Marine Creek Nursing and Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for fourteen (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) of thirty residents reviewed for privacy and confidentiality. 1. The facility failed to ensure LVN C pulled the privacy curtain while suctioning (mechanical aspiration of pulmonary secretions to clear the airway) Resident #1 on 07/12/2025. 2. The facility failed to ensure LVN C closed the door while suctioning Resident #2 on 07/12/2025. 3. The facility failed to ensure LVN D did not leave Residents #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13's medical information on top of his cart on 07/12/2025. 4. The facility failed to ensure RN E closed, locked, or minimized his laptop's monitor, thus, showing Resident #14's medical information on 07/13/2025. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals. Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (is an opening surgically created through the neck to allow air to fill the lungs). Record review of Resident #1's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 05/07/2025, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident had tracheostomy and one of the interventions was to suction as necessary. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Check resident Q2H for suctioning need, suction via trach PRN every shift. Observation on 07/25/2025 at 9:10 AM revealed LVN C entered Resident #1's room to check on the resident. The resident signaled LVN C that she wanted to be suctioned. LVN C sanitized her hands, put on a pair of gloves, and put on a gown. She proceeded to suction the resident without pulling the privacy curtain. Resident #1 could not be seen from the hallway but could be seen by Resident #2, resident's roommate, who was sitting at the side of her bed and facing towards Resident #1's bed. Observation and attempted interview on 07/12/2025 at 10:54 AM, revealed Resident #1 did not reply when asked if it was okay for her that her roommate could see what the nurse was doing to her. 2. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident had tracheostomy and one of the interventions was to suction as necessary. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Check resident Q2H for suctioning need, suction via trach PRN every shift. Observation on 07/25/2025 at 9:25 AM revealed after LVN C was done suctioning Resident #1, Resident #2 requested to be suctioned, as well. LVN C proceeded to suction Resident #2 without closing the door or pulling the privacy curtain. Resident #2 could be seen from the hallway and the treatment being done could be seen from the hallway and her roommate. In an interview on 07/12/2025 at 10:34 AM, LVN C stated she guessed she needed to close the door and pull the privacy curtain every time care or treatment was being done for the residents, not just for Resident #1 and Resident #2, to provide privacy. She said somebody from the hallway might see that they were being suctioned and the residents might be embarrassed. In an interview on 07/12/2025 on 10:54 AM, Resident #2 stated the nurses, not only LVN C, would not close the door or pull the privacy curtain when they were treating them. She said she already got used to it, but a change would be nice so that others would not see that a tube was being inserted in her throat. 3. Record review of Resident #3's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #3's Physician Order, dated 07/12/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . four times a day. Record review of Resident #3's Vital Signs, dated 07/12/2025, reflected BP: 98/60 mmHg, Temp: 97.6, Pulse: 86, Respiration: 20, O2 sats: 99.0%. Record review of Resident #4's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #4's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #4's Vital Signs, dated 07/12/2025, reflected BP: 100/65 mmHg, Temp: 97.5, Pulse: 70, Respiration: 18, O2 sats: 100.0%. Record review of Resident #5's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #5's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #5's Vital Signs, dated 07/12/2025, reflected BP: 81/52 mmHg, Temp: 97.5, Pulse: 80, Respiration: 21, O2 sats: 99.0%. Record review of Resident #6's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #6's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 4 hours as needed. Record review of Resident #6's Vital Signs, dated 07/12/2025, reflected BP: 105/68 mmHg, Temp: 97.5, Pulse: 87, Respiration: 21, O2 sats: 100.0%. Record review of Resident #7's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #7's Physician Order, dated 07/12/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . three times a day. Record review of Resident #7's Vital Signs, dated 07/12/2025, reflected BP: 97/61 mmHg, Temp: 97.6, Pulse: 57, Respiration: 20, O2 sats: 100.0%. Record review of Resident #8's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #8's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 8 hours. Record review of Resident #8's Vital Signs, dated 07/12/2025, reflected BP: 141/84 mmHg, Temp: 97.5, Pulse: 100, Respiration: 24, O2 sats: 99.0%. Record review of Resident #9's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #9's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 4 hours as needed. Record review of Resident #9's Vital Signs, dated 07/12/2025, reflected BP: 129/72 mmHg, Temp: 97.5, Pulse: 70, Respiration: 18, O2 sats: 100.0%. Record review of Resident #10's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #10's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours. Record review of Resident #10's Vital Signs, dated 07/12/2025, reflected BP: 99/68 mmHg, Temp: 97.4, Pulse: 54, Respiration: 16, O2 sats: 100.0%. Record review of Resident 11's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #11's Physician Order, dated 07/03/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . three times a day. Record review of Resident #11's Vital Signs, dated 07/12/2025, reflected BP: 109/69 mmHg, Temp: 97.5, Pulse: 97, Respiration: 20, O2 sats: 97.2%. Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #12's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . four times a day. Record review of Resident #12's Vital Signs, dated 07/12/2025, reflected BP: 89/56 mmHg, Temp: 97.1, Pulse: 64, Respiration: 18, O2 sats: 99.0%. Record review of Resident #13's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #13's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #13's Vital Signs, dated 07/12/2025, reflected BP: 122/80 mmHg, Temp: 97.7, Pulse: 68, Respiration: 17, O2 sats: 98.0%. Observation on 07/12/2025 at 10:19 AM revealed a clipboard was on top of a nurse's cart. On the clipboard were the names of the residents, their room numbers, and their respective vital signs (blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation). In an interview on 07/12/2025 at 10:22 AM, LVN D stated he went to attend to one of the residents that was why he left his cart. He said he should have flipped the clipboard before leaving his cart because the vital signs were medical information and should be secured and not exposed for everybody to see. He said it was a HIPAA violation and the information should be confidential. In an interview on 07/12/2025 at 3:33 PM, ADON A stated the doors should be closed or the privacy pulled when providing treatment to the residents to promote dignity and privacy. She said Resident #1 and Resident #2 might be roommates but they are still entitled for privacy and dignity. She said other staff, other residents, or even visitors could see the treatment being done and might speculate the medical condition of the residents. She said it did not matter if the residents cared or not, the treatment should be done in privacy. ADON A said the staff had been trained about HIPAA over and over again and she did not know why the incident still happened. She said it was a HIPAA violation to leave the residents' health information out for everyone to see. She said the expectation was for the staff to provide privacy during treatment and to secure the residents' medical information. She said the vital signs were examples of medical information. She said she already started an in-service about dignity and privacy as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if there was something in the in-service that the did not understand. 4. Record review of Resident #14's Face Sheet, dated 07/13/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease and emphysema (a lung disease that damages the air sacs in the lung causing shortness of breath). Record review of Resident #14's Comprehensive MDS Assessment, dated 05/01/2025, reflected the resident had moderated impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had COPD and emphysema and was on oxygen therapy. Record review of Resident #14's Comprehensive Care Plan, dated 05/15/2025, reflected the resident had oxygen therapy and the interventions were administer oxygen and medications as ordered. Record review of Resident #14's Physician Order, dated 07/10/2025, reflected Oxygen LPM: 1-5 LPM to maintain O2 sats greater than 92%. Record review of Resident #14's Physician Order, dated 04/05/2025, reflected Symbicort Inhalation Aerosol 80 - 4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for COPD, emphysema. Record review of Resident #14's Physician Order, dated 04/05/2025, reflected Ipratropium Bromide Nasal Solution 0.03 % (Ipratropium Bromide (Nasal)) 2 spray in both nostrils two times a day for nasal congestion. Record review of Resident #14's Physician Order, dated 01/29/2025, reflected Artificial Tears Ophthalmic Solution 0.1-0.3 % (Dextran 70-Hypromellose) Instill 2 drop in both eyes every 4 hours as needed for eye itching. Record review of Resident #14's Physician Order, dated 05/13/2025, reflected Acetaminophen-Codeine Tablet 300-30 MG Give 1 tablet by mouth every 8 hours as needed for pain, ** hold for sedation Not to exceed 3 gms APAP in 24 hour period. Observation on 07/13/2025 at 10:00 AM revealed a cart was parked at the nurses' station and was facing the hallway. On top of the cart was an open laptop and displayed Resident #14's name, status, location, gender, date of birth , age, name of physician, latest vital signs, allergies, code status, emergency instructions, and physician orders. Also seen from the computer were physician orders for the resident. The screen of the computer was facing the hallway. It was also observed that RN E was sitting inside the nurses' station. In an interview on 07/13/2025 at 10:02 AM, RN E stated he was the one using the computer. He saw that his monitor was open and Resident #14's medical information. He said he was not aware that he left his computer open and did not minimize the monitor of the computer. He said the information should be secured and only the resident, family members, and providers could see the resident's information. He said he went inside the nurses' station because he needed to notify a doctor about some laboratory result. He said he would make sure to that his computer was close every time he would leave it. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the privacy issues and ADON A already did an in-service about privacy during treatment and confidentiality of medical records. She said the expectation was for the staff to make sure that the residents were provided privacy during any treatment to prevent humiliation and to secure their medical records so that unauthorized individuals would not see the residents' medical information. She said they would continue to remind the staff about providing privacy and confidentiality. In an interview on 07/14/2025 at 1:00 PM, The DON stated she already knew about the incidents of not providing privacy and not securing the medical records. She said the door should be closed or the privacy curtain pulled when doing a medical procedure so other people would not see what was being done for the resident. She said if confidential information were exposed, non-nursing staff, other resident, and visitors could be able to see it. She said all staff, including her, were expected to provide full privacy during treatment and confidentiality of all the residents' medical information. She said providing privacy is a form of respect to the residents that entrusted their care to the facility. She said ADON A already started the in-service about privacy and confidentiality but she would still do a one-on-one in-service with all the staff and would make sure that they understood the in-service that they were signing. Record review of the facility's policy, RESIDENT RIGHTS undated, revealed The resident has a right to a dignified existence . Privacy and confidentiality . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . 1. Personal privacy includes accommodations, medical treatment . 3. The resident has a right to secure and confidential personal and medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #12) of five residents reviewed for feeding tube (a process of providing nutrition directly to the stomach). The facility failed to ensure LVN C checked Resident #12's g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) placement and residual before administering the resident's medications and failed to administer the resident's medication one by one on 07/12/2025. These failures could place residents with g-tubes at risk for aspiration and drug-to-drug interaction. Findings included: Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #12's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #12's Quarterly Care Plan, dated 05/12/2025, reflected the resident required tube feeding and one of the interventions was to check for tube placement and gastric contents/residual volume. Record review of Resident #12's Physician Order, dated 06/11/2025, reflected every shift start continuous enteral feeding. Formula: Diabetasource; Rate: 65ml/hr, flush 200 ml H2O q 4 hrs. Record review of Resident #12's Physician Order, dated 04/04/2025, reflected every shift check placement prior to feeding and medication administration. Record review of Resident #12's Physician Order, dated 04/04/2025, reflected every shift check residual before medications and feedings; return contents after each check. Record review of Resident #12's Physician Order, dated 06/25/2025, reflected Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet via PEG-Tube (a flexible feeding tube inserted directly to the stomach) every 6 hours for pain, hold for sedation. Record review of Resident #12's Physician Order, dated 06/25/2025, reflected Docusate Sodium Oral Tablet 100 MG (Docusate Sodium) Give 1 tablet via PEG-Tube every 24 hours as needed for constipation. Record review of Resident #12's Physician Order on 07/12/2025 reflected no order that her medications could be cocktailed (could be given altogether at the same time). Observation and interview on 07/12/2025 at 10:38 AM revealed LVN D was preparing Resident #12's medication on his cart. LVN D said he wound administer the resident's 11:00 AM medication. He went inside the room with one small plastic cup with crushed medications in it and a big plastic cup with some water in it and placed them on the resident's overbed table. When inside the room, he incorporated some water on the small cup to dissolve the crushed medications. LVN D sanitized his hands and put on a pair of gloves. He took a 60 ml piston syringe from the resident's side table and placed it also on the overbed table. He raised the bed, lifted the resident's gown to expose the g-tube site. He pulled the plunger of the syringe, attached the syringe to the g-tube, and flushed the g-tube. After flushing the g-tube, he poured the dissolved medication. He did not check for the placement of the g-tube and the gastric content before flushing and administering the medication. After pouring the medications, he flushed the g-tube, and detached the syringe. He cleaned the syringe, took off his gloves, and sanitized his hands. In an interview on 07/12/2025 at 10:51 AM, LVN D stated he forgot to check for the g-tube placement and to check the residual of both residents. He said the right procedure was to check the placement and the residual every medication administration. He said g-tube placement was checked to ensure the tube was correctly positioned. He said the residual was also checked before administering medications to check if the stomach could accommodate the medications and fluid to be given and to prevent aspiration. He said he knew he needed to check for the placement and residual but failed to do so because he was nervous. He said he administered Resident #12's midday medications, which were oxycodone and docusate. He said he crushed the medications and put them both in a single cup. He said he was not sure if the resident had an order that would say her medications could be cocktailed. He said if there was no order to cocktail, then the medications should have been administered one by one. He said the reason for giving one by one was to prevent drug-to-drug interaction or drug-to-formula interaction that could impede the medication's effectiveness. In an interview on 07/12/2025 at 3:33 PM, ADON A stated both the gastric residual and the g-tube placement should be checked before administering the medications. She said g-tube placement should be checked to ensure the g-tube was in the right place. She said even though the residents were on continuous feeding, the placement should still be checked. She said the gastric residual was also checked to prevent aspiration and also to assess if the rate of the formula should be modified. She said the expectation was for the staff to check for g-tube placement and to check for gastric residual every time they administer medications. She said there were two ways to check for placement, one would be through auscultation and the other one was through aspiration of the gastric content. She said the second one could be used to check for placement and at the same time to check for the residual. She said if there was no order that the medications could be mixed, then the medications should be given one at a time to ensure there were no interactions between the drug. She said, as one of the ADONs, she was responsible in ensuring that the staff were following the procedures in administering medications via g-tube. She said she already started an in-service about g-tube as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if they do not understand something about the in-service. She said aside from the in-service, they would randomly check the staff's medication administration via gtube. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the issues pertaining to g-tube and ADON A already started an in-service relating to g-tube. She said the expectation was for the staff to follow the right procedures in administering medications via g-tube. She said she was not a clinician but she would coordinate with the DON to continually remind the staff about providing proper care for residents with g-tube. In an interview on 07/14/2025 at 1:00 PM, the DON she already knew about the incidents of not checking the placement of the g-tube and not checking for the residual. She said the placement should be checked to ensure the medications and the fluid would enter the stomach and not the lungs that could cause aspirations. She said the gastric residual should be checked before medication administration to assess if the resident's stomach was emptying properly. She said the medications should be given one at a time, if there was no order to cocktail them, so that if there were reactions, they could pinpoint what medication were causing the reactions. She said the expectation was for the staff to follow the right procedure for medication administration via g-tube. She said ADON A already started the in-service about g-tube but she would still do a one-on-one in-service with all the staff and would make sure that they understood the in-service that they were signing. Record review of the facility's policy ENTERAL (food or medication administration directly through the digestive system) MEDICATION ADMINISTRATION Pharmacy Policy & Procedure Manual revised 01/25/2013 revealed 6. Check the placement of the tube by aspiration of contents or auscultation . 8. Administer one medication at a time. Record review of the facility's policy Gastrostomy Tube Care Nursing Policy & Procedure Manual revised February 13, 2007 revealed Procedure . 7. Perform intermittent feeding . b. Aspirate gastric contents with a 60 ml syringe and if the residual is less than 50%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #1, Resident #2, Resident #12 and Resident #15) of twenty residents reviewed for infection control. 1. The facility failed to ensure LVN C did not re-use a gown to provide treatment for some residents at hall 400 on 07/12/2025. 2. The facility failed to ensure LVN C changed her gown in between Resident #1 and Resident #2 who were with tracheostomy on 07/12/2025. 3. The facility failed to ensure LVN C changed her gloves and performed hand hygiene when changing Resident #2's tracheostomy dressing on 07/12/2025. 4. The facility failed to ensure LVN D wore a gown while administering Resident #12's medication via g-tube on 07/12/2025 5. The facility failed to ensure CNA F changed her gloves and performed hand hygiene while providing incontinent care to Resident #15 on 07/12/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) and gastrostomy (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy and gastrostomy. Record review of Resident #1's Comprehensive MDS Assessment, dated 05/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care and had a feeding tube. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident was on enhanced barrier protection and one of the interventions was to put on gloves and gowns. Record review of Resident #1's Physician Order, dated 06/11/2025, reflected Trach care every shift and PRN. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Bolus Isosource 1.5 250 ml via g-tube if PO intake < 50 % after meals. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident was on enhanced barrier protection and one of the interventions was to put on gloves and gowns. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Trach care every shift and prn. Observation and interview on 07/12/2025 starting at 9:05 AM revealed gowns were hanging on some of the rooms in hall 400. One of the rooms with a gown hanging on the door was for Resident #1 and Resident #2. LVN C went inside the residents' room, took the gown hanging on the door, and proceeded to do a medical procedure. She said she would hang her gown after use and would just discard the gowns at the end of her shift. She said the other gowns hanging on the doors of the other residents were also hers. 2. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy and gastrostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy and gastrostomy. Record review of Resident #1's Comprehensive MDS Assessment, dated 05/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care and had a feeding tube. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident had tracheostomy and required tube feeding. Record review of Resident #1's Physician Order, dated 06/11/2025, reflected Trach care every shift and PRN. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Bolus Isosource 1.5 250 ml via g-tube if PO intake < 50 % after meals. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident had tracheostomy and one of the interventions was to ensure that trach ties are secured at all times. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Trach care every shift and prn. Observation on 07/12/2025 at 9:10 AM revealed LVN C entered Resident #1 and Resident #2's room to check on the residents. Resident #1 signaled LVN C that she wanted to be suctioned. She sanitized her hands, put on a pair of gloves, and donned the gown that was hanging on the residents' door. After suctioning Resident #1, Resident #2 requested to be suctioned, as well. LVN C proceeded to prepare Resident #2's suction machine without changing the gown that she used to suction Resident #1. When she was about to suction Resident #2, she noticed that the suction machine did not have a canister. She said she would get a canister and would come back. She removed her gown and hung it on the door. She came back with the canister and connected it to the suction machine. When the suction machine was ready, she put on the gown that she hung on the door, and suctioned Resident #2. In an interview on 07/12/2025 at 10:54 AM, Resident #2 stated the staff that would care for her did not always put on a gown. Some did but some did not. 3. Observation on 07/12/2025 at 9:35 AM revealed when LVN C was done suctioning Resident #2, she checked the resident's dressing on her tracheostomy. She told the resident that she would change the dressing. She removed the soiled dressing from the tracheostomy, took a new dressing, and put it on the resident's tracheostomy. She did not change her gloves and perform hand hygiene after suctioning the resident, before inspecting the stoma, and before touching the new dressing. In an interview on 07/12/2025 at 10:34 AM, LVN C stated she should have changed her gown after suctioning Resident #1 and before suctioning Resident #2 to prevent transfer of microorganism from one resident to another. She said she might get some germs from Resident #1 and would unnecessarily give it to Resident #2. She said the gowns should be disposed after every use and not re-used to reduce reproduction of microorganisms and its spread. She said she should have changed her gloves before touching the new dressing because her gloves were already dirtied when she touched the soiled dressing. She said her actions could cause probable infections and she would be mindful the next time she provided treatment to residents on enhanced barrier precautions. 4. Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to gtube because the resident had a g-tube. Record review of Resident #12's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #12's Quarterly Care Plan, dated 05/12/2025, reflected the resident was on enhanced barrier precautions and one of the interventions was to don (put on) gloves and gowns . during enteral feeding . or other high-contact activity. Record review of Resident #12's Physician Order, dated 06/11/2025, reflected Enteral Feed Order every shift start continuous enteral feeding. Formula: Diabetasource; Rate: 65 ml/hr, flush 200 ml H2O q 4 hrs. Observation on 07/12/2025 at 10:38 AM revealed LVN D was preparing resident #12's medication via g-tube. After preparing the medications, LVN D went inside the room and proceeded to administer the medications via g-tube. He did not wear a gown while administering the medications. In an interview on 07/12/2025 at 10:51 AM, LVN D stated he should wear a gown during medication administration if the resident had a g-tube because the resident had an indwelling device and was on enhanced barrier precautions. He said the purpose of the gown was to minimize transfer of microorganism since the g-tube site could be a potential entry of microorganism. He said he did had an in-service about infection control including enhanced barrier protection but could not remember when. 5. Record review of Resident #15's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #15's Comprehensive MDS Assessment, dated 06/25/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel. Record review of Resident #15's Comprehensive Care Plan, dated 05/15/2025, reflected the resident had bladder and bowel incontinence and one of the interventions was provide pericare after each incontinent episode. Record review of Resident #15's Comprehensive Care Plane, dated 07/12/2025, reflected the resident had an indwelling catheter and one of the interventions was to position the catheter and tubing below the level of the bladder. Record review of resident #15's Physician Order, dated 07/12/2025, reflected Provide catheter care. Observation on 07/12/2025 at 11:39 AM revealed CNA F was about to provide incontinent care to Resident #15 prior to wound care. She washed her hands, wore a gown and gloves, and proceeded with incontinent care. She positioned herself on the left side of the resident and placed a plastic bag, with a brief and beddings inside, on the foot part of the bed. She unfastened the resident's brief and pushed it between the resident's thighs. She changed her gloves and sanitized her hands. She pulled some wipes and cleaned the resident's perineal area (area between the thighs) using the front to back technique. She did it five times. After cleaning the perineal area, she instructed and assisted the resident to roll towards the right side. Before rolling the resident, CNA F adjusted the resident's catheter. After adjusting the catheter, she pulled the brief from inside the plastic bag, and placed it beside the resident. She did not change her gloves before touching the new brief. CNA F rolled the resident and cleaned the resident's bottom. After cleaning the resident's bottom, she pulled the soiled brief and threw it on the trash can. After throwing the soiled brief, she pulled the new brief from the resident's side and placed it under the resident. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. She then instructed and assisted the resident to roll to the other side so the WCN could do the wound care before fastening the brief. In an interview on 07/12/2025 at 3:33 PM, ADON A stated the staff must wear a gown every time they provide care or treatment to residents with tracheostomy, g-tube, catheter, colostomy, and with open wound. She said EBP is a new thing but staff were expected to adhere to the EBP policy. She said she was made aware by LVN C and LVN D on the issues of EBP. She said LVN C should not re-use the gown and should have changed her gown her gown from one resident to another. She said the reason for that was to prevent cross contamination and probable infection. She said if one resident had an infection or had any undesirable microorganism, she would transfer it to the next resident that she would care for. She said the disposable gowns were not re-used because it could already be contaminated by bacteria or viruses. She said LVN C should have changed her gloves when she took off the dressing on the resident's tracheostomy because her gloves were already soiled. She said the same reason why CNA F changed her gloves after touching the catheter and after cleaning the resident's bottom. She said LVN D should have worn a gown when he administered medications via g-tube because the staff might introduce any germs to the resident's g-tube and also to protect the staff from any secretions from the resident. She said, as one of the ADONs, she was responsible in ensuring that the staff were compliant with the policy and procedures of infection control. She said she already started an in-service about infection control, hand hygiene, and EBP as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if there was something in the in-service that the did not understand. She said she would randomly check the staff if they were practicing infection control. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the infection control issues and ADON A already did an in-service about it. She said she the expectation was for the staff to be mindful in preventing the development of infection in the facility and to their family, as well. She said she was not a clinician but would coordinate with the DON to continually remind the staff about preventing infection control. In an interview on 07/13/2025 at 11:39 AM, CNA F stated hand hygiene was important to prevent cross contamination and to prevent infection. She said she should have changed her gloves after touching Resident #15's catheter and after cleaning her bottom because her gloves became dirty on both incidents, thus rendering the new brief to be dirty, too. She said on top of changing the gloves, she should also sanitize her hands every time she would change her gloves. She said she would be mindful the next time she does incontinent care to change her gloves after touching something soiled during incontinent care. In an interview on 07/14/2025 at 1:00 PM, the DON she already knew about the infection control issues. She said all the issues observed would contribute to cross contamination and development of infection. She said gowns should never be re-used, staff should change their gowns in between residents, staff should wear gown if the resident was on EBP, and staff should change their gloves after handling something soiled. She said the expectation was for the staff to do what was right to inhibit the development and spread of infection. She said with regards to Resident #16' catheter, the resident just came back from the hospital and she had it when she was admitted back to the facility on [DATE]. She said she already did the orders and the care plan regarding her catheter. Record review of facility policy, Fundamentals of Infection Control Precautions Infection Control Policy & Procedure Manual updated 03/2024 revealed Hand hygiene continues to be the primary means of preventing the transmission of infection . Before and after changing a dressing . After contact with a resident's mucous membranes and body fluids or excretions . After handling soiled or used linens, dressings, bedpans, catheters and urinals . After removing gloves . Gloving . To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin . Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Record review of facility policy, Enhanced Barrier Precautions undated, revealed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities . EBP are used . to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . A single set of PPE cannot be used for more than 1 patient . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, andTracheostomies . Donning PPE for Residents on EBP Based on Activity Provided . Administer medications enterally . must don gloves and gown. Record review of facility policy, Perineal Care Female Nursing Policy and Procedure Manual revised December 08,2009 revealed Purpose: To clean the female perineum without contaminating the urethral area . J. Cleaning the rectal and buttocks area . b. Gently wash the rectal area and buttocks . c. Change gloves. Record review of facility policy, Catheter Care Nursing Policy and Procedure Manual, undated revealed Procedure . 14. Hold catheter tubing . 19. Remove gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 2 of 3 (Emergency cart 1, Emergency cart 2) emergency crush carts reviewed for emergency preparedness.<BR/>1. Facility failed to have an ambu bag [is a portable, handheld device used to provide ventilation to a resident struggling to breathe or has stopped breathing] on Emergency cart 1.<BR/>2. Facility failed to check inventory daily on Emergency cart 2 from [DATE] to [DATE] and from 4/20 to [DATE].<BR/>These failures could place residents at risk for delayed emergency care.<BR/>The findings included: <BR/>Review of emergency crash cart 2's daily inventory check off on [DATE] at 3:30 AM, revealed no check off was completed on [DATE], [DATE] to [DATE] and from 4/20 to [DATE]. RN B completed check off on 4/1, 4/18, and [DATE].<BR/>Review of emergency crash cart 3's daily inventory check off on [DATE] at 3:59 AM, revealed check off was completed from [DATE] to [DATE]. RN A had completed the daily check off on [DATE]. <BR/>Observation and interview with RT F [DATE] at 3:23 AM, revealed an Ambu bag was missing on Emergency Cart 1. RT F said it was not necessary to have an Ambu bag on Emergency Cart 1 because all the residents on 300 hallways (location of emergency cart #1) had two Ambu bags in their rooms. He said there was no risk to the residents. He said if someone needed an Ambu bag they could just go in another resident's room and get one or they could get one from the central supply closet which was in the same 300 hallway. <BR/>Observation and interview with LVN M on [DATE] at 3:30 AM revealed Emergency cart 2 for was not checked from [DATE] to [DATE] and from 4/20 to [DATE], VN M stated the night shift nurses were responsible for checking the emergency carts daily. He said whoever was assigned to the hallway with the emergency cart was responsible for checking and making sure all the necessary emergency supplies were accounted for and if anything was missing to replace it. He said the person responsible for Emergency cart #2 was LVN G which was on the 100 hallways. LVN M said all staff were in-serviced on suction and having a good working suction, so he always makes sure that he checks the suction on the emergency carts. He stated if you have an emergency and you are missing supplies cause a delay in care .<BR/>In an interview with LVN G on [DATE] at 3:43 AM, revealed she had been employed by the facility for one year. She stated she had worked on [DATE] and she did not check Emergency cart #2 because it was not her responsibility alone. She said all nurses were responsible for checking all the crash carts not just her. She said she was aware that the book had to be signed and each item checked to make sure emergency items were on the cart and unexpired. She said the risk of not checking the cart was they would run out of an item needed for an emergency.<BR/>In an interview with LVN B on [DATE] at 3:59 AM, he said the night shift nurses 10 PM-6 AM were responsible for checking the crash carts nightly. He said he did his already for [DATE]. He said it was important to check emergency cart so that you have everything in case of an emergency in the facility.<BR/>In an interview with ADON on [DATE] at 11:57 AM, revealed the expectation was that the 10pm - 6 AM nursing staff checked the emergency carts daily. She said if an item was used, it needed be replaced to make sure that they always have all the necessary emergency equipment in an emergency. She said if a nurse did not know how to do something the expectation was that they would ask.<BR/> In an interview with the DON on [DATE] at 12:08 PM, She said the emergency crash carts was the responsibility of central supply to make sure that nothing was expired monthly. DON said she did not expect the nurses to check the emergency carts each day. She said if the crash cart was used it got replaced by central supply. She said at her old job they had a lock on the crash cart after being stocked and the lock was only broken when the cart was used. she said she did not know the policy on emergency crash carts therefore, she could not say the risk. She said the expectation was the emergency crash carts should be ready to go when needed.<BR/>Interview with CNA I on [DATE] at 1:43PM, she said she checked the emergency crash carts once a month for expired supplies. She said if something were expired, she would replace it and if she did not have it in stock she would order it. CNA I said the log of items on the cart are sent to corporate. She said the nurses at night have a check off list and they are responsible to check that off. She said it was important to have everything on the cart in case there was an emergency and want to make sure all the supplies are there for a code. She said if crash cart was used, it was the responsibility of either day shift or night shift if happened on night to replace it. She said the risk of not having emergency cart readily available was Something bad, they could maybe pass.<BR/>In an interview with ADM on [DATE] at 6:45 PM, she said the expectation was the nurses maintained the crash cart and it should be ready when they have a code, and afterwards it was cleaned and restocked. <BR/>Review of facility in-service titled suction machine was completed on [DATE] lead by ADON and DON. Twenty-two nurses attended the in-service including RT, LVN's and RN's.<BR/>Review of facility policy Cardiopulmonary Resuscitation, revised [DATE], reflected <BR/>20. <BR/>The facility will maintain an emergency cart with at least the following supplies:<BR/>a. <BR/>Backboard<BR/>b. <BR/>Ambu bag<BR/>c. <BR/>O2 and administration set<BR/>d. <BR/>Disposable Gloves<BR/>e. <BR/>Crash cart (ER cart/AED) is checked daily, PRN and restocked immediately after a code is completed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensurethat a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for quality of care.<BR/>The facility failed to obtain physician orders with specific non-rebreather (this is a mask that delivers high concentration oxygen with a minimum of 10 to 15 Liters/minute of Oxygen flow via a mask and has a valve that ensures air only comes in or out one way) amount on resident #1 from 11/11/24 to 11/14/24.<BR/>This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD.<BR/>Findings Included:<BR/>Record review of Resident #1's admission record dated 04/23/25 revealed a [AGE] year-old female with an admission date of 01/16/24. Her primary diagnosis was unspecified dementia (a brain disease that alters brain function and causes a cognitive decline), and her secondary diagnoses were Myxedma coma (this is a rare life threatening endocrine emergency that occurs when the thyroid hormone regulation is disrupted), heart failure, Atrial fibrillation (this is a heart condition that causes an irregular, often rapid heart rate that can cause poor blood flow), acute respiratory failure with hypoxia, COPD (a lung disease that blocks airflow and makes it difficult to breathe). Resident #1 was on hospice and Resident #1 RP was family.<BR/>Record review of Resident #1's quarterly MDS Assessment, dated 09/25/24, revealed the resident's BIMS score was 10 out of 15, indicating she had moderate cognitive impairment. The MDS Assessment reflected Resident #1 was able to make self-understood and understood others. Further review revealed Resident #1 was dependent on staff for all ADLs and required respiratory treatments oxygen therapy.<BR/>Review of Resident #1's care plan initiated on 01/17/24 revealed the following care areas:<BR/>*Resident #1 had emphysema (a chronic lung diseases that progressively damages the tiny air sacs in the lungs)/COPD. The goal was for Resident #1 to display optimal breathing pattern daily through the review date. The interventions were to give oxygen therapy as ordered by the physician. <BR/>*Resident #1 had oxygen therapy. The goal was for Resident #1 not to have any signs and symptoms of poor Oxygen. The interventions were to change residents position every 2 hours to facilitate lung secretion movement and drainage, If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal, Oxygen at 2-4 lpm per nasal canula.<BR/>Review of Resident #1's care plan initiated on 04/20/24 revealed Resident #1 had a terminal prognosis and was receiving hospice services. Resident #1 was admitted to hospice on 02/13/24 for Alzheimer's disease with late onset (this is a brain condition that progressively destroys memory and other important mental functions). Interventions were to review residents living will and ensure it was followed and to involve family in the discussion. Care plan did not reflect use of non-rebreather high flow supplement oxygen therapy for Resident #1.<BR/>Review of Resident#1's physician orders reflected:<BR/>-DNR- Do not Resuscitate ordered on 08/12/24<BR/>-admission to hospice with diagnoses of Alzheimers diseases (with late onset (this is a brain condition that progressively destroys memory and other important mental functions) level of care on 02/13/24.<BR/>- May use oxygen at 2-3 liters/minute via nasal canula every shift (nasal cannula is a thin flexible tube that gives additional oxygen up to 5 L through the nose). Ordered 02/13/24.<BR/>- Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) Microgram/Activation (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for Shortness of Breath [breathing treatment]. Ordered 01/16/24.<BR/>- Acetaminophen Rectal Suppository 650 MG (Acetaminophen) Insert 1 suppository rectally every 4 hours as needed for Pain and /or fever Not to exceed 4 doses in 24-hour period. Ordered 02/12/24. <BR/>- Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every 2 hours as needed for Very excruciating pain and /or very severe SOB. Ordered 02/12/24.<BR/>-Further review of the physician orders did not reflect orders for non-rebreather high flow supplement oxygen therapy<BR/>Review of Resident #1's MAR for November 2024 did not reflect administration orders for non-rebreather high flow supplement oxygen therapy.<BR/>Record review of Resident #1's progress notes for November 2024 reflected as follows:<BR/>Effective Date: 11/12/2024 13:42 [1:42 PM] Type: Nursing Progress Note, Author: RN A:<BR/> Hospice RN in pt room, pt having SOB with 02 at 87% per 3L nasal cannula, Temp 101.2, Resp 24, BP 187/86, pulse 96. Nonrebreather mask placed on pt with 02 turned up to 5L, O2 level at 95% at this time. Hospice RN given orders by provider to start Levaquin 500 mg [antibiotic], Prednisone 20mg [steroid], and Duonebs q 6 hours [breathing treatment]. First doses given along with first Duoneb per nebulizer. Pt ia [is] alert and oriented x 2, with some confusion, with moderate SOB observed. Pt has no c/o pain at this time. Tylenol supp [suppository] given for elevated temperature. Pt head of bed elevated with instructions given to CNAs to keep it elevated due to pt SOB.<BR/>Effective Date: 11/13/2024 07:04 [7:04 AM]- Author: RN A<BR/>Note Text: Pt resting quietly with 02 at 96% per nonrebreather at 4L. B/P 128/79, pulse 74, resp 26, temp 98.9 with rhonchi [lung sound characterized by low pitch rumbling sound] and wheezing heard in bilateral [both] lobes. Duoneb given per order, along with Morphine 1ml sublingually [under the tongue]. Pt alert and responsive to verbal stimuli [awakening] with nodding or shaking her head. Call light within reach and no distress noted at this time.<BR/>Effective Date: 11/13/2024 21:45 [9:45 PM] Type: Nursing Note- Author: LVN B<BR/>Note Text: This resident is being treated for URI . BP-110/72. P-86. R-18. T-97.3. O2-97. Oxygen at LPM: 5 via mask continuously.<BR/>Negative Findings: Hoarseness, Respirations: Labored Breathing, Abnormal breath sounds: Rhonchi, to Right Lower Lobe, to Right Upper Lobe, to Left Lower Lobe, to Left Upper Lobe.<BR/>Interventions: Breathing treatment: DUONEBS TID head of bed up, No Pain.<BR/>Effective Date: 11/14/2024 02:24 [AM] Type: Nursing Note Author: RN C<BR/>This resident is being treated for URI.<BR/>BP-127/64. P-90. R-18. T-97.5. O2-97.<BR/>Oxygen at LPM: 5 via mask continuously.<BR/>Negative Findings: None<BR/>Respirations: Labored Breathing,<BR/>Breath sounds clear.<BR/>Interventions: Breathing treatments: ALBUTEROL TID.<BR/>-11/14/2024 at 14:01 [2:01 PM] change in condition entered by RN D <BR/>Effective Date: 11/14/2024 14:23 [2.23 PM] Type: Nursing Progress Note- Author: RN D<BR/>Note Text: Resident transitioning to end of life. VS T97.3 P93 R12 shallow with apnea, SATS 91-97% on 10L via non-rebreather mask.<BR/>Scheduled morphine and PRN Ativan given throughout shift as needed for pain/SOB. Repositioned Q2hrs for comfort, oral care provided. Family at bed side all shift.<BR/>Effective Date: 11/14/2024 15:38 [3:38 PM] Type: Nursing Progress Note Effective Date: 11/14/2024 14:23 Type: Nursing Progress Note- RN B<BR/>Note Text: Noted change in VS they are dropping BP 86/49, P 74, T 95.6, R20, O2 93% 10L mask, cannot verbalize pain morphine given 1 ML.<BR/>During a phone interview with Resident #1's RP on 03/26/25 at 1:26 PM revealed Resident #1 passed away on 11/14/24 at 6 pm. She said Resident #1 sounded like she was suffocating due to the non-rebreather not set correctly. She said Resident #1's non-rebreather was set to administer only five liters of oxygen instead of the ten liters that were required to support non-rebreather oxygen therapy. She stated, no one noticed the wrong non-rebreather setting of oxygen until the next business day (11/14/24), when RN D corrected it and placed Resident#1 on the recommended 10 Liters to support non-rebreather treatment. She said the non-rebreather was later removed before Resident #1 passed away on 11/14/24.<BR/>Review of Resident #1's respiratory vitals from 11/11/24 to 11/14/24 revealed the following:<BR/>- <BR/>11/11/24 - 18 breaths per minute<BR/>- <BR/>11/13/24 - 26 breaths per minute - out of range for breaths per minute<BR/>- <BR/>11/17/24 - 17 breaths per minute<BR/>- <BR/>11/14/24 - 19 breaths per minute<BR/>Review of Resident #1's oxygen saturation levels from 11/11/24 to 11/14/24 revealed the following:<BR/>- <BR/>11/14/24 - between 93-94 % (day of Resident's passing)<BR/>- <BR/>11/13/24 - between 95-96% - normal range for oxygen<BR/>- <BR/>11/12/24 - between 95-96% - normal range for oxygen<BR/>- <BR/>11/11/24 - 97% - normal range for oxygen<BR/>In an interview with RN A on 04/23/25 at 7:15AM, revealed she had been employed at the facility for eight months. She stated one of the CNA's (CNA J) informed her that Resident #1 was not doing well, she immediately went to Resident #1's room and assessed her [11/12/24]. She said while she was assessing her the hospice nurse RN K walked into the room. She said Resident #1 was on a nasal cannula at 3 L. RN K told her to increase Resident #1's oxygen to 5 L, therefore RN A placed Resident #1 on a non-rebreather because her oxygen level was not going up. She said RN K them got on the phone with hospice physician and obtained other orders immediately . She said she could not remember the orders as it had been a long time ago. RN A stated she had never used a non-rebreather before and she would not have done so without someone telling her to do so. She said, I believe RN K told her to use the non-rebreather for Resident #1 but She did not remember 100 percent. She stated she was not familiar on range of the oxygen on non-rebreather mask. She said she would google and ask someone for the range. She said the process of receiving orders was verbal or written and that she would put the orders in the computer after the hospice nurse gave them to her . She said some hospice nurses put their own orders in, so she was not sure if the order for the non-rebreather was added. RN A said she did not take off the non-rebreather from Resident #1 until she was stable . She said the hospice nurse left after Resident #1 stabilized and she did not tell her to remove the non-rebreather. She said because the hospice nurse was in there, she assumed it was ok to the leave the non-rebreather on because she did not say to remove it and put Resident #1 back on her nasal cannula. RN A said the hospice nurse (RN K) notified the physician and she did not have to because Resident #1 was on hospice and the hospice nurse was in the room. Said it was important to get physician orders for the safety of the patient so they can know how what to do. RN A said she was aware of RT in the facility, but it all happened so fast, and they moved as fast to stabilize Resident #1 that she forgot to ask RT to check Resident #1 who had been placed on the nonrebreather.<BR/>In a phone interview with RN K on 03/26/25 at 2:41 PM, she stated she was Resident #1's hospice nurse. She said she went to see Resident #1 on 11/11/24 the non-rebreather was used on her. She said when she got to Resident#1's room, Resident #1 was having difficulty breathing and had shortness of breath. She said the facility nurse RN A had already placed Resident #1 on the non-rebreather. She said she could not remember the liters of the non-rebreather because she herself and RN A were trying to stabilize Resident #1. RN K said she was knowledgeable that non-rebreathers should be set at minimum ten liters otherwise the patient is not getting the needed oxygen fast. RN K said that she did not get orders for the non-rebreather. She said that she called the hospice physician while she was in Resident #1's room and reported Resident #1's condition and he gave her orders but the hospice physician did not give order to keep Resident #1 on a non-rebreather for supplemental oxygen. RN K said the order process was that she wound send the doctor a text on the phone to get orders then she wrote them down on paper and give the order to the facility nurse to imputed in her computer. She said the written orders are placed in the resident's hospice book afterwards. RN K said a non-rebreather was used in emergency cases to help patients get large amounts of oxygen fast to help them recover. She said non-rebreathers were not for long term use. She said when she left, Resident #1 was still on the non-rebreather, but she was stable. She said she was not aware the facility left Resident #1 on the non-rebreather until 11/14/24. She said she did not give them any verbal orders to keep Resident #1 on the non-rebreather oxygen therapy. She said she was also not aware that the facility had Respiratory Therapists on site 24 hours because no one told her. She said the risk to the resident for not getting orders for non-rebreather was retention of carbon dioxide especially in a resident with COPD. <BR/>In a phone interview with CNA J on 03/26/25 at 2:10 PM, she said that she worked for the hospice company that Resident #1 was admitted to while in the facility. She said she proved ADL care, to Resident #1 three times a week and then the week before she passed away, ADL care was changed to five days a week. She said that she had found Resident #1 without oxygen or still connected to an empty oxygen tank on her wheelchair on multiple occasions. She said she would connect Resident #1 to the oxygen compressor in her room then go out and tell facility nursing staff to let them know what she saw and to get Resident #1 a full oxygen tank to use in the shower room for Resident #1.CNA J said she could not remember the names of the facility staff she reported to. CNA J said the last week before Resident #1 passed away she was assigned to provide daily ADLs care as usual, she said she told the facility that Resident #1 did not need a lot of oxygen and asked them to remove the non-rebreather off Resident #1.CNA J said she could not remember the exact date. She said Resident #1 looked more comfortable with just the nasal canula after the non-rebreather was removed. She said she could not remember the exact date when they removed the non-rebreather, but she had to tell the facility to remove it and put her on the nasal cannula.<BR/>In an interview with LVN B on 04/23/25 at 3:59 AM, he stated he had been employed by the facility for a year and a half. He said he had gotten training on Ventilators, non-rebreathers, tracheostomy, and other supplemental oxygen therapy when he first started working at the facility. He said he knew that non-rebreathers were only used to short term use and when he took care of Resident #1, he used a regular simple oxygen mask on her. He said he did not see any orders for a non-rebreather. He said it was important to make sure residents had physician orders for consistency and to follow orders so that you do not make the patients worse by doing the wrong thing. He stated if he needed clarification on orders, he could reach out to the facility physician or the hospice physician or hospice nurse.<BR/>In a phone interview on 04/23/25 at 11:18 AM, revealed RN C had worked with Resident #1 before she passed away [11/14/24] but he could not remember if Resident #1 was on a non-rebreather. He said he knew that a non-rebreather was used only in an emergency when a residents oxygen level drops to help bring back [NAME] quickly. He said after a resident was stabilized, they should be placed on a nasal cannula or if they do not stabilize 911 would be called. RN C said he did not obtain new orders for Resident #1 because the physicians were already aware of the residents' current conditions. He said he believed the oxygen orders were in the computer and he just continued with what was given to him in report. RN C stated it was always good to look at the residents' orders and verify them so that you did not do something wrong. <BR/>In an interview with RN D on 04/23/25 at 7:40 AM, revealed she had been employed at the facility for four years. She said Resident #1 had been moved to her hallway [100 hall] and was assigned to her on 11/14/24 at 2PM. She said she noticed that Resident #1 was on a non-rebreather connected the hospice compressor however the compressor could only deliver a maximum of 5 Liters of oxygen so she asked the transferring nurse to get an Oxygen compressor that could deliver 10 L of oxygen. She said she then increased the non-rebreather to 10 L of oxygen which was the minimum required setting for non-rebreather mask. RN D said she completed a change of condition. RN D stated at this time, after getting the compressor and non-rebreather set to correct parameters, Resident #1 appeared stable she informed Resident #1's family that the non-rebreather was only to be used for short term use. RN D stated family refused to remove the non-rebreather even after she educated them. RN D said she did not call RT to access Resident #1 because she was already at end of life and both herself and the hospice nurse educated family on no-rebreather. RN D said eventually the family decide to allow her to remove the non-rebreather and Resident #1 was placed on a nasal cannula. RN D said physician orders are required to drive care. She said all nurses were trained on how to use a non-rebreather and for what it was used. RN D sated she forgot to document that Resident #1's RP was refusing to have the non-rebreather removed from Resident #1.<BR/>In an interview with RT E and RT F on 04/23/25 at 3:23 AM, revealed they were not responsible for all the residents on supplemental oxygen therapy in the facility except for the ones on mechanical ventilation. They said in an event nursing needed assistance or had a respiratory question they would help. RT E said if a resident is needing to be on a non-rebreather, and they are a full code they would not be in the facility long, We would be calling 911. He said no-rebreathers are good for short term use to deliver fast 100% oxygen to help bring low oxygen up quickly. Both RT E and RT F said the non-rebreather should be set at 15 L or 10-12 Liters for it to be effective. RT E said a non-rebreather should not be used for 3 days as it affects PH which can cause the lungs to fail to remove enough carbon dioxide from the body. He said non-breathers can only be used for the shortest time possible. Both RT E and RT F said orders are required for all residents on oxygen therapy. <BR/>In an interview with the DON on 04/23/25 at 12:08 PM, revealed she did not expect the nurses to obtain new orders for supplemental oxygen because Resident #1 already had orders to used supplement oxygen. She said even though the method of delivery was different, Resident #1 still had orders to use oxygen. DON said a non-rebreather was used for emergency when Resident #1 was having difficulty breathing and because it was an emergency to stabilize the resident, no physician orders are needed. DON said RN D educated the family that Resident #1 could not be on the no-rebreather for an extended time, but the family would not allow them to take off the non-rebreather. DON stated because Resident #1 was a DNR and was on hospice actively passing away, they did not need to call 911 for the resident needing to be on a nonrebreather oxygen delivery form. DON stated the expectation for a non-rebreather was 10-15 L of oxygen to be effective, she said she would not expect someone to put a non-rebreather at 4-5 L, however the hospice nurse (RN K) who was in the room with Resident #1 and RN A notified the physician, and the physician was aware of the condition of the resident. DON did not state the risk because Resident #1 already had supplemental oxygen orders.<BR/>In a phone interview with the physician on 04/23/25 at 12:53 PM, he said he deferred supplemental Oxygen, or anything related to oxygen to the pulmonologist. He said in the event the nurses cannot reach the pulmonologist then he would put in the orders. He said he could not remember Resident #1 without looking at her records, but the nurses were good about notifying him when there was a change of condition and he expected nurses to reach out to him for oxygen order when they could not reach the pulmonologist first and he would give them the orders. He said physician orders drives care.<BR/>In an interview with ADM on 04/23/25 at 6:45 PM, she said the expectations was that all residents on supplemental oxygen obtain orders. She said she expected all staff to obtain physician orders and to follow the physician orders.<BR/>In an interview with ADM on 04/23/25 at 4:44 AM, she stated all records for residents on hospice were uploaded to the EMR of each resident after they discharge.<BR/>Record review of Resident #1 EMR on 04/23/25 at 4:44 AM did not reflect orders for non-rebreather use.<BR/>Record review of Resident #1's discharge MDS assessmet, dated 11/14/24, did not indicate cause of death.<BR/>Cause of death report requested from hospice company, but surveyor has not yet obtained.<BR/>Review of the facility policy titled Physician Orders dated 2015 reflected the purpose of policy was.<BR/>To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.<BR/>1. <BR/>Nurse will review the order and if needed contact the prescriber for any clarifications.<BR/>2. <BR/>The nurse will enter the order into PCC for the resident and select either verbal or telephone, depending on how the nurse received the order.<BR/>3. <BR/>If the order requires documentation, it will be directed to the proper electronic administration record once the order is completed . <BR/>Review of facility policy titled Oxygen Administration: revised March 21, 2023, reflected .<BR/>The Resident will maintain oxygenation with safe and effective delivery of prescribed Oxygen

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 7 (Resident #8, Resident #12, Resident #3, Resident #44, Resident #81, Resident #24, and Resident #62) of 114 residents reviewed for call lights. <BR/>The facility failed to ensure Resident #8, Resident #12, Resident #3, Resident #44, Resident #81, Resident #24, and Resident #62's call buttons were within reach. <BR/>This failure could place residents at risk for decreased quality of life, self-worth, and dignity.<BR/>Findings included:<BR/>Review of Resident #8's face sheet dated 07/13/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease; Major Depressive Disorder; Unspecified Lack of Coordination; and Other Abnormalities of Gait. <BR/>Review of Resident #8's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #8 required supervision to extensive assistance with ADLs. <BR/>Review of Resident #8's Comprehensive Care Plan revised 07/12/23 reflected Resident #8 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 9:55 AM revealed Resident #8 was in her bed and her call light was hanging across the trash can near the wall between the bed and bedside nightstand. Resident #8 was sleeping.<BR/>Review of Resident #12's face sheet dated 07/13/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following cerebral Infarction Affecting Left Non-Dominant Side (defined as paralysis of partial or total body, whereas hemiparesis is characterized by on-sided weakness, but without complete paralysis); Contracture, Left Wrist; Contracture, Left Hand; Contracture, Left Ankle (a contracture is a fixed tightening of muscle, tendons, ligaments, or skin).<BR/>Review of Resident #12's MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired. Resident #12 required total dependence to extensive assistance with ADLs. <BR/>Review of Resident #12's Comprehensive Care Plan revised 07/07/23 reflected Resident #12 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 9:57 AM revealed Resident #12 was in her bed and her call light was under her bed. Interview with Resident #12 revealed she spoke Spanish but understand what the call button was and made a hand motion that she did not have her call button.<BR/>Review of Resident #3's face sheet dated 07/13/23 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbances, Mood Disturbances, and Anxiety; Unspecified Lack of Coordination; Unsteadiness on Feet; Other Abnormalities of Gait and Mobility.<BR/>Review of Resident #3's MDS assessment dated [DATE] reflected the resident's memory was moderately impaired. Resident #3 required supervision to limited assistance with ADLs. <BR/>Review of Resident #3's Comprehensive Care Plan revised 05/26/23 reflected Resident #3 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 10:02 AM revealed Resident #3 was in his bed sleeping and the call light was stuck under his mattress where the resident could not reach call light. <BR/>Review of Resident #44's face sheet dated 07/13/23 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Parkinson's Disease; Abnormal Posture; Repeated Falls; Difficulty Walking, Not Elsewhere Classified; Unspecified Dementia, Severe, With Other Behavioral Disturbance.<BR/>Review of Resident #44's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #44 required limited assistance to total dependence with ADLs. <BR/>Review of Resident #44's Comprehensive Care Plan initiated 06/29/23 reflected Resident #44 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 1:30 PM revealed Resident #44's call light was clipped to the back of the privacy curtain out of reach. <BR/>An interview with on 07/11/23 at 1:30 PM with Resident #44 in his room revealed that he could not safely reach his call light clipped to back of the privacy curtain. Resident was in his wheelchair beside his bed. Call light was clipped to privacy curtain near the nightside, wall, above wheelchair height, and out of reach.<BR/>Review of Resident #81's face sheet dated 07/13/23 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Severe with Other Behavioral Disturbances; Unspecified Lack of Coordination; Repeated Falls; Unsteadiness on Feet.<BR/>Review of Resident #81's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #81 required partial/moderate assistance to total assistance with ADLs. <BR/>Review of Resident #81's Comprehensive Care Plan revised 06/02/23 reflected Resident #81 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 10:04 AM revealed Resident #81 was currently in her bed asleep and call light was out of reach between the bed and wall. <BR/>Review of Resident #24's face sheet dated 07/13/23 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity with Psychotic Disturbances; Contracture of Right Knee; Contracture of Right Ankle; Contracture of Left Ankle; Contracture of Left Hand; Other Lack of Coordination; Other Abnormalities of Gait and Mobility.<BR/>Review of Resident #24's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #24 required supervision to substantial max assistance with ADLs. <BR/>Review of Resident #24's Comprehensive Care Plan revised 04/26/23 reflected Resident #24 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation and interview on 07/11/23 at 10:30 AM with Resident #24 revealed Resident #24 was in her bed and her call light was under her bed. Interview with the resident revealed she could use her call light if it was within reach.<BR/>Review of Resident #62's face sheet dated 07/13/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Acute Respiratory failure with Hypoxia (defined as an absence of enough oxygen in the tissues to sustain bodily functions); Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery (defined as a middle cerebral artery of the brain is suddenly interrupted (ischemia) or altogether stopped (infarction).<BR/>Review of Resident #62's MDS assessment dated [DATE] reflected the resident's memory reflects decisions consistent and reasonable. Resident #62 required supervision to limited assistance with ADLs. <BR/>Review of Resident #62's Comprehensive Care Plan revised 06/06/23 reflected Resident #81 was a risk for falls r/t impaired balance. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 10:38 AM revealed Resident #62 was in her bed and her call light was under her bed. Interview with the resident revealed she did not want her call light at that time.<BR/>In an interview on 07/11/23 at 11:32 AM with RN A revealed she was not aware of the call lights were not within reach for the residents on Hall 1. RN A was asked what problems could develop if resident did not have the call light within reach and RN A stated the resident may be in pain and need medication, may try, and get up to go to the bathroom and fall, may have a medical emergency that needs attention. RN A would inform the CNAs.<BR/>In an interview on 07/11/23 at 11:37 AM with CNA B revealed she did not know the call lights were on the floor. CNA B was asked what could happen if call light was not within reach of resident who needed assistance and CNA B revealed a resident could try and get up and fall, may be sick and need assistance, or may just need water. CNA B revealed she would make sure all call lights were within reach. Asked CNA who is responsible to make sure call lights are within reach, and she replied, the CNAs.<BR/>Requested a policy for Call Lights from ADM at 4:00 PM on 07/12/23. <BR/>In an interview on 07/13/23 at 11:15 AM, the ADM revealed the facility did not have a policy for Call Lights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 of 3 residents (Residents #1) reviewed for supervision. <BR/>The facility failed to ensure Resident #1, who had severe cognitive impairment and resided on the secure unit, received adequate supervision to prevent her from wandering into the facility's enclosed courtyard without staff knowledge and being left outside for approximately 3 hours while it was raining. The facility failed to ensure the door that led to the enclosed courtyard was locked or supervised, when the door's locking mechanism lost power during the storm. <BR/>The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 04/01/24 and ended on 04/02/24. The facility had corrected the noncompliance before the survey began. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included: <BR/>Review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. <BR/>Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident is rarely/never understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices. <BR/>Review of Resident #1's care plan, dated revised 04/03/24, reflected: Focus: The resident wanders throughout the day and night. Goal: Resident will demonstrate happiness with daily routine through the review date. Resident safety will be maintained through review date. Interventions: Assess for fall risk. Disguise exits: cover door knobs and handles, tape floor. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. The resident will reside in the secure unit.<BR/>Focus: Resident is at risk for elopement as evidenced by impaired safety awareness, attempts at leaving facility, pulling and banging on doors in an attempt to leave the secured unit. Goal: [Resident #1] will remain safe within facility unless accompanied by staff or other authorized person through review date. Intentions: Supervise closely and make regular compliance rounds whenever resident is in room. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. <BR/>Focus: Resident resides in the SecureCare Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Memory loss. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the SecureCare Unit. Interventions: Admit to SecureCare unit per MD orders. Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day.<BR/>Review of Resident #1's Elopement Risk Assessment dated 03/11/24 revealed Resident #1 resided in the secure unit; Cognitive skills for daily decision making - severely impaired -never/rarely made decision; history; one or more times in last week; Behaviors - Restlessness (pacing, wandering or rummaging). <BR/>Review of Resident #1's Elopement Risk Assessment dated 04/02/24 revealed Resident #1 resided in the secure unit; Cognitive skills for daily decision making - severely impaired -never/rarely made decision; history; one or more times in last week; Behaviors - Restlessness (pacing, wandering or rummaging). <BR/>Review of Resident #1's progress notes by LVN AB on 04/02/24 at 00:57 revealed the following: Resident missing from the unit, later found lying on the ground in the courtyard, no bruise/injury noted on full assessment, no pain verbalized in full range of motion, Resident assisted up in w/c, taken to the shower room, given warm bath, assisted to bed, covered with warm blanket, M/d family notified.<BR/>Review of Resident #1's progress notes by DON on 04/02/24 at 11:30 revealed the following: Note Text: DON went to secured unit to re-assess resident and ensure no injury r/t resident being observed on the grass beside the sidewalk in the courtyard on the night of 4/1/24. Resident was observed on the couch in the tv room sleeping. Resident stated to staff that she was not having pain, but would not stand from the couch to allow DON to fully assess her. CNA that gave resident shower on 4/1/24 stated she did not see any new injury related to this incident, there are some healing bruises noted to resident's skull from prior fall and scattered bruises to BUE from resident wandering and her unsteady gait. DON could assess BUE, back, abdomen, and BLE up to her knees; no new injuries noted. Will remain available to resident and staff.<BR/>Review of facility Provider Investigation Report dated 04/05/24 revealed the following: Incident Category: Neglect; Incident Date 04/01/24; Time of Incident: 8:30 PM; Location of Incident: Resident out into courtyard; Description of the Allegation: Resident was not accounted for during walking rounds by nurses at shift change. Assessment: Date 04/01/24 at 11:30PM by LVN F; No noted injuries or behavioral changes from baseline. Head to toe assessment was completed. Xrays and labs ordered along with CT Scan out of the facility. All residents were counted visually as staff continued with the missing resident protocol. All xrays and CT Scan were negative for any new fractures. Investigation Findings: Confirmed; Provider Action Taken post-investigation: Abuse and neglect in serviced completed; missing resident protocols inserviced and drills completed and will continued to monitor and perform drills. Door was checked by outside vendor and I secure; door codes changed. <BR/>Review of Resident #1's Final X-Ray Report completed 04/02/24 revealed no acute fractures or dislocations. <BR/>Review of Resident #1 Ct Head Without Contrast completed 04/04/24 revealed no acute intracranial abnormality. <BR/>Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed, observed floor mats on each side of the bed. Resident #1 was covered up to her forehead, observed a swollen dark purple/blue bump to resident right side of her forehead/temple. Unable to observed Resident #1 full face.<BR/>Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Resident #1 was not a good historian. Resident #1 unable to recall going outside, however, she denied any pain. Interview with Resident #1 Family Member revealed she was notified of Resident #1 leaving the secure unit and being outside the enclosed courtyard. She stated Resident #1 wandered around and walked all over the secure unit. Resident #1's Family Member stated they completed x-rays and CT scans were done with no negative results. <BR/>Review of the facility's surveillance footage dated 04/01/24 at 18:26 [6:26 PM] revealed Resident #1 walking towards the secure unit living room area. Observed double doors being closed. Resident #1 opened the living room area door and was walking towards the courtyard door. However, since the camera was not facing the door, it was not captured when Resident #1 opened and exited the door. <BR/>Interview on 04/13/24 at 1:08 PM with the Administrator revealed the date stamp in the camera footage was off. She stated the time was not correct. The Administrator stated she received a call at around 10:00 PM on 04/01/24 stating that Resident #1 was missing. She stated she contacted the Maintenance Director and asked him to review the camera footage. She stated she arrived at the facility at around 10:30 PM and she received a call from the Maintenance Director telling her to look in the enclosed courtyard. She stated Resident #1 was found around 11:00 PM. She stated the 2:00 PM-10:00 PM LVN was LVN AB and the 10:00 PM-6:00 AM was LVN F. The Administrator stated CNA S placed Resident #1 in bed at 7:20PM and Resident #1 got up and began to walk around the secure unit. She stated the enclosed courtyard had a door code, and it was unknown how Resident #1 was able to open the door. She stated the night of 04/01/24, it was raining and the light flickered and they believe that in that moment when the light [NAME] Resident #1 open the door. She stated when Resident #1 was found outside, she was laying on the floor, and Resident #1 was damped (slightly wet). She stated they gave Resident #1 a warmed bath and no injuries were noted. She stated X-rays and CT were completed and results were negative. <BR/>Observation and interview on 04/13/24 at 1:20 PM of Secure Unit courtyard door with Maintenance Director revealed the door was closed, was unable to be opened without the code. Observed Maintenance Director punch in the door code and door open. Observed additional alarm added to the door; alarm was heard and it was loud. Maintenance Director stated he received a call at around 10:30PM the night of 04/01/24 form the Administrator. He stated he was asked to check the camera footage and he observe Resident #1 walking in the living room toward the courtyard door. He stated the camera was not facing the door so it was unknown how Resident #1 was able to open the door. The Maintenance Director stated the time on the camera footage was off and they cannot go by the time the camera footage was stamped. He stated he notified the Administrator around 11:00 PM to check the enclosed courtyard. He stated the courtyard door needs a code to open it, he stated the night of 04/01/24 it was raining and CNA G stated the lights were flickering. He stated when the light [NAME] they believed that was the time Resident #1 was able to open the door. The Maintenance Director stated since the incident they had in serviced all staff on elopement/missing person, the staff were checking doors every 15 minutes starting from 04/02/24 through 04/11/24. He stated they completed elopement drills on 04/02/24, 04/07/24 and will continue randomly. He stated they had the alarm company come out on 04/02/24 to check the doors, they implemented an additional alarm on the door and door codes would be changed monthly. He stated the alarm company came out and stated due to the light flickering the magnet on the door detached and did not grip on time. He stated they replaced the door closure with a stronger spring. <BR/>Interview on 04/13/24 at 2:05 PM with LVN AB revealed he was the nurse assigned on the secure unit and was the nurse for Resident #1 on 04/01/24 from 2:00 PM-10:00 PM. LVN AB stated Resident #1 was able to ambulate on her own without assistance. He stated Resident #1 was known to wander around. He stated on 04/01/24, the last time he observed Resident #1 was between 7:00 PM-8:00 PM when he provided her with her night medications. He stated during shift change at 10:00 PM he was notified by incoming night staff that Resident #1 could not be located. He stated they began to look for Resident #1 in each room, closets, restroom, dining area, living room and all around the secure unit. He stated they notified the Administrator and the Administrator contact the Maintenance Director for him to review camera footage. He stated at around 10:45 PM close to 11:00PM, Resident #1 was found outside in the courtyard lying on the grass. He stated the courtyard door only opened with a code. He stated he did not know how Resident #1 was able to open the door. He stated he could not remember any lights flickering and denied hearing an alarm. He stated Resident #1 was slightly wet due to the rain. He stated they brought Resident #1 inside and gave her warm bath. LVN AB stated Resident #1 did not sustain any injuries. He stated Resident #1 was her normal self and could not recall the event. <BR/>Interview on 04/13/24 at 2:58 PM with LVN F revealed he was the incoming nurse for the 10:00PM-6:00AM shift on 04/01/24. He stated he was completing his rounds and he was not able to locate Resident #1. He stated it was a little after 10:00PM when they were not able to locate Resident #1. He stated he contacted the Administrator to notify her Resident #1 was not able to be located after looking everywhere in the secure unit. He stated he told the Administrator to look at the video footage starting from 8:00PM. He stated the Maintenance Director was able to look at the camera footage and the Maintenance Director told them to look in the courtyard. LVN F stated they found Resident #1 outside in the enclosed courtyard. LVN F stated he could not recall the time Resident #1 was found. He stated Resident #1 was provided with a warm bath and no injuries were noted. LVN F stated no one goes into the enclosed courtyard. He stated the door had a code and it was unknown how Resident #1 was able to open it. <BR/>Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the incoming CNA assigned to the secure unit on 04/01/24 from 10:00 PM-6:00 AM. She stated she was completing her rounds closed to 10:00PM when she asked the 2:00 PM-10:00 PM aide where Resident #1 was. She stated she could not recall who the aide was. She stated when she asked the aide, the aide told her Resident #1 was here somewhere but not sure where Resident #1 was. She stated she notified LVN F and they began searching for Resident #1. She stated the nurses notified the Administrator and within 30-45 minutes Resident #1 was found outside in the enclosed courtyard. CNA G stated the night of 04/01/24 it was raining. She stated she did not know if the door was open or closed; however, to open the courtyard door they needed a code. She stated no one went out to the enclosed courtyard. She stated the secure unit had another courtyard that they use. She stated Resident #1 was given a warm bath and no injuries were noted. <BR/>Interview on 04/13/24 at 3:53 PM with CNA S revealed she was the CNA assigned to Resident #1 on 04/01/24 from 2:00PM- 10:00PM. She stated on 04/01/24 she had placed Resident #1 in bed at around 7:00PM - 7:15PM; however, Resident #1 got up again and began to walk around. She stated she left her shift at around 9:45PM close to 10:00PM. She stated she last time she observed Resident #1 was on the hallway; however, she could not recall the time. CNA S stated she did not hear any alarms go off. She stated they did not use the enclosed courtyard. She stated they had another courtyard normally used. She stated the enclosed courtyard door needed a code to open and it was unsure how Resident #1 opened it. She stated she did not recall any lights flickering; however, it was raining outside. <BR/>Interview on 04/13/24 at 4:32 PM with the DON revealed the night of 04/01/24 Resident #1 went missing in the secure unit. She stated she began her investigation on 04/02/24. She stated she spoke to CNA S and CNA S stated she had placed Resident #1 in bed around 7:30PM and Resident #1 got up from bed and was walking around the secure unit. She stated LVN AB stated he last observed Resident #1 when he provided resident with her night medications between 7:00PM-8:00PM. She stated at around 10:00PM during shift changed they noticed Resident #1 could not be located. The DON stated Resident #1 was found in the courtyard laying on the grass around 10:30PM. She stated the night of 04/01/24, it was raining and CNA S reported the lights were flickering and they believed during the time the lights [NAME] was when Resident #1 open the enclosed courtyard door. The DON stated the courtyard door needed a code to be opened. She stated she did not even know the code to the door. She stated no one used the enclosed courtyard. She stated when she was investigating the incident, she tried to open the courtyard door without the code and the door would not open. She stated they changed the door code and it would be changed monthly. She stated they implemented a new alarm on the door, they in-serviced all staff on elopement/missing person, staff would check the doors q15 , and alarm company came out to check the doors. She stated Resident #1 had no injuries and her behavior was her normal. She stated they completed x-rays and CT scan without no findings. <BR/>Follow-up interview on 04/13/24 at 4:48 PM with the Administrator revealed they in-serviced all staff on missing person, they conducted missing person drills which consist of getting a volunteer resident and having staff search for that resident. She stated had the alarm company come out and implemented a new alarm and will be changing the door alarm every month. She stated the alarm company came out and stated due to the light flickering the magnet on the door detached and did not grip on time. <BR/>Record review of the facility's Elopement Response policy and procedure, revised January 2023, reflected the following: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented.<BR/>4. Should an employee discover the resident missing from the facility (Code Orange) .<BR/>Record review of the facility's Elopement Prevention policy and procedure, revised January 2023, reflected the following: Every effort will be made to prevent elopement episode while maintaining the least restrictive environment for residents who are at risk of elopement.<BR/>This was determined to be a Past Non-Compliance Immediate Jeopardy on 04/13/24 at 7:20 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/13/23 at 7:20 PM.<BR/>The facility took the following actions to correct the non-compliance prior to the survey:<BR/>Record review of the following in-services dated 04/02/24 Elopement Response, Elopement Prevention and Code Orange. In-service reveal all staff completed the training. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM. <BR/>Review of Resident #1's Elopement Risk Assessment completed on 04/02/24; Resident #1 resided in the Secure unit. <BR/>Door codes on 500 Hall unit changed on 04/03/24. Replaced door with closure with a stronger grip. Added additional alarm to exit door to courtyard. Alarm installed made louder upon opening without code and or left ajar. <BR/>Observation on 04/13/24 at 1:20 PM revealed exit door on the secure unit courtyard door was checked with the Maintenance Director and door was functioning properly. There was an additional louder alarm added so they could be heard throughout the facility if the doors did not latch after being open. <BR/>Interviews on 04/13/24 from 12:04 PM through 5:00 PM with LVN A, CNA B, CNA M, LVN C, LVN AB, Student Nurse Aide, CNA G, CNA H, LVN F, CNA S, CNA AC, CNA AD, CNA O, RN J, Treatment Nurse, ADON L who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM - 6:00 AM revealed they were able to verify education was provided to them. Nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, missing person drills, and door checks.<BR/>Interview on 04/14/24 from 10:22 AM through 2:00 PM with CNA I, CNA Q, HR Coordinator, LVN W, LVN X, Guest Relations Coordinator, ADON K, LVN Y, CNA U and CNA V who work the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM revealed they were able to verify education was provided to them, nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, missing person drills, and door checks.<BR/>Record review of the Facility's Door Checks date 04/02/24 at 2:00 PM through 04/11/24 door checks were completed every 15 minutes<BR/>Record review of the facility's Elopement Drills or Actual Elopement Guide revealed drills were conducted on 04/02/24 and 04/07/24.

Number of residents sampled:<BR/>Number of residents cited:<BR/>Based on observation, interviews, and record reviews, the facility failed to protect residents' right to a safe, clean, comfortable and homelike environment for 20 of 31 residents in the secured unit reviewed for resident rights. The male side of the secured unit had a strong urine smell on 9/16, 9/17 and 9/18/2025. This failure could result in lack of residents' hygiene and could affect their dignity. Findings included:Observation on 9/16/2025 at 7:45am, the end of hallway 100 which was connected to the secured unit had a strong urine smell. Upon entering the secured unit, there was a strong urine smell that spread through the entire male's side of the secured unit. The male side had 20 male residents. Observation on 9/17/2025 at 6:45am, the male side of the secured unit had a strong urine smell. Observation on 9/18/2025 at 9am, the male side of the secured unit had a strong urine smell. In an interview on 9/18/2025 at 9:15am, CNA A, who was the CNA assigned to male side of the secured unit, stated that there were 4 or 5 residents who would urinate in the hallway, in the dining room and in the TV room. She stated that the staff had tried to direct the residents as much as they could, however, residents still urinated in the common area. She stated that she would redirect the residents to their room and clean the residents and inform housekeeping right away so they could come to disinfect and clean the area. CNA A stated that the smell had always been there, and she was unsure if there were more interventions from the facility to decrease the smell. In an interview on 9/18/2025 at 11:01am, LVN B stated that he and CNA A had been keeping residents who wandered and urinated in common areas in the dining room or TV room for better observation. He stated that some residents would urinate while watching TV. He stated that since the residents were cognitively impaired, his interventions had been redirecting them and cleaning them when they urinated and passing feces in the common area. He also stated that housekeeping got notified right away to come and clean the area. In an interview on 9/18/2025 at 10:55am, Resident #76 stated that he did not remember smelling any urine or bad smell in the facility. Record review of Resident#76's face sheet, dated 9/18/2025, revealed the resident had a BIMS score of 4, indicating cognitive impairment. On 9/18/2025 at 11:00am, an attempt to interview Resident #108 was unsuccessful. Resident was not able to respond to surveyor's questions. Record review of Resident #108's face sheet, dated 9/18/2025, revealed the BIMS was not done because assessment revealed Resident #108's cognitive function was severely impaired to be able to complete the BIMS. In an interview on 9/18/2025 at 11:23am, the administrator stated that the male side of the secured unit did not have good ventilation. She stated she made rounds to the secured unit daily and she was aware of the urine smell. She stated that the wife of Resident #88 came to her about 3 weeks ago to complain about the strong urine smell in the unit, when she first visited her husband in the secured unit. The administrator provided 3 estimates with HVAC companies, with dates of 8/26/2025, 9/5/2025 and 9/16/2025. She stated that one company would be chosen to come out soon, she did not have a scheduled date yet. She stated that had the residents been cognitively intact, they would not have urinated in the common area, so she could not answer if the smell affected the residents' dignity and rights. Record review of Resident #88 revealed that the resident was moved to the secured unit due to wandering behavior on 8/21/2025. During an interview on 9/18/2025 at 12:49pm, Resident #88's wife stated that when Resident #88 was moved to the secured unit, she went to visit him, and the smell was horrible. She stated that it had gotten a little better since then, but the smell was still strong. She stated she did not remember complaining about the smell to anyone in the facility. Record review of facility's Resident Rights policy, dated 11/28/2016, revealed that the resident has a right to safe, clean, comfortable and homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #12) of five residents reviewed for feeding tube (a process of providing nutrition directly to the stomach). The facility failed to ensure LVN C checked Resident #12's g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) placement and residual before administering the resident's medications and failed to administer the resident's medication one by one on 07/12/2025. These failures could place residents with g-tubes at risk for aspiration and drug-to-drug interaction. Findings included: Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #12's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #12's Quarterly Care Plan, dated 05/12/2025, reflected the resident required tube feeding and one of the interventions was to check for tube placement and gastric contents/residual volume. Record review of Resident #12's Physician Order, dated 06/11/2025, reflected every shift start continuous enteral feeding. Formula: Diabetasource; Rate: 65ml/hr, flush 200 ml H2O q 4 hrs. Record review of Resident #12's Physician Order, dated 04/04/2025, reflected every shift check placement prior to feeding and medication administration. Record review of Resident #12's Physician Order, dated 04/04/2025, reflected every shift check residual before medications and feedings; return contents after each check. Record review of Resident #12's Physician Order, dated 06/25/2025, reflected Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet via PEG-Tube (a flexible feeding tube inserted directly to the stomach) every 6 hours for pain, hold for sedation. Record review of Resident #12's Physician Order, dated 06/25/2025, reflected Docusate Sodium Oral Tablet 100 MG (Docusate Sodium) Give 1 tablet via PEG-Tube every 24 hours as needed for constipation. Record review of Resident #12's Physician Order on 07/12/2025 reflected no order that her medications could be cocktailed (could be given altogether at the same time). Observation and interview on 07/12/2025 at 10:38 AM revealed LVN D was preparing Resident #12's medication on his cart. LVN D said he wound administer the resident's 11:00 AM medication. He went inside the room with one small plastic cup with crushed medications in it and a big plastic cup with some water in it and placed them on the resident's overbed table. When inside the room, he incorporated some water on the small cup to dissolve the crushed medications. LVN D sanitized his hands and put on a pair of gloves. He took a 60 ml piston syringe from the resident's side table and placed it also on the overbed table. He raised the bed, lifted the resident's gown to expose the g-tube site. He pulled the plunger of the syringe, attached the syringe to the g-tube, and flushed the g-tube. After flushing the g-tube, he poured the dissolved medication. He did not check for the placement of the g-tube and the gastric content before flushing and administering the medication. After pouring the medications, he flushed the g-tube, and detached the syringe. He cleaned the syringe, took off his gloves, and sanitized his hands. In an interview on 07/12/2025 at 10:51 AM, LVN D stated he forgot to check for the g-tube placement and to check the residual of both residents. He said the right procedure was to check the placement and the residual every medication administration. He said g-tube placement was checked to ensure the tube was correctly positioned. He said the residual was also checked before administering medications to check if the stomach could accommodate the medications and fluid to be given and to prevent aspiration. He said he knew he needed to check for the placement and residual but failed to do so because he was nervous. He said he administered Resident #12's midday medications, which were oxycodone and docusate. He said he crushed the medications and put them both in a single cup. He said he was not sure if the resident had an order that would say her medications could be cocktailed. He said if there was no order to cocktail, then the medications should have been administered one by one. He said the reason for giving one by one was to prevent drug-to-drug interaction or drug-to-formula interaction that could impede the medication's effectiveness. In an interview on 07/12/2025 at 3:33 PM, ADON A stated both the gastric residual and the g-tube placement should be checked before administering the medications. She said g-tube placement should be checked to ensure the g-tube was in the right place. She said even though the residents were on continuous feeding, the placement should still be checked. She said the gastric residual was also checked to prevent aspiration and also to assess if the rate of the formula should be modified. She said the expectation was for the staff to check for g-tube placement and to check for gastric residual every time they administer medications. She said there were two ways to check for placement, one would be through auscultation and the other one was through aspiration of the gastric content. She said the second one could be used to check for placement and at the same time to check for the residual. She said if there was no order that the medications could be mixed, then the medications should be given one at a time to ensure there were no interactions between the drug. She said, as one of the ADONs, she was responsible in ensuring that the staff were following the procedures in administering medications via g-tube. She said she already started an in-service about g-tube as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if they do not understand something about the in-service. She said aside from the in-service, they would randomly check the staff's medication administration via gtube. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the issues pertaining to g-tube and ADON A already started an in-service relating to g-tube. She said the expectation was for the staff to follow the right procedures in administering medications via g-tube. She said she was not a clinician but she would coordinate with the DON to continually remind the staff about providing proper care for residents with g-tube. In an interview on 07/14/2025 at 1:00 PM, the DON she already knew about the incidents of not checking the placement of the g-tube and not checking for the residual. She said the placement should be checked to ensure the medications and the fluid would enter the stomach and not the lungs that could cause aspirations. She said the gastric residual should be checked before medication administration to assess if the resident's stomach was emptying properly. She said the medications should be given one at a time, if there was no order to cocktail them, so that if there were reactions, they could pinpoint what medication were causing the reactions. She said the expectation was for the staff to follow the right procedure for medication administration via g-tube. She said ADON A already started the in-service about g-tube but she would still do a one-on-one in-service with all the staff and would make sure that they understood the in-service that they were signing. Record review of the facility's policy ENTERAL (food or medication administration directly through the digestive system) MEDICATION ADMINISTRATION Pharmacy Policy & Procedure Manual revised 01/25/2013 revealed 6. Check the placement of the tube by aspiration of contents or auscultation . 8. Administer one medication at a time. Record review of the facility's policy Gastrostomy Tube Care Nursing Policy & Procedure Manual revised February 13, 2007 revealed Procedure . 7. Perform intermittent feeding . b. Aspirate gastric contents with a 60 ml syringe and if the residual is less than 50%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 of 3 residents (Residents #1) reviewed for supervision. <BR/>The facility failed to ensure Resident #1, who had severe cognitive impairment and resided on the secure unit, received adequate supervision to prevent her from wandering into the facility's enclosed courtyard without staff knowledge and being left outside for approximately 3 hours while it was raining. The facility failed to ensure the door that led to the enclosed courtyard was locked or supervised, when the door's locking mechanism lost power during the storm. <BR/>The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 04/01/24 and ended on 04/02/24. The facility had corrected the noncompliance before the survey began. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included: <BR/>Review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. <BR/>Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident is rarely/never understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices. <BR/>Review of Resident #1's care plan, dated revised 04/03/24, reflected: Focus: The resident wanders throughout the day and night. Goal: Resident will demonstrate happiness with daily routine through the review date. Resident safety will be maintained through review date. Interventions: Assess for fall risk. Disguise exits: cover door knobs and handles, tape floor. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. The resident will reside in the secure unit.<BR/>Focus: Resident is at risk for elopement as evidenced by impaired safety awareness, attempts at leaving facility, pulling and banging on doors in an attempt to leave the secured unit. Goal: [Resident #1] will remain safe within facility unless accompanied by staff or other authorized person through review date. Intentions: Supervise closely and make regular compliance rounds whenever resident is in room. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. <BR/>Focus: Resident resides in the SecureCare Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Memory loss. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the SecureCare Unit. Interventions: Admit to SecureCare unit per MD orders. Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day.<BR/>Review of Resident #1's Elopement Risk Assessment dated 03/11/24 revealed Resident #1 resided in the secure unit; Cognitive skills for daily decision making - severely impaired -never/rarely made decision; history; one or more times in last week; Behaviors - Restlessness (pacing, wandering or rummaging). <BR/>Review of Resident #1's Elopement Risk Assessment dated 04/02/24 revealed Resident #1 resided in the secure unit; Cognitive skills for daily decision making - severely impaired -never/rarely made decision; history; one or more times in last week; Behaviors - Restlessness (pacing, wandering or rummaging). <BR/>Review of Resident #1's progress notes by LVN AB on 04/02/24 at 00:57 revealed the following: Resident missing from the unit, later found lying on the ground in the courtyard, no bruise/injury noted on full assessment, no pain verbalized in full range of motion, Resident assisted up in w/c, taken to the shower room, given warm bath, assisted to bed, covered with warm blanket, M/d family notified.<BR/>Review of Resident #1's progress notes by DON on 04/02/24 at 11:30 revealed the following: Note Text: DON went to secured unit to re-assess resident and ensure no injury r/t resident being observed on the grass beside the sidewalk in the courtyard on the night of 4/1/24. Resident was observed on the couch in the tv room sleeping. Resident stated to staff that she was not having pain, but would not stand from the couch to allow DON to fully assess her. CNA that gave resident shower on 4/1/24 stated she did not see any new injury related to this incident, there are some healing bruises noted to resident's skull from prior fall and scattered bruises to BUE from resident wandering and her unsteady gait. DON could assess BUE, back, abdomen, and BLE up to her knees; no new injuries noted. Will remain available to resident and staff.<BR/>Review of facility Provider Investigation Report dated 04/05/24 revealed the following: Incident Category: Neglect; Incident Date 04/01/24; Time of Incident: 8:30 PM; Location of Incident: Resident out into courtyard; Description of the Allegation: Resident was not accounted for during walking rounds by nurses at shift change. Assessment: Date 04/01/24 at 11:30PM by LVN F; No noted injuries or behavioral changes from baseline. Head to toe assessment was completed. Xrays and labs ordered along with CT Scan out of the facility. All residents were counted visually as staff continued with the missing resident protocol. All xrays and CT Scan were negative for any new fractures. Investigation Findings: Confirmed; Provider Action Taken post-investigation: Abuse and neglect in serviced completed; missing resident protocols inserviced and drills completed and will continued to monitor and perform drills. Door was checked by outside vendor and I secure; door codes changed. <BR/>Review of Resident #1's Final X-Ray Report completed 04/02/24 revealed no acute fractures or dislocations. <BR/>Review of Resident #1 Ct Head Without Contrast completed 04/04/24 revealed no acute intracranial abnormality. <BR/>Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed, observed floor mats on each side of the bed. Resident #1 was covered up to her forehead, observed a swollen dark purple/blue bump to resident right side of her forehead/temple. Unable to observed Resident #1 full face.<BR/>Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Resident #1 was not a good historian. Resident #1 unable to recall going outside, however, she denied any pain. Interview with Resident #1 Family Member revealed she was notified of Resident #1 leaving the secure unit and being outside the enclosed courtyard. She stated Resident #1 wandered around and walked all over the secure unit. Resident #1's Family Member stated they completed x-rays and CT scans were done with no negative results. <BR/>Review of the facility's surveillance footage dated 04/01/24 at 18:26 [6:26 PM] revealed Resident #1 walking towards the secure unit living room area. Observed double doors being closed. Resident #1 opened the living room area door and was walking towards the courtyard door. However, since the camera was not facing the door, it was not captured when Resident #1 opened and exited the door. <BR/>Interview on 04/13/24 at 1:08 PM with the Administrator revealed the date stamp in the camera footage was off. She stated the time was not correct. The Administrator stated she received a call at around 10:00 PM on 04/01/24 stating that Resident #1 was missing. She stated she contacted the Maintenance Director and asked him to review the camera footage. She stated she arrived at the facility at around 10:30 PM and she received a call from the Maintenance Director telling her to look in the enclosed courtyard. She stated Resident #1 was found around 11:00 PM. She stated the 2:00 PM-10:00 PM LVN was LVN AB and the 10:00 PM-6:00 AM was LVN F. The Administrator stated CNA S placed Resident #1 in bed at 7:20PM and Resident #1 got up and began to walk around the secure unit. She stated the enclosed courtyard had a door code, and it was unknown how Resident #1 was able to open the door. She stated the night of 04/01/24, it was raining and the light flickered and they believe that in that moment when the light [NAME] Resident #1 open the door. She stated when Resident #1 was found outside, she was laying on the floor, and Resident #1 was damped (slightly wet). She stated they gave Resident #1 a warmed bath and no injuries were noted. She stated X-rays and CT were completed and results were negative. <BR/>Observation and interview on 04/13/24 at 1:20 PM of Secure Unit courtyard door with Maintenance Director revealed the door was closed, was unable to be opened without the code. Observed Maintenance Director punch in the door code and door open. Observed additional alarm added to the door; alarm was heard and it was loud. Maintenance Director stated he received a call at around 10:30PM the night of 04/01/24 form the Administrator. He stated he was asked to check the camera footage and he observe Resident #1 walking in the living room toward the courtyard door. He stated the camera was not facing the door so it was unknown how Resident #1 was able to open the door. The Maintenance Director stated the time on the camera footage was off and they cannot go by the time the camera footage was stamped. He stated he notified the Administrator around 11:00 PM to check the enclosed courtyard. He stated the courtyard door needs a code to open it, he stated the night of 04/01/24 it was raining and CNA G stated the lights were flickering. He stated when the light [NAME] they believed that was the time Resident #1 was able to open the door. The Maintenance Director stated since the incident they had in serviced all staff on elopement/missing person, the staff were checking doors every 15 minutes starting from 04/02/24 through 04/11/24. He stated they completed elopement drills on 04/02/24, 04/07/24 and will continue randomly. He stated they had the alarm company come out on 04/02/24 to check the doors, they implemented an additional alarm on the door and door codes would be changed monthly. He stated the alarm company came out and stated due to the light flickering the magnet on the door detached and did not grip on time. He stated they replaced the door closure with a stronger spring. <BR/>Interview on 04/13/24 at 2:05 PM with LVN AB revealed he was the nurse assigned on the secure unit and was the nurse for Resident #1 on 04/01/24 from 2:00 PM-10:00 PM. LVN AB stated Resident #1 was able to ambulate on her own without assistance. He stated Resident #1 was known to wander around. He stated on 04/01/24, the last time he observed Resident #1 was between 7:00 PM-8:00 PM when he provided her with her night medications. He stated during shift change at 10:00 PM he was notified by incoming night staff that Resident #1 could not be located. He stated they began to look for Resident #1 in each room, closets, restroom, dining area, living room and all around the secure unit. He stated they notified the Administrator and the Administrator contact the Maintenance Director for him to review camera footage. He stated at around 10:45 PM close to 11:00PM, Resident #1 was found outside in the courtyard lying on the grass. He stated the courtyard door only opened with a code. He stated he did not know how Resident #1 was able to open the door. He stated he could not remember any lights flickering and denied hearing an alarm. He stated Resident #1 was slightly wet due to the rain. He stated they brought Resident #1 inside and gave her warm bath. LVN AB stated Resident #1 did not sustain any injuries. He stated Resident #1 was her normal self and could not recall the event. <BR/>Interview on 04/13/24 at 2:58 PM with LVN F revealed he was the incoming nurse for the 10:00PM-6:00AM shift on 04/01/24. He stated he was completing his rounds and he was not able to locate Resident #1. He stated it was a little after 10:00PM when they were not able to locate Resident #1. He stated he contacted the Administrator to notify her Resident #1 was not able to be located after looking everywhere in the secure unit. He stated he told the Administrator to look at the video footage starting from 8:00PM. He stated the Maintenance Director was able to look at the camera footage and the Maintenance Director told them to look in the courtyard. LVN F stated they found Resident #1 outside in the enclosed courtyard. LVN F stated he could not recall the time Resident #1 was found. He stated Resident #1 was provided with a warm bath and no injuries were noted. LVN F stated no one goes into the enclosed courtyard. He stated the door had a code and it was unknown how Resident #1 was able to open it. <BR/>Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the incoming CNA assigned to the secure unit on 04/01/24 from 10:00 PM-6:00 AM. She stated she was completing her rounds closed to 10:00PM when she asked the 2:00 PM-10:00 PM aide where Resident #1 was. She stated she could not recall who the aide was. She stated when she asked the aide, the aide told her Resident #1 was here somewhere but not sure where Resident #1 was. She stated she notified LVN F and they began searching for Resident #1. She stated the nurses notified the Administrator and within 30-45 minutes Resident #1 was found outside in the enclosed courtyard. CNA G stated the night of 04/01/24 it was raining. She stated she did not know if the door was open or closed; however, to open the courtyard door they needed a code. She stated no one went out to the enclosed courtyard. She stated the secure unit had another courtyard that they use. She stated Resident #1 was given a warm bath and no injuries were noted. <BR/>Interview on 04/13/24 at 3:53 PM with CNA S revealed she was the CNA assigned to Resident #1 on 04/01/24 from 2:00PM- 10:00PM. She stated on 04/01/24 she had placed Resident #1 in bed at around 7:00PM - 7:15PM; however, Resident #1 got up again and began to walk around. She stated she left her shift at around 9:45PM close to 10:00PM. She stated she last time she observed Resident #1 was on the hallway; however, she could not recall the time. CNA S stated she did not hear any alarms go off. She stated they did not use the enclosed courtyard. She stated they had another courtyard normally used. She stated the enclosed courtyard door needed a code to open and it was unsure how Resident #1 opened it. She stated she did not recall any lights flickering; however, it was raining outside. <BR/>Interview on 04/13/24 at 4:32 PM with the DON revealed the night of 04/01/24 Resident #1 went missing in the secure unit. She stated she began her investigation on 04/02/24. She stated she spoke to CNA S and CNA S stated she had placed Resident #1 in bed around 7:30PM and Resident #1 got up from bed and was walking around the secure unit. She stated LVN AB stated he last observed Resident #1 when he provided resident with her night medications between 7:00PM-8:00PM. She stated at around 10:00PM during shift changed they noticed Resident #1 could not be located. The DON stated Resident #1 was found in the courtyard laying on the grass around 10:30PM. She stated the night of 04/01/24, it was raining and CNA S reported the lights were flickering and they believed during the time the lights [NAME] was when Resident #1 open the enclosed courtyard door. The DON stated the courtyard door needed a code to be opened. She stated she did not even know the code to the door. She stated no one used the enclosed courtyard. She stated when she was investigating the incident, she tried to open the courtyard door without the code and the door would not open. She stated they changed the door code and it would be changed monthly. She stated they implemented a new alarm on the door, they in-serviced all staff on elopement/missing person, staff would check the doors q15 , and alarm company came out to check the doors. She stated Resident #1 had no injuries and her behavior was her normal. She stated they completed x-rays and CT scan without no findings. <BR/>Follow-up interview on 04/13/24 at 4:48 PM with the Administrator revealed they in-serviced all staff on missing person, they conducted missing person drills which consist of getting a volunteer resident and having staff search for that resident. She stated had the alarm company come out and implemented a new alarm and will be changing the door alarm every month. She stated the alarm company came out and stated due to the light flickering the magnet on the door detached and did not grip on time. <BR/>Record review of the facility's Elopement Response policy and procedure, revised January 2023, reflected the following: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented.<BR/>4. Should an employee discover the resident missing from the facility (Code Orange) .<BR/>Record review of the facility's Elopement Prevention policy and procedure, revised January 2023, reflected the following: Every effort will be made to prevent elopement episode while maintaining the least restrictive environment for residents who are at risk of elopement.<BR/>This was determined to be a Past Non-Compliance Immediate Jeopardy on 04/13/24 at 7:20 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/13/23 at 7:20 PM.<BR/>The facility took the following actions to correct the non-compliance prior to the survey:<BR/>Record review of the following in-services dated 04/02/24 Elopement Response, Elopement Prevention and Code Orange. In-service reveal all staff completed the training. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM. <BR/>Review of Resident #1's Elopement Risk Assessment completed on 04/02/24; Resident #1 resided in the Secure unit. <BR/>Door codes on 500 Hall unit changed on 04/03/24. Replaced door with closure with a stronger grip. Added additional alarm to exit door to courtyard. Alarm installed made louder upon opening without code and or left ajar. <BR/>Observation on 04/13/24 at 1:20 PM revealed exit door on the secure unit courtyard door was checked with the Maintenance Director and door was functioning properly. There was an additional louder alarm added so they could be heard throughout the facility if the doors did not latch after being open. <BR/>Interviews on 04/13/24 from 12:04 PM through 5:00 PM with LVN A, CNA B, CNA M, LVN C, LVN AB, Student Nurse Aide, CNA G, CNA H, LVN F, CNA S, CNA AC, CNA AD, CNA O, RN J, Treatment Nurse, ADON L who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM - 6:00 AM revealed they were able to verify education was provided to them. Nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, missing person drills, and door checks.<BR/>Interview on 04/14/24 from 10:22 AM through 2:00 PM with CNA I, CNA Q, HR Coordinator, LVN W, LVN X, Guest Relations Coordinator, ADON K, LVN Y, CNA U and CNA V who work the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM revealed they were able to verify education was provided to them, nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, missing person drills, and door checks.<BR/>Record review of the Facility's Door Checks date 04/02/24 at 2:00 PM through 04/11/24 door checks were completed every 15 minutes<BR/>Record review of the facility's Elopement Drills or Actual Elopement Guide revealed drills were conducted on 04/02/24 and 04/07/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 3 of 30 residents (Residents #66, 42, and #103) reviewed for effective pest control.<BR/>The facility failed to maintain an effective pest control program to ensure the facility was free of flies for Resident #66, #42, and #103 in the facilities only dining room. <BR/>This failure could place the residents at risk for an unsanitary environment. <BR/>Findings included:<BR/>Record review of Resident #66's face sheet dated revealed a [AGE] year-old male who had an original admission date of 3-9-2020 and a re-admission date of 2-9-2024. Resident #66's primary diagnosis was a cerebral infarction (stroke) affecting the left dominant side and secondary diagnoses of cognitive communication deficit, ulcer of the right heel and midfoot, lack of coordination, and contracture of the right knee. <BR/>Record review of Resident #66's Quarterly MDS assessment dated [DATE], indicated a BIMS score of 13 revealing being cognitively intact. <BR/>Record review of Resident #66's care plan dated 6-15-2022 revealed Resident #66 was a hemiplegia (paralysis on one side of the body that can affect the arms, legs, and facial muscles) on the left side requiring ADL assistance. <BR/>In an observation and interview on 8-20-2024 at 4:12 PM, Resident #66 was observed to be sitting in his wheelchair asleep, in the facilities only dining room, at a table with a coffee cup on it. Resident #66 was observed to have a fly on his neck, one on his right arm, and one on his head. Resident #66 woke-up and stated flies had been bad at the facility for the past week. Resident #66 stated he did not like the flies and did not want them on him. <BR/>Record review of Resident #42's face sheet dated 8-21-2024, revealed a [AGE] year-old male who had an original admission date of 11-1-2017 and a re-admission date of 6-24-2023. Resident #42's primary diagnosis was Dementia with secondary diagnoses of abnormal posture, repeated falls, difficulty in walking, and Parkinson's disease. <BR/>Record review of Resident 42's Quarterly MDS dated [DATE], indicated a BIMS score of 00 implying being severely cognitively impaired. <BR/>Record review of Resident 42's care plan dated 6-29-2023 indicated Resident #42 had ADL deficits for hygiene and mobility, was care planned for actual falls, and was on antidepressant medications. <BR/>In an observation and interview on 8-20-2024 at 4:15 PM, Resident #42 was observed sitting in a wheelchair sitting at a table in the facilities only dining room by Resident #66. Resident #66 said he saw the flies on Resident #66 and on the dining room tables. Resident #42 stated he did not like the flies especially in the dining room. Resident #42 stated dealing with the flies in the dining room made him feel like he was in a trash dumpster. <BR/>In an observation on 8-20-2024 at 4:20 PM there were 10 flies observed in the facilities only dining room. A fly was observed on 80% of the tables in the dining room. <BR/>Record review of Resident #103's face sheet dated 8-21-2024, revealed an [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of a fracture of T5-T6 vertebra and secondary diagnoses of morbid obesity, depression, asthma, and generalized muscle weakness. <BR/>Record review of Resident #103's Quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating Resident #103 had moderate cognitive impairment. <BR/>Record review of Resident #103's care plan dated 2-6-2024 indicated she had ADL deficient requiring assistance, was on an antidepressant, and was a fall risk. <BR/>On 8-21-2024 at 12:27 PM, Resident #103 was observed in a wheelchair sitting at a table in the facilities only dining room, eating her lunch. Resident #103 was observed shooing away a fly from her food. Resident #103 said the flies are not too bad today but sometimes they have been worse, and she has scared them away by waving her hand over her food. Resident #103 said she does not like the flies. <BR/>In an interview on 8-22-2024 at 2:00 PM, the Maintenance Director revealed the facility contracted with a pest control company and he oversaw the responsibilities. The <BR/>Maintenance Director stated the pest control company came to the facility every Tuesday and treated the facility for spiders, scorpions, rodents, and flies. The Maintenance Director said there was a Pest Control Logbook kept at the nurse's station where anyone could make an entry of a pest control problem. The pest control company comes in and checks the logbook to see where a problem might be to treat that area for that problem. The Maintenance Director said flies were a big challenge for the facility because surrounding the facility was a barn with horses, a creek, a wooded area, and a park. The Maintenance Director said it was a big deal as the facility had trach patients who cannot move to shoo flies off. The Maintenance Director said the risk to residents eating in the dining room was flies could infect residents' food and bring worms in their food. <BR/>In an interview on 8-22-2024 at 3:00 PM, CNA-B stated she had worked at the facility for a month on the 2:00 PM-10:00 PM shift. CNA-B said when she hired in a month ago flies were really bad in the facility, however, they are not as bad as they were. CNA-B said there were still some flies in the facility, and they were disgusting because they land on feces and are especially not good for residents in the dining room trying to eat. <BR/>In an interview on 8-22-2024 at 4:00 PM, the Administrator said the Maintenance Director was responsible for the pest control of the facility. The Administrator stated her expectations for pest control was for the pest control company to come to the facility every Tuesday to treat for flies inside and outside, to keep having blow curtains at all the entry and exit doors except the fire exits, and to have the smoking patio power washed twice a week. The Administrator said the potential risk to residents having flies in the facility was not having a sanitary environment. <BR/>Record review of the facilities Pest Control Company's Logs revealed the following:<BR/>6-18-2024 - Visit at 12:58 PM - treated for flies, spiders, roaches, ants beetles and crickets. <BR/>6-25-2024 - Visit at 12:42 PM - treated for roaches, flies, gnats.<BR/>7-02-2024 - Visit at 10:24 AM - treated for roaches, flies, gnats.<BR/>7-09-2024 - Visit at 10:47 AM - treated for flies, gnats, ants, roaches, and moths.<BR/>7-16-2024 - Visit at 11:00 AM - treated for flies, gnats, and moths.<BR/>7-19-2024 - Visit at 09:19 AM - treated for bedbugs - Observed bedbugs in a wheelchair.<BR/>7-23-2024 - Visit at 02:35 PM - treated for flies and gnats.<BR/>7-30-2024 - Visit at 01:00 PM - treated for flies, gnats, spiders, and moths.<BR/>8-06-2024 - Visit at 03:34 PM - treated for flies, gnats, moths.<BR/>8-13-2024 - Visit at 09:46 AM - treated for ants, roaches flies, and gnats - Logbook reports roaches in a room.<BR/>Record review of the facilities Pest Control Policy dated 2012 states:<BR/>IC 00-12.0<BR/>Insect and Rodent Control<BR/>The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department.<BR/>Procedure:<BR/>1. <BR/>Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required.<BR/>2. <BR/>Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents.<BR/>3. <BR/>Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents.<BR/>4. <BR/>Deliveries of food and supplies will be monitored for prevention of insect and rodent access. <BR/>Dietary Services Policy & Procedure Manual 2012 <BR/>IC 00-12.0

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for fourteen (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) of thirty residents reviewed for privacy and confidentiality. 1. The facility failed to ensure LVN C pulled the privacy curtain while suctioning (mechanical aspiration of pulmonary secretions to clear the airway) Resident #1 on 07/12/2025. 2. The facility failed to ensure LVN C closed the door while suctioning Resident #2 on 07/12/2025. 3. The facility failed to ensure LVN D did not leave Residents #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13's medical information on top of his cart on 07/12/2025. 4. The facility failed to ensure RN E closed, locked, or minimized his laptop's monitor, thus, showing Resident #14's medical information on 07/13/2025. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals. Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (is an opening surgically created through the neck to allow air to fill the lungs). Record review of Resident #1's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 05/07/2025, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident had tracheostomy and one of the interventions was to suction as necessary. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Check resident Q2H for suctioning need, suction via trach PRN every shift. Observation on 07/25/2025 at 9:10 AM revealed LVN C entered Resident #1's room to check on the resident. The resident signaled LVN C that she wanted to be suctioned. LVN C sanitized her hands, put on a pair of gloves, and put on a gown. She proceeded to suction the resident without pulling the privacy curtain. Resident #1 could not be seen from the hallway but could be seen by Resident #2, resident's roommate, who was sitting at the side of her bed and facing towards Resident #1's bed. Observation and attempted interview on 07/12/2025 at 10:54 AM, revealed Resident #1 did not reply when asked if it was okay for her that her roommate could see what the nurse was doing to her. 2. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident had tracheostomy and one of the interventions was to suction as necessary. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Check resident Q2H for suctioning need, suction via trach PRN every shift. Observation on 07/25/2025 at 9:25 AM revealed after LVN C was done suctioning Resident #1, Resident #2 requested to be suctioned, as well. LVN C proceeded to suction Resident #2 without closing the door or pulling the privacy curtain. Resident #2 could be seen from the hallway and the treatment being done could be seen from the hallway and her roommate. In an interview on 07/12/2025 at 10:34 AM, LVN C stated she guessed she needed to close the door and pull the privacy curtain every time care or treatment was being done for the residents, not just for Resident #1 and Resident #2, to provide privacy. She said somebody from the hallway might see that they were being suctioned and the residents might be embarrassed. In an interview on 07/12/2025 on 10:54 AM, Resident #2 stated the nurses, not only LVN C, would not close the door or pull the privacy curtain when they were treating them. She said she already got used to it, but a change would be nice so that others would not see that a tube was being inserted in her throat. 3. Record review of Resident #3's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #3's Physician Order, dated 07/12/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . four times a day. Record review of Resident #3's Vital Signs, dated 07/12/2025, reflected BP: 98/60 mmHg, Temp: 97.6, Pulse: 86, Respiration: 20, O2 sats: 99.0%. Record review of Resident #4's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #4's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #4's Vital Signs, dated 07/12/2025, reflected BP: 100/65 mmHg, Temp: 97.5, Pulse: 70, Respiration: 18, O2 sats: 100.0%. Record review of Resident #5's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #5's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #5's Vital Signs, dated 07/12/2025, reflected BP: 81/52 mmHg, Temp: 97.5, Pulse: 80, Respiration: 21, O2 sats: 99.0%. Record review of Resident #6's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #6's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 4 hours as needed. Record review of Resident #6's Vital Signs, dated 07/12/2025, reflected BP: 105/68 mmHg, Temp: 97.5, Pulse: 87, Respiration: 21, O2 sats: 100.0%. Record review of Resident #7's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #7's Physician Order, dated 07/12/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . three times a day. Record review of Resident #7's Vital Signs, dated 07/12/2025, reflected BP: 97/61 mmHg, Temp: 97.6, Pulse: 57, Respiration: 20, O2 sats: 100.0%. Record review of Resident #8's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #8's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 8 hours. Record review of Resident #8's Vital Signs, dated 07/12/2025, reflected BP: 141/84 mmHg, Temp: 97.5, Pulse: 100, Respiration: 24, O2 sats: 99.0%. Record review of Resident #9's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #9's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 4 hours as needed. Record review of Resident #9's Vital Signs, dated 07/12/2025, reflected BP: 129/72 mmHg, Temp: 97.5, Pulse: 70, Respiration: 18, O2 sats: 100.0%. Record review of Resident #10's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #10's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours. Record review of Resident #10's Vital Signs, dated 07/12/2025, reflected BP: 99/68 mmHg, Temp: 97.4, Pulse: 54, Respiration: 16, O2 sats: 100.0%. Record review of Resident 11's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #11's Physician Order, dated 07/03/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . three times a day. Record review of Resident #11's Vital Signs, dated 07/12/2025, reflected BP: 109/69 mmHg, Temp: 97.5, Pulse: 97, Respiration: 20, O2 sats: 97.2%. Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #12's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . four times a day. Record review of Resident #12's Vital Signs, dated 07/12/2025, reflected BP: 89/56 mmHg, Temp: 97.1, Pulse: 64, Respiration: 18, O2 sats: 99.0%. Record review of Resident #13's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #13's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #13's Vital Signs, dated 07/12/2025, reflected BP: 122/80 mmHg, Temp: 97.7, Pulse: 68, Respiration: 17, O2 sats: 98.0%. Observation on 07/12/2025 at 10:19 AM revealed a clipboard was on top of a nurse's cart. On the clipboard were the names of the residents, their room numbers, and their respective vital signs (blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation). In an interview on 07/12/2025 at 10:22 AM, LVN D stated he went to attend to one of the residents that was why he left his cart. He said he should have flipped the clipboard before leaving his cart because the vital signs were medical information and should be secured and not exposed for everybody to see. He said it was a HIPAA violation and the information should be confidential. In an interview on 07/12/2025 at 3:33 PM, ADON A stated the doors should be closed or the privacy pulled when providing treatment to the residents to promote dignity and privacy. She said Resident #1 and Resident #2 might be roommates but they are still entitled for privacy and dignity. She said other staff, other residents, or even visitors could see the treatment being done and might speculate the medical condition of the residents. She said it did not matter if the residents cared or not, the treatment should be done in privacy. ADON A said the staff had been trained about HIPAA over and over again and she did not know why the incident still happened. She said it was a HIPAA violation to leave the residents' health information out for everyone to see. She said the expectation was for the staff to provide privacy during treatment and to secure the residents' medical information. She said the vital signs were examples of medical information. She said she already started an in-service about dignity and privacy as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if there was something in the in-service that the did not understand. 4. Record review of Resident #14's Face Sheet, dated 07/13/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease and emphysema (a lung disease that damages the air sacs in the lung causing shortness of breath). Record review of Resident #14's Comprehensive MDS Assessment, dated 05/01/2025, reflected the resident had moderated impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had COPD and emphysema and was on oxygen therapy. Record review of Resident #14's Comprehensive Care Plan, dated 05/15/2025, reflected the resident had oxygen therapy and the interventions were administer oxygen and medications as ordered. Record review of Resident #14's Physician Order, dated 07/10/2025, reflected Oxygen LPM: 1-5 LPM to maintain O2 sats greater than 92%. Record review of Resident #14's Physician Order, dated 04/05/2025, reflected Symbicort Inhalation Aerosol 80 - 4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for COPD, emphysema. Record review of Resident #14's Physician Order, dated 04/05/2025, reflected Ipratropium Bromide Nasal Solution 0.03 % (Ipratropium Bromide (Nasal)) 2 spray in both nostrils two times a day for nasal congestion. Record review of Resident #14's Physician Order, dated 01/29/2025, reflected Artificial Tears Ophthalmic Solution 0.1-0.3 % (Dextran 70-Hypromellose) Instill 2 drop in both eyes every 4 hours as needed for eye itching. Record review of Resident #14's Physician Order, dated 05/13/2025, reflected Acetaminophen-Codeine Tablet 300-30 MG Give 1 tablet by mouth every 8 hours as needed for pain, ** hold for sedation Not to exceed 3 gms APAP in 24 hour period. Observation on 07/13/2025 at 10:00 AM revealed a cart was parked at the nurses' station and was facing the hallway. On top of the cart was an open laptop and displayed Resident #14's name, status, location, gender, date of birth , age, name of physician, latest vital signs, allergies, code status, emergency instructions, and physician orders. Also seen from the computer were physician orders for the resident. The screen of the computer was facing the hallway. It was also observed that RN E was sitting inside the nurses' station. In an interview on 07/13/2025 at 10:02 AM, RN E stated he was the one using the computer. He saw that his monitor was open and Resident #14's medical information. He said he was not aware that he left his computer open and did not minimize the monitor of the computer. He said the information should be secured and only the resident, family members, and providers could see the resident's information. He said he went inside the nurses' station because he needed to notify a doctor about some laboratory result. He said he would make sure to that his computer was close every time he would leave it. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the privacy issues and ADON A already did an in-service about privacy during treatment and confidentiality of medical records. She said the expectation was for the staff to make sure that the residents were provided privacy during any treatment to prevent humiliation and to secure their medical records so that unauthorized individuals would not see the residents' medical information. She said they would continue to remind the staff about providing privacy and confidentiality. In an interview on 07/14/2025 at 1:00 PM, The DON stated she already knew about the incidents of not providing privacy and not securing the medical records. She said the door should be closed or the privacy curtain pulled when doing a medical procedure so other people would not see what was being done for the resident. She said if confidential information were exposed, non-nursing staff, other resident, and visitors could be able to see it. She said all staff, including her, were expected to provide full privacy during treatment and confidentiality of all the residents' medical information. She said providing privacy is a form of respect to the residents that entrusted their care to the facility. She said ADON A already started the in-service about privacy and confidentiality but she would still do a one-on-one in-service with all the staff and would make sure that they understood the in-service that they were signing. Record review of the facility's policy, RESIDENT RIGHTS undated, revealed The resident has a right to a dignified existence . Privacy and confidentiality . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . 1. Personal privacy includes accommodations, medical treatment . 3. The resident has a right to secure and confidential personal and medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensurethat a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for quality of care.<BR/>The facility failed to obtain physician orders with specific non-rebreather (this is a mask that delivers high concentration oxygen with a minimum of 10 to 15 Liters/minute of Oxygen flow via a mask and has a valve that ensures air only comes in or out one way) amount on resident #1 from 11/11/24 to 11/14/24.<BR/>This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD.<BR/>Findings Included:<BR/>Record review of Resident #1's admission record dated 04/23/25 revealed a [AGE] year-old female with an admission date of 01/16/24. Her primary diagnosis was unspecified dementia (a brain disease that alters brain function and causes a cognitive decline), and her secondary diagnoses were Myxedma coma (this is a rare life threatening endocrine emergency that occurs when the thyroid hormone regulation is disrupted), heart failure, Atrial fibrillation (this is a heart condition that causes an irregular, often rapid heart rate that can cause poor blood flow), acute respiratory failure with hypoxia, COPD (a lung disease that blocks airflow and makes it difficult to breathe). Resident #1 was on hospice and Resident #1 RP was family.<BR/>Record review of Resident #1's quarterly MDS Assessment, dated 09/25/24, revealed the resident's BIMS score was 10 out of 15, indicating she had moderate cognitive impairment. The MDS Assessment reflected Resident #1 was able to make self-understood and understood others. Further review revealed Resident #1 was dependent on staff for all ADLs and required respiratory treatments oxygen therapy.<BR/>Review of Resident #1's care plan initiated on 01/17/24 revealed the following care areas:<BR/>*Resident #1 had emphysema (a chronic lung diseases that progressively damages the tiny air sacs in the lungs)/COPD. The goal was for Resident #1 to display optimal breathing pattern daily through the review date. The interventions were to give oxygen therapy as ordered by the physician. <BR/>*Resident #1 had oxygen therapy. The goal was for Resident #1 not to have any signs and symptoms of poor Oxygen. The interventions were to change residents position every 2 hours to facilitate lung secretion movement and drainage, If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal, Oxygen at 2-4 lpm per nasal canula.<BR/>Review of Resident #1's care plan initiated on 04/20/24 revealed Resident #1 had a terminal prognosis and was receiving hospice services. Resident #1 was admitted to hospice on 02/13/24 for Alzheimer's disease with late onset (this is a brain condition that progressively destroys memory and other important mental functions). Interventions were to review residents living will and ensure it was followed and to involve family in the discussion. Care plan did not reflect use of non-rebreather high flow supplement oxygen therapy for Resident #1.<BR/>Review of Resident#1's physician orders reflected:<BR/>-DNR- Do not Resuscitate ordered on 08/12/24<BR/>-admission to hospice with diagnoses of Alzheimers diseases (with late onset (this is a brain condition that progressively destroys memory and other important mental functions) level of care on 02/13/24.<BR/>- May use oxygen at 2-3 liters/minute via nasal canula every shift (nasal cannula is a thin flexible tube that gives additional oxygen up to 5 L through the nose). Ordered 02/13/24.<BR/>- Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) Microgram/Activation (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for Shortness of Breath [breathing treatment]. Ordered 01/16/24.<BR/>- Acetaminophen Rectal Suppository 650 MG (Acetaminophen) Insert 1 suppository rectally every 4 hours as needed for Pain and /or fever Not to exceed 4 doses in 24-hour period. Ordered 02/12/24. <BR/>- Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every 2 hours as needed for Very excruciating pain and /or very severe SOB. Ordered 02/12/24.<BR/>-Further review of the physician orders did not reflect orders for non-rebreather high flow supplement oxygen therapy<BR/>Review of Resident #1's MAR for November 2024 did not reflect administration orders for non-rebreather high flow supplement oxygen therapy.<BR/>Record review of Resident #1's progress notes for November 2024 reflected as follows:<BR/>Effective Date: 11/12/2024 13:42 [1:42 PM] Type: Nursing Progress Note, Author: RN A:<BR/> Hospice RN in pt room, pt having SOB with 02 at 87% per 3L nasal cannula, Temp 101.2, Resp 24, BP 187/86, pulse 96. Nonrebreather mask placed on pt with 02 turned up to 5L, O2 level at 95% at this time. Hospice RN given orders by provider to start Levaquin 500 mg [antibiotic], Prednisone 20mg [steroid], and Duonebs q 6 hours [breathing treatment]. First doses given along with first Duoneb per nebulizer. Pt ia [is] alert and oriented x 2, with some confusion, with moderate SOB observed. Pt has no c/o pain at this time. Tylenol supp [suppository] given for elevated temperature. Pt head of bed elevated with instructions given to CNAs to keep it elevated due to pt SOB.<BR/>Effective Date: 11/13/2024 07:04 [7:04 AM]- Author: RN A<BR/>Note Text: Pt resting quietly with 02 at 96% per nonrebreather at 4L. B/P 128/79, pulse 74, resp 26, temp 98.9 with rhonchi [lung sound characterized by low pitch rumbling sound] and wheezing heard in bilateral [both] lobes. Duoneb given per order, along with Morphine 1ml sublingually [under the tongue]. Pt alert and responsive to verbal stimuli [awakening] with nodding or shaking her head. Call light within reach and no distress noted at this time.<BR/>Effective Date: 11/13/2024 21:45 [9:45 PM] Type: Nursing Note- Author: LVN B<BR/>Note Text: This resident is being treated for URI . BP-110/72. P-86. R-18. T-97.3. O2-97. Oxygen at LPM: 5 via mask continuously.<BR/>Negative Findings: Hoarseness, Respirations: Labored Breathing, Abnormal breath sounds: Rhonchi, to Right Lower Lobe, to Right Upper Lobe, to Left Lower Lobe, to Left Upper Lobe.<BR/>Interventions: Breathing treatment: DUONEBS TID head of bed up, No Pain.<BR/>Effective Date: 11/14/2024 02:24 [AM] Type: Nursing Note Author: RN C<BR/>This resident is being treated for URI.<BR/>BP-127/64. P-90. R-18. T-97.5. O2-97.<BR/>Oxygen at LPM: 5 via mask continuously.<BR/>Negative Findings: None<BR/>Respirations: Labored Breathing,<BR/>Breath sounds clear.<BR/>Interventions: Breathing treatments: ALBUTEROL TID.<BR/>-11/14/2024 at 14:01 [2:01 PM] change in condition entered by RN D <BR/>Effective Date: 11/14/2024 14:23 [2.23 PM] Type: Nursing Progress Note- Author: RN D<BR/>Note Text: Resident transitioning to end of life. VS T97.3 P93 R12 shallow with apnea, SATS 91-97% on 10L via non-rebreather mask.<BR/>Scheduled morphine and PRN Ativan given throughout shift as needed for pain/SOB. Repositioned Q2hrs for comfort, oral care provided. Family at bed side all shift.<BR/>Effective Date: 11/14/2024 15:38 [3:38 PM] Type: Nursing Progress Note Effective Date: 11/14/2024 14:23 Type: Nursing Progress Note- RN B<BR/>Note Text: Noted change in VS they are dropping BP 86/49, P 74, T 95.6, R20, O2 93% 10L mask, cannot verbalize pain morphine given 1 ML.<BR/>During a phone interview with Resident #1's RP on 03/26/25 at 1:26 PM revealed Resident #1 passed away on 11/14/24 at 6 pm. She said Resident #1 sounded like she was suffocating due to the non-rebreather not set correctly. She said Resident #1's non-rebreather was set to administer only five liters of oxygen instead of the ten liters that were required to support non-rebreather oxygen therapy. She stated, no one noticed the wrong non-rebreather setting of oxygen until the next business day (11/14/24), when RN D corrected it and placed Resident#1 on the recommended 10 Liters to support non-rebreather treatment. She said the non-rebreather was later removed before Resident #1 passed away on 11/14/24.<BR/>Review of Resident #1's respiratory vitals from 11/11/24 to 11/14/24 revealed the following:<BR/>- <BR/>11/11/24 - 18 breaths per minute<BR/>- <BR/>11/13/24 - 26 breaths per minute - out of range for breaths per minute<BR/>- <BR/>11/17/24 - 17 breaths per minute<BR/>- <BR/>11/14/24 - 19 breaths per minute<BR/>Review of Resident #1's oxygen saturation levels from 11/11/24 to 11/14/24 revealed the following:<BR/>- <BR/>11/14/24 - between 93-94 % (day of Resident's passing)<BR/>- <BR/>11/13/24 - between 95-96% - normal range for oxygen<BR/>- <BR/>11/12/24 - between 95-96% - normal range for oxygen<BR/>- <BR/>11/11/24 - 97% - normal range for oxygen<BR/>In an interview with RN A on 04/23/25 at 7:15AM, revealed she had been employed at the facility for eight months. She stated one of the CNA's (CNA J) informed her that Resident #1 was not doing well, she immediately went to Resident #1's room and assessed her [11/12/24]. She said while she was assessing her the hospice nurse RN K walked into the room. She said Resident #1 was on a nasal cannula at 3 L. RN K told her to increase Resident #1's oxygen to 5 L, therefore RN A placed Resident #1 on a non-rebreather because her oxygen level was not going up. She said RN K them got on the phone with hospice physician and obtained other orders immediately . She said she could not remember the orders as it had been a long time ago. RN A stated she had never used a non-rebreather before and she would not have done so without someone telling her to do so. She said, I believe RN K told her to use the non-rebreather for Resident #1 but She did not remember 100 percent. She stated she was not familiar on range of the oxygen on non-rebreather mask. She said she would google and ask someone for the range. She said the process of receiving orders was verbal or written and that she would put the orders in the computer after the hospice nurse gave them to her . She said some hospice nurses put their own orders in, so she was not sure if the order for the non-rebreather was added. RN A said she did not take off the non-rebreather from Resident #1 until she was stable . She said the hospice nurse left after Resident #1 stabilized and she did not tell her to remove the non-rebreather. She said because the hospice nurse was in there, she assumed it was ok to the leave the non-rebreather on because she did not say to remove it and put Resident #1 back on her nasal cannula. RN A said the hospice nurse (RN K) notified the physician and she did not have to because Resident #1 was on hospice and the hospice nurse was in the room. Said it was important to get physician orders for the safety of the patient so they can know how what to do. RN A said she was aware of RT in the facility, but it all happened so fast, and they moved as fast to stabilize Resident #1 that she forgot to ask RT to check Resident #1 who had been placed on the nonrebreather.<BR/>In a phone interview with RN K on 03/26/25 at 2:41 PM, she stated she was Resident #1's hospice nurse. She said she went to see Resident #1 on 11/11/24 the non-rebreather was used on her. She said when she got to Resident#1's room, Resident #1 was having difficulty breathing and had shortness of breath. She said the facility nurse RN A had already placed Resident #1 on the non-rebreather. She said she could not remember the liters of the non-rebreather because she herself and RN A were trying to stabilize Resident #1. RN K said she was knowledgeable that non-rebreathers should be set at minimum ten liters otherwise the patient is not getting the needed oxygen fast. RN K said that she did not get orders for the non-rebreather. She said that she called the hospice physician while she was in Resident #1's room and reported Resident #1's condition and he gave her orders but the hospice physician did not give order to keep Resident #1 on a non-rebreather for supplemental oxygen. RN K said the order process was that she wound send the doctor a text on the phone to get orders then she wrote them down on paper and give the order to the facility nurse to imputed in her computer. She said the written orders are placed in the resident's hospice book afterwards. RN K said a non-rebreather was used in emergency cases to help patients get large amounts of oxygen fast to help them recover. She said non-rebreathers were not for long term use. She said when she left, Resident #1 was still on the non-rebreather, but she was stable. She said she was not aware the facility left Resident #1 on the non-rebreather until 11/14/24. She said she did not give them any verbal orders to keep Resident #1 on the non-rebreather oxygen therapy. She said she was also not aware that the facility had Respiratory Therapists on site 24 hours because no one told her. She said the risk to the resident for not getting orders for non-rebreather was retention of carbon dioxide especially in a resident with COPD. <BR/>In a phone interview with CNA J on 03/26/25 at 2:10 PM, she said that she worked for the hospice company that Resident #1 was admitted to while in the facility. She said she proved ADL care, to Resident #1 three times a week and then the week before she passed away, ADL care was changed to five days a week. She said that she had found Resident #1 without oxygen or still connected to an empty oxygen tank on her wheelchair on multiple occasions. She said she would connect Resident #1 to the oxygen compressor in her room then go out and tell facility nursing staff to let them know what she saw and to get Resident #1 a full oxygen tank to use in the shower room for Resident #1.CNA J said she could not remember the names of the facility staff she reported to. CNA J said the last week before Resident #1 passed away she was assigned to provide daily ADLs care as usual, she said she told the facility that Resident #1 did not need a lot of oxygen and asked them to remove the non-rebreather off Resident #1.CNA J said she could not remember the exact date. She said Resident #1 looked more comfortable with just the nasal canula after the non-rebreather was removed. She said she could not remember the exact date when they removed the non-rebreather, but she had to tell the facility to remove it and put her on the nasal cannula.<BR/>In an interview with LVN B on 04/23/25 at 3:59 AM, he stated he had been employed by the facility for a year and a half. He said he had gotten training on Ventilators, non-rebreathers, tracheostomy, and other supplemental oxygen therapy when he first started working at the facility. He said he knew that non-rebreathers were only used to short term use and when he took care of Resident #1, he used a regular simple oxygen mask on her. He said he did not see any orders for a non-rebreather. He said it was important to make sure residents had physician orders for consistency and to follow orders so that you do not make the patients worse by doing the wrong thing. He stated if he needed clarification on orders, he could reach out to the facility physician or the hospice physician or hospice nurse.<BR/>In a phone interview on 04/23/25 at 11:18 AM, revealed RN C had worked with Resident #1 before she passed away [11/14/24] but he could not remember if Resident #1 was on a non-rebreather. He said he knew that a non-rebreather was used only in an emergency when a residents oxygen level drops to help bring back [NAME] quickly. He said after a resident was stabilized, they should be placed on a nasal cannula or if they do not stabilize 911 would be called. RN C said he did not obtain new orders for Resident #1 because the physicians were already aware of the residents' current conditions. He said he believed the oxygen orders were in the computer and he just continued with what was given to him in report. RN C stated it was always good to look at the residents' orders and verify them so that you did not do something wrong. <BR/>In an interview with RN D on 04/23/25 at 7:40 AM, revealed she had been employed at the facility for four years. She said Resident #1 had been moved to her hallway [100 hall] and was assigned to her on 11/14/24 at 2PM. She said she noticed that Resident #1 was on a non-rebreather connected the hospice compressor however the compressor could only deliver a maximum of 5 Liters of oxygen so she asked the transferring nurse to get an Oxygen compressor that could deliver 10 L of oxygen. She said she then increased the non-rebreather to 10 L of oxygen which was the minimum required setting for non-rebreather mask. RN D said she completed a change of condition. RN D stated at this time, after getting the compressor and non-rebreather set to correct parameters, Resident #1 appeared stable she informed Resident #1's family that the non-rebreather was only to be used for short term use. RN D stated family refused to remove the non-rebreather even after she educated them. RN D said she did not call RT to access Resident #1 because she was already at end of life and both herself and the hospice nurse educated family on no-rebreather. RN D said eventually the family decide to allow her to remove the non-rebreather and Resident #1 was placed on a nasal cannula. RN D said physician orders are required to drive care. She said all nurses were trained on how to use a non-rebreather and for what it was used. RN D sated she forgot to document that Resident #1's RP was refusing to have the non-rebreather removed from Resident #1.<BR/>In an interview with RT E and RT F on 04/23/25 at 3:23 AM, revealed they were not responsible for all the residents on supplemental oxygen therapy in the facility except for the ones on mechanical ventilation. They said in an event nursing needed assistance or had a respiratory question they would help. RT E said if a resident is needing to be on a non-rebreather, and they are a full code they would not be in the facility long, We would be calling 911. He said no-rebreathers are good for short term use to deliver fast 100% oxygen to help bring low oxygen up quickly. Both RT E and RT F said the non-rebreather should be set at 15 L or 10-12 Liters for it to be effective. RT E said a non-rebreather should not be used for 3 days as it affects PH which can cause the lungs to fail to remove enough carbon dioxide from the body. He said non-breathers can only be used for the shortest time possible. Both RT E and RT F said orders are required for all residents on oxygen therapy. <BR/>In an interview with the DON on 04/23/25 at 12:08 PM, revealed she did not expect the nurses to obtain new orders for supplemental oxygen because Resident #1 already had orders to used supplement oxygen. She said even though the method of delivery was different, Resident #1 still had orders to use oxygen. DON said a non-rebreather was used for emergency when Resident #1 was having difficulty breathing and because it was an emergency to stabilize the resident, no physician orders are needed. DON said RN D educated the family that Resident #1 could not be on the no-rebreather for an extended time, but the family would not allow them to take off the non-rebreather. DON stated because Resident #1 was a DNR and was on hospice actively passing away, they did not need to call 911 for the resident needing to be on a nonrebreather oxygen delivery form. DON stated the expectation for a non-rebreather was 10-15 L of oxygen to be effective, she said she would not expect someone to put a non-rebreather at 4-5 L, however the hospice nurse (RN K) who was in the room with Resident #1 and RN A notified the physician, and the physician was aware of the condition of the resident. DON did not state the risk because Resident #1 already had supplemental oxygen orders.<BR/>In a phone interview with the physician on 04/23/25 at 12:53 PM, he said he deferred supplemental Oxygen, or anything related to oxygen to the pulmonologist. He said in the event the nurses cannot reach the pulmonologist then he would put in the orders. He said he could not remember Resident #1 without looking at her records, but the nurses were good about notifying him when there was a change of condition and he expected nurses to reach out to him for oxygen order when they could not reach the pulmonologist first and he would give them the orders. He said physician orders drives care.<BR/>In an interview with ADM on 04/23/25 at 6:45 PM, she said the expectations was that all residents on supplemental oxygen obtain orders. She said she expected all staff to obtain physician orders and to follow the physician orders.<BR/>In an interview with ADM on 04/23/25 at 4:44 AM, she stated all records for residents on hospice were uploaded to the EMR of each resident after they discharge.<BR/>Record review of Resident #1 EMR on 04/23/25 at 4:44 AM did not reflect orders for non-rebreather use.<BR/>Record review of Resident #1's discharge MDS assessmet, dated 11/14/24, did not indicate cause of death.<BR/>Cause of death report requested from hospice company, but surveyor has not yet obtained.<BR/>Review of the facility policy titled Physician Orders dated 2015 reflected the purpose of policy was.<BR/>To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.<BR/>1. <BR/>Nurse will review the order and if needed contact the prescriber for any clarifications.<BR/>2. <BR/>The nurse will enter the order into PCC for the resident and select either verbal or telephone, depending on how the nurse received the order.<BR/>3. <BR/>If the order requires documentation, it will be directed to the proper electronic administration record once the order is completed . <BR/>Review of facility policy titled Oxygen Administration: revised March 21, 2023, reflected .<BR/>The Resident will maintain oxygenation with safe and effective delivery of prescribed Oxygen

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident, the resident's representative, and the ombudsman were notified in writing of the resident's transfer or discharge, and in a language and manner they understand, for one (Resident #1) of one resident reviewed for discharge. <BR/>The facility failed to provide Resident #1 or their responsible party and the local ombudsman in writing a 30-day notice of discharge from the facility before the resident was transferred to another long-term care facility. <BR/>This failure could affect the residents by placing them at risk of being discharged and not having access to available advocacy services, discharge options and appeal processes. <BR/>Findings include:<BR/>Review of Resident #1's face sheet, dated 05/09/2023, revealed she was a [AGE] year-old female, who admitted to the facility on [DATE] and discharged on 04/28/2023. Contact #1 was listed as the Guardian, Responsible Party, Financial Contact, Care Conference Person, Emergency Contact, Resident Representative, and Essential Caregiver. Resident #1 had the following diagnoses: Dementia, Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbances, and Anxiety; Major Depressive Disorder, Recurrent, Mild; Generalized Anxiety Disorders; Schizoaffective Disorder, Bipolar Type; and Unspecified Psychosis, not due to substance or known Psychological Condition.<BR/>Review of Resident #1's MDS assessment dated [DATE], reflected the resident had a BIMS score of 9. The mental status score of 9. The mental status score of 9 reflected the resident has minimal memory issues with cognition and could understand some information presented to her.<BR/>Record review of Resident#1's care plans dated 07/21/2021 revealed the resident had delirium or acute confusional episodes r/t Alcohol use/abuse; 07/21/2021 revealed the resident had behaviors of cursing, verbal aggression towards others; and the care plan dated 05/26/2022 revealed the resident had a mood problem r/t schizoaffective disorder. <BR/>Review of Resident #1's clinical record revealed the SW documentation, dated 4/27/2023 at 4:26 PM reflected the Guardian was spoken to via email of corporate's decision to restructure the secured unit reflecting, We have started to transition 500 Hall secured unit into a special care unit, for residents who have Alzheimer's and other types of dementia and need special care. As you are aware the resident needed alternate placement because of frequent, noncompliant aggressive behaviors. <BR/>Interview with the Administrator on 05/09/2023 at 5:29 PM revealed the email the SW sent to the Guardian dated 04/27/2023 at 4:26 PM served as the notification to the Guardian. Administrator revealed reason for transfer, All the abuse incidents starting the company decided it will be a more focused on Memory care and away from the behaviors. The Administrator provided the letter of discharge date d 04/27/2023 was mailed on 04/28/2023 to Guardian and the Ombudsman. The Administrator revealed that the physical letter to the Guardian was mailed on 04/28/2023 and served as the notification to the Guardian.<BR/>Interviewed the Guardian on 05/09/2023 at 11:00 AM the Guardian's said she received a phone call on the afternoon of 04/28/2023, by the SW that the resident had been moved to the new facility. The Guardian had not been given sufficient notice of the resident's transfer nor involved in the decision of the choice of the facility. The Guardian had been for a visit from another city on 04/27/2023 and no one had mentioned that the resident was moving the next day. Resident #1 told her Guardian that she was told she was moving.<BR/>A telephone interview with the Ombudsman on 05/09/2023 at 10:30 AM revealed she did not receive a copy of the discharge notification of the facility's intent to discharge Resident #1 as soon as practicable. The Ombudsman received notification from the facility Administrator on 05/01/2023 with the letter dated 04/27/2023. <BR/>Record review of the facility's policy titled Discharge or Transfer to Another Facility, policy undated, revealed r/t facility-initiated discharges: the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered. For facility-initiated transfer or discharge of a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 1 of 1 residents (Resident #1) reviewed for transfers:<BR/>The facility failed to provide Resident #1 with a written bed-hold policy when the resident was transferred out to the hospital. <BR/>This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred; at risk for of being improperly discharged and placed in unsafe conditions.<BR/>Findings included:<BR/>Record review of Resident #1's admission record, dated 07/26/24 revealed she was a [AGE] year-old female who was original admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnosed included: chronic respiratory failure (condition that affects your ability to breathe and exchange oxygen and carbon dioxide) unspecified whether with hypoxia (below-normal level of oxygen in your blood) or hypercapnia (elevated levels of carbon dioxide (CO2) in the bloodstream), candidiasis(overgrowth of a type of yeast that lives in the body) unspecified, chronic obstructive pulmonary disease (persistent respiratory symptoms) with (acute) lower, respiratory infection(infection in the lungs or below the voice box encounter for attention to tracheostomy(a hole in the neck that helps you breathe when your airway is blocked or reduced.) and abnormalities of gait and mobility(a person walks differently due to injuries, conditions, or issues with the legs or feet). Under miscellaneous information Resident#1 was discharge on [DATE] to acute care hospital. <BR/>Record review of Residents#1 optional MDS dated [DATE] revealed she had a BIMS score of 15 which meant cognitive intact. <BR/>Record review of care plan dated reflected Focus: Discharge from the facility is not feasible<BR/>as evidenced by (reason discharge is not feasible). Goal: Resident will be provided an opportunity to receive information on returning to community unless the resident has chosen not to be asked this question on the MDS. Interventions: Respect resident's right to view nursing facility as his/her home.<BR/>Record review of Resident #1's hospital record r07/10/24 revealed she was admitted on [DATE] at 8:49 PM. Further review revealed she was medically cleared to return to the facility on [DATE].<BR/>Record review of the facility Daily census dated 07/26/24 revealed Resident#1 was not on the census.<BR/>Record review of the census list dated 07/29/24 reflected Resident #1's billing was stopped on 7/10/24 at 2:29 PM for room [ROOM NUMBER]A (semi-private)<BR/>Record review of the census list dated 07/29/24 reflected Resident #2 effective date as 07/11/24 at 11:00 AM had a room change to 316 A (semi-private)<BR/>In an interview with Resident#1 on 07/26/24 at 7:30 AM at the hospital revealed that the facility called her family member and told her she had to come and pick up her belongings. Resident#1 revealed she had not received any paperwork from the facility that stated she had been discharged . <BR/>Telephone interview on 07/26/24 at 9:50 AM with hospital social worker revealed resident was ready to be discharged on 07/12/24 and the facility stated they did not have a bed for her. The Hospital Social Worker revealed the resident had candida auris (fungus that can cause serious illness) and used a trach and vent, it was hard to find placement somewhere else for her.<BR/>Telephone interview on 07/26/24 at 2:54 pm the Marketing Manager revealed the facility cannot hold beds in the trach unit if they receive a referral, they must take the resident if they have an available bed. The next closet facility was in another city.<BR/>Interview on 07/26/24 at 3:49 PM the Administrator revealed Resident#1 must be in a C positive (+) (candida auris ) room because of her infection. The Administrator revealed the facility had one female room that was C+ and one male room that was C+. The administrator revealed the facility was the closet vent and trach unit in the area. The Administrator revealed when they get referrals in, the residents are admitted if we have an open spot. The Administrator revealed it cost two thousand a day for a resident in the trach unit and would have to be paid in advanced. The Administrator revealed the facility did not hold beds in the unit. <BR/>Interview on 07/29/24 at 10:00 AM with DON revealed the facility does not hold beds in the facility. <BR/>Interview on 07/29/24 at 10:12 AM the business office manager revealed the facility does not hold beds in the trach unit or general unit.<BR/>Record review of the facility admission packet revised 04/13/22 revealed bed hold information and practices guidelines .2. First notice is given at admission and is re-issued in the event that the bed hold policy was to change .3. The second notice is provided at the time of transfer for hospitalization .4. In the event of an emergency transfer, the facility representative are provided written notice within 24 hours of the transfer, which can include sending a copy of the notice with other documents accompanying the resident to the hospital.7. Bed hold days in excess of the state plan are considered non-covered services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensurethat a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for quality of care.<BR/>The facility failed to obtain physician orders with specific non-rebreather (this is a mask that delivers high concentration oxygen with a minimum of 10 to 15 Liters/minute of Oxygen flow via a mask and has a valve that ensures air only comes in or out one way) amount on resident #1 from 11/11/24 to 11/14/24.<BR/>This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD.<BR/>Findings Included:<BR/>Record review of Resident #1's admission record dated 04/23/25 revealed a [AGE] year-old female with an admission date of 01/16/24. Her primary diagnosis was unspecified dementia (a brain disease that alters brain function and causes a cognitive decline), and her secondary diagnoses were Myxedma coma (this is a rare life threatening endocrine emergency that occurs when the thyroid hormone regulation is disrupted), heart failure, Atrial fibrillation (this is a heart condition that causes an irregular, often rapid heart rate that can cause poor blood flow), acute respiratory failure with hypoxia, COPD (a lung disease that blocks airflow and makes it difficult to breathe). Resident #1 was on hospice and Resident #1 RP was family.<BR/>Record review of Resident #1's quarterly MDS Assessment, dated 09/25/24, revealed the resident's BIMS score was 10 out of 15, indicating she had moderate cognitive impairment. The MDS Assessment reflected Resident #1 was able to make self-understood and understood others. Further review revealed Resident #1 was dependent on staff for all ADLs and required respiratory treatments oxygen therapy.<BR/>Review of Resident #1's care plan initiated on 01/17/24 revealed the following care areas:<BR/>*Resident #1 had emphysema (a chronic lung diseases that progressively damages the tiny air sacs in the lungs)/COPD. The goal was for Resident #1 to display optimal breathing pattern daily through the review date. The interventions were to give oxygen therapy as ordered by the physician. <BR/>*Resident #1 had oxygen therapy. The goal was for Resident #1 not to have any signs and symptoms of poor Oxygen. The interventions were to change residents position every 2 hours to facilitate lung secretion movement and drainage, If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal, Oxygen at 2-4 lpm per nasal canula.<BR/>Review of Resident #1's care plan initiated on 04/20/24 revealed Resident #1 had a terminal prognosis and was receiving hospice services. Resident #1 was admitted to hospice on 02/13/24 for Alzheimer's disease with late onset (this is a brain condition that progressively destroys memory and other important mental functions). Interventions were to review residents living will and ensure it was followed and to involve family in the discussion. Care plan did not reflect use of non-rebreather high flow supplement oxygen therapy for Resident #1.<BR/>Review of Resident#1's physician orders reflected:<BR/>-DNR- Do not Resuscitate ordered on 08/12/24<BR/>-admission to hospice with diagnoses of Alzheimers diseases (with late onset (this is a brain condition that progressively destroys memory and other important mental functions) level of care on 02/13/24.<BR/>- May use oxygen at 2-3 liters/minute via nasal canula every shift (nasal cannula is a thin flexible tube that gives additional oxygen up to 5 L through the nose). Ordered 02/13/24.<BR/>- Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) Microgram/Activation (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for Shortness of Breath [breathing treatment]. Ordered 01/16/24.<BR/>- Acetaminophen Rectal Suppository 650 MG (Acetaminophen) Insert 1 suppository rectally every 4 hours as needed for Pain and /or fever Not to exceed 4 doses in 24-hour period. Ordered 02/12/24. <BR/>- Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every 2 hours as needed for Very excruciating pain and /or very severe SOB. Ordered 02/12/24.<BR/>-Further review of the physician orders did not reflect orders for non-rebreather high flow supplement oxygen therapy<BR/>Review of Resident #1's MAR for November 2024 did not reflect administration orders for non-rebreather high flow supplement oxygen therapy.<BR/>Record review of Resident #1's progress notes for November 2024 reflected as follows:<BR/>Effective Date: 11/12/2024 13:42 [1:42 PM] Type: Nursing Progress Note, Author: RN A:<BR/> Hospice RN in pt room, pt having SOB with 02 at 87% per 3L nasal cannula, Temp 101.2, Resp 24, BP 187/86, pulse 96. Nonrebreather mask placed on pt with 02 turned up to 5L, O2 level at 95% at this time. Hospice RN given orders by provider to start Levaquin 500 mg [antibiotic], Prednisone 20mg [steroid], and Duonebs q 6 hours [breathing treatment]. First doses given along with first Duoneb per nebulizer. Pt ia [is] alert and oriented x 2, with some confusion, with moderate SOB observed. Pt has no c/o pain at this time. Tylenol supp [suppository] given for elevated temperature. Pt head of bed elevated with instructions given to CNAs to keep it elevated due to pt SOB.<BR/>Effective Date: 11/13/2024 07:04 [7:04 AM]- Author: RN A<BR/>Note Text: Pt resting quietly with 02 at 96% per nonrebreather at 4L. B/P 128/79, pulse 74, resp 26, temp 98.9 with rhonchi [lung sound characterized by low pitch rumbling sound] and wheezing heard in bilateral [both] lobes. Duoneb given per order, along with Morphine 1ml sublingually [under the tongue]. Pt alert and responsive to verbal stimuli [awakening] with nodding or shaking her head. Call light within reach and no distress noted at this time.<BR/>Effective Date: 11/13/2024 21:45 [9:45 PM] Type: Nursing Note- Author: LVN B<BR/>Note Text: This resident is being treated for URI . BP-110/72. P-86. R-18. T-97.3. O2-97. Oxygen at LPM: 5 via mask continuously.<BR/>Negative Findings: Hoarseness, Respirations: Labored Breathing, Abnormal breath sounds: Rhonchi, to Right Lower Lobe, to Right Upper Lobe, to Left Lower Lobe, to Left Upper Lobe.<BR/>Interventions: Breathing treatment: DUONEBS TID head of bed up, No Pain.<BR/>Effective Date: 11/14/2024 02:24 [AM] Type: Nursing Note Author: RN C<BR/>This resident is being treated for URI.<BR/>BP-127/64. P-90. R-18. T-97.5. O2-97.<BR/>Oxygen at LPM: 5 via mask continuously.<BR/>Negative Findings: None<BR/>Respirations: Labored Breathing,<BR/>Breath sounds clear.<BR/>Interventions: Breathing treatments: ALBUTEROL TID.<BR/>-11/14/2024 at 14:01 [2:01 PM] change in condition entered by RN D <BR/>Effective Date: 11/14/2024 14:23 [2.23 PM] Type: Nursing Progress Note- Author: RN D<BR/>Note Text: Resident transitioning to end of life. VS T97.3 P93 R12 shallow with apnea, SATS 91-97% on 10L via non-rebreather mask.<BR/>Scheduled morphine and PRN Ativan given throughout shift as needed for pain/SOB. Repositioned Q2hrs for comfort, oral care provided. Family at bed side all shift.<BR/>Effective Date: 11/14/2024 15:38 [3:38 PM] Type: Nursing Progress Note Effective Date: 11/14/2024 14:23 Type: Nursing Progress Note- RN B<BR/>Note Text: Noted change in VS they are dropping BP 86/49, P 74, T 95.6, R20, O2 93% 10L mask, cannot verbalize pain morphine given 1 ML.<BR/>During a phone interview with Resident #1's RP on 03/26/25 at 1:26 PM revealed Resident #1 passed away on 11/14/24 at 6 pm. She said Resident #1 sounded like she was suffocating due to the non-rebreather not set correctly. She said Resident #1's non-rebreather was set to administer only five liters of oxygen instead of the ten liters that were required to support non-rebreather oxygen therapy. She stated, no one noticed the wrong non-rebreather setting of oxygen until the next business day (11/14/24), when RN D corrected it and placed Resident#1 on the recommended 10 Liters to support non-rebreather treatment. She said the non-rebreather was later removed before Resident #1 passed away on 11/14/24.<BR/>Review of Resident #1's respiratory vitals from 11/11/24 to 11/14/24 revealed the following:<BR/>- <BR/>11/11/24 - 18 breaths per minute<BR/>- <BR/>11/13/24 - 26 breaths per minute - out of range for breaths per minute<BR/>- <BR/>11/17/24 - 17 breaths per minute<BR/>- <BR/>11/14/24 - 19 breaths per minute<BR/>Review of Resident #1's oxygen saturation levels from 11/11/24 to 11/14/24 revealed the following:<BR/>- <BR/>11/14/24 - between 93-94 % (day of Resident's passing)<BR/>- <BR/>11/13/24 - between 95-96% - normal range for oxygen<BR/>- <BR/>11/12/24 - between 95-96% - normal range for oxygen<BR/>- <BR/>11/11/24 - 97% - normal range for oxygen<BR/>In an interview with RN A on 04/23/25 at 7:15AM, revealed she had been employed at the facility for eight months. She stated one of the CNA's (CNA J) informed her that Resident #1 was not doing well, she immediately went to Resident #1's room and assessed her [11/12/24]. She said while she was assessing her the hospice nurse RN K walked into the room. She said Resident #1 was on a nasal cannula at 3 L. RN K told her to increase Resident #1's oxygen to 5 L, therefore RN A placed Resident #1 on a non-rebreather because her oxygen level was not going up. She said RN K them got on the phone with hospice physician and obtained other orders immediately . She said she could not remember the orders as it had been a long time ago. RN A stated she had never used a non-rebreather before and she would not have done so without someone telling her to do so. She said, I believe RN K told her to use the non-rebreather for Resident #1 but She did not remember 100 percent. She stated she was not familiar on range of the oxygen on non-rebreather mask. She said she would google and ask someone for the range. She said the process of receiving orders was verbal or written and that she would put the orders in the computer after the hospice nurse gave them to her . She said some hospice nurses put their own orders in, so she was not sure if the order for the non-rebreather was added. RN A said she did not take off the non-rebreather from Resident #1 until she was stable . She said the hospice nurse left after Resident #1 stabilized and she did not tell her to remove the non-rebreather. She said because the hospice nurse was in there, she assumed it was ok to the leave the non-rebreather on because she did not say to remove it and put Resident #1 back on her nasal cannula. RN A said the hospice nurse (RN K) notified the physician and she did not have to because Resident #1 was on hospice and the hospice nurse was in the room. Said it was important to get physician orders for the safety of the patient so they can know how what to do. RN A said she was aware of RT in the facility, but it all happened so fast, and they moved as fast to stabilize Resident #1 that she forgot to ask RT to check Resident #1 who had been placed on the nonrebreather.<BR/>In a phone interview with RN K on 03/26/25 at 2:41 PM, she stated she was Resident #1's hospice nurse. She said she went to see Resident #1 on 11/11/24 the non-rebreather was used on her. She said when she got to Resident#1's room, Resident #1 was having difficulty breathing and had shortness of breath. She said the facility nurse RN A had already placed Resident #1 on the non-rebreather. She said she could not remember the liters of the non-rebreather because she herself and RN A were trying to stabilize Resident #1. RN K said she was knowledgeable that non-rebreathers should be set at minimum ten liters otherwise the patient is not getting the needed oxygen fast. RN K said that she did not get orders for the non-rebreather. She said that she called the hospice physician while she was in Resident #1's room and reported Resident #1's condition and he gave her orders but the hospice physician did not give order to keep Resident #1 on a non-rebreather for supplemental oxygen. RN K said the order process was that she wound send the doctor a text on the phone to get orders then she wrote them down on paper and give the order to the facility nurse to imputed in her computer. She said the written orders are placed in the resident's hospice book afterwards. RN K said a non-rebreather was used in emergency cases to help patients get large amounts of oxygen fast to help them recover. She said non-rebreathers were not for long term use. She said when she left, Resident #1 was still on the non-rebreather, but she was stable. She said she was not aware the facility left Resident #1 on the non-rebreather until 11/14/24. She said she did not give them any verbal orders to keep Resident #1 on the non-rebreather oxygen therapy. She said she was also not aware that the facility had Respiratory Therapists on site 24 hours because no one told her. She said the risk to the resident for not getting orders for non-rebreather was retention of carbon dioxide especially in a resident with COPD. <BR/>In a phone interview with CNA J on 03/26/25 at 2:10 PM, she said that she worked for the hospice company that Resident #1 was admitted to while in the facility. She said she proved ADL care, to Resident #1 three times a week and then the week before she passed away, ADL care was changed to five days a week. She said that she had found Resident #1 without oxygen or still connected to an empty oxygen tank on her wheelchair on multiple occasions. She said she would connect Resident #1 to the oxygen compressor in her room then go out and tell facility nursing staff to let them know what she saw and to get Resident #1 a full oxygen tank to use in the shower room for Resident #1.CNA J said she could not remember the names of the facility staff she reported to. CNA J said the last week before Resident #1 passed away she was assigned to provide daily ADLs care as usual, she said she told the facility that Resident #1 did not need a lot of oxygen and asked them to remove the non-rebreather off Resident #1.CNA J said she could not remember the exact date. She said Resident #1 looked more comfortable with just the nasal canula after the non-rebreather was removed. She said she could not remember the exact date when they removed the non-rebreather, but she had to tell the facility to remove it and put her on the nasal cannula.<BR/>In an interview with LVN B on 04/23/25 at 3:59 AM, he stated he had been employed by the facility for a year and a half. He said he had gotten training on Ventilators, non-rebreathers, tracheostomy, and other supplemental oxygen therapy when he first started working at the facility. He said he knew that non-rebreathers were only used to short term use and when he took care of Resident #1, he used a regular simple oxygen mask on her. He said he did not see any orders for a non-rebreather. He said it was important to make sure residents had physician orders for consistency and to follow orders so that you do not make the patients worse by doing the wrong thing. He stated if he needed clarification on orders, he could reach out to the facility physician or the hospice physician or hospice nurse.<BR/>In a phone interview on 04/23/25 at 11:18 AM, revealed RN C had worked with Resident #1 before she passed away [11/14/24] but he could not remember if Resident #1 was on a non-rebreather. He said he knew that a non-rebreather was used only in an emergency when a residents oxygen level drops to help bring back [NAME] quickly. He said after a resident was stabilized, they should be placed on a nasal cannula or if they do not stabilize 911 would be called. RN C said he did not obtain new orders for Resident #1 because the physicians were already aware of the residents' current conditions. He said he believed the oxygen orders were in the computer and he just continued with what was given to him in report. RN C stated it was always good to look at the residents' orders and verify them so that you did not do something wrong. <BR/>In an interview with RN D on 04/23/25 at 7:40 AM, revealed she had been employed at the facility for four years. She said Resident #1 had been moved to her hallway [100 hall] and was assigned to her on 11/14/24 at 2PM. She said she noticed that Resident #1 was on a non-rebreather connected the hospice compressor however the compressor could only deliver a maximum of 5 Liters of oxygen so she asked the transferring nurse to get an Oxygen compressor that could deliver 10 L of oxygen. She said she then increased the non-rebreather to 10 L of oxygen which was the minimum required setting for non-rebreather mask. RN D said she completed a change of condition. RN D stated at this time, after getting the compressor and non-rebreather set to correct parameters, Resident #1 appeared stable she informed Resident #1's family that the non-rebreather was only to be used for short term use. RN D stated family refused to remove the non-rebreather even after she educated them. RN D said she did not call RT to access Resident #1 because she was already at end of life and both herself and the hospice nurse educated family on no-rebreather. RN D said eventually the family decide to allow her to remove the non-rebreather and Resident #1 was placed on a nasal cannula. RN D said physician orders are required to drive care. She said all nurses were trained on how to use a non-rebreather and for what it was used. RN D sated she forgot to document that Resident #1's RP was refusing to have the non-rebreather removed from Resident #1.<BR/>In an interview with RT E and RT F on 04/23/25 at 3:23 AM, revealed they were not responsible for all the residents on supplemental oxygen therapy in the facility except for the ones on mechanical ventilation. They said in an event nursing needed assistance or had a respiratory question they would help. RT E said if a resident is needing to be on a non-rebreather, and they are a full code they would not be in the facility long, We would be calling 911. He said no-rebreathers are good for short term use to deliver fast 100% oxygen to help bring low oxygen up quickly. Both RT E and RT F said the non-rebreather should be set at 15 L or 10-12 Liters for it to be effective. RT E said a non-rebreather should not be used for 3 days as it affects PH which can cause the lungs to fail to remove enough carbon dioxide from the body. He said non-breathers can only be used for the shortest time possible. Both RT E and RT F said orders are required for all residents on oxygen therapy. <BR/>In an interview with the DON on 04/23/25 at 12:08 PM, revealed she did not expect the nurses to obtain new orders for supplemental oxygen because Resident #1 already had orders to used supplement oxygen. She said even though the method of delivery was different, Resident #1 still had orders to use oxygen. DON said a non-rebreather was used for emergency when Resident #1 was having difficulty breathing and because it was an emergency to stabilize the resident, no physician orders are needed. DON said RN D educated the family that Resident #1 could not be on the no-rebreather for an extended time, but the family would not allow them to take off the non-rebreather. DON stated because Resident #1 was a DNR and was on hospice actively passing away, they did not need to call 911 for the resident needing to be on a nonrebreather oxygen delivery form. DON stated the expectation for a non-rebreather was 10-15 L of oxygen to be effective, she said she would not expect someone to put a non-rebreather at 4-5 L, however the hospice nurse (RN K) who was in the room with Resident #1 and RN A notified the physician, and the physician was aware of the condition of the resident. DON did not state the risk because Resident #1 already had supplemental oxygen orders.<BR/>In a phone interview with the physician on 04/23/25 at 12:53 PM, he said he deferred supplemental Oxygen, or anything related to oxygen to the pulmonologist. He said in the event the nurses cannot reach the pulmonologist then he would put in the orders. He said he could not remember Resident #1 without looking at her records, but the nurses were good about notifying him when there was a change of condition and he expected nurses to reach out to him for oxygen order when they could not reach the pulmonologist first and he would give them the orders. He said physician orders drives care.<BR/>In an interview with ADM on 04/23/25 at 6:45 PM, she said the expectations was that all residents on supplemental oxygen obtain orders. She said she expected all staff to obtain physician orders and to follow the physician orders.<BR/>In an interview with ADM on 04/23/25 at 4:44 AM, she stated all records for residents on hospice were uploaded to the EMR of each resident after they discharge.<BR/>Record review of Resident #1 EMR on 04/23/25 at 4:44 AM did not reflect orders for non-rebreather use.<BR/>Record review of Resident #1's discharge MDS assessmet, dated 11/14/24, did not indicate cause of death.<BR/>Cause of death report requested from hospice company, but surveyor has not yet obtained.<BR/>Review of the facility policy titled Physician Orders dated 2015 reflected the purpose of policy was.<BR/>To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.<BR/>1. <BR/>Nurse will review the order and if needed contact the prescriber for any clarifications.<BR/>2. <BR/>The nurse will enter the order into PCC for the resident and select either verbal or telephone, depending on how the nurse received the order.<BR/>3. <BR/>If the order requires documentation, it will be directed to the proper electronic administration record once the order is completed . <BR/>Review of facility policy titled Oxygen Administration: revised March 21, 2023, reflected .<BR/>The Resident will maintain oxygenation with safe and effective delivery of prescribed Oxygen

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 1 (Resident #1) of 5 residents reviewed for care plans.<BR/> The facility failed to ensure Resident #1's care plan reflected behaviors of not using the call light when he needed assistance, removing his CPAP mask, and throwing both to the floor when agitated.<BR/>This deficient practice could place residents at risk of not receiving appropriate care and interventions to meet their current needs. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet, dated on 05/02/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure (lungs cannot Exchange Oxygen and Carbon Dioxide) with Hypoxia (low oxygen), Emphysema/COPD (air flow blockage and breathing), Atrial Fibrillation (irregular or rapid heart rhythm), Dementia (cognitive decline). <BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 02, indicating the resident was severely cognitively impaired. Resident #1 had a resident mood interview severity score of 3, indicating minimal depression. Resident #1's required maximal assistance for with ADLs of bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Resident #1's requires continuous respiratory oxygen therapy, CPAP (Continuous positive airway pressure), and non-mechanical ventilator, non-invasive respiratory support (NIV). <BR/>Record review of Resident #1's care plan, dated 02/29/24, reflected, the resident has Emphysema/COPD. Monitor/document/report to MD PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (document the amount, color, and consistency), chest pain, increased difficulty breathing (Dyspnea), increased coughing and wheezing .the resident has a communication problem .monitor resident frustration levels .affective communication strategies and assistive care .Resident requires the use of CPAP related to sleep apnea. The care plan did not address Resident #1's behaviors of throwing the call light and BPAP on the floor, also his ability to use the call light r/t dementia. <BR/>Record review of Resident #1's revised care plan focus dated 05/02/24 reflected Resident requires the use of CPAP related to sleep apnea .Resident able to remove mask himself when he wakes up .intervention, Resident will use device as ordered. The care plan did not address behaviors and actions for not using call light, throwing call light on the floor, and disassembling CPAP hose and throwing on the floor when he gets agitated.<BR/>Record review of Resident #1 's physician's order, dated 04/17/24 at 2:00 P.M. reflected May have oxygen at 2-5 l/m via nasal cannula to maintain O2 sats above 92% Q shift .May use home CPAP at home settings at night and when napping. There were no MD orders to address changing oxygen tubing and bagging CPAP when not in use.<BR/>In an observation and interview on 05/02/24 at 10:45 A.M., Resident #1, revealed a nasal cannula positioned in the nasal canal properly with tubing connected to the oxygen concentrators. The CPAP mask was lying on the floor under the bed, and the disconnected hose to CPAP lying across the back of the resident's head. The call light was in the resident's left hand. He stated that I'm not doing good, this call light does not work, I don't' know how the hose got loose. Resident #1 denied SOB. The interview with Resident #1's interview was limited due to confusion r/t dementia.<BR/>In an interview on 05/03/24 at 2:16 P.M., ADON M stated that she managed the staff caring for Resident #1. ADON M stated Resident #1 has behaviors of removing his CPAP mask and hose connected to the mask, throwing mask on the floor, when agitated, inability to use call light system, and yelling out for assistance. ADON M stated these behaviors have been increasing since when his POA was out recovering from surgery for 6 weeks. ADON M stated the DON was responsible for updating care plans timely with interventions. ADON M stated herself and staff nurses were responsible for reporting and monitoring resident care and ensuring all information for residents' treatments were provided to the DON for care plans. ADON M said the risk of not updating timely changes to care plans, could lead to the resident receiving inadequate care and timely. <BR/>In an interview on 05/03/24 at 2:28 P.M., the DON stated she was responsible for updating the care plans with changes to care, behaviors, treatments, and MD orders. She stated that she failed to update Resident #1's care plan to reflect his behaviors related to call light and CPAP. The DON stated that she was aware that Resident #1 had behaviors of removing CPAP mask from the hose and throwing to the floor. The DON said Resident #1 does not use the call light, due to memory decline, and yelling out for help. She stated that this was not documented in the care plan. The DON stated the risk to the resident for not updating the care plan for treatments and behaviors could lead to a decline in breathing and staff monitoring of timely care needs. She stated that she expects the nursing staff to follow up and report new orders, changes in behaviors, and communicate timely for updates to DON and ADM to ensure timely changes to the comprehensive care plans.<BR/>In an interview on 05/03/24 at 3:53 P.M., the ADM was un-aware of resident behaviors with the call systems and removing CPAP equipment. She expects nursing staff to communicate behaviors to the DON timely to provide the necessary care plan updates. The ADM said some behaviors such as removing mask may not be addressed in the care plan. She said the DON was responsible for updating residents care plans with new medical information, care needs, and level of functioning. She does not know the risk of the resident's care plans not being updated.<BR/>The facility's policy, Comprehensive Care planning, undated read in part: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs .the facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Care plans will be person-centered and reflect the resident's goals for admission and desired outcomes. Person centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home. Residents' goals set the expectations for the care and services he or she wishes to receive. Measurable objectives describe the steps toward achieving the resident's goals, and can be measured, quantified, and/or verified. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensurethat a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #1) of 5 residents reviewed for quality of care.<BR/>The facility failed to obtain physician orders with specific non-rebreather (this is a mask that delivers high concentration oxygen with a minimum of 10 to 15 Liters/minute of Oxygen flow via a mask and has a valve that ensures air only comes in or out one way) amount on resident #1 from 11/11/24 to 11/14/24.<BR/>This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD.<BR/>Findings Included:<BR/>Record review of Resident #1's admission record dated 04/23/25 revealed a [AGE] year-old female with an admission date of 01/16/24. Her primary diagnosis was unspecified dementia (a brain disease that alters brain function and causes a cognitive decline), and her secondary diagnoses were Myxedma coma (this is a rare life threatening endocrine emergency that occurs when the thyroid hormone regulation is disrupted), heart failure, Atrial fibrillation (this is a heart condition that causes an irregular, often rapid heart rate that can cause poor blood flow), acute respiratory failure with hypoxia, COPD (a lung disease that blocks airflow and makes it difficult to breathe). Resident #1 was on hospice and Resident #1 RP was family.<BR/>Record review of Resident #1's quarterly MDS Assessment, dated 09/25/24, revealed the resident's BIMS score was 10 out of 15, indicating she had moderate cognitive impairment. The MDS Assessment reflected Resident #1 was able to make self-understood and understood others. Further review revealed Resident #1 was dependent on staff for all ADLs and required respiratory treatments oxygen therapy.<BR/>Review of Resident #1's care plan initiated on 01/17/24 revealed the following care areas:<BR/>*Resident #1 had emphysema (a chronic lung diseases that progressively damages the tiny air sacs in the lungs)/COPD. The goal was for Resident #1 to display optimal breathing pattern daily through the review date. The interventions were to give oxygen therapy as ordered by the physician. <BR/>*Resident #1 had oxygen therapy. The goal was for Resident #1 not to have any signs and symptoms of poor Oxygen. The interventions were to change residents position every 2 hours to facilitate lung secretion movement and drainage, If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal, Oxygen at 2-4 lpm per nasal canula.<BR/>Review of Resident #1's care plan initiated on 04/20/24 revealed Resident #1 had a terminal prognosis and was receiving hospice services. Resident #1 was admitted to hospice on 02/13/24 for Alzheimer's disease with late onset (this is a brain condition that progressively destroys memory and other important mental functions). Interventions were to review residents living will and ensure it was followed and to involve family in the discussion. Care plan did not reflect use of non-rebreather high flow supplement oxygen therapy for Resident #1.<BR/>Review of Resident#1's physician orders reflected:<BR/>-DNR- Do not Resuscitate ordered on 08/12/24<BR/>-admission to hospice with diagnoses of Alzheimers diseases (with late onset (this is a brain condition that progressively destroys memory and other important mental functions) level of care on 02/13/24.<BR/>- May use oxygen at 2-3 liters/minute via nasal canula every shift (nasal cannula is a thin flexible tube that gives additional oxygen up to 5 L through the nose). Ordered 02/13/24.<BR/>- Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) Microgram/Activation (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for Shortness of Breath [breathing treatment]. Ordered 01/16/24.<BR/>- Acetaminophen Rectal Suppository 650 MG (Acetaminophen) Insert 1 suppository rectally every 4 hours as needed for Pain and /or fever Not to exceed 4 doses in 24-hour period. Ordered 02/12/24. <BR/>- Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every 2 hours as needed for Very excruciating pain and /or very severe SOB. Ordered 02/12/24.<BR/>-Further review of the physician orders did not reflect orders for non-rebreather high flow supplement oxygen therapy<BR/>Review of Resident #1's MAR for November 2024 did not reflect administration orders for non-rebreather high flow supplement oxygen therapy.<BR/>Record review of Resident #1's progress notes for November 2024 reflected as follows:<BR/>Effective Date: 11/12/2024 13:42 [1:42 PM] Type: Nursing Progress Note, Author: RN A:<BR/> Hospice RN in pt room, pt having SOB with 02 at 87% per 3L nasal cannula, Temp 101.2, Resp 24, BP 187/86, pulse 96. Nonrebreather mask placed on pt with 02 turned up to 5L, O2 level at 95% at this time. Hospice RN given orders by provider to start Levaquin 500 mg [antibiotic], Prednisone 20mg [steroid], and Duonebs q 6 hours [breathing treatment]. First doses given along with first Duoneb per nebulizer. Pt ia [is] alert and oriented x 2, with some confusion, with moderate SOB observed. Pt has no c/o pain at this time. Tylenol supp [suppository] given for elevated temperature. Pt head of bed elevated with instructions given to CNAs to keep it elevated due to pt SOB.<BR/>Effective Date: 11/13/2024 07:04 [7:04 AM]- Author: RN A<BR/>Note Text: Pt resting quietly with 02 at 96% per nonrebreather at 4L. B/P 128/79, pulse 74, resp 26, temp 98.9 with rhonchi [lung sound characterized by low pitch rumbling sound] and wheezing heard in bilateral [both] lobes. Duoneb given per order, along with Morphine 1ml sublingually [under the tongue]. Pt alert and responsive to verbal stimuli [awakening] with nodding or shaking her head. Call light within reach and no distress noted at this time.<BR/>Effective Date: 11/13/2024 21:45 [9:45 PM] Type: Nursing Note- Author: LVN B<BR/>Note Text: This resident is being treated for URI . BP-110/72. P-86. R-18. T-97.3. O2-97. Oxygen at LPM: 5 via mask continuously.<BR/>Negative Findings: Hoarseness, Respirations: Labored Breathing, Abnormal breath sounds: Rhonchi, to Right Lower Lobe, to Right Upper Lobe, to Left Lower Lobe, to Left Upper Lobe.<BR/>Interventions: Breathing treatment: DUONEBS TID head of bed up, No Pain.<BR/>Effective Date: 11/14/2024 02:24 [AM] Type: Nursing Note Author: RN C<BR/>This resident is being treated for URI.<BR/>BP-127/64. P-90. R-18. T-97.5. O2-97.<BR/>Oxygen at LPM: 5 via mask continuously.<BR/>Negative Findings: None<BR/>Respirations: Labored Breathing,<BR/>Breath sounds clear.<BR/>Interventions: Breathing treatments: ALBUTEROL TID.<BR/>-11/14/2024 at 14:01 [2:01 PM] change in condition entered by RN D <BR/>Effective Date: 11/14/2024 14:23 [2.23 PM] Type: Nursing Progress Note- Author: RN D<BR/>Note Text: Resident transitioning to end of life. VS T97.3 P93 R12 shallow with apnea, SATS 91-97% on 10L via non-rebreather mask.<BR/>Scheduled morphine and PRN Ativan given throughout shift as needed for pain/SOB. Repositioned Q2hrs for comfort, oral care provided. Family at bed side all shift.<BR/>Effective Date: 11/14/2024 15:38 [3:38 PM] Type: Nursing Progress Note Effective Date: 11/14/2024 14:23 Type: Nursing Progress Note- RN B<BR/>Note Text: Noted change in VS they are dropping BP 86/49, P 74, T 95.6, R20, O2 93% 10L mask, cannot verbalize pain morphine given 1 ML.<BR/>During a phone interview with Resident #1's RP on 03/26/25 at 1:26 PM revealed Resident #1 passed away on 11/14/24 at 6 pm. She said Resident #1 sounded like she was suffocating due to the non-rebreather not set correctly. She said Resident #1's non-rebreather was set to administer only five liters of oxygen instead of the ten liters that were required to support non-rebreather oxygen therapy. She stated, no one noticed the wrong non-rebreather setting of oxygen until the next business day (11/14/24), when RN D corrected it and placed Resident#1 on the recommended 10 Liters to support non-rebreather treatment. She said the non-rebreather was later removed before Resident #1 passed away on 11/14/24.<BR/>Review of Resident #1's respiratory vitals from 11/11/24 to 11/14/24 revealed the following:<BR/>- <BR/>11/11/24 - 18 breaths per minute<BR/>- <BR/>11/13/24 - 26 breaths per minute - out of range for breaths per minute<BR/>- <BR/>11/17/24 - 17 breaths per minute<BR/>- <BR/>11/14/24 - 19 breaths per minute<BR/>Review of Resident #1's oxygen saturation levels from 11/11/24 to 11/14/24 revealed the following:<BR/>- <BR/>11/14/24 - between 93-94 % (day of Resident's passing)<BR/>- <BR/>11/13/24 - between 95-96% - normal range for oxygen<BR/>- <BR/>11/12/24 - between 95-96% - normal range for oxygen<BR/>- <BR/>11/11/24 - 97% - normal range for oxygen<BR/>In an interview with RN A on 04/23/25 at 7:15AM, revealed she had been employed at the facility for eight months. She stated one of the CNA's (CNA J) informed her that Resident #1 was not doing well, she immediately went to Resident #1's room and assessed her [11/12/24]. She said while she was assessing her the hospice nurse RN K walked into the room. She said Resident #1 was on a nasal cannula at 3 L. RN K told her to increase Resident #1's oxygen to 5 L, therefore RN A placed Resident #1 on a non-rebreather because her oxygen level was not going up. She said RN K them got on the phone with hospice physician and obtained other orders immediately . She said she could not remember the orders as it had been a long time ago. RN A stated she had never used a non-rebreather before and she would not have done so without someone telling her to do so. She said, I believe RN K told her to use the non-rebreather for Resident #1 but She did not remember 100 percent. She stated she was not familiar on range of the oxygen on non-rebreather mask. She said she would google and ask someone for the range. She said the process of receiving orders was verbal or written and that she would put the orders in the computer after the hospice nurse gave them to her . She said some hospice nurses put their own orders in, so she was not sure if the order for the non-rebreather was added. RN A said she did not take off the non-rebreather from Resident #1 until she was stable . She said the hospice nurse left after Resident #1 stabilized and she did not tell her to remove the non-rebreather. She said because the hospice nurse was in there, she assumed it was ok to the leave the non-rebreather on because she did not say to remove it and put Resident #1 back on her nasal cannula. RN A said the hospice nurse (RN K) notified the physician and she did not have to because Resident #1 was on hospice and the hospice nurse was in the room. Said it was important to get physician orders for the safety of the patient so they can know how what to do. RN A said she was aware of RT in the facility, but it all happened so fast, and they moved as fast to stabilize Resident #1 that she forgot to ask RT to check Resident #1 who had been placed on the nonrebreather.<BR/>In a phone interview with RN K on 03/26/25 at 2:41 PM, she stated she was Resident #1's hospice nurse. She said she went to see Resident #1 on 11/11/24 the non-rebreather was used on her. She said when she got to Resident#1's room, Resident #1 was having difficulty breathing and had shortness of breath. She said the facility nurse RN A had already placed Resident #1 on the non-rebreather. She said she could not remember the liters of the non-rebreather because she herself and RN A were trying to stabilize Resident #1. RN K said she was knowledgeable that non-rebreathers should be set at minimum ten liters otherwise the patient is not getting the needed oxygen fast. RN K said that she did not get orders for the non-rebreather. She said that she called the hospice physician while she was in Resident #1's room and reported Resident #1's condition and he gave her orders but the hospice physician did not give order to keep Resident #1 on a non-rebreather for supplemental oxygen. RN K said the order process was that she wound send the doctor a text on the phone to get orders then she wrote them down on paper and give the order to the facility nurse to imputed in her computer. She said the written orders are placed in the resident's hospice book afterwards. RN K said a non-rebreather was used in emergency cases to help patients get large amounts of oxygen fast to help them recover. She said non-rebreathers were not for long term use. She said when she left, Resident #1 was still on the non-rebreather, but she was stable. She said she was not aware the facility left Resident #1 on the non-rebreather until 11/14/24. She said she did not give them any verbal orders to keep Resident #1 on the non-rebreather oxygen therapy. She said she was also not aware that the facility had Respiratory Therapists on site 24 hours because no one told her. She said the risk to the resident for not getting orders for non-rebreather was retention of carbon dioxide especially in a resident with COPD. <BR/>In a phone interview with CNA J on 03/26/25 at 2:10 PM, she said that she worked for the hospice company that Resident #1 was admitted to while in the facility. She said she proved ADL care, to Resident #1 three times a week and then the week before she passed away, ADL care was changed to five days a week. She said that she had found Resident #1 without oxygen or still connected to an empty oxygen tank on her wheelchair on multiple occasions. She said she would connect Resident #1 to the oxygen compressor in her room then go out and tell facility nursing staff to let them know what she saw and to get Resident #1 a full oxygen tank to use in the shower room for Resident #1.CNA J said she could not remember the names of the facility staff she reported to. CNA J said the last week before Resident #1 passed away she was assigned to provide daily ADLs care as usual, she said she told the facility that Resident #1 did not need a lot of oxygen and asked them to remove the non-rebreather off Resident #1.CNA J said she could not remember the exact date. She said Resident #1 looked more comfortable with just the nasal canula after the non-rebreather was removed. She said she could not remember the exact date when they removed the non-rebreather, but she had to tell the facility to remove it and put her on the nasal cannula.<BR/>In an interview with LVN B on 04/23/25 at 3:59 AM, he stated he had been employed by the facility for a year and a half. He said he had gotten training on Ventilators, non-rebreathers, tracheostomy, and other supplemental oxygen therapy when he first started working at the facility. He said he knew that non-rebreathers were only used to short term use and when he took care of Resident #1, he used a regular simple oxygen mask on her. He said he did not see any orders for a non-rebreather. He said it was important to make sure residents had physician orders for consistency and to follow orders so that you do not make the patients worse by doing the wrong thing. He stated if he needed clarification on orders, he could reach out to the facility physician or the hospice physician or hospice nurse.<BR/>In a phone interview on 04/23/25 at 11:18 AM, revealed RN C had worked with Resident #1 before she passed away [11/14/24] but he could not remember if Resident #1 was on a non-rebreather. He said he knew that a non-rebreather was used only in an emergency when a residents oxygen level drops to help bring back [NAME] quickly. He said after a resident was stabilized, they should be placed on a nasal cannula or if they do not stabilize 911 would be called. RN C said he did not obtain new orders for Resident #1 because the physicians were already aware of the residents' current conditions. He said he believed the oxygen orders were in the computer and he just continued with what was given to him in report. RN C stated it was always good to look at the residents' orders and verify them so that you did not do something wrong. <BR/>In an interview with RN D on 04/23/25 at 7:40 AM, revealed she had been employed at the facility for four years. She said Resident #1 had been moved to her hallway [100 hall] and was assigned to her on 11/14/24 at 2PM. She said she noticed that Resident #1 was on a non-rebreather connected the hospice compressor however the compressor could only deliver a maximum of 5 Liters of oxygen so she asked the transferring nurse to get an Oxygen compressor that could deliver 10 L of oxygen. She said she then increased the non-rebreather to 10 L of oxygen which was the minimum required setting for non-rebreather mask. RN D said she completed a change of condition. RN D stated at this time, after getting the compressor and non-rebreather set to correct parameters, Resident #1 appeared stable she informed Resident #1's family that the non-rebreather was only to be used for short term use. RN D stated family refused to remove the non-rebreather even after she educated them. RN D said she did not call RT to access Resident #1 because she was already at end of life and both herself and the hospice nurse educated family on no-rebreather. RN D said eventually the family decide to allow her to remove the non-rebreather and Resident #1 was placed on a nasal cannula. RN D said physician orders are required to drive care. She said all nurses were trained on how to use a non-rebreather and for what it was used. RN D sated she forgot to document that Resident #1's RP was refusing to have the non-rebreather removed from Resident #1.<BR/>In an interview with RT E and RT F on 04/23/25 at 3:23 AM, revealed they were not responsible for all the residents on supplemental oxygen therapy in the facility except for the ones on mechanical ventilation. They said in an event nursing needed assistance or had a respiratory question they would help. RT E said if a resident is needing to be on a non-rebreather, and they are a full code they would not be in the facility long, We would be calling 911. He said no-rebreathers are good for short term use to deliver fast 100% oxygen to help bring low oxygen up quickly. Both RT E and RT F said the non-rebreather should be set at 15 L or 10-12 Liters for it to be effective. RT E said a non-rebreather should not be used for 3 days as it affects PH which can cause the lungs to fail to remove enough carbon dioxide from the body. He said non-breathers can only be used for the shortest time possible. Both RT E and RT F said orders are required for all residents on oxygen therapy. <BR/>In an interview with the DON on 04/23/25 at 12:08 PM, revealed she did not expect the nurses to obtain new orders for supplemental oxygen because Resident #1 already had orders to used supplement oxygen. She said even though the method of delivery was different, Resident #1 still had orders to use oxygen. DON said a non-rebreather was used for emergency when Resident #1 was having difficulty breathing and because it was an emergency to stabilize the resident, no physician orders are needed. DON said RN D educated the family that Resident #1 could not be on the no-rebreather for an extended time, but the family would not allow them to take off the non-rebreather. DON stated because Resident #1 was a DNR and was on hospice actively passing away, they did not need to call 911 for the resident needing to be on a nonrebreather oxygen delivery form. DON stated the expectation for a non-rebreather was 10-15 L of oxygen to be effective, she said she would not expect someone to put a non-rebreather at 4-5 L, however the hospice nurse (RN K) who was in the room with Resident #1 and RN A notified the physician, and the physician was aware of the condition of the resident. DON did not state the risk because Resident #1 already had supplemental oxygen orders.<BR/>In a phone interview with the physician on 04/23/25 at 12:53 PM, he said he deferred supplemental Oxygen, or anything related to oxygen to the pulmonologist. He said in the event the nurses cannot reach the pulmonologist then he would put in the orders. He said he could not remember Resident #1 without looking at her records, but the nurses were good about notifying him when there was a change of condition and he expected nurses to reach out to him for oxygen order when they could not reach the pulmonologist first and he would give them the orders. He said physician orders drives care.<BR/>In an interview with ADM on 04/23/25 at 6:45 PM, she said the expectations was that all residents on supplemental oxygen obtain orders. She said she expected all staff to obtain physician orders and to follow the physician orders.<BR/>In an interview with ADM on 04/23/25 at 4:44 AM, she stated all records for residents on hospice were uploaded to the EMR of each resident after they discharge.<BR/>Record review of Resident #1 EMR on 04/23/25 at 4:44 AM did not reflect orders for non-rebreather use.<BR/>Record review of Resident #1's discharge MDS assessmet, dated 11/14/24, did not indicate cause of death.<BR/>Cause of death report requested from hospice company, but surveyor has not yet obtained.<BR/>Review of the facility policy titled Physician Orders dated 2015 reflected the purpose of policy was.<BR/>To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.<BR/>1. <BR/>Nurse will review the order and if needed contact the prescriber for any clarifications.<BR/>2. <BR/>The nurse will enter the order into PCC for the resident and select either verbal or telephone, depending on how the nurse received the order.<BR/>3. <BR/>If the order requires documentation, it will be directed to the proper electronic administration record once the order is completed . <BR/>Review of facility policy titled Oxygen Administration: revised March 21, 2023, reflected .<BR/>The Resident will maintain oxygenation with safe and effective delivery of prescribed Oxygen

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equipped to allow for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 6 residents (Resident #1) reviewed for resident call system, in that.<BR/>Resident #1s call lights was on the floor and not within reach. <BR/>This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. <BR/>Findings included: <BR/>Resident #1<BR/>Record review of Resident #1's face sheet, dated on 05/02/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure (lungs cannot Exchange Oxygen and Carbon Dioxide) with Hypoxia (low oxygen), Emphysema/COPD (air flow blockage and breathing), Atrial Fibrillation (irregular or rapid heart rhythm), Dementia (cognitive decline). <BR/>Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 02, indicating the resident was severely cognitively impaired. Resident #1 had a mood interview severity score of 3, indicating minimal depression. Resident #1's required maximal assistance for with ADLs of bed mobility, transfers, dressing, eating, toilet use and personal hygiene. <BR/>Record review of Resident #1's care plan, dated 02/29/24, reflected, the resident was a risk for falls and the intervention reflected, anticipate resident needs, be sure the call light was in reach, and encourage the resident to use it for assistance the care plan did not address Resident #1's ability to use call light or behaviors of throwing the call light on the floor. Resident has a communication problem, intervention, ensure/provide a safe environment: Call light in reach, adequate low glare light, bed in lowest position, and wheels locked. Avoid isolation. There was no documentation of resident behaviors or difficulty using call light.<BR/> In an observation and interview on 05/03/24 at 10:45 A.M. revealed Resident #1's call light lying on the floor under his bed. Resident was agitated stating No, I not doing well, no one have come to help me out of bed.<BR/>In an interview on 05/03/24 at 2:00 P.M., CNA A stated that she conducts rounds with Resident's every 2 hours. She said she was unaware that Resident #1's call light was on the floor. She stated Resident #1 usually yells out for help when he needs assistance. She educates him on the use of the call light frequently throughout the shift. She said that Resident # 1 throws his call light on the floor, and he does use the call system for help. CNA A had not reported behaviors to ADON and DON for additional interventions to be developed.<BR/>In an interview on 05/03/24 at 2:10 P.M., RN K was the assigned charge nurse assigned to Resident #1. She stated she did not know that Resident #1's call light was on the floor and not in reach. She stated the nurse and CNA conduct frequent rounds to ensure resident call light was within reach. Surveyor observed RN K picking up the call light, cleaning with bleach wipes and placing in the resident's hand. She stated residents with confusion and who are bed bound should have call light in reach to call for assistance. The risk of resident call lights not being in reach could result in falls, needs not getting met, anxiety, agitation.<BR/>During an interview on 05/03/24 at 2:28 P.M., the DON said the residents should be able to call the nurse in case of an emergency. She said the call lights within the resident reach at all times, as well as educated on the use of the light. The DON said the nurses and CNAs were checking on the residents every 2 hours. She said the possible negative outcome of not having someone to monitor the call light system on Hall 100 could be injury to the resident. The DON said not all residents with behaviors and confusion require documentation in the care plan or [NAME] (documentation system that allows nurse to write, organize, and easily reference key patient information that shapes their nursing care plan. <BR/>During an interview on 05/03/24 at 3:53 P.M., the Administrator stated she has been licensed for over 11 years in Nursing facility regulations. She said her expectations were for the residents to be able to call the nurse in case of an emergency. She said the possible negative outcome could be injury to the residents. She expects the DON and ADON's to monitor and report resident changes in care, behaviors, and needs to the IDT to review, update, and add needed interventions for resident when necessary. <BR/>The surveyor requested call light policy from the ADM and DON on 05/03/24 at 1:45 PM. The ADM stated that the facility does not have a call light policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 6 residents reviewed for neglect.<BR/>Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. This failure resulted in the resident not being assessed by a nurse, not having neurological checks performed, not receiving monitoring for possible serious injury, and the physician not being notified for approximately six hours after the fall when the resident was discovered to have significant bruising and injury to the right side of her face and head. The facility failed to ensure Student Nurse Aide A knew what to do when a resident was found on floor. <BR/>An Immediate Jeopardy was identified on 04/13/24 at 7:20 PM. While the Immediate Jeopardy was removed on 04/14/24 at 2:15 PM, the facility remained out of compliance at a scope of isolated with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal.<BR/>These failures could place residents at risk for serious injury, hospitalization and/or death.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. <BR/>Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident being rarely/never understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices.<BR/>Record review of Resident #1's Care plan revised dated 04/12/24, revealed Focus: The resident had an actual fall r/t poor safety awareness, impulsive, impaired mobility. Goal: The resident will not sustain serious injury through review date. Interventions: Bed in lowest position. Anticipate and meet the resident's needs. Assist resident back to bed during night shift when she is ambulating and lethargic. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Bolster mattress cover to bed. Continue frequent redirection with resident in an attempt to reduce falls. Encourage resident to sit throughout the day to prevent lethargy. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. fall mat at bedside. Frequent visualization throughout the night to ensure resident safety and redirect as needed. Soft helmet when out of bed as resident tolerates to prevent head injury - refuses to wear.<BR/>Review of Resident #1's progress note documented by Physician dated 04/10/24 at 4:40 AM reflected:<BR/>Fall - Head injury. Plan: [AGE] year-old admitted to [Facility] on 9/8/2023 for rehabilitation and/or long-term care secondary to dementia. The patient has a medical history significant for dementia, diabetes mellitus, generalized anxiety, vitamin B12 deficiency hyperlipidemia and hypertension. <BR/>Plan:<BR/>1. Neuro checks as per protocol<BR/>2. Skulls Series<BR/>3. Contact DON/ADON to schedule care plan and root cause evaluation to establish what interventions are needed.<BR/>4. Hold anticoagulants, Plavix, Eliquis, Xarelto for three days if head injury visualized or suspected.<BR/>5. Consider need to send for labs if hypotensive, tachycardic or has altered mental status/increased impulsivity.<BR/>6. Order xray for relevant bony structures if patient has point tenderness/swelling on exam.<BR/>7. Tylenol 1000 mg po q8h prn pain for 72 hours.<BR/>Review of Resident #1's Event Nurses Note - Bruise dated 04/10/24 at 5:41 AM, revealed the following: Location event occurred - Unknown. Location of Injury: Right side of the forehead. Description: Blue/Purple, Unknown Origin. Nursing description of the event: [CNA reported that had a big purple bruise on the right side of the forehead].<BR/>Review of Resident #1's progress note documented by LVN B at 04/10/24 at 5:57 AM revealed the following: Cna reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified.<BR/>Review of Resident #1's Event Nurses Note - Fall dated 04/10/24 at 6:01 AM revealed the following: Location event occurred - Unknown. Unwitnessed, Hit Head. Injury - Bruise. Right side of forehead. Swelling Present, Blue/Purple. CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified.<BR/>Review of Resident #1's Final X-Ray Report dated 04/10/24 at 15:14 [3:14 PM] revealed the following:<BR/>Examination: PELVIS, RIGHT SHOULDER, SKULL. Clinical Indication: Pain in right shoulder; pelvic and perineal pain; unspecified fall, initial encounter. <BR/>SKULL - Findings: There is no definite displaced or depressed calvarial fracture by plain film. Impression: No definite acute displaced or depressed calvarial fracture by plain film.<BR/>RIGHT SHOULDER - Findings: There is an old healed fracture of the proximal diaphysis of the right humerus. No acute fracture or dislocation is identified. Impression: No acute fracture is identified.<BR/>PELVIS - Findings: No acute fracture or dislocation. Impression: No acute osseous abnormality is seen.<BR/>Review of facility's Incident Report completed by the DON, dated 04/12/24 reflected the following: Date of Incident: 04/10/24 5:47AM - CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Conclusion: Resident observed on the floor by aide beside her bed. Large purple bruise noted to right side of forehead and eye as a delayed injury to fall. Interventions: Frequent visualization during evening and night hours as resident becomes restless. Psych to continue to evaluate and adjust meds as indicated. Resident refuses to allow helmet to be placed on her. Continue low bed and fall mat at bedside. <BR/>Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed with floor mats on each side of her bed. Resident #1 was covered up to her forehead. A swollen dark purple/blue bump was observed on the right side of the resident's forehead/temple. <BR/>Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Resident #1 had significant bruising to her right side of her face. The bruise started from Resident #1's forehead, spread all the way down to her neck and both of her eyes were bruised. Resident #1 was not a good historian, and she was unable to recall having a fall. She denied being in any pain. Interview with Resident #1's Family Member revealed Resident #1 had a fall the night of 04/09/24 at 7:55 PM. She stated Resident #1 was on the floor until 4:33 AM. Resident #1's Family Member stated she had a camera in the resident's room. She stated the camera recorded footage when motion was detected and only recorded in 6 seconds increments. Review of camera footage date stamped 04/09/24 at 19:40 [7:40 PM] revealed Resident #1 was lying in bed trying to get up, and her bed was in a low position with no fall mats observed. Resident #1's bedside table, walker, and a chair on the right side of resident bed closed by. At 19:55 [7:55 PM] Resident #1 was on the floor lying on her right side. Camera footage did not show how the resident fell or if she hit herself and no sounds were made by the resident. Resident #1 was observed moving her head and left arm. At 21:46 [9:46 PM] it was observed a staff member with pink scrubs entered the room and left. The camera footage audio revealed the staff voicing while she was leaving the room at 21:46 [9:46 PM] Hey can you get the aide. At 21:58 [9:58 PM] Resident #1 was observed in bed. The camera footage did not show who or how Resident #1 was placed back in bed. Resident #1 was positioned horizontally on her right side with her feet hanging from the bed. There was no movement in the room for the camera to record from 21:58 [9:58 PM] to 4:17 AM Resident #1 was lying in bed vertical position. No observation of fall mat. At 4:33 AM a CNA was observed prepping to provide incontinence care for Resident #1, and Resident #1 was observed turning to her left side. Resident #1's Family Member stated she had a missed call from the facility on 04/10/24 at 4:59 AM and then within seconds she returned the call. She stated the facility nurse contacted her and notified her of the bruise. She stated the nurse asked her to review the cameras because they were not sure how Resident #1 sustained the bruise. She stated she reviewed the camera footage and noticed Resident #1 had the fall. Resident #1's Family Member stated she could not recall the name of the nurse who called her. She stated she had not been told much about the incident only that they had completed x-rays and results were fine.<BR/>Interview on 04/13/24 at 12:04 PM with LVN A revealed he was the charge nurse assigned to the secure unit. He stated Resident #1 bruise was noted the morning of 04/10/24 by the 10PM-6AM staff. He stated he believed Resident #1 had a fall the night of 04/09/24 unsure how; however, Resident #1 sustained a bruise to her right side of her forehead. He stated throughout the days the bruise began to spread all over Resident #1's right side of the face. LVN A stated Resident #1 was able to ambulate on her own. He stated they provided Resident #1 with a wheelchair or a walker but Resident #1 refused to use them. LVN A stated they completed an x-ray on 04/10/24 with no findings. <BR/>Interview on 04/13/24 at 12:19 PM with CNA B revealed she was the assigned CNA for Resident #1. She stated the morning of 04/10/24 she came in for her shift at around 5:45 AM, she stated she was given report that Resident #1 had a bruise to her forehead, she stated resident had a fall during the 2:00 PM-10:00 PM shift and someone had picked her up. She stated she was not provided with much information. She stated when she completed her rounds the morning of 04/10/24, she was not able to see the bruise due to Resident #1 sleeping on her right side. She stated she could not recall the CNA who noticed the bruise. <BR/>Interview on 04/13/24 at 12:59 PM with LVN C revealed she was the nurse assigned to the secure unit on 04/09/24 from 2:00 PM-10:00 PM shift. She stated during her shift, her CNAs were CNA H for the male side and another CNA for the female side but could not recall her name. LVN C stated her shift ended at around 11:30 PM. She stated the last time she observed Resident #1 on 04/09/24 was around 9:30 PM-10:00 PM, she stated Resident #1 was sleeping on her right side. She stated she did not observe any bruising to her face. She stated she was never notified by her CNAs that resident had a fall. She stated she left her shift without being informed Resident #1 was found on the floor. <BR/>Interview on 04/13/24 at 2:29 PM with Student Nurse Aide revealed she had been employed since November 2023. She stated she had been assigned to the secure unit twice. She stated the last time she had worked in the secure unit was on 04/09/24 from 2:00 PM-10:00 PM. She stated she was the CNA assigned to Resident #1 on 04/09/24. She stated she completed her rounds between 7:00 PM-7:30 PM and Resident #1 was in bed sleeping. She stated when CNA G came in for her 10:00 PM-6:00 AM shift. She stated CNA G was completing her rounds when she voiced Resident #1 was not in her room. She stated she began to look for her and then she returned to Resident #1's room and found Resident #1 on the floor. She stated she called for another staff to come assist her; however, it was the first time she had observed a resident on the floor that the only thought that came to mind was to get her up. She stated she picked up the resident by herself. She stated Resident #1 did not complain of pain. She stated once she placed Resident #1 in the bed, she went to the hall and observed CNA G. She stated she notified CNA G that Resident #1 was on the floor and she picked her up and left for her shift around 10:00 PM. She stated she did not notify the nurse because she thought CNA G was going to notify the nurse. She stated the next morning on 04/10/24 she was called by the ADON asking her if Resident #1 had a fall. She stated she was told Resident #1 sustained a bruise to her forehead. She stated her mistake was not notifying the nurse. She stated she had completed her training on relias but could not recall any other in-services on falls. She stated she was in-serviced after the incident to not move the resident and to notify the nurse. She stated the potential risk of moving a resident after a fall could cause serious injuries and the risk of not notifying the nurse could delay treatment. <BR/>An attempt was made on 04/13/24 at 2:57 PM to contact CNA E by phone; however, there was no response.<BR/>Interview on 04/13/24 at 3:02 PM with LVN F revealed he was the nurse assigned to Resident #1 the night of 04/09/24 from 10:00 PM-6:00 AM. He stated he completed his rounds every 2 hours. He stated Resident #1 was sleeping on her right side and they were not able to observe the bruise. He stated at around 4:00 AM-4:30AM, CNA E, assigned to the hall, notified him that Resident #1 had a bruise on her forehead. He stated he immediately assessed her and notified the Administrator. He stated he could not see any documentation regarding a fall or the bruise. LVN F stated they spoke to CNA G and CNA G stated that Resident #1 had a fall during the 2:00 PM-10:00 PM shift but was unaware if the Student Nurse Aide notified the nurse. LVN F stated he notified the doctor and family. He stated he asked Resident #1's Family Member to review the camera footage to see if Resident #1 had a fall. LVN F stated the doctor ordered x-rays and to monitor the bruise. LVN F stated by the Student Nurse Aide not notifying the nurse caused a delay in assessing the resident. <BR/>Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the assigned CNA for Resident #1 on 04/09/24 from 10:00 PM-6:00 AM for about 20 minutes. She stated on 04/09/24 closed to 10:00 PM she began her rounds. She stated she passed by Resident #1 room and Resident #1 was not in her bed. She stated she notified the Student Nurse Aide Resident #1 was not in her bed, she stated she completed her rounds while the Student Nurse Aide looked for Resident #1. CNA G stated she was not sure the what the aide's name was. She stated when she completed her rounds, the Student Nurse Aide informed her that she had found Resident #1, when she asked her where, Student Nurse Aide told her that Resident #1 was on the floor and that she had picked her up. CNA G stated when she was going to go check on Resident #1, she was called by another nurse to go 100 Hall. CNA G stated she never observed Resident #1 the night on 04/09/24. She stated she never asked the Student Nurse Aide if she had notified the nurse. CNA G stated she did not follow up on Resident #1 because she thought the Student Nurse Aide had notified someone. CNA G stated around 5:00 AM, she was asked by CNA E if she had observed Resident #1's bruise. She stated she notified CNA E and LVN F that the 2:00 PM-10:00 PM Student Nurse Aide staff had told her Resident #1 had a fall but was unsure if the Student Nurse Aide had notified the nurse. CNA G stated after she was asked about the fall it clicked on her and stated she should had followed up with the nurse. CNA G stated the risk of picking up a resident without being assess by a nurse could cause a serious injury and by not notifying the nurse could delay treatment. <BR/>An attempt was made on 04/13/24 at 4:00 PM to contact CNA E by phone; however, there was no response.<BR/>Interview on 04/13/24 at 4:32 PN with the DON revealed Resident #1 had a fall the night of 04/09/24. The DON stated she was unsure how everything happened, she stated she was notified on 04/10/24, that Resident #1 had bruising to her right side of the face. She stated they spoke to Student Nurse Aide and she told them that she had found Resident #1 on the floor unknown of the time and that she picked her up. She stated she spoke to CNA G and CNA G stated that Student Nurse Aide told her that Resident #1 was found on the floor and that the Student Nurse Aide had picked her up. The DON stated the Student Nurse Aide failed to notify the charge nurse of Resident #1 being on the floor and picked her up without being assessed first. The DON stated they completed 1:1 in-serviced with Student Nurse Aide on fall prevention and reporting on 04/10/24. The DON stated staff had completed in-services prior to fall but not after the incident. <BR/>Interview on 04/13/24 at 4:48 PM with the Administrator revealed Resident #1 had a fall on 04/09/24; however, she was notified on 04/10/24. She stated she was told Resident #1 had a fall in her room and that the Student Nurse Aide transferred Resident #1 back into bed. She stated on 04/10/24, during morning stand up, they found out that the Student Nurse Aide failed to notify the nurse that Resident #1 had a fall and that she helped the Resident #1 back up without being assessed. She stated Student Nurse Aide was in-serviced after the incident. <BR/>Review of Student Nurse Aide's personnel file revealed the following forms: <BR/>Student Nurse Aide completed fall prevention training and completed the fall prevention test. Fall Prevention test dated 11/15/23, reflected one of the test questions was regarding, Once you have ensured the person's safety when discovering a fall, what is the next step? Student Nurse Aide responded: Notify the Charge Nurse.<BR/>Coaching Form - dated 04/10/24: Situation: Staff failed to report a fall.<BR/>Student Nurse Aide statement I [name] was making my last round w/ the aide that was working 10-6. We noticed [Resident #1] wasn't in her bed, we went checking other rooms and that's when I went back in and seen [Resident #1] on the floor as if she missed trying to sit on the bed. The first thing I did was help her off the floor onto the bed. I then asked the other aide to help me put her on the bed the right way. She said she's okay and will fix her later. I did not tell the nurse I thought maybe she would've reported it. My mistake.<BR/>Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected the following: <BR/>The resident has the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. <BR/>Adverse Event: An adverse event is an untoward, undesirable, and usually unanticipated even that causes death or serious injury, or the risk thereof. <BR/>Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.<BR/>Reporting: If the allegations involve abuse or results in serious bodily injury, the report is to be made within 2 hours of the allegation. <BR/>If the allegations does not involved abuse or serious bodily injury, the report must be made within 24 hours of the allegations. <BR/>An Immediate Jeopardy was identified on 04/13/24. The Administrator was notified of the Immediate Jeopardy on 04/13/24 at 7:20 PM and was provided with the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/14/24 8:40 AM and reflected the following:<BR/>-As of 4/10/24, Student Nurse Aide A was in-serviced 1:1 by the DON on the following: All in-servicing was completed on 4/13/24. <BR/> -Abuse and Neglect Policy<BR/> - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse:<BR/> - A resident is found on the floor (witnessed or unwitnessed)<BR/> - A resident has an injury that is new (bruise, skin tear, abrasion, laceration)<BR/> - Fall Prevention Policy <BR/>- On 4/13/24 head to toe assessments were initiated for all residents for any injuries including bruising. No additional issues were found. Assessments were completed by the DON, ADON and Tx Nurse on 4/14/24. <BR/>- The medical director was notified of the immediate jeopardy by the administrator on 4/13/24. <BR/>- AD HOC QAPI was held with the Medical Director and facility interdisciplinary team on 4/13/24 to discuss the immediate jeopardy and subsequent plan of removal. <BR/>In-services:<BR/>All staff will be in-serviced on the following topics below by the Administrator, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff and staff on leave received in-services electronically. Staff members who received in-servicing electronically must see the DON/Administrator prior to working their next shift to acknowledge understanding and sign in-services. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date: 4/14/24. <BR/> - Abuse and Neglect Policy<BR/> - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse:<BR/> - A resident is found on the floor (witnessed or unwitnessed)<BR/> - A resident has an injury that is new (bruise, skin tear, abrasion, laceration)<BR/>- Fall Prevention Policy<BR/>-Neuro Checks Policy (Charge Nurses Only)<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Review of the following in-services dated 04/13/24 revealed training for Abuse and Neglect, IR (Incident Report) Reporting, Neuro Checks and Fall Prevention Policy. In-services revealed all staff completed the trainings. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM.<BR/>Review of sample residents Assessments revealed head to toe assessments were completed. <BR/>Review of facility QAPI Meeting revealed meeting was completed on 04/13/24. <BR/>Observations on 04/14/24 from 9:15 AM through 10:48AM revealed no other residents with bruising or injuries noted. <BR/>Interviews on 04/14/24 from 10:22 AM through 2:00 PM with CNA B, LVN C, Student Aide D, CNA G, CNA H, CNA I, RN J, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA T, CNA U, CNA V, LVN W, LVN X, LVN Y, LVN Z, Treatment Nurse, Medication Aide, ADON K, ADON L, HR Coordinator, Assistant BOM, Staffing Coordinator, Medical Records, Guest Relations Coordinator, Social Worker, Dietary Manager, Dietary A, Dietary B, Dietary D, Housekeeping Supervisor, Housekeeping A, Housekeeping B, Housekeeping C, Housekeeping D, Floor Tech, Respiratory Therapist A, Respiratory Therapist B, Occupational Therapist, and Maintenance Director who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM revealed the Staff were able to verify education was provided to them, nursing staff were able to accurately summarize what to do if a resident was found on the floor (witnessed or unwitnessed), if a resident has an injury that is new (bruise, skin tear, abrasion, laceration), fall prevention policy, and neuro checks (Charge Nurses Only). <BR/>The Administrator and DON were informed the Immediate Jeopardy was removed on 04/14/2024 at 2:15 PM. 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 isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 5 residents (Residents #1) reviewed for abuse and neglect. <BR/>Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. This failure resulted in the resident not being assessed by a nurse, not having neurological checks performed, not receiving monitoring for possible serious injury, and the physician not being notified for approximately six hours after the fall when the resident was discovered to have significant bruising and injury to the right side of her face and head. The facility failed to ensure Student Nurse Aide A knew what to do when a resident was found on floor. <BR/>An Immediate Jeopardy was identified on 04/13/24 at 7:20 PM. While the Immediate Jeopardy was removed on 04/14/24 at 2:15 PM, the facility remained out of compliance at a scope of isolated with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal.<BR/>These failures could place residents at risk for serious injury, hospitalization and/or death.<BR/>Findings included: <BR/>Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected the following: <BR/>The resident has the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. <BR/>Adverse Event: An adverse event is an untoward, undesirable, and usually unanticipated even that causes death or serious injury, or the risk thereof. <BR/>Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.<BR/>Reporting: If the allegations involve abuse or results in serious bodily injury, the report is to be made within 2 hours of the allegation. <BR/>If the allegations does not involved abuse or serious bodily injury, the report must be made within 24 hours of the allegations. <BR/>Record review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. <BR/>Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident being rarely/never understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices.<BR/>Record review of Resident #1's Care plan revised dated 04/12/24, revealed Focus: The resident had an actual fall r/t poor safety awareness, impulsive, impaired mobility. Goal: The resident will not sustain serious injury through review date. Interventions: Bed in lowest position. Anticipate and meet the resident's needs. Assist resident back to bed during night shift when she is ambulating and lethargic. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Bolster mattress cover to bed. Continue frequent redirection with resident in an attempt to reduce falls. Encourage resident to sit throughout the day to prevent lethargy. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. fall mat at bedside. Frequent visualization throughout the night to ensure resident safety and redirect as needed. Soft helmet when out of bed as resident tolerates to prevent head injury - refuses to wear.<BR/>Review of Resident #1's progress note documented by Physician dated 04/10/24 at 4:40 AM reflected:<BR/>Fall - Head injury. Plan: [AGE] year-old admitted to [Facility] on 9/8/2023 for rehabilitation and/or long-term care secondary to dementia. The patient has a medical history significant for dementia, diabetes mellitus, generalized anxiety, vitamin B12 deficiency hyperlipidemia and hypertension. <BR/>Plan:<BR/>1. Neuro checks as per protocol<BR/>2. Skulls Series<BR/>3. Contact DON/ADON to schedule care plan and root cause evaluation to establish what interventions are needed.<BR/>4. Hold anticoagulants, Plavix, Eliquis, Xarelto for three days if head injury visualized or suspected.<BR/>5. Consider need to send for labs if hypotensive, tachycardic or has altered mental status/increased impulsivity.<BR/>6. Order xray for relevant bony structures if patient has point tenderness/swelling on exam.<BR/>7. Tylenol 1000 mg po q8h prn pain for 72 hours.<BR/>Review of Resident #1's Event Nurses Note - Bruise dated 04/10/24 at 5:41 AM, revealed the following: Location event occurred - Unknown. Location of Injury: Right side of the forehead. Description: Blue/Purple, Unknown Origin. Nursing description of the event: [CNA reported that had a big purple bruise on the right side of the forehead].<BR/>Review of Resident #1's progress note documented by LVN B at 04/10/24 at 5:57 AM revealed the following: Cna reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified.<BR/>Review of Resident #1's Event Nurses Note - Fall dated 04/10/24 at 6:01 AM revealed the following: Location event occurred - Unknown. Unwitnessed, Hit Head. Injury - Bruise. Right side of forehead. Swelling Present, Blue/Purple. CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified.<BR/>Review of Resident #1's Final X-Ray Report dated 04/10/24 at 15:14 [3:14 PM] revealed the following:<BR/>Examination: PELVIS, RIGHT SHOULDER, SKULL. Clinical Indication: Pain in right shoulder; pelvic and perineal pain; unspecified fall, initial encounter. <BR/>SKULL - Findings: There is no definite displaced or depressed calvarial fracture by plain film. Impression: No definite acute displaced or depressed calvarial fracture by plain film.<BR/>RIGHT SHOULDER - Findings: There is an old healed fracture of the proximal diaphysis of the right humerus. No acute fracture or dislocation is identified. Impression: No acute fracture is identified.<BR/>PELVIS - Findings: No acute fracture or dislocation. Impression: No acute osseous abnormality is seen.<BR/>Review of facility's Incident Report completed by the DON, dated 04/12/24 reflected the following: Date of Incident: 04/10/24 5:47AM - CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Conclusion: Resident observed on the floor by aide beside her bed. Large purple bruise noted to right side of forehead and eye as a delayed injury to fall. Interventions: Frequent visualization during evening and night hours as resident becomes restless. Psych to continue to evaluate and adjust meds as indicated. Resident refuses to allow helmet to be placed on her. Continue low bed and fall mat at bedside. <BR/>Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed with floor mats on each side of her bed. Resident #1 was covered up to her forehead. A swollen dark purple/blue bump was observed on the right side of the resident's forehead/temple. <BR/>Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Resident #1 had significant bruising to her right side of her face. The bruise started from Resident #1's forehead, spread all the way down to her neck and both of her eyes were bruised. Resident #1 was not a good historian, and she was unable to recall having a fall. She denied being in any pain. Interview with Resident #1's Family Member revealed Resident #1 had a fall the night of 04/09/24 at 7:55 PM. She stated Resident #1 was on the floor until 4:33 AM. Resident #1's Family Member stated she had a camera in the resident's room. She stated the camera recorded footage when motion was detected and only recorded in 6 seconds increments. Review of camera footage date stamped 04/09/24 at 19:40 [7:40 PM] revealed Resident #1 was lying in bed trying to get up, and her bed was in a low position with no fall mats observed. Resident #1's bedside table, walker, and a chair on the right side of resident bed closed by. At 19:55 [7:55 PM] Resident #1 was on the floor lying on her right side. Camera footage did not show how the resident fell or if she hit herself and no sounds were made by the resident. Resident #1 was observed moving her head and left arm. At 21:46 [9:46 PM] it was observed a staff member with pink scrubs entered the room and left. The camera footage audio revealed the staff voicing while she was leaving the room at 21:46 [9:46 PM] Hey can you get the aide. At 21:58 [9:58 PM] Resident #1 was observed in bed. The camera footage did not show who or how Resident #1 was placed back in bed. Resident #1 was positioned horizontally on her right side with her feet hanging from the bed. There was no movement in the room for the camera to record from 21:58 [9:58 PM] to 4:17 AM Resident #1 was lying in bed vertical position. No observation of fall mat. At 4:33 AM a CNA was observed prepping to provide incontinence care for Resident #1, and Resident #1 was observed turning to her left side. Resident #1's Family Member stated she had a missed call from the facility on 04/10/24 at 4:59 AM and then within seconds she returned the call. She stated the facility nurse contacted her and notified her of the bruise. She stated the nurse asked her to review the cameras because they were not sure how Resident #1 sustained the bruise. She stated she reviewed the camera footage and noticed Resident #1 had the fall. Resident #1's Family Member stated she could not recall the name of the nurse who called her. She stated she had not been told much about the incident only that they had completed x-rays and results were fine.<BR/>Interview on 04/13/24 at 12:04 PM with LVN A revealed he was the charge nurse assigned to the secure unit. He stated Resident #1 bruise was noted the morning of 04/10/24 by the 10PM-6AM staff. He stated he believed Resident #1 had a fall the night of 04/09/24 unsure how; however, Resident #1 sustained a bruise to her right side of her forehead. He stated throughout the days the bruise began to spread all over Resident #1's right side of the face. LVN A stated Resident #1 was able to ambulate on her own. He stated they provided Resident #1 with a wheelchair or a walker but Resident #1 refused to use them. LVN A stated they completed an x-ray on 04/10/24 with no findings. <BR/>Interview on 04/13/24 at 12:19 PM with CNA B revealed she was the assigned CNA for Resident #1. She stated the morning of 04/10/24 she came in for her shift at around 5:45 AM, she stated she was given report that Resident #1 had a bruise to her forehead, she stated resident had a fall during the 2:00 PM-10:00 PM shift and someone had picked her up. She stated she was not provided with much information. She stated when she completed her rounds the morning of 04/10/24, she was not able to see the bruise due to Resident #1 sleeping on her right side. She stated she could not recall the CNA who noticed the bruise. <BR/>Interview on 04/13/24 at 12:59 PM with LVN C revealed she was the nurse assigned to the secure unit on 04/09/24 from 2:00 PM-10:00 PM shift. She stated during her shift, her CNAs were CNA H for the male side and another CNA for the female side but could not recall her name. LVN C stated her shift ended at around 11:30 PM. She stated the last time she observed Resident #1 on 04/09/24 was around 9:30 PM-10:00 PM, she stated Resident #1 was sleeping on her right side. She stated she did not observe any bruising to her face. She stated she was never notified by her CNAs that resident had a fall. She stated she left her shift without being informed Resident #1 was found on the floor. <BR/>Interview on 04/13/24 at 2:29 PM with Student Nurse Aide revealed she had been employed since November 2023. She stated she had been assigned to the secure unit twice. She stated the last time she had worked in the secure unit was on 04/09/24 from 2:00 PM-10:00 PM. She stated she was the CNA assigned to Resident #1 on 04/09/24. She stated she completed her rounds between 7:00 PM-7:30 PM and Resident #1 was in bed sleeping. She stated when CNA G came in for her 10:00 PM-6:00 AM shift. She stated CNA G was completing her rounds when she voiced Resident #1 was not in her room. She stated she began to look for her and then she returned to Resident #1's room and found Resident #1 on the floor. She stated she called for another staff to come assist her; however, it was the first time she had observed a resident on the floor that the only thought that came to mind was to get her up. She stated she picked up the resident by herself. She stated Resident #1 did not complain of pain. She stated once she placed Resident #1 in the bed, she went to the hall and observed CNA G. She stated she notified CNA G that Resident #1 was on the floor and she picked her up and left for her shift around 10:00 PM. She stated she did not notify the nurse because she thought CNA G was going to notify the nurse. She stated the next morning on 04/10/24 she was called by the ADON asking her if Resident #1 had a fall. She stated she was told Resident #1 sustained a bruise to her forehead. She stated her mistake was not notifying the nurse. She stated she had completed her training on relias but could not recall any other in-services on falls. She stated she was in-serviced after the incident to not move the resident and to notify the nurse. She stated the potential risk of moving a resident after a fall could cause serious injuries and the risk of not notifying the nurse could delay treatment. <BR/>An attempt was made on 04/13/24 at 2:57 PM to contact CNA E by phone; however, there was no response.<BR/>Interview on 04/13/24 at 3:02 PM with LVN F revealed he was the nurse assigned to Resident #1 the night of 04/09/24 from 10:00 PM-6:00 AM. He stated he completed his rounds every 2 hours. He stated Resident #1 was sleeping on her right side and they were not able to observe the bruise. He stated at around 4:00 AM-4:30AM, CNA E, assigned to the hall, notified him that Resident #1 had a bruise on her forehead. He stated he immediately assessed her and notified the Administrator. He stated he could not see any documentation regarding a fall or the bruise. LVN F stated they spoke to CNA G and CNA G stated that Resident #1 had a fall during the 2:00 PM-10:00 PM shift but was unaware if the Student Nurse Aide notified the nurse. LVN F stated he notified the doctor and family. He stated he asked Resident #1's Family Member to review the camera footage to see if Resident #1 had a fall. LVN F stated the doctor ordered x-rays and to monitor the bruise. LVN F stated by the Student Nurse Aide not notifying the nurse caused a delay in assessing the resident. <BR/>Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the assigned CNA for Resident #1 on 04/09/24 from 10:00 PM-6:00 AM for about 20 minutes. She stated on 04/09/24 closed to 10:00 PM she began her rounds. She stated she passed by Resident #1 room and Resident #1 was not in her bed. She stated she notified the Student Nurse Aide Resident #1 was not in her bed, she stated she completed her rounds while the Student Nurse Aide looked for Resident #1. CNA G stated she was not sure the what the aide's name was. She stated when she completed her rounds, the Student Nurse Aide informed her that she had found Resident #1, when she asked her where, Student Nurse Aide told her that Resident #1 was on the floor and that she had picked her up. CNA G stated when she was going to go check on Resident #1, she was called by another nurse to go 100 Hall. CNA G stated she never observed Resident #1 the night on 04/09/24. She stated she never asked the Student Nurse Aide if she had notified the nurse. CNA G stated she did not follow up on Resident #1 because she thought the Student Nurse Aide had notified someone. CNA G stated around 5:00 AM, she was asked by CNA E if she had observed Resident #1's bruise. She stated she notified CNA E and LVN F that the 2:00 PM-10:00 PM Student Nurse Aide staff had told her Resident #1 had a fall but was unsure if the Student Nurse Aide had notified the nurse. CNA G stated after she was asked about the fall it clicked on her and stated she should had followed up with the nurse. CNA G stated the risk of picking up a resident without being assess by a nurse could cause a serious injury and by not notifying the nurse could delay treatment. <BR/>An attempt was made on 04/13/24 at 4:00 PM to contact CNA E by phone; however, there was no response.<BR/>Interview on 04/13/24 at 4:32 PN with the DON revealed Resident #1 had a fall the night of 04/09/24. The DON stated she was unsure how everything happened, she stated she was notified on 04/10/24, that Resident #1 had bruising to her right side of the face. She stated they spoke to Student Nurse Aide and she told them that she had found Resident #1 on the floor unknown of the time and that she picked her up. She stated she spoke to CNA G and CNA G stated that Student Nurse Aide told her that Resident #1 was found on the floor and that the Student Nurse Aide had picked her up. The DON stated the Student Nurse Aide failed to notify the charge nurse of Resident #1 being on the floor and picked her up without being assessed first. The DON stated they completed 1:1 in-serviced with Student Nurse Aide on fall prevention and reporting on 04/10/24. The DON stated staff had completed in-services prior to fall but not after the incident. <BR/>Interview on 04/13/24 at 4:48 PM with the Administrator revealed Resident #1 had a fall on 04/09/24; however, she was notified on 04/10/24. She stated she was told Resident #1 had a fall in her room and that the Student Nurse Aide transferred Resident #1 back into bed. She stated on 04/10/24, during morning stand up, they found out that the Student Nurse Aide failed to notify the nurse that Resident #1 had a fall and that she helped the Resident #1 back up without being assessed. She stated Student Nurse Aide was in-serviced after the incident. <BR/>Review of Student Nurse Aide's personnel file revealed the following forms: <BR/>Student Nurse Aide completed fall prevention training and completed the fall prevention test. Fall Prevention test dated 11/15/23, reflected one of the test questions was regarding, Once you have ensured the person's safety when discovering a fall, what is the next step? Student Nurse Aide responded: Notify the Charge Nurse.<BR/>Coaching Form - dated 04/10/24: Situation: Staff failed to report a fall.<BR/>Student Nurse Aide statement I [name] was making my last round w/ the aide that was working 10-6. We noticed [Resident #1] wasn't in her bed, we went checking other rooms and that's when I went back in and seen [Resident #1] on the floor as if she missed trying to sit on the bed. The first thing I did was help her off the floor onto the bed. I then asked the other aide to help me put her on the bed the right way. She said she's okay and will fix her later. I did not tell the nurse I thought maybe she would've reported it. My mistake.<BR/>An Immediate Jeopardy was identified on 04/13/24. The Administrator was notified of the Immediate Jeopardy on 04/13/24 at 7:20 PM and was provided with the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/14/24 8:40 AM and reflected the following:<BR/>-As of 4/10/24, Student Nurse Aide A was in-serviced 1:1 by the DON on the following: All in-servicing was completed on 4/13/24. <BR/> -Abuse and Neglect Policy<BR/> - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse:<BR/> - A resident is found on the floor (witnessed or unwitnessed)<BR/> - A resident has an injury that is new (bruise, skin tear, abrasion, laceration)<BR/> - Fall Prevention Policy <BR/>- On 4/13/24 head to toe assessments were initiated for all residents for any injuries including bruising. No additional issues were found. Assessments were completed by the DON, ADON and Tx Nurse on 4/14/24. <BR/>- The medical director was notified of the immediate jeopardy by the administrator on 4/13/24. <BR/>- AD HOC QAPI was held with the Medical Director and facility interdisciplinary team on 4/13/24 to discuss the immediate jeopardy and subsequent plan of removal. <BR/>In-services:<BR/>All staff will be in-serviced on the following topics below by the Administrator, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff and staff on leave received in-services electronically. Staff members who received in-servicing electronically must see the DON/Administrator prior to working their next shift to acknowledge understanding and sign in-services. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date: 4/14/24. <BR/> - Abuse and Neglect Policy<BR/> - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse:<BR/> - A resident is found on the floor (witnessed or unwitnessed)<BR/> - A resident has an injury that is new (bruise, skin tear, abrasion, laceration)<BR/>- Fall Prevention Policy<BR/>-Neuro Checks Policy (Charge Nurses Only)<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Review of the following in-services dated 04/13/24 revealed training for Abuse and Neglect, IR (Incident Report) Reporting, Neuro Checks and Fall Prevention Policy. In-services revealed all staff completed the trainings. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM.<BR/>Review of sample residents Assessments revealed head to toe assessments were completed. <BR/>Review of facility QAPI Meeting revealed meeting was completed on 04/13/24. <BR/>Observations on 04/14/24 from 9:15 AM through 10:48AM revealed no other residents with bruising or injuries noted. <BR/>Interviews on 04/14/24 from 10:22 AM through 2:00 PM with CNA B, LVN C, Student Aide D, CNA G, CNA H, CNA I, RN J, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA T, CNA U, CNA V, LVN W, LVN X, LVN Y, LVN Z, Treatment Nurse, Medication Aide, ADON K, ADON L, HR Coordinator, Assistant BOM, Staffing Coordinator, Medical Records, Guest Relations Coordinator, Social Worker, Dietary Manager, Dietary A, Dietary B, Dietary D, Housekeeping Supervisor, Housekeeping A, Housekeeping B, Housekeeping C, Housekeeping D, Floor Tech, Respiratory Therapist A, Respiratory Therapist B, Occupational Therapist, and Maintenance Director who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM revealed the Staff were able to verify education was provided to them, nursing staff were able to accurately summarize what to do if a resident was found on the floor (witnessed or unwitnessed), if a resident has an injury that is new (bruise, skin tear, abrasion, laceration), fall prevention policy, and neuro checks (Charge Nurses Only). <BR/>The Administrator and DON were informed the Immediate Jeopardy was removed on 04/14/2024 at 2:15 PM. 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 isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all alleged violations involving neglect, which included injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents (Resident #1) reviewed for abuse and neglect.<BR/>1. Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. <BR/>2. The Administrator failed to report to HHSC after determining Student Nurse Aide A neglected Resident #1 by placing the resident back in bed and not notifying the charge nurse after she found Resident #1 on the floor in her room, and the resident was determined to have sustained significant bruising and injury to her face/head.<BR/>This deficient practice could affect any resident and contribute to resident neglect. <BR/>Findings included: <BR/>Review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. <BR/>Review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident rarely/never being understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices. MDS revealed Section J - indicated Resident #1 had had two or more falls. <BR/>Review of Resident #1's Care plan revised dated 04/12/24, revealed Focus: The resident had an actual fall r/t poor safety awareness, impulsive, impaired mobility. Goal: The resident will not sustain serious injury through review date. Interventions: Bed in lowest position. Anticipate and meet the resident's needs. Assist resident back to bed during night shift when she is ambulating and lethargic. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Bolster mattress cover to bed. Continue frequent redirection with resident in an attempt to reduce falls. Encourage resident to sit throughout the day to prevent lethargy. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. fall mat at bedside. Frequent visualization throughout the night to ensure resident safety and redirect as needed. Soft helmet when out of bed as resident tolerates to prevent head injury - refuses to wear.<BR/>Review of Resident #1's progress note documented by Physician dated 04/10/24 at 4:40 AM revealed Fall - Head injury. Plan: [AGE] year-old admitted to [Facility] on 9/8/2023 for rehabilitation and/or long-term care secondary to dementia. The patient has a medical history significant for dementia, diabetes mellitus, generalized anxiety, vitamin B12 deficiency hyperlipidemia and hypertension. <BR/>Plan:<BR/>1. Neuro checks as per protocol<BR/>2. Skulls Series<BR/>3. Contact DON/ADON to schedule care plan and root cause evaluation to establish what interventions are needed.<BR/>4. Hold anticoagulants, Plavix, Eliquis, Xarelto for three days if head injury visualized or suspected.<BR/>5. Consider need to send for labs if hypotensive, tachycardic or has altered mental status/increased impulsivity.<BR/>6. Order xray for relevant bony structures if patient has point tenderness/swelling on exam.<BR/>7. Tylenol 1000 mg po q8h prn pain for 72 hours.<BR/>Review of Resident #1's Event Nurses Note - Bruise dated 04/10/24 at 5:41 AM, revealed the following: Location event occurred - Unknown. Location of Injury: Right side of the forehead. Description: Blue/Purple, Unknown Origin. Nursing description of the event: Can reported that had a big purple bruise on the right side of the forehead.<BR/>Review of Resident #1's progress note documented by LVN B at 04/10/24 at 5:57 AM revealed the following: Cna reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified.<BR/>Review of Resident #1's Event Nurses Note - Fall dated 04/10/24 at 6:01 AM revealed the following: Location event occurred - Unknown. Unwitnessed, Hit Head. Injury - Bruise. Right side of forehead. Swelling Present, Blue/Purple. Cna reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified.<BR/>Review of Resident #1's Final X-Ray Report dated 04/10/24 at 15:14 [3:14 PM] revealed the following:<BR/>Examination: PELVIS, RIGHT SHOULDER, SKULL. Clinical Indication: Pain in right shoulder; pelvic and perineal pain; unspecified fall, initial encounter. <BR/>SKULL - Findings: There is no definite displaced or depressed calvarial fracture by plain film. Impression: No definite acute displaced or depressed calvarial fracture by plain film.<BR/>RIGHT SHOULDER - Findings: There is an old healed fracture of the proximal diaphysis of the right humerus. No acute fracture or dislocation is identified. Impression: No acute fracture is identified.<BR/>PELVIS - Findings: No acute fracture or dislocation. Impression: No acute osseous abnormality is seen.<BR/>Review of facility Incident Reported completed by DON, dated 04/12/24 revealed the following: Date of Incident: 04/10/24 5:47AM - Cna reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Conclusion: Resident observed on the floor by aide beside her bed. Large purple bruise noted to right side of forehead and eye as a delayed injury to fall. Interventions: Frequent visualization during evening and night hours as resident becomes restless. Psych to continue to evaluate and adjust meds as indicated. Resident refuses to allow helmet to be placed on her. Continue low bed and fall mat at bedside. <BR/>Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed, observed floor mats on each side of the bed. Resident #1 was covered up to her forehead, observed a swollen dark purple/blue bump to resident right side of her forehead/temple. Unable to observe Resident #1's full face. <BR/>Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Observed Resident #1 to have significant bruising to her right side of her face. The bruise started from Resident #1's forehead, spread all the way down to her neck and both eyes bruised. Resident #1 was not a good historian. Resident #1 was unable to recall fall, however, she denied any pain. Interview with Resident #1's Family Member revealed Resident #1 had a fall the night of 04/09/24 at 7:55 PM, she stated resident was on the floor until 4:33 AM. Resident #1's Family Member stated she had a camera in the resident room, she stated the camera footage were 6 seconds long and it only recorded by movement. Review of camera footage date stamped 04/09/24 at 19:40 [7:40 PM] revealed Resident #1 was lying in bed trying to get up, observed bed at low position. No observation of fall mat. Resident #1's bedside table, walker, and a chair on the right side of resident bed closed by. At 19:55 [7:55 PM] Resident #1 was on the floor lying on her right side. Camera footage did not show how the resident fell or if she hit herself and no sounds were made by the resident. Resident #1 was observed moving her head and left arm. At 21:46 [9:46 PM] it was observed a staff member with pink scrubs entered the room and left. It was heard in the camera footage the staff voicing while she was leaving the room at 21:46 [9:46PM] hey can you get the aide. At 21:58 [9:58PM] it was observed Resident #1 in bed. Camera footage does not show who or how Resident #1 was placed back in bed. Resident #1 was positioned horizontally on her right side and feet hanging from the bed. There was no movement in the room for camera to record from 21:58 [9:58 PM] to 4:17 AM Resident #1 was lying in bed vertical position. No observation of fall mat. At 4:33 AM a CNA was observed prepping to provide incontinent care to Resident #1 and Resident #1 was observed turning to her left side. Resident #1's Family Member stated she had a missed call from the facility on 04/10/24 at 4:59 AM and then within seconds she returned the call. She stated the facility nurse contacted her and notified her of the bruise noted. She stated the nurse asked her to review the cameras because they were not sure how Resident #1 sustained the bruise. She stated she reviewed the camera footage and noticed Resident #1 had the fall. Resident #1's Family Member stated she could not recall the name of the nurse who called her. She stated she had not been told much about the incident only that they had completed x-rays and results were fine.<BR/>Interview on 04/13/24 at 12:04 PM with LVN A revealed he was the charge nurse assigned to the secure unit. He stated Resident #1 bruise was noted the morning of 04/10/24 by the 10:00 PM-6:00 AM staff. He stated he believed Resident #1 had a fall the night of 04/09/24 unsure how; however, Resident #1 sustained a bruise to her right side of her forehead. He stated throughout the days the bruise began to spread all over Resident #1's right side of the face. He stated Resident #1 was a fall risk, he stated Resident #1 was able to ambulate on her own and they would provided Resident #1 with a wheelchair or a walker but Resident #1 refused to use them. LVN A stated they completed an x-ray on 04/10/24 with no findings. <BR/>Interview on 04/13/24 at 12:19 PM with CNA B revealed she was the assigned CNA for Resident #1. She stated the morning of 04/10/24 she came in for her shift at around 5:45 AM, she stated she was given report that Resident #1 had a bruise to her forehead, she stated resident had a fall during the 2:00 PM-10:00 PM shift and someone had picked her up. She stated she was not provided with much information. She stated Resident #1 was a fall risk. She stated when she completed her rounds the morning of 04/10/24, she was not able to see the bruise due to Resident #1 sleeping on her right side. She stated she could not recall the CNA who noticed the bruise.<BR/>Interview on 04/13/24 at 12:59 PM with LVN C revealed she was the nurse assigned to the secure unit on 04/09/24 from 2:00 PM-10:00 PM shift. She stated during her shift her CNAs were CNA H for the male side and another CNA for the female side but could not recall her name. LVN C stated her shift ended at around 11:30 PM. She stated the last time she observed Resident #1 on 04/09/24 was around 9:30 PM-10:00 PM, she stated Resident #1 was sleeping on her right side. She stated she did not observe any bruising to her face. She stated she was never notified by her CNAs that resident had a fall. She stated left her shift without being informed Resident #1 was found on the floor. LVN C stated by not reporting a fall to a nurse may delay treatment. <BR/>Interview on 04/13/24 at 2:29 PM with Student Nurse Aide A revealed she had been employed since November 2023. She stated she had been assigned to the secure unit twice. She stated the last time she had worked in the secure unit was on 04/09/24 from 2:00 PM-10:00 PM. She stated she was the CNA assigned to Resident #1 on 04/09/24. She stated she completed her rounds between 7:00 PM-7:30 PM, and Resident #1 was in bed sleeping. She stated when CNA G came in for her 10:00 PM-6:00 AM shift, CNA G was completing her rounds when she voiced Resident #1 was not in her room. She stated she began to look for her and then she returned to Resident #1's room and found Resident #1 on the floor. She stated she called for another staff to come assist her; however, it was the first time she observed a resident on the floor that the only thought that came to mind was to get her up. She stated she picked up the resident by herself. She stated Resident #1 did not complain of pain. She stated once she placed Resident #1 in the bed, she went to the hall and observed CNA G. She stated she notified CNA G that Resident #1 was on the floor, and she picked her up and left for her shift around 10:00 PM. She stated she did not notify the nurse because she thought CNA G was going to notify the nurse. She stated the next morning on 04/10/24 she was called by the ADON asking her if Resident #1 had a fall. She stated she was told Resident #1 sustained a bruise to her forehead. She stated her mistake was not notifying the nurse. She stated her mistake was considered neglect because she failed to notify the nurse. She stated she had completed training on relias but could not recall any other in-services on falls. She stated she was in-serviced after the incident to not move the resident and to notify the nurse. She stated the potential risk of moving a resident after a fall could cause serious injuries and the risk of not notifying the nurse could delay treatment. <BR/>An attempt was made on 04/13/24 at 2:57 PM to contact CNA E by phone; however, there was no response. <BR/>Interview on 04/13/24 at 3:02 PM with LVN F revealed he was the nurse assigned to Resident #1 the night of 04/09/24 from 10:00 PM-6:00 AM. He stated he completed his round every 2 hours; he stated Resident #1 was sleeping on her right side throughout the night and they were not able to observe the bruise. He stated at around 4:00 AM 4:30 AM CNA E assigned to the hall notified him that Resident #1 had a bruise on her forehead, he stated he immediately assessed her and notify the Administrator. He stated he could not see any documentation regarding a fall or the bruise. LVN F stated they spoke to CNA G and CNA G had stated that Resident #1 had a fall during the 2:00 PM-10:00 PM shift but was unaware if the Student Nurse Aide had notified the nurse. LVN F stated he notified the doctor and family. He stated he had asked Resident #1 Family Member to review the camera footage to see if Resident #1 had a fall. LVN F stated the doctor ordered x-rays and to monitor the bruise. LVN F stated staff failed to report Resident #1 fall which delayed treatment.<BR/>Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the assigned CNA for Resident #1 on 04/09/24 from 10:00 PM-6:00 AM for about 20 minutes. She stated on 04/09/24 closed to 10:00 PM she began her rounds; she stated she passed by Resident #1 room and Resident #1 was not in her bed. She stated she notified Student Nurse Aide A that Resident #1 was not in her bed, she stated she completed her rounds while Student Nurse Aide A looked for Resident #1. CNA G stated she was not sure the what the Aide's name was. She stated when she completed her rounds, the Student Nurse Aide informed her that she had found Resident #1, when she asked her where, Student Nurse Aide told her that Resident #1 was on the floor and that she had picked her up. CNA G stated when she was going to go check on Resident #1, she was called by another nurse to go 100 Hall. CNA G stated she never observed Resident #1 the night on 04/09/24. She stated she never asked the Student Nurse Aide if she had notified the nurse. CNA G stated she did not follow up on Resident #1. CNA G stated around 5:00 AM, she was asked by CNA E if she had observed Resident #1 bruise. She stated she notified CNA E and LVN F that the 2:00 PM-10:00 PM Student Nurse Aide A had told her Resident #1 had a fall but was unsure if Student Nurse Aide A had notified the nurse. CNA G stated after she was asked about the fall it clicked on her and stated she should had followed up with the nurse. CNA G stated the risk of picking up a resident without being assess by a nurse could cause a serious injury and by not notifying the nurse could delay treatment.<BR/>An attempt was made on 04/13/24 at 4:00 PM to contact CNA E by phone; however, there was no response.<BR/>Interview on 04/13/24 at 4:32 PN with the DON revealed Resident #1 had a fall the night of 04/09/24. The DON stated she was unsure how everything happened. She stated she was notified on 04/10/24, that Resident #1 had bruising to her right side of the face. She stated they spoke to Student Nurse Aide A, and she told them that she had found Resident #1 on the floor unknown of the time and that she picked her up. She stated she spoke to CNA G and CNA G stated that Student Nurse Aide told her that Resident #1 was found on the floor and that the Student Nurse Aide had picked her up. The DON stated the Student Nurse Aide failed to notify the charge nurse of Resident #1 being on the floor and picked her up without being assessed first. The DON stated they completed 1:1 in-serviced with Student Nurse Aide on fall prevention, and reporting. The DON stated the Administrator was responsible for reporting to the State and if the Administrator was not here it was her responsibility to report. She stated the Student Nurse Aide did failed to report to the nurse; however, this incident was not something that needed to be reported to the state. <BR/>Interview on 04/13/24 at 4:48 PM with the Administrator revealed Resident #1 had a fall on 04/09/24, and she was notified about the fall on 04/10/24. She stated she was told Resident #1 had a fall in her room and that Student Nurse Aide A transferred Resident #1 back into bed. She stated on 04/10/24 during morning stand up they found out that Student Nurse Aide A failed to notify the nurse Resident #1 had a fall and that she helped the Resident #1 back up without being assessed. She stated Student Nurse Aide A was in-serviced after the incident. She stated Student Nurse Aide A should had reported the incident; however, she made a mistake and forgot to notify the nurse.<BR/>Review of Student Nurse Aide's personnel file revealed the following forms: <BR/>Student Nurse Aide completed fall prevention training and completed the fall prevention test. Fall Prevention test dated 11/15/23, reflected one of the test questions was regarding, Once you have ensured the person's safety when discovering a fall, what is the next step? Student Nurse Aide responded: Notify the Charge Nurse.<BR/>Coaching Form - dated 04/10/24: Situation: Staff failed to report a fall.<BR/>Student Nurse Aide statement I [name] was making my last round w/ the aide that was working 10-6. We noticed [Resident #1] wasn't in her bed, we went checking other rooms and that's when I went back in and seen [Resident #1] on the floor as if she missed trying to sit on the bed. The first thing I did was help her off the floor onto the bed. I then asked the other aide to help me put her on the bed the right way. She said she's okay and will fix her later. I did not tell the nurse I thought maybe she would've reported it. My mistake.<BR/>Record review of the facility Abuse/Neglect policy, revised date 03/29/18 revealed the following: <BR/>The resident has the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. <BR/>Adverse Event: An adverse event is an untoward, undesirable, and usually unanticipated even that causes death or serious injury, or the risk thereof. <BR/>Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.<BR/>Reporting: If the allegations involve abuse or results in serious bodily injury, the report is to be made within 2 hours of the allegation. <BR/>If the allegations does not involved abuse or serious bodily injury, the report must be made within 24 hours of the allegations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 of 3 residents (Residents #1) reviewed for supervision. <BR/>The facility failed to ensure Resident #1, who had severe cognitive impairment and resided on the secure unit, received adequate supervision to prevent her from wandering into the facility's enclosed courtyard without staff knowledge and being left outside for approximately 3 hours while it was raining. The facility failed to ensure the door that led to the enclosed courtyard was locked or supervised, when the door's locking mechanism lost power during the storm. <BR/>The noncompliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began on 04/01/24 and ended on 04/02/24. The facility had corrected the noncompliance before the survey began. <BR/>This failure placed residents at risk of harm and/or serious injury.<BR/>Findings included: <BR/>Review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. <BR/>Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident is rarely/never understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices. <BR/>Review of Resident #1's care plan, dated revised 04/03/24, reflected: Focus: The resident wanders throughout the day and night. Goal: Resident will demonstrate happiness with daily routine through the review date. Resident safety will be maintained through review date. Interventions: Assess for fall risk. Disguise exits: cover door knobs and handles, tape floor. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. The resident will reside in the secure unit.<BR/>Focus: Resident is at risk for elopement as evidenced by impaired safety awareness, attempts at leaving facility, pulling and banging on doors in an attempt to leave the secured unit. Goal: [Resident #1] will remain safe within facility unless accompanied by staff or other authorized person through review date. Intentions: Supervise closely and make regular compliance rounds whenever resident is in room. If the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. <BR/>Focus: Resident resides in the SecureCare Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Memory loss. Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the SecureCare Unit. Interventions: Admit to SecureCare unit per MD orders. Engage resident in group activities and provide them with individualized meaningful projects that they will accomplish throughout the day.<BR/>Review of Resident #1's Elopement Risk Assessment dated 03/11/24 revealed Resident #1 resided in the secure unit; Cognitive skills for daily decision making - severely impaired -never/rarely made decision; history; one or more times in last week; Behaviors - Restlessness (pacing, wandering or rummaging). <BR/>Review of Resident #1's Elopement Risk Assessment dated 04/02/24 revealed Resident #1 resided in the secure unit; Cognitive skills for daily decision making - severely impaired -never/rarely made decision; history; one or more times in last week; Behaviors - Restlessness (pacing, wandering or rummaging). <BR/>Review of Resident #1's progress notes by LVN AB on 04/02/24 at 00:57 revealed the following: Resident missing from the unit, later found lying on the ground in the courtyard, no bruise/injury noted on full assessment, no pain verbalized in full range of motion, Resident assisted up in w/c, taken to the shower room, given warm bath, assisted to bed, covered with warm blanket, M/d family notified.<BR/>Review of Resident #1's progress notes by DON on 04/02/24 at 11:30 revealed the following: Note Text: DON went to secured unit to re-assess resident and ensure no injury r/t resident being observed on the grass beside the sidewalk in the courtyard on the night of 4/1/24. Resident was observed on the couch in the tv room sleeping. Resident stated to staff that she was not having pain, but would not stand from the couch to allow DON to fully assess her. CNA that gave resident shower on 4/1/24 stated she did not see any new injury related to this incident, there are some healing bruises noted to resident's skull from prior fall and scattered bruises to BUE from resident wandering and her unsteady gait. DON could assess BUE, back, abdomen, and BLE up to her knees; no new injuries noted. Will remain available to resident and staff.<BR/>Review of facility Provider Investigation Report dated 04/05/24 revealed the following: Incident Category: Neglect; Incident Date 04/01/24; Time of Incident: 8:30 PM; Location of Incident: Resident out into courtyard; Description of the Allegation: Resident was not accounted for during walking rounds by nurses at shift change. Assessment: Date 04/01/24 at 11:30PM by LVN F; No noted injuries or behavioral changes from baseline. Head to toe assessment was completed. Xrays and labs ordered along with CT Scan out of the facility. All residents were counted visually as staff continued with the missing resident protocol. All xrays and CT Scan were negative for any new fractures. Investigation Findings: Confirmed; Provider Action Taken post-investigation: Abuse and neglect in serviced completed; missing resident protocols inserviced and drills completed and will continued to monitor and perform drills. Door was checked by outside vendor and I secure; door codes changed. <BR/>Review of Resident #1's Final X-Ray Report completed 04/02/24 revealed no acute fractures or dislocations. <BR/>Review of Resident #1 Ct Head Without Contrast completed 04/04/24 revealed no acute intracranial abnormality. <BR/>Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed, observed floor mats on each side of the bed. Resident #1 was covered up to her forehead, observed a swollen dark purple/blue bump to resident right side of her forehead/temple. Unable to observed Resident #1 full face.<BR/>Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Resident #1 was not a good historian. Resident #1 unable to recall going outside, however, she denied any pain. Interview with Resident #1 Family Member revealed she was notified of Resident #1 leaving the secure unit and being outside the enclosed courtyard. She stated Resident #1 wandered around and walked all over the secure unit. Resident #1's Family Member stated they completed x-rays and CT scans were done with no negative results. <BR/>Review of the facility's surveillance footage dated 04/01/24 at 18:26 [6:26 PM] revealed Resident #1 walking towards the secure unit living room area. Observed double doors being closed. Resident #1 opened the living room area door and was walking towards the courtyard door. However, since the camera was not facing the door, it was not captured when Resident #1 opened and exited the door. <BR/>Interview on 04/13/24 at 1:08 PM with the Administrator revealed the date stamp in the camera footage was off. She stated the time was not correct. The Administrator stated she received a call at around 10:00 PM on 04/01/24 stating that Resident #1 was missing. She stated she contacted the Maintenance Director and asked him to review the camera footage. She stated she arrived at the facility at around 10:30 PM and she received a call from the Maintenance Director telling her to look in the enclosed courtyard. She stated Resident #1 was found around 11:00 PM. She stated the 2:00 PM-10:00 PM LVN was LVN AB and the 10:00 PM-6:00 AM was LVN F. The Administrator stated CNA S placed Resident #1 in bed at 7:20PM and Resident #1 got up and began to walk around the secure unit. She stated the enclosed courtyard had a door code, and it was unknown how Resident #1 was able to open the door. She stated the night of 04/01/24, it was raining and the light flickered and they believe that in that moment when the light [NAME] Resident #1 open the door. She stated when Resident #1 was found outside, she was laying on the floor, and Resident #1 was damped (slightly wet). She stated they gave Resident #1 a warmed bath and no injuries were noted. She stated X-rays and CT were completed and results were negative. <BR/>Observation and interview on 04/13/24 at 1:20 PM of Secure Unit courtyard door with Maintenance Director revealed the door was closed, was unable to be opened without the code. Observed Maintenance Director punch in the door code and door open. Observed additional alarm added to the door; alarm was heard and it was loud. Maintenance Director stated he received a call at around 10:30PM the night of 04/01/24 form the Administrator. He stated he was asked to check the camera footage and he observe Resident #1 walking in the living room toward the courtyard door. He stated the camera was not facing the door so it was unknown how Resident #1 was able to open the door. The Maintenance Director stated the time on the camera footage was off and they cannot go by the time the camera footage was stamped. He stated he notified the Administrator around 11:00 PM to check the enclosed courtyard. He stated the courtyard door needs a code to open it, he stated the night of 04/01/24 it was raining and CNA G stated the lights were flickering. He stated when the light [NAME] they believed that was the time Resident #1 was able to open the door. The Maintenance Director stated since the incident they had in serviced all staff on elopement/missing person, the staff were checking doors every 15 minutes starting from 04/02/24 through 04/11/24. He stated they completed elopement drills on 04/02/24, 04/07/24 and will continue randomly. He stated they had the alarm company come out on 04/02/24 to check the doors, they implemented an additional alarm on the door and door codes would be changed monthly. He stated the alarm company came out and stated due to the light flickering the magnet on the door detached and did not grip on time. He stated they replaced the door closure with a stronger spring. <BR/>Interview on 04/13/24 at 2:05 PM with LVN AB revealed he was the nurse assigned on the secure unit and was the nurse for Resident #1 on 04/01/24 from 2:00 PM-10:00 PM. LVN AB stated Resident #1 was able to ambulate on her own without assistance. He stated Resident #1 was known to wander around. He stated on 04/01/24, the last time he observed Resident #1 was between 7:00 PM-8:00 PM when he provided her with her night medications. He stated during shift change at 10:00 PM he was notified by incoming night staff that Resident #1 could not be located. He stated they began to look for Resident #1 in each room, closets, restroom, dining area, living room and all around the secure unit. He stated they notified the Administrator and the Administrator contact the Maintenance Director for him to review camera footage. He stated at around 10:45 PM close to 11:00PM, Resident #1 was found outside in the courtyard lying on the grass. He stated the courtyard door only opened with a code. He stated he did not know how Resident #1 was able to open the door. He stated he could not remember any lights flickering and denied hearing an alarm. He stated Resident #1 was slightly wet due to the rain. He stated they brought Resident #1 inside and gave her warm bath. LVN AB stated Resident #1 did not sustain any injuries. He stated Resident #1 was her normal self and could not recall the event. <BR/>Interview on 04/13/24 at 2:58 PM with LVN F revealed he was the incoming nurse for the 10:00PM-6:00AM shift on 04/01/24. He stated he was completing his rounds and he was not able to locate Resident #1. He stated it was a little after 10:00PM when they were not able to locate Resident #1. He stated he contacted the Administrator to notify her Resident #1 was not able to be located after looking everywhere in the secure unit. He stated he told the Administrator to look at the video footage starting from 8:00PM. He stated the Maintenance Director was able to look at the camera footage and the Maintenance Director told them to look in the courtyard. LVN F stated they found Resident #1 outside in the enclosed courtyard. LVN F stated he could not recall the time Resident #1 was found. He stated Resident #1 was provided with a warm bath and no injuries were noted. LVN F stated no one goes into the enclosed courtyard. He stated the door had a code and it was unknown how Resident #1 was able to open it. <BR/>Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the incoming CNA assigned to the secure unit on 04/01/24 from 10:00 PM-6:00 AM. She stated she was completing her rounds closed to 10:00PM when she asked the 2:00 PM-10:00 PM aide where Resident #1 was. She stated she could not recall who the aide was. She stated when she asked the aide, the aide told her Resident #1 was here somewhere but not sure where Resident #1 was. She stated she notified LVN F and they began searching for Resident #1. She stated the nurses notified the Administrator and within 30-45 minutes Resident #1 was found outside in the enclosed courtyard. CNA G stated the night of 04/01/24 it was raining. She stated she did not know if the door was open or closed; however, to open the courtyard door they needed a code. She stated no one went out to the enclosed courtyard. She stated the secure unit had another courtyard that they use. She stated Resident #1 was given a warm bath and no injuries were noted. <BR/>Interview on 04/13/24 at 3:53 PM with CNA S revealed she was the CNA assigned to Resident #1 on 04/01/24 from 2:00PM- 10:00PM. She stated on 04/01/24 she had placed Resident #1 in bed at around 7:00PM - 7:15PM; however, Resident #1 got up again and began to walk around. She stated she left her shift at around 9:45PM close to 10:00PM. She stated she last time she observed Resident #1 was on the hallway; however, she could not recall the time. CNA S stated she did not hear any alarms go off. She stated they did not use the enclosed courtyard. She stated they had another courtyard normally used. She stated the enclosed courtyard door needed a code to open and it was unsure how Resident #1 opened it. She stated she did not recall any lights flickering; however, it was raining outside. <BR/>Interview on 04/13/24 at 4:32 PM with the DON revealed the night of 04/01/24 Resident #1 went missing in the secure unit. She stated she began her investigation on 04/02/24. She stated she spoke to CNA S and CNA S stated she had placed Resident #1 in bed around 7:30PM and Resident #1 got up from bed and was walking around the secure unit. She stated LVN AB stated he last observed Resident #1 when he provided resident with her night medications between 7:00PM-8:00PM. She stated at around 10:00PM during shift changed they noticed Resident #1 could not be located. The DON stated Resident #1 was found in the courtyard laying on the grass around 10:30PM. She stated the night of 04/01/24, it was raining and CNA S reported the lights were flickering and they believed during the time the lights [NAME] was when Resident #1 open the enclosed courtyard door. The DON stated the courtyard door needed a code to be opened. She stated she did not even know the code to the door. She stated no one used the enclosed courtyard. She stated when she was investigating the incident, she tried to open the courtyard door without the code and the door would not open. She stated they changed the door code and it would be changed monthly. She stated they implemented a new alarm on the door, they in-serviced all staff on elopement/missing person, staff would check the doors q15 , and alarm company came out to check the doors. She stated Resident #1 had no injuries and her behavior was her normal. She stated they completed x-rays and CT scan without no findings. <BR/>Follow-up interview on 04/13/24 at 4:48 PM with the Administrator revealed they in-serviced all staff on missing person, they conducted missing person drills which consist of getting a volunteer resident and having staff search for that resident. She stated had the alarm company come out and implemented a new alarm and will be changing the door alarm every month. She stated the alarm company came out and stated due to the light flickering the magnet on the door detached and did not grip on time. <BR/>Record review of the facility's Elopement Response policy and procedure, revised January 2023, reflected the following: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented.<BR/>4. Should an employee discover the resident missing from the facility (Code Orange) .<BR/>Record review of the facility's Elopement Prevention policy and procedure, revised January 2023, reflected the following: Every effort will be made to prevent elopement episode while maintaining the least restrictive environment for residents who are at risk of elopement.<BR/>This was determined to be a Past Non-Compliance Immediate Jeopardy on 04/13/24 at 7:20 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/13/23 at 7:20 PM.<BR/>The facility took the following actions to correct the non-compliance prior to the survey:<BR/>Record review of the following in-services dated 04/02/24 Elopement Response, Elopement Prevention and Code Orange. In-service reveal all staff completed the training. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM. <BR/>Review of Resident #1's Elopement Risk Assessment completed on 04/02/24; Resident #1 resided in the Secure unit. <BR/>Door codes on 500 Hall unit changed on 04/03/24. Replaced door with closure with a stronger grip. Added additional alarm to exit door to courtyard. Alarm installed made louder upon opening without code and or left ajar. <BR/>Observation on 04/13/24 at 1:20 PM revealed exit door on the secure unit courtyard door was checked with the Maintenance Director and door was functioning properly. There was an additional louder alarm added so they could be heard throughout the facility if the doors did not latch after being open. <BR/>Interviews on 04/13/24 from 12:04 PM through 5:00 PM with LVN A, CNA B, CNA M, LVN C, LVN AB, Student Nurse Aide, CNA G, CNA H, LVN F, CNA S, CNA AC, CNA AD, CNA O, RN J, Treatment Nurse, ADON L who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM - 6:00 AM revealed they were able to verify education was provided to them. Nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, missing person drills, and door checks.<BR/>Interview on 04/14/24 from 10:22 AM through 2:00 PM with CNA I, CNA Q, HR Coordinator, LVN W, LVN X, Guest Relations Coordinator, ADON K, LVN Y, CNA U and CNA V who work the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM revealed they were able to verify education was provided to them, nursing staff were able to accurately summarize missing person/elopement policy, missing/elopement code, missing person drills, and door checks.<BR/>Record review of the Facility's Door Checks date 04/02/24 at 2:00 PM through 04/11/24 door checks were completed every 15 minutes<BR/>Record review of the facility's Elopement Drills or Actual Elopement Guide revealed drills were conducted on 04/02/24 and 04/07/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 7 (Resident #8, Resident #12, Resident #3, Resident #44, Resident #81, Resident #24, and Resident #62) of 114 residents reviewed for call lights. <BR/>The facility failed to ensure Resident #8, Resident #12, Resident #3, Resident #44, Resident #81, Resident #24, and Resident #62's call buttons were within reach. <BR/>This failure could place residents at risk for decreased quality of life, self-worth, and dignity.<BR/>Findings included:<BR/>Review of Resident #8's face sheet dated 07/13/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease; Major Depressive Disorder; Unspecified Lack of Coordination; and Other Abnormalities of Gait. <BR/>Review of Resident #8's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #8 required supervision to extensive assistance with ADLs. <BR/>Review of Resident #8's Comprehensive Care Plan revised 07/12/23 reflected Resident #8 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 9:55 AM revealed Resident #8 was in her bed and her call light was hanging across the trash can near the wall between the bed and bedside nightstand. Resident #8 was sleeping.<BR/>Review of Resident #12's face sheet dated 07/13/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following cerebral Infarction Affecting Left Non-Dominant Side (defined as paralysis of partial or total body, whereas hemiparesis is characterized by on-sided weakness, but without complete paralysis); Contracture, Left Wrist; Contracture, Left Hand; Contracture, Left Ankle (a contracture is a fixed tightening of muscle, tendons, ligaments, or skin).<BR/>Review of Resident #12's MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired. Resident #12 required total dependence to extensive assistance with ADLs. <BR/>Review of Resident #12's Comprehensive Care Plan revised 07/07/23 reflected Resident #12 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 9:57 AM revealed Resident #12 was in her bed and her call light was under her bed. Interview with Resident #12 revealed she spoke Spanish but understand what the call button was and made a hand motion that she did not have her call button.<BR/>Review of Resident #3's face sheet dated 07/13/23 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbances, Mood Disturbances, and Anxiety; Unspecified Lack of Coordination; Unsteadiness on Feet; Other Abnormalities of Gait and Mobility.<BR/>Review of Resident #3's MDS assessment dated [DATE] reflected the resident's memory was moderately impaired. Resident #3 required supervision to limited assistance with ADLs. <BR/>Review of Resident #3's Comprehensive Care Plan revised 05/26/23 reflected Resident #3 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 10:02 AM revealed Resident #3 was in his bed sleeping and the call light was stuck under his mattress where the resident could not reach call light. <BR/>Review of Resident #44's face sheet dated 07/13/23 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Parkinson's Disease; Abnormal Posture; Repeated Falls; Difficulty Walking, Not Elsewhere Classified; Unspecified Dementia, Severe, With Other Behavioral Disturbance.<BR/>Review of Resident #44's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #44 required limited assistance to total dependence with ADLs. <BR/>Review of Resident #44's Comprehensive Care Plan initiated 06/29/23 reflected Resident #44 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 1:30 PM revealed Resident #44's call light was clipped to the back of the privacy curtain out of reach. <BR/>An interview with on 07/11/23 at 1:30 PM with Resident #44 in his room revealed that he could not safely reach his call light clipped to back of the privacy curtain. Resident was in his wheelchair beside his bed. Call light was clipped to privacy curtain near the nightside, wall, above wheelchair height, and out of reach.<BR/>Review of Resident #81's face sheet dated 07/13/23 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Severe with Other Behavioral Disturbances; Unspecified Lack of Coordination; Repeated Falls; Unsteadiness on Feet.<BR/>Review of Resident #81's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #81 required partial/moderate assistance to total assistance with ADLs. <BR/>Review of Resident #81's Comprehensive Care Plan revised 06/02/23 reflected Resident #81 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 10:04 AM revealed Resident #81 was currently in her bed asleep and call light was out of reach between the bed and wall. <BR/>Review of Resident #24's face sheet dated 07/13/23 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity with Psychotic Disturbances; Contracture of Right Knee; Contracture of Right Ankle; Contracture of Left Ankle; Contracture of Left Hand; Other Lack of Coordination; Other Abnormalities of Gait and Mobility.<BR/>Review of Resident #24's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #24 required supervision to substantial max assistance with ADLs. <BR/>Review of Resident #24's Comprehensive Care Plan revised 04/26/23 reflected Resident #24 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation and interview on 07/11/23 at 10:30 AM with Resident #24 revealed Resident #24 was in her bed and her call light was under her bed. Interview with the resident revealed she could use her call light if it was within reach.<BR/>Review of Resident #62's face sheet dated 07/13/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Acute Respiratory failure with Hypoxia (defined as an absence of enough oxygen in the tissues to sustain bodily functions); Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery (defined as a middle cerebral artery of the brain is suddenly interrupted (ischemia) or altogether stopped (infarction).<BR/>Review of Resident #62's MDS assessment dated [DATE] reflected the resident's memory reflects decisions consistent and reasonable. Resident #62 required supervision to limited assistance with ADLs. <BR/>Review of Resident #62's Comprehensive Care Plan revised 06/06/23 reflected Resident #81 was a risk for falls r/t impaired balance. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 10:38 AM revealed Resident #62 was in her bed and her call light was under her bed. Interview with the resident revealed she did not want her call light at that time.<BR/>In an interview on 07/11/23 at 11:32 AM with RN A revealed she was not aware of the call lights were not within reach for the residents on Hall 1. RN A was asked what problems could develop if resident did not have the call light within reach and RN A stated the resident may be in pain and need medication, may try, and get up to go to the bathroom and fall, may have a medical emergency that needs attention. RN A would inform the CNAs.<BR/>In an interview on 07/11/23 at 11:37 AM with CNA B revealed she did not know the call lights were on the floor. CNA B was asked what could happen if call light was not within reach of resident who needed assistance and CNA B revealed a resident could try and get up and fall, may be sick and need assistance, or may just need water. CNA B revealed she would make sure all call lights were within reach. Asked CNA who is responsible to make sure call lights are within reach, and she replied, the CNAs.<BR/>Requested a policy for Call Lights from ADM at 4:00 PM on 07/12/23. <BR/>In an interview on 07/13/23 at 11:15 AM, the ADM revealed the facility did not have a policy for Call Lights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 1 of 23 residents (Resident #97) reviewed for ADLs. <BR/>The facility failed to provide Resident # 97 with showers/bed baths on a consistent basis. <BR/>This failure could place residents at risk for poor personal hygiene and a decline in their quality of life and health status.<BR/>Findings included: <BR/>Record review of Resident #97's electronic face sheet, dated 07/13/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #97 had diagnoses which included anoxic brain damage (no blood flow to brain tissue), chronic respiratory failure with hypoxia (oxygen is not available in sufficient amounts), tracheostomy status (has an opening through neck into the trachea to allow air to fill the lungs), gastrostomy status (has an opening into the stomach for feeding through a tube), and dependence on respiratory [ventilator] status. The electronic face sheet also revealed Resident # 97 was in a B bed. <BR/>Record review of Resident #97's MDS assessment, dated 06/07/23, revealed Resident #97 was comatose (in a state of deep unconsciousness for a prolonged or indefinite period), Further review revealed section G0120. Bathing indicated code 4 (Total dependency), which meant full staff performance every time during entire 7-day period. Resident # 97 was not on hospice. <BR/>Record review of Resident #97's bathing ADLs in her electronic medical record revealed Resident # 97 was supposed to get a bath Mondays, Wednesdays, and Fridays on the 6am to 2pm shift. The bathing task record revealed Resident #97 received a bath on 6/23/23, 7/10/23 and 7/12/23 within a 30-day look back period. Resident # 97 missed a total of 10 showers within the lookback period. One of the 10 days there was no documentation at all (6/30/23). For nine of the 10 days it was documented that activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity. The dates of missed baths were as follows: 6/14/23, 6/16/23, 6/19/23, 6/21/23, 6/26/23, 6/28/23, 7/3/23, 7/5/23, and 7/7/23.<BR/>Observation on 07/11/23 at 10:37AM revealed Resident # 97 was non-interviewable.<BR/>In an interview on 7/12/23 at 9:59 AM with a family representative it was revealed Resident # 97 did not receive bed baths on weekends and was typically found with dirty armpits and ears when the family would visit. <BR/>In an interview on 7/13/23 at 10:42 AM the ADON revealed the aides documented in their POC (electronic system used by aides for charting) and that was the same reflected in the electronic medical record under tasks for residents. The ADON stated the aides did not use shower sheets in addition to the electronic documentation. The ADON stated family members did not do baths or showers for residents. She stated it was either the facility staff or if a resident was on hospice, hospice staff would do their baths. <BR/>In an interview on 7/13/23 at 10:50 AM CNA C revealed she normally worked 6am to 2pm shift. CNA C revealed that Resident # 97 was scheduled for a bath on the evening shift. CNA C revealed that residents in the A beds were morning shift baths and B beds were evening shift baths. CNA C stated the aides documented the baths in only one place in POC. CNA C stated that if a bath was marked as activity did not occur it meant that it did not happen. <BR/>In an interview on 7/13/23 at 11:15 AM the ADM stated most of the time A bed was a 6AM -2 PM shift shower and B bed was a 2PM to 10PM shift shower unless a resident had a preference. <BR/>In an interview on 07/13/23 at 11:17 AM the ADON stated Resident # 97 was previously on a different hall where her bath was scheduled for Mondays, Wednesdays and Fridays on the 6AM to 2PM shift. ADON stated when Resident # 97 moved to her current hallway her shower schedule should have been changed to Tuesdays, Thursdays and Saturdays on the 2PM to 10PM shift. The ADON stated when she went to print the ADL documentation for Resident # 97, she noticed that and had just fixed it. The ADON stated it was not popping up for the aides to document a bath for Resident # 97 and that was why per documentation it only appeared Resident # 97 had three baths in the past month.<BR/>In an interview on 07/13/23 at 11:24 AM the ADON stated she knew the rule that said if it was not documented it was not done. <BR/>Record review of the facility's policy titled, Bath, Tub/Shower, dated 2003, reflected The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #12) of five residents reviewed for feeding tube (a process of providing nutrition directly to the stomach). The facility failed to ensure LVN C checked Resident #12's g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) placement and residual before administering the resident's medications and failed to administer the resident's medication one by one on 07/12/2025. These failures could place residents with g-tubes at risk for aspiration and drug-to-drug interaction. Findings included: Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #12's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #12's Quarterly Care Plan, dated 05/12/2025, reflected the resident required tube feeding and one of the interventions was to check for tube placement and gastric contents/residual volume. Record review of Resident #12's Physician Order, dated 06/11/2025, reflected every shift start continuous enteral feeding. Formula: Diabetasource; Rate: 65ml/hr, flush 200 ml H2O q 4 hrs. Record review of Resident #12's Physician Order, dated 04/04/2025, reflected every shift check placement prior to feeding and medication administration. Record review of Resident #12's Physician Order, dated 04/04/2025, reflected every shift check residual before medications and feedings; return contents after each check. Record review of Resident #12's Physician Order, dated 06/25/2025, reflected Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) *Controlled Drug* Give 1 tablet via PEG-Tube (a flexible feeding tube inserted directly to the stomach) every 6 hours for pain, hold for sedation. Record review of Resident #12's Physician Order, dated 06/25/2025, reflected Docusate Sodium Oral Tablet 100 MG (Docusate Sodium) Give 1 tablet via PEG-Tube every 24 hours as needed for constipation. Record review of Resident #12's Physician Order on 07/12/2025 reflected no order that her medications could be cocktailed (could be given altogether at the same time). Observation and interview on 07/12/2025 at 10:38 AM revealed LVN D was preparing Resident #12's medication on his cart. LVN D said he wound administer the resident's 11:00 AM medication. He went inside the room with one small plastic cup with crushed medications in it and a big plastic cup with some water in it and placed them on the resident's overbed table. When inside the room, he incorporated some water on the small cup to dissolve the crushed medications. LVN D sanitized his hands and put on a pair of gloves. He took a 60 ml piston syringe from the resident's side table and placed it also on the overbed table. He raised the bed, lifted the resident's gown to expose the g-tube site. He pulled the plunger of the syringe, attached the syringe to the g-tube, and flushed the g-tube. After flushing the g-tube, he poured the dissolved medication. He did not check for the placement of the g-tube and the gastric content before flushing and administering the medication. After pouring the medications, he flushed the g-tube, and detached the syringe. He cleaned the syringe, took off his gloves, and sanitized his hands. In an interview on 07/12/2025 at 10:51 AM, LVN D stated he forgot to check for the g-tube placement and to check the residual of both residents. He said the right procedure was to check the placement and the residual every medication administration. He said g-tube placement was checked to ensure the tube was correctly positioned. He said the residual was also checked before administering medications to check if the stomach could accommodate the medications and fluid to be given and to prevent aspiration. He said he knew he needed to check for the placement and residual but failed to do so because he was nervous. He said he administered Resident #12's midday medications, which were oxycodone and docusate. He said he crushed the medications and put them both in a single cup. He said he was not sure if the resident had an order that would say her medications could be cocktailed. He said if there was no order to cocktail, then the medications should have been administered one by one. He said the reason for giving one by one was to prevent drug-to-drug interaction or drug-to-formula interaction that could impede the medication's effectiveness. In an interview on 07/12/2025 at 3:33 PM, ADON A stated both the gastric residual and the g-tube placement should be checked before administering the medications. She said g-tube placement should be checked to ensure the g-tube was in the right place. She said even though the residents were on continuous feeding, the placement should still be checked. She said the gastric residual was also checked to prevent aspiration and also to assess if the rate of the formula should be modified. She said the expectation was for the staff to check for g-tube placement and to check for gastric residual every time they administer medications. She said there were two ways to check for placement, one would be through auscultation and the other one was through aspiration of the gastric content. She said the second one could be used to check for placement and at the same time to check for the residual. She said if there was no order that the medications could be mixed, then the medications should be given one at a time to ensure there were no interactions between the drug. She said, as one of the ADONs, she was responsible in ensuring that the staff were following the procedures in administering medications via g-tube. She said she already started an in-service about g-tube as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if they do not understand something about the in-service. She said aside from the in-service, they would randomly check the staff's medication administration via gtube. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the issues pertaining to g-tube and ADON A already started an in-service relating to g-tube. She said the expectation was for the staff to follow the right procedures in administering medications via g-tube. She said she was not a clinician but she would coordinate with the DON to continually remind the staff about providing proper care for residents with g-tube. In an interview on 07/14/2025 at 1:00 PM, the DON she already knew about the incidents of not checking the placement of the g-tube and not checking for the residual. She said the placement should be checked to ensure the medications and the fluid would enter the stomach and not the lungs that could cause aspirations. She said the gastric residual should be checked before medication administration to assess if the resident's stomach was emptying properly. She said the medications should be given one at a time, if there was no order to cocktail them, so that if there were reactions, they could pinpoint what medication were causing the reactions. She said the expectation was for the staff to follow the right procedure for medication administration via g-tube. She said ADON A already started the in-service about g-tube but she would still do a one-on-one in-service with all the staff and would make sure that they understood the in-service that they were signing. Record review of the facility's policy ENTERAL (food or medication administration directly through the digestive system) MEDICATION ADMINISTRATION Pharmacy Policy & Procedure Manual revised 01/25/2013 revealed 6. Check the placement of the tube by aspiration of contents or auscultation . 8. Administer one medication at a time. Record review of the facility's policy Gastrostomy Tube Care Nursing Policy & Procedure Manual revised February 13, 2007 revealed Procedure . 7. Perform intermittent feeding . b. Aspirate gastric contents with a 60 ml syringe and if the residual is less than 50%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for one (Resident #487) of 2 residents reviewed for intravenous fluids.<BR/>The facility failed to ensure Resident #487 received PICC line orders to manage, access, flush, and perform dressing changes since admission [DATE]. A Peripherally Inserted Central Catheter -PICC line is a soft, flexible catheter inserted into a central vein used for prolonged antibiotic therapy, giving fluids, and or getting clinical nutrients. <BR/>This failure could place residents at risk for infection.<BR/>Review of Resident #487's face sheet dated 08-21-2024 revealed a [AGE] year-old male that was admitted to the facility on [DATE]. His diagnoses included hypotension (low blood pressure), enlarged prostate (this is a condition when the prostate gland becomes larger than normal making it hard to urinate or empty the bladder), pneumonia, nutritional problem or potential nutritional problem, bacterial infection, anemia, cerebral palsy (a congenital disorder of movement, muscle tone and posture),, high blood sugar, tracheostomy status (tracheostomy is a surgical hole made through the front of the neck and into the windpipe (trachea) to keep it open for breathing), gastrotomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), acute respiratory failure with hypoxia (low oxygen), and dependence on respirator ventilation. <BR/>Review of Resident #487's admission MDS assessment, dated 08-19-2024, reflection did not reflect intravenous access PICC line. <BR/>Review of Resident # 487's admission nurse note dated 08-14-2024, reflected Resident #487's BP was 75/57 and he had a PICC line in the left upper extremities. Further admission nurse note reflected Resident #487 had he had a 16 French Indwelling catheter, and he had an enteral tube (G-tube). <BR/>Review of Resident #487's care plans reflected a care plan initiated 08-15-2024 with no reflection intravenous PICC line. <BR/>An observation and interview with ADON K on 08-21-2024 at 08:41 AM, revealed Resident #487 was awake in his bed. He could not answer any questions but smiled when you said hello. Resident #487 was observed with a PICC line with three lumens (ports/outlets) on the upper left arm. Resident #487's PICC line was dated 08-11-2024. The lumens had orange caps on them. ADON K stated Resident #487's PICC line dressing should be changed. She said she was not sure on the policy about how long before the dressing is changed. She stated dressing was changed for infection control. She stated nurses were responsible for assessing IV, dressing, and obtaining orders.<BR/>In an interview with LVN E on 08-21-2024 at 09:05 AM, she stated she was aware Resident #487 had a PICC line. She stated she monitored the PICC line on her shift to make sure dressing was intact, and the lumens were closed, and caps were on the ends of the lumens. She stated being an LVN she could not change the PICC line dressing, and it was the responsibility of an RN, ADON or DON. LVN E stated she did not notify the DON or ADON of Resident #487 PICC line dressing to be changed. She stated she did not pay close attention to the PICC line date on the dressing. LVN E stated it was the nurse's responsibility to obtain orders to manage the PICC line. She stated not having PICC orders and not changing dressing placed residents at risk for infection.<BR/>In an Interview with LVN F on 08-22-2024 at 02:45 PM, he stated he documented in the admission assessment that Resident #487 had a PICC line. He stated he had used the PICC line one time when Resident #487 was admitted due to low BP of 75/57. LVN F stated he obtained an order from the physician to administer one liter of fluid to help bring the BP up. LVN F stated he notified the DON during the time of the low BP. He stated the PICC line had not been used since admission on [DATE]. He stated he could not change the PICC dressing because he was an LVN. He stated only an RN could change PICC line dressing. LVN F stated he should have obtained orders for the PICC line. He stated he forgot. He stated nursing was a twenty-four-hour job therefore whatever he missed someone should have caught it and obtained orders including the DON. He stated the PICC line was somewhat hidden due to location and resident having contractures. LVN F stated he flushed the PICC line with 10 cc on his shift. He stated that flushing the PICC line kept it open and it was nursing practice. He stated PICC dressing should be changed weekly or if it was dirty. He stated he would report to the DON to change the dressing. He stated risk to resident was not making sure PICC was patent, patient was not being taken care of infection wise.<BR/>In an interview with RN L on 08-22-2024 11:58 AM, she stated she had been employed at the facility for five years. She stated as an RN she could perform PICC line dressing changes. She stated PICC dressing were a sterile process for risk of infection. She stated PICC line dressing should be changed every 7 days and PRN dressing change. She stated she had no in-service on central dressing, but it was part of her nursing skill. She stated it was the nurse's responsibility to obtain orders for dressing changes and PICC management. She stated she was not assigned to Resident #487, and no one had asked her to perform his dressing change. RN F stated any nurse could perform an intravenous dressing change if they had their skill check off. She stated only RNs could remove a PICC line. She stated daily document on skin was required for PICC lines . She sated nurses were required to do daily skin assessment and if any clarifications or orders were missing to notify her. She stated during admission assessment on EMR, there was a column for Intravenous lines charting with standing orders when activated in the EMR by the nurse. She stated the risk for not managing the PICC line and any intravenous lines was infection.<BR/>In an interview with DON on 08-22-2024 at 3:19 PM, she stated nurses should have gotten orders. She stated the DON or ADON, does not go through the admission assessment unless nurses asked them to take out the intravenous line or get orders. She stated nurse are good about getting orders. She stated policy does not specify on who could perform PICC line dressing changes if they had the IV Class online through the pharmacy. The DON stated she was not sure why Resident #487 was admitted to the facility with the PICC line because it had not been used. She stated when Resident #487 had a low blood pressure on admission [DATE], a peripheral IV was ordered for fluid resuscitation for the low BP. She stated there no orders to access PICC, orders to flush, make sure there is no redness, flushed are not leaking. She stated she had obtained orders to remove Resident #487 on 08-22-2024. She stated there was no infection noted under the dressing. She stated the policy said to change PICC dressing every week.<BR/>Interview with ADM on 08-22-2024 at 4:31 pm, she stated orders drive care and she expected nursing staff to obtain orders for care. <BR/>On 08-22-2024 ADM, DON and ADON were asked for their policy for PICC/IV Dressing Change , no policy was provided prior to exit. <BR/>Review of the Centers for Disease Control and Prevention guideline titled Prevention of Intravascular Catheter-Related Infections, revision date October 2017, reflected, read in part . 3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled .6. Replace dressings used on short-term CVC sites every 2 days for gauze dressings.7. Replace dressings used on short-term CVC/PICC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing .14. Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source,<BR/> or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 5 residents (Resident #106) reviewed for resident records.<BR/>Facility failed to ensure physician orders were written for ventilator setting for Resident #106 on admission [DATE] to 08-22-2024.<BR/>This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.<BR/>Findings included:<BR/>Review of Resident #106 admission record dated 08-22-2024 revealed a [AGE] year-old female that was admitted to the facility on [DATE]. Her diagnoses included chronic respiratory failure, sepsis (this is a systemic infection), pneumonia, Amyotrophic Lateral Sclerosis (also known as ALS, a nervous system disease that affects nerve cells in the brain and spinal cord. ALS causes loss of muscle control), mechanical ventilator (a machine that helps your lungs to work by pushing air in and out of lungs so that the body can get oxygen) dependent, tracheostomy status (tracheostomy is a surgical hole made through the front of the neck and into the windpipe (trachea) to keep it open for breathing) , gastrotomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), dysphagia (difficulty swallowing), muscle weakness and protein calorie malnutrition. Resident was a full code and her own responsible party.<BR/>Review of Resident #106 quarterly MDS assessment dated [DATE] reflected Resident #106 had a BIMS of 15, indicating resident was cognitively intact. Resident #106 could understand others and others could understand her. The document reflected she had impairment in her upper and lower extremities, was always incontinent, and was completely dependent on staff for all her ADLs. She did not sit up or transfer during the assessment period, due to her clinical condition. Resident #106 received 51% or more of her nutrition through her g-tube. The document reflected Resident #106 was dependent on Invasive mechanical ventilator respiratory ventilator status.<BR/>Review of Resident #106 care plan dated 04-02-2024, revealed the resident was ventilator dependent with a goal to be free of complications related to ventilator dependence such as upper respiratory infection, pneumonia (fluid in lungs), atelectasis (fluid collection in the abdominal and chest cavities), decreased cardiac output, pneumothorax (blood in lungs) and subcutaneous emphysema (air bubbles in the skin in the chest areas), increased intra [NAME] pressure and hepatic congestion (a condition in which blood backs up in the liver due to heart failure). Interventions included. Assess for s/sx of hypoxia [low oxygen]: altered level of consciousness, irritability, listlessness, cyanosis. Educate resident/family/caregivers purpose/mode/and all treatments; encourage resident to relax and breath with the ventilator; explain alarms; teach importance of deep breathing. Monitor for changes in respiratory rate or depth. Observe/document for use of accessory muscles. Notify MD of significant changes. Monitor for tube misplacement at least every 2 hours and PRN - document cm markings for placement. [NAME] at lip/teeth/nares after x-ray confirmation. Monitor oxygen saturation while resident is on mechanical ventilatory support and/or during weaning process. Monitor/document and intervene as indicated for psychosocial problems including isolation, withdrawal, and depression. Monitor/document/report to MD PRN any s/sx of upper respiratory infection, pneumonia, atelectasis, decreased cardiac output, pneumothorax, decreased renal perfusion, increased intracranial pressure, hepatic congestion. <BR/>Review of Resident #106 MAR on 08-20-2024 reflected the following orders: <BR/>1. HME T during the daytime or when the resident is out of bed. Add O2 as needed and every shift. Check O2 saturation Q shift and PRN. <BR/>2. Every shift check resident Q2h for suctioning need, suction via trach prn. every shift<BR/>3. Same size trach and a smaller size at bedside for emergency replacement every shift related to chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (lack of oxygen or accumulation of carbon dioxide)<BR/>4. Ambu bag [a silicone shaped device placed on nose and mouth used to manually force air in lungs] with O2 cylinder at bedside (use at 10- 15 lpm) every shift related to dependence on respirator [ventilator] status<BR/>5. Bleed in O2 as needed to keep O2 sats &gt; 92% every shift related to chronic respiratory failure, unspecified whether with hypoxia or hypercapnia.<BR/>6. MAR did not reflect ventilator setting.<BR/>Review of Resident# 106 order summary on 08-20-2024 did not reflect ventilator setting orders since 06-18-2024 when Resident#106 was readmitted to the facility. <BR/>Record Review of Resident #106 hospital discharge for pulmonary dated 06-18-2024 reflected ventilator setting as Ventilator mode: SIMV, Respiratory Rate total 16 bre/min, Tidal Vol Set (ml) 500 mL [this is the amount of air a ventilator delivers to a patient's lungs with each breath], amount of pressure support 10 (helps a patient breath spontaneously by providing pressure during each breath), peep 5 cm H2O, FiO2 30 %. <BR/>Observation and interview with Resident #106 on 08-20-2024 at 11:26 AM, she stated using a machinal device teleprompter that she was treated with respect and dignity. The reading on her ventilator machine read as follows; SIMV-VC Active PAP, PIP (peak inspirational pressure is the highest pressure applied to lungs during inhalation in mechanical ventilation) 33.2 cm H20, tidal volume 443 mL (this is the amount of air that a mechanical ventilator moves into a patient's lungs during inhalation), RR 16, peep 5 cm H20, PIF 34.4, % spontaneous trigger 0%. FiO2 28%. Her heart rate was 60 and oxygen saturation at 98%. <BR/>Interview with RT on 08-22-2024 at 3:44pm, she stated when Resident #106 returned from the hospital with the EMT who proved the admitting respiratory therapist with the settings on the ventilator. She stated nurses had a copy of the ventilator setting when residents were readmitted to the facility. RT stated she had worked with Resident #106 for a long time that she knew the resident's ventilator settings by heart. RT stated that the ventilator settings were also documented on Resident#106 flow sheet in the EMR. RT stated there was no risk to Resident #106 not having physician ventilator settings orders because RT had to monitor residents and wean their settings as needed depending on residents' vitals and oxygenation. RT stated the ventilator could not turn off by itself, therefore ventilator settings would not be lost and orders were not required. RT stated that either herself or the DON could enter the order set for the ventilator settings.<BR/>Interview with DON on 08-22-2024 at 03:50 pm, she stated the facility had two or three respiratory therapists on duty each shift with twenty-four-hour coverage every day. The DON stated no one had updated the ventilator setting when Resident #106 returned after being in the hospital. The DON stated the admitting nurse should have placed the order for ventilator setting. The DON was informed by RT on 08-22-2024 at 03:50 pm and she input the ventilator setting orders. The DON stated there was no risk to Resident #106 for not having physician ventilator setting orders because it was on the EMR flow sheet.<BR/>Interview with the ADM on 08-22-2024 at 4:31 pm, she stated orders drive care and she expected nursing staff and Respiratory staff to obtain orders for care. The ADM stated she expected Resident #106 to have orders for her ventilator. <BR/>On 08-22-2024 facility was asked for their policy for Physician Orders, no policy was provided.<BR/>Record review of policy titled, Medication Orders revised 2014, reflected Supervision by a Physician 1. Each resident must be under the care of a Licensed Physician .2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order .6. Treatment orders - When recording treatment orders, specify the treatment, frequency, and duration of the treatment .<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (Resident #1, Resident #2, Resident #12 and Resident #15) of twenty residents reviewed for infection control. 1. The facility failed to ensure LVN C did not re-use a gown to provide treatment for some residents at hall 400 on 07/12/2025. 2. The facility failed to ensure LVN C changed her gown in between Resident #1 and Resident #2 who were with tracheostomy on 07/12/2025. 3. The facility failed to ensure LVN C changed her gloves and performed hand hygiene when changing Resident #2's tracheostomy dressing on 07/12/2025. 4. The facility failed to ensure LVN D wore a gown while administering Resident #12's medication via g-tube on 07/12/2025 5. The facility failed to ensure CNA F changed her gloves and performed hand hygiene while providing incontinent care to Resident #15 on 07/12/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) and gastrostomy (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy and gastrostomy. Record review of Resident #1's Comprehensive MDS Assessment, dated 05/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care and had a feeding tube. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident was on enhanced barrier protection and one of the interventions was to put on gloves and gowns. Record review of Resident #1's Physician Order, dated 06/11/2025, reflected Trach care every shift and PRN. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Bolus Isosource 1.5 250 ml via g-tube if PO intake &lt; 50 % after meals. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident was on enhanced barrier protection and one of the interventions was to put on gloves and gowns. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Trach care every shift and prn. Observation and interview on 07/12/2025 starting at 9:05 AM revealed gowns were hanging on some of the rooms in hall 400. One of the rooms with a gown hanging on the door was for Resident #1 and Resident #2. LVN C went inside the residents' room, took the gown hanging on the door, and proceeded to do a medical procedure. She said she would hang her gown after use and would just discard the gowns at the end of her shift. She said the other gowns hanging on the doors of the other residents were also hers. 2. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy and gastrostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy and gastrostomy. Record review of Resident #1's Comprehensive MDS Assessment, dated 05/07/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care and had a feeding tube. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident had tracheostomy and required tube feeding. Record review of Resident #1's Physician Order, dated 06/11/2025, reflected Trach care every shift and PRN. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Bolus Isosource 1.5 250 ml via g-tube if PO intake &lt; 50 % after meals. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident had tracheostomy and one of the interventions was to ensure that trach ties are secured at all times. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Trach care every shift and prn. Observation on 07/12/2025 at 9:10 AM revealed LVN C entered Resident #1 and Resident #2's room to check on the residents. Resident #1 signaled LVN C that she wanted to be suctioned. She sanitized her hands, put on a pair of gloves, and donned the gown that was hanging on the residents' door. After suctioning Resident #1, Resident #2 requested to be suctioned, as well. LVN C proceeded to prepare Resident #2's suction machine without changing the gown that she used to suction Resident #1. When she was about to suction Resident #2, she noticed that the suction machine did not have a canister. She said she would get a canister and would come back. She removed her gown and hung it on the door. She came back with the canister and connected it to the suction machine. When the suction machine was ready, she put on the gown that she hung on the door, and suctioned Resident #2. In an interview on 07/12/2025 at 10:54 AM, Resident #2 stated the staff that would care for her did not always put on a gown. Some did but some did not. 3. Observation on 07/12/2025 at 9:35 AM revealed when LVN C was done suctioning Resident #2, she checked the resident's dressing on her tracheostomy. She told the resident that she would change the dressing. She removed the soiled dressing from the tracheostomy, took a new dressing, and put it on the resident's tracheostomy. She did not change her gloves and perform hand hygiene after suctioning the resident, before inspecting the stoma, and before touching the new dressing. In an interview on 07/12/2025 at 10:34 AM, LVN C stated she should have changed her gown after suctioning Resident #1 and before suctioning Resident #2 to prevent transfer of microorganism from one resident to another. She said she might get some germs from Resident #1 and would unnecessarily give it to Resident #2. She said the gowns should be disposed after every use and not re-used to reduce reproduction of microorganisms and its spread. She said she should have changed her gloves before touching the new dressing because her gloves were already dirtied when she touched the soiled dressing. She said her actions could cause probable infections and she would be mindful the next time she provided treatment to residents on enhanced barrier precautions. 4. Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). The Face Sheet indicated that the resident was on enhanced barrier precaution as a special instruction due to gtube because the resident had a g-tube. Record review of Resident #12's Comprehensive MDS Assessment, dated 05/15/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #12's Quarterly Care Plan, dated 05/12/2025, reflected the resident was on enhanced barrier precautions and one of the interventions was to don (put on) gloves and gowns . during enteral feeding . or other high-contact activity. Record review of Resident #12's Physician Order, dated 06/11/2025, reflected Enteral Feed Order every shift start continuous enteral feeding. Formula: Diabetasource; Rate: 65 ml/hr, flush 200 ml H2O q 4 hrs. Observation on 07/12/2025 at 10:38 AM revealed LVN D was preparing resident #12's medication via g-tube. After preparing the medications, LVN D went inside the room and proceeded to administer the medications via g-tube. He did not wear a gown while administering the medications. In an interview on 07/12/2025 at 10:51 AM, LVN D stated he should wear a gown during medication administration if the resident had a g-tube because the resident had an indwelling device and was on enhanced barrier precautions. He said the purpose of the gown was to minimize transfer of microorganism since the g-tube site could be a potential entry of microorganism. He said he did had an in-service about infection control including enhanced barrier protection but could not remember when. 5. Record review of Resident #15's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #15's Comprehensive MDS Assessment, dated 06/25/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel. Record review of Resident #15's Comprehensive Care Plan, dated 05/15/2025, reflected the resident had bladder and bowel incontinence and one of the interventions was provide pericare after each incontinent episode. Record review of Resident #15's Comprehensive Care Plane, dated 07/12/2025, reflected the resident had an indwelling catheter and one of the interventions was to position the catheter and tubing below the level of the bladder. Record review of resident #15's Physician Order, dated 07/12/2025, reflected Provide catheter care. Observation on 07/12/2025 at 11:39 AM revealed CNA F was about to provide incontinent care to Resident #15 prior to wound care. She washed her hands, wore a gown and gloves, and proceeded with incontinent care. She positioned herself on the left side of the resident and placed a plastic bag, with a brief and beddings inside, on the foot part of the bed. She unfastened the resident's brief and pushed it between the resident's thighs. She changed her gloves and sanitized her hands. She pulled some wipes and cleaned the resident's perineal area (area between the thighs) using the front to back technique. She did it five times. After cleaning the perineal area, she instructed and assisted the resident to roll towards the right side. Before rolling the resident, CNA F adjusted the resident's catheter. After adjusting the catheter, she pulled the brief from inside the plastic bag, and placed it beside the resident. She did not change her gloves before touching the new brief. CNA F rolled the resident and cleaned the resident's bottom. After cleaning the resident's bottom, she pulled the soiled brief and threw it on the trash can. After throwing the soiled brief, she pulled the new brief from the resident's side and placed it under the resident. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. She then instructed and assisted the resident to roll to the other side so the WCN could do the wound care before fastening the brief. In an interview on 07/12/2025 at 3:33 PM, ADON A stated the staff must wear a gown every time they provide care or treatment to residents with tracheostomy, g-tube, catheter, colostomy, and with open wound. She said EBP is a new thing but staff were expected to adhere to the EBP policy. She said she was made aware by LVN C and LVN D on the issues of EBP. She said LVN C should not re-use the gown and should have changed her gown her gown from one resident to another. She said the reason for that was to prevent cross contamination and probable infection. She said if one resident had an infection or had any undesirable microorganism, she would transfer it to the next resident that she would care for. She said the disposable gowns were not re-used because it could already be contaminated by bacteria or viruses. She said LVN C should have changed her gloves when she took off the dressing on the resident's tracheostomy because her gloves were already soiled. She said the same reason why CNA F changed her gloves after touching the catheter and after cleaning the resident's bottom. She said LVN D should have worn a gown when he administered medications via g-tube because the staff might introduce any germs to the resident's g-tube and also to protect the staff from any secretions from the resident. She said, as one of the ADONs, she was responsible in ensuring that the staff were compliant with the policy and procedures of infection control. She said she already started an in-service about infection control, hand hygiene, and EBP as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if there was something in the in-service that the did not understand. She said she would randomly check the staff if they were practicing infection control. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the infection control issues and ADON A already did an in-service about it. She said she the expectation was for the staff to be mindful in preventing the development of infection in the facility and to their family, as well. She said she was not a clinician but would coordinate with the DON to continually remind the staff about preventing infection control. In an interview on 07/13/2025 at 11:39 AM, CNA F stated hand hygiene was important to prevent cross contamination and to prevent infection. She said she should have changed her gloves after touching Resident #15's catheter and after cleaning her bottom because her gloves became dirty on both incidents, thus rendering the new brief to be dirty, too. She said on top of changing the gloves, she should also sanitize her hands every time she would change her gloves. She said she would be mindful the next time she does incontinent care to change her gloves after touching something soiled during incontinent care. In an interview on 07/14/2025 at 1:00 PM, the DON she already knew about the infection control issues. She said all the issues observed would contribute to cross contamination and development of infection. She said gowns should never be re-used, staff should change their gowns in between residents, staff should wear gown if the resident was on EBP, and staff should change their gloves after handling something soiled. She said the expectation was for the staff to do what was right to inhibit the development and spread of infection. She said with regards to Resident #16' catheter, the resident just came back from the hospital and she had it when she was admitted back to the facility on [DATE]. She said she already did the orders and the care plan regarding her catheter. Record review of facility policy, Fundamentals of Infection Control Precautions Infection Control Policy & Procedure Manual updated 03/2024 revealed Hand hygiene continues to be the primary means of preventing the transmission of infection . Before and after changing a dressing . After contact with a resident's mucous membranes and body fluids or excretions . After handling soiled or used linens, dressings, bedpans, catheters and urinals . After removing gloves . Gloving . To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin . Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Record review of facility policy, Enhanced Barrier Precautions undated, revealed Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities . EBP are used . to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . A single set of PPE cannot be used for more than 1 patient . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, andTracheostomies . Donning PPE for Residents on EBP Based on Activity Provided . Administer medications enterally . must don gloves and gown. Record review of facility policy, Perineal Care Female Nursing Policy and Procedure Manual revised December 08,2009 revealed Purpose: To clean the female perineum without contaminating the urethral area . J. Cleaning the rectal and buttocks area . b. Gently wash the rectal area and buttocks . c. Change gloves. Record review of facility policy, Catheter Care Nursing Policy and Procedure Manual, undated revealed Procedure . 14. Hold catheter tubing . 19. Remove gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 3 of 30 residents (Residents #66, 42, and #103) reviewed for effective pest control.<BR/>The facility failed to maintain an effective pest control program to ensure the facility was free of flies for Resident #66, #42, and #103 in the facilities only dining room. <BR/>This failure could place the residents at risk for an unsanitary environment. <BR/>Findings included:<BR/>Record review of Resident #66's face sheet dated revealed a [AGE] year-old male who had an original admission date of 3-9-2020 and a re-admission date of 2-9-2024. Resident #66's primary diagnosis was a cerebral infarction (stroke) affecting the left dominant side and secondary diagnoses of cognitive communication deficit, ulcer of the right heel and midfoot, lack of coordination, and contracture of the right knee. <BR/>Record review of Resident #66's Quarterly MDS assessment dated [DATE], indicated a BIMS score of 13 revealing being cognitively intact. <BR/>Record review of Resident #66's care plan dated 6-15-2022 revealed Resident #66 was a hemiplegia (paralysis on one side of the body that can affect the arms, legs, and facial muscles) on the left side requiring ADL assistance. <BR/>In an observation and interview on 8-20-2024 at 4:12 PM, Resident #66 was observed to be sitting in his wheelchair asleep, in the facilities only dining room, at a table with a coffee cup on it. Resident #66 was observed to have a fly on his neck, one on his right arm, and one on his head. Resident #66 woke-up and stated flies had been bad at the facility for the past week. Resident #66 stated he did not like the flies and did not want them on him. <BR/>Record review of Resident #42's face sheet dated 8-21-2024, revealed a [AGE] year-old male who had an original admission date of 11-1-2017 and a re-admission date of 6-24-2023. Resident #42's primary diagnosis was Dementia with secondary diagnoses of abnormal posture, repeated falls, difficulty in walking, and Parkinson's disease. <BR/>Record review of Resident 42's Quarterly MDS dated [DATE], indicated a BIMS score of 00 implying being severely cognitively impaired. <BR/>Record review of Resident 42's care plan dated 6-29-2023 indicated Resident #42 had ADL deficits for hygiene and mobility, was care planned for actual falls, and was on antidepressant medications. <BR/>In an observation and interview on 8-20-2024 at 4:15 PM, Resident #42 was observed sitting in a wheelchair sitting at a table in the facilities only dining room by Resident #66. Resident #66 said he saw the flies on Resident #66 and on the dining room tables. Resident #42 stated he did not like the flies especially in the dining room. Resident #42 stated dealing with the flies in the dining room made him feel like he was in a trash dumpster. <BR/>In an observation on 8-20-2024 at 4:20 PM there were 10 flies observed in the facilities only dining room. A fly was observed on 80% of the tables in the dining room. <BR/>Record review of Resident #103's face sheet dated 8-21-2024, revealed an [AGE] year-old female who admitted to the facility on [DATE] with a primary diagnosis of a fracture of T5-T6 vertebra and secondary diagnoses of morbid obesity, depression, asthma, and generalized muscle weakness. <BR/>Record review of Resident #103's Quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating Resident #103 had moderate cognitive impairment. <BR/>Record review of Resident #103's care plan dated 2-6-2024 indicated she had ADL deficient requiring assistance, was on an antidepressant, and was a fall risk. <BR/>On 8-21-2024 at 12:27 PM, Resident #103 was observed in a wheelchair sitting at a table in the facilities only dining room, eating her lunch. Resident #103 was observed shooing away a fly from her food. Resident #103 said the flies are not too bad today but sometimes they have been worse, and she has scared them away by waving her hand over her food. Resident #103 said she does not like the flies. <BR/>In an interview on 8-22-2024 at 2:00 PM, the Maintenance Director revealed the facility contracted with a pest control company and he oversaw the responsibilities. The <BR/>Maintenance Director stated the pest control company came to the facility every Tuesday and treated the facility for spiders, scorpions, rodents, and flies. The Maintenance Director said there was a Pest Control Logbook kept at the nurse's station where anyone could make an entry of a pest control problem. The pest control company comes in and checks the logbook to see where a problem might be to treat that area for that problem. The Maintenance Director said flies were a big challenge for the facility because surrounding the facility was a barn with horses, a creek, a wooded area, and a park. The Maintenance Director said it was a big deal as the facility had trach patients who cannot move to shoo flies off. The Maintenance Director said the risk to residents eating in the dining room was flies could infect residents' food and bring worms in their food. <BR/>In an interview on 8-22-2024 at 3:00 PM, CNA-B stated she had worked at the facility for a month on the 2:00 PM-10:00 PM shift. CNA-B said when she hired in a month ago flies were really bad in the facility, however, they are not as bad as they were. CNA-B said there were still some flies in the facility, and they were disgusting because they land on feces and are especially not good for residents in the dining room trying to eat. <BR/>In an interview on 8-22-2024 at 4:00 PM, the Administrator said the Maintenance Director was responsible for the pest control of the facility. The Administrator stated her expectations for pest control was for the pest control company to come to the facility every Tuesday to treat for flies inside and outside, to keep having blow curtains at all the entry and exit doors except the fire exits, and to have the smoking patio power washed twice a week. The Administrator said the potential risk to residents having flies in the facility was not having a sanitary environment. <BR/>Record review of the facilities Pest Control Company's Logs revealed the following:<BR/>6-18-2024 - Visit at 12:58 PM - treated for flies, spiders, roaches, ants beetles and crickets. <BR/>6-25-2024 - Visit at 12:42 PM - treated for roaches, flies, gnats.<BR/>7-02-2024 - Visit at 10:24 AM - treated for roaches, flies, gnats.<BR/>7-09-2024 - Visit at 10:47 AM - treated for flies, gnats, ants, roaches, and moths.<BR/>7-16-2024 - Visit at 11:00 AM - treated for flies, gnats, and moths.<BR/>7-19-2024 - Visit at 09:19 AM - treated for bedbugs - Observed bedbugs in a wheelchair.<BR/>7-23-2024 - Visit at 02:35 PM - treated for flies and gnats.<BR/>7-30-2024 - Visit at 01:00 PM - treated for flies, gnats, spiders, and moths.<BR/>8-06-2024 - Visit at 03:34 PM - treated for flies, gnats, moths.<BR/>8-13-2024 - Visit at 09:46 AM - treated for ants, roaches flies, and gnats - Logbook reports roaches in a room.<BR/>Record review of the facilities Pest Control Policy dated 2012 states:<BR/>IC 00-12.0<BR/>Insect and Rodent Control<BR/>The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department.<BR/>Procedure:<BR/>1. <BR/>Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required.<BR/>2. <BR/>Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents.<BR/>3. <BR/>Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents.<BR/>4. <BR/>Deliveries of food and supplies will be monitored for prevention of insect and rodent access. <BR/>Dietary Services Policy & Procedure Manual 2012 <BR/>IC 00-12.0

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 2 of 5 residents (Residents #1 and #3) reviewed for quality of care.<BR/>The facility failed to provide wound care services for Resident #1 as ordered on 11/03/23, 11/06/23, 11/08/23, 11/11/23 (night), 11/12/23 (night), and 11/13/23 (evening and night). <BR/>The facility failed to provide wound care services for Resident #3 as ordered on 11/06/23 and 11/08/23.<BR/>This failure could place residents at risk of infection and/or deterioration of their wounds. <BR/>Findings include:<BR/>Resident #1:<BR/>Record review of Resident #1's electronic Facesheet, dated 11/14/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included chronic respiratory failure, dependence on ventilator (a machine that helps you breathe or breathes for you), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck), congestive heart failure, rheumatoid arthritis, and myopathy (any disease that affects the muscles that control voluntary movement in the body).<BR/>Record review of Resident #1's Quarterly MDS Assessment, dated 08/30/23, reflected Resident #1's BIMS was 15, which indicated his cognition was intact. The MDS reflected Resident #1 had a skin injury that required treatment of applications of nonsurgical dressings and ointments/medications.<BR/>Record review of Resident #1's Care Plan, dated 03/21/23, reflected Resident #1 had potential for pressure ulcer development due to immobility. The care plan did not address Resident #1's skin injury. <BR/>Record review of Resident #1's physician orders, dated 10/17/23, reflected Wound care to upper back: Cleanse with daikens solution and pat dry, apply gentamycin ointment, cover with ABD pad (gauze pads are used to absorb discharges from abdominal and other heavily draining wounds) with NO tape retention, apply, disposable chux (disposable underpads) and change every shift. every shift for Wound care.<BR/>Record review of Resident #1's WAR, dated November 2023, reflected Wound care to upper back: Cleanse with daikens solution and pat dry, apply gentamycin ointment, cover with ABD pad with NO tape retention, apply disposable chux and change every shift every shift for Wound care. On the following dates the WAR was blank: 11/03/23 for day, evening; 11/06/23 for day, evening, and night; 11/08/23 for day, evening, and night; 11/11/23 for night; 11/12/23 for night; and 11/13/23 for evening and night. The blank spaces without the check mark or initials indicated wound care was not completed.<BR/>In an interview on 11/14/23 at 10:55 AM, Resident #1 stated he had a wound on his back and had just received wound care about 30 minutes ago. Resident #1 stated he believed he was supposed to receive wound care once per day, but sometimes he received wound care twice per day. He stated for the most part he received wound care at least once per day, but never three times per day. Resident #1 stated lately for the last two weeks, there were days he did not receive wound care at all. Resident #1 stated he did not know the exact dates but happened like 1-2 times last week. He stated he saw the wound doctor at least once per week.<BR/>In an interview on 11/14/23 at 1:18 PM, the WCN stated the nurse on the 300 hall had quite about a week and half ago. She stated when the facility could not find anyone to cover the shift, she would be assigned to the hall. The WCN stated on the days she was assigned to work the 300 hall, the nurses were responsible for completing their own wound care to their assigned residents. The WCN stated there had been times she knew wound care had not been completed by the nurses because the bandages were dated and signed by her from the previous day. The WCN stated Resident #1 was supposed to receive wound care every shift, so when she was not there during the evening and night shift, the nurses were supposed to complete the wound care. The WCN stated she knew Resident #1's wound care was not completed the previous day (11/13/23) except morning shift, because the bandages were dated and signed by her from the previous day.<BR/>In an interview on 11/14/23 at 4:05 PM, the DON stated she was made aware that Resident #1's wound care that was ordered every shift was not completed. She stated the issue was the nurse's review the TAR and not the WAR because the facility had a wound care nurse. The DON stated she moved Resident #1's wound orders to the TAR to ensure the nurses would complete the orders . <BR/>Resident #3:<BR/>Record review of Resident #3's electronic Facesheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included respiratory failure, dependence on ventilator (a machine that helps you breathe or breathes for you), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck and generalized muscle weakness. <BR/>Record review of Resident #3's Quarterly MDS Assessment, dated 10/31/23, reflected Section C - Cognitive Patterns was blank. The MDS reflected Resident #3 had skin injury that required treatment of applications of ointments/medications.<BR/>Record review of Resident #3's Care Plan, dated 03/31/23, reflected Resident #3 had a pressure ulcer on the first toe of her right foot. The interventions included Administer medications/supplements as ordered. Monitor/document for side effects and effectiveness.<BR/>Record review of Resident #3's physician orders, dated 09/19/23, reflected Wound care to back of neck for maceration, apply skinfold dry sheet once daily or PRN as needed. One time a day for wound care. An ordered, dated, 10/26/23, reflected Wound Care to great right toe, use collagen powder, apply xeroform gauze and apply gauze island. One time a day for wound care. An order, dated, 9/14/23 reflected Wound care to upper back pustules, cleanse with hibicleanse, pat dry, apply mupirocin ointment. One time a day for wound care. <BR/>Record review of Resident #3's WAR, dated November 2023, reflected Wound care to back of neck for maceration, apply skinfold dry sheet once daily or PRN as needed. one time a day for wound care with hours of 6a-6p. On 11/06/23 and 11/08/23 the WAR was blank. The blank spaces without the check mark or initials indicated wound care was not completed. The November 2023 WAR reflected Wound Care to great right toe, use collagen powder, apply xeroform gauze and apply gauze island.one time a day for wound care with hours of 6a-6p. On 11/06/23 and 11/08/23 the WAR was blank. Further review of the November 2023 WAR reflected Wound care to upper back pustules, cleanse with hibicleanse, pat dry, apply mupirocin ointment. one time a day for wound care with hours of 6a-6p. On 11/06/23 and 11/08/23 the WAR was blank.<BR/>An attempt to interview Resident #3 was completed on 11/14/23 at 10:50 AM. Resident #3 was non-verbal. <BR/>On 11/16/23 a Nurse Surveyor completed wound care observations for Resident #1's wound at 9:27 AM and Resident #3's wound at 10:09 AM, which revealed there were no signs or symptoms of infection and no concerns regarding the resident's wound care. <BR/>In an interview on 11/16/23 at 10:45, the WMD stated the WCN was doing a good job with the wounds, and they were all progressively healing. The WMD stated she was unaware there were days wound care was not completed. She stated she was aware there was a nurse that quit and sometimes the WCN was filling in for her, but from her understanding, on those days the nurses were responsible for completing wound care on their assigned residents. The WMD stated there were no wounds in the facility that were infected or had issues with healing. She stated Resident #1, and #3's wounds were healing well. WMD stated wound care should always be completed per the orders, but she did not have any concerns with the wound care at the facility. <BR/>Record review of the facility's Daily Schedule For Hall 300 reflected on 11/03/23, 11/06/23, and 11/08/23 the WCN was scheduled to work on hall 300 from 6AM- 2PM for rooms 308B-316B (Resident #1 and #3). On 11/03/23 the schedule reflected LVN C was assigned to the 300 hall from 2PM-10PM for rooms 308B-316B. On 11/06/23 the schedule reflected the ADON was assigned to the 300 hall from 2PM-10PM for rooms 308B-316B until 6:00PM and then LVN C from 6:00PM to 6AM. On 11/08/23 the schedule reflected RN D was assigned to the 300 hall from 2PM-10PM for rooms 308B-316B. <BR/>In a follow up interview on 11/16/23 at 12:56 PM, the WCN stated when she worked the 300 hall, she was assigned to the back of the hall (rooms 308B-316B), so she was the nurse assigned to Resident #1 and #3. She stated because 300 hall was the ventilator unit, it was heavy on nursing services, so she and the 2-10PM nurse would split the wound care duties. The WCN stated she would do the residents who had multiple severe wounds and leave the easier wounds for the 2-10PM nurse. She stated Residents #1 and #3 had easier wounds so she would always leave them to the 2-10PM nurse. She stated she did work the back of 300 hall on 11/03/23, 11/06/23, and 11/08/23. The WCN stated she did not complete the wound care for Resident #1 and #3. She stated The WCN stated during shift change, she would let the 2-10PM nurse know what wounds needed to be completed. She stated on Friday, 11/03/23 LVN C was the 2-10PM nurse, and she did advise him that Residents #1 and #3 needed wound care. The WCN stated she could not recall who was the 2-10PM nurse on 11/06/23 or 11/08/23, but she knew she always let the oncoming nurses know what wounds needed to be completed. <BR/>In an interview on 11/16/23 at 2:32 PM, LVN C stated on 11/03/23 he was assigned to the back of the 300 hall (rooms 308B-316B), so he was the nurse assigned to Residents #1 and #3. He stated he normally worked overnight from 10PM- 6AM but had been helping out and coming in early at 6PM. LVN C stated he worked from 6PM-6AM. He stated he could not remember what nurse he relieved on 11/03/23, but no one told him he needed to do wound care. LVN C stated the facility had a wound care nurse, and wound care was done during the 6AM- 2PM shift. He stated no one told him he needed to do wound care for Residents #1 and #3, so he did not complete it. <BR/>In an interview on 11/16/23 at 2:54 PM, RN D stated he worked 2-10PM on 11/03/23 and 11/08/23. He stated on 11/03/23 he was assigned to the front of Hall 300 and on 11/08/23 he was assigned to the back of 300 Hall. RN D stated Residents #1 and #3 were located at the back of the 300 Hall. RN D stated he did not do wound care for Residents #1 and #3 on 11/08/23. He stated he was the 2-10PM relief for the WCN on 11/08/23 and assumed she did wound care. RN D stated the WCN did not tell him he needed to complete wound care for Residents #1 and #3. He stated their wound information was not on the TAR, which is the record he followed. RN D stated he would not review the WAR, unless he was asked to complete wound care, which did not happen very often. He stated he would have completed the wound care if the WCN told him it needed to be done. <BR/>In an interview on 11/16/23 at 3:02 PM, the ADON stated she worked the back of the 300 Hall on 11/06/23. The ADON stated the WCN worked the back of 300 Hall from 6AM-2PM and she relieved her at 2PM. She stated LVN C came in early at 6PM. The ADON stated she did not do wound care for Residents #1 and #3. The ADON stated the WCN did not tell her she had not completed wound care for Residents #1 and #3. She stated she would have done it. The ADON stated she did check the TAR and completed the nursing services that needed to be done, but the wounds are not on there. The ADON stated she did not check the WAR and assumed the WCN had completed all the wounds. <BR/>In an interview on 11/16/23 at 3:46 PM, the DON stated a nurse from the 300 Hall quit about two weeks ago. The DON stated the 300 Hall was the ventilator unit, so it was heavy and difficult to find someone to cover it. She stated she had to use the WCN sometimes. The DON stated on days the WCN was assigned to a hall, the nursers were responsible for their own wound care. She stated she would announce when WCN was assigned to hall in the morning meetings. The DON stated if the 6AM-2PM nurses were unable to complete all their wound care during their shift, it would be their responsibility to tell the 2-10PM nurses what needed to be completed. She stated it was her responsibility to monitor the WAR to ensure wound care was completed. The DON stated she had not checked the WAR in a while, so she was unaware there were dates wound care had been missed. The DON stated going forward she would be checking the WAR daily to ensure wound care was completed. She stated she had started in-servicing nurses they were required to check the WAR during their shift and ensure wound care had been completed by the end. The DON stated she had in-served nurses if the WCN was assigned to a hall and they were scheduled from 6AM-2PM and unable to complete wound care, then they were required to notify her, notify 2-10PM relief, and document. <BR/>A record review of the facility's policy titled Skin Integrity Management, dated 10/15/16, reflected General Guidelines . 3. Wound care should be performed as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for 1 of 5 residents (Resident #2) reviewed for wound care.<BR/>The facility failed to provide wound care services for Resident #2 as ordered on 11/03/23, 11/06/23, and 11/08/23.<BR/>This failure could place residents at risk of infection and/or deterioration of their pressure ulcers. <BR/>Resident #2:<BR/>Record review of Resident #2's electronic Facesheet, dated 11/14/23, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included acute respiratory failure, dependence on ventilator (a machine that helps you breathe or breathes for you), and quadriplegia (a form of paralysis that affects all four limbs, plus the torso). <BR/>Record review of Resident #2's Quarterly MDS Assessment, dated 10/16/23, reflected Resident #2's BIMS was 14, which indicated his cognition was intact. The MDS reflected Resident #2 had one Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) that was present upon admission/entry or reentry.<BR/>Record review of Resident #2's Care Plan, dated 06/06/23, reflected Resident #2 had a Stage 4 pressure ulcer to right ischium (a paired bone of the pelvis that forms the lower and back part of the hip bone, as well as the posterior). The interventions included Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN.<BR/>Record review of Resident #2's physician orders, dated 08/18/23, reflected wound to right ischium, cleanse with daikins, wet to moist, sterile gauze, super absorbent dressing. One time a day for wound healing. <BR/>Record review of Resident #2's WAR, dated November 2023, reflected wound to right ischium, cleanse with daikins, wet to moist, sterile gauze, super absorbent dressing. one time a day for wound healing with hours of 6a-6p. On 11/03/23, 11/06/23, and 11/08/23 the WAR was blank. The blank spaces without the check mark or initials indicated wound care was not completed.<BR/>In an interview on 11/16/23 at 11:58 AM, Resident #2 stated she had a wound on her bottom. Resident #2 stated she was supposed to receive wound care daily and most of the time she received it. She stated there were a few times recently she had not received wound care because the wound nurse was assigned to a hall, so she did not have time to complete wound care. Resident #2 stated there has been maybe 2 or 3 times in the last two weeks that she did not receive wound care for the day. Resident #2 stated she did not have concerns with wound care, and felt the facility was doing a good job with wound care because her wounds were getting better .<BR/>On 11/16/23 a Nurse Surveyor completed wound care observations for Resident #2's wound at 10:29 AM, which revealed there were no signs or symptoms of infection and no concerns regarding the resident's wound care. <BR/>In an interview on 11/16/23 at 10:45, the WMD stated the WCN was doing a good job with the wounds, and they were all progressively healing. The WMD stated she was unaware there were days wound care was not completed. She stated she was aware there was a nurse that quit and sometimes the WCN was filling in for her, but from her understanding, on those days the nurses were responsible for completing wound care on their assigned residents. The WMD stated there were no wounds in the facility that were infected or had issues with healing. She stated Resident #2's pressure sore had significantly decreased in size and depth, since she admitted to the facility. The WMD stated wound care should always be completed per the orders, but she did not have any concerns with the wound care at the facility. <BR/>Record review of the facility's Daily Schedule For Hall 300 reflected on 11/03/23, 11/06/23, and 11/08/23 the WCN was scheduled to work on hall 300 from 6AM- 2PM for rooms 308B-316B (Resident #2). On 11/03/23 the schedule reflected LVN C was assigned to the 300 hall from 2PM-10PM for rooms 308B-316B. On 11/06/23 the schedule reflected the ADON was assigned to the 300 hall from 2PM-10PM for rooms 308B-316B until 6:00PM and then LVN C from 6:00PM to 6AM. On 11/08/23 the schedule reflected RN D was assigned to the 300 hall from 2PM-10PM for rooms 308B-316B. <BR/>In a follow up interview on 11/16/23 at 12:56 PM, the WCN stated when she worked the 300 hall, she was assigned to the back of the hall (rooms 308B-316B), so she was the nurse assigned to Resident #2. She stated because 300 hall was the ventilator unit, it was heavy on nursing services, so she and the 2-10PM nurse would split the wound care duties. The WCN stated she would do the residents who had multiple severe wounds and leave the easier wounds for the 2-10PM nurse. She stated Resident #2 had easier wounds so she would always leave them to the 2-10PM nurse. She stated she did work the back of 300 hall on 11/03/23, 11/06/23, and 11/08/23. The WCN stated she did not complete the wound care for Resident #2. She stated The WCN stated during shift change, she would let the 2-10PM nurse know what wounds needed to be completed. She stated on Friday, 11/03/23 LVN C was the 2-10PM nurse, and she did advise him that Resident #2 needed wound care. The WCN stated she could not recall who was the 2-10PM nurse on 11/06/23 or 11/08/23, but she knew she always let the oncoming nurses know what wounds needed to be completed. <BR/>In an interview on 11/16/23 at 2:32 PM, LVN C stated on 11/03/23 he was assigned to the back of the 300 hall (rooms 308B-316B), so he was the nurse assigned to Resident #2. He stated he normally worked overnight from 10PM- 6AM but had been helping out and coming in early at 6PM. LVN C stated he worked from 6PM-6AM. He stated he could not remember what nurse he relieved on 11/03/23, but no one told him he needed to do wound care. LVN C stated the facility had a wound care nurse, and wound care was done during the 6AM- 2PM shift. He stated no one told him he needed to do wound care for Residents #2, so he did not complete it. <BR/>In an interview on 11/16/23 at 2:54 PM, RN D stated he worked 2-10PM on 11/03/23 and 11/08/23. He stated on 11/03/23 he was assigned to the front of Hall 300 and on 11/08/23 he was assigned to the back of 300 Hall. RN D stated Resident #2 was located at the back of the 300 Hall. RN D stated he did not do wound care for Resident #2 on 11/08/23. He stated he was the 2-10PM relief for the WCN on 11/08/23 and assumed she did wound care. RN D stated the WCN did not tell him he needed to complete wound care for Resident #2. He stated their wound information was not on the TAR, which is the record he followed. RN D stated he would not review the WAR, unless he was asked to complete wound care, which did not happen very often. He stated he would have completed the wound care if the WCN told him it needed to be done. <BR/>In an interview on 11/16/23 at 3:02 PM, the ADON stated she worked the back of the 300 Hall on 11/06/23. The ADON stated the WCN worked the back of 300 Hall from 6AM-2PM and she relieved her at 2PM. She stated LVN C came in early at 6PM. The ADON stated she did not do wound care for Resident #2. The ADON stated the WCN did not tell her she had not completed wound care for Resident #2. She stated she would have done it. The ADON stated she did check the TAR and completed the nursing services that needed to be done, but the wounds are not on there. The ADON stated she did not check the WAR and assumed the WCN had completed all the wounds. <BR/>In an interview on 11/16/23 at 3:46 PM, the DON stated a nurse from the 300 Hall quit about two weeks ago. The DON stated the 300 Hall was the ventilator unit, so it was heavy and difficult to find someone to cover it. She stated she had to use the WCN sometimes. The DON stated on days the WCN was assigned to a hall, the nursers were responsible for their own wound care. She stated she would announce when WCN was assigned to hall in the morning meetings. The DON stated if the 6AM-2PM nurses were unable to complete all their wound care during their shift, it would be their responsibility to tell the 2-10PM nurses what needed to be completed. She stated it was her responsibility to monitor the WAR to ensure wound care was completed. The DON stated she had not checked the WAR in a while, so she was unaware there were dates wound care had been missed. The DON stated going forward she would be checking the WAR daily to ensure wound care was completed. She stated she had started in-servicing nurses they were required to check the WAR during their shift and ensure wound care had been completed by the end. The DON stated she had in-served nurses if the WCN was assigned to a hall and they were scheduled from 6AM-2PM and unable to complete wound care, then they were required to notify her, notify 2-10PM relief, and document. <BR/>A record review of the facility's policy titled Skin Integrity Management, dated 10/15/16, reflected General Guidelines . 3. Wound care should be performed as ordered by the physician.<BR/>A record review of the facility's policy titled Pressure Injury: Prevention, Assessment, and Treatment, dated 08/12/16, reflected Procedure: . 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure orders were provided for the resident's immediate care and needs for 1 of 1 resident (Resident #1) reviewed.<BR/>LVN B failed to ensure a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided orders for Mupirocin cream applied topically to Resident #1.<BR/>This failure had the potential to place Resident #1 at risk of an adverse drug reaction.<BR/>Findings included:<BR/>A record review on 11/16/23 at 9:13 AM of Resident #1's Quarterly MDS assessment dated [DATE] revealed a 74 y.o. male initially admitted to SNF on 03/09/23 and the most recent reentry into the SNF was 07/19/23. Resident #1 had a primary medical condition of Debility, Cardiorespiratory Conditions with invasive mechanical ventilation (have a tube in the airway connected to a ventilator). Resident #1's diagnoses information included chronic respiratory failure; Neuromuscular dysfunction of bladder (urinary condition when lack of bladder control is due to a brain, spinal cord or nerve problem); HF (when the heart cannot pump enough blood and oxygen to support other organs in your body); cerebral infarction (parts of the brain become damaged or die due to blood vessel blockage); and BPH (frequent need to urinate [during the day and night], a weak urine stream, and leaking or dribbling of urine) with lower urinary tract symptoms (not being able to fully empty the bladder raise the risk of infection in the urinary tract). The Quarterly MDS reflected a BIMS score of 15, which suggested Resident #1 was cognitively intact. Resident #1 did not reject evaluation or care that was necessary to achieve the goals for health and well-being during the Quarterly MDS review period. Resident #1 required two+ persons physical ADLs assistance. Resident #1 had an indwelling catheter in place. <BR/>Record review of Resident #1's physician's orders reflected:<BR/>Indwelling catheter irrigation with 0.9% sterile NS every shift<BR/>Empty (indwelling catheter) drainage bag every shift<BR/>Ensure (indwelling) catheter strap in place and holding every shift as needed<BR/>Monitor F/C every shift for leakage, blockage, sediment buildup, or low output<BR/>Provide catheter care every shift<BR/>Urinary catheter 18Fr/10cc r/t neurogenic bladder to gravity drainage every shift<BR/>Record review of Resident #1's November MAR reflected LVN B entered a chart/follow up code, check mark = Administered, and her user initials in the time row (AM or Day) under the date column (11/16/2023) that indicated the following scheduled orders were completed:<BR/>Irrigate F/C with 0.9% sterile NS<BR/>Ensure catheter strap in place and holding<BR/>Monitor F/C every shift for leakage, blockage, sediment buildup, or low output<BR/>Provide catheter care every shift<BR/>Urinary catheter 18Fr/10cc r/t neurogenic bladder to gravity drainage every shift<BR/>Review of Resident #1's care plan initiated on 03/13/23 reflected:<BR/>Focus: Resident #1 has Indwelling Catheter: Neurogenic bladder [Initiated 04/17/23; Revised 06/23/23].<BR/>Goal:<BR/>- <BR/>Resident #1 would show no s/s of urinary infection through review date [Initiated 04/17/23; Revised 09/06/23; Target date 12/11/23].<BR/>- <BR/>Resident #1 will be/remain free from catheter-related trauma through review date [Initiated 04/17/23; Revised 09/06/23; Target date 12/11/23].<BR/>Interventions: [Initiated 04/17/23; Revised 05/02/23]<BR/>- <BR/>CATHETER: Urinary Catheter 18 Fr/10cc to gravity drainage. Position catheter bag and tubing below the level of the bladder and in a privacy bag. <BR/>- <BR/>Change the catheter as ordered.<BR/>- <BR/>Check tubing for kinks and maintain the drainage bag off the floor.<BR/>- <BR/>Ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra.<BR/>- <BR/>Monitor and document intake and output as per facility policy.<BR/>- <BR/>Monitor/document for pain/discomfort due to catheter<BR/>Observation of Resident #1 on 11/16/23 at 9:27 AM lying in bed with head of bed raised between 30 and 45 degrees. Resident #1 received respiratory support by ventilator via trach. Resident #1's catheter drainage bag was lying next to left upper outer thigh on the bed. The catheter bag was covered with a privacy bag and dull yellow drainage with sediment (white particles or specks in the urine that makes the urine appear cloudy) was noted in the curled catheter tubing between the insert site and the drainage bag. The catheter drainage bag remained on the bed while LVN A performed wound care. Resident #1 consented to observation of the indwelling catheter insert site. LVN A assisted with visual observation by opening and pulling back Resident #1's brief to expose Resident #1's pubic area and external genitalia. LVN A raised Resident #1's penis for visual inspection, then retracted the foreskin to allow visual inspection of the indwelling catheter insertion site. [NAME] fluid (discharge) was noted around the head of the penis and at the urethral meatus (the external opening through which, in males, urine is expelled and the insert site of the indwelling catheter tubing). Resident #1's urethral meatus appeared to have an approximate one-inch tear or split where the tubing rested. The indwelling catheter was not secured or anchored to prevent pulling, tugging, prolonged tension or pressure at the insert site. There was no foul odor or bleeding noted at the time of visual inspection, and Resident #1 denied pain or discomfort. LVN A returned the retracted foreskin to its original position around the indwelling catheter tubing. Resident #1 was repositioned, and the indwelling catheter was hung on the bed rail below the bladder and did not allow tubing or any part of the drainage system to touch the floor.<BR/>During an interview on 11/16/23 at 10:42 AM, the WMD indicated that the approximate one-inch tear or split at Resident #1's urethral meatus was known as erosion (tearing) of the urinary meatus that occurred in individuals with indwelling catheters for a long period of time. The WMD indicated that erosion was usually secondary to catheter tension at the meatus. The WMD indicated the easiest and most effective practice of properly securing the indwelling catheter could avoid erosion. The WMD stated there were no concerns of infection or trauma of Resident #1's urethral meatus.<BR/>During an interview on 11/16/23 at 1:20 PM, LVN B stated indwelling catheter care included perineal care, to always secure the catheter, irrigate as needed to allow the catheter to remain patent and to monitor for complications. LVN B said that as the nurse she was responsible for doing or ensuring catheter care was done. LVN B said that the catheter should be secured to prevent trauma, or the catheter dislodge. LVN B said that CNAs provided perineal care during incontinence care and would report any complications. LVN B said that she was informed on 11/16/23 between 10:00 AM and 10:30 AM (was unable to give an exact time) by the DON to assess, check for any sores while provided perineal care to Resident #1, and to apply Mupirocin cream to the catheter insert site. LVN B said that she noted faint blood-tinged discharge when she provided perineal care and applied Mupirocin cream to the catheter insert site as instructed by the DON. LVN B denied she received an order from the physician before she applied the Mupirocin cream to Resident #1's catheter insert site. LVN B said she entered the order into the EHR for Mupirocin Cream but would text the physician right away to obtain an order. LVN B stated that a physician order is required before any medication or treatment is administered. LVN B stated the risk to a resident when a treatment is done without a physician order could be an allergic reaction. LVN B indicated she was aware that she was not supposed to provide a treatment without an order from the attending physician and following directions from the DON to treat a resident was not acceptable because the DON was not licensed to give orders to treat a resident.<BR/>Record review of Resident #1's order audit report revealed a Standard Medication [MAR] phone order entered 11/16/23 at 1:18 PM by LVN B. The order summary reflected Mupirocin Calcium External Cream 2% (Topical). Apply to meatus topically two times a day for catheter care. Cleanse meatus and apply mupirocin cream to abrasion. Adjust catheter tubing so it is not pulling until healed. The order was discontinued by the DON on 11/16/23 at 1:31 PM for the reason: no order received - per wound care, no orders needed.<BR/>During an interview on 11/16/23 at 1:35 PM, the DON said she expected staff to ensure catheter tubing was secured, was not kinked, or had dependent loops and catheter bags always remained below the level of the bladder. The DON said those failures could lead to an increased risk of urinary tract infections. The DON stated catheter care should be done every shift and reflected on the TAR. The DON stated that she received a text [11/16/23 between 9:30 AM and 10:30 AM] from LVN A that indicated Resident #1 had a little area where it looked like the catheter was pulling that looked nasty. The DON clarified the little area referred to the insert site of the indwelling catheter tubing. The DON stated she told LVN B to do peri-care and to see if an order was needed for the referenced area.<BR/>During an interview on 11/16/23 at 4:06 PM, LVN A said that she texted the DON that Resident #1's genital area looked nasty after visual inspection (with the surveyor). LVN A said that she observed white substance when she retracted the foreskin. LVN A stated that it appeared that Resident #1 needed peri-/catheter care. LVN A stated that she did not observe any abrasions, sores, or irritation to Resident #1's urethral meatus where the indwelling catheter tubing was inserted.<BR/>Review of an undated policy, Physician's Orders, indicated the following, in part:<BR/>Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident.<BR/>Written Orders by the Physician or Nurse Practitioner<BR/>1. <BR/>Nurse will review the order and if needed contact the prescriber for any clarifications<BR/>Verbal or Telephone Orders by the Physician or Nurse Practitioner<BR/>1. <BR/>Nurse will receive the order and read the order back to the prescriber to ensure it is correct<BR/>Preventing Verbal or Telephone Order Errors:<BR/>1. <BR/>Clarify all communications

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the resident and/or representative had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the resident and/or representative for one (Resident #1) of three resident reviewed for care plans. <BR/>The facility failed to ensure the IDT included Resident #1's RP, in the review of her comprehensive assessment and were able to discuss her individualized care needs for services to include her need for medical and nursing care, medications, therapy, psychological and dietary needs. <BR/>The failure could affect residents by placing them at risk for not receiving adequate or individualized care. <BR/>Findings included:<BR/>Review of Resident #1's admission MDS assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's active diagnoses included non-Alzheimer's dementia, Parkinson's disease, thyroid disorder and hyperlipidemia. Resident #1 had minimal difficulty hearing, clear speech, was usually understood and had no vision issues. Her BIMS score was 10, which indicated moderately impaired cognition. Resident #1 had delirium as evidenced by fluctuating inattention and mood issues related to depression and lack of appetite. Resident #1 also had potential indicators of psychosis such as delusions (misconceptions or beliefs that are firmly held, contrary to reality). Her assessment reflected no physical or verbal behaviors, no rejection of care or wandering and she felt activities were very important to her. Resident #1 required supervision of one staff for mobility and limited assistance of one to two staff for dressing and toilet use, and extensive physical assistance of two staff for personal hygiene. Resident #1 was totally dependent on two staff for bathing, used a wheelchair for ambulation, and had range of motion impairment in both her upper and lower extremities. Resident #1 received antipsychotic and antidepressant medications on a routine basis and a gradual dose reduction had not been attempted. Resident #1's care areas triggered for care planning included cognitive loss/dementia and psychotropic drug use. <BR/>Review of Resident #1's physician's orders for April 2023 and signed by PHY E, reflected on 04/07/23 she was prescribed Quetiapine Fumarate (Seroquel) 100 mg once at bedtime for delusions related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. (Note: FDA WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-warning, atypical antipsychotic drugs are associated with an increased risk of death; Quetiapine is not approved for elderly patients with Dementia Related Psychosis, www.fda.gov. accessed 05/26/23). <BR/>Review of Resident #1's April 2023 MAR reflected she was administered Seroquel every evening from 04/07/23 through 04/28/23.<BR/>Review of Resident #1's care plan dated 04/10/23 reflected she used antidepressant medication and antianxiety medication. There was no documented care area for her use of an antipsychotic medication and interventions/goals, nor was there documented care plan discussion related to her cognitive loss/dementia.<BR/>Review of Resident #1's Face Sheet dated 05/19/23 reflected her daughter was her responsible party. <BR/>An interview with the SW on 05/19/23 at 12:23 PM revealed she had a care plan meeting with Resident #1 in the first week of admission. The SW said she called Resident #1's RP for a care plan meeting, but when she talked to residents and they were their own RP, she asked if they wanted family involved. The SW said she did not know if Resident #1 had a diagnosis of dementia. The SW stated if a resident did have a diagnosis of dementia, she had never been told she had to include the resident's RP with the care plan meeting. She said, When I feel I reach out and they don't return my calls, I feel I have to move forward with the resident and what they want. I do leave messages. I should document in PCC when I do that. Should I? Yes. Did I? I don't know. If I did, it would be in the care plan assessments. The SW was asked to provide any evidence that a care plan meeting was held with the resident and members of the IDT, including her RP. She did not return with any information.<BR/>An interview with Resident #1's RP on 05/19/23 at 12:01 PM revealed someone from the facility had called the day before (05/18/23) stating Resident #1 was having a lot of trouble, thinking the secret service was coming to pick her up and take her, seeing people who were dead and in an agitated state .The RP said Resident #1 had been on psychotropic medications in the past but this psychosis is new; .from what I understand, she has been very agitated lately, we think because of a UTI. The RP said when the resident went to the hospital, she had been complaining of chest pain, but the doctors determined if was musculoskeletal, anxiety based but she also had a UTI. The RP stated the facility had told her the day before that Resident #1 was not eating, not interacting, a little childish, throwing things, which she did when she got frustrated, so the facility had asked the RP permission to give the resident Depakote. The RP was asked if she was aware the facility had prescribed Resident #1 Seroquel for several weeks in April 2023 and she stated no. She said the day prior, the facility wanted her to start on the mood stabilizer but the RP did not want her to be drugged up all the time. The RP stated there was suspicion that Resident #1's dementia was related ot her Parkinson's disease. Behavioral wise, the RP stated Resident #1 would get upset if someone was in her room, especially if they were touching her belongings, because she would think they were going to steal it. The RP stated there had been no care plan meeting since Resident #1's admission yet and I really did want to do that because I want to be active in her care.<BR/>Review of the facility's policy titled, Comprehensive Care Plan (undated), reflected, A comprehensive care plan will be developed within 7 days after the completion of the comprehensive assessment; prepared and/or contributed to by an interdisciplinary team, that includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, to the extent practicable, the participation of the resident and the resident's representative(s). An explanation will be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan; .The facility will provide the resident and the resident representative, if applicable with advance notice of care planning conferences to enable resident/resident representative participation, Resident and resident representative participation in care planning can be accomplished in many forms such as holding care planning conferences at a time the resident representative is available to participate, holding conference calls or video conferencing. Facilities are expected to facilitate the residents' and if applicable, the resident representative's participation in the care planning process .If the facility determines that the inclusion of the resident and/or resident representative is not practicable, documentation of the reasons, including the steps the facility took to include the resident and/or resident representative, will be included in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of three residents reviewed for care plans.<BR/>The facility failed to ensure Resident #1's comprehensive care plan addressed her need for an antipsychotic medication-Seroquel (Quetiapine Fumarate) and related behavioral interventions. <BR/>This failure could place residents at risk of receiving inadequate interventions not individualized to their health care needs. <BR/>Findings included:<BR/>Review of Resident #1's admission MDS assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's active diagnoses included non-Alzheimer's dementia, Parkinson's disease, thyroid disorder and hyperlipidemia. Her BIMS score was 10, which indicated moderately impaired cognition. Resident #1 had delirium as evidenced by fluctuating inattention and mood issues related to depression and lack of appetite. Resident #1 also had potential indicators of psychosis such as delusions (misconceptions or beliefs that are firmly held, contrary to reality). Her assessment reflected no physical or verbal behaviors, no rejection of care or wandering and she felt activities were very important to her. Resident #1 received antipsychotic and antidepressant medications on a routine basis and a gradual dose reduction had not been attempted. Resident #1's care areas triggered for care planning included cognitive loss/dementia and psychotropic drug use. <BR/>Review of Resident #1's care plan dated 04/10/23 reflected she used antidepressant medication and antianxiety medication. There was no documented care area for her use of an antipsychotic medication and interventions/goals, nor was there documented care plan discussion related to her cognitive loss/dementia.<BR/>Review of Resident #1's physician's orders for April 2023 and signed by PHY E, reflected on 04/07/23 she was prescribed Quetiapine Fumarate (Seroquel) 100 mg once at bedtime for delusions related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. (Note: FDA WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-warning, atypical antipsychotic drugs are associated with an increased risk of death; Quetiapine is not approved for elderly patients with Dementia Related Psychosis, www.fda.gov. accessed 05/26/23). <BR/>Review of Resident #1's April 2023 MAR reflected she was administered Seroquel every evening from 04/07/23 through 04/28/23.<BR/>An interview with the SW on 05/19/23 at 12:23 PM revealed the behavioral goals and interventions for a resident were written by the MDS nurse and the psychotropic medications were care planned by the nurse or the MDS nurse. The SW stated she had no responsibility in developing those parts of the care plan. <BR/>An interview with the MDS nurse (LVN J) on 05/19/23 at 12:36 PM revealed if a behavior was acute, then the DON or ADONs completed the care plan, and if a resident had a new order for a psychotropic medications, then that was considered acute and the DON or ADONs would write the acute care plan update, but anyone can, but that is usually who. We have two ADONs here.<BR/>An interview with ADON F on 05/19/23 1t 12:46 PM revealed if Resident #1 came into the facility with no known behaviors, then the nurse management would have not documented anything on her care plan. However, if her behaviors started after admission and showed a change in condition, then the care plan would have to be updated, but she did not know how quickly or the time frame. She said there were chronic and acute care plans and any of the nursing management had access to update the care plans. <BR/>An interview with the ADM on 05/19/23 at 5:04 PM revealed anything acute should be care planned by the DON, ADONs or the charge nurse. The ADM stated, When you have someone like [Resident #1], who has behavioral issues, you are going to have things that auto populate, but for a care plan to be resident specific, you have to go in and put each individual goal. <BR/>Review of the facility's policy titled, Comprehensive Care Planning, (not dated), reflected, Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs; .If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA and how the risk, weakness or need affects that resident. Documentation regarding these assessments and the facility's rationale for deciding whether or not to proceed with care planning for each area triggered will be recorded in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident's drug regimen must be free from unnecessary drugs, to include an excessive dose (including duplicate drug therapy); excessive duration; without adequate monitoring; without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued for one (Resident #1) of three residents reviewed for psychotropic medications. <BR/>1. The facility failed to ensure Resident #1 was prescribed Seroquel (quetiapine fumarate) without adequate indications for its use. <BR/>2. The facility failed to ensure Resident #1, who had a diagnosis of dementia and Parkinson's disease, was not prescribed an anti-psychotic medication prior to determining if there were other causes for her escalating behaviors. After the medication was initiated, Resident #1 went to the hospital where she was diagnosed with a UTI.<BR/>This failure could affect residents by placing them at risk for possible adverse side effects, a decreased quality of life and continued use of possible unnecessary medications.<BR/>Findings included:<BR/>Review of Resident #1's admission MDS assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's active diagnoses included non-Alzheimer's dementia, Parkinson's disease, thyroid disorder and hyperlipidemia. Resident #1 had minimal difficulty hearing, clear speech, was usually understood and had no vision issues. Her BIMS score was 10, which indicated moderately impaired cognition. Resident #1 had delirium as evidenced by fluctuating inattention and mood issues related to depression and lack of appetite. Resident #1 also had potential indicators of psychosis such as delusions (misconceptions or beliefs that are firmly held, contrary to reality). Her assessment reflected no physical or verbal behaviors, no rejection of care or wandering and she felt activities were very important to her. Resident #1 received antipsychotic and antidepressant medications on a routine basis and a gradual dose reduction had not been attempted. Resident #1's care areas triggered for care planning included cognitive loss/dementia and psychotropic drug use. <BR/>Review of Resident #1's care plan dated 04/10/23 reflected she used antidepressant medication and antianxiety medication. There was no documented care area for her use of an antipsychotic medication and interventions/goals, nor was there documented care plan discussion related to her cognitive loss/dementia. <BR/>Review of Resident #1's initial visit on 03/31/23 from NP A (the physician extender for the attending physician) reflected it was an initial admission visit. The NP documented that Resident #1 was at the facility for rehabilitation and long-term care status post hospitalization and the diagnosis and assessment section reflected her ICD diagnoses were: Parkinson's disease, hypothyroidism, hyperlipidemia, protein malnutrition, lower back pain, chronic pain and reduced mobility. The NP's plan for Resident #1 was documented as, .4. Psyche to eval and treat and the listed medications were Carvidopa-Levidopa and Neupro transdermal patch for Parkinson's disease, Clonazepam for anxiety, Doxepin for depression, Excedrin tension headache OTC for headaches, Omeprazole for GERD, Colace and Miralax for constipation and Mirtazapine for malnutrition. NP A's visit did not reflect any discussion of behaviors or a need for any additional psychotropic medications. <BR/>Review of Resident #1's Face Sheet dated 05/19/23 reflected her daughter was her responsible party.<BR/>Review of Resident #1's clinical progress notes reflected:<BR/>-04/01/23 by the SW-Resident agreed to psyche services, referral pending physician order for [PSY C] to [NAME] (sic) and treat for emotional health and medication management. Resident also agreed to [counseling/med management company] Psychologist to evaluate and treat for behavioral health, 1:1 therapy, pending physician order. Nursing is aware.<BR/>-04/07/23 by LVN D- PSYCH NP [PHY NP H] notified of residents behaviors(See SBAR for details). New orders given to d/c clonazepam and Buspar and to start Seroquel 100mg QHS and Xanax 0.5mg q8hrs PRN for anxiety. [family member] made aware and gave consent to administer medication.<BR/>-04/11/23 by SW- SW notified charge nurse SW did not refer resident to [name of hospital]Behavioral Health for psych services; referral made to [PHY E] 3/31/23, after consent for psych were obtained. 4/1/23 SW progress notes referral made.<BR/>-04/18/2023 Nursing Progress Note-Resident is yelling and screaming that she want to go home. Resident is also throwing her clothes and other items to the floor.<BR/>-4/18/2023 Nursing Progress Note-Alprazolam 0.5mg administered for increased agitation. Psych NP informed of adverse behavior. Will continue to monitor.<BR/>-04/18/2023 Nursing Progress Note-[Resident #1] in the middle of the 200 hall shouting that she was not going to be staying here and that someone told her she need to have a BM before she could leave. She stated that the doctor and the secret service were coming for her as soon as she had a BM and they would take her to her home. I tried to redirect her but it only made her more angry and screamed even louder I hate this place I asked could I do anything for her and she just kept screaming, I then asked if she would return to her room because other residents were getting upset. She screamed I'll go to my room but I hate it here. She went to her room and got in the bed.<BR/>-04/26/2023 Nursing Progress Note- 10:30 Resident complained of having moderate pain to her left chest. Vitals: B/P 125/67, P88, R18, Temp 97.0, O2 Sats 96% on RA. This nurse had a televisit about the resident status with [PHY E]. New order: may send Resident to Hospital for evaluation. 11:25 Resident sent To [hospital name]for evaluation via EMS. RP [name] informed about the transfer via voice mail.<BR/>-04/26/2023 Nursing Progress Note-Patient returned from the [hospital name] ER per [family member] via private auto with new orders noted. Cefdinir 300 mg capsule PO BID x 10 days -Dx: UTI.<BR/>-04/29/2023 Nursing Progress Note-Patient complaining heart attack, patient restless nurse unable assess. Temp 96.9, 02 sat 96%. 911 called an ambulance here 2:10 PM. Patient sent to hospital at 2:30 Pm. [PHY E] notified at 2:30 PM. DON notified at 1:30 PM, [family member] notified at 2 pm and 2:22 PM.<BR/>-04/30/23 Nursing Progress Note- Resident re-admitted back from the hospital. Respirations even and unlabored. No c/o chest pains. Medication reconciliation request sent to [PHY E]. Vitals: B/P 108/72, P68, R18, Temp 97.9 O2 sat 96% 0n RA. Will continue to evaluate.<BR/>Review of Resident #1's physician's orders for April 2023 and signed by PHY E, reflected on 04/07/23 she was currently prescribed Quetiapine Fumarate (Seroquel) 100 mg once at bedtime for delusions related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. (Note: FDA WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-warning, atypical antipsychotic drugs are associated with an increased risk of death; Quetiapine is not approved for elderly patients with Dementia Related Psychosis, www.fda.gov. accessed 05/26/23). <BR/>Review of Resident #1's April 2023 MAR reflected she was administered Seroquel every evening from 04/07/23 through 04/28/23.<BR/>Review of Resident #1's hospital clinical notes for her 04/29/23-04/30/23 visit reflected her chest pain was indicative of anxiety and musculoskeletal pain. Her EKG was abnormal, however, and was consistent with acute myocardial ischemia (eg: ST segment or T-wave changes that are new, dynamic or otherwise suspicious for acute ischemia). During her hospital stay, Resident #1's Seroquel was discontinued. <BR/>An interview with Resident #1's RP on 05/19/23 at 12:01 PM revealed someone from the facility had called the day before (05/18/23) stating Resident #1 was having a lot of trouble, thinking the secret service was coming to pick her up and take her, seeing people who were dead and in an agitated state .The RP said Resident #1 had been on psychotropic medications in the past but this psychosis is new; .from what I understand, she has been very agitated lately, we think because of a UTI. The RP said when the resident went to the hospital, she had been complaining of chest pain but the doctors determined if was musculoskeletal, anxiety based but she also had a UTI. The RP stated the facility had told her the day before that Resident #1 was not eating, not interacting, a little childish, throwing things, which she did when she got frustrated, so the facility had asked the RP permission to give the resident Depakote. The RP was asked if she was aware the facility had prescribed Resident #1 Seroquel for several weeks in April 2023 and she stated no. She said the day prior, the facility wanted her to start on the mood stabilizer but the RP did not want her to be drugged up all the time. The RP stated there was suspicion that Resident #1's dementia was related ot her Parkinson's disease. Behavioral wise, the RP stated Resident #1 would get upset if someone was in her room, especially if they were touching her belongings, because she would think they were going to steal it. The RP stated there had been no care plan meeting since Resident #1's admission yet and I really did want to do that because I want to be active in her care.<BR/>An interview with ADON F on 05/19/23 at 12:46 PM revealed when a resident admitted to the facility, they were either set up with one of the two psychiatric providers the facility contracted with who did psychotropic medication management. She said, So we put orders for both to see who will pick the resident up. She said [Psychiatric Agency I] I should have been discontinued since PSY C's practice was over her services. ADON F stated PSY C and his extender's role were to come in, talk to the nurses, asses the resident, see what behaviors they had, talk to the resident, and see what medications they might benefit from according to their diagnosis. ADON F said [Psychiatric Agency I] did the same thing, it just depended on who picked them up for services. ADON F stated the reason Psyche NP H from Psychiatric Agency I made changes to Resident #1's medications was because the facility nurse may have seen an order and reached out to them. ADON F stated when Resident #1 came to the facility, she came in with behaviors, so they were just trying to treat her. When she first admitted , she was in a room by herself which was what ADON F stated they usually did with new skilled resident and then she was placed with a roommate. ADON F stated Resident #1 had some behaviors of rummaging through her roommate's belongings and decorations and flowers and was trying to get the resident up by herself, so they switched rooms, but it was not working. ADON F stated, For example, she this morning, she had gotten all the clothes out of both sides and they were piled up on her side of the bed, she is packing up and ready to go. We will need to revisit that and come together as a team to see what we can do for her. ADON F was asked what was the difference between treating delusions that come from psychosis versus from a UTI. She stated, When they are first new to us and we don't know then, we may think UTI, so we get a UA with C/S to rule it out; once we get to know them better, we can determine whether it is a behavior or UTI.<BR/>An interview with ADON G on 05/19/23 at 1:16 PM revealed with a resident with dementia, Let's say for example, medicine, if a resident refuses, then we get family involved. We will try redirecting, if that doesn't work, we try activities, a snack, food. That is what we do, then contact the doctor and psyche. ADON G stated when a resident was new and had not been seen yet person to person with either of the two contracted psyche providers, we can do a televisit .Psyche NP H is with [Psychiatric Agency I]; MHNP B is with PSY C's practice. Both do medication management. ADON G stated a new resident could not be prescribed a new psychotropic medication without being seen. ADON G stated, No. What I tell my nurses is let them see nurse practitioner see the patient, do a televisit, because over the phone I can say one thing, but seeing another. If a resident had escalating behaviors, ADON G stated an SBAR would need to be completed which indicated a change in condition. If a nurse thought it was a UTI, then they could select that option as the probable cause on the SBAR and it would give the nurse symptoms to cross reference and whatever symptoms the resident had, the nurse would click on these and then the SBAR would indicate if the resident was appropriate for antibiotics. If it said that, then the nurse would contact the doctor, give a recommendation for a UA with culture and wait for further orders. ADON G stated the management team had a Standard of Care meeting once a week with the DON where various topics, including new psychotropic medications were discussed. She said with antipsychotic medication, they discuss if it a PRN and why the medication was needed, place behavior monitoring on the TAR and observe for any side effects. <BR/>An interview and observation of Resident #1 on 05/19/23 at 3:01 PM revealed she was in bed on her side of the room with a blanket, a pillow, and a few items of clothing on her bed. She said her family member was coming to get her later today. Resident #1 said she remembered going to the hospital but it was because her appendix had grown back. She said it was hurting her and pointed to her lower groin area. She was asked her if she was having any chest pain and she responded, Yes, I had heart attack and stroke. Resident #1 had a large pile of clothing piled on the floor next to her be with her roommate's name clearly written on the top articles in plain view, however, Resident #1 refused to acknowledge or admit the clothes belonged to the roommate. She denied having trouble remembering things and appeared to have adequate vocabulary and was able to understand questions. However, her responses were not congruent with the truth/reality.<BR/>An interview with the DON on 05/19/23 at 4:00 PM revealed she had been employed for four months at the facility. She said with an anti-psychotic, she always watched to make sure there was a proper diagnosis. The DON did not know why a UTI had not been ruled out prior to initiating Resident #1 on an antipsychotic. The DON stated, I asked if a UA had been done and I can't remember what the response was because that is my first thought on everything. The DON stated the danger of giving a resident with dementia an antipsychotic was they could have heart issues, increased behaviors, or the opposite effect where they are knocked out so badly, they cannot function. The DON did not know why the nurse did not rule out a UTI prior to calling Psyche NP H. <BR/>An interview with the ADM on 05/19/23 at 5:04 PM revealed Resident #1 was very anxious and had anxiety disorder but she did not know where it manifested from. The ADM stated Resident #1 would get anxious and then say she was having a heart attack and was ordered psyche services but she was not sure who ended up seeing her. The ADM felt Resident #1 admitted with an unresolved UTI which may have caused some of her behaviors. She said when a resident was ordered a new antipsychotic, it was supposed to be discussed in the morning meeting to make sure the correct documentation as done, notifications done and consents completed. The ADM stated, [Resident #1] is going to continue to escalate just due to her psychosis. The schizoaffective part she had going on, you can't change that, no reversal of that and meds sometimes makes it worse. <BR/>An interview with MHNP B on 05/23/23 at 3:29 PM revealed both contracted psychiatric companies cannot see Resident #1. He said therapy could be with the other agency and medication management could be with him, but they cannot have two psychiatric prescribers, So sometimes they don't know which one to call but there is no way he [Psyche NP H] should have made a med decision without seeing her. MHNP B said his first face to face visit with Resident #1 was on 04/12/23 and he was not a part of her getting prescribed an antipsychotic. When he came into the picture, he stated she was on PRN Xanax and then at one point she went to the hospital and he say her in May 2023. MHNP B stated, I think they just screwed up. He stated he often asked for a UA first before starting a psychotropic medication and will treat the symptoms until he can figure out what is going on. If it was a UTI, then he would continue with those medications until the UTI was resolved. MHNP B stated, For us, especially in the last years, antipsychotics is a last resort, we always try anxiety meds first then mood stabilizer then if that doesn't do the trick, we go through antipsychotics.<BR/>Review of the facility policy titled, Psychotropic Drugs, revised 10/25/17, reflected, Antipsychotic Medications: .While antipsychotic medication may be prescribed for expressions or indications of distress, the IDT must first identify and address any medical, physical, psychological causes, and/or social/environmental triggers; .Diagnoses alone do not necessarily warrant the use of an antipsychotic medications. Antipsychotic medications may be indicated if: behavioral symptoms present a danger to the resident of others; expressions or indications of distress that are significant distress to the resident; If not clinically contraindicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are presenting a danger or significant distress; and/or a GDR was attempted, but clinical symptoms returned. If antipsychotic medications are prescribed, documentation must clearly show the indication for the antipsychotic medication, the multiple attempts to implement care-panned, non-pharmacological approaches, and ongoing evaluation of the effectiveness of these interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 7 (Resident #8, Resident #12, Resident #3, Resident #44, Resident #81, Resident #24, and Resident #62) of 114 residents reviewed for call lights. <BR/>The facility failed to ensure Resident #8, Resident #12, Resident #3, Resident #44, Resident #81, Resident #24, and Resident #62's call buttons were within reach. <BR/>This failure could place residents at risk for decreased quality of life, self-worth, and dignity.<BR/>Findings included:<BR/>Review of Resident #8's face sheet dated 07/13/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease; Major Depressive Disorder; Unspecified Lack of Coordination; and Other Abnormalities of Gait. <BR/>Review of Resident #8's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #8 required supervision to extensive assistance with ADLs. <BR/>Review of Resident #8's Comprehensive Care Plan revised 07/12/23 reflected Resident #8 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 9:55 AM revealed Resident #8 was in her bed and her call light was hanging across the trash can near the wall between the bed and bedside nightstand. Resident #8 was sleeping.<BR/>Review of Resident #12's face sheet dated 07/13/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following cerebral Infarction Affecting Left Non-Dominant Side (defined as paralysis of partial or total body, whereas hemiparesis is characterized by on-sided weakness, but without complete paralysis); Contracture, Left Wrist; Contracture, Left Hand; Contracture, Left Ankle (a contracture is a fixed tightening of muscle, tendons, ligaments, or skin).<BR/>Review of Resident #12's MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired. Resident #12 required total dependence to extensive assistance with ADLs. <BR/>Review of Resident #12's Comprehensive Care Plan revised 07/07/23 reflected Resident #12 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 9:57 AM revealed Resident #12 was in her bed and her call light was under her bed. Interview with Resident #12 revealed she spoke Spanish but understand what the call button was and made a hand motion that she did not have her call button.<BR/>Review of Resident #3's face sheet dated 07/13/23 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbances, Mood Disturbances, and Anxiety; Unspecified Lack of Coordination; Unsteadiness on Feet; Other Abnormalities of Gait and Mobility.<BR/>Review of Resident #3's MDS assessment dated [DATE] reflected the resident's memory was moderately impaired. Resident #3 required supervision to limited assistance with ADLs. <BR/>Review of Resident #3's Comprehensive Care Plan revised 05/26/23 reflected Resident #3 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 10:02 AM revealed Resident #3 was in his bed sleeping and the call light was stuck under his mattress where the resident could not reach call light. <BR/>Review of Resident #44's face sheet dated 07/13/23 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Parkinson's Disease; Abnormal Posture; Repeated Falls; Difficulty Walking, Not Elsewhere Classified; Unspecified Dementia, Severe, With Other Behavioral Disturbance.<BR/>Review of Resident #44's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #44 required limited assistance to total dependence with ADLs. <BR/>Review of Resident #44's Comprehensive Care Plan initiated 06/29/23 reflected Resident #44 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 1:30 PM revealed Resident #44's call light was clipped to the back of the privacy curtain out of reach. <BR/>An interview with on 07/11/23 at 1:30 PM with Resident #44 in his room revealed that he could not safely reach his call light clipped to back of the privacy curtain. Resident was in his wheelchair beside his bed. Call light was clipped to privacy curtain near the nightside, wall, above wheelchair height, and out of reach.<BR/>Review of Resident #81's face sheet dated 07/13/23 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Severe with Other Behavioral Disturbances; Unspecified Lack of Coordination; Repeated Falls; Unsteadiness on Feet.<BR/>Review of Resident #81's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #81 required partial/moderate assistance to total assistance with ADLs. <BR/>Review of Resident #81's Comprehensive Care Plan revised 06/02/23 reflected Resident #81 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 10:04 AM revealed Resident #81 was currently in her bed asleep and call light was out of reach between the bed and wall. <BR/>Review of Resident #24's face sheet dated 07/13/23 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity with Psychotic Disturbances; Contracture of Right Knee; Contracture of Right Ankle; Contracture of Left Ankle; Contracture of Left Hand; Other Lack of Coordination; Other Abnormalities of Gait and Mobility.<BR/>Review of Resident #24's MDS assessment dated [DATE] reflected the resident was severely cognitively impaired. Resident #24 required supervision to substantial max assistance with ADLs. <BR/>Review of Resident #24's Comprehensive Care Plan revised 04/26/23 reflected Resident #24 was a risk for falls. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation and interview on 07/11/23 at 10:30 AM with Resident #24 revealed Resident #24 was in her bed and her call light was under her bed. Interview with the resident revealed she could use her call light if it was within reach.<BR/>Review of Resident #62's face sheet dated 07/13/23 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Acute Respiratory failure with Hypoxia (defined as an absence of enough oxygen in the tissues to sustain bodily functions); Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery (defined as a middle cerebral artery of the brain is suddenly interrupted (ischemia) or altogether stopped (infarction).<BR/>Review of Resident #62's MDS assessment dated [DATE] reflected the resident's memory reflects decisions consistent and reasonable. Resident #62 required supervision to limited assistance with ADLs. <BR/>Review of Resident #62's Comprehensive Care Plan revised 06/06/23 reflected Resident #81 was a risk for falls r/t impaired balance. Interventions included, Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 07/11/23 at 10:38 AM revealed Resident #62 was in her bed and her call light was under her bed. Interview with the resident revealed she did not want her call light at that time.<BR/>In an interview on 07/11/23 at 11:32 AM with RN A revealed she was not aware of the call lights were not within reach for the residents on Hall 1. RN A was asked what problems could develop if resident did not have the call light within reach and RN A stated the resident may be in pain and need medication, may try, and get up to go to the bathroom and fall, may have a medical emergency that needs attention. RN A would inform the CNAs.<BR/>In an interview on 07/11/23 at 11:37 AM with CNA B revealed she did not know the call lights were on the floor. CNA B was asked what could happen if call light was not within reach of resident who needed assistance and CNA B revealed a resident could try and get up and fall, may be sick and need assistance, or may just need water. CNA B revealed she would make sure all call lights were within reach. Asked CNA who is responsible to make sure call lights are within reach, and she replied, the CNAs.<BR/>Requested a policy for Call Lights from ADM at 4:00 PM on 07/12/23. <BR/>In an interview on 07/13/23 at 11:15 AM, the ADM revealed the facility did not have a policy for Call Lights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 1 of 23 residents (Resident #97) reviewed for ADLs. <BR/>The facility failed to provide Resident # 97 with showers/bed baths on a consistent basis. <BR/>This failure could place residents at risk for poor personal hygiene and a decline in their quality of life and health status.<BR/>Findings included: <BR/>Record review of Resident #97's electronic face sheet, dated 07/13/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #97 had diagnoses which included anoxic brain damage (no blood flow to brain tissue), chronic respiratory failure with hypoxia (oxygen is not available in sufficient amounts), tracheostomy status (has an opening through neck into the trachea to allow air to fill the lungs), gastrostomy status (has an opening into the stomach for feeding through a tube), and dependence on respiratory [ventilator] status. The electronic face sheet also revealed Resident # 97 was in a B bed. <BR/>Record review of Resident #97's MDS assessment, dated 06/07/23, revealed Resident #97 was comatose (in a state of deep unconsciousness for a prolonged or indefinite period), Further review revealed section G0120. Bathing indicated code 4 (Total dependency), which meant full staff performance every time during entire 7-day period. Resident # 97 was not on hospice. <BR/>Record review of Resident #97's bathing ADLs in her electronic medical record revealed Resident # 97 was supposed to get a bath Mondays, Wednesdays, and Fridays on the 6am to 2pm shift. The bathing task record revealed Resident #97 received a bath on 6/23/23, 7/10/23 and 7/12/23 within a 30-day look back period. Resident # 97 missed a total of 10 showers within the lookback period. One of the 10 days there was no documentation at all (6/30/23). For nine of the 10 days it was documented that activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity. The dates of missed baths were as follows: 6/14/23, 6/16/23, 6/19/23, 6/21/23, 6/26/23, 6/28/23, 7/3/23, 7/5/23, and 7/7/23.<BR/>Observation on 07/11/23 at 10:37AM revealed Resident # 97 was non-interviewable.<BR/>In an interview on 7/12/23 at 9:59 AM with a family representative it was revealed Resident # 97 did not receive bed baths on weekends and was typically found with dirty armpits and ears when the family would visit. <BR/>In an interview on 7/13/23 at 10:42 AM the ADON revealed the aides documented in their POC (electronic system used by aides for charting) and that was the same reflected in the electronic medical record under tasks for residents. The ADON stated the aides did not use shower sheets in addition to the electronic documentation. The ADON stated family members did not do baths or showers for residents. She stated it was either the facility staff or if a resident was on hospice, hospice staff would do their baths. <BR/>In an interview on 7/13/23 at 10:50 AM CNA C revealed she normally worked 6am to 2pm shift. CNA C revealed that Resident # 97 was scheduled for a bath on the evening shift. CNA C revealed that residents in the A beds were morning shift baths and B beds were evening shift baths. CNA C stated the aides documented the baths in only one place in POC. CNA C stated that if a bath was marked as activity did not occur it meant that it did not happen. <BR/>In an interview on 7/13/23 at 11:15 AM the ADM stated most of the time A bed was a 6AM -2 PM shift shower and B bed was a 2PM to 10PM shift shower unless a resident had a preference. <BR/>In an interview on 07/13/23 at 11:17 AM the ADON stated Resident # 97 was previously on a different hall where her bath was scheduled for Mondays, Wednesdays and Fridays on the 6AM to 2PM shift. ADON stated when Resident # 97 moved to her current hallway her shower schedule should have been changed to Tuesdays, Thursdays and Saturdays on the 2PM to 10PM shift. The ADON stated when she went to print the ADL documentation for Resident # 97, she noticed that and had just fixed it. The ADON stated it was not popping up for the aides to document a bath for Resident # 97 and that was why per documentation it only appeared Resident # 97 had three baths in the past month.<BR/>In an interview on 07/13/23 at 11:24 AM the ADON stated she knew the rule that said if it was not documented it was not done. <BR/>Record review of the facility's policy titled, Bath, Tub/Shower, dated 2003, reflected The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 6 residents reviewed for neglect.<BR/>Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. This failure resulted in the resident not being assessed by a nurse, not having neurological checks performed, not receiving monitoring for possible serious injury, and the physician not being notified for approximately six hours after the fall when the resident was discovered to have significant bruising and injury to the right side of her face and head. The facility failed to ensure Student Nurse Aide A knew what to do when a resident was found on floor. <BR/>An Immediate Jeopardy was identified on 04/13/24 at 7:20 PM. While the Immediate Jeopardy was removed on 04/14/24 at 2:15 PM, the facility remained out of compliance at a scope of isolated with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal.<BR/>These failures could place residents at risk for serious injury, hospitalization and/or death.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. <BR/>Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident being rarely/never understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices.<BR/>Record review of Resident #1's Care plan revised dated 04/12/24, revealed Focus: The resident had an actual fall r/t poor safety awareness, impulsive, impaired mobility. Goal: The resident will not sustain serious injury through review date. Interventions: Bed in lowest position. Anticipate and meet the resident's needs. Assist resident back to bed during night shift when she is ambulating and lethargic. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Bolster mattress cover to bed. Continue frequent redirection with resident in an attempt to reduce falls. Encourage resident to sit throughout the day to prevent lethargy. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. fall mat at bedside. Frequent visualization throughout the night to ensure resident safety and redirect as needed. Soft helmet when out of bed as resident tolerates to prevent head injury - refuses to wear.<BR/>Review of Resident #1's progress note documented by Physician dated 04/10/24 at 4:40 AM reflected:<BR/>Fall - Head injury. Plan: [AGE] year-old admitted to [Facility] on 9/8/2023 for rehabilitation and/or long-term care secondary to dementia. The patient has a medical history significant for dementia, diabetes mellitus, generalized anxiety, vitamin B12 deficiency hyperlipidemia and hypertension. <BR/>Plan:<BR/>1. Neuro checks as per protocol<BR/>2. Skulls Series<BR/>3. Contact DON/ADON to schedule care plan and root cause evaluation to establish what interventions are needed.<BR/>4. Hold anticoagulants, Plavix, Eliquis, Xarelto for three days if head injury visualized or suspected.<BR/>5. Consider need to send for labs if hypotensive, tachycardic or has altered mental status/increased impulsivity.<BR/>6. Order xray for relevant bony structures if patient has point tenderness/swelling on exam.<BR/>7. Tylenol 1000 mg po q8h prn pain for 72 hours.<BR/>Review of Resident #1's Event Nurses Note - Bruise dated 04/10/24 at 5:41 AM, revealed the following: Location event occurred - Unknown. Location of Injury: Right side of the forehead. Description: Blue/Purple, Unknown Origin. Nursing description of the event: [CNA reported that had a big purple bruise on the right side of the forehead].<BR/>Review of Resident #1's progress note documented by LVN B at 04/10/24 at 5:57 AM revealed the following: Cna reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified.<BR/>Review of Resident #1's Event Nurses Note - Fall dated 04/10/24 at 6:01 AM revealed the following: Location event occurred - Unknown. Unwitnessed, Hit Head. Injury - Bruise. Right side of forehead. Swelling Present, Blue/Purple. CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified.<BR/>Review of Resident #1's Final X-Ray Report dated 04/10/24 at 15:14 [3:14 PM] revealed the following:<BR/>Examination: PELVIS, RIGHT SHOULDER, SKULL. Clinical Indication: Pain in right shoulder; pelvic and perineal pain; unspecified fall, initial encounter. <BR/>SKULL - Findings: There is no definite displaced or depressed calvarial fracture by plain film. Impression: No definite acute displaced or depressed calvarial fracture by plain film.<BR/>RIGHT SHOULDER - Findings: There is an old healed fracture of the proximal diaphysis of the right humerus. No acute fracture or dislocation is identified. Impression: No acute fracture is identified.<BR/>PELVIS - Findings: No acute fracture or dislocation. Impression: No acute osseous abnormality is seen.<BR/>Review of facility's Incident Report completed by the DON, dated 04/12/24 reflected the following: Date of Incident: 04/10/24 5:47AM - CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Conclusion: Resident observed on the floor by aide beside her bed. Large purple bruise noted to right side of forehead and eye as a delayed injury to fall. Interventions: Frequent visualization during evening and night hours as resident becomes restless. Psych to continue to evaluate and adjust meds as indicated. Resident refuses to allow helmet to be placed on her. Continue low bed and fall mat at bedside. <BR/>Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed with floor mats on each side of her bed. Resident #1 was covered up to her forehead. A swollen dark purple/blue bump was observed on the right side of the resident's forehead/temple. <BR/>Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Resident #1 had significant bruising to her right side of her face. The bruise started from Resident #1's forehead, spread all the way down to her neck and both of her eyes were bruised. Resident #1 was not a good historian, and she was unable to recall having a fall. She denied being in any pain. Interview with Resident #1's Family Member revealed Resident #1 had a fall the night of 04/09/24 at 7:55 PM. She stated Resident #1 was on the floor until 4:33 AM. Resident #1's Family Member stated she had a camera in the resident's room. She stated the camera recorded footage when motion was detected and only recorded in 6 seconds increments. Review of camera footage date stamped 04/09/24 at 19:40 [7:40 PM] revealed Resident #1 was lying in bed trying to get up, and her bed was in a low position with no fall mats observed. Resident #1's bedside table, walker, and a chair on the right side of resident bed closed by. At 19:55 [7:55 PM] Resident #1 was on the floor lying on her right side. Camera footage did not show how the resident fell or if she hit herself and no sounds were made by the resident. Resident #1 was observed moving her head and left arm. At 21:46 [9:46 PM] it was observed a staff member with pink scrubs entered the room and left. The camera footage audio revealed the staff voicing while she was leaving the room at 21:46 [9:46 PM] Hey can you get the aide. At 21:58 [9:58 PM] Resident #1 was observed in bed. The camera footage did not show who or how Resident #1 was placed back in bed. Resident #1 was positioned horizontally on her right side with her feet hanging from the bed. There was no movement in the room for the camera to record from 21:58 [9:58 PM] to 4:17 AM Resident #1 was lying in bed vertical position. No observation of fall mat. At 4:33 AM a CNA was observed prepping to provide incontinence care for Resident #1, and Resident #1 was observed turning to her left side. Resident #1's Family Member stated she had a missed call from the facility on 04/10/24 at 4:59 AM and then within seconds she returned the call. She stated the facility nurse contacted her and notified her of the bruise. She stated the nurse asked her to review the cameras because they were not sure how Resident #1 sustained the bruise. She stated she reviewed the camera footage and noticed Resident #1 had the fall. Resident #1's Family Member stated she could not recall the name of the nurse who called her. She stated she had not been told much about the incident only that they had completed x-rays and results were fine.<BR/>Interview on 04/13/24 at 12:04 PM with LVN A revealed he was the charge nurse assigned to the secure unit. He stated Resident #1 bruise was noted the morning of 04/10/24 by the 10PM-6AM staff. He stated he believed Resident #1 had a fall the night of 04/09/24 unsure how; however, Resident #1 sustained a bruise to her right side of her forehead. He stated throughout the days the bruise began to spread all over Resident #1's right side of the face. LVN A stated Resident #1 was able to ambulate on her own. He stated they provided Resident #1 with a wheelchair or a walker but Resident #1 refused to use them. LVN A stated they completed an x-ray on 04/10/24 with no findings. <BR/>Interview on 04/13/24 at 12:19 PM with CNA B revealed she was the assigned CNA for Resident #1. She stated the morning of 04/10/24 she came in for her shift at around 5:45 AM, she stated she was given report that Resident #1 had a bruise to her forehead, she stated resident had a fall during the 2:00 PM-10:00 PM shift and someone had picked her up. She stated she was not provided with much information. She stated when she completed her rounds the morning of 04/10/24, she was not able to see the bruise due to Resident #1 sleeping on her right side. She stated she could not recall the CNA who noticed the bruise. <BR/>Interview on 04/13/24 at 12:59 PM with LVN C revealed she was the nurse assigned to the secure unit on 04/09/24 from 2:00 PM-10:00 PM shift. She stated during her shift, her CNAs were CNA H for the male side and another CNA for the female side but could not recall her name. LVN C stated her shift ended at around 11:30 PM. She stated the last time she observed Resident #1 on 04/09/24 was around 9:30 PM-10:00 PM, she stated Resident #1 was sleeping on her right side. She stated she did not observe any bruising to her face. She stated she was never notified by her CNAs that resident had a fall. She stated she left her shift without being informed Resident #1 was found on the floor. <BR/>Interview on 04/13/24 at 2:29 PM with Student Nurse Aide revealed she had been employed since November 2023. She stated she had been assigned to the secure unit twice. She stated the last time she had worked in the secure unit was on 04/09/24 from 2:00 PM-10:00 PM. She stated she was the CNA assigned to Resident #1 on 04/09/24. She stated she completed her rounds between 7:00 PM-7:30 PM and Resident #1 was in bed sleeping. She stated when CNA G came in for her 10:00 PM-6:00 AM shift. She stated CNA G was completing her rounds when she voiced Resident #1 was not in her room. She stated she began to look for her and then she returned to Resident #1's room and found Resident #1 on the floor. She stated she called for another staff to come assist her; however, it was the first time she had observed a resident on the floor that the only thought that came to mind was to get her up. She stated she picked up the resident by herself. She stated Resident #1 did not complain of pain. She stated once she placed Resident #1 in the bed, she went to the hall and observed CNA G. She stated she notified CNA G that Resident #1 was on the floor and she picked her up and left for her shift around 10:00 PM. She stated she did not notify the nurse because she thought CNA G was going to notify the nurse. She stated the next morning on 04/10/24 she was called by the ADON asking her if Resident #1 had a fall. She stated she was told Resident #1 sustained a bruise to her forehead. She stated her mistake was not notifying the nurse. She stated she had completed her training on relias but could not recall any other in-services on falls. She stated she was in-serviced after the incident to not move the resident and to notify the nurse. She stated the potential risk of moving a resident after a fall could cause serious injuries and the risk of not notifying the nurse could delay treatment. <BR/>An attempt was made on 04/13/24 at 2:57 PM to contact CNA E by phone; however, there was no response.<BR/>Interview on 04/13/24 at 3:02 PM with LVN F revealed he was the nurse assigned to Resident #1 the night of 04/09/24 from 10:00 PM-6:00 AM. He stated he completed his rounds every 2 hours. He stated Resident #1 was sleeping on her right side and they were not able to observe the bruise. He stated at around 4:00 AM-4:30AM, CNA E, assigned to the hall, notified him that Resident #1 had a bruise on her forehead. He stated he immediately assessed her and notified the Administrator. He stated he could not see any documentation regarding a fall or the bruise. LVN F stated they spoke to CNA G and CNA G stated that Resident #1 had a fall during the 2:00 PM-10:00 PM shift but was unaware if the Student Nurse Aide notified the nurse. LVN F stated he notified the doctor and family. He stated he asked Resident #1's Family Member to review the camera footage to see if Resident #1 had a fall. LVN F stated the doctor ordered x-rays and to monitor the bruise. LVN F stated by the Student Nurse Aide not notifying the nurse caused a delay in assessing the resident. <BR/>Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the assigned CNA for Resident #1 on 04/09/24 from 10:00 PM-6:00 AM for about 20 minutes. She stated on 04/09/24 closed to 10:00 PM she began her rounds. She stated she passed by Resident #1 room and Resident #1 was not in her bed. She stated she notified the Student Nurse Aide Resident #1 was not in her bed, she stated she completed her rounds while the Student Nurse Aide looked for Resident #1. CNA G stated she was not sure the what the aide's name was. She stated when she completed her rounds, the Student Nurse Aide informed her that she had found Resident #1, when she asked her where, Student Nurse Aide told her that Resident #1 was on the floor and that she had picked her up. CNA G stated when she was going to go check on Resident #1, she was called by another nurse to go 100 Hall. CNA G stated she never observed Resident #1 the night on 04/09/24. She stated she never asked the Student Nurse Aide if she had notified the nurse. CNA G stated she did not follow up on Resident #1 because she thought the Student Nurse Aide had notified someone. CNA G stated around 5:00 AM, she was asked by CNA E if she had observed Resident #1's bruise. She stated she notified CNA E and LVN F that the 2:00 PM-10:00 PM Student Nurse Aide staff had told her Resident #1 had a fall but was unsure if the Student Nurse Aide had notified the nurse. CNA G stated after she was asked about the fall it clicked on her and stated she should had followed up with the nurse. CNA G stated the risk of picking up a resident without being assess by a nurse could cause a serious injury and by not notifying the nurse could delay treatment. <BR/>An attempt was made on 04/13/24 at 4:00 PM to contact CNA E by phone; however, there was no response.<BR/>Interview on 04/13/24 at 4:32 PN with the DON revealed Resident #1 had a fall the night of 04/09/24. The DON stated she was unsure how everything happened, she stated she was notified on 04/10/24, that Resident #1 had bruising to her right side of the face. She stated they spoke to Student Nurse Aide and she told them that she had found Resident #1 on the floor unknown of the time and that she picked her up. She stated she spoke to CNA G and CNA G stated that Student Nurse Aide told her that Resident #1 was found on the floor and that the Student Nurse Aide had picked her up. The DON stated the Student Nurse Aide failed to notify the charge nurse of Resident #1 being on the floor and picked her up without being assessed first. The DON stated they completed 1:1 in-serviced with Student Nurse Aide on fall prevention and reporting on 04/10/24. The DON stated staff had completed in-services prior to fall but not after the incident. <BR/>Interview on 04/13/24 at 4:48 PM with the Administrator revealed Resident #1 had a fall on 04/09/24; however, she was notified on 04/10/24. She stated she was told Resident #1 had a fall in her room and that the Student Nurse Aide transferred Resident #1 back into bed. She stated on 04/10/24, during morning stand up, they found out that the Student Nurse Aide failed to notify the nurse that Resident #1 had a fall and that she helped the Resident #1 back up without being assessed. She stated Student Nurse Aide was in-serviced after the incident. <BR/>Review of Student Nurse Aide's personnel file revealed the following forms: <BR/>Student Nurse Aide completed fall prevention training and completed the fall prevention test. Fall Prevention test dated 11/15/23, reflected one of the test questions was regarding, Once you have ensured the person's safety when discovering a fall, what is the next step? Student Nurse Aide responded: Notify the Charge Nurse.<BR/>Coaching Form - dated 04/10/24: Situation: Staff failed to report a fall.<BR/>Student Nurse Aide statement I [name] was making my last round w/ the aide that was working 10-6. We noticed [Resident #1] wasn't in her bed, we went checking other rooms and that's when I went back in and seen [Resident #1] on the floor as if she missed trying to sit on the bed. The first thing I did was help her off the floor onto the bed. I then asked the other aide to help me put her on the bed the right way. She said she's okay and will fix her later. I did not tell the nurse I thought maybe she would've reported it. My mistake.<BR/>Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected the following: <BR/>The resident has the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. <BR/>Adverse Event: An adverse event is an untoward, undesirable, and usually unanticipated even that causes death or serious injury, or the risk thereof. <BR/>Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.<BR/>Reporting: If the allegations involve abuse or results in serious bodily injury, the report is to be made within 2 hours of the allegation. <BR/>If the allegations does not involved abuse or serious bodily injury, the report must be made within 24 hours of the allegations. <BR/>An Immediate Jeopardy was identified on 04/13/24. The Administrator was notified of the Immediate Jeopardy on 04/13/24 at 7:20 PM and was provided with the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/14/24 8:40 AM and reflected the following:<BR/>-As of 4/10/24, Student Nurse Aide A was in-serviced 1:1 by the DON on the following: All in-servicing was completed on 4/13/24. <BR/> -Abuse and Neglect Policy<BR/> - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse:<BR/> - A resident is found on the floor (witnessed or unwitnessed)<BR/> - A resident has an injury that is new (bruise, skin tear, abrasion, laceration)<BR/> - Fall Prevention Policy <BR/>- On 4/13/24 head to toe assessments were initiated for all residents for any injuries including bruising. No additional issues were found. Assessments were completed by the DON, ADON and Tx Nurse on 4/14/24. <BR/>- The medical director was notified of the immediate jeopardy by the administrator on 4/13/24. <BR/>- AD HOC QAPI was held with the Medical Director and facility interdisciplinary team on 4/13/24 to discuss the immediate jeopardy and subsequent plan of removal. <BR/>In-services:<BR/>All staff will be in-serviced on the following topics below by the Administrator, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff and staff on leave received in-services electronically. Staff members who received in-servicing electronically must see the DON/Administrator prior to working their next shift to acknowledge understanding and sign in-services. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date: 4/14/24. <BR/> - Abuse and Neglect Policy<BR/> - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse:<BR/> - A resident is found on the floor (witnessed or unwitnessed)<BR/> - A resident has an injury that is new (bruise, skin tear, abrasion, laceration)<BR/>- Fall Prevention Policy<BR/>-Neuro Checks Policy (Charge Nurses Only)<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Review of the following in-services dated 04/13/24 revealed training for Abuse and Neglect, IR (Incident Report) Reporting, Neuro Checks and Fall Prevention Policy. In-services revealed all staff completed the trainings. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM.<BR/>Review of sample residents Assessments revealed head to toe assessments were completed. <BR/>Review of facility QAPI Meeting revealed meeting was completed on 04/13/24. <BR/>Observations on 04/14/24 from 9:15 AM through 10:48AM revealed no other residents with bruising or injuries noted. <BR/>Interviews on 04/14/24 from 10:22 AM through 2:00 PM with CNA B, LVN C, Student Aide D, CNA G, CNA H, CNA I, RN J, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA T, CNA U, CNA V, LVN W, LVN X, LVN Y, LVN Z, Treatment Nurse, Medication Aide, ADON K, ADON L, HR Coordinator, Assistant BOM, Staffing Coordinator, Medical Records, Guest Relations Coordinator, Social Worker, Dietary Manager, Dietary A, Dietary B, Dietary D, Housekeeping Supervisor, Housekeeping A, Housekeeping B, Housekeeping C, Housekeeping D, Floor Tech, Respiratory Therapist A, Respiratory Therapist B, Occupational Therapist, and Maintenance Director who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM revealed the Staff were able to verify education was provided to them, nursing staff were able to accurately summarize what to do if a resident was found on the floor (witnessed or unwitnessed), if a resident has an injury that is new (bruise, skin tear, abrasion, laceration), fall prevention policy, and neuro checks (Charge Nurses Only). <BR/>The Administrator and DON were informed the Immediate Jeopardy was removed on 04/14/2024 at 2:15 PM. 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 isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident, the resident's representative, and the ombudsman were notified in writing of the resident's transfer or discharge, and in a language and manner they understand, for one (Resident #1) of one resident reviewed for discharge. <BR/>The facility failed to provide Resident #1 or their responsible party and the local ombudsman in writing a 30-day notice of discharge from the facility before the resident was transferred to another long-term care facility. <BR/>This failure could affect the residents by placing them at risk of being discharged and not having access to available advocacy services, discharge options and appeal processes. <BR/>Findings include:<BR/>Review of Resident #1's face sheet, dated 05/09/2023, revealed she was a [AGE] year-old female, who admitted to the facility on [DATE] and discharged on 04/28/2023. Contact #1 was listed as the Guardian, Responsible Party, Financial Contact, Care Conference Person, Emergency Contact, Resident Representative, and Essential Caregiver. Resident #1 had the following diagnoses: Dementia, Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbances, and Anxiety; Major Depressive Disorder, Recurrent, Mild; Generalized Anxiety Disorders; Schizoaffective Disorder, Bipolar Type; and Unspecified Psychosis, not due to substance or known Psychological Condition.<BR/>Review of Resident #1's MDS assessment dated [DATE], reflected the resident had a BIMS score of 9. The mental status score of 9. The mental status score of 9 reflected the resident has minimal memory issues with cognition and could understand some information presented to her.<BR/>Record review of Resident#1's care plans dated 07/21/2021 revealed the resident had delirium or acute confusional episodes r/t Alcohol use/abuse; 07/21/2021 revealed the resident had behaviors of cursing, verbal aggression towards others; and the care plan dated 05/26/2022 revealed the resident had a mood problem r/t schizoaffective disorder. <BR/>Review of Resident #1's clinical record revealed the SW documentation, dated 4/27/2023 at 4:26 PM reflected the Guardian was spoken to via email of corporate's decision to restructure the secured unit reflecting, We have started to transition 500 Hall secured unit into a special care unit, for residents who have Alzheimer's and other types of dementia and need special care. As you are aware the resident needed alternate placement because of frequent, noncompliant aggressive behaviors. <BR/>Interview with the Administrator on 05/09/2023 at 5:29 PM revealed the email the SW sent to the Guardian dated 04/27/2023 at 4:26 PM served as the notification to the Guardian. Administrator revealed reason for transfer, All the abuse incidents starting the company decided it will be a more focused on Memory care and away from the behaviors. The Administrator provided the letter of discharge date d 04/27/2023 was mailed on 04/28/2023 to Guardian and the Ombudsman. The Administrator revealed that the physical letter to the Guardian was mailed on 04/28/2023 and served as the notification to the Guardian.<BR/>Interviewed the Guardian on 05/09/2023 at 11:00 AM the Guardian's said she received a phone call on the afternoon of 04/28/2023, by the SW that the resident had been moved to the new facility. The Guardian had not been given sufficient notice of the resident's transfer nor involved in the decision of the choice of the facility. The Guardian had been for a visit from another city on 04/27/2023 and no one had mentioned that the resident was moving the next day. Resident #1 told her Guardian that she was told she was moving.<BR/>A telephone interview with the Ombudsman on 05/09/2023 at 10:30 AM revealed she did not receive a copy of the discharge notification of the facility's intent to discharge Resident #1 as soon as practicable. The Ombudsman received notification from the facility Administrator on 05/01/2023 with the letter dated 04/27/2023. <BR/>Record review of the facility's policy titled Discharge or Transfer to Another Facility, policy undated, revealed r/t facility-initiated discharges: the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered. For facility-initiated transfer or discharge of a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Additionally, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who enters the facility with an indwelling catheter or subsequently receives one, based on the resident's comprehensive assessment, receives appropriate treatment and services for 1 of 1 resident (Resident #1) reviewed for incontinence.<BR/>The facility failed to ensure: <BR/> Resident #1's catheter bag was placed below the level of the bladder and remained free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag) on 11/16/23.<BR/> Resident #1 had a catheter strap and was held in place to prevent pulling or tugging of indwelling catheter tubing at insert site on 11/16/23.<BR/>Perineal cleaning for Resident #1 with an indwelling catheter in accordance with the resident's needs, goals for care and professional standards of practice to provide ongoing monitoring, to recognize, and report any changes in condition to Resident #1 on 11/16/23.<BR/>These failures resulted in harm to Resident #1 in that Resident #1 had white fluid (discharge) was noted around the head of the penis and at the urethral meatus (insert site of the indwelling catheter tubing). Resident #1's urethral meatus appeared to have an approximate one-inch tear or split where the tubing rested and could place residents at risk of improper catheter care and catheter-associated urinary tract infections.<BR/>Findings included:<BR/>A record review on 11/16/23 at 9:13 AM of Resident #1's face sheet revealed a 74 y.o. male initially admitted to SNF on 03/09/23. Resident #1's diagnoses information included chronic respiratory failure; Neuromuscular dysfunction of bladder (urinary condition when lack of bladder control is due to a brain, spinal cord or nerve problem); HF (when the heart cannot pump enough blood and oxygen to support other organs in your body); cerebral infarction (parts of the brain become damaged or die due to blood vessel blockage); and BPH (frequent need to urinate [during the day and night], a weak urine stream, and leaking or dribbling of urine) with lower urinary tract symptoms (not being able to fully empty the bladder raise the risk of infection in the urinary tract).<BR/>Resident #1's Quarterly MDS assessment dated [DATE] revealed most recent reentry into the SNF was 07/19/23. Resident #1 had a primary medical condition of Debility, Cardiorespiratory Conditions with invasive mechanical ventilation (have a tube in the airway connected to a ventilator). The Quarterly MDS reflected a BIMS score of 15, which suggested Resident #1 was cognitively intact. Resident #1 did not reject evaluation or care that was necessary to achieve the goals for health and well-being during the Quarterly MDS review period. Resident #1 required two+ persons physical ADLs assistance. Resident #1 had an indwelling catheter in place. Resident #1 was always incontinent of bowel.<BR/>Record review of Resident #1's physician's orders reflected:<BR/>BPH medication one time a day (scheduled every night)<BR/>Medication for constipation relief one time a day (scheduled every morning)<BR/>Stool softener one time a day (scheduled every morning)<BR/>Indwelling catheter irrigation with 0.9% sterile NS every shift<BR/>Empty (indwelling catheter) drainage bag every shift<BR/>Ensure (indwelling) catheter strap in place and holding every shift as needed<BR/>Monitor F/C every shift for leakage, blockage, sediment buildup, or low output<BR/>Provide catheter care every shift<BR/>Urinary catheter 18Fr/10cc r/t neurogenic bladder to gravity drainage every shift<BR/>Record review of Resident #1's November MAR reflected LVN B entered a chart/follow up code, check mark = Administered, and her user initials in the time row (AM or Day) under the date column (11/16/2023) that indicated the following scheduled orders were completed:<BR/>Irrigate F/C with 0.9% sterile NS<BR/>Ensure catheter strap in place and holding<BR/>Monitor F/C every shift for leakage, blockage, sediment buildup, or low output<BR/>Provide catheter care every shift<BR/>Urinary catheter 18Fr/10cc r/t neurogenic bladder to gravity drainage every shift<BR/>Review of Resident #1's care plan initiated on 03/13/23 reflected:<BR/>Focus: Resident #1 had a communication problem r/t Trach (a curved tube that is inserted into the opening made in the neck and trachea [windpipe]) status [Revised 06/23/23].<BR/>Goal: Resident #1 would be able to make basic needs known daily through the review date [Revised 11/15/23; Target date 12/11/23].<BR/>Interventions:<BR/>- <BR/>Resident #1 preferred communication: (face to face, while family is present to translate) [Revised 06/24/23]<BR/>- <BR/>Observation, monitoring, education, assessing, evaluation, documentation, and reporting to MD about Resident #1's ability to express and comprehend thought(s); confounding problems; nonverbal indicators of discomfort or distress; and feedback to communication techniques that enhanced interaction. <BR/>- <BR/>Additional interventions included: ensure/provide a safe environment; monitor/document [Resident #1] frustration level; resident able to communicate by: lip reading, writing, using communication board, gestures, sign language, translator [Revised 03/31/23]; Use communication techniques which enhance interaction [Revised 03/31/23]; Use effective strategies touch, facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, interpreter, time to communicate, 1:1, quiet setting for communicating with resident [Revised 03/31/23]; and validate resident's message by repeating aloud [Revised 03/31/23]<BR/>Focus: Resident #1 has history of or BPH [Initiated 03/13/23; Revised 11/15/23].<BR/>Goal: Resident #1 will be free of urinary complication for the next 90 days. [Initiated 03/13/23; Revised 09/06/23; Target date 12/11/23].<BR/>Interventions: LVNs/RNs to monitor for urinary retention [Initiated 03/13/23; Revised 11/15/23].<BR/>Focus: Resident #1 has Indwelling Catheter: Neurogenic bladder [Initiated 04/17/23; Revised 06/23/23].<BR/>Goal:<BR/>- <BR/>Resident #1 would show no s/s of urinary infection through review date [Initiated 04/17/23; Revised 09/06/23; Target date 12/11/23].<BR/>- <BR/>Resident #1 will be/remain free from catheter-related trauma through review date [Initiated 04/17/23; Revised 09/06/23; Target date 12/11/23].<BR/>Interventions: [Initiated 04/17/23; Revised 05/02/23]<BR/>- <BR/>CATHETER: Urinary Catheter 18 Fr/10cc to gravity drainage. Position catheter bag and tubing below the level of the bladder and in a privacy bag. <BR/>- <BR/>Change the catheter as ordered.<BR/>- <BR/>Check tubing for kinks and maintain the drainage bag off the floor.<BR/>- <BR/>Ensure tubing is anchored to the resident's leg or linens so that tubing is not pulling on the urethra.<BR/>- <BR/>Monitor and document intake and output as per facility policy.<BR/>- <BR/>Monitor/document for pain/discomfort due to catheter<BR/>Focus: Resident #1 has an ADL Self Care Performance Deficit [Initiated 03/13/23].<BR/>Goal: Resident #1 will maintain or improve current level of function through the review date. [Initiated 03/13/23; Revised 09/06/23; Target date 12/11/23].<BR/>Interventions: <BR/>- <BR/>Assist with personal hygiene as required.<BR/>- <BR/>Bathing: requires two staff for assistance; prefers bed baths as he feels like he is drowning when in the shower [Initiated 03/13/23; Revised 11/15/23]<BR/>- <BR/>Monitor/document/report to MD PRN any changes.<BR/>Observation of Resident #1 on 11/16/23 at 9:27 AM lying in bed with head of bed raised between 30 and 45 degrees. Resident #1 received respiratory support by ventilator via trach. Resident #1's catheter drainage bag was lying next to left upper outer thigh on the bed. The catheter bag was covered with a privacy bag and dull yellow drainage with sediment (white particles or specks in the urine that makes the urine appear cloudy) was noted in the curled catheter tubing between the insert site and the drainage bag. The catheter drainage bag remained on the bed while LVN A performed wound care. Resident #1 consented to observation of the indwelling catheter insert site. LVN A assisted with visual observation by opening and pulling back Resident #1's brief to expose Resident #1's pubic area and external genitalia. LVN A raised Resident #1's penis for visual inspection, then retracted the foreskin to allow visual inspection of the indwelling catheter insertion site. [NAME] fluid (discharge) was noted around the head of the penis and at the urethral meatus (insert site of the indwelling catheter tubing). Resident #1's urethral meatus appeared to have an approximate one-inch tear or split where the tubing rested. The indwelling catheter was not secured or anchored to prevent pulling, tugging, prolonged tension or pressure at the insert site. There was no foul odor or bleeding noted at the time of visual inspection, and Resident #1 denied pain or discomfort. LVN A returned the retracted foreskin to its original position around the indwelling catheter tubing. Resident #1 was repositioned, and the indwelling catheter was hung on the bed rail below the bladder and did not allow tubing or any part of the drainage system to touch the floor.<BR/>During an interview on 11/16/23 at 10:42 AM, the WMD indicated that the approximate one-inch tear or split at Resident #1's urethral meatus was known as erosion (tearing) of the urinary meatus that occurred in individuals with indwelling catheters for a long period of time. The WMD indicated that erosion was usually secondary to catheter tension at the meatus. The WMD indicated the easiest and most effective practice of properly securing the indwelling catheter could avoid erosion. The WMD stated there were no concerns of infection or trauma of Resident #1's urethral meatus.<BR/>During an interview on 11/16/23 at 1:20 PM, LVN B stated indwelling catheter care included perineal care, to always secure the catheter, irrigate as needed to allow the catheter to remain patent and to monitor for complications. LVN B said that as the nurse she was responsible for doing or ensuring catheter care was done. LVN B said that the catheter should be secured to prevent trauma or the catheter dislodge. LVN B said that CNAs provided perineal care during incontinence care and would report any complications. LVN B said that she was informed by the DON to assess, check for any sores while provided perineal care to Resident #1, and to apply Mupirocin cream to the catheter insert site. LVN B said that she noted faint blood-tinged discharge when provided perineal care and applied Mupirocin cream to the catheter insert site. LVN B said that the catheter was not secured, however the catheter drainage bag was covered by a privacy bag and hung from the bed rail above the floor.<BR/>During an interview on 11/16/23 at 1:35 PM, the DON said she expected staff to ensure catheter tubing was secured, was not kinked, or had dependent loops and catheter bags always remained below the level of the bladder. The DON said those failures could lead to an increased risk of urinary tract infections. The DON stated catheter care should be done every shift and reflected on the TAR. The DON stated that she received a text [on 11/16/23 between 9:30 AM and 10:30 AM] from LVN A that indicated Resident #1 had a little area where it looked like the catheter was pulling that looked nasty. The DON clarified the little area referred to the insert site of the indwelling catheter tubing. The DON stated she told LVN B to do peri-care and to see if an order was needed for the referenced area.<BR/>During an interview on 11/16/23 at 4:06 PM, LVN A said that she texted the DON that Resident #1's genital area looked nasty after visual inspection (with the surveyor). LVN A said that she observed a white substance when she retracted the foreskin. LVN A stated that it appeared that Resident #1 needed peri-/catheter care.<BR/>The DON did not provide a related policy for catheter care on 11/16/23 before exit. Record review of the facility procedure titled Catheter Insertion, Male/Female GP UR 03-1.0 from the Nursing Policy & Procedure Manual 2003 that reflected the steps of procedure for female and male catheter insertion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for for 1 (Resident #1) of 5 residents reviewed for quality of care. <BR/>The facility failed to ensure RN A was trained on using a non-rebreather on Resident #1 and what parameters are required and when to discontinue use of the non-rebreather. <BR/>This failure could place the resident at risk for receiving inaccurate oxygen therapy and retention of too much carbon dioxide in residents with COPD. <BR/>Findings Included: <BR/>Record review of Resident #1 ' s admission record dated 04/23/25 revealed a [AGE] year-old female with an admission date of 01/16/24. Her primary diagnosis was unspecified dementia (a brain disease that alters brain function and causes a cognitive decline), and her secondary diagnoses were Myxedma coma (this is a rare life threatening endocrine emergency that occurs when the thyroid hormone regulation is disrupted), heart failure, Atrial fibrillation (this is a heart condition that causes an irregular, often rapid heart rate that can cause poor blood flow), acute respiratory failure with hypoxia, COPD (a lung disease that blocks airflow and makes it difficult to breathe). Resident #1 was on hospice and Resident #1 RP was family. <BR/>Record review of Resident #1's quarterly MDS Assessment, dated 09/25/24, revealed the resident's BIMS score was 10 out of 15, indicating she had moderate cognitive impairment. The MDS Assessment reflected Resident #1 was able to make self-understood and understood others. Further review revealed Resident #1 was dependent on staff for all ADLs and required respiratory treatments oxygen therapy. <BR/>Review of Resident #1 ' s care plan initiated on 01/17/24 revealed the following care areas: <BR/>*Resident #1 had emphysema (a chronic lung diseases that progressively damages the tiny air sacs in the lungs)/COPD. The goal was for Resident #1 to display optimal breathing pattern daily through the review date. The interventions were to give oxygen therapy as ordered by the physician. <BR/>*Resident #1 had oxygen therapy. The goal was for Resident #1 not to have any signs and symptoms of poor Oxygen. The interventions were to change residents position every 2 hours to facilitate lung secretion movement and drainage, If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal, Oxygen at 2-4 lpm per nasal canula. <BR/>Review of Resident #1 ' s care plan initiated on 04/20/24 revealed Resident #1 had a terminal prognosis and was receiving hospice services. Resident #1 was admitted to hospice on 02/13/24 for Alzheimer ' s disease with late onset (this is a brain condition that progressively destroys memory and other important mental functions). Interventions were to review residents living will and ensure it was followed and to involve family in the discussion. Care plan did not reflect use of non-rebreather high flow supplement oxygen therapy for Resident #1. <BR/>During a phone interview with Resident #1 ' s RP on 03/26/25 at 1:26 PM revealed Resident #1 passed away on 11/14/24 at 6 pm. She said Resident #1 sounded like she was suffocating due to the non-rebreather not set correctly. She said Resident #1 ' s non-rebreather was set to administer only five liters of oxygen instead of the ten liters that were required to support non-rebreather oxygen therapy. She stated, no one noticed the wrong non-rebreather setting of oxygen until the next business day (11/14/24), when RN D corrected it and placed Resident#1 on the recommended 10 Liters to support non-rebreather treatment. She said the non-rebreather was later removed before Resident #1 passed away. <BR/>In an interview with RN A on 04/23/25 at 7:15AM, revealed she had been employed at the facility for eight months. She stated one of the CNA's (CNA J) informed her that Resident #1 was not doing well, she immediately went to Resident #1's room and assessed her [11/12/24]. She said while she was assessing her the hospice nurse RN K walked into the room. She said Resident #1 was on a nasal cannula at 3 L. RN K told her to increase Resident #1's oxygen to 5 L, therefore RN A placed Resident #1 on a non-rebreather because her oxygen level was not going up. She said RN K them got on the phone with hospice physician and obtained other orders immediately . She said she could not remember the orders as it had been a long time ago. RN A stated she had never used a non-rebreather before and she would not have done so without someone telling her to do so. She said, I believe RN K told her to use the non-rebreather for Resident #1 but She did not remember 100 percent. She stated she was not familiar on range of the oxygen on non-rebreather mask. She said she would google and ask someone for the range. She said the process of receiving orders was verbal or written and that she would put the orders in the computer after the hospice nurse gave them to her . She said some hospice nurses put their own orders in, so she was not sure if the order for the non-rebreather was added. RN A said she did not take off the non-rebreather from Resident #1 until she was stable . She said the hospice nurse left after Resident #1 stabilized and she did not tell her to remove the non-rebreather. She said because the hospice nurse was in there, she assumed it was ok to the leave the non-rebreather on because she did not say to remove it and put Resident #1 back on her nasal cannula. RN A said the hospice nurse (RN K) notified the physician and she did not have to because Resident #1 was on hospice and the hospice nurse was in the room. Said it was important to get physician orders for the safety of the patient so they can know how what to do. RN A said she was aware of RT in the facility, but it all happened so fast, and they moved as fast to stabilize Resident #1 that she forgot to ask RT to check Resident #1 who had been placed on the nonrebreather.<BR/>In a phone interview with RN K on 03/26/25 at 2:41 PM, she stated she was Resident #1 ' s hospice nurse. She said she went to see Resident #1 on 11/11/24 the non-rebreather was used on her. She said when she got to Resident#1 ' s room, Resident #1 was having difficulty breathing and had shortness of breath. She said the facility nurse RN A had already placed Resident #1 on the non-rebreather. She said she could not remember the liters of the non-rebreather because she herself and RN A were trying to stabilize Resident #1. RN K said she was knowledgeable that non-rebreathers should be set at minimum ten liters otherwise the patient is not getting the needed oxygen fast. RN K said a non-rebreather was used in emergency cases to help patients get large amounts of oxygen fast to help them recover. She said non-rebreathers were not for long term use. She said when she left, Resident #1 was still on the non-rebreather, but she was stable. She said she was not aware the facility left Resident #1 on the non-rebreather until 11/14/24. She said she did not give them any verbal orders to keep Resident #1 on the non-rebreather oxygen therapy. She said the risk to the resident for not getting orders for non-rebreather was retention of carbon dioxide especially in a resident with COPD. <BR/>In a phone interview with CNA J on 03/26/25 at 2:10 PM, she said that she worked for the hospice company that Resident #1 was admitted to while in the facility. She said she proved ADL care, to Resident #1 three times a week and then the week before she passed away, ADL care was changed to five days a week. She said that she had found Resident #1 without oxygen or still connected to an empty oxygen tank on her wheelchair on multiple occasions. She said she would connect Resident #1 to the oxygen compressor in her room then go out and tell facility nursing staff to let them know what she saw and to get Resident #1 a full oxygen tank to use in the shower room for Resident #1.CNA J said she could not remember the names of the facility staff she reported to. CNA J said the last week before Resident #1 passed away she was assigned to provide daily ADLs care as usual, she said she told the facility that Resident #1 did not need a lot of oxygen and asked them to remove the non-rebreather off Resident #1. She said Resident #1 looked more comfortable with just the nasal canula after the non-rebreather was removed. She said she could not remember the exact date when they removed the non-rebreather, but she had to tell the facility to remove it and put her on the nasal cannula. <BR/>In an interview with the DON on 04/23/25 at 12:08 PM, revealed the expectation for a non-rebreather was 10-15 L of oxygen to be effective, she said she would not expect someone to put a non-rebreather at 4-5 L DON did not state the risk because Resident #1 already had supplemental oxygen orders. <BR/>Review of facility policy titled Oxygen Administration: revised March 21, 2023, reflected . <BR/>The resident will maintain oxygenation with safe and effective delivery of prescribed oxygen .become familiar with the type of oxygen administration, medical diagnosis and reason for oxygen, intermittent or continuous use of oxygen, amount to be delivered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for fourteen (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) of thirty residents reviewed for privacy and confidentiality. 1. The facility failed to ensure LVN C pulled the privacy curtain while suctioning (mechanical aspiration of pulmonary secretions to clear the airway) Resident #1 on 07/12/2025. 2. The facility failed to ensure LVN C closed the door while suctioning Resident #2 on 07/12/2025. 3. The facility failed to ensure LVN D did not leave Residents #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13's medical information on top of his cart on 07/12/2025. 4. The facility failed to ensure RN E closed, locked, or minimized his laptop's monitor, thus, showing Resident #14's medical information on 07/13/2025. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals. Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy (is an opening surgically created through the neck to allow air to fill the lungs). Record review of Resident #1's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 05/07/2025, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 00. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #1's Comprehensive Care Plan, dated 05/21/2025, reflected the resident had tracheostomy and one of the interventions was to suction as necessary. Record review of Resident #1's Physician Order, dated 07/01/2025, reflected Check resident Q2H for suctioning need, suction via trach PRN every shift. Observation on 07/25/2025 at 9:10 AM revealed LVN C entered Resident #1's room to check on the resident. The resident signaled LVN C that she wanted to be suctioned. LVN C sanitized her hands, put on a pair of gloves, and put on a gown. She proceeded to suction the resident without pulling the privacy curtain. Resident #1 could not be seen from the hallway but could be seen by Resident #2, resident's roommate, who was sitting at the side of her bed and facing towards Resident #1's bed. Observation and attempted interview on 07/12/2025 at 10:54 AM, revealed Resident #1 did not reply when asked if it was okay for her that her roommate could see what the nurse was doing to her. 2. Record review of Resident #2's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was receiving tracheostomy care while a resident of the facility. Record review of Resident #2's Comprehensive Care Plan, dated 06/08/2025, reflected the resident had tracheostomy and one of the interventions was to suction as necessary. Record review of Resident #2's Physician Order, dated 01/16/2025, reflected Check resident Q2H for suctioning need, suction via trach PRN every shift. Observation on 07/25/2025 at 9:25 AM revealed after LVN C was done suctioning Resident #1, Resident #2 requested to be suctioned, as well. LVN C proceeded to suction Resident #2 without closing the door or pulling the privacy curtain. Resident #2 could be seen from the hallway and the treatment being done could be seen from the hallway and her roommate. In an interview on 07/12/2025 at 10:34 AM, LVN C stated she guessed she needed to close the door and pull the privacy curtain every time care or treatment was being done for the residents, not just for Resident #1 and Resident #2, to provide privacy. She said somebody from the hallway might see that they were being suctioned and the residents might be embarrassed. In an interview on 07/12/2025 on 10:54 AM, Resident #2 stated the nurses, not only LVN C, would not close the door or pull the privacy curtain when they were treating them. She said she already got used to it, but a change would be nice so that others would not see that a tube was being inserted in her throat. 3. Record review of Resident #3's Face Sheet, dated 07/12/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #3's Physician Order, dated 07/12/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . four times a day. Record review of Resident #3's Vital Signs, dated 07/12/2025, reflected BP: 98/60 mmHg, Temp: 97.6, Pulse: 86, Respiration: 20, O2 sats: 99.0%. Record review of Resident #4's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #4's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #4's Vital Signs, dated 07/12/2025, reflected BP: 100/65 mmHg, Temp: 97.5, Pulse: 70, Respiration: 18, O2 sats: 100.0%. Record review of Resident #5's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #5's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #5's Vital Signs, dated 07/12/2025, reflected BP: 81/52 mmHg, Temp: 97.5, Pulse: 80, Respiration: 21, O2 sats: 99.0%. Record review of Resident #6's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #6's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 4 hours as needed. Record review of Resident #6's Vital Signs, dated 07/12/2025, reflected BP: 105/68 mmHg, Temp: 97.5, Pulse: 87, Respiration: 21, O2 sats: 100.0%. Record review of Resident #7's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #7's Physician Order, dated 07/12/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . three times a day. Record review of Resident #7's Vital Signs, dated 07/12/2025, reflected BP: 97/61 mmHg, Temp: 97.6, Pulse: 57, Respiration: 20, O2 sats: 100.0%. Record review of Resident #8's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #8's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 8 hours. Record review of Resident #8's Vital Signs, dated 07/12/2025, reflected BP: 141/84 mmHg, Temp: 97.5, Pulse: 100, Respiration: 24, O2 sats: 99.0%. Record review of Resident #9's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #9's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 4 hours as needed. Record review of Resident #9's Vital Signs, dated 07/12/2025, reflected BP: 129/72 mmHg, Temp: 97.5, Pulse: 70, Respiration: 18, O2 sats: 100.0%. Record review of Resident #10's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #10's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours. Record review of Resident #10's Vital Signs, dated 07/12/2025, reflected BP: 99/68 mmHg, Temp: 97.4, Pulse: 54, Respiration: 16, O2 sats: 100.0%. Record review of Resident 11's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #11's Physician Order, dated 07/03/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . three times a day. Record review of Resident #11's Vital Signs, dated 07/12/2025, reflected BP: 109/69 mmHg, Temp: 97.5, Pulse: 97, Respiration: 20, O2 sats: 97.2%. Record review of Resident #12's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #12's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . four times a day. Record review of Resident #12's Vital Signs, dated 07/12/2025, reflected BP: 89/56 mmHg, Temp: 97.1, Pulse: 64, Respiration: 18, O2 sats: 99.0%. Record review of Resident #13's Face Sheet, dated 07/12/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with tracheostomy. Record review of Resident #13's Physician Order, dated 07/10/2025, reflected Assess before & after a treatment - O2 Sat, Resp Rate, Pulse . every 6 hours as needed. Record review of Resident #13's Vital Signs, dated 07/12/2025, reflected BP: 122/80 mmHg, Temp: 97.7, Pulse: 68, Respiration: 17, O2 sats: 98.0%. Observation on 07/12/2025 at 10:19 AM revealed a clipboard was on top of a nurse's cart. On the clipboard were the names of the residents, their room numbers, and their respective vital signs (blood pressure, respiratory rate, pulse rate, temperature, and oxygen saturation). In an interview on 07/12/2025 at 10:22 AM, LVN D stated he went to attend to one of the residents that was why he left his cart. He said he should have flipped the clipboard before leaving his cart because the vital signs were medical information and should be secured and not exposed for everybody to see. He said it was a HIPAA violation and the information should be confidential. In an interview on 07/12/2025 at 3:33 PM, ADON A stated the doors should be closed or the privacy pulled when providing treatment to the residents to promote dignity and privacy. She said Resident #1 and Resident #2 might be roommates but they are still entitled for privacy and dignity. She said other staff, other residents, or even visitors could see the treatment being done and might speculate the medical condition of the residents. She said it did not matter if the residents cared or not, the treatment should be done in privacy. ADON A said the staff had been trained about HIPAA over and over again and she did not know why the incident still happened. She said it was a HIPAA violation to leave the residents' health information out for everyone to see. She said the expectation was for the staff to provide privacy during treatment and to secure the residents' medical information. She said the vital signs were examples of medical information. She said she already started an in-service about dignity and privacy as soon as she heard about the issues and would coordinate with the DON on how to prevent the issues from happening again. She said they would teach more and hopefully the staff would let them know if there was something in the in-service that the did not understand. 4. Record review of Resident #14's Face Sheet, dated 07/13/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease and emphysema (a lung disease that damages the air sacs in the lung causing shortness of breath). Record review of Resident #14's Comprehensive MDS Assessment, dated 05/01/2025, reflected the resident had moderated impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident had COPD and emphysema and was on oxygen therapy. Record review of Resident #14's Comprehensive Care Plan, dated 05/15/2025, reflected the resident had oxygen therapy and the interventions were administer oxygen and medications as ordered. Record review of Resident #14's Physician Order, dated 07/10/2025, reflected Oxygen LPM: 1-5 LPM to maintain O2 sats greater than 92%. Record review of Resident #14's Physician Order, dated 04/05/2025, reflected Symbicort Inhalation Aerosol 80 - 4.5 MCG/ACT (Budesonide-Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for COPD, emphysema. Record review of Resident #14's Physician Order, dated 04/05/2025, reflected Ipratropium Bromide Nasal Solution 0.03 % (Ipratropium Bromide (Nasal)) 2 spray in both nostrils two times a day for nasal congestion. Record review of Resident #14's Physician Order, dated 01/29/2025, reflected Artificial Tears Ophthalmic Solution 0.1-0.3 % (Dextran 70-Hypromellose) Instill 2 drop in both eyes every 4 hours as needed for eye itching. Record review of Resident #14's Physician Order, dated 05/13/2025, reflected Acetaminophen-Codeine Tablet 300-30 MG Give 1 tablet by mouth every 8 hours as needed for pain, ** hold for sedation Not to exceed 3 gms APAP in 24 hour period. Observation on 07/13/2025 at 10:00 AM revealed a cart was parked at the nurses' station and was facing the hallway. On top of the cart was an open laptop and displayed Resident #14's name, status, location, gender, date of birth , age, name of physician, latest vital signs, allergies, code status, emergency instructions, and physician orders. Also seen from the computer were physician orders for the resident. The screen of the computer was facing the hallway. It was also observed that RN E was sitting inside the nurses' station. In an interview on 07/13/2025 at 10:02 AM, RN E stated he was the one using the computer. He saw that his monitor was open and Resident #14's medical information. He said he was not aware that he left his computer open and did not minimize the monitor of the computer. He said the information should be secured and only the resident, family members, and providers could see the resident's information. He said he went inside the nurses' station because he needed to notify a doctor about some laboratory result. He said he would make sure to that his computer was close every time he would leave it. In an interview on 07/13/2025 at 10:32 AM, the Administrator stated she was made aware about the privacy issues and ADON A already did an in-service about privacy during treatment and confidentiality of medical records. She said the expectation was for the staff to make sure that the residents were provided privacy during any treatment to prevent humiliation and to secure their medical records so that unauthorized individuals would not see the residents' medical information. She said they would continue to remind the staff about providing privacy and confidentiality. In an interview on 07/14/2025 at 1:00 PM, The DON stated she already knew about the incidents of not providing privacy and not securing the medical records. She said the door should be closed or the privacy curtain pulled when doing a medical procedure so other people would not see what was being done for the resident. She said if confidential information were exposed, non-nursing staff, other resident, and visitors could be able to see it. She said all staff, including her, were expected to provide full privacy during treatment and confidentiality of all the residents' medical information. She said providing privacy is a form of respect to the residents that entrusted their care to the facility. She said ADON A already started the in-service about privacy and confidentiality but she would still do a one-on-one in-service with all the staff and would make sure that they understood the in-service that they were signing. Record review of the facility's policy, RESIDENT RIGHTS undated, revealed The resident has a right to a dignified existence . Privacy and confidentiality . The resident has a right to personal privacy and confidentiality of his or her personal and medical records . 1. Personal privacy includes accommodations, medical treatment . 3. The resident has a right to secure and confidential personal and medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #1) of 6 residents reviewed for neglect.<BR/>Student Nurse Aide A, who worked the 2:00 PM-10:00 PM shift, failed to report to the charge nurse when she found Resident #1 on the floor on 04/09/24 at 9:46 PM resulting in the resident not receiving immediate treatment and care until 4:40 AM on 04/10/24, when 10:00 PM-6:00 AM staff, discovered significant bruising and injury to the resident's face/head. This failure resulted in the resident not being assessed by a nurse, not having neurological checks performed, not receiving monitoring for possible serious injury, and the physician not being notified for approximately six hours after the fall when the resident was discovered to have significant bruising and injury to the right side of her face and head. The facility failed to ensure Student Nurse Aide A knew what to do when a resident was found on floor. <BR/>An Immediate Jeopardy was identified on 04/13/24 at 7:20 PM. While the Immediate Jeopardy was removed on 04/14/24 at 2:15 PM, the facility remained out of compliance at a scope of isolated with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal.<BR/>These failures could place residents at risk for serious injury, hospitalization and/or death.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 04/14/24, revealed the resident was an [AGE] year-old female, who was admitted to the facility 09/08/23. Resident #1 had diagnoses which included dementia with other behavioral disturbance (impaired ability to remember, think, or make decisions), Type 2 diabetes, repeated falls, lack of coordination, unsteadiness on feet, essential hypertension (high blood pressure) and muscle weakness. <BR/>Record review of Resident #1's MDS quarterly assessment dated [DATE], revealed her BIMS score was not completed due to resident being rarely/never understood. MDS further revealed Section E - Behaviors for Wandering occurred daily. Resident #1 was able to ambulate without any mobility devices.<BR/>Record review of Resident #1's Care plan revised dated 04/12/24, revealed Focus: The resident had an actual fall r/t poor safety awareness, impulsive, impaired mobility. Goal: The resident will not sustain serious injury through review date. Interventions: Bed in lowest position. Anticipate and meet the resident's needs. Assist resident back to bed during night shift when she is ambulating and lethargic. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Bolster mattress cover to bed. Continue frequent redirection with resident in an attempt to reduce falls. Encourage resident to sit throughout the day to prevent lethargy. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. fall mat at bedside. Frequent visualization throughout the night to ensure resident safety and redirect as needed. Soft helmet when out of bed as resident tolerates to prevent head injury - refuses to wear.<BR/>Review of Resident #1's progress note documented by Physician dated 04/10/24 at 4:40 AM reflected:<BR/>Fall - Head injury. Plan: [AGE] year-old admitted to [Facility] on 9/8/2023 for rehabilitation and/or long-term care secondary to dementia. The patient has a medical history significant for dementia, diabetes mellitus, generalized anxiety, vitamin B12 deficiency hyperlipidemia and hypertension. <BR/>Plan:<BR/>1. Neuro checks as per protocol<BR/>2. Skulls Series<BR/>3. Contact DON/ADON to schedule care plan and root cause evaluation to establish what interventions are needed.<BR/>4. Hold anticoagulants, Plavix, Eliquis, Xarelto for three days if head injury visualized or suspected.<BR/>5. Consider need to send for labs if hypotensive, tachycardic or has altered mental status/increased impulsivity.<BR/>6. Order xray for relevant bony structures if patient has point tenderness/swelling on exam.<BR/>7. Tylenol 1000 mg po q8h prn pain for 72 hours.<BR/>Review of Resident #1's Event Nurses Note - Bruise dated 04/10/24 at 5:41 AM, revealed the following: Location event occurred - Unknown. Location of Injury: Right side of the forehead. Description: Blue/Purple, Unknown Origin. Nursing description of the event: [CNA reported that had a big purple bruise on the right side of the forehead].<BR/>Review of Resident #1's progress note documented by LVN B at 04/10/24 at 5:57 AM revealed the following: Cna reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified.<BR/>Review of Resident #1's Event Nurses Note - Fall dated 04/10/24 at 6:01 AM revealed the following: Location event occurred - Unknown. Unwitnessed, Hit Head. Injury - Bruise. Right side of forehead. Swelling Present, Blue/Purple. CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified.<BR/>Review of Resident #1's Final X-Ray Report dated 04/10/24 at 15:14 [3:14 PM] revealed the following:<BR/>Examination: PELVIS, RIGHT SHOULDER, SKULL. Clinical Indication: Pain in right shoulder; pelvic and perineal pain; unspecified fall, initial encounter. <BR/>SKULL - Findings: There is no definite displaced or depressed calvarial fracture by plain film. Impression: No definite acute displaced or depressed calvarial fracture by plain film.<BR/>RIGHT SHOULDER - Findings: There is an old healed fracture of the proximal diaphysis of the right humerus. No acute fracture or dislocation is identified. Impression: No acute fracture is identified.<BR/>PELVIS - Findings: No acute fracture or dislocation. Impression: No acute osseous abnormality is seen.<BR/>Review of facility's Incident Report completed by the DON, dated 04/12/24 reflected the following: Date of Incident: 04/10/24 5:47AM - CNA reported that Resident had a big purple bruise to the right side of the forehead, completed head-to-toe skin assessment completed, area looked tender and painful to touch, full range of motion done, patient moved all extremities in good rang of motions without pain, M/d and family notified. Conclusion: Resident observed on the floor by aide beside her bed. Large purple bruise noted to right side of forehead and eye as a delayed injury to fall. Interventions: Frequent visualization during evening and night hours as resident becomes restless. Psych to continue to evaluate and adjust meds as indicated. Resident refuses to allow helmet to be placed on her. Continue low bed and fall mat at bedside. <BR/>Observation on 04/13/24 at 9:44 AM revealed Resident #1 in her room sleeping in B Bed with floor mats on each side of her bed. Resident #1 was covered up to her forehead. A swollen dark purple/blue bump was observed on the right side of the resident's forehead/temple. <BR/>Observation and interview on 04/13/24 at 11:10 AM revealed Resident #1 in her room sitting on a chair. Resident #1 had significant bruising to her right side of her face. The bruise started from Resident #1's forehead, spread all the way down to her neck and both of her eyes were bruised. Resident #1 was not a good historian, and she was unable to recall having a fall. She denied being in any pain. Interview with Resident #1's Family Member revealed Resident #1 had a fall the night of 04/09/24 at 7:55 PM. She stated Resident #1 was on the floor until 4:33 AM. Resident #1's Family Member stated she had a camera in the resident's room. She stated the camera recorded footage when motion was detected and only recorded in 6 seconds increments. Review of camera footage date stamped 04/09/24 at 19:40 [7:40 PM] revealed Resident #1 was lying in bed trying to get up, and her bed was in a low position with no fall mats observed. Resident #1's bedside table, walker, and a chair on the right side of resident bed closed by. At 19:55 [7:55 PM] Resident #1 was on the floor lying on her right side. Camera footage did not show how the resident fell or if she hit herself and no sounds were made by the resident. Resident #1 was observed moving her head and left arm. At 21:46 [9:46 PM] it was observed a staff member with pink scrubs entered the room and left. The camera footage audio revealed the staff voicing while she was leaving the room at 21:46 [9:46 PM] Hey can you get the aide. At 21:58 [9:58 PM] Resident #1 was observed in bed. The camera footage did not show who or how Resident #1 was placed back in bed. Resident #1 was positioned horizontally on her right side with her feet hanging from the bed. There was no movement in the room for the camera to record from 21:58 [9:58 PM] to 4:17 AM Resident #1 was lying in bed vertical position. No observation of fall mat. At 4:33 AM a CNA was observed prepping to provide incontinence care for Resident #1, and Resident #1 was observed turning to her left side. Resident #1's Family Member stated she had a missed call from the facility on 04/10/24 at 4:59 AM and then within seconds she returned the call. She stated the facility nurse contacted her and notified her of the bruise. She stated the nurse asked her to review the cameras because they were not sure how Resident #1 sustained the bruise. She stated she reviewed the camera footage and noticed Resident #1 had the fall. Resident #1's Family Member stated she could not recall the name of the nurse who called her. She stated she had not been told much about the incident only that they had completed x-rays and results were fine.<BR/>Interview on 04/13/24 at 12:04 PM with LVN A revealed he was the charge nurse assigned to the secure unit. He stated Resident #1 bruise was noted the morning of 04/10/24 by the 10PM-6AM staff. He stated he believed Resident #1 had a fall the night of 04/09/24 unsure how; however, Resident #1 sustained a bruise to her right side of her forehead. He stated throughout the days the bruise began to spread all over Resident #1's right side of the face. LVN A stated Resident #1 was able to ambulate on her own. He stated they provided Resident #1 with a wheelchair or a walker but Resident #1 refused to use them. LVN A stated they completed an x-ray on 04/10/24 with no findings. <BR/>Interview on 04/13/24 at 12:19 PM with CNA B revealed she was the assigned CNA for Resident #1. She stated the morning of 04/10/24 she came in for her shift at around 5:45 AM, she stated she was given report that Resident #1 had a bruise to her forehead, she stated resident had a fall during the 2:00 PM-10:00 PM shift and someone had picked her up. She stated she was not provided with much information. She stated when she completed her rounds the morning of 04/10/24, she was not able to see the bruise due to Resident #1 sleeping on her right side. She stated she could not recall the CNA who noticed the bruise. <BR/>Interview on 04/13/24 at 12:59 PM with LVN C revealed she was the nurse assigned to the secure unit on 04/09/24 from 2:00 PM-10:00 PM shift. She stated during her shift, her CNAs were CNA H for the male side and another CNA for the female side but could not recall her name. LVN C stated her shift ended at around 11:30 PM. She stated the last time she observed Resident #1 on 04/09/24 was around 9:30 PM-10:00 PM, she stated Resident #1 was sleeping on her right side. She stated she did not observe any bruising to her face. She stated she was never notified by her CNAs that resident had a fall. She stated she left her shift without being informed Resident #1 was found on the floor. <BR/>Interview on 04/13/24 at 2:29 PM with Student Nurse Aide revealed she had been employed since November 2023. She stated she had been assigned to the secure unit twice. She stated the last time she had worked in the secure unit was on 04/09/24 from 2:00 PM-10:00 PM. She stated she was the CNA assigned to Resident #1 on 04/09/24. She stated she completed her rounds between 7:00 PM-7:30 PM and Resident #1 was in bed sleeping. She stated when CNA G came in for her 10:00 PM-6:00 AM shift. She stated CNA G was completing her rounds when she voiced Resident #1 was not in her room. She stated she began to look for her and then she returned to Resident #1's room and found Resident #1 on the floor. She stated she called for another staff to come assist her; however, it was the first time she had observed a resident on the floor that the only thought that came to mind was to get her up. She stated she picked up the resident by herself. She stated Resident #1 did not complain of pain. She stated once she placed Resident #1 in the bed, she went to the hall and observed CNA G. She stated she notified CNA G that Resident #1 was on the floor and she picked her up and left for her shift around 10:00 PM. She stated she did not notify the nurse because she thought CNA G was going to notify the nurse. She stated the next morning on 04/10/24 she was called by the ADON asking her if Resident #1 had a fall. She stated she was told Resident #1 sustained a bruise to her forehead. She stated her mistake was not notifying the nurse. She stated she had completed her training on relias but could not recall any other in-services on falls. She stated she was in-serviced after the incident to not move the resident and to notify the nurse. She stated the potential risk of moving a resident after a fall could cause serious injuries and the risk of not notifying the nurse could delay treatment. <BR/>An attempt was made on 04/13/24 at 2:57 PM to contact CNA E by phone; however, there was no response.<BR/>Interview on 04/13/24 at 3:02 PM with LVN F revealed he was the nurse assigned to Resident #1 the night of 04/09/24 from 10:00 PM-6:00 AM. He stated he completed his rounds every 2 hours. He stated Resident #1 was sleeping on her right side and they were not able to observe the bruise. He stated at around 4:00 AM-4:30AM, CNA E, assigned to the hall, notified him that Resident #1 had a bruise on her forehead. He stated he immediately assessed her and notified the Administrator. He stated he could not see any documentation regarding a fall or the bruise. LVN F stated they spoke to CNA G and CNA G stated that Resident #1 had a fall during the 2:00 PM-10:00 PM shift but was unaware if the Student Nurse Aide notified the nurse. LVN F stated he notified the doctor and family. He stated he asked Resident #1's Family Member to review the camera footage to see if Resident #1 had a fall. LVN F stated the doctor ordered x-rays and to monitor the bruise. LVN F stated by the Student Nurse Aide not notifying the nurse caused a delay in assessing the resident. <BR/>Interview on 04/13/24 at 3:35 PM with CNA G revealed she was the assigned CNA for Resident #1 on 04/09/24 from 10:00 PM-6:00 AM for about 20 minutes. She stated on 04/09/24 closed to 10:00 PM she began her rounds. She stated she passed by Resident #1 room and Resident #1 was not in her bed. She stated she notified the Student Nurse Aide Resident #1 was not in her bed, she stated she completed her rounds while the Student Nurse Aide looked for Resident #1. CNA G stated she was not sure the what the aide's name was. She stated when she completed her rounds, the Student Nurse Aide informed her that she had found Resident #1, when she asked her where, Student Nurse Aide told her that Resident #1 was on the floor and that she had picked her up. CNA G stated when she was going to go check on Resident #1, she was called by another nurse to go 100 Hall. CNA G stated she never observed Resident #1 the night on 04/09/24. She stated she never asked the Student Nurse Aide if she had notified the nurse. CNA G stated she did not follow up on Resident #1 because she thought the Student Nurse Aide had notified someone. CNA G stated around 5:00 AM, she was asked by CNA E if she had observed Resident #1's bruise. She stated she notified CNA E and LVN F that the 2:00 PM-10:00 PM Student Nurse Aide staff had told her Resident #1 had a fall but was unsure if the Student Nurse Aide had notified the nurse. CNA G stated after she was asked about the fall it clicked on her and stated she should had followed up with the nurse. CNA G stated the risk of picking up a resident without being assess by a nurse could cause a serious injury and by not notifying the nurse could delay treatment. <BR/>An attempt was made on 04/13/24 at 4:00 PM to contact CNA E by phone; however, there was no response.<BR/>Interview on 04/13/24 at 4:32 PN with the DON revealed Resident #1 had a fall the night of 04/09/24. The DON stated she was unsure how everything happened, she stated she was notified on 04/10/24, that Resident #1 had bruising to her right side of the face. She stated they spoke to Student Nurse Aide and she told them that she had found Resident #1 on the floor unknown of the time and that she picked her up. She stated she spoke to CNA G and CNA G stated that Student Nurse Aide told her that Resident #1 was found on the floor and that the Student Nurse Aide had picked her up. The DON stated the Student Nurse Aide failed to notify the charge nurse of Resident #1 being on the floor and picked her up without being assessed first. The DON stated they completed 1:1 in-serviced with Student Nurse Aide on fall prevention and reporting on 04/10/24. The DON stated staff had completed in-services prior to fall but not after the incident. <BR/>Interview on 04/13/24 at 4:48 PM with the Administrator revealed Resident #1 had a fall on 04/09/24; however, she was notified on 04/10/24. She stated she was told Resident #1 had a fall in her room and that the Student Nurse Aide transferred Resident #1 back into bed. She stated on 04/10/24, during morning stand up, they found out that the Student Nurse Aide failed to notify the nurse that Resident #1 had a fall and that she helped the Resident #1 back up without being assessed. She stated Student Nurse Aide was in-serviced after the incident. <BR/>Review of Student Nurse Aide's personnel file revealed the following forms: <BR/>Student Nurse Aide completed fall prevention training and completed the fall prevention test. Fall Prevention test dated 11/15/23, reflected one of the test questions was regarding, Once you have ensured the person's safety when discovering a fall, what is the next step? Student Nurse Aide responded: Notify the Charge Nurse.<BR/>Coaching Form - dated 04/10/24: Situation: Staff failed to report a fall.<BR/>Student Nurse Aide statement I [name] was making my last round w/ the aide that was working 10-6. We noticed [Resident #1] wasn't in her bed, we went checking other rooms and that's when I went back in and seen [Resident #1] on the floor as if she missed trying to sit on the bed. The first thing I did was help her off the floor onto the bed. I then asked the other aide to help me put her on the bed the right way. She said she's okay and will fix her later. I did not tell the nurse I thought maybe she would've reported it. My mistake.<BR/>Record review of the facility's Abuse/Neglect policy, revised 03/29/18, reflected the following: <BR/>The resident has the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. <BR/>Adverse Event: An adverse event is an untoward, undesirable, and usually unanticipated even that causes death or serious injury, or the risk thereof. <BR/>Neglect: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.<BR/>Reporting: If the allegations involve abuse or results in serious bodily injury, the report is to be made within 2 hours of the allegation. <BR/>If the allegations does not involved abuse or serious bodily injury, the report must be made within 24 hours of the allegations. <BR/>An Immediate Jeopardy was identified on 04/13/24. The Administrator was notified of the Immediate Jeopardy on 04/13/24 at 7:20 PM and was provided with the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy.<BR/>The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/14/24 8:40 AM and reflected the following:<BR/>-As of 4/10/24, Student Nurse Aide A was in-serviced 1:1 by the DON on the following: All in-servicing was completed on 4/13/24. <BR/> -Abuse and Neglect Policy<BR/> - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse:<BR/> - A resident is found on the floor (witnessed or unwitnessed)<BR/> - A resident has an injury that is new (bruise, skin tear, abrasion, laceration)<BR/> - Fall Prevention Policy <BR/>- On 4/13/24 head to toe assessments were initiated for all residents for any injuries including bruising. No additional issues were found. Assessments were completed by the DON, ADON and Tx Nurse on 4/14/24. <BR/>- The medical director was notified of the immediate jeopardy by the administrator on 4/13/24. <BR/>- AD HOC QAPI was held with the Medical Director and facility interdisciplinary team on 4/13/24 to discuss the immediate jeopardy and subsequent plan of removal. <BR/>In-services:<BR/>All staff will be in-serviced on the following topics below by the Administrator, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff and staff on leave received in-services electronically. Staff members who received in-servicing electronically must see the DON/Administrator prior to working their next shift to acknowledge understanding and sign in-services. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date: 4/14/24. <BR/> - Abuse and Neglect Policy<BR/> - Notification of Change in Condition: In the event of a resident incident, the nurse should immediately be notified so an assessment can be completed, and management can be notified if needed for further investigation of incident. Residents are NOT to be moved or transferred until an assessment is completed by a nurse and you are further directed by a nurse. Examples of when to notify the nurse:<BR/> - A resident is found on the floor (witnessed or unwitnessed)<BR/> - A resident has an injury that is new (bruise, skin tear, abrasion, laceration)<BR/>- Fall Prevention Policy<BR/>-Neuro Checks Policy (Charge Nurses Only)<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Review of the following in-services dated 04/13/24 revealed training for Abuse and Neglect, IR (Incident Report) Reporting, Neuro Checks and Fall Prevention Policy. In-services revealed all staff completed the trainings. The in-services were conducted and signed by all facility staff on all three shifts, 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM.<BR/>Review of sample residents Assessments revealed head to toe assessments were completed. <BR/>Review of facility QAPI Meeting revealed meeting was completed on 04/13/24. <BR/>Observations on 04/14/24 from 9:15 AM through 10:48AM revealed no other residents with bruising or injuries noted. <BR/>Interviews on 04/14/24 from 10:22 AM through 2:00 PM with CNA B, LVN C, Student Aide D, CNA G, CNA H, CNA I, RN J, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA T, CNA U, CNA V, LVN W, LVN X, LVN Y, LVN Z, Treatment Nurse, Medication Aide, ADON K, ADON L, HR Coordinator, Assistant BOM, Staffing Coordinator, Medical Records, Guest Relations Coordinator, Social Worker, Dietary Manager, Dietary A, Dietary B, Dietary D, Housekeeping Supervisor, Housekeeping A, Housekeeping B, Housekeeping C, Housekeeping D, Floor Tech, Respiratory Therapist A, Respiratory Therapist B, Occupational Therapist, and Maintenance Director who worked the shifts of 6:00 AM-2:00 PM, 2:00 PM-10:00 PM and 10:00 PM-6:00 AM revealed the Staff were able to verify education was provided to them, nursing staff were able to accurately summarize what to do if a resident was found on the floor (witnessed or unwitnessed), if a resident has an injury that is new (bruise, skin tear, abrasion, laceration), fall prevention policy, and neuro checks (Charge Nurses Only). <BR/>The Administrator and DON were informed the Immediate Jeopardy was removed on 04/14/2024 at 2:15 PM. 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 isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for two of three medication carts and one of one respiratory treatment carts reviewed for medication storage<BR/>The facility failed to ensure two (Medication Cart#1 and Medication Cart#2) facility medication cart and one (RTC) respiratory treatment cart were locked when unattended on 08/14/24. <BR/>This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. <BR/>Findings included: <BR/>An observation on 08/14/24 at 5:00 AM revealed the medication cart#1 was unlocked at the nursing station with no staff in view of the medication cart. Observation of medication cart#1 revealed the medication cart was facing outward toward the hallway. Observation of the lock mechanism was popped out and revealed a red indicater. Observation revealed LVN A was at the end of hallway 400. <BR/>An observation on 08/14/24 at 5:06 AM revealed the medication cart#2 on hallway 100 was unlocked and faced the hallway.Observed the red indicator on the lock mechanism popped out which revealed the medication cart was unlocked. <BR/>An observation on 08/14/24 at 5:38 AM revealed the Respiratory treatment cart was unlocked on hallway 300. Observed respiratory treatment cart faced outward and staff was not in view of the cart. Observed the red indicator on the lock mechanism popped out which revealed the treatment cart was unlocked. <BR/>An interview on 08/14/24 at 5:10 AM with LVN B revealed he went into a resident's room to give him medication and did not lock the medication cart#2. LVN B stated there can be a loss of medication and residents could take the medication. <BR/>An interview on 08/14/24 at 5:15 AM with LVN A stated that residents and visitors could have access to the medication on medication cart#1.<BR/>An interview on 08/14/24 at 5:25 AM with LVN C stated residents can take medication or someone else could walk off with medications from an unlocked cart. LVN C stated the medication cart had to be locked.<BR/>An interview on 08/14/24 at 5:35 AM with LVN D stated mobile residents could get into the medication cart and take medications.<BR/>An interview on 08/14/24 at 5:39 AM with Respiratory Therapist E who stated the treatment cart was supposed to be locked when not in use.<BR/>An interview on 08/14/24 at 6:45 AM with Respiratory Therapist F who stated the treatment cart should be locked when not being used. Respiratory Therapist F revealed the residents are not at risk because the cart contained breathing treatments, inhaler, mouth wash, and saline. <BR/>An interview on 08/19/24 at 10:00 AM with DON who stated the medication carts and treatment carts should be locked when not in eyesight view and not being used. Residents could take medications. <BR/>An interview on 08/19/24 at 10:15 AM with Administrator who stated she expect staff to follow facility policy and procedures for the medication and treatment carts. <BR/>Record review of facility policy titled, Medication carts, pharmacy policy and procedure manual dated 2003, reflected: 2. The carts are to be locked when not in use or under direct supervision of the designated nurse. 4.carts must be secured

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for one (Resident #1) of five residents reviewed for personal property.<BR/>The Administrator took Resident #1's cell phone away from her because she had called 911 several times.<BR/>This failure could place residents at risk of not being able to retain and use personal property.<BR/>Findings included:<BR/>Record review of Resident #1's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and expired on [DATE]. Resident #1 had diagnoses which included congestive heart failure, respiratory failure requiring the use of a tracheostomy, and ventilator dependence. (The resident's heart was failing, she developed breathing issues, was intubated and placed on a ventilator. The resident could not breathe without the ventilator, so a breathing tube was placed in her neck and she continued to rely on the ventilator to breathe.)<BR/>Record review of Resident #1's baseline care plan, dated [DATE], reflected she was dependent on a ventilator, she was on oxygen, and she had a pacemaker. <BR/>Interview on [DATE] at 10:28 AM with Resident #1's family member revealed the resident had called 911 several times on [DATE] because she felt she could not breathe. The resident could not speak to the 911 operator and would hang up. The family was advised by the Administrator the resident's phone was taken away because she kept calling 911. The family member stated the phone was her only way of communicating with family via text messages. The resident would also text staff members when she needed something. <BR/>Interview on [DATE] at 11:50 AM with the Administrator revealed she had been contacted by the local police department regarding someone in the facility calling 911 seven times and then hanging up. The Administrator stated they investigated and discovered it was Resident #1 who had been making the calls. The Administrator stated she was contacted by a sergeant from the police department, who stated if the resident continued to call 911, she would be written a citation for abuse of the 911 system. The Administrator stated she took Resident #1's phone from her to prevent her from calling 911 and being issued a ticket. She explained the situation to the family, and they stated he would text the resident to stop calling 911. The Administrator stated the ADON returned the phone to the resident within about 10 minutes. <BR/>The resident's death was not the result of her phone being taken away.<BR/>Record review of the facility's policy Resident Rights dated [DATE], reflected:<BR/> .Respect and dignity<BR/> .2. The right to retain and use personal possessions unless to do so would infringe on the rights or health and safety of other residents .