Every finding on record at Woodville Health and Rehabilitation Center

Based on interviews and record reviews, the facility failed to treat each resident with respect and dignity and provided care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 10 residents reviewed for resident rights. (Resident #1) The facility failed to treat Resident #1 with dignity and respect by LVN A denying his multiple requests to seek medical treatment at local ER on [DATE]. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.Findings included: Record review of an admission record dated 05/05/2026 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of abscess of lung (bacterial infection in the lung develops into a pus-filled cavity) with pneumonia (infection that inflames the air sacs in one or both lungs), arthritis (swelling and tenderness of one or more joints) of right wrist, anxiety disorder (persistent and excessive worry that interferes with daily activities), pain and [NAME] cell carcinoma (rare but aggressive type of skin cancer that can be life-threatening). Resident #1 was discharged on 05/02/2026. Record review of the admission MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 15, which indicated intact cognition. Resident #1 was dependent on staff for most mobility and self-care. Record review of a care plan dated 04/08/2026 indicated Resident #1 had limited physical mobility, ADL self-care performance deficit, and is resistive to care. Interventions include requiring assistance for ADL and allowing the resident to make decisions about treatment regime and provide sense of control. Record review of a progress notes for Resident #1 dated 04/28/2026 at 9:00 p.m. authored by LVN A indicated, . Patient was in bed with eyes closed, appears to be asleep. Patient was awakened by this nurse for routine nebulizer treatment. Patient immediately started moaning and yelling, stating that he was in pain, patient finally quit yelling long enough to say his hands hurt. Patient was demanding to go to the ER, rolling around in bed, yelling at the top of his voice. Multiple staff attempted to calm patient, unsuccessfully. [Resident #1] was not listening to anything staff said. 9:15p.m. Patient agreed to let this nurse rub Diclofenac (topical nonsteroidal anti-inflammatory drug used to relieve pain, inflammation, and swelling in muscles, joints, and soft tissues) gel on right hand. This nurse gently rubbed gel on right hand, using one hand, while patient continues moving around in bed. 9:30 p.m. [Resident #1] is walking down the hall with no oxygen, only t-shirt on, he was demanding to go to the hospital, stated that he was walking out and going himself. Staff were able to get patient to agree to wait and sit down in the w/c for now. 9:46 p.m. DON was notified of [Resident #1's] behavior and demanding to go to the hospital. [Resident #1] refused any vital signs. 11:13 p.m. N.P. notified of [Resident #1's] complaints and new orders received. Record review of local hospital ER visit on 04/29/2026 at 4:00 p.m., indicated Resident #1 was seen in ER for right arm swelling and pain. Discharge instructions indicated Resident #1's wrist injury was a sprain and there was no evidence of a fracture. A chest x-ray revealed pneumonia was resolving and the resident should continue to take the previously ordered antibiotic IV daily via the IV line during his rehabilitation at the nursing home. A splint was applied to his right wrist and splint care provided. Record review of provider investigation report dated 05/04/2026 indicated Resident #1 reported to the Administrator on 04/29/2026 at 7:45 p.m. he told the nurse last night (4/28/2026) that his arm was hurting but they would not bring him to the ER.He was provided pain medication for intervention.He said they still refused to bring him to ER so he tried to walk over there himself but they would not let him go He said when he woke up, they still refused to send him to ER, so he tried again to go by walking next door to ER. Attempted calls to Resident #1 on 05/05/2026 at 1:39 p.m. and 05/06/2026 at 10:45 a.m., with messages left and no return call. During an interview on 05/06/2026 at 9:00 a.m., LVN A said she was the charge nurse for Resident #1 on the evening/night of 04/28/2026. She said Resident #1 was complaining of pain to his wrists which was a chronic problem for Resident #1. She said that he did request to go to ER, but she encouraged him to allow the facility to intervene with a treatment plan to prevent unnecessary ER visits. She said that she provided Resident #1 with pain and antianxiety medications. She said that Resident #1 did request to go to the ER twice and was redirected from an attempt to walk to the local ER next door once during her shift. She said that she now realizes that not allowing Resident #1 to go to the ER as he requested would be violating his rights to seek medical attention. She said that the interventions provided during the shift did help his pain and similar treatments that would have been provided at the ER were ordered to be done at the facility. She said Resident #1 was sent to the local ER on [DATE]. She said that she was suspended related to the incident and received training regarding abuse, neglect, and resident rights prior to being allowed to return to work. She said Resident #1 was not abused or neglected during the incident. During an interview on 05/06/2026 at 4:30 p.m., the Administrator said staff should be following and knowledgeable on the facility policy and procedures on resident rights. She said LVN A should have transferred Resident #1 to local ER for medical treatment as requested. She said that she understood LVN A was trying to intervene to prevent unnecessary ER visits but with multiple requests to go to ER from Resident #1 as identified, she should have abided by Resident #1 wishes/rights and transferred him to the ER. She said a negative outcome could be delayed medical care or treatment. During an interview on 05/06/2026 at 4:40 p.m., the Interim DON/RDCS said staff should be following the resident rights facility policies and procedures and if residents request to go to the hospital or ER to review or assess residents and offer services available at facility and if multiple requests made to send resident for the requested medical attention. She said the residents have the right to seek medical attention. She said negative outcome for residents not being sent for requested medical treatment could be lack of specific needs being addressed, and/or delayed treatment. She indicated that Resident #1 was transferred to the local ER the next day and received similar treatments that were ordered by the facility NP. Record review of a Resident Rights facility policy last revised 02/2021 indicated, Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident's right to .a dignified existence .self-determination . Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. a. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights. 2. Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including . e. The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. 4. Respect and dignity. The resident has a right to be treated with respect and dignity, including a. The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. 5. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: a. The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part. b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on observation, interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were completely documented for 2 of 7 residents reviewed for complete medical records. (Residents #1 and #2) * The facility did not have any documentation of Resident #1 having elopement behaviors prior to her placement on the secured unit. * The facility did not have orders for Residents #1 and #2 to reside on the secured unit. This failure could place residents at risk of restraint and isolation. Findings included:1. Record review of a face sheet dated 01/17/26 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions) and dementia (loss of cognitive functioning). During an observations on 01/17/26 from 12:00 p.m. through 04:00 p.m. indicated Resident #1 was residing on the secured unit of the facility. Record review of a list provided by RN A on 01/17/26 at 12:55 p.m. indicated Resident #1 was placed on the secured unit in the last 3 months. Record review of an Elopement Risk assessment dated [DATE] indicated Resident #1 had no history of elopement or an attempted elopement while at home; no history of elopement or attempted leaving the facility without informing staff; did not verbally express the desire to go home or pack belongings to go home; and did not wander with a specific destination in mind, attempting to open secured doors, trying to leavethe facility to go home, etc. Record review of the quarterly MDS dated [DATE] indicated Resident #1 had severely impaired cognition with a BIMS of 00 out of 15 and she had no behaviors. Record review of a care plan dated 12/31/25 indicated Resident #1 had risk for wandering/elopement identified with appropriate interventions. Record review of Nurse Notes from 11/17/25 through 12/26/25 indicated Resident #1 had no exit seeking behaviors. Record review of an Elopement Risk assessment dated [DATE] indicated Resident #1 had history of elopement or attempted leaving the facility without informing staff; and had wandering with a specific destination in mind, attempting to open secured doors, trying to leave the facility to go home, etc. Record review of physician orders for January 2026 indicated Resident #1 had no order for placement on the secured unit. During an interview on 01/17/26 at 12:56 p.m. RN A said Resident #1 was her family member and was placed on the secured unit a few weeks ago. She said the resident was having exit seeking behaviors at times wanting to go out and down the road to find her husband. She said the facility contacted the RP about this and the RP agreed to place her on the unit for her safety. 2. Record review of a face sheet dated 01/17/26 indicated Resident #2 was admitted on [DATE] and readmitted on [DATE]. Her diagnosis included dementia (loss of cognitive functioning). Record review of an Elopement Risk assessment dated [DATE] indicated Resident #2 was not bedfast or non-ambulatory; did not have a history of elopement or an attempted elopement while at home; did not have a history of elopement or attempted leaving the facility without informing staff; did not verbally expressed the desire to go home or packed belongings to go home; and did not wander with a specific destination in mind, attempting to open secured doors, trying to leave the facility to go home, etc. Record review of Nurse Notes for Resident #2 indicated the following entries:* on 11/28/2025 at 03:39 p.m. Attempted to administer resident Rocephin antibiotic shot to treat UTI in progress. Resident noted with increased agitation and restlessness. Refused for staff to administer medication. Resident currently in room, rummaging through drawers. No symptoms of distress noted. Ambulating with walker.* on 11/29/2025 at 12:37a.m. Resident continues to refuse medications. Resident states, No, I am not taking anything from any of ya'll. I don't know, but I think ya'll all be in this together. I don't know what ya'll are trying to give me. * on 12/01/2025 at 12:23 a.m. Resident had been paranoid that family members are trying to take her money away. Resident had periods of forgetfulness. Resident at times thinks that she still has an apartment that she needs to pay the rent for. Thinks that she needs to go to the hospital so things can get straightened out money wise. Resident thought that we, the facility are trying to poison her and will refuse medications at times. Resident thinks that we are on her family member's side. Attempted to explain to resident the situation, where she was but does not believe staff.* on 12/01/2025 at 09:00 resident was given lorazepam as prn order for agitation, yelling, anxious. Continued with paranoia regarding family issues, thinks facility was trying to poison her, refuses meds at times.* on 12/01/2025 at 06:00 p.m. Resident is upset stating that her son and sister are up to no good. Resident is yelling and cursing saying, we can't hold her here like a prison. Resident states you are trying to poison me; you aren't even a nurse Resident has been anxious and very paranoid. Notified MD, psychiatric referral in, unable to give prn Ativan due to resident not trusting staff. MD aware. Record review of an Elopement Risk assessment dated [DATE] indicated Resident #2 was not bedfast, non-ambulatory or unable to self-propel in a wheelchair independently; and had been seen packing belongings to go home without a discharge plan in place. Record review of Nurse Notes for Resident #2 indicated an entry on 12/03/2025 at 04:01 p.m. Resident moved to the unit from 200 hall, resident is alert and oriented to self with no acute distress noted, RP made aware of room change, resident tolerated adjustment well, resident orientated to room, and call light in reach. Record review of the quarterly MDS dated [DATE] indicated Resident #2 had moderately impaired cognition with a BIMS of 08 out of 15 and had no behaviors. Record review of physician orders for January 2026 indicated Resident #2 had no order for placement on the secured unit. Record review of a care plan dated 01/17/26 indicated Resident #2 was at risk for elopement as evidenced by history of attempts to leave facility. Resident wanders aimlessly. Appropriate interventions were in place. During an observations on 01/17/26 from 12:00 p.m. through 04:00 p.m. indicated Resident #2 was residing on the secured unit of the facility. During a phone interview on 01/17/26 at 11:35 a.m. Administrator B said residents on the Memory Care Unit have to meet criteria to be placed on the unit. She said they had not had any residents that recently moved to the unit that she could think of at the time. She said most residents initially admitted to the unit due to history of elopement/wandering at home or another facility. She said if a resident had exit seeking behaviors after they were admitted to the facility then they would be assessed, permission from the family, an order obtained from the physician, and it should all be documented in the resident's chart. During an interview on 01/17/26 at 11:55 a.m. LVN C said Resident #1 had moved to the secured unit a few weeks ago due to having issues with trying to get out of the building. She said Resident #2 had been moved to the secured unit also because of saying they were trying to keep her prisoner when she would head to one of the doors. She said they monitor them with the others to ensure they do not elope, but she can wander around the unit. During an interview on 01/17/26 at 12:56 p.m. RN A said they had a criteria that had to be met for placement on the secured unit. She said there should be documentation in the clinical record to show why an Elopement Risk Assessment was done and why the resident was moved to the secured unit. She said they had to have an order from the physician also to place someone on the secured unit. She said if documentation was not done or an order was not received there would be no indication as to why a resident was placed on the secured unit and the record would be incomplete. During an interview on 01/17/26 at 03:52 p.m. Administrator D indicated residents should have placement on the Memory Care unit assessed, an order written, and a care plan addressing placement otherwise they could be inappropriately placed on the unit.Record review of an admission Criteria for Memory Care Program dated 02/01/23 indicated POLICY: Criteria have been established for admission to the Memory Care Program when the patient's needs warrant placement into secured care. admission to the Memory Care Program must meet the criteria and must be approved by the IDT. PROCEDURE:1. A patient's placement into the Memory Care Program is based upon an interdisciplinary assessment of the resident's cognitive and functional status. 2.A patient's placement or transfer to the Memory Care Program is determined at such time as a patient constitutes a need to be in a safer environment that provides quality of life within the limits of the facility's ability or is determined to be a wandering or elopement risk.5. The patient representative for the resident will be contacted regarding placement in the Memory Care Program pending room available.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1of 1 kitchens reviewed for effective pest control in that: Numerous flies were observed throughout the kitchen during the noon meal preparation time on 07/07/2025. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.Findings included: During observations and interviews on 07/07/2025 from 11:00 - 12:00 noon, during meal preparation and serving, numerous flies were swarming throughout the preparation area. Flies were observed landing on steamtable, cabinets, near handwashing sink, and near food cart. Six or 7 flies were killed with flyswatter within this period. [NAME] D and dietary aide E acknowledged the numerous flies and said the flies would come in through the side exit door of the kitchen which was approximately 10 yards from the rear exit door to the facility. They added the flies seemed to come inside more after it had rained. They said facility staff were constantly going in and out of the back door because it would lead to the laundry area, parking lot, and the garbage dumpster. During an interview on 07/07/2025 at 09:45 a.m., the DM (dietary manager) said she had been aware of flies in the kitchen area. She said she had requested the kitchen staff not use the side exit door from kitchen due to it being near the rear exit door of facility. She said she had requested the facility to obtain a fly trap wall sconce for the kitchen. She said a potential negative outcome would be cross contamination of food, possibly causing food-borne illnesses. She said should an insect land on the food, it would have to be thrown out and possibly delay meals for the residents. During a confidential interview with members of the Resident Council on 07/07/2025 at 10:00 a.m., the Resident Council said they had observed numerous flies in dining room on occasion. They said they sometimes would swat flies at mealtimes. Resident Council members said obviously the facility pest control was ineffective. During observations and interview on 07/08/2025 at 08:00 a.m., the maintenance supervisor acknowledged the facility had concerns with flies outside the rear exit of facility which also led to side entrance door to kitchen. He said there were 3 fly trap light wall sconces throughout facility. Observations were made of the 3 fly trap wall sconces with these results:#1 located at rear exit door - the sticky strip was missing;#2 located in closed hallway leading from Hall 400 to exit door near laundry; and #3 located in common area in front lobby of facility - the sticky strip was missing.The maintenance supervisor said without the sticky strip in the wall sconces, the flies were less likely to be trapped and eliminated. He said the facility had a pest control service that would come to facility monthly. He said he was responsible for ensuring sticky strips were intact as well. Record review of the facility contracts revealed a contract, undated, for pest control service was in place. Record review of the pest control visit logs indicated the pest control service visited the facility monthly with last visit 06/25/2025.During an interview on 07/08/2025 at 8:30 a.m., the Administrator said the pest control service came out monthly to service the fly trap sconces. He said the most recent service was 06/25/2025 and at that time he had requested a 4th sconce to be delivered. The administrator said the fly trap sconces work by ultraviolent light and sticky pads that were designed to trap any insect that flies and lands on the strip including flies, bugs, wasps, etc. During an interview on 07/08/2025 at 2:00 p.m., the DON said her expectations were for there to no flying insects or rodents in the kitchen or dining area. She said the facility had fly traps located in specific areas. She said a negative outcome would be flies or insects getting into resident food. She said it would be unsanitary, cross contamination, and could potentially cause symptoms related to stomach issues. Record review of facility policy dated May 2008 titled Pest Control indicated facility shall maintain an effective pest control policy. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 2 of 10 residents (Residents #13 and #34) reviewed for unnecessary medication. 1. The facility failed to monitor Resident #13 for side effects of the antianxiety medication, lorazepam (used to treat anxiety) routinely and PRN.2. The facility failed to ensure a stop date or reorder date was ordered for the PRN lorazepam for Resident #13. 3. The facility failed to ensure Resident #13 was monitored for side effects of the antipsychotic medication quetiapine fumarate (used to treat bipolar disorder).4. The facility failed to monitor Resident #34 for side effects of the antipsychotic medication Abilify (used to treat several mental health conditions).These failures could place residents at risk for adverse consequences and decline in health.Findings include:1. Record review of Resident #13's face sheet, dated 07/06/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #13 had diagnoses which included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), dementia (a group of thinking and social symptoms that interfere with daily function) and anxiety (intense, excessive and persistent worry and fear about everyday situations).Record review of Resident #13's admission MDS assessment, dated 05/30/25, documented a BIMS score of 00, which indicated severely impaired cognition. Resident #13 had diagnoses which included bipolar disorder, depression (a serious mental illness characterized by sadness and a loss of interest in activities) and anxiety. The assessment indicated Resident #13 received an antipsychotic and antianxiety medication during the last 7 days.Record review of Resident #13's MAR, dated 07/08/25, indicated Resident #13 received lorazepam 1 mg at bedtime for dementia and anxiety with a start date of 05/23/25, Quetiapine fumarate 25 mgs at bedtime for bipolar disorder with a start date of 06/03/25 and lorazepam 1 mg every 4 hours as needed for dementia and anxiety with a start date of 05/23/25 and no stop or reorder date.Record review of Resident #13's physician orders, dated 07/06/25, indicated Resident #3 was prescribed lorazepam 1 mg at bedtime for dementia and anxiety with a start date of 05/23/25, lorazepam 1 mg every 4 hours as needed for dementia and anxiety with a start date of 05/23/25 and no stop or reorder date and quetiapine fumarate 25 mg at bedtime for bipolar disorder with a start date of 06/03/25. The orders did not address monitoring the antianxiety or antipsychotic medication for side effects or a reorder or stop date for the PRN antianxiety medication.Record review of Resident #13's care plan, with a target date of 09/04/25, indicated Resident #13 was prescribed an antianxiety medication with interventions which included administer antianxiety medication as ordered by physician and monitor, document and report any adverse reactions every shift and monitor for side effects and effectiveness every shift Resident #13's care plan indicated she received psychotropic medication with interventions including administer as ordered by the physician, monitor for side effects and effectiveness every shift. Record review of Resident #13's electronic medical record, from 05/23/25 to 07/07/25, for Resident #13 did not indicate the nurses' documented monitoring of side effects of the routine or PRN antianxiety medication lorazepam or the psychotropic medication quetiapine fumarate with medication administration.During an observation and interview on 07/06/25 at 9:20 a.m., Resident #13 was sitting on her bed and said she was unsure what medication she took.2. Record review of Resident #34's face sheet, dated 07/06/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #13 had diagnoses which included schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder such as depression or bipolar disorder) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #34's quarterly MDS assessment, dated 06/06/25, documented a BIMS score of 3, which indicated severely impaired cognition. Resident #34 had diagnoses which included Alzheimer's disease and schizoaffective disorder. The assessment indicated Resident #34 received an antipsychotic medication during the last 7 days.Record review of Resident #34's MAR, dated 07/08/25, indicated Resident #34 received Ability 2 mg daily for schizoaffective disorder with a start date of 05/31/25. Record review of Resident #34's physician orders, dated 07/06/25, indicated Resident #34 was prescribed Ability 2 mg daily for schizoaffective disorder with an order date of 07/02/25. The orders did not address monitoring of the antipsychotic medication for side effects.Record review of Resident #34's care plan, with a target date of 09/07/25, indicated Resident #34 was prescribed a psychotropic medication, Abilify with interventions including administer as ordered by the physician, monitor for side effects and effectiveness every shift.Record review of Resident #34's electronic medical record, dated 07/01/25 to 07/07/25, did not indicate the nurses' documented monitoring of side effects of or the psychotropic medication Abilify with medication administration.During an observation and interview on 07/06/25 at 8:40 a.m., Resident #34 was lying in bed and said she was unsure of what medication she took.During an interview on 07/08/25 at 10:00 a.m., LVN C said she was responsible for providing care for Resident #13 and she received lorazepam and quetiapine fumarate and should be monitored for side effects in the computer system and was not, it was overlooked. She said she was responsible for providing care for Resident #34 and she received Ability and should be monitored for side effects in the computer system and was not. LVN C said the nurse ordering the medication was responsible for adding monitoring into the computer system and the Unit Manager was the back up. She said she was educated to monitor psychotropic medication for side effects, but it was overlooked. She said the DON monitored the PRN medication for 14 day stop dates. LVN C said the resident risk of not monitoring psychotropic medication for side effects was the medication may not be effective and may not be the correct dose for the resident.During an interview on 07/08/25 at 10:30 a.m., the DON said the nurse ordering the medication was responsible for adding side effect monitoring into the computer system and the UM was the back up to double check and ensure all psychotropic medication was monitored for side effects. The DON said the nurses were educated on monitoring all psychotropic medication for side effects. She said these were overlooked. The DON said the resident risk of a psychotropic medication not monitored for side effects was the resident could have a side effect and staff be unaware. The DON said she was responsible for adding a 14 day stop date to Resident #13 's PRN lorazepam and the UM was the back to double check and ensure the stop date was added to the physician order. She said it was overlooked. The DON said her expectation was all psychotropic medication monitored for side effects and all PRN psychotropic medication had a 14 day stop date added into the computer system so they could be reevaluated by the physician as required.During an interview on 07/08/25 at 11:00 a.m., the Administrator said the nurse ordering the medication was responsible for adding the side effect monitoring into the computer system and the UM was the back up to double check and ensure all psychotropic medication was monitored for side effects. He said all nurses were educated on monitoring psychotropic medication for side effects and these were overlooked. The Administrator said the resident risk of a psychotropic medication not monitored for side effects was the resident could have a side effect and staff be unaware. He said the DON was responsible for adding a 14 day stop date to Resident #13 's lorazepam and the UM was a double check. He said the 14-day stop date was overlooked. The Administrator said his expectation was all psychotropic medication monitored for side effects and all PRN psychotropic medication had a 14 day stop date added into the computer system so they could be reevaluated by the physician as recommended.During an interview on 07/08/25 at 12:45 p.m., the UM said the nurse ordering the medication was responsible for adding the side effect monitoring into the computer system and she was the back up to double check and ensure all psychotropic medication was monitored for side effects. She said the DON was responsible for adding a 14-day stop date to PRN psychotropic medication and she was the back up to ensure all PRN psychotropic medication had a 14 day stop date. She said she did a 24-hour audit on all admissions during the morning meeting to ensure all orders were put in the computer system correctly and the monitoring for side effects and 14-day stop date were added to all PRN psychotropic medication. She said she was educated on monitoring psychotropic medication for side effects and ensuring a 14-day stop date was added to all PRN psychotropic medication. The UM said they were overlooked. She said the resident risk of was the possibility of the facility not being aware of an adverse reaction a resident may have.Record review of the facility's, policy, dated November 2017. titled, Medications indicated, . b. patients must not receive PRN psychotropic medication orders unless that medication is necessary to treat a diagnoses specific condition that is documented in the clinical record and are limited to 14-days. If longer than 14-days, the physician must document their rational in the patient's medical record and are indicate the duration for the PRN order. c. PRN orders for antipsychotic medications are limited to 14-days and cannot be renewed unless the physician evaluates the patient for the appropriateness of the medication.8. Behaviors and side effects of the use of medication must be monitored and documented for Patient/Residents receiving psychotropic medication.

Based on observation, interview and record review, the facility failed to ensure each resident in a nursing facility was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID were evaluated and receive care and services in the most integrated setting appropriate to their needs for 1 of 8 residents (Resident #1) reviewed for PASRR screenings. The facility failed to submit a new PL1 screening to TMHP (a group of contractors that administer Texas Medicaid on behalf of the Texas Health and Human Services Commission) dated 03/06/25, which indicated Resident #1 had positive evidence of mental illness. This failure could place residents at risk of not receiving specialized services. Findings include:Record review of Resident #1's face sheet, dated 07/06/25, indicated a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #1 had diagnoses of generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities) and major depressive disorder (a serious mental illness characterized by persistent sadness, loss of interest in activities and symptoms that interfere with daily life).Record review of Resident #1's PASRR Level 1 Screening, dated 09/29/23, indicated Resident #1 was negative for mental illness, intellectual disability, and developmental disability and negative for dementia as the primary diagnosis. Record review of Resident #1's PASRR Level 1 Screening, dated 03/06/25, indicated Resident #1 was positive for mental illness, negative for intellectual disability, and developmental disability and negative for dementia as the primary diagnosis. There was no PASRR Level II Screening or Form 1012 (Mental Illness/Dementia Resident Review) found in the clinical record from the resident's admission on [DATE] through 07/07/25.Record review of Resident #1's care plan, initiated on 05/02/25 indicated, Resident #1 received psychotropic medication for depression of bupropion with a goal to monitor and report adverse reactions. Record review of Resident #1's most recent significant change MDS assessment, dated 06/21/25, indicated Resident #1 was not PASRR positive and had a BIMS score of 7, which indicated severely impaired of cognition. Resident #1 had diagnoses which included major depressive disorder and anxiety.Record review of Resident #1's physician orders, dated 07/18/25, indicated she was prescribed bupropion HCL 150 mgs XL (antidepressant medication) every day for major depressive disorder with a start date of 04/01/25. During an observation and interview on 07/06/25 at 9:48 a.m., Resident #1 was lying in bed and said she was treated well and received needed care and services. During an interview on 07/07/25 at 11:29 a.m., the MDS Nurse said she was responsible for all PASRR forms in the facility and was educated on PASRR completion. She said her back up was the Regional MDS Coordinator. The MDS Nurse said Resident #1 was considered PASRR negative but had a PL1 dated 03/06/25 which indicated she was positive for mental illness uploaded into the facility's computer system but not sent into TMHP through Simple LTC (long term care software that facilitates claims data analysis and regulatory compliance, reimbursement optimization and quality measurement for healthcare practices). She said she would send in a 1012 form (Mental Illness/ dementia resident review- form used to determine if a resident initially assessed as not needing further evaluation for Mental illness or dementia requires a more in-depth assessment based on new information or changes in their condition) and new positive PL1 immediately. She said the PL1 was overlooked and should have been sent into TMHP on admission. The MDS Nurse said the resident risk of a resident's positive PL1 not sent into TMHP was a resident's needs may not be met. She said the positive PL1 was overlooked before she was hired on 04/01/25.During an interview on 07/08/25 at 10:30 a.m., the DON said the MDS Nurse was responsible for all PASSR forms in the facility and was educated on correctly completing PASRR forms. She said the Regional MDS Coordinator was the back up. The DON said Resident #1's PL1 form was overlooked and only uploaded into the facility's computer system and not uploaded into the Medicaid system. She said the resident risk was a potential lack of services for the resident. The DON said her expectation was every resident had a PL1 form completed on admission and uploaded into the Medicaid system and if it was positive for the resident to receive needed services. During an interview on 07/08/25 at 11:00 a.m., the Administrator said the MDS Nurse was responsible for all PASSR forms in the facility and the Regional MDS Coordinator was the back up. He said the MDS Nurse was educated on completion of PASRR forms and Resident #1's PL1 form was overlooked and only uploaded into the facility's computer system and not uploaded into the Medicaid system. The Administrator said the resident risk was a potential lack of services. The Administrator said his expectation was every resident had a PL1 form completed on admission and uploaded into the Medicaid system and if it was positive for the resident to receive needed services. During an interview on 07/08/25 at 4:17 p.m., the Regional MDS Coordinator said the MDS Nurse was responsible for all PASSR forms in the facility, and she was the back up. She said she spot checked MDSs and PASRR forms and would cover the facility if the MDS Nurse was out on leave. The Regional MDS Coordinator said the MDS Nurse was educated on completion of PASRR forms. She said Resident #1's PL1 form was overlooked and only uploaded into the facility's computer system and not uploaded into the Medicaid system. She said the resident risk was a resident may not receive PASRR services she should be receiving.Record review of the October 2023 Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions . o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State Record review of the facility's, undated, policy titled PASRR Process indicated, PASRR is required of each state's Medicaid program to ensure that those with Mental Illness (MI)/ Intellectual or Developmental Disability (IDD) are cared for properly . PCC - submits the PL1 and becomes the gate keeper of all things PASRR.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was less than five percent or greater. The facility had a medication error rate of 7.79% based on 2 errors out of 26 opportunities, which involved 2 of 6 residents (Residents #6 and #49) and 2 of 3 staff observed during medication administration reviewed for medication error. 1. The facility failed to ensure LVN A administered Dorzolamide Solution 2% Ophthalmic (eye drops) per facility policy to Resident #49. 2. The facility failed to ensure LVN B did not administer Levothyroxine 75 MCG to Resident #6 on an empty stomach. These failures could place residents at risk of unwanted side effects and not receiving the therapeutic dosage of medications. Findings include: 1. Record review of Resident #49's face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), and open-angle glaucoma (a chronic eye condition where the eye’s drainage canals gradually clog, leading to a slow increase in the intraocular pressure). Record review of Resident #49's Quarterly MDS assessment, dated 04/18/25 indicated a BIMS score of 10, which indicated Resident #49's cognition was moderately impaired. Record Review of Resident #49's physician orders dated July 2025 indicated Dorzolamide Ophthalmic Solution 2% instill 1 drop each eye two times daily for glaucoma. Record review of Resident #49's medication administration record (MAR) dated 07/08/25 indicated Dorzolamide ophthalmic solution 2% instill one drop in both eyes two times a day for Glaucoma at 7:00 a.m. and 7:00 p.m. During an observation of medication pass on 07/07/25 at 7:18 a.m., LVN A instilled Dorzolamide ophthalmic solution 2% one drop into the inner corners of each eye. During an interview on 07/08/25 at 11:14 a.m., LVN A said she always administered eye drops to the inner corners of the eyes and was careful not to place the drop directly on the eyeball. She said Resident #49 usually pulled his own lower lid down, but he had not done so today. She said even on days when he did pull his lower eye lid down, she still administered his eye drops into the inner corners of his eyes. She said she did not know what facility policy said about administering eye drops. She said the facility watched her give medications including eye drops and had never instructed her she should administer the drops differently. 2. Record review of Resident #6's face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Parkinsonism (a syndrome characterized by tremor, bradykinesia (slowness of movement) , rigidity, and postural instability) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #71 's quarterly MDS assessment dated [DATE] indicated a BIMS score of 4, which indicated Resident #6’s cognition was severely impaired. Record review of Resident #6's physician orders dated July 2025 indicated Levothyroxine Sodium 75 MCG give one tablet by mouth one time a day for low thyroid hormone. Record review of Resident #6's MAR dated 07/08/25 indicated Levothyroxine Sodium 75 MCG give one tablet by mouth one time a day for low thyroid hormone at 8:00 a.m. During a medication pass observation and interview on 07/08/25 at 8:05 a.m., LVN B administered the following medications to Resident #6 orally: - Benztropine 1mg 1 tablet - Famotidine 20mg 1 tablet - Iron 325mg 1 tablet - Haloperidol 1mg 1 tablet - Levothyroxine Sodium 75MCG 1 tablet - Oxcarbazepine 200mg 1 tablet - Paliperidone ER 3mg 1 tablet - Vitamin D 325MCG 1 tablet - Clonazepam 1mg 1 tablet LVN B said Resident #6 had just finished his breakfast. During an interview on 07/08/25 at 11:55 a.m., LVN B said Levothyroxine should always be given on an empty stomach for best absorption. She said she usually gave Resident #6’s medications before breakfast, but she had been running late and gave all his medications after he had eaten. She said giving the Levothyroxine with breakfast and other medications could interfere with the medication's absorption and it might not be as effective. During an interview on 07/08/25 at 3:05 p.m., the DON said the facility policy was to instill eye drops by averting the lower lid and instilling the drop into the pocket created by averting the lower eye lid. She said the Pharmacy Consultant for the facility watched medication pass with the nurses quarterly. She said she had called the Pharmacy Consultant, and she said she was surprised because she had observed LVN A administering eye drops by averting the resident's lower eye lid and instilling the drop into the pocket. She said that when the facility changed to the electronic medical record (EMR) systems on April 1st, 2025, all thyroid medications had been rescheduled to be given at 8:00 a.m. She said the former EMR system had all thyroid medications scheduled to be given at 6:00 a.m. She said she reviewed all resident's records and corrected the scheduling error for all thyroid medications. She said he was the direct supervisor of all nursing staff. She said she expected all medications to be given according to facility policy, medication recommendations, physician orders, and the 6 rights of medication administration. She said the possible negative outcome of administering eye drops into the inner corners of the eyes and thyroid medications with other medications on a full stomach was decreased absorption of the medications. Record review of the facility’s undated policy titled Medication Administration indicated … *Use index or middle finger to pull down the eye lid and instill drop into lower lid conjunctival sac. You can no longer drop onto the eyeball” … Record review of Synthroid.com indicated … “The way you take Synthroid (Levothyroxine) can affect how much your body is getting. … Take Synthroid once a day, every day at the same time before breakfast. Only take Synthroid with water and on an empty stomach. Wait 30 minutes to 1 hour before eating or drinking anything other than water.” …

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 residents room reviewed for food safety (room [ROOM NUMBER]) in that: The refrigerator located in room [ROOM NUMBER] was not monitored for expiration/used by dates. This failure could place residents at risk for food illnesses. Findings included:During an observation and interview on 07/06/2025 at 09:30 a.m., revealed the following expired items in Resident #2's personal refrigerator:-one 18-ounce bottle of mayonnaise with expiration date of 06/16/2025;- one 9-ounce package of ham lunch meat with expiration date of 07/02/2025;-one 15-ounce bottle of sandwich spread with expiration date of 12/02/2024;-one 13 -ounce bottled cold coffee drink with expiration date of 02/03/2025;-two 8-ounce supplemental milk shake with expiration date of 02/01/2025;-one 15-ounce bottle of mayonnaise with expiration date of 06/11/2025; and-one 20-ounce strawberry Jell-O with expiration date of 04/04/2024. Resident #2 said her family brought her the items. She said the nursing staff would hand her whatever items she requested. Resident #2 said she did not know who was responsible to oversee items in the refrigerator for expiration dates. The Regional Clinical Director of Services was present and disposed of the expired items. She said they should not have remained available after the expiration date on each item. Consumption could lead to food-borne illnesses. During an interview on 0708/2025 at 2:00 p.m., the DON said nursing staff were expected to check items for expirations weekly. She said all food from outside should be dated when opened and discard when reached expiration date. Consumption of expired food or drink could cause negative adverse effects including gastrointestinal symptoms. Record review of the facility policy, dated November 2016, and titled Patient/Resident Food from Outside indicated the following:1) Patients/Residents may accept food from family and visitors as part of their foodchoices.2) The facility staff should monitor foods being brought to Patients/Residents to ensurethe food items do not place the Patient/Resident at risk for choking based upon anyphysician ordered restrictions.3) Food or beverages brought in from the outside will be dated. Food items placed [NAME] common refrigerator/freezer will also be labeled with the patient's/resident's nameand room number.4) The facility staff should monitor and assist Patients/Residents and visitors with safefood handling practices to ensure avoidance of food borne illnesses.5) Food or beverages in the original container that is past the manufacturer's expirationdate will be discarded by the facility staff.

Based on observation, interview, and record review, the facility failed to ensure the resident had a right to a clean and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 2 shower rooms and 1 of 15 residents reviewed for environmental concerns. The facility failed to ensure Hall 400's shower room did not have one shower chair soiled with a brown substance with grayish area surrounding below the seat. The facility failed to ensure Resident #26's wheelchair and wheelchair cushion did not have smears of food and food particles.These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.Findings include:1. During an observation and interview on 07/06/2025 at 08:45 a.m., Hall 400's shower room had one shower chair soiled with brown substance with grayish area surrounding below the seat. CNA F and CNA M acknowledged the soiled areas were below the seat of the shower chair. They said the staff who provide the daily showers were responsible for cleaning between uses. CNA F said the shower chairs and shower walls were to be sprayed with a disinfectant spray and rinsed with water after each use. She acknowledged under the seat of shower chairs had not been cleaned by wiping or using a cleaning brush. CNA F and CNA M said the disinfectant was kept in a storage cabinet in the shower room and occasionally had to ask housekeeping for disinfectant. During an interview on 07/06/2025 at 8:50 a.m., Housekeeper G said the aides were responsible for cleaning the shower chairs after each use. She said housekeeping was responsible for cleaning the entire shower area. Housekeeper G said she would also clean shower chairs during her routine if they were soiled. During an interview on 07/08/2025 at 2:00 p.m., the DON said her expectations included all shower chairs to be cleaned between each use. This would include spraying chairs with disinfectant, wiping all surfaces on top and below before rinsing. The DON said soiled resident equipment could lead to cross-contamination and potentially cause infections/illnesses due to encountering soiled items. During an observation and interviews on 07/07/2025 at 09:15 a.m., the shower room for Halls 100/200 was in use. Both shower chairs were in use during the observation. CNA H and CNA J said the shower chairs are to be cleaned and disinfected between each resident. CNA H pulled a bottle of disinfectant from storage cabinet. She said it was to be used on surfaces and chair frames. During a confidential interview with members of the Resident Council on 07/07/2025 at 10:00 a.m., the Resident Council said the shower chairs were cleaned between uses with disinfectant and wiped by the aides, however had not observed shower chairs having been cleaned from underneath the seat. Record review of Resident #26’s face sheet, dated 07/08/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #26 had diagnoses which included Alzheimer’s disease and stroke (lack of oxygen to the brain). Record review of Resident #26’s annual MDS assessment, dated 04/21/25, indicated Resident #26 was with BIMS of 3, which indicated severely impaired cognition. He used a wheelchair daily for mobility. Record review of Resident #26's care plan, updated on 07/07/25 after surveyor intervention, indicated Resident #26 had a behavior problem, resident spits on the wall, floor bed rails and drops food in chairs and spits food. The goal indicated the resident will have fewer episodes of spitting on the walls, bed, and floor. During an observation on 07/06/25 at 11:00 a.m., Resident #26‘s wheelchair and wheelchair cushion had food particles and food smeared on the sides of the wheelchair, foot pedals and on tires. The cushion had a beige substance smeared and appeared to be dry and was flaking. During an interview and observation on 07/7/25 at 12:30 p.m., Resident #26’s family said she never saw his wheelchair and cushion without food smears and food particles. The wheelchair and cushion had food smears and food particles. The foot pedals had food particles. She said she had not complained about the condition of the wheelchair or the cushion to the facility. During an interview on 07/8/25 at 10:00 a.m., the DON said night shift was responsible for washing wheelchairs and cushions. Her expectation was for all the wheelchairs to be cleaned each week on the night shift. She said Resident #26’s wheelchair should have been cleaned on Saturday nights. She said the wheelchairs being dirty was not homelike and could cause infection control issues. During an interview on 07/08/25 at 11:00 a.m., the DON said both regular night shift CNAs were on vacation. She said the charge nurse this past weekend was LVN N and the UM was working on the night shift and provided direct resident care. She dialed the unnamed night shift CNAs, and we were unable to leave message. During an interview on 07/08/25 at 11:30 a.m., LVN N said she was responsible to ensure the CNAs cleaned the wheelchairs and cushion on the night shift. She said she did not notice Resident #26 wheelchair was dirty. During an interview on 07/8/25 at 3:15 p.m., the UM said she worked Saturday night (07/05/25) as an aide but she didn’t recall Resident #26 wheelchair being dirty or if it was washed. She said on the night shift the wheelchairs were washed weekly. A facility policy dated May 2017 and titled “Homelike Environment” indicated the following. …” Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. … 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment.”

Based on observation, interview, and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 3 residents on the secured unit reviewed for clinical records. (Resident #32 and #7) The facility did not have a physician order for placement on the Secured Unit and an Elopement Assessment upon admission to the Secured Unit for Resident #32. The facility did not have an Elopement Risk Assessment for change in condition, a physician order for placement on the Secured Unit, and a complete care plan for Resident #7. These failures could place residents on the Secured Unit at risk of being inappropriately place and staff not being aware of needs for residents. Findings included: 1. Record review of the face sheet dated 06/19/24 indicated Resident #32 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included vascular dementia (a type of loss of cognitive functioning caused by conditions that damage blood vessels and block blood flow to your brain), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), and amnestic disorder (a deficit in memory caused by brain damage or brain diseases). Record review of Nurse Notes with entry dated 02/24/24 for Resident #32 indicated She walks ad lib about secure unit with steady gait and balance Record review of a care plan dated 02/24/24 indicated Resident #32 was at risk for elopement and resided on the Secured Unit. Record review of the MDS dated [DATE] indicated Resident #32 had a BIMS score of 06 indicating she had severely impaired cognition. Record review of the clinical record from February 2024 through June 2024 for Resident #32 indicated the following: * no physician order for placement on the Secured Unit; and * no Elopement Assessment upon admission to the Secured Unit. During an observation and interview on 06/17/24 at 09:10 a.m., Resident #32 resided on the Secured Unit. She was sitting in a chair in her room. She said she was doing fine. During an interview on 06/19/24 at 01:48 p.m., the DON said there was not an Elopement Risk Assessment done on Resident #32 on admission and one should have been done. She said one was done almost 2 months after admission on 04/02/24. Record review of an Accident/Incident policy dated 05/2016 indicated 6. An Elopement Risk Assessment must be completed the day of admission (including readmission) and upon any significant change in a Patient's condition 2. Record review of face sheet dated 06/19/24 indicated Resident #7 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoseis of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), mood disturbance (feelings of distress or sadness, or symptoms of depression and anxiety), and cognitive communication deficit (a communication difficulty caused by an underlying cognitive impairment). Record review of a quarterly MDS dated [DATE] indicated Resident #7 had a BIMS score of 3 indicating severe cognitive impairment, had no behaviors, and required partial/moderate assistance with most ADLs. Record review of an undated care plan indicated Resident #7 was at risk for wandering as evidenced by dementia. Interventions included reporting any attempts to exit the facility to IDT, family, and physician and record in the clinical record. Placement on secure unit was not addressed in the care plan. Record review of a progress note dated 02/04/24 indicated Resident #7 was threatening to leave the facility and was being transferred to the secure unit for her own safety. Record review of physician orders dated June 2023 did not indicate an order for Resident #7 to reside to reside on the secure unit. During an observation on 06/17/24 at 09:23 a.m., Resident #7 was in bed in her room on the secure unit. She was unable to answer questions. During an interview on 06/19/24 at 01:10 p.m., the DON said she was unsure if a physician order was required for resident admission or transfer to the secure unit. She said Resident #7 was placed on the secure unit because she required low stimulation and was exit seeking. She said an elopement assessment was included in admission, re-admission, and quarterly nursing assessments, but was not completed before transferring Resident #7 to the secure unit. She said Resident #7's care plan should include an intervention of secure unit placement. She said possible negative outcome for not obtaining a physician order and including secure unit placement on Resident #7's care plan could be staff being unaware of why the resident required placement and inconsistencies of nursing care . Record review of an Accident/Incident policy dated 05/2016 indicated 6. An Elopement Risk Assessment must be completed the day of admission (including readmission) and upon any significant change in a Patient's condition 36214

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for2 of 4 residents reviewed for infection control. (Residents #102 and #252) The facility did not have appropriate signage indicating Resident #102 was on Droplet Isolation. The facility did not ensure staff implemented appropriate infection control measures while providing care for Resident #252. These failures could place residents, staff, and visitors at risk of exposure to Infectious diseases, decreased health, and/or hospitalization . Findings included: 1. Record review of a face sheet dated 06/17/24 indicated Resident #102 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included MRSA (infections caused by specific bacteria that are resistant to commonly used antibiotics) of the sputum (mixture of saliva and mucus produced by the lungs as a result of viral or bacterial infections). Record review of physician orders for June 2022 indicated Resident #102 had an order dated 06/15/24 for Droplet Isolation and received Linezolid (antibiotic) twice daily ordered to treat respiratory infection. Record review of a Baseline Care Plan dated 06/15/24 indicated Resident #102 was on Droplet Precautions. During an observation on 06/17/24 at 09:20 a.m., outside Resident #102 room indicated an isolation set up cart with sign on top indicating Enhanced Barrier Precautions there was no indication of Droplet Precautions. During an observation on 06/17/24 at 12:20 p.m., outside Resident #102 room indicated an isolation set up cart with sign on top indicating Enhanced Barrier Precautions there was no indication of Droplet Precautions. During an observation on 06/17/24 at 02:10 p.m., outside of Resident #102 room indicated there was an isolation set up cart with sign on top indicating Enhanced Barrier Precautions there was no indication of Droplet Precautions. During an interview on 06/17/24 at 02:12 p.m., LVN A said Resident #102 had MRSA of the sputum and was on Droplet Precautions not on Enhanced Barrier Precautions. During an interview on 06/17/24 at 03:25 p.m., the DON said she did not know why the signage was not indicating Droplet Precautions. She said it was the responsibility of the nurses to place the signage on the door. She said the signage missing would not let visitors know to apply a mask or face shield when entering the room and could expose them to infections. Record review of an Isolation-Categories of Transmission-Based Precautions policy revised September 2022 indicated .Policy Interpretation and Implementation: 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room 33460 2. Record review of a face sheet dated 06/17/24 indicated Resident #252 was [AGE] year-old male admitted on [DATE]. His diagnoses included pneumonia (infection in lung or lungs) due to methicillin (antibiotic) susceptible staphylococcus aureus (bacteria). Record review of the admission MDS dated [DATE] indicated Resident #252 was intact with cognition. He had diagnoses of pneumonia and methicillin susceptible staphylococcus aureus during the last seven days. Record review of care plan date 05/31/24 indicated Resident #252 required droplet isolation for methicillin susceptible staphylococcus aureus. Record review of the physician orders dated 06/17/24 indicated Resident #252 orders included cefazolin 2-gram solution for intravenous every eight hours for seven days with start date of 06/17/2024. Flush right upper arm PICC (peripherally inserted central catheter) line using the SASH (saline, administer medication, saline, heparin) Method every shift and after each use: 10 cc normal saline, administer medications/fluids, then 10 cc normal saline, and then 5 cc of heparin with start date of 06/01/24. Droplet isolation precautions (a set of precautions used to prevent spread of germs from a patient with respiratory Infection) pneumonia with methicillin susceptible staphylococcus aureus with start date of 06/02/24. During an observation on 06/18/24 at 9:50 a.m., LVN A donned her mask, gown, and gloves and went into Resident #252's room to disconnect his IV. She disconnected the tubing and cleaned the PICC line port for 30 seconds with an alcohol pad. She reached under her isolation gown and obtained a 10-cc normal saline flush and a heparin flush out of her pocket without hand hygiene or changing gloves. LVN A then flushed his PICC line with the 10-cc of normal saline and flushed with heparin without hand hygiene or changing gloves. During an interview on 06/18/24 at 9:55 a.m., LVN A said she should not have placed the normal saline flush and heparin flush in her pocket and should not have reached under her gown. She said reaching under her isolation gown and into her pocket would contaminate her pocket and her gloves. During an interview on 06/18/24 at 2:00 p.m., DON said the staff should not reach under the isolation gowns when in the rooms with droplet precautions as they could spread germs. Record review of Droplet Precautions policy dated August 2012 indicated Droplet Precautions are designed to reduce the risk of droplet transmission of infectious. In addition to Standard Precaution and contact Precautions, use droplet precautions for a patient known or suspected to be infected with microorganisms transmitted by droplets that can be generated by the patient during coughing, sneezing, talking or the performance of procedures. Standard Precaution Handwashing 1. Hand washing after touching blood, body fluids, secretions, and contaminated items, whether gloves were worn. Wash hands immediately after gloves are removed, between patient contacts, and otherwise indicated to avoid transfer of microorganism other patients or environment.

Based on interview and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 1 of 15 residents reviewed for resident assessments (Resident #6). The facility did not have a PASRR level 1 screening (PL1) for Resident #6 upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a face sheet dated 06/19/24 indicated Resident #6 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral palsy (a congenital disorder of movement, due to abnormal development). Record review of the electronic record from 05/02/24 to 06/17/24 indicated no evidence of PL1 for Resident #6. Record review of the admission MDS assessment dated [DATE] indicated Resident #6's PL1 was completed and was PASARR positive. Record review of the PL 1 was dated 05/02/24 for Resident #6 was not completed until after surveyor intervention. Record review of the LIDDA portal for Resident #6 indicated the PL 1 was transmitted to LIDDA on 06/17/24. During an interview on 06/18/24 at 3:30 p.m., the MDS Nurse said Resident #6's PL 1 was not sent to LIDDA until yesterday (06/17/24). She said the PL 1 for Resident #6 was never completed or sent to LIDDA on 05/02/24. She said when being trained by the corporate office, she was instructed upon completing a late PL 1, to date the PL 1 with the date it should have been completed before transmitting to the LIDDA. She said the marketing staff would tell her when a resident was going to admit and might be PASARR positive. She said if LIDDA was not notified, the resident could have a delay in services, and not receive services paid for by LIDDA. She said she was trained that a cerebral palsy diagnosis was a Developmental Disability, and the resident would be considered positive for PASARR. She said she had no policy on PASARR. During an attempted phone interview on 06/18/24 and 06/19/24, there was no answer on the marketing staff's phone number, and she was not at the facility. During an interview on 06/19/24 at 2:00 p.m., the DON said her expectation was for the PL 1 to be completed and transmitted to LIDDA prior to admission. The MDS nurse had been helping this facility while the regular MDS nurse was out of the building. She said if the PL 1 is not completed timely, could delay PASARR services.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 3 residents reviewed for care plans on the Secured Unit. (Resident #10) The facility did not have an Elopement care plan for Resident #10. This failure could place residents on the Secured Unit at risk of not having individual needs met and not receive needed services. Findings included: Record review of the face sheet dated 06/19/24 indicated Resident #10 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning). Record review of an Elopement Risk assessment dated [DATE] indicated Resident #10 was a moderate risk for elopement with actions including Implement Elopement Care Plan Record review of physician orders for June 2024 indicated Resident #10 had an order dated 04/15/24 to admit to the Secured Unit. Record review of the care plan dated 04/15/24 indicated Resident #10 had no care plan for Elopement. Record review of an MDS assessment dated [DATE] indicated Resident #10 had a BIMS of 05 indicating she had severely impaired cognition. During an observation and interview on 06/17/24 at 09:07 a.m., Resident #10 resided on the Secured Unit. She said she was doing good and liked it at the facility. During an interview on 06/19/24 at 01:10 p.m., the DON said a care plan should include a care plan for elopement with interventions for prevention of elopement and assessments to be done. She said ultimately it was her responsibility to ensure one was done. She said not having the care plan could result in nursing staff not being aware of care. Record review of an Accident/Incident policy dated 5/2016 indicated 6 .An Elopement Risk Care Plan must be completed for all Patients based upon the Elopement Risk Assessment

Based on observation, interview, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 15 residents reviewed for care plans. (Resident #43) The facility failed to ensure Resident #43's care plan accurately addressed his diagnosis of urinary tract infection (UTI) and administration of antibiotics. This failure could place residents at risk for staff not being aware of the resident needs and not receiving the care and services to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of a face sheet dated 06/19/24 indicated Resident #43 was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of benign prostatic hyperplasia (A benign {not cancer} condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine) and retention of urine (difficulty urinating and completely emptying the bladder). Record review of an admission MDS dated [DATE] indicated Resident #43 had a BIMS score of 7 indicating he was severely cognitively impairment and had an indwelling catheter (a tube that is inserted into the bladder through the urethra and left in place to drain urine). Record review of a care plan dated 05/10/24 indicated Resident #43 had impaired urinary elimination related to obstruction of urinary flow secondary to enlarge prostate gland. Care plan indicated he was at risk for infection related to his indwelling urinary catheter but did not address his UTI. Record review of a physician order dated 06/11/24 Indicated Resident #43 was to receive Ceftriaxone (antibiotic) 1 gram solution for injection intramuscular daily for seven days for diagnosis of UTI. During an observation on 06/17/24 at 08:51 a.m., Resident #43 was sitting in a wheelchair in the common area of the secure unit with a catheter bag hung for gravity drainage (below the level of the bladder) at the bottom of his wheelchair. He was unable to answer questions about his catheter. During an interview on 06/17/24 at 02:16 p.m., Resident #43's family member said he had a catheter due to his BPH and was currently being treated for a UTI. During an interview on 06/19/24 at 08:33 a.m., the DON said there was no care plan for Resident #43's UTI and antibiotic treatment. She said the Infection Control Nurse was responsible for completing care plans related to infections. She said she was the infection Control Nurse's supervisor. The DON said not updating the care plan could result in other staff not being aware of the change in Resident #43's care. She said her expectation was for care plans to be updated to reflect changes in resident care. During an interview on 06/19/24 at 08:40 a.m., the Infection Control Nurse said she was responsible for updating care plans related to infections and antibiotics. She said she was aware of Resident #43's UTI and ordered antibiotic, but she had not revised his care plan to reflect the changes in his care. She said it was just overlooked. She said not updating the care plan could result in nursing staff not being aware of changes in care. Record Review of a facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022 indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents' conditions change.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 13 residents reviewed for significant medication errors. (Resident #152) The facility did not continue to hold Resident #152's Eliquis following an outpatient minimal invasive procedure. This failure could place residents at risk of harm, impairment, or death from receiving a significant medication when it should have been held. Findings included: Record review of physician orders dated June 2024 indicated Resident #152, admitted [DATE], was an [AGE] year-old female with diagnosis including atrial fibrillation (type of irregular heartbeat). Resident #152 was prescribed Eliquis 2.5 mg twice daily. (a blood thinner). Record review of the entry MDS assessment dated [DATE] indicated Resident #152 was admitted to the facility on [DATE] from a short-term general hospital. The entry MDS did not include BIMS score. Review of Resident #152's care plan dated 06/12/24 indicated the resident had a high risk for increased bleeding and/or bruising related to blood thinning agent Eliquis. The interventions included Hold medication before planned surgery as ordered by MD. Record review of Resident #152's Clinical Notes dated 06/13/24 at 13:01 p.m. indicated LVN A documented an entry to hold Eliquis tonight and tomorrow per MD. (06/13/24 at 7 p.m. and 06/14/24 at 7 a.m.) Record review of Resident #152's Clinical Notes dated 06/14/24 at 09:08 a.m. indicated LVN A documented an entry resident is having a loop recorder aka (also known as) an internal EKG (electrocardiogram - a test that measures the electrical activity of the heart to help diagnose heart problems). Resident (#152) should return to the facility today. Eliquis was held per cardiologist orders. Will remain on hold until further instructions. At 09:09 a.m., LVN A documented spoke with cardiologist office and Eliquis is to be resumed on 06/17/24. Review of the June 2024 MAR indicated on the following dates and times, Resident #152 was administered Eliquis 2.5 mg when it should have been held: *06/14/24 at 7:00 p.m.; *06/15/24 at 7:00 a.m.; *06/15/24 at 7:00 p.m.; *06/16/24 at 7:00 a.m.; and *06/16/24 at 7:00 p.m . During an interview and record review on 06/19/24 at 10:15 a.m., the DON and the state surveyor reviewed Resident #152's June 2024 MAR which indicated Eliquis was administered on the evening of the 14th, and twice daily on the 15th and 16th when it should have been held. The DON said her expectations were for all medications to be administered or held per physician orders. She said this was a medication error and the physician would be notified of it, the cardiologist, and RP (responsible party). Staff would be re-in serviced and disciplinary action would be taken. The DON said when charge nurses obtain an order, it should be documented in the resident's clinical record immediately. She said the electronic medical record program used by the facility had an area to place medications on hold and can be seen by other staff who were responsible for administering medications. She said Resident #152's Eliquis was not documented as held in her MAR, which contributed to the medication error of Eliquis being administered when it should have been held. She added the Unit Managers were responsible for chart audits, and ultimately, she was also. This error could have placed Resident #152 at an increased risk of bleeding following the procedure. During an interview on 06/19/24 at 2:00 p.m., LVN A said she had received an order from Resident #152's cardiologist for her Eliquis to be held on 06/13/24 and to resume on 06/17/24. She said she documented in Resident #152's clinical notes but did not place the Eliquis on hold on the electronic MAR. LVN A said by not documenting to hold the medication, Resident #152 was administered 5 doses of Eliquis while it should have been withheld. She said she now realized the error of not placing Resident #152's Eliquis on hold in the Electronic MAR where the following shifts would know to hold the medication. LVN A said her interventions post incident was to monitor Resident #152 for signs of bleeding and/or bruising, monitor vital signs, and to assess skin during follow up assessments. She said she would also verify orders when receiving them and document at the time orders are taken. LVN A said she notified Resident #152's cardiologist and primary physician of the medication error. She said this error could have placed Resident #152 at an increased risk of bleeding following the procedure. A Charting and Documentation policy date July 2017 indicated the following. All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for one of one kitchen reviewed food service safety. * There were unlabeled, undated, and unsealed containers of food items stored in the refrigerator and dry goods storage. * The facility failed to ensure the DM did not handle uncovered food plates with his bare hands. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings included: 1. During an observation and interview with Dietary Manager (DM) (who identified foods) on [DATE] beginning at 9:37 a.m. of the refrigerators and dry goods storage in the kitchen revealed the following: Refrigerator/Cooler #1 *Bag of lettuce left open with lettuce exposed was unlabeled (identifying what it was) and undated (when opened or when to discard), DM stated, this lettuce will be thrown away because it was not sealed properly, labeled, or dated. Refrigerator/Cooler #2 *Bag of chopped celery open to air with brown patches visible on celery not labeled or dated. *,d+[DATE] onion laying half outside sandwich bag with no label or date on bag. *One peeled cucumber partially sliced in sandwich bag with no label or date. DM stated, all the vegetables would be thrown away because they were not labeled, dated, or sealed properly. Dry Goods Storage *Packet of chicken country gravy dry mix cut open on the top and left open to air. *Bag of flour-like substance open to air with no identifying label. Dated [DATE]. DM threw away both sacks and said the flour-like substance was breadcrumbs and had not been used in a very long time. He said he had not seen the sack on the shelf, and it should have already been thrown away. During an interview on [DATE] at 9:47 a.m., the DM stated he checks food storage two times weekly when making food orders, but he was not checking enough. He said he was responsible for assuring foods were labeled, dated, and stored appropriately. DM said all kitchen staff had been trained on labeling, dating, and sealing foods when stored. He said all foods should be labeled identifying the food and dated when opened to ensure food was not served to residents after it expired. He said he would re-educate his staff to label, date, and seal foods after opening. During an interview on [DATE] at 9:30 a.m., Administrator stated the food in the kitchen must be sealed and labeled and dated properly. The Administrator said she was the DM's direct supervisor, and he was responsible for ensuring/monitoring foods were stored properly. She said an in-service was completed with kitchen staff on [DATE] re-educating staff on sealing, labeling, and dating food items after opening. She said she made rounds in the kitchen and viewed storage of food and the unlabeled, undated, and open foods was not how foods are normally stored at the facility. When asked for a possible negative outcome for opened foods being unlabeled, undated, and not sealed properly she said it was out of the normal. She said there was no possible negative outcome because it had not happened before and would not happen again. Record Review of the facility's policy titled Food Storage revised ,d+[DATE], documented the following: Procedure .4. Plastic containers storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled, including the date the package was opened. 15. d. All foods should be covered, labeled and dated. Texas Food Establishment Rules documented . 228.66 (b) Food storage containers, identified with common name of food. Except for containers holding food than can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with common name of the food. 2. During observations of the lunch meal on [DATE]: * at 12:33 PM DM exited the kitchen with an uncovered plate containing a grilled cheese sandwich. He was touching the plate on the top edge with his bare hand. * at 12:44 PM DM exited the kitchen with an uncovered plate containing a piece of pie. He was touching the plate on the top edge with his bare hand. During an interview on [DATE] at 05:20 PM the DM said dietary staff were only to wear gloves when carrying food plates out of the kitchen. He said food plates were to be covered when coming out of the kitchen except when serving to the dining room. He said uncovered plates were not to be touched with bare hands. He said he did not realize he did not have a glove on when touching the top edge of the plates. According to the FDA Food Code 2022 dated [DATE]: ,d+[DATE] Protection From Contamination After Receiving ,d+[DATE]. Preventing Contamination by Employees. ,d+[DATE].11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S ,d+[DATE].12. (B) Except when washing fruits and vegetables as specified under S,d+[DATE].15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT

Based on interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 2 of 15 residents reviewed for PASARR (Preadmission Screening and Resident Review). *The facility did not complete a new PASARR Level 1 Screening (a preliminary assessment) completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine if a person has, or is suspected of having, a mental illness, intellectual disability or related condition) when Resident #4 was diagnosed with schizoaffective disorder (combination of schizophrenia (serious mental illness) and mood disorder) on 12/19/22. *The facility did not complete a new PASARR Level I Screening (a preliminary assessment) completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine if a person has, or is suspected of having, a mental illness, intellectual disability or related condition) when Resident #7 was diagnosed with major depression and psychotic disorder on 10/26/21. This failure could place the residents at risk for not receiving PASARR care and services. Findings included: 1. Record review of Physician orders dated May 2023 indicated Resident #4, admitted [DATE], was [AGE] years old with diagnoses of schizoaffective disorder. Record review of the 5-day MDS assessment dated [DATE] indicated Resident #4 had verbal or physical behaviors towards others 1 to 3 days and diagnosis of schizoaffective and had received antipsychotic medications 7 times in the last 7 days. Record review of care plan dated 1/30/2022 to present indicated Resident #4 had verbal aggression, physical aggression and resistance to care and was currently taking psychotropic medications for his diagnosis of schizoaffective disorder. Record review of a PASARR Level I dated 01/29/22 indicated Resident #4 did not have a mental illness, intellectual disability or developmental disability. Record review of a pharmacy note to the attending physician dated 12/15/22 indicated the physician had given Resident #4 a new diagnosis of other schizoaffective disorder. During an interview and observation on 05/03/23 at 8:32 a.m., the MDS nurse said the diagnosis of schizoaffective disorder must have been placed in his record in error. The MDS nurse was viewing the electronic record and said yes, he was given the diagnosis on 12/19/22 and she was unaware of this new diagnosis . She said when a new diagnosis was given the nurses should have told her of the changesThe MDS nurse said there should have been a new screen sent to LHMA (Local Mental Health Authority) when that diagnosis was given to Resident #4. She said the possible negative outcome of not updating the PASARR Level I and notifying LMHA could be the resident does not receive the needed services. During an interview on 05/03/23 at 11:50 a.m., the administrator said her expectation was for the MDS nurse, to send a new PASARR level 1 when required. 2. Record review of physician orders dated May 2023 indicated Resident #7, admitted [DATE], was [AGE] years old with diagnoses of psychotic disorder with known hallucinations and major depressive disorder, recurrent, severe with psychotic symptoms. The resident had orders for a psychiatric evaluation dated 3/11/21. Record review of the most recent MDS dated [DATE] indicated Resident #7 had hallucinations and delusions occur every 1 to 3 days, had a diagnosis of depression and received antipsychotic medications 7 times in the last 7 days. Record review of care plans dated 10/11/20 to present indicated Resident #7 had short term memory problems and was currently taking psychotropic medications for depression with psychotic features and psychotic mood disorder. Record review of a psychiatric note dated 10/26/21 indicated Resident #7 had a diagnosis of moderate major depressive disorder. Record review of a PASARR Level I dated 10/27/20 indicated Resident #7 did not have a mental illness, intellectual disability or developmental disability. During an interview on 05/03/23 at 11:07 a.m., the MDS nurse said she was not aware a PASARR had to be updated when a resident received a new psychotic disorder diagnosis. She said the only PASARR Level I Resident #7 had was the one dated 10/27/20. She said a new PASARR Level I was not completed when the resident was diagnosed with psychotic disorder and major depression on 10/26/21. She said the possible negative outcome of not updating the PASARR Level I and notifying LMHA (Local Mental Health Authority) would be the resident could possibly not receive the needed services. During an interview on 05/03/23 at 11:10 a.m., the interim DON said not having a correct PASARR in place could cause the resident to not receive the appropriate PASARR services. She said her expectations was for Resident #7 to have a current and correct PASARR in place . The interim DON said Resident #7 was seeing people outside of her room when there was no one there, so we did have to have her evaluated and seen by the psychiatrist. She was diagnosed with psychotic disorder on 10/26/21. During interview and record review on 05/03/23 at 11:30 a.m., the MDS nurse said the only information in the PASARR transmission portal was the PASARR Level I from 10/27/20. Review of the Simple system (an online system to transmit required PASARR forms to the LMHA) indicated there was no documentation to indicate Resident #7 received a PASARR Level I assessment after the resident was diagnosed with psychotic disorder on 10/26/21. The undated . PASARR Process policy indicated: . PASRR is required of each state's Medicaid program to ensure that those with Mental Illness (MI)/Intellectual or Developmental Disability (IDD) are cared for properly. PCC (Person Centered Care) update and print Positive PASRR list and review at least 1 x week. 33460

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 11 residents (Resident #6) and in 2 of 2 medication carts (100/200 hall nurse cart and 300/400 hall medication aide cart) reviewed for pharmacy services. * Resident #6 had 2 sets of hold parameters for her verapamil (blood pressure medication). LVN C held Resident #6's verapamil without verifying which set of parameters were correct. * The facility had a medication error rate of 4%. * The facility did not dispose of expired medications from the 100/200 hall nurse cart and 300/400 hall medication aide cart. These failures could place residents at risk of not receiving necessary medications, not receiving the intended therapeutic benefits of their medications, and a decline in health. Findings included: 1. Record review of the face sheet indicated Resident #6 was an [AGE] year-old female admitted on [DATE]. He diagnoses included high blood pressure. Record review of the physician orders for May 2023 indicated Resident #6 had a physician order dated 02/15/23 for verapamil 180 mg tablet twice daily with blood pressure and/or pulse hold: systolic (upper number) blood pressure less than 120 to hold; diastolic (lower number) blood pressure less than 60 to hold; and pulse less than 60 to hold. There was also blood pressure and/or pulse hold: pulse less than 60 to hold; diastolic blood pressure less than 80 to hold; systolic blood pressure less than 130 to hold. During an interview on 05/03/23 at 09:21 AM MA C said Resident #6 had 2 sets of hold parameters for the Verapamil. She said she had reported this to the nurse several times, but it still had not been fixed. During an interview on 05/03/23 at 09:25 AM LVN E reviewed Resident #6's physician order and said Resident #6 had 2 sets of hold parameters. During an interview on 05/03/23 at 09:26 AM the ADON reviewed Resident #6's physician orders and said Resident #6 should not have 2 sets of hold parameters. 2. During an observation and interview on 05/02/23 at 03:12 PM LVN C checked Resident #6's blood pressure. The reading was 160/72. She said she was holding Resident #6's Verapamil 180mg due to blood pressure parameters to hold if the lower number was less than 80. Record review of physician orders for May 2023 indicated Resident #6 had a physician order dated 02/15/23 for verapamil 180 mg tablet twice daily with blood pressure and/or pulse hold: systolic (upper number) blood pressure less than 120 to hold; diastolic (lower number) blood pressure less than 60 to hold; and pulse less than 60 to hold. There was also blood pressure and/or pulse hold: pulse less than 60 to hold; diastolic blood pressure less than 80 to hold; systolic blood pressure less than 130 to hold. During an interview on 05/03/23 at 09:42 AM the ADON said Resident #6's physician ordered blood pressure and/or pulse hold: pulse less than 60 to hold; diastolic blood pressure less than 80 to hold; systolic blood pressure less than 130 to hold originally in September 2022. She said he made rounds on 02/15/23 and changed them to the blood pressure and/or pulse hold: systolic blood pressure less than 120 to hold; diastolic blood pressure less than 60 to hold; pulse < 60 Hold. She said she clarified this with the physician. She said the LVN should have clarified which set of hold orders were valid and the Verapamil should not have been held otherwise medication could be held when it should be given. Observation of medication reconciliation of medication pass and record review of physician orders on 05/03/23 at 08:35 AM indicated 1 error out of 25 opportunities resulted in a 4% medication error rate. 3. During an observation and interview on 05/03/23 at 12:50 PM of the Nurse Cart for the 100/200 Hall with the ADON indicated the following: * a bottle if Senna Tab 8.6 expired 04/23; and * a bottle of Fish Oil 500mg expired 04/23. The ADON said nurses should be checking the medications for expiration dates when they pass medications. During an observation and interview on 05/03/23 at 12:55 PM of the Medication Aide Cart for the 300/400 Hall with MA B indicated the following: * a card of Hyoscyamine 0.125mg expired 11/18/22 * a bag of meds with the following: * a bottle of Vitamin C 1000mg expired 01/20; * a bottle of Hyoscyamine 0.125 mg expired 08/03/22; * a bottle of Haldol 2mg tab expired 08/03/22; * a bottle of Promethazine 25mg expired 08/03/22; * a bottle of Nitroglycerine 0.4mg expired 02/08/23; * a bottle of Bisacodyl 10mg 08/03/22. MA B said MA/Medication Nurse should always check medications for expiration dates. She said expired medications were to be pulled and given to the DON. She said the bag of medication was what a family brought from home and should have been sent home with them. During an interview on 05/03/23 at 01:25 PM the interim DON said she expected nurses to check medications when brought from home upon admission. She said nurses and MAs were to check the carts for expired medications, they were to be removed from the cart, and brought to her for destruction. Policies were requested on 05/01/23 upon entrance but were not provided prior to exit.

Based on observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 15 residents (Resident #7) reviewed for ROM (range of motion). The facility did not have a treatment in place for Resident #7's contractures of the left hand to prevent further decline in ROM. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated May 2023 indicated Resident #7, admitted [DATE], was [AGE] years old with diagnoses of cerebral infarction (stroke), lack of coordination and muscle wasting/atrophy. The resident was admitted to Hospice services on 11/18/21. Record review of the most recent MDS dated [DATE] indicated Resident #7 had a decrease in range of motion to one side of the upper extremities. The resident had not received physical or occupational therapy. Record review of care plans dated 10/11/20 to present indicated Resident #7 had short term memory problems, required extensive assistance for bathing and dressing, and had contractures, which placed the resident at risk for skin breakdown. The contracture care plan interventions indicated to monitor for increased pain/stiffness . The most recent occupational therapy note dated 9/15/21 to 10/15/21 indicated Resident #7 received therapy services to the upper extremities with discharge instructions included no restorative was indicated and and 24 hour care maintance. The most recent Nursing Restorative Care Program notes dated 2/01/21 to 2/26/21 indicated Resident #7 completed the program with good response. The note indicated the plan of care was appropriate and the program was to continue. During observations and interview on 05/01/23 at 10:51 a.m., Resident #7 had contractures to the last three fingers of the left hand. The 3 fingers were contracted downwards to the bottom of the palm of the hand. The pointer finger was partially contracted inward at the 1st and 2nd joint. The resident could not move the 3 fingers when asked to do so by the surveyor. The resident was not interviewable and could only answer simple yes/no questions. The resident said no, when asked by the surveyor if the left contracted hand was painful. There was not a handroll in place to the left contracted hand. During observations on the following dates, Resident #7 did not have a handroll to the left contracted hand: *05/01/23 at 10:51 a.m., *05/02/23 7:49 a.m.; and *05/02/23 03:20 p.m. During an interview on 05/02/23 at 3:28 p.m., the therapy services supervisor said Resident #7 was on Hospice services and the Hospice would not order therapy services for the resident. She said residents on Hospice services did not usually receive therapy. She said residents with contractures should receive strengthening and stretching exercises and carrots or handrolls should be used. During observation of Resident #7 and interview on 05/02/23 at 3:47 p.m., the therapy services supervisor said Resident #7 did have contractures of the left hand and needed a handroll to prevent further contractures. She said the last time she assessed the resident; it was for a fall and she did not assess her hand. She said the possible negative outcome of not placing a handroll in the resident's contracted hand could be a decrease in ROM and pain. During observation of Resident #7 and interview on 05/02/23 at 3:50 p.m., LVN A said Resident #7's left hand was contracted, and the resident did need a handroll in her hand to prevent further contractures. She said the possible negative outcome of not having a handroll in the resident's hand would be a further decrease in the resident's ROM or possible wounds with infection. During an interview on 05/02/23 at 4:00 p.m., the interim DON said her expectations were for the residents to avoid a decline in their ROM. She said the possible negative outcome of not having a handroll in Resident #7's contracted hand could be a possible decline in ROM. The DON said the resident had not had therapy services or restorative services since 2021. During an interview on 05/02/23 at 4:05 p.m., the administrator said her expectations were for the resident's ROM to be maintained. She said Resident #7 should have a handroll placed in the contracted hand. She said the residents should be seen by restorative to prevent further decline. During an observation on 05/03/23 at 1:14 p.m., after surveyor intervention, Resident #7 was lying in bed with a handroll to the left hand. A Range of Motion policy dated July 2014 indicated: . Objective- to prevent contractures, to maintain normal range of motion, to increase joint motion to the best possible range, to stimulate circulation and to prevent deformities, and any contractures from becoming worse.

Based on interview and record review the facility failed to ensure an accurate MDS was completed for 1 of 18 residents reviewed for MDS assessment accuracy. (Resident #18) * The facility incorrectly coded Resident #18's antiplatelet as an anticoagulant on his MDS. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: Record review of a face sheet dated 05/03/23 indicated Resident #18 was a [AGE] year-old male admitted on [DATE]. His diagnoses included long term use of antithrombotic/antiplatelets (blood thinning medications but not anticoagulants). Record review of the physician orders dated March 2023 indicated Resident #18 received clopidogrel 75 mg daily starting on 03/24/23. Record review of an MDS with ARD date 03/31/23 indicated Resident #18 received an anticoagulant for 5 days of the 7 day look back period. During an interview on 05/03/23 at 10:50 AM the MDS nurse said Resident #18 was on the clopidogrel, so he was coded on an anticoagulant because she thought the medication was an anticoagulant. When she looked up the medication it was classified as an antiplatelet. She said it was not an anticoagulant and was coded incorrectly. She said she was responsible for ensuring the information was correct. She said the wrong information could have medications not financially covered. When a policy was requested the MDS nurse said she was not aware of a policy they just followed the MDS manual. During an interview on 05/03/23 at 01:25 PM the interim DON said she would expect the MDSs to be filled out correctly by staff who obtained information from the residents' charts.

Based on observation and interview the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity 1 of 4 residents reviewed for resident rights. (Resident #145) * The facility did not serve Resident #145's lunch tray when they served his tablemate's, and he was served his dessert before the lunch meal tray. This failure could place residents at risk of poor self-esteem and decreased self-worth. Findings included: During observations and interviews of the lunch meal on 05/01/23: * at 12:25 PM Resident #23 served his tray and his tablemate Resident #145 was not served his tray; * at 12:31 PM Resident #23 eating his lunch but Resident #145 had not received his lunch tray; * at 12:32 PM Resident #23 and Resident #145 served cake. Resident #145 still not served his lunch tray; * at 12:35 PM Resident #23 finished eating and left the table. Resident #145 still not served his lunch tray. The Dietician was asked where Resident #145's tray was and she said she did not know; * at 12:36 PM Hall 100/200 tray cart from kitchen. Resident #145 still not served his lunch tray. The DM was asked where Resident #145's tray was and he said he did not know; * at 12:45 PM Resident #145 was brought the wrong tray; and * at 12:47 PM Resident #145 was brought the correct tray. During an interview on 05/01/23 at 12:54 PM Resident #145 said he did not think they were going to feed him. He said they brought his dessert before they brought his food. He said his tablemate received his food and was finished and gone by the time they brought his food. He said he kind of felt left out not getting to eat at the same time as his tablemate. During an interview on 05/02/23 at 05:20 PM the DM said all residents siting at a table should be served food at the same time. He said the dessert should not be served before the meal was served. During an interview on 05/03/23 at 09:35 AM the ADM said he expected all residents sitting at the same table to be served their meal so they can eat together.

Based on interview and record review the facility failed to ensure that a resident who needs respiratory care, including [CONDITION(S)] care and tracheal suctioning, is provided such care, consistent with professional standards of practice for one (CR #1) of 2 residents reviewed for respiratory care. The facility failed to notify CR #1's physician of his refusal to use the [CONDITION(S)] with his [CONDITION(S)] due to discomfort during his first two nights in the facility and were unable to implement possible physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to provide care to Resident #1 when he experienced difficulty breathing and decreased 02 saturation The facility failed to adequately assess and document CR #1's respiratory status after his [CONDITION(S)] refusals and was found in respiratory distress the second night he refused. CR #1 went into [CONDITION(S)] and died in the facility after interventions were attempted by EMS. An Immediate Jeopardy (IJ) was identified on [DATE] at 11:00AM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a severity of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents who are dependent on [CONDITION(S)] at risk of hypoxemia, hospitalization , and death. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . When that happens, your lungs can't release oxygen into your blood.) with [CONDITION(S)] (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), [CONDITION(S)] pneumonia (an infection of your lungs caused by a virus), COVID - 19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus), [CONDITION(S)] heart disease of coronary artery (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) without [CONDITION(S)] pectoris (a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) [CONDITION(S)] [CONDITION(S)] (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of CR #1 baseline care plan dated [DATE] revealed he had special treatments of [CONDITION(S)] (a type of ventilator; a device that helps with breathing) with [CONDITION(S)] (an incision in the windpipe made to relieve an obstruction to breathing ). Record review of CR #1's care plan dated [DATE] revealed he was unable to maintain O2 saturation and received oxygen at ,d+[DATE] L/min. His interventions included to change the tubing, check/fill the humidifier, check/record oxygen saturation every 8 hours and PRN when oxygen was in use. CR #1's care plan reflected he had a [CONDITION(S)] and was at risk for increased secretions/congestion and infections. His interventions included to monitor for needed suctioning of increase secretions/congestion and assess for relief, provide O2, [CONDITION(S)] care and tubing change per order, give medications per orders, monitor labs/x-rays and report abnormalities to the MD, provide for support to prevent anxiety if episodes of shortness of breath occur, monitor for signs and symptoms of infection, report to MD, and encourage socializations and activity attendance. Record review of CR #1's 5-day scheduled assessment MDS dated [DATE] revealed a staff assessment for mental status which indicated his short term and long-term memory were okay and he had modified independence in his cognitive skills for daily decision making . The MDS reflected resident could make himself understood and understood others. Further review of the MDS revealed he had special treatments of oxygen, suctioning, and [CONDITION(S)] care. T Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR and TAR revealed no vitals were entered from [DATE] - [DATE]. Record review of CR #1's electronic record for vitals revealed no vital entries from [DATE] - [DATE]. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] TAR revealed no entries on [DATE] for order to check pulse oximetry every shift . Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] TAR revealed order for [CONDITION(S)] care was not completed on [DATE]. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] >0 marking on bottle) every shift. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 20 every shift. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify MD if more frequent suctioning required. May use 3cc NS for lavage when suctioning PRN. Starting on [DATE] night shift. Record review of CR #1's [DATE] TAR revealed no entries on [DATE] for tracheobronchial suctioning as needed . Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] TAR revealed all treatment orders were started on [DATE] night shift and there was not documented evidence they were completed. Record review of CR #1's progress notes dated [DATE] at 4:00 PM by RT A revealed, At facility to set up [CONDITION(S)] and O2 concentrator with compressor. Resident scheduled to arrive tomorrow. Record review of CR #1's progress notes dated [DATE] at 8:50 AM by the DON revealed, [AGE] year-old male resident with recurrent pleural effusions (A buildup of fluid between the tissues that line the lungs and the chest), diabetes, long term anticoagulation therapy (chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time), arrived via EMS x 2 with stretcher. Taken to [NAME] (post-acute monitoring) room [ROOM NUMBER] due to non-vaccinated status. [CONDITION(S)] intact with O2 connected via [CONDITION(S)] mask at 6lpm. [CONDITION(S)] at bedside. Transferred to bed with extensive assist of 3. Noted Aspira pleural catheter tube (a tunneled, long-term catheter used to drain accumulated fluid from the pleural or peritoneal cavity to relieve symptoms associated with complications of malignant tumors) with intact dressing to right lower chest - to be drained Monday, Wednesday, and Friday. G-tube to mid abdomen in place with light redness to stoma with min dried drainage present. Resident is full code to receive anticoagulant and HS (bedtimes) finger sticks. Alert and oriented x 3 requires [CONDITION(S)] at night. Able to speak with speaking valve which is in place to make needs known. Uses urinal for bladder continence and bedside commode for bowel. Resident with shortness of breath after transfer and assessment but recovered well from 93 - 95% with in a few minutes. Resident is a full code. Regular bite size diet ordered. Noted weight from hospital to be 117.8g (257.4 pounds). Record review of CR #1's progress notes dated [DATE] at 10:00 AM by RT A revealed, Resident in bed with head elevated. His [family member] is at bedside. He has a [CONDITION(S)] in place and is on ATC (automatic tube compensation) 28% 5LPM. SpO2 92%, HR 88, RR 20. He is resting comfortably. He has some course rales (A loud and low-pitched, discontinuous, 'explosive' crackling sound heard in patients lungs). Equal and unlabored respirations. He has a productive cough. I suctioned him with three passes, and he has a tan loose secretion. He does have an effective cough and is able to clear most of his own secretions without suctioning. I am setting up t-bar to deliver high humidity. Placed T-bar on [CONDITION(S)] 28% 5LPM and monitored his respirations and effort. Placed his speaking valve in line with T-bar. He has a strong voice and is able to communicate well. He is tolerating the T-bar well. SpO2 94%. HR 92, RR 20. Set up his [CONDITION(S)] ,d+[DATE] with 5LPM bled in. Removed his T-bar, placed his [CONDITION(S)] on, I placed 5ml of distilled water into his pilot balloon to fill his cuff and monitored him. He appears to be tolerating well. SpO2 99% HR 86, RR 18. His speaking valve removed for [CONDITION(S)]. He is a little anxious. Spoke to him about trying to relax and get adjusted to the machine. He closed his eyes and appeared to be tolerating the [CONDITION(S)] well. Asked him if the pressure was comfortable and he nodded yes. I monitored him for approximately 30 minutes, and he was in no distress, resting comfortably, stated it feels a little different from what he been on in the hospital. I advised him I expected it to a little . After wearing it, if he can't adjust it, we can adjust the setting to make it more comfortable for him. He was in agreeance of this. His nurse came to the room. I walked her through the set up. Showed her how to take him off the [CONDITION(S)] and place the T-bar on his [CONDITION(S)]. Told her to remove the water from his cuff then to remove the [CONDITION(S)] and then place his T-bar onto his [CONDITION(S)]. Resident was left on his T-bar due to family in room visit. He is tolerating the setup well. Resident is in no distress and appears to be comfortable at this time. Record review of CR #1's progress notes dated [DATE] at 2:00 AM by LVN B revealed, Resident was requesting to be suctioned at this time. Resident was suctioned x 2 with monitoring of O2 sat. Resident O2 sat recovered within 2 min of post sterile suctioning and RR decreased appropriately. Resident denied the use of [CONDITION(S)] throughout the night stating he breathes better without it. O2 sat was 96%. Record review of progress notes dated [DATE] at 2:56 AM by the DON revealed, Resting without signs of distress on initial rounds. Found resident to not be on his [CONDITION(S)]. [LVN C], informed resident that he needed to be on his [CONDITION(S)] and he stated, 'no, I breath better without it'. He was educated on need for [CONDITION(S)] and he continued to refuse. Pulse ox checked and found to be at 93%. Declined offer to remove speaking valve at this time. Hs fingerstick done, resident aroused and offered finger of choice for task. Hs due insulin admin without complications. At 10:20PM [RN D] went to administer medication and found g-tube pulled out and lying on resident's abdomen. Resident denied knowing how it came out when asked. Site unremarkable, no bleeding or other signs of trauma noted. Md notified. New order received to discontinue g-tube. 1:36AM [LVN C] went to administer due medications. CNA rounds had just been completed and resident tolerated cares well and was without distress or complaints. Resident alert and talking. BP checked with results of ,d+[DATE] pulse 89 before [LVN C] was able to take o2 sat, he stated that he was 'having a little trouble breathing' 'please raise my bed (head) up some' bed adjusted then he stated, 'no, put it back down'. Pulse ox obtained with results of 53%, reached for suction, but noted resident with dusky coloration, resident was breathing on his own at this time. [LVN C] noted resident to be a full code and called 911. At same time she also notified this nurse DON. Suctioning initiated at 1:47 EMS arrived, resident still breathing at this time. [LVN C] left room to obtain paperwork for EMS and returned to find EMS performing CPR. CPR continued until EMS called the code at 2:24AM. Strip obtained for records. 3:15AM family notified and requested funeral home be notified to pick him up. 3:30AM funeral home notified of need for pick up. Record review of CR #1's EMS report dated [DATE] revealed the facility called 911 on [DATE] at 1:36 AM for a resident with difficulty breathing and the onset of symptoms was noted to be on [DATE] at 1:25 AM. EMS was noted to arrive at resident on [DATE] at 1:54 AM. Further review of the EMS report revealed in part, Arrived on scene to find a [AGE] year-old male on [CONDITION(S)] via his [CONDITION(S)] tube. He was cyanotic (marked by or causing a bluish or purplish discoloration [as of the skin and mucous membranes] due to deficient oxygenation of the blood) and unresponsive. The nurse stated he was just talking to her then went unresponsive. She stated his O2 saturation is in the 40s. He was placed on our SPO2 which also read in the 40s . I suctioned him and got thick yellow sputum from his [CONDITION(S)]. His O2 saturation did not improve and no waveform. A BVM (A bag valve mask, sometimes known by Ambu bag or generically as a manual resuscitator or self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) at 15 LPM was placed on the [CONDITION(S)] along with a CO2 detector. His O2 saturation did not improve, and no waveform was noted on the capnography (the monitoring of the concentration or partial pressure of carbon [MEDICATION(S)] in the respiratory gases). A carotid pulse was present, but weak. He was placed on the ECG monitor (Electrocardiography is the process of producing an electrocardiogram, a recording of the heart's electrical activity) and was sinus [CONDITION(S)] (a type of slow heartbeat). The AED pads were placed on the patient. His rhythm changed to asystole (a type of [CONDITION(S)], which is when your heart stops beating entirely). He was moved to the floor and CPR was initiated. He was suctioned again with no changes. A size 5 King Airway was place and the bulb was filled with air using a syringe. He was ventilated via a BVM at 15LPM. He had bilateral chest rise, bilateral lung sounds upon auscultation (listening to the internal sounds of the body, usually using a stethoscope) and capnography waveform. His CO2 was in the 40s . he was still asystole . 1000 ml of NS started TKO (to keep open). The patients BGL (blood glucose level) was obtained and was elevated. He was given EPI 1:10 MG x 2 with changes. He was given [MEDICATION(S)] and his rhythm changed to PEA (Pulseless electrical activity refers to [CONDITION(S)] in which the electrocardiogram shows a heart rhythm that should produce a pulse but does not). CPR was continued he was given EPI 1:10 x 2. He still remained in asystole. CPR was discontinued at 2:35AM . Nurse left the room to meet with her DON and never returned . I found the nurse and DON talking at a table. The nurse appeared to be distraught and unable to sign paperwork Further review of the EMS report indicated the resident went into [CONDITION(S)] after EMS arrival and the [CONDITION(S)] etiology was respiratory/asphyxia (a condition arising when the body is deprived of oxygen, causing unconsciousness or death; suffocation). Vitals sign notes and procedures performed notes indicated at 2:05AM the insertion of an [CONDITION(S)] tracheal double lumen improved CR #1's response and his O2 sats went from 36% to 96% after tube was inserted. Interview on [DATE] at 2:10 PM, CR #1's family member said CR #1 passed away in the facility and after reviewing the EMS report and the facility records, she had concerns of what the facility did to care for CR #1. CR #1's family member said the EMS notes indicated CR #1 was on a [CONDITION(S)] when they arrived, but the facility records reflected he had refused to wear the [CONDITION(S)]. The family member also said she could not find anywhere in the resident's records besides the notes of where they monitored his vitals or if he was suctioned because the facility documentation did not indicate LVN C suctioned him after he complained of problems with breathing. The family member said she wanted to know what LVN C did for CR #1 after he became unresponsive and called 911 because the EMS report indicated it took them 18 minutes to arrive from the time the call was placed. The family member said the EMS report reflected they suctioned him when they got to the facility and was able to remove thick yellow sputum from his [CONDITION(S)]. The family member said CR #1 was wearing his [CONDITION(S)] in the hospital with no problems and it seemed unlike him to refuse to wear it but said if he had refused to wear it the family was not told about it. The family member said another family member was at the facility on [DATE] visiting with CR #1 and he reported he was unable to sleep the night before and asked her if he was pushing the right button for help because he was not getting a response when he used his call light. The family member said by 6:00 PM on [DATE], CR #1 was resting soundly so the visiting family left, and they did not know what happened after that. The family member said her main concern was the nurse interventions when CR #1 was having difficulty breathing and the facility's monitoring of the resident since the records did not reflect, they were routinely checking his vitals. Interview on [DATE] at 12:45 AM, the DON said LVN C called her on [DATE] around 1:30 AM and told her she called 911 for CR #1 having difficulty breathing. The DON said when she arrived at the facility EMS was already in the room with CR #1. The DON said LVN C was very shaken up and unable to complete documentation, so she had her tell her what happened, and she transcribed what she told her into the progress notes which was why the note regarding the night's events on [DATE] were entered by her for LVN C. The DON said she recalled LVN C saying CR #1 was awake talking and then went unresponsive when EMS arrived. The DON said CR #1 had refused to wear his [CONDITION(S)] because he could not wear the speaking valve while on it. The DON said RT A came to the facility to setup all of CR #1's respiratory equipment and train staff on [DATE] . Interview on [DATE] at 12:42 PM, RT A said she came to the facility as a contract worker on [DATE] to setup CR #1's respiratory equipment including his [CONDITION(S)]. RT A said she showed LVN E who was his nurse while she was there how to connect and disconnect his [CONDITION(S)] to his [CONDITION(S)]. RT A said she did test the [CONDITION(S)] on CR #1 while she was there and he tolerated it but did tell her if felt different from the [CONDITION(S)] he had in the hospital. RT A said she spoke with the resident about why it felt different and the importance of him wearing it. RT A said if he did not wear the [CONDITION(S)] his CO2 levels could get high and cause issues with breathing or further complications. RT A said CR #1 and a family member at bedside voiced understanding. RT A said she did not return to the facility before CR #1 passed away and did not recall anyone contacting her about him refusing to wear his [CONDITION(S)] or of him having any complications. RT A said she planned to return to the facility on [DATE] to see how CR #1 was tolerating everything but he expired before she could return. RT A said she provided training to all facility staff regarding respiratory care. RT A said she had gone over training related to [CONDITION(S)] care, [CONDITION(S)], and suctioning with all staff and she provided the additional training for CR #1's [CONDITION(S)] because his [CONDITION(S)] and [CONDITION(S)] setup was a little different than what the staff were used to because he had the t-bar and speaking valve. Interview on [DATE] at 1:58 PM, LVN E said she worked with CR #1 the evening of [DATE] for about 4 hours until the night shift nurse came to relieve her. LVN E said RT A had come to the facility on [DATE] and trained her on CR #1's [CONDITION(S)] and [CONDITION(S)]. LVN E said RT A took CR #1 off the [CONDITION(S)] before she left so he could visit with his family. LVN E said when the night nurse (LVN B) came to relieve her she showed her the training RT A gave her regarding CR #1's [CONDITION(S)] and instructions for him to wear [CONDITION(S)] overnight while sleeping. LVN E said during her time with CR #1 he was fine, and she did not have to provide any type of [CONDITION(S)] care to him. Interview on [DATE] at 2:05 PM, LVN B said she worked with CR #1 his first night in the facility but could not recall what time she got there because she was called in to help, it was not her normal shift. She said she spoke with CR #1 about wearing his [CONDITION(S)], but he refused to wear it and said he felt he could breathe better without it . LVN B said overnight CR #1 did ask for his speaking valve to be taken out and he had some coughing, he wanted it put back in and after she put it back in he asked to be suctioned. LVN B said she noticed CR #1 did not have orders for suctioning yet, but she went ahead and suctioned him because he requested it and he needed to be suctioned . She said she documented that she suctioned him in her nurse's note. LVN B said she was not at the facility when RT A was there, but LVN E passed along the training she received regarding CR #1's [CONDITION(S)] and for it to be worn at night when CR #1 slept. LVN B said CR #1 never agreed to let her put his [CONDITION(S)] on and said CR #1 was anxious that night as well since it was his first night in the facility. LVN B said she think called RT A and reported CR #1 was not wearing his [CONDITION(S)] and she told her it was okay and to make sure his O2 sats did not go below 92%. LVN B said she did monitor CR #1 O2 sats and checked on him frequently overnight because he was so antsy and having anxiety being in a new place. LVN B said his O2 sats were high the whole night and said she recalled documenting his O2 sat level in her nurse's note. LVN B said she noticed CR #1's had no treatment orders, and she could not locate hospital paperwork to create treatment orders in the facility records. LVN B said she told the next shift nurse (day shift nurse) to contact the hospital or physician about CR #1's orders being incomplete and needing orders related to respiratory care and [CONDITION(S)]. LVN B said CR #1 was restless and stayed up all night but when she left the next morning he was finally resting. Interview on [DATE] at 2:27 PM, LVN F said she worked the morning of [DATE] and all of CR #1 nighttime orders for treatment and medications were incomplete from the night nurse (LVN C). LVN F said she had to go into the system and log that the orders were not completed/administered for LVN C so they could clear CR #1 out the system because he had passed away. Interview on [DATE] at 2:42 PM, RN D said she did not work with CR #1 at all on [DATE] and said she was just helping out his nurse (LVN C) by calling the physician for her about CR #1's g-tube coming out. RN D said she reported the g-tube coming out to the physician and he ordered to leave it out since the resident was eating food by mouth with no issues. RN D said she passed some medications for CR #1 but could not recall which ones and did not know if they required her to take any vitals. RN D said if she did it might have been a blood pressure for blood pressure medication. RN D said she did not provide any type of care or assessment for CR #1 and said she only passed his medications to him on [DATE] evening and she left the facility before he had any respiratory issues at night. Interview on [DATE] at 3:24 PM, LVN C said she worked 6 PM - 6 AM on [DATE]. LVN C said CR #1 had been doing fine during the shift, but he had refused to wear his [CONDITION(S)] while sleeping. LVN C said the previous nurse (LVN H) had told her CR #1 used a [CONDITION(S)] at night. LVN C said she did try counseling with him about the importance of wearing the [CONDITION(S)] to assist with his breathing while sleeping and he still refused. LVN C said CR #1 had a blood pressure medication due around 1 AM and when she went into the room, he complained of having difficulty breathing. LVN C said she checked his O2 sats and they were low, in the 50's . LVN C said he asked her to sit him up some more, but his oxygen was still low after she elevated the HOB. LVN C said she asked CR #1 if he had been suctioned today ([DATE]) and he said no. LVN C said she got everything ready to suction him and as she was about to begin, she noticed his coloration started to get dusky and he became unconscious. LVN C said she immediately went to call 911 and the DON. LVN C said CR #1 was unconscious, but he still had vitals. LVN C said the EMT's arrived, and they started working on him. LVN C said the EMT's suctioned CR #1 when they got there and was able to get some sputum out but not a lot. LVN C said she left the room to get paperwork and when she came back the EMT's were performing CPR. LVN C said the paramedics did CPR for a while but pronounced him dead. LVN C said it took EMS maybe 10 minutes to get to the facility and during that time she monitored CR #1's vitals and prepared paperwork for EMS. LVN C said she never touched CR #1's [CONDITION(S)]. LVN C said she had training from the facility and previous work experience on how to care for residents with [CONDITION(S)] and [CONDITION(S)]. LVN C said she was familiar with RT A and had received some training from her related to respiratory. Interview on [DATE] at 4:06 PM, CNA G said she worked the night shift on [DATE] with CR #1 and he seemed okay when she went in to provide care and he had no complaints. CNA G said she just knew LVN C went in shortly after they provided care and CR #1 complained of not breathing well. CNA G said LVN C ended up calling 911 and another CNA went into the room to watch CR #1 while LVN C called 911. CNA G said she knew CR #1 was still breathing before EMS got there but not sure what happened afterwards. Interview on [DATE] at 5:13 PM, the DON said a nurse should do everything they can for a patient in respiratory distress which could include trying to suction the resident, placing the resident on the [CONDITION(S)] when he was unable to refuse it anymore, turning up the resident's oxygen or using the ambu bag. The DON said LVN C could have had the CNA's call 911 so she could have stayed with the resident and provided care. The DON said 18 minutes should have been enough time for the LVN to attempt some interventions. The DON said all staff had been training on respiratory care and caring for residents with [CONDITION(S)]. The DON said she thought LVN C told her she had tried to suction CR #1. The DON said LVN C was hysterical the night CR #1 died , and she had a hard time recollecting the events from his death. The DON said LVN C also had a habit of not remembering things clearly and she would have LVN C call the surveyor if she remembered anything different or wanted to change something she said. Interview on [DATE] at 2:58 PM, RT A said she did not recall CR #1 stating he preferred to be on his T-bar over his [CONDITION(S)]. RT A said she did not recall speaking with LVN B about CR #1 refusing to wear his [CONDITION(S)] and said she recalled learning after he had passed that he had completely refused to wear it. RT A said if CR #1's had low O2 sats and complained of difficulty breathing she would increase his oxygen and attempt to suction him to make sure there was not a mucous plug and possibly remove the inner cannula and put a new one in if suctioning did not help. RT A said there was a BVM (Ambu bag) at bedside that could have been used to give some rescue breaths and the [CONDITION(S)] could have helped as well depending on how he was breathing. RT A said she would have to be there with the resident to assess him to know what specific interventions she would have tried to help CR #1. Interview on [DATE] at 1:35PM, the EMT said she arrived at the facility on [DATE] and CR #1's [CONDITION(S)] was on and attached to his [CONDITION(S)], but he was not conscious. The EMT said the nurse reported CR #1 was just awake and talking to her. The EMT said CR #1's O2 sats were low, in the 40's with the [CONDITION(S)] on so she asked the nurse (LVN C) if CR #1 had been suctioned and she said the nurse reported she had not suctioned him during her shift. The EMT said she took CR #1's [CONDITION(S)] off and suctioned out some thick [MEDICATION(S)] and tried to ventilate him with their equipment and his O2 sats remained low, in the 40's. The EMT said she tried suctioning CR #1 again and was not able to get all the [MEDICATION(S)] out, so they inserted a king tube (designed for positive pressure ventilation over 30 cm H2O and spontaneously breathing patients, yet offers the unique ability to easily pass a gastric tube through a second channel of the airway and into the esophagus and stomach). The EMT said CR #1's O2 sats began to improve after the tube was inserted which meant CR #1 [CONDITION(S)] was clogged and why ventilation efforts through the [CONDITION(S)] were unsuccessful. The EMT said CR #1 coded before they could get his O2 sats to improve and they had to pronounce him dead after they attempted CPR. The EMT said she saw a lot of cases with [CONDITION(S)]'s being clogged due to lack of suctioning. The EMT said for residents with clogged traches staff would have to apply some saline to loosen up dried mucous/clog and suction it out and possibly change out the [CONDITION(S)] if it cannot be cleared through suctioning. Interview on [DATE] at 1:39 PM, LVN C said she did not recall doing anything with CR #1's [CONDITION(S)] and did not know how it would have been connected when EMS got there. LVN C said the night of [DATE] was sort of a blur for her because of everything that transpired. LVN C said while she was waiting on EMS to get to the facility, she had tried to suction CR #1 and was not able to get anything out and his O2 sats did not change . LVN C said she had checked CR #1's O2 sats at the start of her shift around 6 PM and his O2 sats were not below 92% and he had no complaints. LVN C said maybe around 10:30PM his feeding tube had come out and she checked his vitals along with O2 sats and they were fine. She could not recall what the vitals were. LVN C said CR #1 was resting throughout the shift and the next time she checked him was at 1:00 AM when she went to pass his medication and he complained of difficulty breathing. LVN C said CR #1 started having issues with breathing before she could notify anyone of his refusal to wear his [CONDITION(S)] or enter any documentation regarding his care. LVN C confirmed the DON did assist her with the documentation from what happened with CR #1 on [DATE] because she was shaken up afterwards and everything seem to had escalated so quickly with CR #1. Interview on [DATE] at 3:00 PM, the NP said she did not get to see CR #1 while he was in the facility and was not familiar with him. The NP said she had not been contacted about CR #1 refusing to wear his [CONDITION(S)] and said she checked her messages and notes and did not see any documentation about herself, or the physician being informed. The NP said she had reviewed CR #1's previous hospital records which reflected he was a very sick patient and had been hospitalized for a long time, not doing well. Interview on [DATE] at 3:45 PM, the DON said she was having issues with entering CR #1's [CONDITION(S)] orders into the facility electronic records so she put it in the notes under the order for the [CONDITION(S)]. The DON said she had searched everywhere and looked through all the records they had on CR #1 and could not find hospital discharge orders/re

Based on interview and record review, the facility failed to immediately consult with the physician when there was a need to alter a resident's treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 1 of 3 residents (CR #1) reviewed for refusal or treatments. The facility failed to notify and consult a physician for interventions regarding CR #1's discomfort with his [CONDITION(S)] and refusing to wear it during his first two nights in the facility. The second night CR #1 refused to wear his [CONDITION(S)] he had difficulty breathing and went into respiratory distress, 911 was called and after EMS intervention he went into [CONDITION(S)] and died in the facility. 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 isolated with a severity of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for delay of appropriate medical treatment and a worsening of a resident's condition, including death. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . When that happens, your lungs can't release oxygen into your blood.) with [CONDITION(S)] (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), [CONDITION(S)] pneumonia (an infection of your lungs caused by a virus), COVID - 19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus), [CONDITION(S)] heart disease of coronary artery (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) without [CONDITION(S)] pectoris (a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart), and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) [CONDITION(S)] [CONDITION(S)] (an irregular, often rapid heart rate that commonly causes poor blood flow). Record review of CR #1 baseline care plan dated [DATE] revealed he had special treatments of [CONDITION(S)] (a type of ventilator; a device that helps with breathing) with [CONDITION(S)] (an incision in the windpipe made to relieve an obstruction to breathing). Record review of CR #1's care plan dated [DATE] revealed he was unable to maintain O2 saturation and received oxygen at ,d+[DATE] L/min. His interventions included to change the tubing, check/fill the humidifier, check/record oxygen saturation every 8 hours and PRN when oxygen was in use. CR #1's care plan reflected he had a [CONDITION(S)] and was at risk for increased secretions/congestion and infections. His interventions included to monitor for needed suctioning of increase secretions/congestion and assess for relief, provide O2, [CONDITION(S)] care and tubing change per order, give medications per orders, monitor labs/x-rays and report abnormalities to the MD, provide for support to prevent anxiety if episodes of shortness of breath occur, monitor for signs and symptoms of infection, report to MD, and encourage socializations and activity attendance. Record review of CR #1's 5-day scheduled assessment MDS dated [DATE] revealed a staff assessment for mental status which indicated his short term and long-term memory were okay and he had modified independence in his cognitive skills for daily decision making. The MDS reflected resident could make himself understood and understood others. Further review of the MDS revealed he had special treatments of oxygen, suctioning, and [CONDITION(S)] care. T Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] MAR and TAR revealed no vitals were entered from [DATE] - [DATE]. Record review of CR #1's electronic record for vitals revealed no vital entries from [DATE] - [DATE]. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] TAR revealed no entries on [DATE] for order to check pulse oximetry every shift . Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] TAR revealed order for [CONDITION(S)] care was not completed on [DATE]. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] >0 marking on bottle) every shift. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 20 every shift. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify MD if more frequent suctioning required. May use 3cc NS for lavage when suctioning PRN. Starting on [DATE] night shift. Record review of CR #1's [DATE] TAR revealed no entries on [DATE] for tracheobronchial suctioning as needed . Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's [DATE] TAR revealed all treatment orders were started on [DATE] night shift and there was not documented evidence they were completed. Record review of CR #1's progress notes dated [DATE] at 4:00 PM by RT A revealed, At facility to set up [CONDITION(S)] and O2 concentrator with compressor. Resident scheduled to arrive tomorrow. Record review of CR #1's progress notes dated [DATE] at 8:50 AM by the DON revealed, [AGE] year-old male resident with recurrent pleural effusions (A buildup of fluid between the tissues that line the lungs and the chest), diabetes, long term anticoagulation therapy (chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time), arrived via EMS x 2 with stretcher. Taken to [NAME] (post-acute monitoring) room [ROOM NUMBER] due to non-vaccinated status. [CONDITION(S)] intact with O2 connected via [CONDITION(S)] mask at 6lpm. [CONDITION(S)] at bedside. Transferred to bed with extensive assist of 3. Noted Aspira pleural catheter tube (a tunneled, long-term catheter used to drain accumulated fluid from the pleural or peritoneal cavity to relieve symptoms associated with complications of malignant tumors) with intact dressing to right lower chest - to be drained Monday, Wednesday, and Friday. G-tube to mid abdomen in place with light redness to stoma with min dried drainage present. Resident is full code to receive anticoagulant and HS (bedtimes) finger sticks. Alert and oriented x 3 requires [CONDITION(S)] at night. Able to speak with speaking valve which is in place to make needs known. Uses urinal for bladder continence and bedside commode for bowel. Resident with shortness of breath after transfer and assessment but recovered well from 93 - 95% with in a few minutes. Resident is a full code. Regular bite size diet ordered. Noted weight from hospital to be 117.8g (257.4 pounds). Record review of CR #1's progress notes dated [DATE] at 10:00 AM by RT A revealed, Resident in bed with head elevated. His [family member] is at bedside. He has a [CONDITION(S)] in place and is on ATC (automatic tube compensation) 28% 5LPM. SpO2 92%, HR 88, RR 20. He is resting comfortably. He has some course rales (A loud and low-pitched, discontinuous, 'explosive' crackling sound heard in patients lungs). Equal and unlabored respirations. He has a productive cough. I suctioned him with three passes, and he has a tan loose secretion. He does have an effective cough and is able to clear most of his own secretions without suctioning. I am setting up t-bar to deliver high humidity. Placed T-bar on [CONDITION(S)] 28% 5LPM and monitored his respirations and effort. Placed his speaking valve in line with T-bar. He has a strong voice and is able to communicate well. He is tolerating the T-bar well. SpO2 94%. HR 92, RR 20. Set up his [CONDITION(S)] ,d+[DATE] with 5LPM bled in. Removed his T-bar, placed his [CONDITION(S)] on, I placed 5ml of distilled water into his pilot balloon to fill his cuff and monitored him. He appears to be tolerating well. SpO2 99% HR 86, RR 18. His speaking valve removed for [CONDITION(S)]. He is a little anxious. Spoke to him about trying to relax and get adjusted to the machine. He closed his eyes and appeared to be tolerating the [CONDITION(S)] well. Asked him if the pressure was comfortable and he nodded yes. I monitored him for approximately 30 minutes, and he was in no distress, resting comfortably, stated it feels a little different from what he been on in the hospital. I advised him I expected it to a little . After wearing it, if he can't adjust it, we can adjust the setting to make it more comfortable for him. He was in agreeance of this. His nurse came to the room. I walked her through the set up. Showed her how to take him off the [CONDITION(S)] and place the T-bar on his [CONDITION(S)]. Told her to remove the water from his cuff then to remove the [CONDITION(S)] and then place his T-bar onto his [CONDITION(S)]. Resident was left on his T-bar due to family in room visit. He is tolerating the setup well. Resident is in no distress and appears to be comfortable at this time. Record review of CR #1's progress notes dated [DATE] at 2:00 AM by LVN B revealed, Resident was requesting to be suctioned at this time. Resident was suctioned x 2 with monitoring of O2 sat. Resident O2 sat recovered within 2 min of post sterile suctioning and RR decreased appropriately. Resident denied the use of [CONDITION(S)] throughout the night stating he breathes better without it. O2 sat was 96%. Record review of progress notes dated [DATE] at 2:56 AM by the DON revealed, Resting without signs of distress on initial rounds. Found resident to not be on his [CONDITION(S)]. [LVN C], informed resident that he needed to be on his [CONDITION(S)] and he stated, 'no, I breath better without it'. He was educated on need for [CONDITION(S)] and he continued to refuse. Pulse ox checked and found to be at 93%. Declined offer to remove speaking valve at this time. Hs fingerstick done, resident aroused and offered finger of choice for task. Hs due insulin admin without complications. At 10:20PM [RN D] went to administer medication and found g-tube pulled out and lying on resident's abdomen. Resident denied knowing how it came out when asked. Site unremarkable, no bleeding or other signs of trauma noted. Md notified. New order received to discontinue g-tube. 1:36AM [LVN C] went to administer due medications. CNA rounds had just been completed and resident tolerated cares well and was without distress or complaints. Resident alert and talking. BP checked with results of ,d+[DATE] pulse 89 before [LVN C] was able to take o2 sat, he stated that he was 'having a little trouble breathing' 'please raise my bed (head) up some' bed adjusted then he stated, 'no, put it back down'. Pulse ox obtained with results of 53%, reached for suction, but noted resident with dusky coloration, resident was breathing on his own at this time. [LVN C] noted resident to be a full code and called 911. At same time she also notified this nurse DON. Suctioning initiated at 1:47 EMS arrived, resident still breathing at this time. [LVN C] left room to obtain paperwork for EMS and returned to find EMS performing CPR. CPR continued until EMS called the code at 2:24AM. Strip obtained for records. 3:15AM family notified and requested funeral home be notified to pick him up. 3:30AM funeral home notified of need for pick up. Record review of CR #1's EMS report dated [DATE] revealed the facility called 911 on [DATE] at 1:36 AM for a resident with difficulty breathing and the onset of symptoms was noted to be on [DATE] at 1:25 AM. EMS was noted to arrive at resident on [DATE] at 1:54 AM. Further review of the EMS report revealed in part, Arrived on scene to find a [AGE] year-old male on [CONDITION(S)] via his [CONDITION(S)] tube. He was cyanotic (marked by or causing a bluish or purplish discoloration [as of the skin and mucous membranes] due to deficient oxygenation of the blood) and unresponsive. The nurse stated he was just talking to her then went unresponsive. She stated his O2 saturation is in the 40s. He was placed on our SPO2 which also read in the 40s . I suctioned him and got thick yellow sputum from his [CONDITION(S)]. His O2 saturation did not improve and no waveform. A BVM (A bag valve mask, sometimes known by Ambu bag or generically as a manual resuscitator or self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) at 15 LPM was placed on the [CONDITION(S)] along with a CO2 detector. His O2 saturation did not improve, and no waveform was noted on the capnography (the monitoring of the concentration or partial pressure of carbon [MEDICATION(S)] in the respiratory gases). A carotid pulse was present, but weak. He was placed on the ECG monitor (Electrocardiography is the process of producing an electrocardiogram, a recording of the heart's electrical activity) and was sinus [CONDITION(S)] (a type of slow heartbeat). The AED pads were placed on the patient. His rhythm changed to asystole (a type of [CONDITION(S)], which is when your heart stops beating entirely). He was moved to the floor and CPR was initiated. He was suctioned again with no changes. A size 5 King Airway was place and the bulb was filled with air using a syringe. He was ventilated via a BVM at 15LPM. He had bilateral chest rise, bilateral lung sounds upon auscultation (listening to the internal sounds of the body, usually using a stethoscope) and capnography waveform. His CO2 was in the 40s . he was still asystole . 1000 ml of NS started TKO (to keep open). The patients BGL (blood glucose level) was obtained and was elevated. He was given EPI 1:10 MG x 2 with changes. He was given [MEDICATION(S)] and his rhythm changed to PEA (Pulseless electrical activity refers to [CONDITION(S)] in which the electrocardiogram shows a heart rhythm that should produce a pulse but does not). CPR was continued he was given EPI 1:10 x 2. He still remained in asystole. CPR was discontinued at 2:35AM . Nurse left the room to meet with her DON and never returned . I found the nurse and DON talking at a table. The nurse appeared to be distraught and unable to sign paperwork Further review of the EMS report indicated the resident went into [CONDITION(S)] after EMS arrival and the [CONDITION(S)] etiology was respiratory/asphyxia (a condition arising when the body is deprived of oxygen, causing unconsciousness or death; suffocation). Vitals sign notes and procedures performed notes indicated at 2:05AM the insertion of an [CONDITION(S)] tracheal double lumen improved CR #1's response and his O2 sats went from 36% to 96% after tube was inserted. Interview on [DATE] at 2:10 PM, CR #1's family member said CR #1 passed away in the facility and after reviewing the EMS report and the facility records, she had concerns of what the facility did to care for CR #1. CR #1's family member said the EMS notes indicated CR #1 was on a [CONDITION(S)] when they arrived, but the facility records reflected he had refused to wear the [CONDITION(S)]. The family member also said she could not find anywhere in the resident's records besides the notes of where they monitored his vitals or if he was suctioned because the facility documentation did not indicate LVN C suctioned him after he complained of problems with breathing. The family member said she wanted to know what LVN C did for CR #1 after he became unresponsive and called 911 because the EMS report indicated it took them 18 minutes to arrive from the time the call was placed. The family member said the EMS report reflected they suctioned him when they got to the facility and was able to remove thick yellow sputum from his [CONDITION(S)]. The family member said CR #1 was wearing his [CONDITION(S)] in the hospital with no problems and it seemed unlike him to refuse to wear it but said if he had refused to wear it the family was not told about it. The family member said another family member was at the facility on [DATE] visiting with CR #1 and he reported he was unable to sleep the night before and asked her if he was pushing the right button for help because he was not getting a response when he used his call light. The family member said by 6:00 PM on [DATE], CR #1 was resting soundly so the visiting family left, and they did not know what happened after that. The family member said her main concern was the nurse interventions when CR #1 was having difficulty breathing and the facility's monitoring of the resident since the records did not reflect, they were routinely checking his vitals. Interview on [DATE] at 12:45 AM, the DON said LVN C called her on [DATE] around 1:30 AM and told her she called 911 for CR #1 having difficulty breathing. The DON said when she arrived at the facility EMS was already in the room with CR #1. The DON said LVN C was very shaken up and unable to complete documentation, so she had her tell her what happened, and she transcribed what she told her into the progress notes which was why the note regarding the night's events on [DATE] were entered by her for LVN C. The DON said she recalled LVN C saying CR #1 was awake talking and then went unresponsive when EMS arrived. The DON said CR #1 had refused to wear his [CONDITION(S)] because he could not wear the speaking valve while on it. The DON said RT A came to the facility to setup all of CR #1's respiratory equipment and train staff on [DATE] . Interview on [DATE] at 12:42 PM, RT A said she came to the facility as a contract worker on [DATE] to setup CR #1's respiratory equipment including his [CONDITION(S)]. RT A said she showed LVN E who was his nurse while she was there how to connect and disconnect his [CONDITION(S)] to his [CONDITION(S)]. RT A said she did test the [CONDITION(S)] on CR #1 while she was there and he tolerated it but did tell her if felt different from the [CONDITION(S)] he had in the hospital. RT A said she spoke with the resident about why it felt different and the importance of him wearing it. RT A said if he did not wear the [CONDITION(S)] his CO2 levels could get high and cause issues with breathing or further complications. RT A said CR #1 and a family member at bedside voiced understanding. RT A said she did not return to the facility before CR #1 passed away and did not recall anyone contacting her about him refusing to wear his [CONDITION(S)] or of him having any complications. RT A said she planned to return to the facility on [DATE] to see how CR #1 was tolerating everything but he expired before she could return. RT A said she provided training to all facility staff regarding respiratory care. RT A said she had gone over training related to [CONDITION(S)] care, [CONDITION(S)], and suctioning with all staff and she provided the additional training for CR #1's [CONDITION(S)] because his [CONDITION(S)] and [CONDITION(S)] setup was a little different than what the staff were used to because he had the t-bar and speaking valve. Interview on [DATE] at 1:58 PM, LVN E said she worked with CR #1 the evening of [DATE] for about 4 hours until the night shift nurse came to relieve her. LVN E said RT A had come to the facility on [DATE] and trained her on CR #1's [CONDITION(S)] and [CONDITION(S)]. LVN E said RT A took CR #1 off the [CONDITION(S)] before she left so he could visit with his family. LVN E said when the night nurse (LVN B) came to relieve her she showed her the training RT A gave her regarding CR #1's [CONDITION(S)] and instructions for him to wear [CONDITION(S)] overnight while sleeping. LVN E said during her time with CR #1 he was fine, and she did not have to provide any type of [CONDITION(S)] care to him. Interview on [DATE] at 2:05 PM, LVN B said she worked with CR #1 his first night in the facility but could not recall what time she got there because she was called in to help, it was not her normal shift. She said she spoke with CR #1 about wearing his [CONDITION(S)], but he refused to wear it and said he felt he could breathe better without it . LVN B said overnight CR #1 did ask for his speaking valve to be taken out and he had some coughing, he wanted it put back in and after she put it back in he asked to be suctioned. LVN B said she noticed CR #1 did not have orders for suctioning yet, but she went ahead and suctioned him because he requested it and he needed to be suctioned . She said she documented that she suctioned him in her nurse's note. LVN B said she was not at the facility when RT A was there, but LVN E passed along the training she received regarding CR #1's [CONDITION(S)] and for it to be worn at night when CR #1 slept. LVN B said CR #1 never agreed to let her put his [CONDITION(S)] on and said CR #1 was anxious that night as well since it was his first night in the facility. LVN B said she think called RT A and reported CR #1 was not wearing his [CONDITION(S)] and she told her it was okay and to make sure his O2 sats did not go below 92%. LVN B said she did monitor CR #1 O2 sats and checked on him frequently overnight because he was so antsy and having anxiety being in a new place. LVN B said his O2 sats were high the whole night and said she recalled documenting his O2 sat level in her nurse's note. LVN B said she noticed CR #1's had no treatment orders, and she could not locate hospital paperwork to create treatment orders in the facility records. LVN B said she told the next shift nurse (day shift nurse) to contact the hospital or physician about CR #1's orders being incomplete and needing orders related to respiratory care and [CONDITION(S)]. LVN B said CR #1 was restless and stayed up all night but when she left the next morning he was finally resting. Interview on [DATE] at 2:27 PM, LVN F said she worked the morning of [DATE] and all of CR #1 nighttime orders for treatment and medications were incomplete from the night nurse (LVN C). LVN F said she had to go into the system and log that the orders were not completed/administered for LVN C so they could clear CR #1 out the system because he had passed away. Interview on [DATE] at 2:42 PM, RN D said she did not work with CR #1 at all on [DATE] and said she was just helping out his nurse (LVN C) by calling the physician for her about CR #1's g-tube coming out. RN D said she reported the g-tube coming out to the physician and he ordered to leave it out since the resident was eating food by mouth with no issues. RN D said she passed some medications for CR #1 but could not recall which ones and did not know if they required her to take any vitals. RN D said if she did it might have been a blood pressure for blood pressure medication. RN D said she did not provide any type of care or assessment for CR #1 and said she only passed his medications to him on [DATE] evening and she left the facility before he had any respiratory issues at night. Interview on [DATE] at 3:24 PM, LVN C said she worked 6 PM - 6 AM on [DATE]. LVN C said CR #1 had been doing fine during the shift, but he had refused to wear his [CONDITION(S)] while sleeping. LVN C said the previous nurse (LVN H) had told her CR #1 used a [CONDITION(S)] at night. LVN C said she did try counseling with him about the importance of wearing the [CONDITION(S)] to assist with his breathing while sleeping and he still refused. LVN C said CR #1 had a blood pressure medication due around 1 AM and when she went into the room, he complained of having difficulty breathing. LVN C said she checked his O2 sats and they were low, in the 50's . LVN C said he asked her to sit him up some more, but his oxygen was still low after she elevated the HOB. LVN C said she asked CR #1 if he had been suctioned today ([DATE]) and he said no. LVN C said she got everything ready to suction him and as she was about to begin, she noticed his coloration started to get dusky and he became unconscious. LVN C said she immediately went to call 911 and the DON. LVN C said CR #1 was unconscious, but he still had vitals. LVN C said the EMT's arrived, and they started working on him. LVN C said the EMT's suctioned CR #1 when they got there and was able to get some sputum out but not a lot. LVN C said she left the room to get paperwork and when she came back the EMT's were performing CPR. LVN C said the paramedics did CPR for a while but pronounced him dead. LVN C said it took EMS maybe 10 minutes to get to the facility and during that time she monitored CR #1's vitals and prepared paperwork for EMS. LVN C said she never touched CR #1's [CONDITION(S)]. LVN C said she had training from the facility and previous work experience on how to care for residents with [CONDITION(S)] and [CONDITION(S)]. LVN C said she was familiar with RT A and had received some training from her related to respiratory. Interview on [DATE] at 4:06 PM, CNA G said she worked the night shift on [DATE] with CR #1 and he seemed okay when she went in to provide care and he had no complaints. CNA G said she just knew LVN C went in shortly after they provided care and CR #1 complained of not breathing well. CNA G said LVN C ended up calling 911 and another CNA went into the room to watch CR #1 while LVN C called 911. CNA G said she knew CR #1 was still breathing before EMS got there but not sure what happened afterwards. Interview on [DATE] at 5:13 PM, the DON said a nurse should do everything they can for a patient in respiratory distress which could include trying to suction the resident, placing the resident on the [CONDITION(S)] when he was unable to refuse it anymore, turning up the resident's oxygen or using the ambu bag. The DON said LVN C could have had the CNA's call 911 so she could have stayed with the resident and provided care. The DON said 18 minutes should have been enough time for the LVN to attempt some interventions. The DON said all staff had been training on respiratory care and caring for residents with [CONDITION(S)]. The DON said she thought LVN C told her she had tried to suction CR #1. The DON said LVN C was hysterical the night CR #1 died , and she had a hard time recollecting the events from his death. The DON said LVN C also had a habit of not remembering things clearly and she would have LVN C call the surveyor if she remembered anything different or wanted to change something she said. Interview on [DATE] at 2:58 PM, RT A said she did not recall CR #1 stating he preferred to be on his T-bar over his [CONDITION(S)]. RT A said she did not recall speaking with LVN B about CR #1 refusing to wear his [CONDITION(S)] and said she recalled learning after he had passed that he had completely refused to wear it. RT A said if CR #1's had low O2 sats and complained of difficulty breathing she would increase his oxygen and attempt to suction him to make sure there was not a mucous plug and possibly remove the inner cannula and put a new one in if suctioning did not help. RT A said there was a BVM (Ambu bag) at bedside that could have been used to give some rescue breaths and the [CONDITION(S)] could have helped as well depending on how he was breathing. RT A said she would have to be there with the resident to assess him to know what specific interventions she would have tried to help CR #1. Interview on [DATE] at 1:35PM, the EMT said she arrived at the facility on [DATE] and CR #1's [CONDITION(S)] was on and attached to his [CONDITION(S)], but he was not conscious. The EMT said the nurse reported CR #1 was just awake and talking to her. The EMT said CR #1's O2 sats were low, in the 40's with the [CONDITION(S)] on so she asked the nurse (LVN C) if CR #1 had been suctioned and she said the nurse reported she had not suctioned him during her shift. The EMT said she took CR #1's [CONDITION(S)] off and suctioned out some thick [MEDICATION(S)] and tried to ventilate him with their equipment and his O2 sats remained low, in the 40's. The EMT said she tried suctioning CR #1 again and was not able to get all the [MEDICATION(S)] out, so they inserted a king tube (designed for positive pressure ventilation over 30 cm H2O and spontaneously breathing patients, yet offers the unique ability to easily pass a gastric tube through a second channel of the airway and into the esophagus and stomach). The EMT said CR #1's O2 sats began to improve after the tube was inserted which meant CR #1 [CONDITION(S)] was clogged and why ventilation efforts through the [CONDITION(S)] were unsuccessful. The EMT said CR #1 coded before they could get his O2 sats to improve and they had to pronounce him dead after they attempted CPR. The EMT said she saw a lot of cases with [CONDITION(S)]'s being clogged due to lack of suctioning. The EMT said for residents with clogged traches staff would have to apply some saline to loosen up dried mucous/clog and suction it out and possibly change out the [CONDITION(S)] if it cannot be cleared through suctioning. Interview on [DATE] at 1:39 PM, LVN C said she did not recall doing anything with CR #1's [CONDITION(S)] and did not know how it would have been connected when EMS got there. LVN C said the night of [DATE] was sort of a blur for her because of everything that transpired. LVN C said while she was waiting on EMS to get to the facility, she had tried to suction CR #1 and was not able to get anything out and his O2 sats did not change . LVN C said she had checked CR #1's O2 sats at the start of her shift around 6 PM and his O2 sats were not below 92% and he had no complaints. LVN C said maybe around 10:30PM his feeding tube had come out and she checked his vitals along with O2 sats and they were fine. She could not recall what the vitals were. LVN C said CR #1 was resting throughout the shift and the next time she checked him was at 1:00 AM when she went to pass his medication and he complained of difficulty breathing. LVN C said CR #1 started having issues with breathing before she could notify anyone of his refusal to wear his [CONDITION(S)] or enter any documentation regarding his care. LVN C confirmed the DON did assist her with the documentation from what happened with CR #1 on [DATE] because she was shaken up afterwards and everything seem to had escalated so quickly with CR #1. Interview on [DATE] at 3:00 PM, the NP said she did not get to see CR #1 while he was in the facility and was not familiar with him. The NP said she had not been contacted about CR #1 refusing to wear his [CONDITION(S)] and said she checked her messages and notes and did not see any documentation about herself, or the physician being informed. The NP said she had reviewed CR #1's previous hospital records which reflected he was a very sick patient and had been hospitalized for a long time, not doing well. Interview on [DATE] at 3:45 PM, the DON said she was having issues with entering CR #1's [CONDITION(S)] orders into the facility electronic records so she put it in the notes under the order for the [CONDITION(S)]. The DON said she had searched everywhere and looked through all the records they had on CR #1 and could not find hospital discharge orders/records regarding his respiratory related orders ([CONDITION(S)], [CONDITION(S)], oxygen, etc.). The DON said she believed the facility got CR #1 respiratory related orders from RT A because s

Based on interview and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 staff (CNA A) reviewed for infection control: The facility failed to ensure CNA A, who had signs and symptoms related to COVID-19, was screened, tested , or prevented from working. CNA A called in sick on 5/21/22 due to a fever, headache, and vomiting. CNA A returned to work on 05/22/22 without a negative Covid-19 test and did not accurately answer the screening questions. An Immediate Jeopardy (IJ) was identified on 05/25/22 at 10:42 a.m. While the IJ was removed on 5/25/22 at 5:00 p.m., the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of widespread because the facility was still monitoring the effectiveness of their corrective systems. This failure placed residents at risk of exposure to COVID-19, which could result in serious illness, hospitalization , and/or death. Findings included: Record review of the facility investigation initiated on 05/23/22 indicated CNA A's electronic screening record for 05/22/22 revealed she answered no to the following screening questions: -In the last 14 days, have YOU tested positive for Covid-19? -To the best of your knowledge, in the past 14 days have you had close contact (defined as within 6 feet for a total of 15 minutes or more) with someone who has tested positive for Covid-19 or had a respiratory illness suspected of being Covid-19? -In the past 24 hours, have you experienced signs or symptoms of respiratory infection, fever, cough, shortness of breath, sore throat, loss of smell, loss of taste, vomiting, diarrhea, OR other flu-like symptoms? -In the past 14 days, have you experienced signs or symptoms of respiratory infection, fever, cough, shortness of breath, sore throat, loss of smell, loss of taste, vomiting, diarrhea OR flu-like symptoms? -In the past 24 hours, have you taken any fever reducing medication that is not part of your prescribed routine daily medication regimen? -Have you take any fever-reducing medication in the last 24 hours? During an interview on 05/24/22 at 12:56 p.m. CNA A said she called in sick to LVN B for her 10:00 p.m. to 6:00 a.m. shift on 05/21/22 because she was sick; had a headache, was dizzy, had vomited phlegm and had allergy symptoms. She said she last worked on 05/17/22. She said she was also scheduled to work on 05/22/22 from 10:00 p.m. to 6:00 a.m. She said she notified LVN B she had no fever and would be coming in to work at 10:00 p.m. on 05/22/22. She said she was not directed to test for Covid-19 prior to her shift. She said she came to work on 05/22/22 and was still coughing up phlegm but she had no fever. She said she did not test for Covid-19. She said she was only around a family member the previous week who also had sinus symptoms but did not test for Covid-19. She said she started feeling bad on 05/23/22 at approximately 3:00 a.m. and told LVN C She said she believed her symptoms were only a sinus infection and not signs and symptoms of Covid because she had Covid previously and had different and worse symptoms. She said she usually worked through the entire facility. She said she was not instructed to test for Covid-19 until she had almost worked her whole shift on 05/22/22 - 05/23/22. She said she was trained on the signs and symptoms of Covid-19 but felt she had a sinus infection. She said she did not go to the doctor to be tested for Covid-19 or to be diagnosed with a sinus infection. During an interview on 05/24/22 at 3:04 p.m., the RDCS said CNA A did not answer the screening questions accurately on 05/22/22 because CNA A called in sick the previous night on 05/21/22 and reported experiencing signs and symptoms of Covid-19 within 24 hours as asked on the electronic screener. She said LVN B indicated she was not aware she should have directed CNA A to obtain a negative Covid-19 test prior to working her shift on 05/22/22 since she called in on 5/21/22 with symptoms related to Covid-19. She said LVN B was trained on Covid-19 and signs and symptoms and should have known CNA A required a negative Covid test prior to working on 05/22/22. During an interview on 05/24/22 at 3:35 p.m., LVN B said CNA A called in sick on 05/21/22 because she had a fever and thought she had a sinus infection. She said CNA A texted her the next day and said she had no fever, and she was going to work her scheduled shift. She said she did not direct CNA A to obtain a negative Covid-19 test prior to her shift. She said she did not think CNA A needed a negative test because she had tested negative during the regular staff testing the previous week. LVN B said she did not ask CNA A if she had tested for Covid-19 at a clinic or doctor's office. She said she should have asked CNA A if she was tested for Covid-19 prior to working her shift on 05/22/22. During an interview on 05/24/22 at 6:03 p.m., LVN C said she was not aware CNA A had any illness symptoms. She said CNA A reported she felt bad at approximately 3:00 a.m. on 05/23/22 and had a runny nose. She said she tested CNA A for Covid-19 with an antigen test and the test came back positive within 15 minutes. She said she immediately notified the DON of the CNA's positive Covid-19 results and sent CNA A home. She said she was not aware of CNA A having signs or symptoms related to Covid prior to 3:00 a.m. on 05/23/22. She said CNA A worked throughout the entire facility on 05/22-23/22 since there were only 35 residents. During an interview on 05/25/22 at 3:50 p.m., the DON said CNA A came to work her shift on 05/22/22 at 10:00 p.m. and should have answered the screening questions accurately. She said if CNA A had answered Yes to any of the screening questions, she and the Administrator would have received a text message automatically and then would have directed CNA A to obtain a negative Covid-19 test prior to working her shift. She said LVN B should have directed CNA A to obtain a negative Covid-19 test prior to her shift on 05/22/22 because she had called in sick for her shift on 05/21/22. She said LVN B had been verbally instructed to call the DON or the ADON if any staff had signs or symptoms related to Covid-19. The DON could not recall when LVN B was verbally instructed to call the DON or the ADON if any staff had signs or symptoms of Covid-19. The DON said the facility's Covid-19 prevention and screening policy was not followed. She said staff were educated on Covid-19 and what to do if they had signs and symptoms related to Covid-19 prior to the incident on 05/22/22. She said CNA A worked throughout the facility on 05/22-23/22. During an interview on 05/25/22 at 3:50 p.m., the ADON/IP indicated the facility's policy was not followed and LVN B should have directed CNA A to test for Covid-19 before returning to work on 05/22/22. She said the facility conducted outbreak testing on 05/23/22 and 5 residents and 1 additional staff tested positive for Covid-19. The second positive CNA worked with CNA A on 5/17/22 and 5/18/22. She said since there was a census of 35 and only one other aide on duty on 05/22/22, CNA A had the potential to have close, direct contact with all residents of the facility and it was likely she had direct contact with the positive residents and staff. She said none of the residents had signs and symptoms of Covid-19 or had to go to the hospital. Review of the facility's Covid-19 testing log provided by the facility on 05/24/22 indicated on 05/23/22 five residents and one additional staff tested positive for COVID-19. Record review of the facility's Coronavirus-Covid-19 policy dated 03/02/22 (revised 09/14/20) indicated Coronavirus (COVID-19) poses a serious threat to adults, 65 and over, especially those greater than [AGE] years old and for those patients with underlying health conditions. Processes have been established in order to decrease risk of exposure, transmission and to determine appropriate tasks if a patient is diagnosed with COVID-19 in a facility.1) COVID-19 Screening to be completed on all patients (new and existing), visitors, providers and employees using the COVID-19 CDC tool.5) Proactive Health Checks for employee that includes Temperature Checks and a questionnaire q shift worked: a. Perform prior to start of shift. B. Employees with observed respiratory symptoms and/or a temp of 99.4 degrees [Fahrenheit] or higher will be sent home and not allowed to work. Infection Surveillance . 4) Follow CDC guidelines for test criteria. Record review of the facility's policy Covid Testing & Response dated 08/24/21 indicated . follows testing requirements set forth by the Center for Medicare and Medicaid Services (CMS) and the Center for Disease Control and Prevention (CDC). State agency guidelines should also be considered if more stringent testing requirements are mandated. Purpose: To identify Covid-19 cases. Goals: 1. Prevent Covid-19 in nursing facilities. 2. Identify Covid-19 cases early to decrease the risk of spread. 3. Protect residents, patients, staff, family members, and visitors. 4. Manage Covid Outbreaks as they occur to aid in recovery. Staff: Vaccinated or unvaccinated staff with signs and symptoms of Covid must be tested regardless of circumstances. The Administrator was notified of the IJ on 05/25/22 at 10:42 a.m. and was provided with the IJ template on 05/25/22 at 10:42 a.m. The Administrator provided the following IJ plan of removal on 05/25/22 at 3:34 p.m.: Please accept this Plan of Removal for the alleged Immediate Jeopardy related to Covid-19 Employee Screening and Testing called at 10:42 a.m. Systematic Approach: 1. The facility Medical Director was informed of the Immediate Jeopardy on 05/25/22 at 10:52 a.m. 2. The Covid-19 positive CNA was currently at home recovering from Covid-19. 3. The LVN that was on-call when signs and symptoms of COVID were reported was suspended on 5/25/22 due to failure to test the symptomatic employee. 4. Contact tracing was performed on 5/24/22 to determine potentially exposed patients and employees. Contract tracing was performed on the 5 positive patients and 1 positive employee. The Executive Director and Director of Nursing performed the contact tracing on 5/24/22. 5. The facility began Outbreak Testing on 5/23/22 and identified 5 asymptomatic patients and 2 asymptomatic employees who tested positive. The outbreak testing included all facility staff and all patients. 6. The electronic screening device was audited 5/24/22 to determine visitors for the positive patients and aide in contact tracing. The audit revealed that there were several visits noted from outside family and friends. Visits were reviewed from 5/9/22 until 5/23/22. Patient A had 1 visitor with a total of 2 visits. Patient B had 2 visitors with a total of 8 visits. Patient C had 2 visitors with a total of 4 visits. Patient D had 1 visitor with a total of 2 visits. Patient E had a total of 5 visitors with 5 total visits. The positive CNA stated that her family member had been ill with similar symptoms for about a week, but had not been tested for Covid-19. The second positive CNA did not know of anyone that she had been exposed to but had been to a grocery store within the week. 7. The electronic screening device was reviewed 5/24/22 for the Covid-19 positive CNA, and all questions related to symptoms and exposure were answered no. 8. The Covid-19 positive CNA has been suspended 5/24/22 due to failure to report signs and symptoms related to Covid-19 on the electronic screening device at the start of her shift. 9. Education on employee screening requirements was completed and included all full-time employees, the education was conducted by the Director of Nurses. The education was initiated on 5/24/22 and was completed on 5/25/22. The education included answering the questions honestly and In-servicing included: a. Manual or electronic questionnaire and temperature checks to be completed by every employee prior to each shift. b. If the employee did not pass screening, Covid-19 testing would be performed. c. If the employee was symptomatic, Covid-19 testing would be performed. d. Symptoms include abdominal pain, chills or repeated shaking, cough, diarrhea or other GI Upset, headache, loss of smell or taste, muscle pain, nausea, vomiting, reddened eyes, shortness of breath, sore throat, temperature, tingling sensation of face or hands. e. If the employee had symptoms they would not work until symptoms were resolved 10. Education for employee testing requirements had been completed and included all full-time employees and was conducted by the Director of Nurses. The education was initiated on 5/24/22 and was completed on 5/25/22. The education included: a. An outbreak was when one or more residents or staff members test positive for Covid-19-(Residents admitted with Covid-19 were not included). b. If an outbreak occurs there were two options for testing. c. If unable to perform Contact Tracing, ALL staff and residents were to be tested regardless of vaccine vaccination status. d. If able to successfully complete Contact Tracing to determine exposure, only those affected needed to be tested during the outbreak. e. The County Health Department could direct the facility to perform full outbreak testing based on local orders and recommendations, even if able to complete contact tracing and determine those exposed. f. All staff and residents that tested negative must be retested weekly at a minimum until no new cases were identified for at least 14 days from the first positive result. g. The facility must follow the most stringent guidelines available. 11. Nursing staff unavailable for the education would not be allowed to work until in-servicing and competency completed. All full-time staff had been trained. All PRN staff would not be allowed to work until they had been in-serviced and competency completed. 12. The Director of Nurses or designee would continue to educate new staff upon hire and monthly on employee screening and testing protocols. 13. Monitoring would be done by the DON or designee daily for seven days and then weekly for 30 days to ensure screening, testing, and appropriate PPE to mitigate the spread of Covid-19. a. The DON/designee would monitor employee screening at the beginning of each shift to ensure any employee with signs/symptoms related to Covid-19 were immediately tested for the virus prior to beginning their work throughout the facility. b. Anyone with signs/symptoms related to Covid-19 noted at the time of screening will be administered a Covid-19 test with results received prior to beginning their shift. If the employee tested positive for Covid-19 the employee would then follow the facility protocol along with the guidance of the Public Health Department, CDC, CMS and HHSC regulations to mitigate the spread of COVID 19. c. Anyone with signs/symptoms related to COVID 19 would not be permitted to work until those signs/symptoms were alleviated. 14. Emergency QAPI meeting occurred on 5/25/22. Monitoring the Plan of Removal: Record review of the facility electronic screening records on 05/25/22 indicated all staff on duty were screened and answered the screening questions. No staff answers triggered Administrator or DON intervention. Interviews conducted from on 05/25/22 from 12:45 p.m. through 5:00 p.m. with the Administrator, the DON, the ADON, 7 LVN , 3 CNAs, 2 housekeeping staff, 2 dietary staff, and 2 office staff indicated they were aware of the signs and symptoms related to Covid-19 and a negative Covid-19 test was required before working a shift after calling in sick. All staff indicated they were trained to electronically screen prior to their shift, to answer accurately, and to report all signs and symptoms to the DON or the ADON. All staff said they answered truthfully on the screening and denied any Covid-19 related symptoms. Record review of all staff working on 05/24/22 and 05/25/22 indicated they were appropriately and accurately screened. The DON and ADON/IP were actively monitoring staff responses. Record review of in-services dated 05/24/22 and 05/25/22 and corresponding facility staff list indicated all staff working on 05/25/22 had received education for employee testing requirements. The in-service included all full-time employees and was conducted by the DON. The education was initiated on 5/24/2022 and was completed on 5/25/2022. On 05/25/22 at 5:00 p.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a potential for more than minimal harm with a scope identified as a widespread due to the facility's need to complete in-services training and evaluate the effectiveness of the corrective systems.