a left distal femur fracture (upper leg) and a fracture of the proximal fibular shaft (lower leg). On [DATE] at 1:25 p.m., Resident #35 was interviewed. He stated CNA X did not use the Hoyer lift to transfer him the other day, and his leg was fractured in three places. He stated when the CNA sat him down when he was slipping, she sat him on his leg. On [DATE] at 5:30 p.m., CNA W was asked by the surveyor how she transferred Resident #35. She stated she used a Hoyer lift. The surveyor asked her how she knew to use the Hoyer lift. The CNA stated, "I just know to use a Hoyer with (Resident #35) because I was told, but nothing is in writing." CNA W went on to say the different colored stars were recently placed on the residents' name plates just outside their rooms. The green star meant the resident was a Hoyer lift, the gold star meant the resident was a fall risk and a red star meant the resident had experienced a fall. 4) The facility's current p/p related to falls was provided post survey on [DATE] by the Director of Staff Development, RN M. The p/p was dated revised [DATE] and reflected the following: Facility staff would evaluate and document falls, which occurred while the resident resided in the facility. If underlying causes could not be readily identified or corrected, staff would try various relevant interventions based on an assessment of the nature or category of falling, until the resident had fewer falls or stopped falling or until a reason was identified for the continued use of the intervention implemented. 5) An IJ was identified on [DATE]. The Administrator and DON were notified on [DATE] at 1:45 PM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, dated [DATE], was accepted on [DATE] and reflected: The "(facility) respectfully submits the following plan of removal in response to the Immediate Jeopardy related to: Quality of Care/Administration and Resident Behavior/Facility Practice This immediate jeopardy is related to the lack of an effective fall prevention program including identification of residents at risk for falls/injury and residents who have a fall history with/without injury, interventions to decrease the risk for falls / injury, process for informing the direct and ancillary staff for routine monitoring in resident rooms and in common areas." Residents #8, #34, and #35 sustained falls resulting in significant injury. Resident #8 expired on [DATE]. Resident #34 is an assist of one staff member for transfers and currently utilizes a bed/chair alarm for safety. Resident #35 is a Hoyer transfer with two staff assist. CNAs and Licensed Nurses have access to a comprehensive care guide individualized to the specific needs of Resident #34 and Resident #35 as well as all other residents residing in the facility The lack of an effective fall prevention program puts residents at risk for falls and fall-related injuries. A facility fall prevention system has been developed and implemented to remove the immediate jeopardy and to decrease the risk and potential for other residents in the facility to sustain injury from falls. The following people have been contacted and provided assistance with developing this Plan of Removal: 1. The facility Medical Director and Physician Y, primary physician for Residents #34 and #35, who were identified during the immediate jeopardy investigation 2. The facility Nurse Consultants AAA and ZZ 3. Administrative Nursing Staff including ADON J, the DON, ADON F, Therapy Director BBB, ADON N, MDS Coordinator U, LVN CCC, LVN DDD, RN M, and LVN EEE 4. Therapy Director BBB Plan of Removal: Assessment: 1. Residents at risk for falls/injury are identified with fall risk evaluations to be completed upon admission, quarterly and with significant change. 2. Residents with a history of falls were identified based on the incident log for falls documenting falls with/without injury within the last 30 days. 3. The DON conducted an audit of current Fall Risk Assessments for all residents residing in the Facility on [DATE] from approximately 12:00 PM to 3:00 PM. This audit was generated from a medical records program. Fall Risk Assessments are completed in conjunction with the MDS upon admission, quarterly, with off-cycle quarterly assessments and significant change assessments by the Unit Managers All residents who were identified as being at risk for falls/injury based on their fall risk assessment are identified by a yellow star placed on the name plate of their room door to inform staff that resident is at risk for falls/injury. A YELLOW STAR indicates the resident meets the criteria per their Fall Risk Assessment to be at risk for falls. The facility is placing a yellow bracelet on the right wrist of each resident identified as being at risk to inform staff of their risk for fall/injury when outside of the resident's room. This program is referred to as Look to the Stars. Residents identified as 'at risk for falls' in the facility equals 104. 4. The DON conducted an audit of Incident Reports of Falls from the medical records program for the time period from [DATE] ~ [DATE] to determine which residents have sustained falls with/without injury. The audit was completed between 12:00 PM and 3:00 PM on [DATE]. Residents with a significant history of falls with/without injury within the last 30 calendar days ([DATE] ~ [DATE]) based on the facility incident log for falls with/without injury are identified by a red star on the name plate of their room door to inform staff that resident has a fall history. The facility is placing a red bracelet on each identified resident with a fall history to inform staff of their history of falls when outside of the residents' room. A RED STAR indicates the resident has sustained a fall within the last 30 calendar days, [DATE] ~ [DATE]. This program is referred to as Look to the Stars. Thirty-three residents were identified to have had falls during the time period of [DATE] ~ [DATE]. A total of 137 residents were placed on the Look to the Stars Program, which identified them as having fallen or being at risk for falling. 5. All residents residing in the Facility are at risk for falls/fall related injury due to a lack of staff knowledge regarding transfer status, bed mobility and level of assistance required to maintain their highest practicable well-being. 6. The DON conducted a training for completion of the Fall Risk Assessments from the medical records program Tech on [DATE] for ADON N, ADON J and ADON F. The Unit Manager completed a data set of general resident information, which generates the Falls Risk Assessment. Staff Training: 1. The Nursing Management of the Facility (Director of Staff Development, Unit Managers, Resident Assessment Coordinator Nurses, Therapy Manager and Treatment Nurse) met with the Administrator, the DON and the Nurse Consultant to address the Immediate Jeopardy determination and formulate a Plan of Removal. 2. RN M and assistant identified staff (including all staff: Nursing, Dietary, Housekeeping/Laundry, Activities, Administration and Maintenance) who had received in-service training related to the Look to the Stars fall-prevention program and initiated in-service training each shift for those staff members who had not received in-service training. This training started at 3:00 PM on [DATE] and continued each shift until all staff members had been in-serviced either in person or by phone. Expected completion date is [DATE]. Any staff members who had not received in-service training will not be allowed to work until they have received in-service training. 3. RN M and assistant to conduct in-services on the CNA ADL Guide to direct care staff. This Guide determines the level of supervision and assistance needed for the following areas: bed mobility, transfer, eating, bathing and toileting. This training started at 3:00 PM on [DATE] and continued each shift until all staff members had been in-serviced either in person or by phone. Expected completion date is [DATE]. Any staff members who have not received in-service training will not be allowed to work until they have received in-service training. The CNA ADL Guide will be located in the ADL Flow Sheet Books at each nurses station. CNAs will be offered the opportunity to phot

Based on observation, interview and record review, the facility failed to implement the facility's written policies and procedures, which prohibit neglect, for four (Residents #4, #8, #34, and #35) of ten residents reviewed for neglect. 1) The facility failed to implement interventions shen Resident #8 sustained a fall resulting in fractures of the right clavicle (shoulder) and right wrist and a subdural hematoma on [DATE], and required supervision with transfers and ambulation and physical therapy identified her as a fall risk. This failure contributed to Resident #8 falling on [DATE], sustaining a significant facial fracture and subarachnoid hemorrhage, and returning to the facility on [DATE] to be admitted to hospice for continuous care. Resident #8 expired on [DATE]. 2) The facility failed to implement interventions when Resident #34 was identified as requiring extensive assistance with toileting, ambulating during the evening/night, and fell while transferring herself independently to the toilet and sustained multiple pelvic fractures on [DATE]. 3) The facility failed to ensure the Hoyer lift was used to transfer Resident #35 on [DATE] when the resident fell sustaining two fractures of the left leg. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still inservicing staff and monitoring the effectiveness of the Plan of Removal. The facility's failure to provide residents with supervision or implement interventions to assist with the prevention of falls could affect the facility's 149 residents, who required some type of assistance with ambulation, including Residents #34 and #35, and placed them at risk for falls and possible injuries, including fractures and hematoma's resulting in the need for hospital treatment and/or loss of life. Findings included: After Administrative Review, it was determined the visit needed to be reopened for further investigation on [DATE]. The facility's Abuse and Neglect Prevention Policy, provided by the DON and identified as current on [DATE] reflected: "Definitions ...Neglect is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care." Policies and Procedures: This policy ...this important aspect of abuse/neglect prevention. It defines abuse and neglect; the organizational response to perceived, actual, or possible abuse/neglect;... Clinical Protocols: These should be utilized when the provider offers clinical care in support of efforts to meet accepatable industy standards. Clinical Outcomes: Clinical outcomes are tracked and assessed to detrmine deviation for industry standards or norms. Associated care paractices are assessed to determine unfavorable outcomes..... Identify: Abuse and neglect are often linked with as combination of psychological, emotional, social, and economic fators....In order to establish a proactive approach to detection and prevention, facility seeks to identify the factors that potentially put resdients at risk for abuse and neglect. Characteristics of Residents: ....They may also be physically a or verbally agresive. Monitoring these risk factors and practices to identify siuations or incidents tha may be precursors to abuse and neglect are ongoing. Mangement staff observed employee stress, track incidents of abuse and neglect, and monitor staff performances. 1) Resident #8's Face Sheet printed [DATE] reflected an original admission date of [DATE] with a readmission date of [DATE]. Her discharge date was [DATE], when she expired in the facility. Resident #8's MDS assessment dated [DATE] for Resident #8, a [AGE] year-old female, reflected the resident scored a ,[DATE] on the BIMS, which indicated she was cognitively intact. The MDS assessment reflected she required supervision-oversight/encouragement or cueing for transfers and ambulation, but when support was provided, she required one person's physical assistance to ambulate in room and corridors, for dressing and toileting. The MDS further reflected she was continent of bladder and bowel. Active [DIAGNOSES REDACTED]. Resident #8's care plan dated [DATE] reflected the resident had short and long-term memory problems, had an altered ability to understand others and altered ability to make herself understood, was easily distracted and had disorganized thinking. The goals and approaches/needs for these problems were not changed when the care plan was updated on [DATE] and [DATE]. Resident #8 had a care plan dated [DATE], which identified the problem of sustaining a fall in the last ,[DATE]-180 days and was on a hypnotic medication. The goals were for the resident to have no injuries due to falls in the next 90 days and to consistently use the call light for assistance in the next 90 days. There were no approaches/needs identified to use. This care plan was updated on [DATE] and on [DATE] without any changes being made to the problem, goals or approaches/needs. Resident #8's care plan dated [DATE] addressed the resident's ADLs. The problems included: Needs assist: --Bed mobility - S was circled --Transfer - S was circled --Walk in room - S was circled --Walk in corridor - S was circled --Locomotion on unit - S was circled --Locomotion off unit - S was circled --Toilet use - S and L were circled --Dressing/Personal Hygiene - S and L were circled --Bathing - S and L were circled A key indicated S was for supervision to be provided by staff and L was for Limited physical assistance. The goal on this care plan was for the resident to maintain her current level of function for the next 90 days. Approaches/needs included: The Staff will: --Assist with showers, peri care, dressing and grooming, shaving, cleaning of hands, face, oral care every morning, after meals and prn. --Refer to therapy or restorative nursing as indicated. --Provide active/passive ROM exercises. --Visually check the resident every 2 hours and pr, assuring the call light is in reach. --Remind the resident to use the call light to call for assist. --Answer the call light in timely manner. --Take time to encourage the resident to participate in their own care. --One/two staff to assist with transfers. Written in was "Supervised." --Meals in room. Set-up was indicated. The care plan was updated on [DATE] to continue the plan of care. The care plan was updated on [DATE] with the notation Resident #8 needed more assist at this time due to her fractured clavicle. The resident's fractured right wrist and subdural hematoma were not mentioned. There was no change in any of the approaches/needs to identify the increased assistance to be provided to Resident #8. A Resident Incident Report dated [DATE] reflected Resident #8 had sustained a [MEDICAL CONDITION] clavicle and right wrist as a result of a fall during the night shift on [DATE] at 10:20 p.m. According to the report, the resident was ambulating to the bathroom when she fell , hit her forehead, right shoulder and wrist. Resident #8 also sustained a wound to the right eyebrow, a bruise and a scratch to the right knee. Resident #8's Resident Incident Follow-up Report dated [DATE] reflected the additional fall prevention measure added after the resident's fall was for "frequent monitoring." There was nothing to indicate how "frequent monitoring" was defined: when, where or how often the frequent monitoring would occur. ADON J was queried on [DATE] at 10:45 a.m. about what "frequent monitoring" consisted of as documented on the incident follow-up dated [DATE]. The ADON stated, "That's just every two hours." According to ADON J all residents were provided with every two hour monitoring. The surveyor queried ADON J about every two hours being considered frequent and/or specific for Resident #8. ADON J stated, "I couldn't tell you, I don't have a specific time for frequent monitoring." Resident #8's Daily Skilled Nurse's Note dated [DATE] with an untimed entry reflected the resident had returned from the hospital with a splint on her right wrist and wearing a sling for the right clavicle fracture. A report from the hospital nurse to the facility nurse reflected Resident #8 had also sustained a subdural hematoma, and the resident declined surgery or any life-saving procedures. Resident #8's care plan dated [DATE] reflected the problem as having fallen within the last ,[DATE]-180 days. Further clarification indicated on [DATE], Resident #8 fell while walking to the bathroom and fractured her right clavicle and right wrist. There was nothing about the subdural hematoma. Goals included she would have no injuries due to falls in the next 90 days and Resident #8 would consistently use the call light for assistance in the next 90 days. Approaches/needs included: The staff will: --Keep bed in lowest position. --Keep call light, bed controls within easy reach. --Evaluate medications for possible adjustment or reductions in dose. --Keep room clean and uncluttered. --Encourage to wear non-skid footwear at all times (grippy socks, proper shoes). --Observe for and correct safety hazards. --Refer to therapy as needed. There was nothing individualized for Resident #8 to indicate she might need increased assistance to prevent falls in the next 90 days. "Frequent monitoring," which was the fall prevention measure on the Resident Incident Report dated [DATE], was not included. Resident #8's care plans did not address the resident's potential for falls when she ambulated. Resident #8's Daily Skilled Nurse's Note dated [DATE] reflected the resident was ambulating independently to the bathroom. The most recent fall risk assessment for Resident #8 was dated [DATE] and reflected she was a low risk for falls. The resident was assessed as being a low risk for falls even though she had sustained fractures of the right clavicle and right wrist and had a subdural hematoma from a fall on [DATE]. Resident #8's Daily Skilled Nurse's Note dated [DATE] at 9:00 a.m. reflected the resident continued to ambulate without assistance and was independent with her ADLs. At 6:00 p.m., documentation reflected Resident #8 was able to participate in her ADLs with supervision. Resident #8's Care Plan Conference Summary dated [DATE] reflected the resident was independent with her ADLs and was on fall precautions dated [DATE] for a right collar bone fracture. The summarization included the resident was "out to hospital [DATE] (wrong date entered) broken (right) clavicle D/T Fall." The right wrist fracture and subdural hematoma were not included. Resident #8's Telephone Orders from the physician dated [DATE] reflected an order for [REDACTED]. Review of Resident #8's Physical Therapy Evaluation dated [DATE] revealed the resident would benefit from physical therapy by improving her transfers, gait and balance and possibly begin right arm movement when approved by the physician. Resident #8's Physical Therapy Assistant Weekly Progress Report dated [DATE] reflected the following Clinical Summary: Resident at risk for falling without arm support during gait training. Resident #8's Physical Therapy Assistant Weekly Progress Report dated [DATE] reflected the following Clinical Summary: Resident reports continued pain to right arm and fear of falling. Resident #8's Physical Therapy progress Report dated [DATE] reflected the following precaution: "fall risk," right upper arm in sling, right wrist in brace. Outcome of training: "fair outcome - slow progress...." Resident #8's Physical Therapy progress Report dated [DATE] reflected the following: Resident still has limitations of right arm mobility due to clavicle fracture and wrist sprain (sic). Precautions included: fall risk, right arm sling, right wrist splint. Resident #8's Physical Therapy progress Report dated [DATE] reflected the following: Resident having restriction of right shoulder mobility and right wrist fracture. Precautions included: fall risk, right arm sling, right wrist cast. Resident #8 was observed during initial rounds with the DON on [DATE] at 9:40 a.m. resting in bed. During this time, the DON told the surveyor the resident was ambulatory without assistance and had recently experienced a fall, which resulted in a fracture. The resident was observed with a right arm cast and a sling. Resident #8 was observed on [DATE] at 10:06 a.m. resting in bed and again at 12:30 p.m. eating lunch in her room. On [DATE] at 9:20 a.m., Resident #8's bed was observed to be empty. An interview with Resident #8's roommate at that time revealed Resident #8 was in the hospital. The roommate stated Resident #8 did not see well and had an unsteady gait but she "got up all the time" to walk without assistance. According to the roommate, Resident #8 fell during the night ([DATE]) and was sent to the hospital. On [DATE] at 9:20 a.m., LVN B confirmed Resident #8 was in the hospital as a result of a fall during the night shift on [DATE]. LVN B had no information related to the resident's condition. During this time LVN B was queried about the amount and type of assistance Resident #8 required after her fall on [DATE]. The nurse stated the resident had been able to ambulate and transfer without assistance. The nurse further stated the resident required no supervision and was able to and did ambulate in the hallway. A Resident Incident Report dated [DATE] reflected Resident #8 was found lying on the floor in another resident's room during the night shift on [DATE] at 11:20 p.m. The report further reflected blood was on the resident's face and on the floor. Resident #8 was assessed with [REDACTED]. The resident was transferred to the hospital. An interview with LVN R on [DATE] at 11:30 p.m. revealed she was the charge nurse on duty when Resident #8 fell during the night shift on [DATE]. LVN R stated she heard loud yelling and found the resident on the floor of another resident's room. The nurse further stated the resident was bleeding from the face, unable to explain what happened and a large amount of blood was on the floor. During this interview, LVN R stated Resident #8 often ambulated in the hallways without assistance and held on to the handrails to steady herself even after the fall/fracture on [DATE]. During an interview with ADON J on [DATE] at 10:00 a.m., the ADON stated Resident #8 was heard yelling out for help last p.m. ([DATE]) and was found on the floor in another resident's room. When ADON J was queried about the type and amount of assistance the resident required, ADON J stated the resident was independent with ambulation. Resident #8's Nurse's Notes dated [DATE] at 10:00 p.m. reflected the resident was in bed. Documentation at 11:20 p.m. reflected a noise was heard and "help, help down the hall...." Resident #8 was found on the floor in another resident's room with a "full amount of blood on her nose and face and on floor...." At 11:45 p.m., Resident #8 was sent by ambulance to the hospital for evaluation and was admitted . There were no other notes for Resident #8 during [DATE]. An interview with LVN B on [DATE] at 2:30 p.m. revealed nurses charted by exception, and there were no other notes for Resident #8 for [DATE]. An interview with CNA P on [DATE] at 9:30 a.m. revealed she had provided care for Resident #8. When asked how she knew what care and assistance to provide to the resident, CNA P stated, "We just tell each other." Additionally, CNA P stated Resident #8 was able to ambulate and transfer without assistance. The CNA stated the facility no longer used assignment sheets to ensure staff was aware of care needs for residents. An interview with CNA Q on [DATE] at 10:30 a.m. revealed she had provided care for Resident #8. The CNA stated the resident did not see well and required assistance with meal tray setup but did not require any assistance with ambulation. Additionally, CNA Q stated she had never been informed of a need to monitor, assist and/or supervise Resident #8. According to ADON J on [DATE] at 10:45 a.m., Resident #8 was independent with ambulation. ADON J stated she was not aware of any care plan related to providing Resident #8 with supervision. The ADON further stated if she was not aware of a care plan providing Resident #8 with supervision, she did not expect or think direct care staff (CNAs) would be aware the resident required assistance and supervision with ambulation and transfers. An interview with the Rehab Director (RD) on [DATE] at 1:00 p.m. revealed physical therapy services were being provided to Resident #8. Services included gait training with a cane and contact assist. According to the RD, the resident had an unsteady gait and was fearful of falling. When queried whether the resident was able to ambulate independently in her room and in the hall, the RD said Resident #8 had "maybe" been safe to ambulate in her room but not outside the room. The undated hospital records for Resident #8, which the facility obtained on [DATE], reflected Resident #8 "sustained a significant facial fracture, as well as subarachnoid hemorrhage." The radiology report, dated [DATE], reflected Resident #8 had a subdural hematoma in the right temporal region and extensive facial bone fractures. On [DATE] at 8:20 a.m., the DON stated Resident #8 expired in the facility on [DATE] after coming back from the hospital. She was placed on hospice continuous care. The fall she experienced the night of [DATE] resulted in a subdural hematoma and facial fractures. On [DATE] at approximately 5:30 p.m., the DON was queried about Resident #8 being placed on hospice continuous care (around the clock, one-on-one care). The DON stated the reason Resident #8 was placed on continuous care hospice was because it was obvious she was declining. 2) On [DATE] at 9:08 a.m., Resident #34 was observed awake in bed wearing a gown and a brief. A gold star was observed on her name plate just outside her door. According to the MDS assessment, dated [DATE], Resident #34 was an [AGE] year old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment reflected Resident #34 had short and long term memory problems, was moderately impaired for decision-making, had [MEDICAL CONDITION] with [MEDICAL CONDITION], was occasionally incontinent with bladder and required the extensive assistance of one person with toilet use. The care plan, dated [DATE], reflected Resident #34 required supervised assistance and extensive assistance with "toilet use." A Resident Incident Report, dated [DATE], reflected "Res (Resident #34) in RR (restroom), transferred from toilet to w/c, slid on floor, able to move all extremities, assist x 3 to bed. C/O pain to R (right) hip when touched. Sent out to ER via (ambulance)." The report included a witness statement, dated [DATE], and reflected CNA Q was transferring Resident #34's roommate with another CNA when they heard yelling in the bathroom. The last time they observed Resident #34 was in her room while they were transferring the roommate. CNA Q's statement reflected she did not observe Resident #34 fall. When she heard the resident yelling, she went into the bathroom and found Resident #34 on the floor. An Imaging Report, dated [DATE], reflected Resident #34 had multiple fractures of her pelvis. The hospital's discharge instructions, dated [DATE], reflected Resident #34 had a pelvic fracture. On [DATE] at 11:40 a.m., ADON J stated the CNAs were verbally told how to care for the residents they were assigned to, including Resident #34. She stated nothing was provided to the CNAs in writing. She stated Resident #34 was independent before her fall on [DATE] when she fractured her hip. The surveyor inquired about the [DATE] MDS assessment and [DATE] care plan, which reflected Resident #34 required extensive assistance with toileting. ADON J directed the surveyor to the MDS coordinator. On [DATE] at about 1:00 p.m., MDS Coordinator U confirmed the MDS assessment for Resident #34 reflected she required extensive assistance with "toilet use" even before her fall, which resulted in her [MEDICAL CONDITION]. She stated the expectation of staff, who saw Resident #34 making her way to the bathroom without help, would have been for staff to provide physical assistance. On [DATE] at 11:42 a.m., CNA S stated she cared for Resident #34 before and after her fall, which resulted in a [MEDICAL CONDITION]. She stated before Resident #34's fall, she was independent but now she needed more help. The CNA thought they had a book with instructions for each resident she could access, if for some reason, she forgot the resident's care or if the resident's care had changed and she had been off for a couple of days. However, CNA S could not find a resident instruction book at the nurses station. The CNA then told the surveyor she could just look at the resident and could tell what care they needed. She stated she was also instructed verbally by the staff, who were coming off the previous shift. On [DATE] at 12:37 p.m., CNA T stated she was given verbal instructions regarding care issues for Resident #34 and other residents she was assigned to on her shift. She stated she had 12 residents today ([DATE]), and she remembered what she was told by the charge nurse and CNAs from the previous shift. She said she was not provided any documentation about resident care unless she wrote it down. The ADL sheets were for documenting when and what care they provided. On [DATE] at 3:08 p.m., interview via telephone with CNA Q revealed she was in Resident #34's room assisting the roommate when Resident #34 fell and fractured her pelvis. CNA Q stated Resident #34 was independent and toileted herself, so she did not question Resident #34 when she saw her wheel herself into the bathroom. The minute she heard Resident #34 yelling, she went to her and found Resident #34 on the bathroom floor. She stated Resident #34 now required more care. CNA Q confirmed care instructions were not written anywhere, and they are told by the previous shift what care the residents need. Review of Resident #34's care plans revealed it did not address the resident's tendency to ambulate in the evening and/or night. No interventions were implemented, which would have potentially prevented the resident from getting up during the night or her requirements for extensive assistance from staff. Resident #34's Assessment of Risk for Falls, dated [DATE], reflected a score of "5," which put her at a low risk for falls. A note at the bottom of the assessment reflected, "A low score does not necessarily constitute a low risk. It is simply a guideline. The assessor must still look at the resident and apply clinical judgement...." 3) On [DATE] at 9:15 a.m., Resident #35 was observed awake in bed wearing street clothes and talking on a cell telephone. A [MEDICAL CONDITION] and an indwelling urethral catheter were observed in use. Additionally, a green and gold star was observed on his name plate just outside his door. According to the MDS assessment, dated [DATE], Resident #35 was a [AGE] year-old male, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment reflected Resident #35 was interviewable, had [MEDICAL CONDITION], used an indwelling catheter and ostomy, and required extensive physical assistance of two people with transfers. Resident #35's care plan, dated [DATE], reflected a hand written entry, which reflected, "use hoyer lift all transfers." The care plan also reflected Resident #35 required assistance with transfers and to "evaluate need for assistive devices...." Review of the Resident Incident Report, dated [DATE], reflected the "nurse aide (CNA X) was attempting to transfer resident to bed when she noticed resident was too weak and eased him down to the floor." The facility had obtained a written statement from CNA X on [DATE], which reflected, "I turn his (Resident #35) chair around close to bed, I put gait belt on him, he scooted to end of chair. I counted 123 I helped him up, and he said I'm hurting, and started going down, so I told him I was gonna ease him down to the floor, when I did he said my leg my leg, I moved his leg, lowered him to floor put pillow up under his head, told him I was going to get the nurse... I got him up the way I was showed since I've been working here...." Resident #35's x-ray report dated [DATE] reflected there was a left distal femur fracture (upper leg) and a [MEDICAL CONDITION] fibular shaft (lower leg). On [DATE] at 1:25 p.m., Resident #35 was interviewed. He stated CNA X did not use the Hoyer lift to transfer him the other day, and his leg was fractured in three places. He stated when the CNA sat him down when he was slipping, she sat him on his leg. On [DATE] at 5:30 p.m., CNA W was asked by the surveyor how she transferred Resident #35. She stated she used a Hoyer lift. The surveyor asked her how she knew to use the Hoyer lift. The CNA stated, "I just know to use a Hoyer with (Resident #35) because I was told, but nothing is in writing." CNA W went on to say the different colored stars were recently placed on the residents' name plates just outside their rooms. The green star meant the resident was a Hoyer lift, the gold star meant the resident was a fall risk and a red star meant the resident had experienced a fall. 4) The facility's current p/p related to falls was provided post survey on [DATE] by the Director of Staff Development, RN M. The p/p was dated revised [DATE] and reflected the following: Facility staff would evaluate and document falls, which occurred while the resident resided in the facility. If underlying causes could not be readily identified or corrected, staff would try various relevant interventions based on an assessment of the nature or category of falling, until the resident had fewer falls or stopped falling or until a reason was identified for the continued use of the intervention implemented. 5) An IJ was identified on [DATE]. The Administrator and DON were notified on [DATE] at 1:45 PM of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, dated [DATE], was accepted on [DATE] and reflected: The "(facility) respectfully submits the following plan of removal in response to the Immediate Jeopardy related to: Quality of Care/Administration and Resident Behavior/Facility Practice This immediate jeopardy is related to the lack of an effective fall prevention program including identification of residents at risk for falls/injury and residents who have a fall history with/without injury, interventions to decrease the risk for falls / injury, process for informing the direct and ancillary staff for routine monitoring in resident rooms and in common areas." Residents #8, #34, and #35 sustained falls resulting in significant injury. Resident #8 expired on [DATE]. Resident #34 is an assist of one staff member for transfers and currently utilizes a bed/chair alarm for safety. Resident #35 is a Hoyer transfer with two staff assist. CNAs and Licensed Nurses have access to a comprehensive care guide individualized to the specific needs of Resident #34 and Resident #35 as well as all other residents residing in the facility The lack of an effective fall prevention program puts residents at risk for falls and fall-related injuries. A facility fall prevention system has been developed and implemented to remove the immediate jeopardy and to decrease the risk and potential for other residents in the facility to sustain injury from falls. The following people have been contacted and provided assistance with developing this Plan of Removal: 1. The facility Medical Director and Physician Y, primary physician for Residents #34 and #35, who were identified during the immediate jeopardy investigation 2. The facility Nurse Consultants AAA and ZZ 3. Administrative Nursing Staff including ADON J, the DON, ADON F, Therapy Director BBB, ADON N, MDS Coordinator U, LVN CCC, LVN DDD, RN M, and LVN EEE 4. Therapy Director BBB Plan of Removal: Assessment: 1. Residents at risk for falls/injury are identified with fall risk evaluations to be completed upon admission, quarterly and with significant change. 2. Residents with a history of falls were identified based on the incident log for falls documenting falls with/without injury within the last 30 days. 3. The DON conducted an audit of current Fall Risk Assessments for all residents residing in the Facility on [DATE] from approximately 12:00 PM to 3:00 PM. This audit was generated from a medical records program. Fall Risk Assessments are completed in conjunction with the MDS upon admission, quarterly, with off-cycle quarterly assessments and significant change assessments by the Unit Managers All residents who were identified as being at risk for falls/injury based on their fall risk assessment are identified by a yellow star placed on the name plate of their room door to inform staff that resident is at risk for falls/injury. A YELLOW STAR indicates the resident meets the criteria per their Fall Risk Assessment to be at risk for falls. The facility is placing a yellow bracelet on the right wrist of each resident identified as being at risk to inform staff of their risk for fall/injury when outside of the resident's room. This program is referred to as Look to the Stars. Residents identified as 'at risk for falls' in the facility equals 104. 4. The DON conducted an audit of Incident Reports of Falls from the medical records program for the time period from [DATE] ~ [DATE] to determine which residents have sustained falls with/without injury. The audit was completed between 12:00 PM and 3:00 PM on [DATE]. Residents with a significant history of falls with/without injury within the last 30 calendar days ([DATE] ~ [DATE]) based on the facility incident log for falls with/without injury are identified by a red star on the name plate of their room door to inform staff that resident has a fall history. The facility is placing a red bracelet on each identified resident with a fall history to inform staff of their history of falls when outside of the residents' room. A RED STAR indicates the resident has sustained a fall within the last 30 calendar days, [DATE] ~ [DATE]. This program is referred to as Look to the Stars. Thirty-three residents were identified to have had falls during the time period of [DATE] ~ [DATE]. A total of 137 residents were placed on the Look to the Stars Program, which identified them as having fallen or being at risk for falling. 5. All residents residing in the Facility are at risk for falls/fall related injury due to a lack of staff knowledge regarding transfer status, bed mobility and level of assistance required to maintain their highest practicable well-being. 6. The DON conducted a training for completion of the Fall Risk Assessments from the medical records program Tech on [DATE] for ADON N, ADON J and ADON F. The Unit Manager completed a data set of general resident information, which generates the Falls Risk Assessment. Staff Training: 1. The Nursing Management of the Facility (Director of Staff Development, Unit Managers, Resident Assessment Coordinator Nurses, Therapy Manager and Treatment Nurse) met wi

Based on interview and record review, the Administrator and the DON failed to effectively and efficiently use its resources to maintain the physical well-being of one (Resident #1) of one resident with a HeartMate 2, a left ventricle assistive device (LVAD). The Administrator and the DON both assumed all licensed nursing staff had been trained and were knowledgable in the care and needs of Resident #1. Staff failed to monitor the resident's LVAD every two hours as ordered by the physician. Staff were not trained on the operation, monitoring and changing of the LVAD from the battery to the power-based unit (PBU). CNAs were not trained an immediate response was needed from licensed staff when the LVAD's alarm sounded. Staff did not call 911 immediately per the Emergency Assistance Guide on the resident's chart. These failures contributed to the death of Resident #1 on [DATE] at 11:11 PM. On [DATE], it was determined these failures resulted in a Past Non-Compliance Immediate Jeopardy situation. The facility took action to correct the non-compliance prior to the entrance of the surveyor. Facility staff were aware of the procedures being implemented. These failures could affect the ten residents receiving tube feedings, three residents who received suctioning, three residents who received intravenous therapy/[MEDICATION NAME] nutrition/blood transfusion, two residents receiving tracheotomy care, and nineteen residents receiving respiratory treatment, placing them at risk for injury and possibly death, if receiving care from licensed staff, who had no knowledge on the care and use of the equipment. Findings included: According to the manufacturer, the left ventricular assistant device (LVAD) (HeartMate 2) or heart pump helps circulate the blood in patients with advanced heart failure. Resident #1's LVAD was attached to the heart and provided continuous blood flow. The HeartMate 2 ran on electricity provided by either a power-based unit (PBU) or power module during stationary use, or by rechargeable batteries during mobile use. The HeartMate 2 LVAD was a life-sustaining device. In the event it stopped operating, all attempts should have been made to restore pump function immediately. When working, the device makes a quiet, swirling sound. Warning: In the event the HeartMate 2 LVAD stopped operating, the patient should seek immediate medical attention to treat retrograde flow into the pump. Treatment measures may include [MEDICATION NAME], standard interventions for acutely decompensated [MEDICAL CONDITION], and surgical exploration. Referenced from the Thoratec Corporation, 2009. 1) The Face Sheet dated [DATE] for Resident #1, a [AGE] year-old male, reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Face Sheet reflected [DIAGNOSES REDACTED]. Resident #1's Care Plan, dated [DATE], reflected a problem with alteration in cardiac function, and he had an LVAD. The Goal was for Resident #1 to retain his cardiac function with the use of his pacemaker x 90 days. Approaches included: LVAD checks per the physician's orders [REDACTED]. Review of the MDS asessment for Resident #1, dated [DATE], revealed the resident required no special supervision for ADLs. He was independent and ambulatory. Resident #1 was interviewable and could make informed decisions. Resident #1's admission orders [REDACTED]. Orders included to monitor pressures every shift and to document every two hours on the flow sheet the following measurements of the LVAD with the following parameters: Speed - 9.200 Flow - 4.9 - 5.3 PI - 5.2 - 5.3 Power - 6.4 - 6.6 Review of Resident #1's flow sheets from [DATE] to [DATE] for documentation of the every two hour measurements/readings and monitoring of the LVAD equipment revealed the following shifts when there was no documentation at all: [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 6 AM to 2 PM shift 2 PM to 10 PM shift [DATE] 6 AM to 2 PM shift 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] no shift [DATE] 2 PM to 10 PM shift 10 PM to 6 AM shift [DATE] 2 PM to 10 PM shift Information recorded in Resident #1's medical record reflected: A Resource: HeartMate 2 by Thoratec Corporation, an article dated 2009, HeartMate 2, LVAD, Emergency Assistance Guide. Important: If a HeartMate 2 LVAD patient is having a medical emergency, first dial 911, then call the hospital contact person listed on the patient's emergency contact card. The Provider Investigation Report dated [DATE] reflected when Resident #1 was readmitted to the facility on [DATE], he was readmitted with the following Diagnoses: [REDACTED]. Resident #1's nurse's notes dated [DATE] at 11:20 PM reflected, "Entered patient's room. Patient was lying in bed with eyes closed, unresponsive to voice, tapping, or shaking. No breathing sounds noted. No apical pulse. Pupils were fixed and dilated. Pronounced patient dead at 23:11 (11:11 PM). Doctor notified. Family notified." 2) The Provider Investigation Report dated [DATE] reflected CNA A responded to an alarm she heard coming from Resident #1's room on [DATE] at approximately 10:15 or 10:20 PM. Resident #1 told CNA A his batteries needed to be changed. CNA A stated she left the resident's room, went to the nurse's station and told LVN B Resident #1 needed to have his batteries changed. CNA A stated she did not receive a verbal response from LVN B, which would have indicated she had heard the CNA and would respond. LVN B stated she was not told anything by CNA A and counted narcotics and then gave report to the oncoming shift while conducting "walking rounds" and then returned to the nurse's desk. LVN B stated LVN I then came to the nurse's station and indicated to LVN B Resident #1 had expired and LVN D needed LVN B's help with the LVAD. LVN B went to Resident #1's room. LVN D asked LVN B to get LVN E, which she did. LVN B said she then went home. LVN B, in further interviews, has continued to state CNA A did not say anything to her. The Investigation Report continued with LVN D stating she was explaining Resident #1's LVAD to LVN I when LVN I asked what the noise was. They entered Resident #1's room. LVN D saw what appeared to be signs of death upon Resident #1 and realized the noise was the LVAD alarm and asked LVN I to call for RN H or one of the nurses familiar with the LVAD. LVN D and RN H then tried to change the LVAD to alternative battery power. RN H stated when she came into Resident #1's room, she recognized Resident #1 was presenting with signs of death. The RN auscultated heart and respiratory sounds, neither of which were present. Resident #1's pupils were fixed and dilated. RN H then pronounced Resident #1 at 11:11 PM. 3) On [DATE] at 10:30 AM, the DON was interviewed regarding Resident #1. The DON stated CNA A reported to her she responded to an alarm she heard on the hall when she arrived on duty on [DATE] at 10:05 PM. The DON stated CNA A told her she went to Resident #1's room and asked him what he needed. The resident told CNA A he needed to get his battery changed, and he asked her (CNA A) to change the battery. CNA A stated she told Resident #1 she did not know how to change the battery, but she would tell the nurse. CNA A stated she went to tell the charge nurse on the evening shift (2 PM to 10 PM). CNA A described the charge nurse, whom she reported the battery to, as an LVN with a red scarf, a ponytail and glasses, which described LVN B. The DON stated CNA A was one of the newer employees, who transferred from another facility on [DATE], and she was familiar with reporting to the charge nurse. CNA A stated when she told LVN B Resident #1 needed his battery changed, LVN B did not respond to the CNA, but kept her head down and continued her work. The DON stated she interviewed CNA C, the 2nd CNA on Resident #1's hall for the 10 PM to 6 AM shift. The DON stated CNA C told her she heard the alarm also and saw CNA A respond to the noise and saw her go into Resident #1's room. The DON further stated CNA C told her she went on to answer another light and when she came back out into the hall, she heard conversation between CNA A and Resident #1. The DON stated CNA C told her CNA A came out of Resident #1's room and walked towards the nurse's station. The DON stated CNA C was a very dependable CNA. The DON said during the investigation, every person she spoke to had written a statement. The DON stated she could not prove CNA A told LVN B about the alarm and Resident #1's battery needing to be changed. It came down to nurse against CNA. The DON stated, "I terminated LVN B." The DON said the CNAs were not trained on life sustaining equipment and did not know the seriousness of the alarm (noise) they heard coming from Resident #1's room. The DON also stated she was aware of the gaps in the monitoring log for Resident #1's LVAD. On [DATE] at 11:00 AM, a telephone interview was conducted with LVN B. LVN B stated she was hired [DATE]. She stated she was on the East Wing and Resident #1 was on the West Wing. LVN B stated it was during the change of shift, and she was the only nurse left on duty from the 2 PM to 10 PM shift. Another CNA was there. LVN B stated the incident occurred after shift change. "I was still there working on records. It was almost 10 or 11 PM, I cannot remember the time. No one reported anything to me about Resident #1's battery. If someone had reported it, I would have gone to someone else and reported it. I was never trained to change _____ (Resident #1's) battery, and I do not know anything about the machine." The nurse on duty for the 10 PM to 6 AM shift assigned to Resident #1's hall was LVN D. LVN B then stated she heard LVN D call out she needed her (LVN B), and she went to Resident #1's room and saw LVN D was trying to change the battery, but did not know how. LVN B stated she went to Station 3 to find a nurse who knew how to change the battery. LVN E was at Station 3, and she ran back to Resident #1's room. LVN E stated she saw the video but had not performed the battery change and did not know how to change Resident #1's battery. LVN B stated, "By the time the staff found ____ (LVN F), who had trained to change the battery, it was too late." She stated she left the room. LVN B stated, "____ (Resident #1) had expired. Before I left duty, I told ____ (LVN E) and ____ (LVN D) I did not know how to change the battery." LVN B further stated, "I now know the resident depended on the battery for his life. If I had been told ____ (Resident #1) needed a battery change, I would have gotten help." LVN B stated LVN G was Resident #1's nurse on the 6 AM to 2 PM shift and his nurse on the 2 PM to 10 PM shift. LVN B further stated LVN G was a new nurse and did not know anything about the LVAD machine either. LVN B further stated, "I was told by the DON that ____ (LVN E) and ____ (LVN F) were trained on the LVAD machine. These nurses were in the building the night of the incident, and ____ (Resident #1) expired because no one could change his batteries." On [DATE] at 11:30 AM, CNA A was interviewed concerning Resident #1. CNA A stated she transferred to the facility on [DATE]. CNA A stated, "I clocked in about 10:05 (PM), walked down the hall to check halls, approaching ____ (Resident #1's) room." CNA A stated, "I heard the noise before I got to the room. I went to his room because the noise sounded like a siren. ____ (Resident #1) asked me if I knew how to change his battery. He said he need his battery changed." CNA A stated she told Resident #1 she did not know how to change the battery, and "I did not know what the machine was. I went to the nurse's station and told the 2 PM to 10 PM nurse because my patients were all brown, wringing wet. They needed incontinent care. The nurse was sitting at the desk when I approached her. They might have been changing shifts. I told her that ____ (Resident #1), in room ___, needed his battery changed, and then I went on back down the hall. His battery alarm kept sounding off. At 10:50 (PM), the noise stopped. I heard ____ (Resident #1's) 10 PM to 6 AM nurse, ____ (LVN D) screaming." CNA A further stated the night supervisor, RN H announced Resident #1 expired. CNA A stated when she arrived for the 10 PM to 6 AM shift, the battery was low, and the alarm sound was loud. CNA A further stated, "I do not see how a person could not hear the alarm." CNA A stated the CNAs did not know what the noise was and what would happen if the LVNs did not take care of the noise. The surveyor was unable to reach CNA C by telephone. Review of the statement provided by CNA C revealed, "On [DATE], at 10:15 PM, me and ____ (CNA A) walked to West Hall, and it was a loud beeping going on in room ____, and she went there, and I went to room ___. And when I was going to the closet, I could still hear the beeping, and I stopped on ___ and ____ (CNA A) was in the room talking to ____ (Resident #1), but I did not know what they said, and I passed and went to get some linens. When I got back to ___ changing the resident's bed sheet, I saw ___ (CNA A) walked to the nurse's station when I was taking my dirty linen out and do now know what happened. After that, ____ (LVN D) and the new nurse ____ (LVN I) made rounds and went into ____ (Resident #1's) room. I heard ____ (LVN D) say, 'What happened?' loud, and I ran to the room. ____ (LVN D) said, 'Where is the cord going to?' 'here is the cord.' I said to ___ (LVN D). ____ (Resident #1) was a patient on Station 1. I will go and get the nurse on Station 1. ____ (LVN F), charge nurse on Station 1 came to ____ (Resident #1's) room to help." On [DATE] at 12:10 PM LVN G, the charge nurse on Station 2, was interviewed concerning Resident #1. LVN G stated she normally worked the 6 AM to 2 PM shift, but worked a double and had worked from 6:00 AM until 10:00 PM on [DATE]. She stated, "That was my second day to take care of ____ (Resident #1)." LVN G said she was hired [DATE]. LVN G further stated, "____ (LVN J) showed me how to disconnect the resident from the machine and connect him to the battery pack he used in the wheelchair during the day." LVN G stated the second day she was on the job, the other nurse connected Resident #1 to his battery and she did not watch. LVN G stated she graduated from LVN school six months ago. LVN G stated she had not been in-serviced on the LVAD machine, how to connect Resident #1's LVAD to the batteries and how to reconnect him to the machine when he went to bed. LVN G stated she did not know how to change Resident #1's battery devices and did not know to check for the amount of charge left in the battery. LVN G stated the other nurse had connected Resident #1 to his batteries at 9:00 AM the day he expired. She then said, "I could not remember the exact time. I did not know ____ (Resident #1's) batteries only lasted for ,[DATE] hours." LVN G further stated, "In the future, I am going to refuse to be the nurse for a resident I do not know how to take care of." At 1:30 PM on [DATE], LVN E was interviewed by telephone concerning Resident #1. LVN E stated she saw a video during the summer (2010) in the facility on the LVAD. LVN E stated she was told the facility would be getting a resident with an LVAD, and all the nurses should know how to care for him. LVN E stated, "I never had to work with ____ (Resident #1), and I did not know how to change his battery." LVN E further stated she had never heard an LVAD alarm sound. LVN E stated she had worked four years at the facility and had not worked with ____ (Resident #1). LVN E stated, "Around 10:15 or 10:20 (PM), a nurse came and asked me if I knew how to change the battery in the LVAD machines. I told the nurse I did not know how to work the machine. I went to the room, and the nurses were in the room trying to get the battery connected. I was busy on the hall." LVN E stated Resident #1 should have had nurses working with him every shift who were trained on how to operate the LVAD equipment. LVN E stated when the CNA ran to get her for help with Resident #1, "I told the nurses to get ____ (LVN F). I was told ____ (LVN F) was trained on the LVAD machine. I had only seen the video and did not know how to operate the equipment." On [DATE] at 2:18 PM, a telephone interview was conducted with RN H, the evening supervisor hired on [DATE]. RN H stated she was on Station 4 talking with the evening nurse receiving report. She stated she got a call over the intercom to come to Station 2. RN H stated, "I was called at 11:07 PM, and when I arrived, the new nurse, ____ (LVN I), was standing outside ____ (Resident #1's) room. I walked into the room, and ____ (LVN D) said, '____ (RN H), he has only a few seconds, help me change the battery.' " RN H then stated, "____ (Resident #1) had already expired. I told ____ (LVN D) I was not trained on the LVAD and could not do anything. ____ (Resident #1) was warm but had started to cool down." RN H stated she started working in the facility on [DATE] and had not had an in-service on the LVAD. RN H further stated every night when she arrived on duty, she walked the hall and asked about all residents. She stated when she went to Station 2, one nurse was at the medication cart, and two nurses were sitting at the nurse's desk and stated nothing was going on. RN H stated, "When the staff called me (about Resident #1), it was too late." Resident #1's roommate, Resident #2, was interviewed in his room on [DATE] at 4:00 PM. Resident #2 stated he was awake the night of [DATE] when Resident #1 expired. Resident #2 stated they were both in bed when Resident #1's alarm began to go off. When asked if the alarm was loud, Resident #2 stated, "The alarm was very loud." Resident #2 stated no staff came to the room. Resident #2 stated Resident #1 called for the nurses to come to the room. Resident #2 stated he remembered the call light going off. Resident #2 stated by the time the nurses came to the room, Resident #1 was not talking anymore, and he (Resident #2) thought Resident #1 had gone to sleep. On [DATE] at 12:24 PM, an interview was conducted with LVN F concerning Resident #1. LVN F stated, "When ____ (Resident #1) was on Station 1, I worked with him. I was trained on the LVAD DVD. I learned how to disconnect the alarms, change the batteries, and disconnect the LVAD from the battery to the PBU at bedtime. ____ (Resident #1) was transferred to Station 2." LVN F stated, "On [DATE], I worked the 10 PM to 6 AM shift on Station 1." LVN F further stated she was in the middle of giving report and counting narcotics in the medication room and about 10:30 PM, a CNA came and said, "We need you in _____ (Resident #1's room)." LVN F stated she went to Resident #1's room and everyone was "standing around." LVN F stated she asked RN H what she was needed for. LVN F said RN H said she needed her (LVN F) to help change the battery for Resident #1. LVN F could not remember the exact time she was called. She stated it could have been around 11:00 PM. LVN F then stated she told RN H there was nothing she could do, Resident #1 had expired. LVN F said the alarms were off, and the alarms only stayed on for about 20 to 30 minutes to alert staff of an emergency. LVN F stated, "I went back to my area to work." On [DATE] at 2:30 PM, an interview was conducted with LVN K concerning Resident #1. LVN K stated she worked on [DATE] on Station 2 on the 2:00 PM to 10:00 PM shift. The surveyor asked LVN K why there were gaps in the two-hour monitoring/battery check log for Resident #1's LVAD. LVN K stated, "The nurses got lax and did not document or monitor the machine results every two hours." LVN K stated when she monitored the LVAD, she made sure the batteries were charged, and Resident #1 was connected to the "big machine" he used when he was in bed. LVN K further stated, "____ (Resident #1) was not connected to the big machine (PBU) at his bedside when he was placed in bed the night he expired." LVN K stated LVN G worked the night of [DATE], and she thought LVN G had been trained by LVN J that day to reconnect Resident #1 to the PBU when he got in bed that night. LVN K stated during the 2:00 PM to 10:00 PM shift, she did not know if the resident was monitored, because LVN G was responsible for Resident #1. LVN K stated, "____ (LVN G) did not ask for my help." LVN K stated when she was responsible for Resident #1, "I went in and transferred ____ (Resident #1) from the battery to the big machine that sat at his bedside. The batteries always had some charge when I would switch him over. I do not know when they changed the batteries. It did not occur on my shift. When the resident was transferred over, you have to ensure all wires are connected." LVN D, Charge Nurse on the 10 PM to 6 AM shift for [DATE], submitted a recap from when she clocked in at 9:44 PM on [DATE]. According to the recap, LVN D and LVN I, who was receiving orientation, were on walking rounds. LVN D and LVN I got to Resident #1's room, and LVN D was giving LVN I information on Resident #1 and the LVAD. LVN I interrupted, asking what the noise was. LVN D went into Resident #1's room. "____ (Resident #1) was in bed, in a supine position, motionless and unresponsive, eyes closed, and had a white sheet covering him. Resident #1 appeared to have expired." LVN D checked the PBU at the bedside, and it read "not connected." LVN D grabbed the leads, removing the resident's gown and was unable to locate the connectors to connect him to the PBU. LVN D told LVN I to get RN H, the house supervisor. RN H arrived. LVN D gave her report. LVN D told the CNAs to get LVN E, and yelled, "I need anyone who knows how to work this LVAD." LVN D told someone else to go check Resident #1's chart to see if he was a DNR and to call the DON. RN H found the connectors in a black bag next to the resident's hip and removed them. The batteries were still alarming. RN H was able to disconnect and then reconnect the battery she held and then assisted LVN D with reconnecting the battery she (LVN D) had. LVN E arrived at Resident #1's room and said the resident was gone. LVN D added Resident #1 was pronounced at 11:11 PM. LVN D further documented she notified Resident #1's family member and the physician and spoke with the DON several times. LVN D signed and dated the document [DATE]. 4) On [DATE] at 12:00 noon, the DON was interviewed in regard to the CNAs' in-services. The DON stated she agreed all individuals in the facility should be in-serviced on the LVAD, so when an alarm sounds, any CNA can report to the nurses immediately. The CNA heard the alarm, but did not realize the seriousness of the LVAD alarm. The DON stated when Resident #1 was admitted to the facility, the hospital's training professional decided only the LVNs received the training. On [DATE] at 11:14 AM, the surveyor asked the DON what was she doing to orientate new hires. The DON stated skilled check list would be completed and there would be continuing monthly topics to do proficiency checks. The DON stated there would be a skills fair completed monthly instead of yearly. On [DATE] at 11:18 AM, the DON stated she left the position as DON at the facility temporarily in [DATE] and returned to the facility as DON on [DATE]. The DON stated when she returned to the facility, she assumed the training of the staff on the LVAD had been completed. The surveyor asked the DON what she did to train the nurses, who were hired after [DATE]. The DON stated there were no nurses hired between [DATE] and [DATE]. Note: LVN G was hired on [DATE] and RN H was hired on [DATE]. On [DATE] at 11:16 AM, during an interview with the Administrator concerning how this Immediate Jeopardy occurred, he stated there was an assumption the training on the LVAD for nurses had been conducted. The Administrator stated he was not the Administrator from [DATE] and had returned [DATE] as the interim Administrator. The Administrator stated there was Administrator in place when he arrived in [DATE], and he assumed all the staff had the proper training. Review of the in-services dated [DATE] and [DATE] provided to facility staff for Resident #1's LAVD revealed a HeartMate 2 was the Left Ventricular Assist System placed in Resident #1 for his LVAD. The sign-in sheets reflected only LVNs attended the in-services. On [DATE], at 3:30 PM, a telephone interview was conducted with the Nurse Practitioner, a contact person from the hospital for the LVAD services for Resident #1. During the interview, the Nurse Practitioner stated Resident #1's batteries had worn down, and "obviously, there was an issue of (staff) training." When staff who were not trained attempted to correct the situation, they ruined the wires connecting the batteries to the LVAD. The Nurse Practitioner stated, "We left the DVD in July (2010) for ongoing training (of the LVAD) for new hires. It is a shame this happened. Competency must be kept current. We go in (initially) and do hands-on with staff." The Nurse Practitioner stated the DON had called (a couple days before the incident with Resident #1) and asked for the Nurse Practitioner to come back and do some re-training with the facility staff. The Nurse Practitioner stated it was not their policy to go out each time a new employee was hired; they leave brochures and a very self-explanatory DVD for training. The Nurse Practitioner stated she had placed the facility on the in-service schedule due to the DON's request. On [DATE] at 11:49 AM, an interview was conducted with LVN J concerning the night Resident #1 expired. LVN J worked the 6:00 AM to 2:00 PM shift on Station 2 East wing on [DATE]. LVN J stated the first time she cared for Resident #1, she watched a video on LVAD care on [DATE]. LVN J stated on [DATE], during the 6 AM to 2 PM shift, she demonstrated to LVN G how to test Resident #1's batteries. LVN G was only in training one day. LVN J stated, "When ____ (Resident #1) was on Station I, the staff on every shift did not know how to operate the LVAD equipment." LVN J stated she tried not to be assigned to Resident #1, because it was so critical to know how to care for the Resident #1's power outage and keep him on a fresh battery pack. LVN J further stated, "The only crisis we had, ____ (Resident #1) became septic in December (2010) and I had to go to the hospital with the resident, because no one else knew how and what to do for him." LVN J further stated, "I understand you could hear the alarm if it went off." LVN J said Resident #1 was transferred to a room so the nurses could hear the alarm at the desk. LVN J stated she was told during her in-service on the LVAD, Resident #1 did not qualify for a heart transplant. LVN J stated she felt insecure about caring for Resident #1 even though she had been oriented. LVN J then said she did not know where the DVD was so that she could have watched it again. The surveyor asked LVN J why the nurses stopped documenting on the observation and monitoring log for Resident #1's LVAD. LVN J stated the nurses became lax and just stopped monitoring and documenting every two hour visual checks. 5) Further review of the Provider Investigation Report dated [DATE] revealed the following "Provider Action taken Post-Investigation:" 1. The facility did not currently have any other residents with an LVAD. The facility planned to screen residents prior to admission to ensure all direct-care staff was competent to provide care for each resident's individual needs. 2. All staff have been in-serviced regarding the importance of receiving a verbal response/recognition when making a licensed nurse aware of a resident's need or request, a resident emergency or any alarms associated with the resident's care. All staff have been in-serviced regarding their responsibility to ensure the licensed nurse is responding in a timely manner or to seek out another licensed nurse or supervisor. 3. All licensed staff have been in-serviced regarding the need for an immediate physical response to alarms realted to special needs equipment. 4. A manual containing manufacturer's written instructions for opeation and maintenance of special needs equipment currently in use in the facility has been made available at each nurse's station. 5. The 24-hour report had been updated to indicate the skilled need of each resident in regard to life-sustaining devices. All licensed nurses have been in-serviced on acknowledging whether they have the skills to provide care for the residents they have been assigned and to responsibly report otherwise to the Unit Manager. 6. Nurse Consultant Staff will provide training for the DON and direct-care Admin Nursing Staff regarding preadmission screening of residents and monthly review of residents to ensure special needs are being met. This was signed by the DON on [DATE]. An in-service was conducted entitled Response to alarms on life-sustaining equipment initially on [DATE] with most licensued staff attending and continued through [DATE] with the rest of the licensed staff attending. Equipment included, but was not limited to: [MEDICAL CONDITIONS], suction machines, oxygen concentrators, central lines, and tube feeding pumps. Competency evaluations were conducted. An in-service entitled Nurse Responsibility related to acceptance of Resident Assignment was first conducted on [DATE] with most licensed staff attending and continued through [DATE] with the rest of the licensed staff attending. Nurses were instructed to review their work load upon arriving at the facility for their shift and to notify the Unit Manager if he/she did not have the skills to care for the resident. An in-service was initiated on [DATE] by the DON on "Staff Communication," which was attended by every employee and completed on [DATE]. A description of the program reflected, "When informing a nurse of a resident need, you MUST request the following: 1) The nurse state the need back to you. 2) Must state that he/she is going to address the resident's need and 3) If the nurse does not respond you must bring the situation to a supervisor immediately." Sign-in sheets indicated all departments attended: Nursing, Admissions, Front Office, Maintenance, Transport, Social Work, Medical Records, Staffing, MDS, Dietary, Housekeeping, Laundry, Porter. An in-service was provided to the DON on [DATE]. A description of the program included: Pre-admission screening of special needs residents to ensure direct-care competency and training. DON job description. BNE Rule 213.27 (Good Professional Character), BNE Rule 217.11 (Standards of Nursing Practice), BNE Rule 224.6 (General Criteria for Delegation, Facility Admissions Policies, QA Committee-Role of the DON Services, QA Committee-Role of Resident Care Services and Admissions to the Facility. An in-service was provided to the facility's three ADONs on [DATE]. A description of the program inc

Based on interview and record review, the facility failed to ensure the necessary care and services were provided to maintain the highest practicable physical well-being for one (Resident #1) of one resident with a Left Ventricular Assist Device (LVAD) in accordance with his comprehensive assessment and plan of care. Staff failed to monitor the resident's LVAD every two hours as ordered by the physician. Staff were not trained on the operation, monitoring and changing of the LVAD from the battery to the power-based unit (PBU). CNAs were not trained an immediate response was needed from licensed staff when the LVAD's alarm sounded. Staff did not call 911 immediately per the Emergency Assistance Guide on the resident's chart. These failures contributed to the death of Resident #1 on [DATE] at 11:11 PM. On [DATE], it was determined these failures resulted in a Past Non-Compliance Immediate Jeopardy situation. The facility took action to correct the non-compliance prior to the entrance of the surveyor. Facility staff were aware of the procedures being implemented. These failures could affect the ten residents receiving tube feedings, three residents who received suctioning, three residents who received intravenous therapy/[MEDICATION NAME] nutrition/blood transfusion, two residents receiving tracheotomy care, and nineteen residents receiving respiratory treatment, placing them at risk for injury and possibly death, if receiving care from licensed staff, who had no knowledge on the care and use of the equipment. Findings included: According to the manufacturer, the left ventricular assistant device (LVAD) (HeartMate 2) or heart pump helps circulate the blood in patients with advanced heart failure. Resident #1's LVAD was attached to the heart and provided continuous blood flow. The HeartMate 2 ran on electricity provided by either a power-based unit (PBU) or power module during stationary use, or by rechargeable batteries during mobile use. The HeartMate 2 LVAD was a life-sustaining device. In the event it stopped operating, all attempts should have been made to restore pump function immediately. When working, the device makes a quiet, swirling sound. Warning: In the event the HeartMate 2 LVAD stopped operating, the patient should seek immediate medical attention to treat retrograde flow into the pump. Treatment measures may include [MEDICATION NAME], standard interventions for acutely decompensated [MEDICAL CONDITION], and surgical exploration. Referenced from the Thoratec Corporation, 2009. 1) The Face Sheet dated [DATE] for Resident #1, a [AGE] year-old male, reflected he was originally admitted to the facility on [DATE] and readmitted on [DATE]. The Face Sheet reflected [DIAGNOSES REDACTED]. Resident #1's Care Plan, dated [DATE], reflected a problem with alteration in cardiac function, and he had an LVAD. The Goal was for Resident #1 to retain his cardiac function with the use of his pacemaker x 90 days. Approaches included: LVAD checks per the physician's orders [REDACTED]. Review of the MDS asessment for Resident #1, dated [DATE], revealed the resident required no special supervision for ADLs. He was independent and ambulatory. Resident #1 was interviewable and could make informed decisions. Resident #1's admission orders [REDACTED]. Orders included to monitor pressures every shift and to document every two hours on the flow sheet the following measurements of the LVAD with the following parameters: Speed - 9.200 Flow - 4.9 - 5.3 PI - 5.2 - 5.3 Power - 6.4 - 6.6 Review of Resident #1's flow sheets from [DATE] to [DATE] for documentation of the every two hour measurements/readings and monitoring of the LVAD equipment revealed the following shifts when there was no documentation at all: [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 6 AM to 2 PM shift 2 PM to 10 PM shift [DATE] 6 AM to 2 PM shift 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] 2 PM to 10 PM shift [DATE] no shift [DATE] 2 PM to 10 PM shift 10 PM to 6 AM shift [DATE] 2 PM to 10 PM shift Information recorded in Resident #1's medical record reflected: A Resource: HeartMate 2 by Thoratec Corporation, an article dated 2009, HeartMate 2, LVAD, Emergency Assistance Guide. Important: If a HeartMate 2 LVAD patient is having a medical emergency, first dial 911, then call the hospital contact person listed on the patient's emergency contact card. The Provider Investigation Report dated [DATE] reflected when Resident #1 was readmitted to the facility on [DATE], he was readmitted with the following Diagnoses: [REDACTED]. Resident #1's nurse's notes dated [DATE] at 11:20 PM reflected, "Entered patient's room. Patient was lying in bed with eyes closed, unresponsive to voice, tapping, or shaking. No breathing sounds noted. No apical pulse. Pupils were fixed and dilated. Pronounced patient dead at 23:11 (11:11 PM). Doctor notified. Family notified." 2) The Provider Investigation Report dated [DATE] reflected CNA A responded to an alarm she heard coming from Resident #1's room on [DATE] at approximately 10:15 or 10:20 PM. Resident #1 told CNA A his batteries needed to be changed. CNA A stated she left the resident's room, went to the nurse's station and told LVN B Resident #1 needed to have his batteries changed. CNA A stated she did not receive a verbal response from LVN B, which would have indicated she had heard the CNA and would respond. LVN B stated she was not told anything by CNA A and counted narcotics and then gave report to the oncoming shift while conducting "walking rounds" and then returned to the nurse's desk. LVN B stated LVN I then came to the nurse's station and indicated to LVN B Resident #1 had expired and LVN D needed LVN B's help with the LVAD. LVN B went to Resident #1's room. LVN D asked LVN B to get LVN E, which she did. LVN B said she then went home. LVN B, in further interviews, has continued to state CNA A did not say anything to her. The Investigation Report continued with LVN D stating she was explaining Resident #1's LVAD to LVN I when LVN I asked what the noise was. They entered Resident #1's room. LVN D saw what appeared to be signs of death upon Resident #1 and realized the noise was the LVAD alarm and asked LVN I to call for RN H or one of the nurses familiar with the LVAD. LVN D and RN H then tried to change the LVAD to alternative battery power. RN H stated when she came into Resident #1's room, she recognized Resident #1 was presenting with signs of death. The RN auscultated heart and respiratory sounds, neither of which were present. Resident #1's pupils were fixed and dilated. RN H then pronounced Resident #1 at 11:11 PM. 3) On [DATE] at 10:30 AM, the DON was interviewed regarding Resident #1. The DON stated CNA A reported to her she responded to an alarm she heard on the hall when she arrived on duty on [DATE] at 10:05 PM. The DON stated CNA A told her she went to Resident #1's room and asked him what he needed. The resident told CNA A he needed to get his battery changed, and he asked her (CNA A) to change the battery. CNA A stated she told Resident #1 she did not know how to change the battery, but she would tell the nurse. CNA A stated she went to tell the charge nurse on the evening shift (2 PM to 10 PM). CNA A described the charge nurse, whom she reported the battery to, as an LVN with a red scarf, a ponytail and glasses, which described LVN B. The DON stated CNA A was one of the newer employees, who transferred from another facility on [DATE], and she was familiar with reporting to the charge nurse. CNA A stated when she told LVN B Resident #1 needed his battery changed, LVN B did not respond to the CNA, but kept her head down and continued her work. The DON stated she interviewed CNA C, the 2nd CNA on Resident #1's hall for the 10 PM to 6 AM shift. The DON stated CNA C told her she heard the alarm also and saw CNA A respond to the noise and saw her go into Resident #1's room. The DON further stated CNA C told her she went on to answer another light and when she came back out into the hall, she heard conversation between CNA A and Resident #1. The DON stated CNA C told her CNA A came out of Resident #1's room and walked towards the nurse's station. The DON stated CNA C was a very dependable CNA. The DON said during the investigation, every person she spoke to had written a statement. The DON stated she could not prove CNA A told LVN B about the alarm and Resident #1's battery needing to be changed. It came down to nurse against CNA. The DON stated, "I terminated LVN B." The DON said the CNAs were not trained on life sustaining equipment and did not know the seriousness of the alarm (noise) they heard coming from Resident #1's room. The DON also stated she was aware of the gaps in the monitoring log for Resident #1's LVAD. On [DATE] at 11:00 AM, a telephone interview was conducted with LVN B. LVN B stated she was hired [DATE]. She stated she was on the East Wing and Resident #1 was on the West Wing. LVN B stated it was during the change of shift, and she was the only nurse left on duty from the 2 PM to 10 PM shift. Another CNA was there. LVN B stated the incident occurred after shift change. "I was still there working on records. It was almost 10 or 11 PM, I cannot remember the time. No one reported anything to me about Resident #1's battery. If someone had reported it, I would have gone to someone else and reported it. I was never trained to change _____ (Resident #1's) battery, and I do not know anything about the machine." The nurse on duty for the 10 PM to 6 AM shift assigned to Resident #1's hall was LVN D. LVN B then stated she heard LVN D call out she needed her (LVN B), and she went to Resident #1's room and saw LVN D was trying to change the battery, but did not know how. LVN B stated she went to Station 3 to find a nurse who knew how to change the battery. LVN E was at Station 3, and she ran back to Resident #1's room. LVN E stated she saw the video but had not performed the battery change and did not know how to change Resident #1's battery. LVN B stated, "By the time the staff found ____ (LVN F), who had trained to change the battery, it was too late." She stated she left the room. LVN B stated, "____ (Resident #1) had expired. Before I left duty, I told ____ (LVN E) and ____ (LVN D) I did not know how to change the battery." LVN B further stated, "I now know the resident depended on the battery for his life. If I had been told ____ (Resident #1) needed a battery change, I would have gotten help." LVN B stated LVN G was Resident #1's nurse on the 6 AM to 2 PM shift and his nurse on the 2 PM to 10 PM shift. LVN B further stated LVN G was a new nurse and did not know anything about the LVAD machine either. LVN B further stated, "I was told by the DON that ____ (LVN E) and ____ (LVN F) were trained on the LVAD machine. These nurses were in the building the night of the incident, and ____ (Resident #1) expired because no one could change his batteries." On [DATE] at 11:30 AM, CNA A was interviewed concerning Resident #1. CNA A stated she transferred to the facility on [DATE]. CNA A stated, "I clocked in about 10:05 (PM), walked down the hall to check halls, approaching ____ (Resident #1's) room." CNA A stated, "I heard the noise before I got to the room. I went to his room because the noise sounded like a siren. ____ (Resident #1) asked me if I knew how to change his battery. He said he need his battery changed." CNA A stated she told Resident #1 she did not know how to change the battery, and "I did not know what the machine was. I went to the nurse's station and told the 2 PM to 10 PM nurse because my patients were all brown, wringing wet. They needed incontinent care. The nurse was sitting at the desk when I approached her. They might have been changing shifts. I told her that ____ (Resident #1), in room ___, needed his battery changed, and then I went on back down the hall. His battery alarm kept sounding off. At 10:50 (PM), the noise stopped. I heard ____ (Resident #1's) 10 PM to 6 AM nurse, ____ (LVN D) screaming." CNA A further stated the night supervisor, RN H announced Resident #1 expired. CNA A stated when she arrived for the 10 PM to 6 AM shift, the battery was low, and the alarm sound was loud. CNA A further stated, "I do not see how a person could not hear the alarm." CNA A stated the CNAs did not know what the noise was and what would happen if the LVNs did not take care of the noise. The surveyor was unable to reach CNA C by telephone. Review of the statement provided by CNA C revealed, "On [DATE], at 10:15 PM, me and ____ (CNA A) walked to West Hall, and it was a loud beeping going on in room ____, and she went there, and I went to room ___. And when I was going to the closet, I could still hear the beeping, and I stopped on ___ and ____ (CNA A) was in the room talking to ____ (Resident #1), but I did not know what they said, and I passed and went to get some linens. When I got back to ___ changing the resident's bed sheet, I saw ___ (CNA A) walked to the nurse's station when I was taking my dirty linen out and do now know what happened. After that, ____ (LVN D) and the new nurse ____ (LVN I) made rounds and went into ____ (Resident #1's) room. I heard ____ (LVN D) say, 'What happened?' loud, and I ran to the room. ____ (LVN D) said, 'Where is the cord going to?' 'here is the cord.' I said to ___ (LVN D). ____ (Resident #1) was a patient on Station 1. I will go and get the nurse on Station 1. ____ (LVN F), charge nurse on Station 1 came to ____ (Resident #1's) room to help." On [DATE] at 12:10 PM LVN G, the charge nurse on Station 2, was interviewed concerning Resident #1. LVN G stated she normally worked the 6 AM to 2 PM shift, but worked a double and had worked from 6:00 AM until 10:00 PM on [DATE]. She stated, "That was my second day to take care of ____ (Resident #1)." LVN G said she was hired [DATE]. LVN G further stated, "____ (LVN J) showed me how to disconnect the resident from the machine and connect him to the battery pack he used in the wheelchair during the day." LVN G stated the second day she was on the job, the other nurse connected Resident #1 to his battery and she did not watch. LVN G stated she graduated from LVN school six months ago. LVN G stated she had not been in-serviced on the LVAD machine, how to connect Resident #1's LVAD to the batteries and how to reconnect him to the machine when he went to bed. LVN G stated she did not know how to change Resident #1's battery devices and did not know to check for the amount of charge left in the battery. LVN G stated the other nurse had connected Resident #1 to his batteries at 9:00 AM the day he expired. She then said, "I could not remember the exact time. I did not know ____ (Resident #1's) batteries only lasted for ,[DATE] hours." LVN G further stated, "In the future, I am going to refuse to be the nurse for a resident I do not know how to take care of." At 1:30 PM on [DATE], LVN E was interviewed by telephone concerning Resident #1. LVN E stated she saw a video during the summer (2010) in the facility on the LVAD. LVN E stated she was told the facility would be getting a resident with an LVAD, and all the nurses should know how to care for him. LVN E stated, "I never had to work with ____ (Resident #1), and I did not know how to change his battery." LVN E further stated she had never heard an LVAD alarm sound. LVN E stated she had worked four years at the facility and had not worked with ____ (Resident #1). LVN E stated, "Around 10:15 or 10:20 (PM), a nurse came and asked me if I knew how to change the battery in the LVAD machines. I told the nurse I did not know how to work the machine. I went to the room, and the nurses were in the room trying to get the battery connected. I was busy on the hall." LVN E stated Resident #1 should have had nurses working with him every shift who were trained on how to operate the LVAD equipment. LVN E stated when the CNA ran to get her for help with Resident #1, "I told the nurses to get ____ (LVN F). I was told ____ (LVN F) was trained on the LVAD machine. I had only seen the video and did not know how to operate the equipment." On [DATE] at 2:18 PM, a telephone interview was conducted with RN H, the evening supervisor hired on [DATE]. RN H stated she was on Station 4 talking with the evening nurse receiving report. She stated she got a call over the intercom to come to Station 2. RN H stated, "I was called at 11:07 PM, and when I arrived, the new nurse, ____ (LVN I), was standing outside ____ (Resident #1's) room. I walked into the room, and ____ (LVN D) said, '____ (RN H), he has only a few seconds, help me change the battery.' " RN H then stated, "____ (Resident #1) had already expired. I told ____ (LVN D) I was not trained on the LVAD and could not do anything. ____ (Resident #1) was warm but had started to cool down." RN H stated she started working in the facility on [DATE] and had not had an in-service on the LVAD. RN H further stated every night when she arrived on duty, she walked the hall and asked about all residents. She stated when she went to Station 2, one nurse was at the medication cart, and two nurses were sitting at the nurse's desk and stated nothing was going on. RN H stated, "When the staff called me (about Resident #1), it was too late." Resident #1's roommate, Resident #2, was interviewed in his room on [DATE] at 4:00 PM. Resident #2 stated he was awake the night of [DATE] when Resident #1 expired. Resident #2 stated they were both in bed when Resident #1's alarm began to go off. When asked if the alarm was loud, Resident #2 stated, "The alarm was very loud." Resident #2 stated no staff came to the room. Resident #2 stated Resident #1 called for the nurses to come to the room. Resident #2 stated he remembered the call light going off. Resident #2 stated by the time the nurses came to the room, Resident #1 was not talking anymore, and he (Resident #2) thought Resident #1 had gone to sleep. On [DATE] at 12:24 PM, an interview was conducted with LVN F concerning Resident #1. LVN F stated, "When ____ (Resident #1) was on Station 1, I worked with him. I was trained on the LVAD DVD. I learned how to disconnect the alarms, change the batteries, and disconnect the LVAD from the battery to the PBU at bedtime. ____ (Resident #1) was transferred to Station 2." LVN F stated, "On [DATE], I worked the 10 PM to 6 AM shift on Station 1." LVN F further stated she was in the middle of giving report and counting narcotics in the medication room and about 10:30 PM, a CNA came and said, "We need you in _____ (Resident #1's room)." LVN F stated she went to Resident #1's room and everyone was "standing around." LVN F stated she asked RN H what she was needed for. LVN F said RN H said she needed her (LVN F) to help change the battery for Resident #1. LVN F could not remember the exact time she was called. She stated it could have been around 11:00 PM. LVN F then stated she told RN H there was nothing she could do, Resident #1 had expired. LVN F said the alarms were off, and the alarms only stayed on for about 20 to 30 minutes to alert staff of an emergency. LVN F stated, "I went back to my area to work." On [DATE] at 2:30 PM, an interview was conducted with LVN K concerning Resident #1. LVN K stated she worked on [DATE] on Station 2 on the 2:00 PM to 10:00 PM shift. The surveyor asked LVN K why there were gaps in the two-hour monitoring/battery check log for Resident #1's LVAD. LVN K stated, "The nurses got lax and did not document or monitor the machine results every two hours." LVN K stated when she monitored the LVAD, she made sure the batteries were charged, and Resident #1 was connected to the "big machine" he used when he was in bed. LVN K further stated, "____ (Resident #1) was not connected to the big machine (PBU) at his bedside when he was placed in bed the night he expired." LVN K stated LVN G worked the night of [DATE], and she thought LVN G had been trained by LVN J that day to reconnect Resident #1 to the PBU when he got in bed that night. LVN K stated during the 2:00 PM to 10:00 PM shift, she did not know if the resident was monitored, because LVN G was responsible for Resident #1. LVN K stated, "____ (LVN G) did not ask for my help." LVN K stated when she was responsible for Resident #1, "I went in and transferred ____ (Resident #1) from the battery to the big machine that sat at his bedside. The batteries always had some charge when I would switch him over. I do not know when they changed the batteries. It did not occur on my shift. When the resident was transferred over, you have to ensure all wires are connected." LVN D, Charge Nurse on the 10 PM to 6 AM shift for [DATE], submitted a recap from when she clocked in at 9:44 PM on [DATE]. According to the recap, LVN D and LVN I, who was receiving orientation, were on walking rounds. LVN D and LVN I got to Resident #1's room, and LVN D was giving LVN I information on Resident #1 and the LVAD. LVN I interrupted, asking what the noise was. LVN D went into Resident #1's room. "____ (Resident #1) was in bed, in a supine position, motionless and unresponsive, eyes closed, and had a white sheet covering him. Resident #1 appeared to have expired." LVN D checked the PBU at the bedside, and it read "not connected." LVN D grabbed the leads, removing the resident's gown and was unable to locate the connectors to connect him to the PBU. LVN D told LVN I to get RN H, the house supervisor. RN H arrived. LVN D gave her report. LVN D told the CNAs to get LVN E, and yelled, "I need anyone who knows how to work this LVAD." LVN D told someone else to go check Resident #1's chart to see if he was a DNR and to call the DON. RN H found the connectors in a black bag next to the resident's hip and removed them. The batteries were still alarming. RN H was able to disconnect and then reconnect the battery she held and then assisted LVN D with reconnecting the battery she (LVN D) had. LVN E arrived at Resident #1's room and said the resident was gone. LVN D added Resident #1 was pronounced at 11:11 PM. LVN D further documented she notified Resident #1's family member and the physician and spoke with the DON several times. LVN D signed and dated the document [DATE]. 4) On [DATE] at 12:00 noon, the DON was interviewed in regard to the CNAs' in-services. The DON stated she agreed all individuals in the facility should be in-serviced on the LVAD, so when an alarm sounds, any CNA can report to the nurses immediately. The CNA heard the alarm, but did not realize the seriousness of the LVAD alarm. The DON stated when Resident #1 was admitted to the facility, the hospital's training professional decided only the LVNs received the training. On [DATE] at 11:14 AM, the surveyor asked the DON what was she doing to orientate new hires. The DON stated skilled check list would be completed and there would be continuing monthly topics to do proficiency checks. The DON stated there would be a skills fair completed monthly instead of yearly. On [DATE] at 11:18 AM, the DON stated she left the position as DON at the facility temporarily in [DATE] and returned to the facility as DON on [DATE]. The DON stated when she returned to the facility, she assumed the training of the staff on the LVAD had been completed. The surveyor asked the DON what she did to train the nurses, who were hired after [DATE]. The DON stated there were no nurses hired between [DATE] and [DATE]. Note: LVN G was hired on [DATE] and RN H was hired on [DATE]. On [DATE] at 11:16 AM, during an interview with the Administrator concerning how this Immediate Jeopardy occurred, he stated there was an assumption the training on the LVAD for nurses had been conducted. The Administrator stated he was not the Administrator from [DATE] and had returned [DATE] as the interim Administrator. The Administrator stated there was Administrator in place when he arrived in [DATE], and he assumed all the staff had the proper training. Review of the in-services dated [DATE] and [DATE] provided to facility staff for Resident #1's LAVD revealed a HeartMate 2 was the Left Ventricular Assist System placed in Resident #1 for his LVAD. The sign-in sheets reflected only LVNs attended the in-services. On [DATE], at 3:30 PM, a telephone interview was conducted with the Nurse Practitioner, a contact person from the hospital for the LVAD services for Resident #1. During the interview, the Nurse Practitioner stated Resident #1's batteries had worn down, and "obviously, there was an issue of (staff) training." When staff who were not trained attempted to correct the situation, they ruined the wires connecting the batteries to the LVAD. The Nurse Practitioner stated, "We left the DVD in July (2010) for ongoing training (of the LVAD) for new hires. It is a shame this happened. Competency must be kept current. We go in (initially) and do hands-on with staff." The Nurse Practitioner stated the DON had called (a couple days before the incident with Resident #1) and asked for the Nurse Practitioner to come back and do some re-training with the facility staff. The Nurse Practitioner stated it was not their policy to go out each time a new employee was hired; they leave brochures and a very self-explanatory DVD for training. The Nurse Practitioner stated she had placed the facility on the in-service schedule due to the DON's request. On [DATE] at 11:49 AM, an interview was conducted with LVN J concerning the night Resident #1 expired. LVN J worked the 6:00 AM to 2:00 PM shift on Station 2 East wing on [DATE]. LVN J stated the first time she cared for Resident #1, she watched a video on LVAD care on [DATE]. LVN J stated on [DATE], during the 6 AM to 2 PM shift, she demonstrated to LVN G how to test Resident #1's batteries. LVN G was only in training one day. LVN J stated, "When ____ (Resident #1) was on Station I, the staff on every shift did not know how to operate the LVAD equipment." LVN J stated she tried not to be assigned to Resident #1, because it was so critical to know how to care for the Resident #1's power outage and keep him on a fresh battery pack. LVN J further stated, "The only crisis we had, ____ (Resident #1) became septic in December (2010) and I had to go to the hospital with the resident, because no one else knew how and what to do for him." LVN J further stated, "I understand you could hear the alarm if it went off." LVN J said Resident #1 was transferred to a room so the nurses could hear the alarm at the desk. LVN J stated she was told during her in-service on the LVAD, Resident #1 did not qualify for a heart transplant. LVN J stated she felt insecure about caring for Resident #1 even though she had been oriented. LVN J then said she did not know where the DVD was so that she could have watched it again. The surveyor asked LVN J why the nurses stopped documenting on the observation and monitoring log for Resident #1's LVAD. LVN J stated the nurses became lax and just stopped monitoring and documenting every two hour visual checks. 5) Further review of the Provider Investigation Report dated [DATE] revealed the following "Provider Action taken Post-Investigation:" 1. The facility did not currently have any other residents with an LVAD. The facility planned to screen residents prior to admission to ensure all direct-care staff was competent to provide care for each resident's individual needs. 2. All staff have been in-serviced regarding the importance of receiving a verbal response/recognition when making a licensed nurse aware of a resident's need or request, a resident emergency or any alarms associated with the resident's care. All staff have been in-serviced regarding their responsibility to ensure the licensed nurse is responding in a timely manner or to seek out another licensed nurse or supervisor. 3. All licensed staff have been in-serviced regarding the need for an immediate physical response to alarms realted to special needs equipment. 4. A manual containing manufacturer's written instructions for opeation and maintenance of special needs equipment currently in use in the facility has been made available at each nurse's station. 5. The 24-hour report had been updated to indicate the skilled need of each resident in regard to life-sustaining devices. All licensed nurses have been in-serviced on acknowledging whether they have the skills to provide care for the residents they have been assigned and to responsibly report otherwise to the Unit Manager. 6. Nurse Consultant Staff will provide training for the DON and direct-care Admin Nursing Staff regarding preadmission screening of residents and monthly review of residents to ensure special needs are being met. This was signed by the DON on [DATE]. An in-service was conducted entitled Response to alarms on life-sustaining equipment initially on [DATE] with most licensued staff attending and continued through [DATE] with the rest of the licensed staff attending. Equipment included, but was not limited to: [MEDICAL CONDITIONS], suction machines, oxygen concentrators, central lines, and tube feeding pumps. Competency evaluations were conducted. An in-service entitled Nurse Responsibility related to acceptance of Resident Assignment was first conducted on [DATE] with most licensed staff attending and continued through [DATE] with the rest of the licensed staff attending. Nurses were instructed to review their work load upon arriving at the facility for their shift and to notify the Unit Manager if he/she did not have the skills to care for the resident. An in-service was initiated on [DATE] by the DON on "Staff Communication," which was attended by every employee and completed on [DATE]. A description of the program reflected, "When informing a nurse of a resident need, you MUST request the following: 1) The nurse state the need back to you. 2) Must state that he/she is going to address the resident's need and 3) If the nurse does not respond you must bring the situation to a supervisor immediately." Sign-in sheets indicated all departments attended: Nursing, Admissions, Front Office, Maintenance, Transport, Social Work, Medical Records, Staffing, MDS, Dietary, Housekeeping, Laundry, Porter. An in-service was provided to the DON on [DATE]. A description of the program included: Pre-admission screening of special needs residents to ensure direct-care competency and training. DON job description. BNE Rule 213.27 (Good Professional Character), BNE Rule 217.11 (Standards of Nursing Practice), BNE Rule 224.6 (General Criteria for Delegation, Facility Admissions Policies, QA Committee-Role of the DON Services, QA Committee-Role of Resident Care Services and Admissions to the Facility. An in-service was provided to the facility's three ADONs on [DATE]. A description of the program included: BNE Rule 213.27 (Good Professional Character), BNE Rule 217.11 (Standards of Nur