BIRCHWOOD OF GRAPEVINE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 1 resident (Resident #1) reviewed for pharmaceutical services.<BR/>The facility failed to ensure MAs and nurses were following physician orders for administering Resident #1's Lidocaine Patch 4%, which was used for preventing pain, on 05/04/25.<BR/>This failure could put residents at risk of not receiving their medications as ordered.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS assessment, dated 03/24/25, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included age-related osteoporosis without current pathological fracture (a condition where bone density and mass decrease significantly due to the natural aging process, increasing the risk of fractures). The resident's cognition was moderately impaired with a BIMS score of 8. The MDS reflected the resident received a scheduled pain medication regimen.<BR/>Record review of Resident #1's care plan, dated 08/15/24, reflected Resident #1 has Acute Pain / Chronic Pain. Goal:-she Will Report Satisfactory Pain Control. Interventions:- Educate Resident / Representative on prescribed analgesics and / or anti-inflammatory medications<BR/>Record review of Resident #1's May 2024 Physician Orders dated 1/24/2025 reflected the following: Lidocaine Pain Relieving External Patch 4% (Lidocaine). Apply to right hip 1 patch topically one time a day for PAIN and remove per schedule. <BR/>Record review of Resident #1's May 2025 MAR revealed reflected LVN C worked on 05/04/25 and had signed on the MAR that he had removed the resident's patch at 5:59 PM.<BR/>Observation on 05/06/25 at 11:40 AM revealed Resident #1 had two lidocaine external patches on her right hip, one was dated 05/04/25 and the other was dated 05/06/25. The resident's skin was intact.<BR/>Observation and interview with MA B on 05/06/25 at 11:50 AM revealed Resident #1 had two lidocaine patches on the right hip. MA B stated Resident #1s patch was supposed to be applied in the morning at 6:00 AM and then removed at 5:59 AM as per the order. She stated it was the responsibility of the nurse and herself to apply and remove the patch. She stated she worked on 05/04/25 and the patch was applied by the night shift nurse before she left after her shift and that evening she had left early. She expected the nurse to remove the patch because they use the same MAR and anytime the patch was due for application or removal it will pop on the electronic record showing as due. She stated she was the one that applied the patch on 05/05/25 and denied seeing the one dated 05/04/25. She stated failure to remove an old patch before applying a new could lead to overdose. She had done in-service on medication administration. <BR/>An interview was attempted via telephone with LVN C on 05/06/25 at 2:20 PM; however, the attempt was not successful. A voicemail message was left without a return call back from LVN C. <BR/>Interview with RN D on 05/06/25 at 2:57 PM revealed she was the one, who had removed the patch 05/05/25 in the evening, for Resident #1. She stated she did not see the old patch dated 05/04/25. RN D stated she was aware she was supposed to remove the old patch before administering the new one. She stated the risk of not removing the old patch was over medication and skin irritation. RN D stated she had done in-services on medication administration.<BR/>Interview with the DON on 05/06/25 at 4:34 PM revealed his expectation was that nurses and MAs should remove the old patch before applying the new patch. He stated failure to remove the old patch would lead to overdose and skin irritation. He stated facility had done in-service on medication administration but not on patches removal. <BR/>Record review of the facility medication administration in-service record, dated 04/23/25, reflected MA B, LVN C and RN D were in attendance.<BR/>Record review of the facility's current Pharmacy Services policy, dated April 2019, reflected: .4.Medications are administered in accordance with prescriber orders, including any required time frame The policy did not address patch administration and removal. The DON stated they did not have a policy that addressed patch removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #6) reviewed for abuse.<BR/>The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 pushed her on 01/21/25, causing Resident #6 to fall which resulted in a pelvic fracture.<BR/>An IJ was identified on 03/12/25. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on 03/13/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>This failure placed residents at risk for abuse.<BR/>Findings included: <BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #6's significant change in status MDS Assessment, dated 01/29/25, reflected she had a BIMS score of 06, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included unspecified fracture of sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) and depression.<BR/>Record review of Resident #6's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #6] had a fall. Was accidentally pushed by another resident. Sent to ER.<BR/>Record review of Resident #6's Progress Notes reflected the following: <BR/>01/21/25 5:36 PM - Resident was pushed to floor by another resident, resident was crying stating her hip hurt, resident was assessed, assisted from floor to dining chair, pain medication administered. DON, MD and RP notified. Stat hip x-ray ordered. Resident is now sittingin [sic] dinning [sic] area, away from other resident eating dinner. Resident stated she has no pain at this time and will let staff know if her hip starts to hurt again. This entry was written by LVN Z.<BR/>01/21/25 11:11 PM - X-ray performed at this time awaiting for results. This entry was written by LVN Y.<BR/>01/22/25 2:15 AM - Result viewed, No acute fracture, dislocation, destructive bony process noted, result will be relayed to MD by incoming nurse. This entry was written by LVN Y.<BR/>01/22/25 9:15 AM - Resident has been sent out to [Hospital X] r/t uncontrolled pain (L) hip. Resident is status post fall 1/22/25. STAT Xray result (L) hip shows No Acute Fracture, Dislocation or destructive bony process. Resident c/o pain (L) hip, Tramadol 50mg prn and Tylenol 650mg was administered for pain. Medication was not effective, resident unable to ambulate as she normally does. Notified [the DON] and resident sent out to ER for [NAME] evaluation. [Resident #6's RP] was also notified. This entry was written by LVN W.<BR/>01/25/25 12:15 PM - Resident arrived facility [sic] from [Hospital X] by ambulance via stretcher accompanied by [Resident #6's RP] DX open displaced fracture of anterior wall of left acetabulum [an anterior wall acetabular fracture is a break in the front column of bone or area around the bony rim (wall) of your hip socket].Resident [sic] assisted in bed by two nurses, complained of some little pain, tylenol [sic] 650 mg prn given with positive outcome . This entry was written by LVN V.<BR/>Record review of Resident #6's hospital records, dated 01/30/25, reflected the following: <BR/>As Per admission history and physical dated 1/22/2025 <BR/>Patient is a 84 y.o. female has a past medical history of Dementia (HCC). admitted after fall at care facility resulting in pelvic fracture and difficulty ambulating. [Resident #6's RP] reports [Resident #6] was previously independent, 'very active' and 'walks on her own'. Recently completed PT at facility and 'checked all the boxes', discharged from therapy last Friday [01/17/25]. Fall mechanism- patient reports being pushed by 'lady' and feeling pain 'from the back'. [Resident #6's RP] unaware of circumstances, states facility noticed fall and difficulty walking.<BR/>Hospital Course/Summary:<BR/>Ptient [sic] presented after fall unable to bear weight. Found to acute minimally displaced fractures of the anterior left acetabulum, left inferior pubic ramus [describes a type of crack or break in a person's pelvis] and left sacrum .<BR/>Record review of Resident #6's Radiology Results Report, dated 01/21/25, reflected: Procedure: HIP UNI W OR W/O PELVIS 2-3 V .INTERPRETATION: Findings: No acute fracture, dislocation or destructive bony process. No soft tissue abnormally. Osteopenia. Mild degenerative changes. Conclusion: No acute osseous abnormality.<BR/>Interview on the phone on 02/27/25 at 11:15 AM with Resident #6's RP revealed Resident #6 was pushed by a different resident and her pelvis was fractured as a result. Resident #6's RP said Resident #6 was admitted to the hospital and the fracture did not require screws or any surgery, so the doctor said it was going to heal on its own. Resident #6's RP said before the incident, Resident #6 was able to walk around freely without the use of a walker or wheelchair and now she was no longer mobile, requiring the use of a wheelchair. Resident #6's RP said Resident #6 was able to stand and take some steps, but it hurt the resident and she was not like she was before. <BR/>Observation and interview on 02/27/25 at 11:57 AM with Resident #6 revealed she was sitting in a wheelchair at the nurse's station. Resident #6 said she was not in any pain, had never had a fall, and would never let anyone push her. Resident #6 did not appear to be in any pain. <BR/>Record review of Resident #7's face sheet, dated 02/27/25, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. <BR/>Record review of Resident #7's Quarterly MDS Assessment, dated 01/24/25, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included heart failure, non-Alzheimer's dementia, and depression. <BR/>Record review of Resident #7's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #7] accidentally pushed another resident to the floor. Education completed, Redirected as needed. Goal: [Resident #7] will not harm self or others through the review date. Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Record review of Resident #7's Progress Notes reflected the following entries:<BR/>01/21/25 5:25 PM - Resident pushed another resident to the floor, no injuries noted to this resident. Resident was separated from resident she pushed to floor. DON, MD, and RP notified. This entry was written by LVN Z.<BR/>01/23/25 4:06 PM - .Patient is seen per staff request due to reports of combativeness, and agitation. Patient is up in the dining area, calm at the moment, and in no distress at this time. She reportedly pushed another resident who sustained injuries, requiringhospitalization [sic]. Patient presents with spontaneous disruptive mood, and combativeness. She is alert to self, and unwilling or unable to participate in the assessment at this time .Chart reviewed, medication profile reviewed .Upon review, based on presenting will further increase Depakote and start patient on Atarax 10 mg twice daily as needed for anxiety. Primary nurse notified, will monitor closely. This entry was written by NP LL.<BR/>Observation and interview on 02/27/25 at 2:00 PM with Resident #7 revealed she was sitting in a chair at a table with other residents around her. Resident #7 said she was doing good today and did not appear to have any behaviors. <BR/>Interview on 02/27/25 at 11:57 AM with LVN Z revealed she was passing medications when Residents #6 and #7 were having an argument and Resident #7 stood up. LVN Z said before she could get to the area where the residents were at, Resident #7 ended up pushing Resident #6. LVN Z said she assessed Resident #6, gave her some pain medication, took her to her room to assess her, and then brought her back to the dining room to eat dinner and everything was fine. LVN Z said she did not see any obvious signs of injuries and Resident #6's pain seemed to be managed. LVN Z said a STAT x-ray was ordered for Resident #6, she notified Resident #6's RP, the DON, the ADON, and the doctor of the incident. LVN Z said during the assessment, there was not any discoloration or bruising to make her think something was injured but the resident did have a slight limp when she pivoted to sit in the chair. LVN Z said before the incident, Resident #6 was completely and independently ambulatory but the next day she was not able to walk so that nurse on shift sent her to the hospital. LVN Z said at the hospital, they found out she had a pelvic fracture. LVN Z said Resident #7 had not been physically aggressive towards other residents before, only combative during care with staff. LVN Z said Resident #7 did get upset though when people were talking around her, thinking that they were talking to her. LVN Z said she knew the Administrator was the abuse coordinator for the facility and that a resident-to-resident altercation that resulted in injuries would be considered abuse. <BR/>Interview on 02/27/25 at 12:23 PM with CNA V revealed it was around dinner time while staff were serving trays, and Resident #7 was talking to the air and yelling, and some residents were replying back to her. CNA V said they were trying to calm the residents down and telling them to relax when all of a sudden, she saw Resident #7 get up and storm over to push Resident #6 down. CNA V said she went over to stay at Resident #6's side until LVN Z came over. CNA V said after LVN Z took over, she went to check on Resident #7 who was in her room upset but wanted to be left alone. CNA V said Resident #6 looked like she was injured after being pushed because she was shouting and screaming in pain. CNA V said before the incident occurred, Resident #6 was up and walking around and did not need a wheelchair or walker. CNA V said Resident #7 did not have any physically aggressive behaviors before this incident. CNA V said she knew to report abuse to the Administrator who was the abuse coordinator for the facility. <BR/>Interview on 02/27/25 at 2:36 PM with the DON revealed he received a report that Resident #6 had a fall and then the resident complained of pain and was sent to the ER. The DON said that another resident (Resident #7) had pushed Resident #6 and she fell. The DON said Resident #6 had a pelvic fracture. The DON said he was notified immediately after it happened and when Resident #6 was sent to the ER. The DON said Resident #7 was a little feisty with staff during care but had never attacked another resident. The DON said he was not sure what happened to make Resident #7 push Resident #6 but that it was an accident and was not intentional. The DON said he talked to Resident #7, and she did not mean to hurt anyone, but a resident-to-resident altercation was considered abuse. The DON said he would have to ask the Administrator if she reported the situation or not. The DON said all residents had the right to be free from abuse and all staff were responsible for making sure residents were free from abuse. The DON said Resident #6 was harmed from the situation because she suffered a pelvic fracture and now required the use of a wheelchair. The DON said Resident #6 was independently ambulatory before the incident.<BR/>Interview on 02/27/25 at 3:03 PM with the Administrator revealed what she understood was the situation happened in the hallway, LVN Z was standing there and talking with Resident #6 when Resident #7 walked past and bumped her, causing Resident #6 to fall and sustained a fracture. The Administrator said when she spoke to the staff about it, she did not get the impression that it was intentional. The Administrator said Resident #6 was able to ambulate independently before the incident and since the fracture occurred she now used a wheelchair. The Administrator said she did not complete an investigation into what happened because of what she was told by the staff. The Administrator said she only talked to LVN Z about the incident but was not aware she did not see what had happened. The Administrator said she did not speak with CNA V who witnessed the incident between the two residents. The Administrator said she only knew that Resident #6 had a fall, and an x-ray was ordered which had negative results, but she was still complaining of pain. The Administrator said since she was still complaining of pain the facility sent her to the ER and that was when they found out about the fracture. The Administrator said if LVN Z documented that Resident #7 pushed Resident #6 then that was intentional and had a different connotation than an accidental bumping into each other. The Administrator said with the new information regarding the situation, it was considered abuse between two residents. The Administrator said she would have wanted staff to report the incident to her immediately. The Administrator said if she had known the details of the incident, she would have reported it to HHSC. The Administrator said all residents had the right to be free from abuse, even from other residents. The Administrator said everyone was responsible for making sure residents were free from abuse. The Administrator said the purpose of keeping residents safe from abuse was to ensure their continued health and safety. <BR/>Interview on 03/12/25 at 1:08 PM with LVN W revealed while he did not directly work with Resident #7, he worked on the secured unit and was familiar with her. LVN W said he had never seen or heard about Resident #7 being physically aggressive towards a resident prior to the 01/21/25 incident. LVN W said if Resident #7 started to get agitated he would try to calm her down by redirecting her away from the area or removing the other residents from the area. LVN W said he had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. <BR/>Interview on 03/12/25 at 1:28 PM with CNA Q revealed while she did not directly work with Resident #7, she worked on the secured unit and was familiar with her. CNA Q said she had never seen or heard about Resident #7 being physically aggressive towards a resident. CNA Q said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. CNA Q said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. <BR/>Interview on the phone on 03/12/25 at 1:40 PM with RN R revealed she cared for Resident #7 before and knew that sometimes she would get aggressive towards others by yelling at them. RN R said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. RN R said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. <BR/>Interview on the phone on 03/12/25 at 1:54 PM with CNA S revealed she cared for Resident #7 and knew she had behaviors of yelling at others. CNA S said she had not seen Resident #7 be physically aggressive towards anyone at the facility. CNA S said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. CNA S said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse.<BR/>Interview on 03/12/25 at 2:00 PM with RA T revealed she cared for Resident #7 and knew that she had behaviors of yelling at others. RA T said she had not seen Resident #7 be physically aggressive towards anyone at the facility. RA T said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. RA T said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse.<BR/>Record review of the facility's Course Completion History report from 09/12/24 to 03/12/25 regarding Abuse, Neglect, and Exploitation Training reflected the following: LVN Z had completed the trainings on 11/30/24 and 02/2/25; CNA V had completed the training on 02/11/25. <BR/>Record review of the facility's incidents/accidents report from 11/27/24 to 02/27/25 reflected there were no other situations that involved Resident #6 or Resident #7.<BR/>Record review of the facility's policy, revised September 2022, and titled Identifying Types of Abuse reflected: 1. Abuse of any kind against residents is strictly prohibited .4. 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Abuse toward a resident can occur as: a. resident-to-resident abuse .<BR/>An IJ was identified on 03/12/25. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on 03/13/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>The facility's Plan of Removal for the Immediate Jeopardy was accepted on 03/13/25 at 9:45 AM and reflected the following:<BR/> .F600<BR/>Plan of Removal<BR/>03/12/2025<BR/>Immediate Corrective Action for residents affected by the alleged deficient practice:<BR/>On 01/21/25 resident #7 was noted to be walking towards her room, at this time she pushed past resident #6 who fell to the ground. Residents were separated by the nurse and redirected. At this time the staff assisted resident #6 up and assessed her, she was medicated for pain. Stat X-rays were called, initial series was negative for fracture. Upon further complaints of pain, the resident was sent to the hospital for additional imaging. The DON, MD, and daughter were notified. These revealed a pelvic fracture for which no surgery was necessary. Resident #6 returned to the facility with no additional injuries noted. <BR/>Actions taken to prevent a serious adverse outcome from recurring:<BR/>This alleged deficient practice had the potential to affect all residents who reside in the facility. <BR/>The medical director was notified of the IJ by assistant director of nursing. <BR/>On 01/21/2025 MDS nurse care planned a new behavior of aggressiveness towards other residents. With interventions of a psych consult and redirection when agitated, this has not been displayed since the initial incident. Staff will be able to identify this behavior and de-escalation techniques in the future based on the resident's care plan and [NAME]. Education on de-escalation techniques will be provided to all staff. <BR/>A psychiatric consult was called by the medical director for resident #7 to review medications and behaviors, this was completed the next day on 01/22/2025.<BR/>On 03/12/2025 the Administrator and Director of Nursing were educated on abuse and neglect, resident to resident altercations, and de-escalation of resident behaviors. This was done by the VP of Clinical Operations. <BR/>Staff were previously trained on abuse and neglect as well as de-escalation of resident behaviors in December, by the administrator and DON and through [facility training software] in January and February. We will continue to educate new staff as they are hired. <BR/>New educations on abuse and neglect, resident to resident altercations, and de-escalation of resident behaviors were started on 03/12/2025. These were implemented by the DON and the administrator; all staff will be educated prior to the start of their next shift. <BR/>An Ad Hoc QAPI meeting was held on 03/12/2025 to inform all the management team. <BR/>The DON and ADON will review resident behaviors daily in morning clinical meetings while viewing the 24-hour report/EMR and then weekly in IDT. This will be monitored monthly in QAPI. <BR/>When Actions will be complete:<BR/>The [Facility Name] will have completed staff education by 03/13/2025, if any staff member working in the facility is unable to be educated, they will be removed from the schedule until training has been provided.<BR/>The [Facility Name] requests the removal of the immediate jeopardy on 03/12/2025.<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Interviews with the following staff from 03/13/25 at 9:46 AM to 2:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on de-escalation techniques for when a resident has aggressive behaviors towards another resident, abuse and neglect, and resident-to-resident altercations: LVN D, LVN G, LVN U, CNA BB, CNA CC, CNA DD, RA EE, CNA FF, CNA GG, CNA HH, CNA II, MA JJ, RN KK, LVN W, CNA V, CNA Q, CNA M, RA T, the ADON, the DON, and the Administrator.<BR/>Record review of an in-service sign in sheet, dated 03/12/25, and titled Resident to Resident Abuse reflected 52 staff had been in-serviced.<BR/>Record review of an Ad Hoc QAPI Agenda, dated 03/12/25, reflected all IDT members were in attendance. <BR/>Record review of an in-service sign in sheets, dated 03/12/25, and titled Abuse, Neglect, and Misappropriation Policy and Redirection of a resident that is becoming combative with others, reflected both the DON and Administrator had signed.<BR/>An IJ was identified on 03/12/25. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on 03/13/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 8 residents (Resident #12) reviewed for misappropriation of property.<BR/>The facility failed to prevent the misappropriation of Resident #12's debit card when it was taken by CNA I.<BR/>The noncompliance was identified as past noncompliance. The noncompliance began on 09/18/24 and ended on 09/18/24. The facility had corrected the noncompliance before the abbreviated survey began.<BR/>This failure could place residents at risk of misappropriation of property. <BR/>Findings included:<BR/>Record review of Resident #12's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included diabetes, multiple sclerosis (a chronic autoimmune disease that affects the central nervous system), and anxiety disorder. The resident had a BIMS score of 14 which indicated her cognition was intact. <BR/>Record review of the facility's Provider Investigation Report dated 09/26/24 reflected the following:<BR/>[Resident #12's] [family] called to report the resident's debit card stolen and it had been used at three locations in [city] <BR/>[business] - $54.00<BR/>[business] - $157.00<BR/>[business] - $48.00 <BR/>On 09/18/24 the photos from the [business] were sent to the administrator. The DON identified the staff member [CNA I] At the time [CNA I] was suspended and when asked to provide a statement did not [CNA I] has been terminated, the staff have been educated on abuse, neglect, and misappropriation.<BR/>Interview on 02/27/25 at 11:18 AM with Resident #12 revealed she was in her room in her wheelchair. The resident said her [family] had called her and asked if she had her debit card because it appeared it had been used at several businesses. Resident #12 said she usually kept her card in her purse in the top drawer of her night stand and when she went to look for it, it was not there and there was also $20 missing from her purse. The resident also said it appeared to have been a new staff member that had not worked at the facility long and the day after the incident, a police officer had gone to talk to her about the theft. <BR/>Interview on 02/28/25 at 1:49 PM with Resident #12's family revealed the resident had a fanny pack in the drawer of her night stand where she kept some of her personal belongings. The family said they noticed there were some charges at three businesses that appeared to be suspicious. so He called the facility so they could check if her debit card was still in the resident's possession, and they noticed it was gone. One of the businesses were able to share their camera footage where the facility management was able to recognize CNA I as the one who had taken and used the debit card. The family also said the debit card was frozen and he pressed charges in hopes that it would not happen to anyone else. <BR/>Interview on 02/28/25 at 2:28 PM with the Social Worker revealed she had been made aware a staff member had taken and used Resident #12's debit card. She said she did not participate in the investigation but had interviewed other alert and oriented residents to ensure there were no other missing personal belongings and there were no other concerns noted.<BR/>Interview on 02/28/25 at 2:49 PM with the ADON revealed she had been made aware by the Administrator that CNA I had taken Resident #12's debit card and used it because they had recognized her in the business video footage. The ADON said CNA I was new to the facility and had only worked at the facility for about two weeks. The ADON further stated she was responsible for in-servicing the staff on abuse, neglect, and misappropriation. <BR/>Interview on 02/28/25 at 3:11 PM with the Administrator revealed Resident #12's family called the facility and asked if someone could check the resident's purse to see if her debit card was in there. The staff went to go look and they were not able to find it anywhere in the resident's room. The family made her aware there had been some fraudulent charges made to the account, so they began their investigation. The Administrator said they had checked the facility camera footage to see what staff had entered the room that day and when the business shared their video footage, they were able to recognize CNA I as the staff member who had used the stolen card. CNA I was called and asked to give a statement, but she refused and denied the allegations even after she was told she had been identified in the business footage. CNA I was terminated, and the rest of the facility staff were re-in-serviced on abuse, neglect, and misappropriation. Interviews with other residents revealed there were no other concerns with misappropriation. <BR/>Attempts to interview CNA I on 02/28/25 were unsuccessful as the phone number was no longer active. <BR/>Record review of the facility's policy titled Identifying Exploitation, Theft, and Misappropriation of Resident Property dated April 2021 reflected the following:<BR/> .1. Exploitation, theft, and misappropriation of resident property are strictly prohibited <BR/> .4. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent <BR/>Record review of the facility's in-service titled Abuse; Identifying Exploitation, Theft, Misappropriation dated 09/18/24 revealed 25 staff members participated. <BR/>Interview on 02/28/25 from 9:53 PM to 2:49 PM with the ADON, LVN B, Activity Director, Housekeeper J, Housekeeper K, Floor Tech, MA L, Restorative Aide, CNA M, CNA N, CNA O, CNA P, LVN D, LVN E, RN F, LVN G, and LVN H revealed they were in-serviced on the types on abuse, neglect, and misappropriation. All staff were able to name the different types of abuse, define misappropriation, and to report any type of abuse to the Administrator who was the abuse coordinator. <BR/>Record review of CNA I's personnel file revealed she was terminated on 09/18/24 for theft of Resident #12's debit card. <BR/>Interview on 02/27/25 and 02/28/25 with 12 alert and oriented residents revealed they did not have any concerns/issues with theft or misappropriation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and misappropriation for 1 of 2 incidents (Resident #6) reviewed for reporting. <BR/>1. The facility failed to implement its policy by ensuring LVN Z and CNA V reported an incident of resident-to-resident abuse immediately to the Administrator, who was the Abuse Coordinator, on 01/21/25 when Resident #7 pushed Resident #6, causing her to fall and sustain a pelvic fracture.<BR/>2. The Administrator failed to investigate an incident of abuse when Resident #6 was pushed by Resident #7 on 01/21/25 and sustained a pelvic fracture. <BR/>3. The Administrator failed to report to HHSC when Resident #7 pushed Resident #6 causing Resident #6 to sustain a pelvic fracture.<BR/>This failure could place the residents in the facility at risk of continued abuse.<BR/>Findings included:<BR/>Record review of the facility's Identifying Types of Abuse policy, revised September 2022, reflected: 1. Abuse of any kind against residents is strictly prohibited .4. 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Abuse toward a resident can occur as: a. resident-to-resident abuse .<BR/>Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy, revised September 2022, reflected: Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation; Reporting Allegations to the Administrator and Authorities, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .<BR/>Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, reflected: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. This includes but is not limited to freedom of corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; .2. Develop and implement policies and procedures to prevent and identify: a. abuse or mistreatment of residents .<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #6's significant change in status MDS Assessment, dated 01/29/25, reflected she had a BIMS score of 06, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included unspecified fracture of sacrum and depression.<BR/>Record review of Resident #6's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #6] had a fall. Was accidentally pushed by another resident. Sent to ER.<BR/>Record review of Resident #6's Progress Notes reflected the following: <BR/>01/21/25 5:36 PM - Resident was pushed to floor by another resident, resident was crying stating her hip hurt, resident was assessed, assisted from floor to dining chair, pain medication administered. DON, MD and RP notified. Stat hip x-ray ordered. Resident is now sittingin [sic] dinning [sic] area, away from other resident eating dinner. Resident stated she has no pain at this time and will let staff know if her hip starts to hurt again. This entry was written by LVN Z.<BR/>01/21/25 11:11 PM - X-ray performed at this time awaiting for results. This entry was written by LVN Y.<BR/>01/22/25 2:15 AM - Result viewed, No acute fracture, dislocation, destructive bony process noted, result will be relayed to MD by incoming nurse. This entry was written by LVN Y.<BR/>01/22/25 9:15 AM - Resident has been sent out to [Hospital X] r/t uncontrolled pain (L) hip. Resident is status post fall 1/22/25. STAT Xray result (L) hip shows No Acute Fracture, Dislocation or destructive bony process. Resident c/o pain (L) hip, Tramadol 50mg prn and Tylenol 650mg was administered for pain. Medication was not effective, resident unable to ambulate as she normally does. Notified [the DON] and resident sent out to ER for [NAME] evaluation. [Resident #6's RP] was also notified. This entry was written by LVN W.<BR/>01/25/25 12:15 PM - Resident arrived facility [sic] from [Hospital X] by ambulance via stretcher accompanied by [Resident #6's RP] DX open displaced fracture of anterior wall of left acetabulum [an anterior wall acetabular fracture is a break in the front column of bone or area around the bony rim (wall) of your hip socket].Resident [sic] assisted in bed by two nurses, complained of some little pain, tylenol [sic] 650 mg prn given with positive outcome . This entry was written by LVN V.<BR/>Record review of Resident #6's hospital records, dated 01/30/25, reflected the following: <BR/>As Per admission history and physical dated 1/22/2025 <BR/>Patient is a 84 y.o. female has a past medical history of Dementia (HCC). admitted after fall at care facility resulting in pelvic fracture and difficulty ambulating. [Resident #6's RP] reports [Resident #6] was previously independent, 'very active' and 'walks on her own'. Recently completed PT at facility and 'checked all the boxes', discharged from therapy last Friday [01/17/25]. Fall mechanism- patient reports being pushed by 'lady' and feeling pain 'from the back'. [Resident #6's RP] unaware of circumstances, states facility noticed fall and difficulty walking.<BR/>Hospital Course/Summary:<BR/>Ptient [sic] presented after fall unable to bear weight. Found to acute minimally displaced fractures of the anterior left acetabulum, left inferior pubic ramus [describes a type of crack or break in a person's pelvis] and left sacrum .<BR/>Record review of Resident #6's Radiology Results Report, dated 01/21/25, reflected: Procedure: HIP UNI W OR W/O PELVIS 2-3 V .INTERPRETATION: Findings: No acute fracture, dislocation or destructive bony process. No soft tissue abnormally. Osteopenia. Mild degenerative changes. Conclusion: No acute osseous abnormality.<BR/>Interview on the phone on 02/27/25 at 11:15 AM with Resident #6's RP revealed Resident #6 was pushed by a different resident, and her pelvis was fractured as a result. Resident #6's RP said Resident #6 was admitted to the hospital. The RP stated the fracture did not require screws or any surgery, so the doctor said it was going to heal on its own. Resident #6's RP said before the incident, Resident #6 was able to walk around freely without the use of a walker or wheelchair, and now she was no longer mobile, requiring the use of a wheelchair. Resident #6's RP said Resident #6 was able to stand and take some steps, but it hurt the resident. She stated Resident #6 was not like she was before. <BR/>Observation and interview on 02/27/25 at 11:57 AM with Resident #6 revealed she was sitting in a wheelchair at the nurses' station. Resident #6 said she was not in any pain, had never had a fall, and would never let anyone push her. Resident #6 did not appear to be in any pain. <BR/>Record review of Resident #7's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. <BR/>Record review of Resident #7's Quarterly MDS Assessment, dated 01/24/25, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included heart failure, non-alzheimer's dementia, and depression. <BR/>Record review of Resident #7's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #7] accidentally pushed another resident to the floor. Education completed, Redirected as needed. Goal: [Resident #7] will not harm self or others through the review date. Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Record review of Resident #7's Progress Notes reflected the following:<BR/>01/21/25 5:25 PM - Resident pushed another resident to the floor, no injuries noted to this resident. Resident was separated from resident she pushed to floor. DON, MD, and RP notified. This entry was written by LVN Z.<BR/>01/23/25 4:06 PM - .Patient is seen per staff request due to reports of combativeness, and agitation. Patient is up in the dining area, calm at the moment, and in no distress at this time. She reportedly pushed another resident who sustained injuries, requiringhospitalization [sic]. Patient presents with spontaneous disruptive mood, and combativeness. She is alert to self, and unwilling or unable to participate in the assessment at this time .Chart reviewed, medication profile reviewed .Upon review, based on presenting will further increase Depakote and start patient on Atarax 10 mg twice daily as needed for anxiety. Primary nurse notified, will monitor closely. This entry was written by NP LL.<BR/>Interview on 02/27/25 at 11:57 AM with LVN Z revealed she was passing medications when Residents #6 and #7 were having an argument, and Resident #7 stood up. LVN Z said before she could get to the area where the residents were at, Resident #7 ended up pushing Resident #6. LVN Z said she assessed Resident #6, gave her some pain medication, took her to her room to assess her, and then brought her back to the dining room to eat dinner and everything was fine. LVN Z said she did not see any obvious signs of injuries and Resident #6's pain seemed to be managed. LVN Z said a STAT x-ray was ordered for Resident #6, she notified Resident #6's RP, the DON, ADON, and the doctor of the incident. LVN Z said during the assessment, there was not any discoloration or bruising to make her think something was injured but the resident did have a slight limp when she pivoted to sit in the chair. LVN Z said before the incident, Resident #6 was completely and independently ambulatory, but the next day she was not able to walk so that nurse on shift sent her to the hospital. LVN Z said at the hospital, they found out she had a pelvic fracture. LVN Z said Resident #7 has not been physically aggressive towards other residents before, only combative during care with staff. LVN Z said Resident #7 did get upset though when people were talking around her, thinking they were talking to her. LVN Z said she knew the Administrator was the Abuse Coordinator for the facility and that a resident-to-resident altercation that resulted in injuries would be considered abuse. LVN Z said she would report that situation to the Administrator, but she did not think it was abuse at the time so she did not immediately report the situation. LVN Z said because Resident #7 had dementia and was very confused, she did not think it would be considered abuse at the time. <BR/>Interview on 02/27/25 at 12:23 PM with CNA V revealed it was around dinner time while staff were serving trays, and Resident #7 was talking to the air and yelling and some residents were replying back to her. CNA V said they were trying to calm the residents down and telling them to relax. CNA V said all of a sudden, she saw Resident #7 get up and storms over to push Resident #6 down. CNA V said she went over to stay at Resident #6's side until LVN Z came over. CNA V said after LVN Z took over, she went to check on Resident #7 who was in her room upset but wanted to be left alone. CNA V said Resident #6 looked like she was injured after being pushed because she was shouting and screaming in pain. CNA V said before the incident occurred, Resident #6 was up and walking around and did not need a wheelchair or walker. CNA V said Resident #7 did not have any physically aggressive behaviors before this incident. CNA V said she knew to report abuse to the Administrator who was the abuse coordinator for the facility. CNA V said she was not sure why she did not report the situation to the Administrator . CNA V said when the situation happened between Residents #6 and #7 she had only been working at the facility for a couple of weeks. <BR/>Interview on 02/27/25 at 2:36 PM with the DON revealed he received a report that Resident #6 had a fall and then the resident complained of pain and was sent to the ER. The DON said that another resident (Resident #7) had pushed Resident #6 and she fell. The DON said Resident #6 had a pelvic fracture. The DON said he was notified immediately after it happened and when Resident #6 was sent to the ER. The DON said Resident #7 was a little feisty with staff during care, but she had never attacked another resident. The DON said he was not sure what happened to make Resident #7 push Resident #6, but it was an accident and was not intentional. The DON said he talked to Resident #7, and she did not mean to hurt anyone. The DON said a resident-to-resident altercation was considered abuse. The DON said he would have to ask the Administrator if she reported the situation or not. The DON said all residents had the right to be free from abuse and all staff were responsible for making sure residents were free from abuse. The DON said Resident #6 was harmed from the situation because she suffered a pelvic fracture and now required the use of a wheelchair. The DON said Resident #6 was independently ambulatory before the incident.<BR/>Interview on 02/27/25 at 3:03 PM with the Administrator revealed what she understood was that the situation happened in the hallway, LVN Z was standing there and talking with Resident #6 when Resident #7 walked past and bumped her, causing Resident #6 to fall and sustained a fracture. The Administrator said when she spoke to the staff about it, she did not get the impression that it was intentional. The Administrator said Resident #6 was able to ambulate independently before the incident and since the fracture occurred she now used a wheelchair. The Administrator said she did not complete an investigation into what happened because of what she was told by the staff. The Administrator said she only talked to LVN Z about the incident but was not aware that she did not see what had happened. The Administrator said she did not speak with CNA V who witnessed the incident between the two residents. The Administrator said she only knew that Resident #6 had a fall and an x-ray was ordered which had negative results but she was still complaining of pain. The Administrator said since she was still complaining of pain the facility sent her to the ER and that was when they found out about the fracture. The Administrator said if LVN Z documented that Resident #7 pushed Resident #6 then that was intentional and has a different connotation than an accidental bumping into each other. The Administrator said with the new information regarding the situation, it was considered abuse between two residents. The Administrator said she would have wanted staff to report the incident to her immediately. The Administrator said if she had known the details of the incident she would have reported it to HHSC. The Administrator said all residents had the right to be free from abuse, even from other residents. The Administrator said everyone was responsible for making sure that residents were free from abuse. The Administrator said the purpose of keeping residents safe from abuse was to ensure their continued health and safety. The Administrator said all staff were responsible for reporting abuse to her immediately. The Administrator said if staff were not immediately reporting abuse to her then that could pave the way for people to be injured or harmed in some way or for abuse to continue. The Administrator said she expected all staff to follow the facility's abuse policy. The Administrator said she would have completed an investigation into the situation had she known about the details beforehand. The Administrator said her investigation would have included resident records, witness statements, safe surveys, assessments, and education with staff. The Administrator said if there was not an investigation into what happened, there would not be measures in place to make sure residents were safe from abuse. The Administrator said if she did not know what happened she could not fix it. The Administrator said she and the DON would be responsible for completing the investigation together.<BR/>Record review of the facility's Course Completion History report from 09/12/24 to 03/12/25 regarding Abuse, Neglect, and Exploitation Training reflected the following: LVN Z had completed the trainings on 11/30/24 and 02/2/25; CNA V had completed the training on 02/11/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse were immediately report, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator of the facility and to other officials including the State Survey Agency (HHSC) in a timely manner for 1 of 3 residents (Resident #6) reviewed for abuse.<BR/>1. LVN Z and CNA V failed to report an incident of resident-to-resident abuse immediately to the Administrator, who was the Abuse Coordinator, on 01/21/25 when Resident #7 pushed Resident #6, causing her to fall and sustain a pelvic fracture.<BR/>2. The Administrator failed to report to HHSC within 2 hours of Resident #6 being pushed by Resident #6 causing her to sustain a pelvic fracture.<BR/>The failure could place residents at risk of serious harm or neglect. <BR/>Findings included:<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #6's significant change in status MDS Assessment, dated 01/29/25, reflected she had a BIMS score of 06, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included unspecified fracture of sacrum and depression.<BR/>Record review of Resident #6's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #6] had a fall. Was accidentally pushed by another resident. Sent to ER.<BR/>Record review of Resident #6's Progress Notes reflected the following: <BR/>-Resident was pushed to floor by another resident, resident was crying stating her hip hurt, resident was assessed, assisted from floor to dining chair, pain medication administered. DON, MD and RP notified. Stat hip x-ray ordered. Resident is now sittingin [sic] dinning [sic] area, away from other resident eating dinner. Resident stated she has no pain at this time and will let staff know if her hip starts to hurt again. Written by LVN Z on 01/21/25 at 5:36 PM.<BR/>-X-ray performed at this time awaiting for results. Written by LVN Y on 01/21/25 at 11:11 PM.<BR/>-Result viewed, No acute fracture, dislocation, destructive bony process noted, result will be relayed to MD by incoming nurse. Written by LVN Y on 01/22/25 at 2:15 AM. <BR/>-Resident has been sent out to [Hospital X] r/t uncontrolled pain (L) hip. Resident is status post fall 1/22/25. STAT Xray result (L) hip shows No Acute Fracture, Dislocation or destructive bony process. Resident c/o pain (L) hip, Tramadol 50mg prn and Tylenol 650mg was administered for pain. Medication was not effective, resident unable to ambulate as she normally does. Notified [the DON] and resident sent out to ER for [NAME] evaluation. [Resident #6's RP] was also notified. Written by LVN W on 01/22/25 at 9:15 AM.<BR/>-Resident arrived facility [sic] from [Hospital X] by ambulance via stretcher accompanied by [Resident #6's RP] DX open displaced fracture of anterior wall of left acetabulum [an anterior wall acetabular fracture is a break in the front column of bone or area around the bony rim (wall) of your hip socket].Resident [sic] assisted in bed by two nurses, complained of some little pain ,tylenol [sic] 650 mg prn given with positive outcome . Written by LVN V on 01/25/25 at 12:15 PM.<BR/>Record review of Resident #6's hospital records, dated 01/30/25, reflected the following: <BR/>As Per admission history and physical dated 1/22/2025 <BR/>Patient is a 84 y.o. female has a past medical history of Dementia (HCC). admitted after fall at care facility resulting in pelvic fracture and difficulty ambulating. [Resident #6's RP] reports [Resident #6] was previously independent, 'very active' and 'walks on her own'. Recently completed PT at facility and 'checked all the boxes', discharged from therapy last Friday [01/17/25]. Fall mechanism- patient reports being pushed by 'lady' and feeling pain 'from the back'. [Resident #6's RP] unaware of circumstances, states facility noticed fall and difficulty walking.<BR/>Hospital Course/Summary:<BR/>Ptient [sic] presented after fall unable to bear weight. Found to acute minimally displaced fractures of the anterior left acetabulum, left inferior pubic ramus [describes a type of crack or break in a person's pelvis] and left sacrum .<BR/>Record review of Resident #6's Radiology Results Report, dated 01/21/25, reflected: Procedure: HIP UNI W OR W/O PELVIS 2-3 V .INTERPRETATION: Findings: No acute fracture, dislocation or destructive bony process. No soft tissue abnormally. Osteopenia. Mild degenerative changes. Conclusion: No acute osseous abnormality.<BR/>Interview on the phone on 02/27/25 at 11:15 AM with Resident #6's RP revealed Resident #6 was pushed by a different resident and her pelvis was fractured as a result. Resident #6's RP said Resident #6 was admitted to the hospital and the fracture did not require screws or any surgery so the doctor said it was going to heal on it's own. Resident #6's RP said before the incident, Resident #6 was able to walk around freely without the use of a walker or wheelchair and now she is no longer mobile, requiring the use of a wheelchair. Resident #6's RP said Resident #6 was able to stand and take some steps but it hurt the resident and was not like she was before. <BR/>Observation and interview on 02/27/25 at 11:57 AM with Resident #6 revealed she was sitting in a wheelchair at the nurse's station. Resident #6 said she was not in any pain, had never had a fall, and would never let anyone push her. Resident #6 did not appear to be in any pain. <BR/>Record review of Resident #7's face sheet, dated 02/27/25, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. <BR/>Record review of Resident #7's Quarterly MDS Assessment, dated 01/24/25, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included heart failure, non-alzheimer's dementia, and depression. <BR/>Record review of Resident #7's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #7] accidentally pushed another resident to the floor. Education completed, Redirected as needed. Goal: [Resident #7] will not harm self or others through the review date. Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Record review of Resident #7's Progress Notes reflected the following:<BR/>-Resident pushed another resident to the floor, no injuries noted to this resident. Resident was separated from resident she pushed to floor. DON, MD, and RP notified. Written by LVN Z on 01/21/25 at 5:25 PM.<BR/>- .Patient is seen per staff request due to reports of combativeness, and agitation. Patient is up in the dining area, calm at the moment, and in no distress at this time. She reportedly pushed another resident who sustained injuries, requiringhospitalization [sic]. Patient presents with spontaneous disruptive mood, and combativeness. She is alert to self, and unwilling or unable to participate in the assessment at this time .Chart reviewed, medication profile reviewed .Upon review, based on presenting will further increase Depakote and start patient on Atarax 10 mg twice daily as needed for anxiety. Primary nurse notified, will monitor closely. Written by NP LL on 01/23/25 at 4:06 PM<BR/>Observation and interview on 02/27/25 at 2:00 PM with Resident #7 revealed she was sitting in a chair at a table with other residents around her. Resident #7 said she was doing good today and did not appear to have any behaviors. <BR/>Interview on 02/27/25 at 11:57 AM with LVN Z revealed she was passing medications when Residents #6 and #7 were having an argument and Resident #7 stood up. LVN Z said before she could get to the area where the residents were at, Resident #7 ended up pushing Resident #6. LVN Z said she assessed Resident #6, gave her some pain medication, took her to her room to assess her, and then brought her back to the dining room to eat dinner and everything was fine. LVN Z said she did not see any obvious signs of injuries and Resident #6's pain seemed to be managed. LVN Z said a STAT x-ray was ordered for Resident #6, she notified Resident #6's RP, the DON, ADON, and the doctor of the incident. LVN Z said during the assessment, there was not any discoloration or bruising to make her think something was injured but the resident did have a slight limp when she pivoted to sit in the chair. LVN Z said before the incident, Resident #6 was completely and independently ambulatory but the next day she was not able to walk so that nurse on shift sent her to the hospital. LVN Z said at the hospital, they found out she had a pelvic fracture. LVN Z said Resident #7 has not been physically aggressive towards other residents before, only combative during care with staff. LVN Z said Resident #7 does get upset though when people were talking around her, thinking that they were talking to her. LVN Z said she knew the Administrator was the abuse coordinator for the facility and that a resident-to-resident altercation that resulted in injuries would be considered abuse. LVN Z said she would report that situation to the Administrator but did not think it was abuse at the time so she did not immediately report the situation. LVN Z said because Resident #7 had dementia and was very confused she did not think it would be considered abuse at the time. <BR/>Interview on 02/27/25 at 12:23 PM with CNA V revealed it was around dinner time while staff were serving trays, and Resident #7 was talking to the air and yelling and some residents were replying back to her. CNA V said they were trying to calm the residents down and telling them to relax. CNA V said all of a sudden, she saw Resident #7 get up and storms over to push Resident #6 down. CNA V said she went over to stay at Resident #6's side until LVN Z came over. CNA V said after LVN Z took over, she went to check on Resident #7 who was in her room upset but wanted to be left alone. CNA V said Resident #6 looked like she was injured after being pushed because she was shouting and screaming in pain. CNA V said before the incident occurred, Resident #6 was up and walking around and did not need a wheelchair or walker. CNA V said Resident #7 did not have any physically aggressive behaviors before this incident. CNA V said she knew to report abuse to the Administrator who was the abuse coordinator for the facility. CNA V said she was not sure why she did not report the situation to the Administrator. <BR/>Interview on 02/27/25 at 2:36 PM with the DON revealed he received a report that Resident #6 had a fall and then the resident complained of pain and was sent to the ER. The DON said that another resident (Resident #7) had pushed Resident #6 and she fell. The DON said Resident #6 had a pelvic fracture. The DON said he was notified immediately after it happened and when Resident #6 was sent to the ER. The DON said Resident #7 was a little feisty with staff during care but has never attacked another resident. The DON said he was not sure what happened to make Resident #7 push Resident #6 but that it was an accident and was not intentional. The DON said he talked to Resident #7 and she did not mean to hurt anyone, but a resident-to-resident altercation was considered abuse. The DON said he would have to ask the Administrator if she reported the situation or not. The DON said all residents had the right to be free from abuse and all staff were responsible for making sure residents were free from abuse. The DON said Resident #6 was harmed from the situation because she suffered a pelvic fracture and now required the use of a wheelchair. The DON said Resident #6 was independently ambulatory before the incident.<BR/>Interview on 02/27/25 at 3:03 PM with the Administrator revealed what she understood was that the situation happened in the hallway, LVN Z was standing there and talking with Resident #6 when Resident #7 walked past and bumped her, causing Resident #6 to fall and sustained a fracture. The Administrator said when she spoke to the staff about it, she did not get the impression that it was intentional. The Administrator said Resident #6 was able to ambulate independently before the incident and since the fracture occurred she now used a wheelchair. The Administrator said she did not complete an investigation into what happened because of what she was told by the staff. The Administrator said she only talked to LVN Z about the incident but was not aware that she did not see what had happened. The Administrator said she did not speak with CNA V who witnessed the incident between the two residents. The Administrator said she only knew that Resident #6 had a fall and an x-ray was ordered which had negative results but she was still complaining of pain. The Administrator said since she was still complaining of pain the facility sent her to the ER and that was when they found out about the fracture. The Administrator said if LVN Z documented that Resident #7 pushed Resident #6 then that was intentional and has a different connotation than an accidental bumping into each other. The Administrator said with the new information regarding the situation, it was considered abuse between two residents. The Administrator said she would have wanted staff to report the incident to her immediately. The Administrator said if she had known the details of the incident she would have reported it to HHSC. The Administrator said all residents have the right to be free from abuse, even from other residents. The Administrator said everyone was responsible for making sure that residents were free from abuse. The Administrator said the purpose of keeping residents safe from abuse was to ensure their continued health and safety. The Administrator said all staff were responsible for reporting abuse to her immediately. The Administrator said if staff were not immediately reporting abuse to her then that could pave the way for people to be injured or harmed in some way or for abuse to continue. The Administrator said she expected all staff to follow the facility's abuse policy. The Administrator said she would have completed an investigation into the situation had she known about the details beforehand. The Administrator said her investigation would have included resident records, witness statements, safe surveys, assessments, and education with staff. The Administrator said if there was not an investigation into what happened, there would not be measures in place to make sure residents were safe from abuse. The Administrator said if she did not know what happened she could not fix it. The Administrator said she and the DON would be responsible for completing the investigation together. <BR/>Record review of the facility's policy, revised September 2022, and titled Identifying Types of Abuse reflected: 1. Abuse of any kind against residents is strictly prohibited .4. 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Abuse toward a resident can occur as: a. resident-to-resident abuse .<BR/>Record review of the facility's policy, revised September 2022, and titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating reflected: Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation; Reporting Allegations to the Administrator and Authorities, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .<BR/>Record review of the facility's policy, revised April 2021, and titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program reflected: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. This includes but is not limited to freedom of corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; .2. Develop and implement policies and procedures to prevent and identify: a. abuse or mistreatment of residents .<BR/>Record review of the facility's Course Completion History report from 09/12/24 to 03/12/25 regarding Abuse, Neglect, and Exploitation Training reflected the following: LVN Z had completed the trainings on 11/30/24 and 02/2/25; CNA V had completed the training on 02/11/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to investigate and report an allegation of abuse for 1 of 3 residents (Resident #6) reviewed for abuse allegations. <BR/>The Administrator failed to investigate an incident of abuse when Resident #6 was pushed by Resident #7 on 01/21/25 and sustained a pelvic fracture. <BR/>This failure could place residents at risk of harm and injuries related to abuse and a delay in investigating.<BR/>Findings included:<BR/>Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #6's significant change in status MDS Assessment, dated 01/29/25, reflected she had a BIMS score of 06, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included unspecified fracture of sacrum and depression.<BR/>Record review of Resident #6's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #6] had a fall. Was accidentally pushed by another resident. Sent to ER.<BR/>Record review of Resident #6's Progress Notes reflected the following: <BR/>-Resident was pushed to floor by another resident, resident was crying stating her hip hurt, resident was assessed, assisted from floor to dining chair, pain medication administered. DON, MD and RP notified. Stat hip x-ray ordered. Resident is now sittingin [sic] dinning [sic] area, away from other resident eating dinner. Resident stated she has no pain at this time and will let staff know if her hip starts to hurt again. Written by LVN Z on 01/21/25 at 5:36 PM.<BR/>-X-ray performed at this time awaiting for results. Written by LVN Y on 01/21/25 at 11:11 PM.<BR/>-Result viewed, No acute fracture, dislocation, destructive bony process noted, result will be relayed to MD by incoming nurse. Written by LVN Y on 01/22/25 at 2:15 AM. <BR/>-Resident has been sent out to [Hospital X] r/t uncontrolled pain (L) hip. Resident is status post fall 1/22/25. STAT Xray result (L) hip shows No Acute Fracture, Dislocation or destructive bony process. Resident c/o pain (L) hip, Tramadol 50mg prn and Tylenol 650mg was administered for pain. Medication was not effective, resident unable to ambulate as she normally does. Notified [the DON] and resident sent out to ER for [NAME] evaluation. [Resident #6's RP] was also notified. Written by LVN W on 01/22/25 at 9:15 AM.<BR/>-Resident arrived facility [sic] from [Hospital X] by ambulance via stretcher accompanied by [Resident #6's RP] DX open displaced fracture of anterior wall of left acetabulum [an anterior wall acetabular fracture is a break in the front column of bone or area around the bony rim (wall) of your hip socket].Resident [sic] assisted in bed by two nurses, complained of some little pain ,tylenol [sic] 650 mg prn given with positive outcome . Written by LVN V on 01/25/25 at 12:15 PM.<BR/>Record review of Resident #6's hospital records, dated 01/30/25, reflected the following: <BR/>As Per admission history and physical dated 1/22/2025 <BR/>Patient is a 84 y.o. female has a past medical history of Dementia (HCC). admitted after fall at care facility resulting in pelvic fracture and difficulty ambulating. [Resident #6's RP] reports [Resident #6] was previously independent, 'very active' and 'walks on her own'. Recently completed PT at facility and 'checked all the boxes', discharged from therapy last Friday [01/17/25]. Fall mechanism- patient reports being pushed by 'lady' and feeling pain 'from the back'. [Resident #6's RP] unaware of circumstances, states facility noticed fall and difficulty walking.<BR/>Hospital Course/Summary:<BR/>Ptient [sic] presented after fall unable to bear weight. Found to acute minimally displaced fractures of the anterior left acetabulum, left inferior pubic ramus [describes a type of crack or break in a person's pelvis] and left sacrum .<BR/>Record review of Resident #6's Radiology Results Report, dated 01/21/25, reflected: Procedure: HIP UNI W OR W/O PELVIS 2-3 V .INTERPRETATION: Findings: No acute fracture, dislocation or destructive bony process. No soft tissue abnormally. Osteopenia. Mild degenerative changes. Conclusion: No acute osseous abnormality.<BR/>Interview on the phone on 02/27/25 at 11:15 AM with Resident #6's RP revealed Resident #6 was pushed by a different resident and her pelvis was fractured as a result. Resident #6's RP said Resident #6 was admitted to the hospital and the fracture did not require screws or any surgery so the doctor said it was going to heal on it's own. Resident #6's RP said before the incident, Resident #6 was able to walk around freely without the use of a walker or wheelchair and now she is no longer mobile, requiring the use of a wheelchair. Resident #6's RP said Resident #6 was able to stand and take some steps but it hurt the resident and was not like she was before. <BR/>Observation and interview on 02/27/25 at 11:57 AM with Resident #6 revealed she was sitting in a wheelchair at the nurse's station. Resident #6 said she was not in any pain, had never had a fall, and would never let anyone push her. Resident #6 did not appear to be in any pain. <BR/>Record review of Resident #7's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE]. <BR/>Record review of Resident #7's Quarterly MDS Assessment, dated 01/24/25, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included heart failure, non-alzheimer's dementia, and depression. <BR/>Record review of Resident #7's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #7] accidentally pushed another resident to the floor. Education completed, Redirected as needed. Goal: [Resident #7] will not harm self or others through the review date. Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.<BR/>Record review of Resident #7's Progress Notes reflected the following:<BR/>-Resident pushed another resident to the floor, no injuries noted to this resident. Resident was separated from resident she pushed to floor. DON, MD, and RP notified. Written by LVN Z on 01/21/25 at 5:25 PM.<BR/>- .Patient is seen per staff request due to reports of combativeness, and agitation. Patient is up in the dining area, calm at the moment, and in no distress at this time. She reportedly pushed another resident who sustained injuries, requiringhospitalization [sic]. Patient presents with spontaneous disruptive mood, and combativeness. She is alert to self, and unwilling or unable to participate in the assessment at this time .Chart reviewed, medication profile reviewed .Upon review, based on presenting will further increase Depakote and start patient on Atarax 10 mg twice daily as needed for anxiety. Primary nurse notified, will monitor closely. Written by NP LL on 01/23/25 at 4:06 PM<BR/>Observation and interview on 02/27/25 at 2:00 PM with Resident #7 revealed she was sitting in a chair at a table with other residents around her. Resident #7 said she was doing good today and did not appear to have any behaviors. <BR/>Interview on 02/27/25 at 11:57 AM with LVN Z revealed she was passing medications when Residents #6 and #7 were having an argument and Resident #7 stood up. LVN Z said before she could get to the area where the residents were at, Resident #7 ended up pushing Resident #6. LVN Z said she assessed Resident #6, gave her some pain medication, took her to her room to assess her, and then brought her back to the dining room to eat dinner and everything was fine. LVN Z said she did not see any obvious signs of injuries and Resident #6's pain seemed to be managed. LVN Z said a STAT x-ray was ordered for Resident #6, she notified Resident #6's RP, the DON, ADON, and the doctor of the incident. LVN Z said during the assessment, there was not any discoloration or bruising to make her think something was injured but the resident did have a slight limp when she pivoted to sit in the chair. LVN Z said before the incident, Resident #6 was completely and independently ambulatory but the next day she was not able to walk so that nurse on shift sent her to the hospital. LVN Z said at the hospital, they found out she had a pelvic fracture. LVN Z said Resident #7 has not been physically aggressive towards other residents before, only combative during care with staff. LVN Z said Resident #7 does get upset though when people were talking around her, thinking that they were talking to her. LVN Z said she knew the Administrator was the abuse coordinator for the facility and that a resident-to-resident altercation that resulted in injuries would be considered abuse. LVN Z said she would report that situation to the Administrator but did not think it was abuse at the time so she did not immediately report the situation. LVN Z said because Resident #7 had dementia and was very confused she did not think it would be considered abuse at the time. <BR/>Interview on 02/27/25 at 12:23 PM with CNA V revealed it was around dinner time while staff were serving trays, and Resident #7 was talking to the air and yelling and some residents were replying back to her. CNA V said they were trying to calm the residents down and telling them to relax. CNA V said all of a sudden, she saw Resident #7 get up and storms over to push Resident #6 down. CNA V said she went over to stay at Resident #6's side until LVN Z came over. CNA V said after LVN Z took over, she went to check on Resident #7 who was in her room upset but wanted to be left alone. CNA V said Resident #6 looked like she was injured after being pushed because she was shouting and screaming in pain. CNA V said before the incident occurred, Resident #6 was up and walking around and did not need a wheelchair or walker. CNA V said Resident #7 did not have any physically aggressive behaviors before this incident. CNA V said she knew to report abuse to the Administrator who was the abuse coordinator for the facility. CNA V said she was not sure why she did not report the situation to the Administrator. <BR/>Interview on 02/27/25 at 2:36 PM with the DON revealed he received a report that Resident #6 had a fall and then the resident complained of pain and was sent to the ER. The DON said that another resident (Resident #7) had pushed Resident #6 and she fell. The DON said Resident #6 had a pelvic fracture. The DON said he was notified immediately after it happened and when Resident #6 was sent to the ER. The DON said Resident #7 was a little feisty with staff during care but has never attacked another resident. The DON said he was not sure what happened to make Resident #7 push Resident #6 but that it was an accident and was not intentional. The DON said he talked to Resident #7 and she did not mean to hurt anyone, but a resident-to-resident altercation was considered abuse. The DON said he would have to ask the Administrator if she reported the situation or not. The DON said all residents had the right to be free from abuse and all staff were responsible for making sure residents were free from abuse. The DON said Resident #6 was harmed from the situation because she suffered a pelvic fracture and now required the use of a wheelchair. The DON said Resident #6 was independently ambulatory before the incident.<BR/>Interview on 02/27/25 at 3:03 PM with the Administrator revealed what she understood was that the situation happened in the hallway, LVN Z was standing there and talking with Resident #6 when Resident #7 walked past and bumped her, causing Resident #6 to fall and sustained a fracture. The Administrator said when she spoke to the staff about it, she did not get the impression that it was intentional. The Administrator said Resident #6 was able to ambulate independently before the incident and since the fracture occurred she now used a wheelchair. The Administrator said she did not complete an investigation into what happened because of what she was told by the staff. The Administrator said she only talked to LVN Z about the incident but was not aware that she did not see what had happened. The Administrator said she did not speak with CNA V who witnessed the incident between the two residents. The Administrator said she only knew that Resident #6 had a fall and an x-ray was ordered which had negative results but she was still complaining of pain. The Administrator said since she was still complaining of pain the facility sent her to the ER and that was when they found out about the fracture. The Administrator said if LVN Z documented that Resident #7 pushed Resident #6 then that was intentional and has a different connotation than an accidental bumping into each other. The Administrator said with the new information regarding the situation, it was considered abuse between two residents. The Administrator said she would have wanted staff to report the incident to her immediately. The Administrator said if she had known the details of the incident she would have reported it to HHSC. The Administrator said all residents have the right to be free from abuse, even from other residents. The Administrator said everyone was responsible for making sure that residents were free from abuse. The Administrator said the purpose of keeping residents safe from abuse was to ensure their continued health and safety. The Administrator said all staff were responsible for reporting abuse to her immediately. The Administrator said if staff were not immediately reporting abuse to her then that could pave the way for people to be injured or harmed in some way or for abuse to continue. The Administrator said she expected all staff to follow the facility's abuse policy. The Administrator said she would have completed an investigation into the situation had she known about the details beforehand. The Administrator said her investigation would have included resident records, witness statements, safe surveys, assessments, and education with staff. The Administrator said if there was not an investigation into what happened, there would not be measures in place to make sure residents were safe from abuse. The Administrator said if she did not know what happened she could not fix it. The Administrator said she and the DON would be responsible for completing the investigation together. <BR/>Record review of the facility's Course Completion History report from 09/12/24 to 03/12/25 regarding Abuse, Neglect, and Exploitation Training reflected the following: LVN Z had completed the trainings on 11/30/24 and 02/2/25; CNA V had completed the training on 02/11/25. <BR/>Record review of the facility's policy, revised September 2022, and titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating reflected: Policy statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation; Reporting Allegations to the Administrator and Authorities, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .Investigation Allegations: 1. All allegations are thoroughly investigated. The administrator initiates investigations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure personnel provided basic life support, 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 1 of 8 residents (Resident #11) reviewed for CPR.<BR/>LVN A failed to initiate CPR when Resident #11 did not have a State recognized advance directive which meant the resident was a Full Code status, and he was found on the floor on the fall mat with his face noted to be reddish purple, weak pulse with no obvious respirations or breathing patterns noted. <BR/>An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>These failures could affect the residents by placing them at risk for a delay in intervention and life-saving treatments, which could result in death. <BR/>Findings included:<BR/>Record review of Resident #11's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke, heart failure, high blood pressure, diabetes, aphasia (language disorder), alcohol abuse, other psychoactive substance abuse, and cerebral ischemia (condition where the brain does not receive enough blood flow, leading to a lack of oxygen and nutrients). Resident #11's cognition was moderately impaired with a BIMS score of 11. The MDS further reflected the resident required assistance with most all ADLs. <BR/>Record review of Resident #11's care plan revised on [DATE] reflected he was a full code. Interventions included to initiate basic life support CPR if the resident was without a heartbeat or not breathing. <BR/>Record review of Resident #11's progress notes dated [DATE] documented by LVN A reflected the following:<BR/>8:45 PM<BR/>Upon walking halls in observation of residents, this nurse, upon peeping into res room, noticed resident in prone position while on landing mat appearing asleep. Called res name while attempting to clear visual of res and/or breathing pattern while entering room. After reaching resident, head noted on pillow slightly tilted, face abnormal in color appearing reddish purple. Neck palpated. Weak pulse ascertained. Sternal rub to no avail. No obvious respirations or breathing pattern noted. Nurses X2 assisted res to bed as other nursing staff initiated Emergency response while simultaneously checking resident's code status. During this time at res bedside, O2 initiated and continued efforts were made to arouse res. by this nurse. Res, per demographics in echart, reported to be a DNR as relayed by additional staff. <BR/>9:00 PM<BR/>Emergency response noted in facility in resident's room. Writer informed first responders of said code status as documented in echart. Cpr initiated by fire dept pending receipt of physical copy of advance directives with md signature. This nurse continued to obtain signed verification of code status while calling resident's [family] several times at both listed numbers to no avail. Resuscitation efforts continued awaiting requested info. Spoke with Resident #11's [friend] first contact to notify of incident. Speaker was aware of res code status but did not know specifics, he stated. [sic]Contnued to try to reach [family] in which after approximately 15 min did answer. Was informed by resident's [family] who is listed as surrogate per [county] stated in hospital dnr received upon admission [DATE] that is was resident's wishes to decline life saving measures in the event res codes or is incapacitated, he explained. Per fire dept, they were attempting to reach [family] in which I did notably transfer call to fireman to confirm res code status as explained. [Family] spoke with said fireman in which he stated twice that I was his father's request to not be resuscitated. Emergency did inform res [family] that they would be ceasing resuscitation in 15 min <BR/>9:15 PM<BR/> .Cellphone was brought to this nurse by fire dept in which their medical director stated the requirements of dnr also informing me that the issue 'would be moved up' in chain due to our inability to produce said document During conversation with their medical director I, in fact had located hospital dnr signed by NP with surrogate [family] present and in aggreeance with resident's wishes to not perform 'life saving measures' decision was made by the fire dept to transfer res to ER also stating 'we would probably get a visit tomorrow morning' This nurse stated to fire dept [family] was awaiting on line in which he then informed to tell [family] they were transferring him to hospital after obtaining signs of life after resuscitation because we could not produce documentation <BR/>Record review of Resident #1's monthly physician orders for February 2025 reflected LVN B input an DNR order on [DATE]. Further review of Resident #1's electronic health record reflected there was not a State recognized Advance Directive nor an Out-of-Hospital DNR for Resident #1.<BR/>Record review of Resident #11's hospital form titled Medical Orders for Scope of Treatment dated [DATE] signed by a nurse practitioner reflected <BR/>A Do Not Attempt Resuscitation/Allow Natural Death <BR/> .D. Direct conversation with surrogate decision-maker/proxy for incapacitated patient<BR/>Surrogate/Proxy Name: [Resident #1's family]<BR/>Relationship: Adult Child<BR/>Primary Contact Number:<BR/>Designated in: Texas Statutory Surrogate<BR/>Signature of Physician<BR/>[NP]<BR/>Date and Time: [DATE] 4:08 PM <BR/>Record review of Resident #11's Fire Department Run Form dated [DATE] reflected the following:<BR/>A Physician Resuscitation Order: Has no pulse or is not breathing.<BR/>Do Not Attempt Resuscitation/Allow Natural Death <BR/>Narrative: Subjective<BR/>Medic was called for a reported breathing problem at 1500 [Facility] in the [City]. Call notes stated 'faintly breathing//currently getting oxygen', 'patient is confused' 'patient has dementia'. On arrival, a [AGE] year old male made was found in cardiac arrest. Staff stated the patient has a DNR. Staff later stated they could not find the DNR. Multiple attempts to contact patient's family were unsuccessful. <BR/>Objective:<BR/>At 20:57, the patient was lying supine on the bed. A NRB was on the patient's face, placed by staff, with oxygen connected but no staff was nearby. Initial assessment revealed the patient was pulseless and apneic (a condition where breathing temporarily ceases). The patient's skin was mottled by warm. The patient had no visible trauma or external bleeding. <BR/>Assessment:<BR/>The field impression of the patient was Cardiac Arrest<BR/>Plan:<BR/>Upon finding the patient pulseless and apneic a 4-lead was established (a diagnostic tool that uses four electrodes to record the heart's electrical activity) and the patient was confirmed to be in asystole (a cardiac arrest that occurs when the heart stops beating and there is no electrical activity. After the staff stated that they could not find the DNR, the patient was transferred to the ground and CPR was initiated. Using the face sheet, family was contact was attempted but failed After 15 minutes of ACLS (Advanced Cardiac Life Support- a set of medical procedures and skills used to treat cardiac emergencies) the patient had a rhythm change for asystole to PEA (Pulse Electrical Activity - type of cardiac arrest where the heart's electrical activity is present, but there is no pulse) Due to the change in rhythm and rate of PEA, medical direction instructed us to transport the patient to the ER No further change in rhythm was noted throughout transport. Upon arrival at the ER the resident was transferred from the stretcher to the hospital bed The medical director checked heart motion and continued CPR for two more minutes before ending resuscitation attempts. <BR/>Multiple attempts to contact LVN A on [DATE] and on [DATE] were unsuccessful.<BR/>Attempts to contact Resident #11's family on [DATE] were unsuccessful. <BR/>Interview on [DATE] at 1:21 PM with the Social Worker revealed Resident #11 was a full code and did not have DNR paperwork. The Social Worker said someone in the family said they had been discussing Resident #11 become a DNR but that was a far as that went, and nothing else was said . <BR/>Interview on [DATE] at 4:24 PM with LVN C revealed LVN A said she was making rounds, [DATE], when she found Resident #11 unresponsive, and he had gone to assist and noticed he had a weak pulse. The resident's lips were blue, and he was not responding. LVN C said they checked the computer, and it showed the resident was a DNR and 911 was called. When EMS arrived, they asked for Resident #11's DNR paperwork and they were not able to produce it, so EMS started CPR as LVN A and LVN C continued to look for the DNR. LVN C said that because they thought Resident #11 was a DNR, the AED machine was not applied. LVN C further stated he heard one of the EMS staff members say Resident #11 had flatlined when they put the machines on the resident . <BR/>Interview on [DATE] at 1:29 PM with the ADON revealed she was not aware CPR had not been initiated on Resident #11 on [DATE] and if the resident was a full code, then CPR should have been initiated .<BR/>Interview on [DATE] at 2:07 PM with the DON revealed he was told Resident #11 had coded, [DATE], and had been found unresponsive. The DON said the resident just returned from the hospital, [DATE], and with a DNR but it was not an Out of Hospital DNR. Based on the progress notes, had read Resident #11 had a weak pulse, put oxygen on, and staff dialed 911. The DON said it appeared the AED was not used because the resident still had a pulse. The DON also said it appeared LVN A was unsure if Resident #11 was a full code. The DON further stated the staff could have used the AED machine to confirm the resident had a pulse . The DON further stated CPR should have been initiated if a resident was a full code or the code status was unknown. <BR/>Interview on [DATE] at 5:47 PM with the Administrator revealed the EMS had met with her, because they had a concern, because the staff had gone back and forth whether Resident #11 was a DNR on [DATE]. The Administrator said it appeared they had a hospital DNR on file and the nurse, LVN A, did not know it was not valid in a nursing home. The EMS told her they required an Out of Hospital DNR and the facility staff should have started CPR when Resident #11 was found unresponsive . <BR/>Interview on [DATE] at 1:18 PM with the Physician revealed Resident #11 was known to the facility and the nurses assumed the resident was a DNR because the resident had a hospital DNR. He said he was glad the resident was not revived because everyone knew that is what Resident #11 wanted. The Physician said nursing homes required Out of Hospital DNR's and that paperwork should be done when the residents were admitted . He further stated if the residents were a full code, CPR should be initiated if they code. <BR/>Interview on [DATE] at 9:08 AM with the EMS Captain revealed they were called to the facility for a resident having difficulty breathing. When EMS arrived, they found Resident #11 with oxygen on a high flow, and he was not breathing. When the EMS crew put the monitors on the resident, he was flatlined. The EMS staff asked the facility staff if Resident #11 was a full code or a DNR. They were told the resident was a DNR but 20 or 30 minutes later the facility staff were still trying look for the DNR paperwork. When the facility staff finally said they found the DNR it was make shift from a nurse practitioner that was not valid in the state of Texas for a nursing home. He said Texas required an Out of Hospital DNR in a nursing home, otherwise the residents were a full code. The EMS Captain stated they were not able to get a heart beat on the resident and he had to be transported because they were able to get a PEA . They were not able to get in touch with the family so there was no one that could tell them to stop CPR. The EMS Captain further stated, after the incident, he met with the Administrator because he had been concerned there was so much confusion on whether a resident was a DNR or a full code.<BR/>Record review of the facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation revised on 09/2024 reflected the following:<BR/> .6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR <BR/>.7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR <BR/>An Immediate Jeopardy/Immediate Threat was identified on [DATE]. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 4:36 PM. The IJ template was provided to the facility on [DATE] at 4:45 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. <BR/>The facility's Plan of Removal for the Immediate Jeopardy was accepted on [DATE] at 9:00 AM and reflected the following:<BR/>Immediate Corrective Action for residents affected by the alleged deficient practice:<BR/>On [DATE] the resident was noted to be in a prone position appearing asleep during staff rounds. The staff member entered the room and checked the resident who was noted with weak pulse but was unresponsive to sternal rub. At this time the facility called 911, while checking residents code status. The resident was placed on oxygen and efforts were made to arouse the resident who had a pulse. <BR/>EMS arrived at the facility and began resuscitation efforts for the resident, who was taken to [Hospital] by the EMS team.<BR/>Actions taken to prevent a serious adverse outcome from recurring:<BR/>This deficient practice had the potential to affect all residents who reside in the facility, the EMS Captain visited the facility on [DATE] to discuss the incident with the administrator. At this time the administrator completed a code status audit of all residents residing in the facility. All were found to have the appropriate documentation in the miscellaneous section of the chart listed as advanced directives or out of hospital DNRs. The administrator also had the social worker complete a chart audit to double-check that no code statuses were missed. <BR/>On [DATE] the administrator reached out to the EMS captain to inform him of the results of the audit and thank him for the collaboration with the facility.<BR/>The director of nursing started an education on Code Status and CPR on [DATE], education continues at present. <BR/>The director of nursing and administrator were educated by vice president of clinical services on the topics of: Code Status, Out of Hospital DNRs, when to initiate CPR, and when to apply the AED. This education took place on [DATE]. <BR/>New training initiated on [DATE] will include all nurses. They will be educated on identifying the appropriate code status including out of hospital DNR vs. Hospital DNR, when to initiate CPR, and how to use the AED correctly. <BR/>The nursing staff checks all residents for orders and appropriate paperwork on code status upon admission/readmission to the facility. This is checked again by the nurse management team in the morning meeting, and the social worker in weekly audits. <BR/>The administrator and social services director will continue to audit code statuses weekly. All results will be discussed monthly in QAPI. <BR/>The Medical Director was notified of the deficiency (F678) on [DATE].<BR/>When Actions will be complete:<BR/>The [Facility] will have completed education by [DATE], if any staff member working in the facility is unable to be educated, they will be removed from the schedule until training has been provided.<BR/>The [facility] requests the removal of the immediate jeopardy on [DATE]. <BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Record review of the facility DNR audit dated [DATE] revealed all residents had the appropriate paperwork if they were a DNR. <BR/>Record review of 12 current facility residents on [DATE] revealed they had the correct code status, physician order, and Out of Hospital DNR in their clinical file. <BR/>Record review of in-services dated [DATE] reflected staff were educated on code status, Out of Hospital DNRs, when to initiate CPR, and when to apply the AED. They were also educated to check all residents' orders and appropriate paperwork on code status before they input the order. <BR/>Interview on [DATE] from 9:53 am to 4:00 PM with staff from various shifts were the Administrator, DON, ADON, LVN A, LVN B, LVN C, LVN D, LVN E, RN F, LVN G, and LVN H. All staff stated they were educated on the following:<BR/>- <BR/>On code status - Full code/DNR<BR/>- <BR/>Identify the difference between a hospital and Out of Hospital DNR<BR/>- <BR/>When to initiate CPR<BR/>- <BR/>If code status is unclear, resident is a full code until further notice and CPR will be initiated.<BR/>- <BR/>How to apply and use the AED<BR/>- <BR/>Verify through orders and paperwork a resident's code status before it is put in the computer system. <BR/>Interview on [DATE] at 2:28 PM with the Social Worker she was responsible for conducting weekly DNR audits to ensure each resident had the correct code status. <BR/>An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

**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, consistent with the resident rights as set forth at 483.10(c) and 483.10(c)3, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #239) for care plan revisions, in that:<BR/>The facility failed to develop a care plan addressing Resident #239's elected code status or advance directive.<BR/>These failures could place residents at risk of receiving inappropriate care.<BR/>Findings included:<BR/>Record review of Resident #239's face sheet dated [DATE] reflected the resident was a [AGE] year-old female admitted on [DATE].<BR/>Record review of Resident #239's admission MDS assessment dated [DATE] reflected the resident's cognition was intact with a BIMS score of 15. The resident's diagnoses included multiple sclerosis (chronic disease of the central nervous system), anxiety disorder (mental health disorder) and hyperkalemia (high potassium). <BR/>Record review of Resident #239's care plan dated [DATE] reflected there was not a care plan addressing the resident's code status or advance directives.<BR/>Record review of Resident #239's physician order summary report dated [DATE] reflected it did not have an active physician's order for code status, such as full code status or any other order to support her advanced directive. <BR/>Record review of the facility's Order List Report dated [DATE] located in the facility's emergency crash cart reflected Resident #239 was not on the list for code status. <BR/>Interview on [DATE] at 10:24 AM, Resident #239 stated admitted to the facility about two weeks ago. Resident #239 stated she had not been asked about her code status. She stated her preference would be DNR. <BR/>Interview on [DATE] at 10:35 AM, LVN K stated she was the nurse assigned to Resident #239. LVN K stated when a resident admitted to the facility, it was the responsibility of the admission nurse to ask the resident for their code status and document in the resident's chart. LVN K stated it was the responsibility of the Social Worker to follow-up with the resident and include the code status in the resident's care plan. LVN K reviewed Resident #239 clinical records and stated she was not aware Resident #239 did not have a physician order for code status or that it was not documented in the resident's care plan. <BR/>Record review of Resident #239's physician order summary report dated [DATE] reflected a physician order for Full Code. <BR/>Interview on [DATE] at 10:56 AM, the Social Worker stated it was the responsibility of the admission nurse to ask residents about their code status. She stated she would follow-up shortly after their admission. She stated once she obtained the resident's code status it was her responsibility to care plan it. She stated she was not aware Resident #239's code status was not documented in the resident's chart. She stated the code status should be in PCC (electronic health record system) under the physician orders and care plan. She stated Resident #239's code status was Full Code, and she forgot to care plan Resident #239's code status. She stated the risk of not having a code status would be doing CPR or not doing CPR. <BR/>Interview on [DATE] at 2:46 PM, the ADON stated it was the responsibility of the admission nurse to obtain and document code status. She stated she was not aware Resident #239 did not have a code status until today ([DATE]) when LVN K informed her. She stated it was the responsibility of the social worker to follow up when she completes her code status audits. The ADON stated code status should be care planned which were completed by the social worker. She stated the potential risk of not having code status would be confusion during an emergency. <BR/>Interview on [DATE] at 3:23 PM, the DON stated advance directives were obtained upon a resident's admission to the facility by the admitting nurse. She stated the Social Worker would then follow-up with the resident. She stated she was not aware Resident #239 did not have a code status. She stated she was informed today ([DATE]). She stated she expected her nurses to obtain residents' code statuses upon admission, and she expected the Social Worker to follow-up and care plan the code status. She stated code status should be documented in PCC and on the care plan. She stated the potential risk would be doing CPR on the resident when they had elected to be a DNR. <BR/>Record review of the facility's Care Planning - Interdisciplinary Team policy, revised [DATE], reflected: The interdisciplinary team is responsible for the development of resident care plans.<BR/>Record review of the facility's Advance Directives policy, revised [DATE], reflected: The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise and review the care plan for 1 of 5 residents (Resident #10) reviewed for comprehensive care plans timing and revision. The facility failed to revise and review Resident #10's care plan to include his physician orders to have a 70 ml water flush during his tube feedings. This failure could lead to the residents not receiving appropriate hydration intake. Findings included:Record review of Resident #10's MDS assessment reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10's MDS assessment, dated 08/07/25, reflected Resident #10's BIMS score of 00 indicating resident was not able to complete the interview. Resident #10's MDS indicated he had parenteral/IV feeding and feeding tube while a resident of the facility. His diagnoses included paraplegia (inability to move or control the legs and lower body), contracture of muscle right and left lower leg (muscles or other tissues tighten or shorten causing deformity), unspecified protein-calorie malnutrition (inadequate intake of protein and calories), dysphagia (difficulty swallowing), gastrostomy status (an opening in the stomach through the abdominal wall, allowing for the placement of a feeding tube) . The MDS reflected Resident #10 was dependent on staff for eating and all activities of daily living skills. Record review of Resident #10's care plan further indicated Resident #10 had an Activity of Daily Living Skills performance deficit. Goal: will maintain or improve current level of function in eating. Interventions included eating: required 1 staff assistance. Resident #10's care plan also noted he required tube feeding related to Dysphagia calorie requirements changed and new order received for 1. Nutren 2.0 at 44mL/hr x 22hr 2. Water flush at 50mL/hr x 22hr. Provides 1936kcal, 968mL formula, 1770ml Total water. Revision on: 04/18/2025 Goal: Resident #10 will remain free of side effects or complications related to tube feeding. Interventions included to clean insertion site daily as ordered, monitoring for signs and symptoms infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to physician if symptoms arise. Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. Monitor/document/report to Physician PRN: Aspiration- fever, Short of Breath, Tube dislodged. Infection at tube site, Self-extubation (patient deliberately removes their own tubing), Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. NPO status Revision on 04/23/2025 1. Nutren 2.0 at 44mL/hr x 22hr 2. Water flush at 50mL/hr x 22hr. Provides 1936kcal, 968mL formula, 1770ml Total water (not counting med flushes). Obtain and monitor lab/diagnostic work as ordered. Report results to Physician and follow up as indicated. Provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection. Registered Dietitian to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. The resident is dependent with tube feeding and water flushes. See physician orders for current feeding orders. The resident needs assistance with tube feeding and water flushes. See physician orders. for current feeding orders. The resident needs the Head of Bed elevated 30 degrees during and thirty minutes after tube feed. Record review of Resident #10's care plan also indicated Resident #10 has alteration in gastrointestinal status (G-Tube) related to Dysphagia; Nutren 2.0 at 44 cc/hr x 22 hours and 100 water flush every hour. Goal: Resident #10 will remain free from discomfort, complications, signs, or symptoms related to gastrointestinal alterations. Interventions included Keep Head of Bed elevated. Give medications as ordered. Monitor/document side effects and effectiveness. Monitor vital signs as ordered/per protocol and record. Notify physician of significant abnormalities (rapid pulse, shallow, rapid, or labored respirations, low blood pressure). Obtain and monitor lab/ diagnostic work as ordered. Report results to physician and follow up as indicated. Revision on: 05/08/2025. Record review of Resident #10's physician's order for feeding revealed one time a day Nutren 2.0 at 44mL/hr via PEG, up at 1200pm until total volume of 968mL has been infused. Provides 1936kcal. FWF 70mL/hr x 22hrs. Total volume= 1540mL fluid. Enteral Feed Active 9/16/2025 12:00 9/16/2025. Observation of Resident #10 on 09/16/25 at 11:18 AM revealed him sitting in the television room. Resident #10 was not connected to his tube feeding machine, it was left in his room. Resident #10's tube feeding machine was currently off, the formula bag was dated 9/15/25 12:30 PM with rate of 44ml, water was dated 09/15/25 12:30 PM rate 70ml. Observation of Resident #10 on 09/16/2025 at 1:12 PM revealed him in the bed with staff checking for tube placement, residual and connecting the tube for his feeding. Observation of Resident #10 on 09/16/2025 at 1:54 PM revealed Resident #10 in bed, observation of feeding machine revealed 44ml 1698, water flush 70 ml. Resident #10's formula bag or water bag did not indicate the date, time, initials, or rate. Observation and Interview on 09/17/2025 at 12:15 PM with LVN B revealed that Resident #10 had been on an alternative formula until the Nutren 2.0 was available, allowing for changes with his feedings and water flushes. LVN B stated any changes with Resident #10's formula or water flow rate should be updated in the care plan by the nursing staff which could include the charge nurse, ADON C or the DON. LVN B stated not doing so could place Resident #10 at risk of receiving the wrong flow rate. Interview on 09/18/25 2:02 PM with ADON C revealed nursing staff were responsible for updating acute changes on the care plan and the MDS Coordinator was responsible for updates during comprehensive reviews. The ADON stated she was not aware that Resident #10's care plan was updated with accurate water flushing. ADON C stated not having the care plan updated could place Resident #10 at risk for not getting the correct amount of hydration. Interview on 09/18/25 at 2:45 PM with the DON revealed Resident #10 had use of tube feeding machine, his expectation was if there was a change in condition or resident status the charge nurse was responsible for updating the care plan. The DON stated when there were any updates or changes, it was brought to the morning meetings and discussed daily. The DON stated a change in formula or water flush rates would be something that he would expect the charge nurse to update on the care plan and the ADON C or himself would review. The DON stated not updating the care plan could place residents at risk of not receiving the personalized care they desire. Interview on 09/18/25 at 4:18 PM with the MDS Coordinator revealed she had been employed for 3 weeks. She stated she was responsible for care plans and the ADONs and DON were responsible for reviewing them and updating care plans. MDS Coordinator stated residents on tube feeding and water flushes should be care planned for it. She stated she was not aware Resident #10's care plan was not updated with the new orders for water flushes. The MDS Coordinator stated, she updated care plans quarterly during the care plan meetings when the resident, family and staff are together to discuss residents' required care. She stated the potential risk would be staff not aware of the interventions that were put in place and dehydration. Record review of facility Care Plans, Comprehensive Person-Centered policy, revised date March 2022, reflected the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care and services in accordance with subsection (a) of this section for the following activities of daily living, hygiene (grooming) for 1 of 5 residents (Resident #67) reviewed for ADL care. The facility failed to provide Resident #67 assistance with nail care. Resident #67 nails were observed to be about half inch long with black debris under nails on both hands. This failure could place the residents at risk for decreased feelings of self-worth and infection. Findings included:Record review of Resident #67's Quarterly MDS assessment, dated 08/02/25, reflected the resident was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted [DATE]. Resident #67 had cognition intact with a BIMS score of 99 (indicating he was not able to complete interview). Resident #67 was dependent on staff with shower/bathe self, and personal hygiene. Active diagnosis included Non- Alzheimer's Dementia (memory loss), bipolar disorder (mood swings of emotional highs and lows). Record review of Resident #67's current, undated care plan reflected Resident #67 had a self-care performance deficit. The resident required more assistance /cueing with activities of daily living skills. The care plan reflected: Goal: [Resident #67] will maintain current level of function in personal hygiene. Interventions included Bathing/Showering: Check nail length, trim and clean on shower days and as needed. Staff will be aware that resident require more assistance with activities of daily living and provide additional cueing and redirection. Observation and interview on 09/16/25 at 2:06 PM with Resident #67 revealed him in his room sitting in his wheelchair. His nails were at least half inch long with black debris underneath and around the nail bed. Resident #67 stated he was unsure of the last time staff assisted with trimming or cleaning his nails. According to Resident #67 his nails were long and would not mind if someone helped him to cut them down, however he was not bothered by them being dirty. Interview on 09/18/25 at 10:24 AM with the Staffing Coordinator revealed Resident #67's nails were dirty and need to be trimmed. The Staffing Coordinator further stated [Resident #67] is a combative person, however when I care for him I usually will take a towel and clean up under his nails. Nail days are on Sundays, CNAs are responsible for cleaning nails, if residents are not diabetic, on Monday, Wednesday, and Fridays during his shower. The Staffing Coordinator stated not providing nail care to residents could place them at risk for infections, especially someone like Resident #67 because he is a digger, so that is poop underneath his nails. Interview on 09/18/25 at 10:37 AM with CNA F revealed she was not currently working with Resident #67, but resident nail care was to be completed during shower days. She stated she usually paid attention to resident nails daily and would clean or trim them if needed. CNA F revealed it was the responsibility of the aides to complete nail care and grooming for residents on their respective halls and not doing so placed residents at risk of scratching or cutting themselves or others. Interview on 07/24/25 at 1:26 PM with ADON C and the DON revealed they both expected residents to have hand hygiene which included nail care. ADON C stated it was the responsibility of the CNAs to complete nail care if residents were not diagnosed with Diabetes, otherwise the charge nurse would trim and clean resident nails, or resident would be referred to podiatry. According to the DON, previously there was an CNA that was responsible for completing nail care on all residents, that was her specific task, however she has been on maternity leave, so the failure is that no one else has been assigned or has continued that task. Both ADON C and the DON stated not having a plan in place to continue nail care for residents placed them at risk of infections and skin tears. Record review of the facility's Activities of Daily Living (ADL), Supporting policy, updated February 2025, reflected: Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene - (bathing, dressing, grooming, and oral care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care.<BR/>LVN A failed to ensure Resident #1 was provided with timely treatment when the resident had a changed of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which revealed the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment.<BR/>An Immediate Jeopardy (IJ) situation was identified on 0719/24. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk for delay in needed treatment and care.<BR/>Findings included:<BR/>Record review of Resident #1's MDS assessment, dated 06/24/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, vitamin D deficiency, hypocalcemia (calcium deficiency), and cognitive communication deficit. Resident #1 had long and short- term memory impairment and decision making was severely impaired. Resident #1 had unclear speech rarely understood/understands. The MDS further reflected the resident was in a manual wheelchair and dependent for all ADLs.<BR/>Record review of Resident #1's care plan, revised 07/29/21, reflected she had a communication problem related to dementia. Interventions included to monitor and document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. <BR/>Record review of Resident #1's progress notes, dated 06/15/24, documented by LVN A reflected:<BR/>Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed. At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to oncoming nurse to monitor resident discomfort if worsens to report to NP/MD .<BR/>Record review of Resident #1's x-ray report, dated 06/16/24, reflected:<BR/> .EXAM: Pelvis and left hip<BR/>HISTORY: Pain<BR/> .FINDINGS: There is a fracture involving the proximal left femur centered within the intertrochanteric space. There does appear to be approximately a centimeter of shortening as well as a few degrees of varus angulation. There is no dislocations. A significant joint effusion is not seen. Mild symmetric osteoarthritis is seen .<BR/>IMPRESSION:<BR/>1. Proximal left femur fracture .<BR/>Record review of Resident #1's hospital records, dated 06/16/24, reflected Resident #1 had been diagnosed with an acute fracture of the left proximal femur (hip fracture).<BR/>Record review of the facility's Provider Investigation Report, dated 06/17/24, reflected the following:<BR/> .This resident is a 60 yo (year old) female who resides on the secured unit. The resident ambulates independently on the unit. This resident also ambulates in a wheelchair. This resident has dementia, osteoarthritis, and vitamin D deficiency. The weekend RN supervisor informed this admin that x-rays were ordered due to a resident possible leg fracture .On-coming aide notified charge nurse that during peri care resident was favoring her left leg. Charge nurse stated that resident is non-verbal and that she would monitor resident throughout her shift. Charge nurse indicated that resident slept through the night. Facility received x-rays, indicating possible fracture .<BR/>Observation on 07/02/24 at 10:00 AM of Resident #1 revealed she was in a low bed with her eyes closed. After knocking, the resident's name was called out, but Resident #1 barely opened her eye, closed them right away and did not speak. <BR/>Interview on 07/02/24 at 10:54 AM CNA B stated she was making her rounds on, 06/15/24, around 7:45 PM. She went in to change Resident #1 and when she started peri care, Resident #1 yelled out like she was in pain, so she went to get LVN A. At that time both the CNA B and LVN A tried to assist the resident to a standing position and Resident #1 yelled again. and They noted something was wrong, and it appeared like her left foot was hurting so she was put back in bed. Resident #1 was not able to speak therefore could not tell them what was wrong. CNA B said it was not normal for Resident #1 to yell out when she was being changed. CNA B further stated she worked from 7:00 PM to 7:00 AM and during the night she continued to monitor Resident #1. and during her brief change, the resident did not groan or appear to be in pain the remainder of her shift. <BR/>Record review of LVN A's undated handwritten and signed statement reflected the following:<BR/>To whom it may concern,<BR/>Cc: [Resident #1]<BR/>Upon my shift on June 15th, this writer [LVN A] noted patient sitting on w/c but seems sleepy (eyes closed). Notified nurse aide to lay patient in bed. During rounds for incontinent care with nurse aide, noted facial grimacing when touching pt on left leg but since patient is non-verbal, assessed pt left extremities no bruises noted, or any other skin issues. Layed [laid] pt comfortably in bed, while continuous monitoring, pt slept all night long. This writer reported oncoming nurse to monitor if patient persist with pain to touch to notify MD.<BR/>Review of LVN A's undated typed and signed statement on 07/02/24 reflected the following:<BR/>To whom it may concern<BR/>Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed., At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to on coming nurse to monitor resident discomfort if worsens to report to NP/MD.<BR/>Record review of LVN A's personnel file on 07/02/24 reflected the signature on LVN A's handwritten statement matched the signatures on her new hire paperwork.<BR/>Interview on 07/02/24 at 2:25 PM LVN A stated she arrived to work around 6:00 PM on, 06/15/24, and Resident #1 was in her wheelchair and appeared to look tired, so she asked an aide to lay her down in bed. Later that evening, CNA B told her the resident was having some discomfort while she was trying to change her brief, so she went into Resident #1's room to assess the resident. LVN A denied trying to make the resident stand up and said Resident #1 indeed looked to have some discomfort, but it was not pain. LVN A described the discomfort as someone that was tired and did not want to be touched and again denied the discomfort as pain. LVN A said she continued to monitor the resident throughout the night and there were no concerns as Resident #1 has slept comfortably the whole night. LVN A was asked about her handwritten statement where she had documented facial grimacing when the resident's left leg was touched and LVN A denied writing a statement. LVN A further stated the only thing she wrote was her narrative in the progress notes of Resident #1's clinical record and again denied she wrote a statement of the incident. LVN A also said she did not contact the doctor because Resident #1 was not in pain and the resident had slept comfortably all night. <BR/>Interview on 07/02/24 at 1:40 PM with RN C revealed when she arrived to the facility on, 06/16/24 at 6:00 AM, Resident #1 was in bed sleeping. She got report from the night nurse, LVN A, that Resident #1 was having pain to her left leg. RN C went in to assess the resident in her room and Resident #1 did not appear well, was not her normal self, and when she tried to move her left leg, the resident expressed pain through facial grimacing. RN C called the doctor and ordered an x-ray of the resident's leg, and the results came back positive for a hip fracture, so she was sent out to the hospital. <BR/>Interview on 07/02/24 at 1:54 PM with the ADON revealed she was not informed of all the details with Resident #1. The ADON said she only assisted in gathering a few statements from the staff and the Administrator had conducted the investigation with Resident #1's incident.<BR/>Interview on 07/02/24 at 2:43 PM with the Administrator revealed she had been made aware of Resident #1's hip fracture and she began an investigation of the incident. The Administrator was made aware LVN A denied writing a statement., and she was shown the handwritten statement that was part of the provider investigation report and shown the matching signatures. and The Administrator said she had provided the wrong statement. The Administrator said had found LVN A's handwritten statement under her door and because corporate preferred their statements to be typed out, the [NAME] President of Clinical Operations had gotten LVN A's other statement. The Administrator further stated she would provide LVN A's typed statement and that was the correct one. The Administrator could not explain why there were two statements where one addressed Resident #1 was having pain and the other statement did not.<BR/>Interview on 07/02/24 at 3:19 PM with the [NAME] President of Clinical Operations revealed she was not aware LVN A had written a statement. and the facility did not have a DON at the time, so she called LVN A into the facility and had her type up a statement. The [NAME] President of Clinical Operations said LVN A further stated LVN A had been suspended and educated on pain management and resident assessment after the incident with Resident #1 because they felt like LVN A could have assessed the resident better and wanted to make sure she knew how to fully assess a resident and contact the doctor if needed. <BR/>Record review of the facility's Change in Resident's Status or Condition policy, revised February 2021, reflected the following:<BR/>Policy Statement: <BR/>Our promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status <BR/> .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): <BR/> .b. discovery of injuries of an unknown source;<BR/> .i. specific instruction to notify the physician of changes in the resident's condition.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 07/19/24 at 8:44 AM. The Administrator, the DON and ADON were notified. The Administrator was provided with the IJ template on 07/19/24 at 8:50 AM. <BR/>The following Plan of Removal submitted by the facility was accepted on 07/19/24 at 2:37 PM:<BR/>Problem: Facility failed to immediately consult with the resident's physician when there was a change in the resident's condition, when Resident #1 had a change of condition on 06/15/24 and did not receive timely treatment.<BR/>- The following in-services were initiated by - started on 7/2/2024 and completed on 7/5/2024 COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged. <BR/>Licensed Nurses:<BR/>- Promptly and accurately assessing a resident when change of condition has been identified / reported. Education started on 7/2/2024 and completed on 7/5/2024.<BR/>- Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner. Education started on 7/2/2024 and completed on 7/5/2024.<BR/>-Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form. Education started 7/2/2024 and completed on 7/5/2024.<BR/>Non-licensed nursing staff:<BR/>- Reporting changes in a resident's condition to a nurse immediately. Education started 6/16/2024 and completed on 7/5/2024.<BR/>- If the nurse does not assess timely, the DON/Designee must be notified. Education started 6/16/2024 and completed 7/5/2024.<BR/>The Administrator, DON and ADON were in-serviced .regarding .ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement. <BR/>An ADHOC QAPI meeting was conducted on 7/8/2024 regarding this plan and monitoring.<BR/>The Medical Director .was notified of this plan and monitoring on 7/2/2024.<BR/>Monitoring <BR/>-The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely.<BR/>-The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was report to them that a resident had a change of condition. <BR/>-The QAPI committee will review the findings and make any needed changes.<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Record review of the facility's Incident by Incident type reflected Resident #2, Resident #3, Resident #4, Resident #5 had unwitnessed falls and nursing staff documented, assessed the residents, and reported to the Interim DON, family, and physician. <BR/>Record review of Admit/Discharge Report, from 06/16/24 through 07/19/24, reflected Resident #6, Resident #7, Resident #8, Resident #9 were discharged to the hospital due to change in condition. Residents were assessed and nursing staff documented change in condition using SBAR and notified the Interim DON, family, and physician. <BR/>Record review of the facility's Change in Condition Evaluation - SBAR (Situation, Background, Assessment, and Recommendation), undated, reflected the form addressed signs and symptoms identified, start date, review findings and provider notifications, mental status evaluation, functional status evaluation, vital signs evaluation, provider notification and feedback, behavioral status evaluation, respiratory status evaluation, cardiovascular status evaluation, abdominal/GI status evaluation, genitourinary status evaluation, skin status evaluation, pain status evaluation, neurological status evaluation, general background evaluation and available laboratory test/diagnostic procedures and resident representative notification. <BR/>Record review of the facility's Record of In-service Education, dated 06/16/24, reflected training for abuse, neglect policy - who is coordinator; resident rights; pain policy; and timely notification. In-services reflected all staff completed the trainings. The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 06/25/24, reflected the training participant would be able to verbalize and demonstrate proper transfer techniques in order to safely provide patient care handling, transfers included sit to stand, stand - pivot, squat- pivot, slide board, and mechanical lift. The in-services were conducted and signed by CNAs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 06/26/24, reflected the Administrator, the Interim DON and ADON were in-serviced on all staff applicable to receive training to use online resources or in person training to ensure all trained staff have attested to receiving education.<BR/>Record review of the facility's Record of In-service Education, dated 07/02/24, reflected training for what was change of condition, what to do when a change of condition happens, who to notify, orders to receive, full head to toe assessment, assess for pain, medicate as ordered and continue to assess and to follow through any new orders. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 07/03/24, reflected training regarding: how to identify pain and what to do. The training record reflected: .pain may be late on set and resident may not be able to verbalize, job is to assess pain and treat timely, once treated - [you] have to assess for effectiveness, continue to monito if not effective new orders may be needed. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Monthly QA Meeting reflected the meeting was completed on 07/08/24.<BR/>Interviews conducted on 07/19/24 from 2:40 PM through 5:45 PM with the Administrator, the Interim DON, ADON, LVN A, RN D, RN E, RN F, LVN G, LVN M, RN O, LVN Q, who worked the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM revealed nurses were able to verify education was provided to them. Nursing staff were able to accurately summarize what was change of condition, what to do when a change of condition occurred, who to notify, orders to receive, completing a full head-to-toe assessment, assessing for pain, medicating as ordered and continuing to assess, following through any new orders, documenting, and completing the SBAR. The Interim DON and ADON stated they would be responsible for monitor all kiosk (dashboard) alert a minimum of 4 times per week to ensure any potential change of condition had been addressed timely and continue education on change of condition. <BR/>Interviews conducted on 07/19/24 from 3:48 PM through 5:45 PM with CNA B, CNA H, CNA I, CNA J, CNA K, CNA L, CNA N, CNA P, CNA R, CNA S, and CNA T who work the shifts of 6:00 AM- 6:00 PM- 6:00 PM - 6:00 AM revealed staff were able to verify education was provided to them, staff were able to accurately summarize what was change of condition, how to identify pain and who to notify. <BR/>The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/19/2024 at 5:50 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 ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #10) reviewed for tube feeding management.The facility failed to label and date Resident #10's tube feeding formula and water bags to indicate when the feeding was started.This failure could place residents receiving tube feedings at risk of gastrointestinal disturbances (relating to the stomach and the intestines), and bacterial infection. Findings included:Record review of Resident #10's MDS quarterly assessment, dated 08/07/25, reflected Resident #10 was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #10's MDS assessment reflected Resident #10's BIMS score of 00 indicating resident was not able to complete the interview. Resident #10's MDS indicated he had parenteral/IV feeding and feeding tube while a resident of the facility. His diagnoses included paraplegia (inability to move or control the legs and lower body), contracture of muscle right and left lower leg (muscles or other tissues tighten or shorten causing deformity), unspecified protein-calorie malnutrition (inadequate intake of protein and calories), dysphagia (difficulty swallowing), gastrostomy status (an opening in the stomach through the abdominal wall, allowing for the placement of a feeding tube). The MDS reflected Resident #10 was dependent on staff for eating and all activities of daily living skills. Record review of Resident #10's care plan, last reviewed/revised 10/05/21, revealed Resident #10 had an impaired nutritional status. Goal: Resident #10's intake of nutrients will meet metabolic needs . Interventions included to consult a dietician per order. Educate Resident to consume high-calorie foods first. Encourage intake of nutritional supplements between meals. Record review of Resident #10's care plan further indicated Resident #10 had an Activity of Daily Living Skills performance deficit. Goal: will maintain or improve current level of function in eating. Interventions included eating: required 1 staff assistance. Record review of Resident #10's care plan also indicated Resident #10 has alteration in gastrointestinal status (G-Tube) related to Dysphagia; Nutren 2.0 at 44 cc/hr x 22 hours and 100 water flush every hour. Goal: Resident #10 will remain free from discomfort, complications, signs, or symptoms related to gastrointestinal alterations. Interventions included Keep Head Of Bed elevated. Give medications as ordered. Monitor/document side effects and effectiveness. Monitor vital signs as ordered/per protocol and record. Notify physician of significant abnormalities (rapid pulse, shallow, rapid, or labored respirations, low blood pressure). Obtain and monitor lab/ diagnostic work as ordered. Report results to physician and follow up as indicated. Revision on: 05/08/2025.Resident #10's care plan also noted he required tube feeding related to Dysphagia calorie requirements changed and new order received for 1. Nutren 2.0 at 44mL/hr x 22hr 2. Water flush at 50mL/hr x 22hr. Provides 1936kcal, 968mL formula, 1770ml Total water. Revision on: 04/18/2025 Goal: Resident #10 will remain free of side effects or complications related to tube feeding. Interventions included to Clean insertion site daily as ordered, monitoring for signs and symptoms infection or breakdown such as redness, pain, drainage, swelling, and/or ulceration and report to physician if symptoms arise. Discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. Monitor/document/report to Physician PRN: Aspiration- fever, Short of Breath, Tube dislodged. Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. NPO status Revision on 04/23/2025 1. Nutren 2.0 at 44mL/hr x 22hr 2. Water flush at 50mL/hr x 22hr. Provides 1936kcal, 968mL formula, 1770ml Total water (not counting med flushes). Obtain and monitor lab/diagnostic work as ordered. Report results to Physician and follow up as indicated. Provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection. Registered Dietitian to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed. The resident is dependent with tube feeding and water flushes. See physician orders for current feeding orders. The resident needs assistance with tube feeding and water flushes. See physician orders for current feeding orders. The resident needs the Head of Bed elevated 30 degrees during and thirty minutes after tube feed.Record review of Resident #10's physician's order for feeding revealed one time a day Nutren 2.0 at 44mL/hr via PEG, up at 1200pm until total volume of 968mL has been infused. Provides 1936kcal. FWF 70mL/hr x 22hrs. Total volume= 1540mL fluid. Enteral Feed Order Active as of 9/16/2025. Observation of Resident #10 on 09/16/25 at 11:18 AM revealed him sitting in the television room. Resident #10 was not connected to his tube feeding machine, it was left in his room. Observation of Resident #10's room revealed his tube feeding machine was currently off, the formula bag was dated 9/15/25 12:30 PM with rate of 44ml, water was dated 09/15/25 12:30 PM rate 70ml.Observation of Resident #10 on 09/16/2025 at 1:12 PM revealed him in the bed with staff checking for tube placement, residual and connecting the tube for his feeding. Observation of Resident #10 on 09/16/2025 at 1:54 PM revealed Resident #10 in bed, observation of feeding machine revealed 44ml 1698, water flush 70 ml. Resident #10's formula bag or water bag did not indicate the date, time, initials, or rate.Observation and interview on 09/17/2025 at 12:15 PM with LVN B revealed him working with Resident #10. LVN B checked for placement of the feeding tube, checked for residual, and connected Resident #10 to the tube feeding machine. LVN B was observed prior to leaving the room writing information on the formula bag and the water bag. Interview with LVN B revealed he did not write Resident #10's name, date, flow rate, his initials or the time formula was administered on either bag on 09/17/25. According to LVN B every feeding and water bag should have written the patient's name, date, time, the flow rate, and nurse initials so that the next nursing staff could follow up if needed. LVN B stated he was responsible for ensuring the clinical information was on both the formula and water bags, however thought it was done for each administration. LVN B stated not doing so could place residents with feeding tubes at risk of receiving the wrong flow rate, malnutrition, or dehydration.Interview on 09/18/25 2:02 PM with ADON C revealed Resident #10 was on tube feeding 22 hours a day, his machine was turned off at 10:00 AM and turned back on at 12:00 PM. ADON C stated nursing staff were responsible for taking Resident #10 off his feeding machine, hooking him back to his feeding machine with a new bag of formula and water according to physician orders. ADON C stated nurses from the next shift, ADON C and the DON were responsible to follow up and monitor residents throughout their shifts to ensure residents on tube feedings were provided with the correct formula and flow rates. ADON C stated her expectations included checking for placement of the tube, checking for residual and connecting the feeding tube. ADON C further stated she expected nurses to include clinical information on the formula and the water bag that included resident name, date, time, flow rate and nurse initials. ADON C stated not doing so placed Resident #10 at risk of feeding from outdated formula and water, diarrhea, infections, and unwanted side effects. ADON C stated nurse from the next shift, ADON C and the DON were responsible to follow up and monitor residents throughout their shifts. During an interview on 09/18/25 at 3:52 PM with the DON revealed he was aware Resident #10 utilized tube feeding for nutrition. The DON stated nurses on the floor were responsible for ensuring resident name, date, time, flow rates and staff initials were written on the formula and water bags during administration. The DON said it was important for Resident #10's tube feeding to have been properly labeled, not doing so placed him at risk of feeding errors and not following physician orders. Record review of the facility's policy revised November 2014, updated February 2025 Physician Orders policy reflected: Purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services. Enteral Orders - when recording orders for enteral tube feedings, specify the type of feedings, specify the type of feeding, amount, frequency of feeding and rationale if as needed. The order should always specify the amount of flush following the feeding. Record review of the facility's policy revised November 2018, Enteral Nutrition revealed The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment and is consistent with current standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater on 3 errors of 33 opportunities for errors leading to 9.09% medication error rates for one (LVN B) of two staff observed for medication pass.<BR/>The facility failed to ensure LVN B administered all the crushed medication in the medication cups without leaving residue for Resident #2.<BR/>These failures resulted in a 9.09% medication error rate and could put residents at risk who received medications via g-tube for not receiving the correct dose of medication and getting intended therapy.<BR/>Findings included:<BR/>Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE]. Resident #2 had diagnoses which included difficulty in swallowing, oropharyngeal phase (middle part of the throat), and gastrostomy status (an opening into the stomach from the abdominal wall made surgically). Resident #2 had a BIMS status score of 99 indicating cognition was severely impaired. <BR/>Review of Resident #2's June 2023 MAR revealed physician orders to administer medications via g- tube (a tube inserted through the wall of the abdomen directly into the stomach).<BR/>Review of Resident #2's physician orders revealed the following medications were prescribed:<BR/>- Buspirone 15 mg (used to treat anxiety), <BR/>- Levothyroxine 150 mg (used treat an underactive thyroid gland),<BR/>- Tylenol with Codeine, Tylenol #3 (pain medication), <BR/>- Amiodarone 200 mg (used to treat life-threatening heart rhythm problems), <BR/>- Asa 81 mg (blood thinner), <BR/>- Baclofen 10 mg (muscle relaxant), <BR/>- Multi-Vite liquid 15 ml (multi-vitamin), <BR/>- Docusate 100 mg (constipation), <BR/>- Eliquis 5 mg (blood thinner), <BR/>- Lamotrigine 100 mg (mood stabilizer), <BR/>- Miralax 17 gm (laxative that provides relief from occasional constipation), <BR/>- Senna 8.6 mg (laxative), and <BR/>- Seroquel Tablet 150 mg (an antipsychotic medication) to be crushed. <BR/>Observation on 06/21/23 at 9:12 AM revealed LVN B crushed the following medications to administer to Resident #2 via g-tube in separate medication cups:<BR/>- Buspirone 15 mg, <BR/>- Levothyroxine 150 mg, <BR/>- Tylenol with Codeine, Tylenol #3, <BR/>- Amiodarone 200 mg,<BR/>- Asa 81 mg, <BR/>- Baclofen 10 mg, <BR/>- Multi-Vite liquid 15 ml, <BR/>- Docusate 100 mg, <BR/>- Eliquis 5 mg, <BR/>- Lamotrigine 100 mg, <BR/>- MiraLAX 17 gm, <BR/>- Senna 8.6 mg, and <BR/>- Seroquel Tablet 150 mg. <BR/>LVN B was observed mixing medications with 5 ml water in each cup wit crushed medication. She administered each of these thirteen medications via g-tube flushing the g-tube between each medication administration with 5 ml of water. Three cups were noted to have medication residue remaining in the cups.<BR/>Interview with LVN B on 06/21/23 at 10:12 AM revealed she was aware for good results she was supposed to stir the medication well and administer the whole dose to the resident, but she did not do that, and she had no reason for not rinsing the cups. She stated she was supposed to give all the contents in the cup for Resident #2 to get the full dose of those medications. She stated failure to administer the full doses to Resident #2 would lead to Resident #2 not getting the therapy needed. She stated she had been trained on g-tube medication administration by her DON.<BR/>Interview with the DON on 06/21/23 at 2:58 PM revealed her expectation was that nurses should try to give as much as possible of all the content in the medication cups. She stated she had done training on medication administration through g-tubes with all nurses one- onone, so she did not understand why the nurse did not administer all the medications. She stated failure to administer the full dose could lead to Resident #2 not getting the right therapy, and the medications would not be effective.<BR/>Record review of facility's general Guidelines for Administering Medication via Enteral Tube policy and procedure, revised August 2020, reflected the following: <BR/> .5 .b. Crushed medications are not mixed. The powder from each medication is mixed with 10 ml of water before administration. The souffl&eacute; cup is rinsed with water to get all the medication.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (medication cabinet in the central supplies unit) and one refrigerator in the medication room for 100 and 200 halls reviewed for pharmacy services.<BR/>The facility failed to ensure expired influenza vaccine, with an expiration date of 05/10/2024, in the Hall 100/200 Medication Room refrigerator and expired medications in the Central Supply medication cabinet were removed and destroyed on 08/28/2024 at 10:45 AM.<BR/>The failure placed residents at risk of receiving medications that were ineffective due to having expired.<BR/>Findings included:<BR/>Observation on 08/29/2024 at 10:45 AM of the 100 and 200 Medication Room refrigerators with LVN K revealed 4 vials of the influenza vaccine lot 370677 with expiration date of 05/10/2024. <BR/>Interview on 08/29/2024 at 10:55 AM, LVN K stated the night shift nurses were the ones who were supposed to check the carts and the refrigerators for expired medications, but it was all nurses' responsibility to check and remove expired medications from the refrigerator. She stated she had done training on when to discard the vaccines once they expired. She stated by failing to remove the expired medication they could be administered and cause reactions, and the resident would not get the required therapy.<BR/>Interview on 08/29/2024 at 11:05 AM, the ADON stated it was her responsibility to go behind the nurses to check whether they were removing the expired medications from the refrigerators and carts. She stated she could not remember the date she checked the carts and refrigerator, but it was in August. She stated by failing to check for the expired medications, they could be administered and would not be effective. The ADON stated she was not aware whether the facility had offered training to staff regarding removing expired medications.<BR/>Interview on 08/29/2024 at 11:15 AM, the DON stated she expected the night shift nurses to check the refrigerator for expired medications, and she and the ADON were responsible for following up. The DON stated she checked the carts and the refrigerator in August, but she could not recall the date. She stated if staff were not checking the refrigerator for expired medications and medications were administered to residents, they would not be effective. She stated she had not done training on refrigerator monitoring with staff since she was new to the facility.<BR/>Observation on 08/29/2024 at 11:20 AM of the facility's Central Supply cabinet where over-the-counter medications were stored revealed the following expired medications: <BR/>- Saline Nasal spray with expiry date of 08/22/2024,<BR/>- one bottle of Vitamin B12 with expiry date of April 2024,<BR/>- one bottle of Vitamin B6 with expiry date of 04/24/2024, and <BR/>- one bottle of Acetaminophen 500 mg/15 ml with an expiry date of 03/24/2024.<BR/>Interview on 08/29/2024 at 11:30 AM, the Central Supply Staff stated it was her responsibility to check and ensure medications were labeled and not expired. She stated the cabinet was shared by all the nurses, and she was responsible for acquiring all the over-the-counter medications and storage and ensuring they were not expired. She stated the side effects of giving expired medication was they would not work and would not be effective. She stated all expired medications were supposed to be removed from the cabinet and put in destruction boxes for the Pharmacist to destroy. She stated she had done training on storage and labeling of medications. She stated she had last checked the cabinet on 08/28/2024, and she did not know how she missed the expired medication but stated she thought the nurses removed the medications from their carts and brought them to the cabinet.<BR/>Interview via telephone was attempted with the night shift nurses on 08/29/2024 at 3:24 PM, but the attempt was not successful and a voice mail was left.<BR/>Interview on 08/29/2024 at 3:48 PM, the DON stated she expected all over-the-counter medications be labeled and not expired. She stated she and the ADON were responsible for checking the cabinet in the Central Supply Room for expired medications. She stated she checked the cabinet in the Central Supply Room on 08/26/2024, and there were no expired medications. She stated if expired medications were administered to residents, they would not be effective. She stated she had done training on checking for expired medications in the medication carts, refrigerator and the supply unit, but no in-service record was provided prior to exit. <BR/>Review of the facility's Storage of Medication policy, revised August 2020, reflected the following: <BR/> .1. Expiration dates (beyond-use dates) of dispensed medications shall be determined by the pharmacist at the time of dispensing.<BR/>2. Drugs dispensed in the manufacturers' original container will be labeled with the manufacturer's expiration date.<BR/> .8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Residents #2) of 2 residents reviewed for infection control. <BR/>LVN L failed to put on a gown before entering Resident #2's room to administer a bolus feeding and medications to Resident #2, who was on enhanced barrier precautions.<BR/>This failure placed residents at risk of cross contamination and the spread of infection.<BR/>Findings included:<BR/>Record review of Resident #2's face sheet dated 08/29/2024 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected his diagnoses included hypertension (high blood pressure), dysphagia (difficulty swallowing) and gastrostomy status (presence of an artificial opening in the stomach, also known as a gastrostomy tube). Resident #2 had severe cognitive impairment with a BIMS score of 3. The MDS reflected the resident received his nutrition via feeding tube. <BR/>Record review of Resident #2's care plan revised on 04/02/2024 reflected: Focus: [Resident #2 is on enhanced barrier precautions. Goal: [Resident #2] will have no complications related to enhance barrier precautions. Interventions: All staff will wear gown and gloves during high-contact care activities.<BR/>Record review of Resident #2's physician order dated 04/18/2024 reflected: Enteral Feed every 6 hours Nurten 2.0 bolus 1 carton/brick (250 ml) Fluid flush 150 ml before and after each bolus. <BR/>Observation on 08/28/2024 at 11:53 AM revealed a sign on Resident #2's door reflecting: Stop, enhanced barrier precautions - providers and staff must also wear Gown and Gloves. PPE was outside the room. LVN L entered Resident #2's room to administer Resident #2 a bolus feeding. LVN L performed hand hygiene and then donned gloves. Without donning a gown, LVN L administered a bolus feeding to Resident #2 via the resident's gastrostomy tube.<BR/>Observation on 08/28/2024 at 2:16 PM revealed a sign on Resident #2's door reflecting: Stop, enhanced barrier precautions - providers and staff must also wear Gown and Gloves. PPE was outside the room. LVN L entered Resident #2's room to administer medications and a bolus feeding to the resident. LVN L performed appropriate hand hygiene and donned a pair of gloves. Without donning a gown, LVN L administered medications via gastrostomy tube to Resident #2. <BR/>Interview on 08/28/2024 at 2:37 PM, LVN L stated she was the nurse assigned to Resident #2. LVN L stated she saw the PPE at the door, and she was aware they were for enhanced barrier. She stated the PPE was supposed to be worn during care, at all times, but she forgot. She stated any resident who had a catheter, g-tube, or wound was on enhanced barrier precautions. She stated Resident #2 was on enhanced barrier precautions due to having a g-tube. She stated she should have donned a gown but forgot to do it. She stated the risk of not donning PPE was that it could lead to the spread of infection. She stated she could not remember whether she had done training on enhanced barrier precautions.<BR/>Interview on 08/28/2024 at 2:55 PM, the DON stated she expected staff to put on PPE when providing care to a resident who had a wound, catheter, or a g-tube. She stated residents who were on enhanced barrier precautions had signs on their doors to indicate the resident was on enhanced barrier precautions. The DON stated Resident #2 was on enhanced barrier precautions due to having a g-tube and staff should put on PPE before providing any type of care. She stated the potential risk of not putting on PPE would be spread of infection. She stated the facility had done training on infection control and enhanced barrier precautions.<BR/>Record review of the facility's training records reflected training on infection control, reverse isolation and enhanced barrier precaution dated 04/15/2024 and 04/2/2024. The records reflected LVN L was not in attendance.<BR/>Record review of the facility's Enhanced Barrier Precautions policy, dated August 2024, reflected:<BR/>1. Enhanced barrier precautions (EBP) are used an infection prevention and control intervention to reduce the spread of multi-drug resistant organism to residents. <BR/> .3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include:<BR/>a. Dressing<BR/>b. Bathing /showering<BR/>c. Providing hygiene<BR/> .g. Device care use (central line urinary catheter, feeding tube and <BR/>h. Wound care (any skin opening requiring a dressing) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care.<BR/>LVN A failed to ensure Resident #1 was provided with timely treatment when the resident had a changed of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which revealed the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment.<BR/>An Immediate Jeopardy (IJ) situation was identified on 0719/24. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk for delay in needed treatment and care.<BR/>Findings included:<BR/>Record review of Resident #1's MDS assessment, dated 06/24/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, vitamin D deficiency, hypocalcemia (calcium deficiency), and cognitive communication deficit. Resident #1 had long and short- term memory impairment and decision making was severely impaired. Resident #1 had unclear speech rarely understood/understands. The MDS further reflected the resident was in a manual wheelchair and dependent for all ADLs.<BR/>Record review of Resident #1's care plan, revised 07/29/21, reflected she had a communication problem related to dementia. Interventions included to monitor and document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. <BR/>Record review of Resident #1's progress notes, dated 06/15/24, documented by LVN A reflected:<BR/>Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed. At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to oncoming nurse to monitor resident discomfort if worsens to report to NP/MD .<BR/>Record review of Resident #1's x-ray report, dated 06/16/24, reflected:<BR/> .EXAM: Pelvis and left hip<BR/>HISTORY: Pain<BR/> .FINDINGS: There is a fracture involving the proximal left femur centered within the intertrochanteric space. There does appear to be approximately a centimeter of shortening as well as a few degrees of varus angulation. There is no dislocations. A significant joint effusion is not seen. Mild symmetric osteoarthritis is seen .<BR/>IMPRESSION:<BR/>1. Proximal left femur fracture .<BR/>Record review of Resident #1's hospital records, dated 06/16/24, reflected Resident #1 had been diagnosed with an acute fracture of the left proximal femur (hip fracture).<BR/>Record review of the facility's Provider Investigation Report, dated 06/17/24, reflected the following:<BR/> .This resident is a 60 yo (year old) female who resides on the secured unit. The resident ambulates independently on the unit. This resident also ambulates in a wheelchair. This resident has dementia, osteoarthritis, and vitamin D deficiency. The weekend RN supervisor informed this admin that x-rays were ordered due to a resident possible leg fracture .On-coming aide notified charge nurse that during peri care resident was favoring her left leg. Charge nurse stated that resident is non-verbal and that she would monitor resident throughout her shift. Charge nurse indicated that resident slept through the night. Facility received x-rays, indicating possible fracture .<BR/>Observation on 07/02/24 at 10:00 AM of Resident #1 revealed she was in a low bed with her eyes closed. After knocking, the resident's name was called out, but Resident #1 barely opened her eye, closed them right away and did not speak. <BR/>Interview on 07/02/24 at 10:54 AM CNA B stated she was making her rounds on, 06/15/24, around 7:45 PM. She went in to change Resident #1 and when she started peri care, Resident #1 yelled out like she was in pain, so she went to get LVN A. At that time both the CNA B and LVN A tried to assist the resident to a standing position and Resident #1 yelled again. and They noted something was wrong, and it appeared like her left foot was hurting so she was put back in bed. Resident #1 was not able to speak therefore could not tell them what was wrong. CNA B said it was not normal for Resident #1 to yell out when she was being changed. CNA B further stated she worked from 7:00 PM to 7:00 AM and during the night she continued to monitor Resident #1. and during her brief change, the resident did not groan or appear to be in pain the remainder of her shift. <BR/>Record review of LVN A's undated handwritten and signed statement reflected the following:<BR/>To whom it may concern,<BR/>Cc: [Resident #1]<BR/>Upon my shift on June 15th, this writer [LVN A] noted patient sitting on w/c but seems sleepy (eyes closed). Notified nurse aide to lay patient in bed. During rounds for incontinent care with nurse aide, noted facial grimacing when touching pt on left leg but since patient is non-verbal, assessed pt left extremities no bruises noted, or any other skin issues. Layed [laid] pt comfortably in bed, while continuous monitoring, pt slept all night long. This writer reported oncoming nurse to monitor if patient persist with pain to touch to notify MD.<BR/>Review of LVN A's undated typed and signed statement on 07/02/24 reflected the following:<BR/>To whom it may concern<BR/>Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed., At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to on coming nurse to monitor resident discomfort if worsens to report to NP/MD.<BR/>Record review of LVN A's personnel file on 07/02/24 reflected the signature on LVN A's handwritten statement matched the signatures on her new hire paperwork.<BR/>Interview on 07/02/24 at 2:25 PM LVN A stated she arrived to work around 6:00 PM on, 06/15/24, and Resident #1 was in her wheelchair and appeared to look tired, so she asked an aide to lay her down in bed. Later that evening, CNA B told her the resident was having some discomfort while she was trying to change her brief, so she went into Resident #1's room to assess the resident. LVN A denied trying to make the resident stand up and said Resident #1 indeed looked to have some discomfort, but it was not pain. LVN A described the discomfort as someone that was tired and did not want to be touched and again denied the discomfort as pain. LVN A said she continued to monitor the resident throughout the night and there were no concerns as Resident #1 has slept comfortably the whole night. LVN A was asked about her handwritten statement where she had documented facial grimacing when the resident's left leg was touched and LVN A denied writing a statement. LVN A further stated the only thing she wrote was her narrative in the progress notes of Resident #1's clinical record and again denied she wrote a statement of the incident. LVN A also said she did not contact the doctor because Resident #1 was not in pain and the resident had slept comfortably all night. <BR/>Interview on 07/02/24 at 1:40 PM with RN C revealed when she arrived to the facility on, 06/16/24 at 6:00 AM, Resident #1 was in bed sleeping. She got report from the night nurse, LVN A, that Resident #1 was having pain to her left leg. RN C went in to assess the resident in her room and Resident #1 did not appear well, was not her normal self, and when she tried to move her left leg, the resident expressed pain through facial grimacing. RN C called the doctor and ordered an x-ray of the resident's leg, and the results came back positive for a hip fracture, so she was sent out to the hospital. <BR/>Interview on 07/02/24 at 1:54 PM with the ADON revealed she was not informed of all the details with Resident #1. The ADON said she only assisted in gathering a few statements from the staff and the Administrator had conducted the investigation with Resident #1's incident.<BR/>Interview on 07/02/24 at 2:43 PM with the Administrator revealed she had been made aware of Resident #1's hip fracture and she began an investigation of the incident. The Administrator was made aware LVN A denied writing a statement., and she was shown the handwritten statement that was part of the provider investigation report and shown the matching signatures. and The Administrator said she had provided the wrong statement. The Administrator said had found LVN A's handwritten statement under her door and because corporate preferred their statements to be typed out, the [NAME] President of Clinical Operations had gotten LVN A's other statement. The Administrator further stated she would provide LVN A's typed statement and that was the correct one. The Administrator could not explain why there were two statements where one addressed Resident #1 was having pain and the other statement did not.<BR/>Interview on 07/02/24 at 3:19 PM with the [NAME] President of Clinical Operations revealed she was not aware LVN A had written a statement. and the facility did not have a DON at the time, so she called LVN A into the facility and had her type up a statement. The [NAME] President of Clinical Operations said LVN A further stated LVN A had been suspended and educated on pain management and resident assessment after the incident with Resident #1 because they felt like LVN A could have assessed the resident better and wanted to make sure she knew how to fully assess a resident and contact the doctor if needed. <BR/>Record review of the facility's Change in Resident's Status or Condition policy, revised February 2021, reflected the following:<BR/>Policy Statement: <BR/>Our promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status <BR/> .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): <BR/> .b. discovery of injuries of an unknown source;<BR/> .i. specific instruction to notify the physician of changes in the resident's condition.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 07/19/24 at 8:44 AM. The Administrator, the DON and ADON were notified. The Administrator was provided with the IJ template on 07/19/24 at 8:50 AM. <BR/>The following Plan of Removal submitted by the facility was accepted on 07/19/24 at 2:37 PM:<BR/>Problem: Facility failed to immediately consult with the resident's physician when there was a change in the resident's condition, when Resident #1 had a change of condition on 06/15/24 and did not receive timely treatment.<BR/>- The following in-services were initiated by - started on 7/2/2024 and completed on 7/5/2024 COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged. <BR/>Licensed Nurses:<BR/>- Promptly and accurately assessing a resident when change of condition has been identified / reported. Education started on 7/2/2024 and completed on 7/5/2024.<BR/>- Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner. Education started on 7/2/2024 and completed on 7/5/2024.<BR/>-Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form. Education started 7/2/2024 and completed on 7/5/2024.<BR/>Non-licensed nursing staff:<BR/>- Reporting changes in a resident's condition to a nurse immediately. Education started 6/16/2024 and completed on 7/5/2024.<BR/>- If the nurse does not assess timely, the DON/Designee must be notified. Education started 6/16/2024 and completed 7/5/2024.<BR/>The Administrator, DON and ADON were in-serviced .regarding .ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement. <BR/>An ADHOC QAPI meeting was conducted on 7/8/2024 regarding this plan and monitoring.<BR/>The Medical Director .was notified of this plan and monitoring on 7/2/2024.<BR/>Monitoring <BR/>-The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely.<BR/>-The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was report to them that a resident had a change of condition. <BR/>-The QAPI committee will review the findings and make any needed changes.<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Record review of the facility's Incident by Incident type reflected Resident #2, Resident #3, Resident #4, Resident #5 had unwitnessed falls and nursing staff documented, assessed the residents, and reported to the Interim DON, family, and physician. <BR/>Record review of Admit/Discharge Report, from 06/16/24 through 07/19/24, reflected Resident #6, Resident #7, Resident #8, Resident #9 were discharged to the hospital due to change in condition. Residents were assessed and nursing staff documented change in condition using SBAR and notified the Interim DON, family, and physician. <BR/>Record review of the facility's Change in Condition Evaluation - SBAR (Situation, Background, Assessment, and Recommendation), undated, reflected the form addressed signs and symptoms identified, start date, review findings and provider notifications, mental status evaluation, functional status evaluation, vital signs evaluation, provider notification and feedback, behavioral status evaluation, respiratory status evaluation, cardiovascular status evaluation, abdominal/GI status evaluation, genitourinary status evaluation, skin status evaluation, pain status evaluation, neurological status evaluation, general background evaluation and available laboratory test/diagnostic procedures and resident representative notification. <BR/>Record review of the facility's Record of In-service Education, dated 06/16/24, reflected training for abuse, neglect policy - who is coordinator; resident rights; pain policy; and timely notification. In-services reflected all staff completed the trainings. The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 06/25/24, reflected the training participant would be able to verbalize and demonstrate proper transfer techniques in order to safely provide patient care handling, transfers included sit to stand, stand - pivot, squat- pivot, slide board, and mechanical lift. The in-services were conducted and signed by CNAs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 06/26/24, reflected the Administrator, the Interim DON and ADON were in-serviced on all staff applicable to receive training to use online resources or in person training to ensure all trained staff have attested to receiving education.<BR/>Record review of the facility's Record of In-service Education, dated 07/02/24, reflected training for what was change of condition, what to do when a change of condition happens, who to notify, orders to receive, full head to toe assessment, assess for pain, medicate as ordered and continue to assess and to follow through any new orders. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 07/03/24, reflected training regarding: how to identify pain and what to do. The training record reflected: .pain may be late on set and resident may not be able to verbalize, job is to assess pain and treat timely, once treated - [you] have to assess for effectiveness, continue to monito if not effective new orders may be needed. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Monthly QA Meeting reflected the meeting was completed on 07/08/24.<BR/>Interviews conducted on 07/19/24 from 2:40 PM through 5:45 PM with the Administrator, the Interim DON, ADON, LVN A, RN D, RN E, RN F, LVN G, LVN M, RN O, LVN Q, who worked the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM revealed nurses were able to verify education was provided to them. Nursing staff were able to accurately summarize what was change of condition, what to do when a change of condition occurred, who to notify, orders to receive, completing a full head-to-toe assessment, assessing for pain, medicating as ordered and continuing to assess, following through any new orders, documenting, and completing the SBAR. The Interim DON and ADON stated they would be responsible for monitor all kiosk (dashboard) alert a minimum of 4 times per week to ensure any potential change of condition had been addressed timely and continue education on change of condition. <BR/>Interviews conducted on 07/19/24 from 3:48 PM through 5:45 PM with CNA B, CNA H, CNA I, CNA J, CNA K, CNA L, CNA N, CNA P, CNA R, CNA S, and CNA T who work the shifts of 6:00 AM- 6:00 PM- 6:00 PM - 6:00 AM revealed staff were able to verify education was provided to them, staff were able to accurately summarize what was change of condition, how to identify pain and who to notify. <BR/>The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/19/2024 at 5:50 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 immediately consult with the resident's physician when there was a change in the resident's condition or a need to alter treatment for one (Resident #1) of three residents reviewed for physician consultation. <BR/>LVN A failed to consult with the physician for Resident #1 when the resident had a change of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which reflected the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment.<BR/>An Immediate Jeopardy (IJ) situation was identified on 0719/24. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>The failure placed residents at risk for delayed physician intervention. <BR/>Findings included:<BR/>Record review of Resident #1's MDS assessment, dated 06/24/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, vitamin D deficiency, hypocalcemia (calcium deficiency), and cognitive communication deficit. Resident #1 had long and short- term memory impairment and decision making was severely impaired. Resident #1 had unclear speech and rarely understood/understands. The MDS further reflected the resident was in a manual wheelchair and dependent for all ADLs.<BR/>Record review of Resident #1's care plan, revised 07/29/21, reflected she had a communication problem related to dementia. Interventions included to monitor and document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. <BR/>Record review of Resident #1's progress notes, dated 06/15/24, documented by LVN A reflected:<BR/>Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed. At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to oncoming nurse to monitor resident discomfort if worsens to report to NP/MD.<BR/>Record review of Resident #1's x-ray report, dated 06/16/24, reflected:<BR/> .EXAM: Pelvis and left hip<BR/>HISTORY: Pain<BR/> .FINDINGS: There is a fracture involving the proximal left femur centered within the intertrochanteric space. There does appear to be approximately a centimeter of shortening as well as a few degrees of varus angulation. There is no dislocations. A significant joint effusion is not seen. Mild symmetric osteoarthritis is seen .<BR/>IMPRESSION:<BR/>1. Proximal left femur fracture .<BR/>Record review of Resident #1's hospital records, dated 06/16/24, reflected Resident #1 had been diagnosed with an acute fracture of the left proximal femur (hip fracture).<BR/>Record review of the facility's Provider Investigation Report, dated 06/17/24, reflected the following:<BR/> .This resident is a 60 yo (year old) female who resides on the secured unit. The resident ambulates independently on the unit. This resident also ambulates in a wheelchair. This resident has dementia, osteoarthritis, and vitamin D deficiency. The weekend RN supervisor informed this admin that x-rays were ordered due to a resident possible leg fracture .On-coming aide notified charge nurse that during peri care resident was favoring her left leg. Charge nurse stated that resident is non-verbal and that she would monitor resident throughout her shift. Charge nurse indicated that resident slept through the night. Facility received x-rays, indicating possible fracture .<BR/>Observation on 07/02/24 at 10:00 AM of Resident #1 revealed she was in a low bed with her eyes closed. After knocking, the resident's name was called out, but Resident #1 barely opened her eye, closed them right away and did not speak. <BR/>Interview on 07/02/24 at 10:54 AM CNA B stated she was making her rounds on, 06/15/24, around 7:45 PM. She went in to change Resident #1 and when she started peri care, Resident #1 yelled out like she was in pain, so she went to get LVN A. At that time both the CNA B and LVN A tried to assist the resident to a standing position and Resident #1 yelled again. and They noted something was wrong, and it appeared like her left foot was hurting so she was put back in bed. Resident #1 was not able to speak therefore could not tell them what was wrong. CNA B said it was not normal for Resident #1 to yell out when she was being changed. CNA B further stated she worked from 7:00 PM to 7:00 AM and during the night she continued to monitor Resident #1. and during her brief change, the resident did not groan or appear to be in pain the remainder of her shift. <BR/>Record review of LVN A's undated handwritten and signed statement reflected the following:<BR/>To whom it may concern,<BR/>Cc: [Resident #1]<BR/>Upon my shift on June 15th, this writer [LVN A] noted patient sitting on w/c but seems sleepy (eyes closed). Notified nurse aide to lay patient in bed. During rounds for incontinent care with nurse aide, noted facial grimacing when touching pt on left leg but since patient is non-verbal, assessed pt left extremities no bruises noted, or any other skin issues. Layed [laid] pt comfortably in bed, while continuous monitoring, pt slept all night long. This writer reported oncoming nurse to monitor if patient persist with pain to touch to notify MD.<BR/>Review of LVN A's undated typed and signed statement on 07/02/24 reflected the following:<BR/>To whom it may concern,<BR/>Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed., At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3: 00 AM ] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to on coming nurse to monitor resident discomfort if worsens to report to NP/MD.<BR/>Record review of LVN A's personnel file on 07/02/24 reflected the signature on LVN A's handwritten statement matched the signatures on her new hire paperwork.<BR/>Interview on 07/02/24 at 2:25 PM LVN A stated she arrived to work around 6:00 PM on, 06/15/24, and Resident #1 was in her wheelchair and appeared to look tired, so she asked an aide to lay her down in bed. Later that evening, CNA B told her the resident was having some discomfort while she was trying to change her brief, so she went into Resident #1's room to assess the resident. LVN A denied trying to make the resident stand up and said Resident #1 indeed looked to have some discomfort, but it was not pain. LVN A described the discomfort as someone that was tired and did not want to be touched and again denied the discomfort as pain . LVN A said she continued to monitor the resident throughout the night and there were no concerns as Resident #1 has slept comfortably the whole night. LVN A was asked about her handwritten statement where she had documented facial grimacing when the resident's left leg was touched and LVN A denied writing a statement. LVN A further stated the only thing she wrote was her narrative in the progress notes of Resident #1's clinical record and again denied she wrote a statement of the incident. LVN A also said she did not contact the doctor because Resident #1 was not in pain and the resident had slept comfortably all night. <BR/>Interview on 07/02/24 at 1:40 PM RN C stated when she arrived at the facility on, 06/16/24 at 6:00 AM, Resident #1 was in bed sleeping. She got report from the night nurse, LVN A, that Resident #1 was having pain to her left leg. RN C went in to assess the resident in her room and Resident #1 did not appear well, was not her normal self, and when she tried to move her left leg, the resident expressed pain through facial grimacing. RN C called the doctor and ordered an x-ray of the resident's leg, and the results came back positive for a hip fracture, so she was sent out to the hospital. <BR/>Interview on 07/02/24 at 1:54 PM ADON stated she was not informed of all the details with Resident #1. The ADON said she only assisted in gathering a few statements from the staff and the Administrator had conducted the investigation with Resident #1's incident.<BR/>Interview on 07/02/24 at 2:43 PM Administrator stated she had been made aware of Resident #1's hip fracture and she began an investigation of the incident. The Administrator was made aware LVN A denied writing a statement., and she was shown the handwritten statement that was part of the provider investigation report and shown the matching signatures. The Administrator said she had provided the wrong statement. The Administrator said had found LVN A's handwritten statement under her door and because corporate preferred their statements to be typed out, the [NAME] President of Clinical Operations had gotten LVN A's other statement. The Administrator further stated she would provide the LVN A's typed statement and that was the correct one. The Administrator could not explain why there were two statements where one addressed Resident #1 was having pain and the other statement did not.<BR/>Interview on 07/02/24 at 3:19 PM with the [NAME] President of Clinical Operations revealed she was not aware LVN A had written a statement. and the facility did not have a DON at the time, so she called LVN A into the facility and had her type up a statement. The [NAME] President of Clinical Operations said LVN A further stated LVN A had been suspended and educated on pain management and resident assessment after the incident with Resident #1 because they felt like LVN A could have assessed the resident better and wanted to make sure she knew how to fully assess a resident and contact the doctor if needed. <BR/>Record review of the facility's Change in Resident's Status or Condition policy, revised February 2021, reflected the following:<BR/>Policy Statement: <BR/>Our promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status <BR/> .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): <BR/> .b. discovery of injuries of an unknown source;<BR/> .i. specific instruction to notify the physician of changes in the resident's condition.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 07/19/24 at 8:44 AM. The Administrator, the DON and ADON were notified. The Administrator was provided with the IJ template on 07/19/24 at 8:50 AM. <BR/>The following Plan of Removal submitted by the facility was accepted on 07/19/24 at 2:37 PM:<BR/>Problem: Facility failed to immediately consult with the resident's physician when there was a change in the resident's condition, when Resident #1 had a change of condition on 06/15/24 and did not receive timely treatment.<BR/>- The following in-services were initiated by - started on 7/2/2024 and completed on 7/5/2024 COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged. <BR/>Licensed Nurses:<BR/>- Promptly and accurately assessing a resident when change of condition has been identified / reported. Education started on 7/2/2024 and completed on 7/5/2024.<BR/>- Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner. Education started on 7/2/2024 and completed on 7/5/2024.<BR/>-Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form. Education started 7/2/2024 and completed on 7/5/2024.<BR/>Non-licensed nursing staff:<BR/>- Reporting changes in a resident's condition to a nurse immediately. Education started 6/16/2024 and completed on 7/5/2024.<BR/>- If the nurse does not assess timely, the DON/Designee must be notified. Education started 6/16/2024 and completed 7/5/2024.<BR/>The Administrator, DON and ADON were in-serviced .regarding .ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement. <BR/>An ADHOC QAPI meeting was conducted on 7/8/2024 regarding this plan and monitoring.<BR/>The Medical Director .was notified of this plan and monitoring on 7/2/2024.<BR/>Monitoring <BR/>-The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely.<BR/>-The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was report to them that a resident had a change of condition. <BR/>-The QAPI committee will review the findings and make any needed changes.<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Record review of the facility's Incident by Incident type reflected Resident #2, Resident #3, Resident #4, Resident #5 had unwitnessed falls and nursing staff documented, assessed the residents, and reported to the Interim DON, family, and physician. <BR/>Record review of Admit/Discharge Report, from 06/16/24 through 07/19/24, reflected Resident #6, Resident #7, Resident #8, Resident #9 were discharged to the hospital due to change in condition. Residents were assessed and nursing staff documented change in condition using SBAR and notified the Interim DON, family, and physician. <BR/>Record review of the facility's Change in Condition Evaluation - SBAR (Situation, Background, Assessment, and Recommendation), undated, reflected the form addressed signs and symptoms identified, start date, review findings and provider notifications, mental status evaluation, functional status evaluation, vital signs evaluation, provider notification and feedback, behavioral status evaluation, respiratory status evaluation, cardiovascular status evaluation, abdominal/GI status evaluation, genitourinary status evaluation, skin status evaluation, pain status evaluation, neurological status evaluation, general background evaluation and available laboratory test/diagnostic procedures and resident representative notification. <BR/>Record review of the facility's Record of In-service Education, dated 06/16/24, reflected training for abuse, neglect policy - who was coordinator; resident rights; pain policy; and timely notification. In-services reflected all staff completed the trainings. The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 06/25/24, reflected the training participant would be able to verbalize and demonstrate proper transfer techniques in order to safely provide patient care handling, transfers included sit to stand, stand - pivot, squat- pivot, slide board, and mechanical lift. The in-services were conducted and signed by CNAs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 06/26/24, reflected the Administrator, the Interim DON and ADON were in-serviced on all staff applicable to receive training to use online resources or in person training to ensure all trained staff have attested to receiving education.<BR/>Record review of the facility's Record of In-service Education, dated 07/02/24, reflected training for what was change of condition, what to do when a change of condition happens, who to notify, orders to receive, full head to toe assessment, assess for pain, medicate as ordered and continue to assess and to follow through any new orders. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 07/03/24, reflected training regarding how to identify pain and what to do. The training record reflected: .pain may be late on set and resident may not be able to verbalize, job is to assess pain and treat timely, once treated - [you] have to assess for effectiveness, continue to monito if not effective new orders may be needed. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Monthly QA Meeting reflected the meeting was completed on 07/08/24.<BR/>Interviews conducted on 07/19/24 from 2:40 PM through 5:45 PM with the Administrator, the Interim DON, ADON, LVN A, RN D, RN E, RN F, LVN G, LVN M, RN O, LVN Q, who worked the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM verbally revealed nurses were able to verify education was provided to them. Nursing staff were able to accurately summarize what was change of condition, what to do when a change of condition occurred, who to notify, orders to receive, completing a full head-to-toe assessment, assessing for pain, medicating as ordered and continuing to assess, following through any new orders, documenting, and completing the SBAR. The Interim DON and ADON stated they would be responsible for monitor all kiosk (dashboard) alert a minimum of 4 times per week to ensure any potential change of condition had been addressed timely and continue education on change of condition. <BR/>Interviews conducted on 07/19/24 from 3:48 PM through 5:45 PM with CNA B, CNA H, CNA I, CNA J, CNA K, CNA L, CNA N, CNA P, CNA R, CNA S, and CNA T who work the shifts of 6:00 AM- 6:00 PM- 6:00 PM - 6:00 AM verbally revealed staff were able to verify education was provided to them, staff were able to accurately summarize what was change of condition, how to identify pain and who to notify. <BR/>The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/19/2024 at 5:50 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 ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care.<BR/>LVN A failed to ensure Resident #1 was provided with timely treatment when the resident had a changed of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which revealed the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment.<BR/>An Immediate Jeopardy (IJ) situation was identified on 0719/24. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>This failure could place residents at risk for delay in needed treatment and care.<BR/>Findings included:<BR/>Record review of Resident #1's MDS assessment, dated 06/24/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, vitamin D deficiency, hypocalcemia (calcium deficiency), and cognitive communication deficit. Resident #1 had long and short- term memory impairment and decision making was severely impaired. Resident #1 had unclear speech rarely understood/understands. The MDS further reflected the resident was in a manual wheelchair and dependent for all ADLs.<BR/>Record review of Resident #1's care plan, revised 07/29/21, reflected she had a communication problem related to dementia. Interventions included to monitor and document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. <BR/>Record review of Resident #1's progress notes, dated 06/15/24, documented by LVN A reflected:<BR/>Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed. At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to oncoming nurse to monitor resident discomfort if worsens to report to NP/MD .<BR/>Record review of Resident #1's x-ray report, dated 06/16/24, reflected:<BR/> .EXAM: Pelvis and left hip<BR/>HISTORY: Pain<BR/> .FINDINGS: There is a fracture involving the proximal left femur centered within the intertrochanteric space. There does appear to be approximately a centimeter of shortening as well as a few degrees of varus angulation. There is no dislocations. A significant joint effusion is not seen. Mild symmetric osteoarthritis is seen .<BR/>IMPRESSION:<BR/>1. Proximal left femur fracture .<BR/>Record review of Resident #1's hospital records, dated 06/16/24, reflected Resident #1 had been diagnosed with an acute fracture of the left proximal femur (hip fracture).<BR/>Record review of the facility's Provider Investigation Report, dated 06/17/24, reflected the following:<BR/> .This resident is a 60 yo (year old) female who resides on the secured unit. The resident ambulates independently on the unit. This resident also ambulates in a wheelchair. This resident has dementia, osteoarthritis, and vitamin D deficiency. The weekend RN supervisor informed this admin that x-rays were ordered due to a resident possible leg fracture .On-coming aide notified charge nurse that during peri care resident was favoring her left leg. Charge nurse stated that resident is non-verbal and that she would monitor resident throughout her shift. Charge nurse indicated that resident slept through the night. Facility received x-rays, indicating possible fracture .<BR/>Observation on 07/02/24 at 10:00 AM of Resident #1 revealed she was in a low bed with her eyes closed. After knocking, the resident's name was called out, but Resident #1 barely opened her eye, closed them right away and did not speak. <BR/>Interview on 07/02/24 at 10:54 AM CNA B stated she was making her rounds on, 06/15/24, around 7:45 PM. She went in to change Resident #1 and when she started peri care, Resident #1 yelled out like she was in pain, so she went to get LVN A. At that time both the CNA B and LVN A tried to assist the resident to a standing position and Resident #1 yelled again. and They noted something was wrong, and it appeared like her left foot was hurting so she was put back in bed. Resident #1 was not able to speak therefore could not tell them what was wrong. CNA B said it was not normal for Resident #1 to yell out when she was being changed. CNA B further stated she worked from 7:00 PM to 7:00 AM and during the night she continued to monitor Resident #1. and during her brief change, the resident did not groan or appear to be in pain the remainder of her shift. <BR/>Record review of LVN A's undated handwritten and signed statement reflected the following:<BR/>To whom it may concern,<BR/>Cc: [Resident #1]<BR/>Upon my shift on June 15th, this writer [LVN A] noted patient sitting on w/c but seems sleepy (eyes closed). Notified nurse aide to lay patient in bed. During rounds for incontinent care with nurse aide, noted facial grimacing when touching pt on left leg but since patient is non-verbal, assessed pt left extremities no bruises noted, or any other skin issues. Layed [laid] pt comfortably in bed, while continuous monitoring, pt slept all night long. This writer reported oncoming nurse to monitor if patient persist with pain to touch to notify MD.<BR/>Review of LVN A's undated typed and signed statement on 07/02/24 reflected the following:<BR/>To whom it may concern<BR/>Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed., At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to on coming nurse to monitor resident discomfort if worsens to report to NP/MD.<BR/>Record review of LVN A's personnel file on 07/02/24 reflected the signature on LVN A's handwritten statement matched the signatures on her new hire paperwork.<BR/>Interview on 07/02/24 at 2:25 PM LVN A stated she arrived to work around 6:00 PM on, 06/15/24, and Resident #1 was in her wheelchair and appeared to look tired, so she asked an aide to lay her down in bed. Later that evening, CNA B told her the resident was having some discomfort while she was trying to change her brief, so she went into Resident #1's room to assess the resident. LVN A denied trying to make the resident stand up and said Resident #1 indeed looked to have some discomfort, but it was not pain. LVN A described the discomfort as someone that was tired and did not want to be touched and again denied the discomfort as pain. LVN A said she continued to monitor the resident throughout the night and there were no concerns as Resident #1 has slept comfortably the whole night. LVN A was asked about her handwritten statement where she had documented facial grimacing when the resident's left leg was touched and LVN A denied writing a statement. LVN A further stated the only thing she wrote was her narrative in the progress notes of Resident #1's clinical record and again denied she wrote a statement of the incident. LVN A also said she did not contact the doctor because Resident #1 was not in pain and the resident had slept comfortably all night. <BR/>Interview on 07/02/24 at 1:40 PM with RN C revealed when she arrived to the facility on, 06/16/24 at 6:00 AM, Resident #1 was in bed sleeping. She got report from the night nurse, LVN A, that Resident #1 was having pain to her left leg. RN C went in to assess the resident in her room and Resident #1 did not appear well, was not her normal self, and when she tried to move her left leg, the resident expressed pain through facial grimacing. RN C called the doctor and ordered an x-ray of the resident's leg, and the results came back positive for a hip fracture, so she was sent out to the hospital. <BR/>Interview on 07/02/24 at 1:54 PM with the ADON revealed she was not informed of all the details with Resident #1. The ADON said she only assisted in gathering a few statements from the staff and the Administrator had conducted the investigation with Resident #1's incident.<BR/>Interview on 07/02/24 at 2:43 PM with the Administrator revealed she had been made aware of Resident #1's hip fracture and she began an investigation of the incident. The Administrator was made aware LVN A denied writing a statement., and she was shown the handwritten statement that was part of the provider investigation report and shown the matching signatures. and The Administrator said she had provided the wrong statement. The Administrator said had found LVN A's handwritten statement under her door and because corporate preferred their statements to be typed out, the [NAME] President of Clinical Operations had gotten LVN A's other statement. The Administrator further stated she would provide LVN A's typed statement and that was the correct one. The Administrator could not explain why there were two statements where one addressed Resident #1 was having pain and the other statement did not.<BR/>Interview on 07/02/24 at 3:19 PM with the [NAME] President of Clinical Operations revealed she was not aware LVN A had written a statement. and the facility did not have a DON at the time, so she called LVN A into the facility and had her type up a statement. The [NAME] President of Clinical Operations said LVN A further stated LVN A had been suspended and educated on pain management and resident assessment after the incident with Resident #1 because they felt like LVN A could have assessed the resident better and wanted to make sure she knew how to fully assess a resident and contact the doctor if needed. <BR/>Record review of the facility's Change in Resident's Status or Condition policy, revised February 2021, reflected the following:<BR/>Policy Statement: <BR/>Our promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status <BR/> .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): <BR/> .b. discovery of injuries of an unknown source;<BR/> .i. specific instruction to notify the physician of changes in the resident's condition.<BR/>This was determined to be an Immediate Jeopardy (IJ) on 07/19/24 at 8:44 AM. The Administrator, the DON and ADON were notified. The Administrator was provided with the IJ template on 07/19/24 at 8:50 AM. <BR/>The following Plan of Removal submitted by the facility was accepted on 07/19/24 at 2:37 PM:<BR/>Problem: Facility failed to immediately consult with the resident's physician when there was a change in the resident's condition, when Resident #1 had a change of condition on 06/15/24 and did not receive timely treatment.<BR/>- The following in-services were initiated by - started on 7/2/2024 and completed on 7/5/2024 COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged. <BR/>Licensed Nurses:<BR/>- Promptly and accurately assessing a resident when change of condition has been identified / reported. Education started on 7/2/2024 and completed on 7/5/2024.<BR/>- Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner. Education started on 7/2/2024 and completed on 7/5/2024.<BR/>-Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form. Education started 7/2/2024 and completed on 7/5/2024.<BR/>Non-licensed nursing staff:<BR/>- Reporting changes in a resident's condition to a nurse immediately. Education started 6/16/2024 and completed on 7/5/2024.<BR/>- If the nurse does not assess timely, the DON/Designee must be notified. Education started 6/16/2024 and completed 7/5/2024.<BR/>The Administrator, DON and ADON were in-serviced .regarding .ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement. <BR/>An ADHOC QAPI meeting was conducted on 7/8/2024 regarding this plan and monitoring.<BR/>The Medical Director .was notified of this plan and monitoring on 7/2/2024.<BR/>Monitoring <BR/>-The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely.<BR/>-The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was report to them that a resident had a change of condition. <BR/>-The QAPI committee will review the findings and make any needed changes.<BR/>Monitoring of the facility's Plan of Removal included the following:<BR/>Record review of the facility's Incident by Incident type reflected Resident #2, Resident #3, Resident #4, Resident #5 had unwitnessed falls and nursing staff documented, assessed the residents, and reported to the Interim DON, family, and physician. <BR/>Record review of Admit/Discharge Report, from 06/16/24 through 07/19/24, reflected Resident #6, Resident #7, Resident #8, Resident #9 were discharged to the hospital due to change in condition. Residents were assessed and nursing staff documented change in condition using SBAR and notified the Interim DON, family, and physician. <BR/>Record review of the facility's Change in Condition Evaluation - SBAR (Situation, Background, Assessment, and Recommendation), undated, reflected the form addressed signs and symptoms identified, start date, review findings and provider notifications, mental status evaluation, functional status evaluation, vital signs evaluation, provider notification and feedback, behavioral status evaluation, respiratory status evaluation, cardiovascular status evaluation, abdominal/GI status evaluation, genitourinary status evaluation, skin status evaluation, pain status evaluation, neurological status evaluation, general background evaluation and available laboratory test/diagnostic procedures and resident representative notification. <BR/>Record review of the facility's Record of In-service Education, dated 06/16/24, reflected training for abuse, neglect policy - who is coordinator; resident rights; pain policy; and timely notification. In-services reflected all staff completed the trainings. The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 06/25/24, reflected the training participant would be able to verbalize and demonstrate proper transfer techniques in order to safely provide patient care handling, transfers included sit to stand, stand - pivot, squat- pivot, slide board, and mechanical lift. The in-services were conducted and signed by CNAs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 06/26/24, reflected the Administrator, the Interim DON and ADON were in-serviced on all staff applicable to receive training to use online resources or in person training to ensure all trained staff have attested to receiving education.<BR/>Record review of the facility's Record of In-service Education, dated 07/02/24, reflected training for what was change of condition, what to do when a change of condition happens, who to notify, orders to receive, full head to toe assessment, assess for pain, medicate as ordered and continue to assess and to follow through any new orders. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Record of In-service Education, dated 07/03/24, reflected training regarding: how to identify pain and what to do. The training record reflected: .pain may be late on set and resident may not be able to verbalize, job is to assess pain and treat timely, once treated - [you] have to assess for effectiveness, continue to monito if not effective new orders may be needed. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM.<BR/>Record review of the facility's Monthly QA Meeting reflected the meeting was completed on 07/08/24.<BR/>Interviews conducted on 07/19/24 from 2:40 PM through 5:45 PM with the Administrator, the Interim DON, ADON, LVN A, RN D, RN E, RN F, LVN G, LVN M, RN O, LVN Q, who worked the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM revealed nurses were able to verify education was provided to them. Nursing staff were able to accurately summarize what was change of condition, what to do when a change of condition occurred, who to notify, orders to receive, completing a full head-to-toe assessment, assessing for pain, medicating as ordered and continuing to assess, following through any new orders, documenting, and completing the SBAR. The Interim DON and ADON stated they would be responsible for monitor all kiosk (dashboard) alert a minimum of 4 times per week to ensure any potential change of condition had been addressed timely and continue education on change of condition. <BR/>Interviews conducted on 07/19/24 from 3:48 PM through 5:45 PM with CNA B, CNA H, CNA I, CNA J, CNA K, CNA L, CNA N, CNA P, CNA R, CNA S, and CNA T who work the shifts of 6:00 AM- 6:00 PM- 6:00 PM - 6:00 AM revealed staff were able to verify education was provided to them, staff were able to accurately summarize what was change of condition, how to identify pain and who to notify. <BR/>The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/19/2024 at 5:50 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 treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Residents #22 and #47) of 3 residents reviewed for dignity.<BR/>RN D failed to maintain Resident #22 and #47's dignity and respect by standing between the residents while feeding both of them during lunch time on 08/27/24 at 12:17 PM . The failure could negatively affect the mental and psychological well-being of all residents who required the assistance of staff with eating. <BR/>Findings included:<BR/>Record review of Resident #22's face sheet dated 08/29/2024 reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of Alzheimer's disease (most common type of dementia), lack of coordination, dysphasia (language disorder marked by deficiency in the generation of speech), and cognitive communication deficit (difficulty thinking and how someone uses language).<BR/>Record review of Resident #22's Quarterly MDS assessment dated [DATE] reflected the resident had severe cognitive impairment with a BIMS score of 03 with short- and long-term memory problems. The MDS reflected the resident required partial to moderate assistance with eating. <BR/>Record review Resident 22's care plan revised 07/02/2024 reflected: has a significant unplanned/unexpected weight loss poor food intake. Interventions: Provide hands on assistance during meals.<BR/>Record review of Resident #47's face sheet dated 08/29/2024 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, lack of coordination, dysphasia, cognitive communication deficit, and dementia (loss of cognitive functioning impacting daily life and activities). <BR/>Record review of Resident #47's Significant Change MDS assessment dated [DATE] reflected a BIMS score of 0 indicating the resident had severe cognitive impairment. The MDS reflected the resident was dependent on staff for eating.<BR/>Record review Resident #47's care plan dated 12/23/2023 reflected the resident had an ADL self-care performance deficit related to eating, and she was totally dependent upon one staff to assist her with eating.<BR/>Observation on 08/27/2024 at 12:17 PM revealed RN D stood between Residents #22 and #47 in the dining room. She alternately fed each resident from their respective plates of food while standing. <BR/>Interview on 08/27/2024 at 2:45 PM, RN D stated she did not see anything wrong with feeding both residents while standing. She stated if she had seen a chair she would have sat down; however, since there was none, she decided to stand. RN D stated she did not know why she should sit while feeding resident. She stated it helped to slow down the feeding. She stated she was not aware of the risk of standing while assisting with feeding, and she had not done training on dignity. <BR/>Interview and record review on 08/29/2024 at 3:00 PM, the DON stated she expected staff to sit next to residents and be on the same level when assisting them to eat. She said this respected their dignity by promoting a respectful environment and prevent aspiration. She said staff needed to be mindful of residents' dignity. She said staff were trained on resident rights and dignity. She provided a copy of an in-service record covering the topic of dignity dated 08/23/2024, and RN D's name was not documented as being an attendee of the training. The in-service training record reflected: Ensure all residents are shown dignity you always sit down while feeding residents.<BR/>Interview on 08/29/2024 at 3:04 PM, the ADON stated she expected staff to sit while feeding residents. She said the staff needed to be sure they paid attention to the residents to ensure their needs were met while eating. She stated the staff should be face-to-face to prevent shock and food spilling on residents. She said staff had been trained on resident dignity. <BR/>Record review of the facility's Resident Rights policy, revised February 2022, reflected:<BR/> .All residents have a right to: <BR/>a. Dignified existence,<BR/>b. Be treated with respect, kindness, and dignity.<BR/> .e. Self-determination, <BR/>f. communication with and access to persons and services inside and outside the facility. <BR/>The Facility must and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 1 of 18 residents (Resident #239) reviewed for advanced directives.<BR/>The facility failed to ensure Resident #239's code status (advance directives) was accurate and consistent with all records at the facility and did not provide information to the resident related to her right to formulate an advance directive. <BR/>This failure placed residents at risk of not having their end of life wishes honored.<BR/>Findings included:<BR/>Record review of Resident #239's face sheet dated [DATE] reflected the resident was a [AGE] year-old female admitted on [DATE]. <BR/>Record review of Resident #239's admission MDS assessment dated [DATE] reflected the resident was cognitively intact with a BIMS score of 15. The resident's diagnoses included multiple sclerosis (chronic disease of the central nervous system), anxiety disorder (mental health disorder) and hyperkalemia (high potassium). <BR/>Record review of Resident #239's care plan dated [DATE] reflected there was not a care plan addressing the resident's code status or advanced directives. <BR/>Record review of Resident #239's physician order summary report dated [DATE] reflected it did not have an active physician's order regarding the resident's elected code status, such as full code status or any other order to support her advance directive. <BR/>Record review of facility Order List Report dated [DATE] located in the facility's emergency crash cart reflected Resident #239 was not on the list for code status. <BR/>Interview on [DATE] at 10:24 AM with Resident #239 revealed she admitted to the facility about two weeks ago. Resident #239 stated she had not been asked about her code status. She stated her preference would be DNR.<BR/>Interview and record review on [DATE] at 10:35 AM with LVN K revealed she was the nurse assigned to Resident #239. She stated when a resident admitted to the facility, it was the responsibility of the admission nurse to ask the resident for their code status and document it in the resident's chart. LVN K stated it was the responsibility of the Social Worker to follow-up with the resident and include the code status in the resident's care plan. LVN K reviewed Resident #239's clinical records and stated she was not aware Resident #239 did not have a physician order for code status or that it was not documented in the resident's care plan. <BR/>Record review of Resident #239's physician order summary report dated [DATE] reflected a physician order for Full Code. <BR/>Interview on [DATE] at 10:56 AM, the Social Worker stated it was the responsibility of the admission nurse to ask residents about their code status. She stated she would follow-up shortly after their admission. She stated once she obtained the resident's code status it was her responsibility to care plan it. She stated she was not aware Resident #239's code status was not documented in the resident's chart. She stated the code status should be in PCC (electronic health record system) under the physician orders and care plan. She stated Resident #239's code status was Full Code, and she forgot to care plan Resident #239's code status. She stated the risk of not having a code status would be doing CPR or not doing CPR. <BR/>Interview on [DATE] at 2:46 PM, the ADON stated it was the responsibility of the admission nurse to obtain and document code status. She stated she was not aware Resident #239 did not have a code status until today ([DATE]) when LVN K informed her. She stated it was the responsibility of the social worker to follow up when she completes her code status audits. The ADON stated code status should be care planned which were completed by the social worker. She stated the potential risk of not having code status would be confusion during an emergency. <BR/>Interview on [DATE] at 3:23 PM, the DON stated advance directives were obtained upon a resident's admission to the facility by the admitting nurse. She stated the Social Worker would then follow-up with the resident. She stated she was not aware Resident #239 did not have a code status. She stated she was informed today ([DATE]). She stated she expected her nurses to obtain residents' code statuses upon admission, and she expected the Social Worker to follow-up and care plan the code status. She stated code status should be documented in PCC and on the care plan. She stated the potential risk would be doing CPR on the resident when they had elected to be a DNR. <BR/>Record review of the facility's Advance Directives policy, revised [DATE], reflected the following:<BR/>The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance Directives are honored in accordance with state law and facility policy. <BR/>Determining Existing of Advance Directives: <BR/>1. <BR/>Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his legal representative, about the existence of nay written advance directives.

**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, consistent with the resident rights as set forth at 483.10(c) and 483.10(c)3, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #239) for care plan revisions, in that:<BR/>The facility failed to develop a care plan addressing Resident #239's elected code status or advance directive.<BR/>These failures could place residents at risk of receiving inappropriate care.<BR/>Findings included:<BR/>Record review of Resident #239's face sheet dated [DATE] reflected the resident was a [AGE] year-old female admitted on [DATE].<BR/>Record review of Resident #239's admission MDS assessment dated [DATE] reflected the resident's cognition was intact with a BIMS score of 15. The resident's diagnoses included multiple sclerosis (chronic disease of the central nervous system), anxiety disorder (mental health disorder) and hyperkalemia (high potassium). <BR/>Record review of Resident #239's care plan dated [DATE] reflected there was not a care plan addressing the resident's code status or advance directives.<BR/>Record review of Resident #239's physician order summary report dated [DATE] reflected it did not have an active physician's order for code status, such as full code status or any other order to support her advanced directive. <BR/>Record review of the facility's Order List Report dated [DATE] located in the facility's emergency crash cart reflected Resident #239 was not on the list for code status. <BR/>Interview on [DATE] at 10:24 AM, Resident #239 stated admitted to the facility about two weeks ago. Resident #239 stated she had not been asked about her code status. She stated her preference would be DNR. <BR/>Interview on [DATE] at 10:35 AM, LVN K stated she was the nurse assigned to Resident #239. LVN K stated when a resident admitted to the facility, it was the responsibility of the admission nurse to ask the resident for their code status and document in the resident's chart. LVN K stated it was the responsibility of the Social Worker to follow-up with the resident and include the code status in the resident's care plan. LVN K reviewed Resident #239 clinical records and stated she was not aware Resident #239 did not have a physician order for code status or that it was not documented in the resident's care plan. <BR/>Record review of Resident #239's physician order summary report dated [DATE] reflected a physician order for Full Code. <BR/>Interview on [DATE] at 10:56 AM, the Social Worker stated it was the responsibility of the admission nurse to ask residents about their code status. She stated she would follow-up shortly after their admission. She stated once she obtained the resident's code status it was her responsibility to care plan it. She stated she was not aware Resident #239's code status was not documented in the resident's chart. She stated the code status should be in PCC (electronic health record system) under the physician orders and care plan. She stated Resident #239's code status was Full Code, and she forgot to care plan Resident #239's code status. She stated the risk of not having a code status would be doing CPR or not doing CPR. <BR/>Interview on [DATE] at 2:46 PM, the ADON stated it was the responsibility of the admission nurse to obtain and document code status. She stated she was not aware Resident #239 did not have a code status until today ([DATE]) when LVN K informed her. She stated it was the responsibility of the social worker to follow up when she completes her code status audits. The ADON stated code status should be care planned which were completed by the social worker. She stated the potential risk of not having code status would be confusion during an emergency. <BR/>Interview on [DATE] at 3:23 PM, the DON stated advance directives were obtained upon a resident's admission to the facility by the admitting nurse. She stated the Social Worker would then follow-up with the resident. She stated she was not aware Resident #239 did not have a code status. She stated she was informed today ([DATE]). She stated she expected her nurses to obtain residents' code statuses upon admission, and she expected the Social Worker to follow-up and care plan the code status. She stated code status should be documented in PCC and on the care plan. She stated the potential risk would be doing CPR on the resident when they had elected to be a DNR. <BR/>Record review of the facility's Care Planning - Interdisciplinary Team policy, revised [DATE], reflected: The interdisciplinary team is responsible for the development of resident care plans.<BR/>Record review of the facility's Advance Directives policy, revised [DATE], reflected: The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a final summary of the resident's status at the time of the discharge was available for release to authorized persons and agencies, with consent of the resident or resident's representative for 1 of 3 residents (Resident #87) reviewed for discharge summary.<BR/>The facility failed to complete a discharge summary after Resident #87 left the facility and did not return. <BR/>This failure could place residents at risk for a lack of continued care and services. <BR/>Findings included: <BR/>Record review of Resident #87's face sheet dated 08/29/2024 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. He discharged from the facility on 08/08/2024 to his home. <BR/>Record review of Resident #87's most recent MDS assessment dated [DATE] reflected he had diagnoses of bipolar disorder (a mental health condition that causes extreme mood swings between emotional highs and lows) and alzheimer's disease (a brain disorder that causes memory loss, thinking problems, and behaviors changes). The MDS assessment did not indicate the BIMS score was captured at the time of completion.<BR/>Record review of Resident #87's August 2024 Progress Notes reflected there was no documentation concerning the resident's discharge from the facility. <BR/>Record review of Resident #87's assessments did not reflect any information about his discharge on [DATE]. <BR/>Interview on 08/29/2024 at 11:43 AM, the Social Worker revealed Resident #87 was taken out of the facility on pass with his family, and they never brought the resident back. She said Resident #87 left the faciity on pass often with his family, so there was not a concern when he left and did not return. She said she did not complete a discharge summary for Resident #87 but would normally complete one when a resident discharged from the facility. She said she was responsible for completing the discharge summary, and she was not sure why she did not complete one. She said the purpose of the discharge summary was to find out what the resident needed in the community such as equipment or services. She stated if a discharge summary was not completed, the resident could be at risk for readmission or wind up in the hospital. The Social Worker stated she was not aware that anyone was monitoring to ensure that discharge summaries were completed after a resident discharged . <BR/>Interview on 08/29/2024 at 3:23 PM, the DON revealed the facility did not have a UDA for a resident's discharge summary for staff to fill out. She said she would assume a nurse would at least add a progress note in the resident's chart related to the discharge. She said Resident #87 went out on pass with his family to visit for a few days when the resident's family called and said they did not want him to return to the facility. The DON said Resident #87's discharge was not planned and was determined by the family that he would just stay home with them. She said she thought the Social Worker should have made a note about it in Resident #87's chart since she was the last person to talk to his family. She said the purpose of a discharge summary or note was to have the information to know where people went. She said the concern was that staff might think the resident was missing if they did not see the resident had discharged . The DON said she was not sure if anyone was monitoring to ensure discharge summaries or notes were being completed. <BR/>Interview on 08/29/2024 at 4:14 PM, the Administrator revealed the facility did not have a policy that addressed discharge summaries.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (medication cabinet in the central supplies unit) and one refrigerator in the medication room for 100 and 200 halls reviewed for pharmacy services.<BR/>The facility failed to ensure expired influenza vaccine, with an expiration date of 05/10/2024, in the Hall 100/200 Medication Room refrigerator and expired medications in the Central Supply medication cabinet were removed and destroyed on 08/28/2024 at 10:45 AM.<BR/>The failure placed residents at risk of receiving medications that were ineffective due to having expired.<BR/>Findings included:<BR/>Observation on 08/29/2024 at 10:45 AM of the 100 and 200 Medication Room refrigerators with LVN K revealed 4 vials of the influenza vaccine lot 370677 with expiration date of 05/10/2024. <BR/>Interview on 08/29/2024 at 10:55 AM, LVN K stated the night shift nurses were the ones who were supposed to check the carts and the refrigerators for expired medications, but it was all nurses' responsibility to check and remove expired medications from the refrigerator. She stated she had done training on when to discard the vaccines once they expired. She stated by failing to remove the expired medication they could be administered and cause reactions, and the resident would not get the required therapy.<BR/>Interview on 08/29/2024 at 11:05 AM, the ADON stated it was her responsibility to go behind the nurses to check whether they were removing the expired medications from the refrigerators and carts. She stated she could not remember the date she checked the carts and refrigerator, but it was in August. She stated by failing to check for the expired medications, they could be administered and would not be effective. The ADON stated she was not aware whether the facility had offered training to staff regarding removing expired medications.<BR/>Interview on 08/29/2024 at 11:15 AM, the DON stated she expected the night shift nurses to check the refrigerator for expired medications, and she and the ADON were responsible for following up. The DON stated she checked the carts and the refrigerator in August, but she could not recall the date. She stated if staff were not checking the refrigerator for expired medications and medications were administered to residents, they would not be effective. She stated she had not done training on refrigerator monitoring with staff since she was new to the facility.<BR/>Observation on 08/29/2024 at 11:20 AM of the facility's Central Supply cabinet where over-the-counter medications were stored revealed the following expired medications: <BR/>- Saline Nasal spray with expiry date of 08/22/2024,<BR/>- one bottle of Vitamin B12 with expiry date of April 2024,<BR/>- one bottle of Vitamin B6 with expiry date of 04/24/2024, and <BR/>- one bottle of Acetaminophen 500 mg/15 ml with an expiry date of 03/24/2024.<BR/>Interview on 08/29/2024 at 11:30 AM, the Central Supply Staff stated it was her responsibility to check and ensure medications were labeled and not expired. She stated the cabinet was shared by all the nurses, and she was responsible for acquiring all the over-the-counter medications and storage and ensuring they were not expired. She stated the side effects of giving expired medication was they would not work and would not be effective. She stated all expired medications were supposed to be removed from the cabinet and put in destruction boxes for the Pharmacist to destroy. She stated she had done training on storage and labeling of medications. She stated she had last checked the cabinet on 08/28/2024, and she did not know how she missed the expired medication but stated she thought the nurses removed the medications from their carts and brought them to the cabinet.<BR/>Interview via telephone was attempted with the night shift nurses on 08/29/2024 at 3:24 PM, but the attempt was not successful and a voice mail was left.<BR/>Interview on 08/29/2024 at 3:48 PM, the DON stated she expected all over-the-counter medications be labeled and not expired. She stated she and the ADON were responsible for checking the cabinet in the Central Supply Room for expired medications. She stated she checked the cabinet in the Central Supply Room on 08/26/2024, and there were no expired medications. She stated if expired medications were administered to residents, they would not be effective. She stated she had done training on checking for expired medications in the medication carts, refrigerator and the supply unit, but no in-service record was provided prior to exit. <BR/>Review of the facility's Storage of Medication policy, revised August 2020, reflected the following: <BR/> .1. Expiration dates (beyond-use dates) of dispensed medications shall be determined by the pharmacist at the time of dispensing.<BR/>2. Drugs dispensed in the manufacturers' original container will be labeled with the manufacturer's expiration date.<BR/> .8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Residents #2) of 2 residents reviewed for infection control. <BR/>LVN L failed to put on a gown before entering Resident #2's room to administer a bolus feeding and medications to Resident #2, who was on enhanced barrier precautions.<BR/>This failure placed residents at risk of cross contamination and the spread of infection.<BR/>Findings included:<BR/>Record review of Resident #2's face sheet dated 08/29/2024 reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE].<BR/>Record review of Resident #2's Quarterly MDS assessment dated [DATE] reflected his diagnoses included hypertension (high blood pressure), dysphagia (difficulty swallowing) and gastrostomy status (presence of an artificial opening in the stomach, also known as a gastrostomy tube). Resident #2 had severe cognitive impairment with a BIMS score of 3. The MDS reflected the resident received his nutrition via feeding tube. <BR/>Record review of Resident #2's care plan revised on 04/02/2024 reflected: Focus: [Resident #2 is on enhanced barrier precautions. Goal: [Resident #2] will have no complications related to enhance barrier precautions. Interventions: All staff will wear gown and gloves during high-contact care activities.<BR/>Record review of Resident #2's physician order dated 04/18/2024 reflected: Enteral Feed every 6 hours Nurten 2.0 bolus 1 carton/brick (250 ml) Fluid flush 150 ml before and after each bolus. <BR/>Observation on 08/28/2024 at 11:53 AM revealed a sign on Resident #2's door reflecting: Stop, enhanced barrier precautions - providers and staff must also wear Gown and Gloves. PPE was outside the room. LVN L entered Resident #2's room to administer Resident #2 a bolus feeding. LVN L performed hand hygiene and then donned gloves. Without donning a gown, LVN L administered a bolus feeding to Resident #2 via the resident's gastrostomy tube.<BR/>Observation on 08/28/2024 at 2:16 PM revealed a sign on Resident #2's door reflecting: Stop, enhanced barrier precautions - providers and staff must also wear Gown and Gloves. PPE was outside the room. LVN L entered Resident #2's room to administer medications and a bolus feeding to the resident. LVN L performed appropriate hand hygiene and donned a pair of gloves. Without donning a gown, LVN L administered medications via gastrostomy tube to Resident #2. <BR/>Interview on 08/28/2024 at 2:37 PM, LVN L stated she was the nurse assigned to Resident #2. LVN L stated she saw the PPE at the door, and she was aware they were for enhanced barrier. She stated the PPE was supposed to be worn during care, at all times, but she forgot. She stated any resident who had a catheter, g-tube, or wound was on enhanced barrier precautions. She stated Resident #2 was on enhanced barrier precautions due to having a g-tube. She stated she should have donned a gown but forgot to do it. She stated the risk of not donning PPE was that it could lead to the spread of infection. She stated she could not remember whether she had done training on enhanced barrier precautions.<BR/>Interview on 08/28/2024 at 2:55 PM, the DON stated she expected staff to put on PPE when providing care to a resident who had a wound, catheter, or a g-tube. She stated residents who were on enhanced barrier precautions had signs on their doors to indicate the resident was on enhanced barrier precautions. The DON stated Resident #2 was on enhanced barrier precautions due to having a g-tube and staff should put on PPE before providing any type of care. She stated the potential risk of not putting on PPE would be spread of infection. She stated the facility had done training on infection control and enhanced barrier precautions.<BR/>Record review of the facility's training records reflected training on infection control, reverse isolation and enhanced barrier precaution dated 04/15/2024 and 04/2/2024. The records reflected LVN L was not in attendance.<BR/>Record review of the facility's Enhanced Barrier Precautions policy, dated August 2024, reflected:<BR/>1. Enhanced barrier precautions (EBP) are used an infection prevention and control intervention to reduce the spread of multi-drug resistant organism to residents. <BR/> .3. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include:<BR/>a. Dressing<BR/>b. Bathing /showering<BR/>c. Providing hygiene<BR/> .g. Device care use (central line urinary catheter, feeding tube and <BR/>h. Wound care (any skin opening requiring a dressing) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 1 resident (Resident #1) reviewed for pharmaceutical services.<BR/>The facility failed to ensure MAs and nurses were following physician orders for administering Resident #1's Lidocaine Patch 4%, which was used for preventing pain, on 05/04/25.<BR/>This failure could put residents at risk of not receiving their medications as ordered.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS assessment, dated 03/24/25, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included age-related osteoporosis without current pathological fracture (a condition where bone density and mass decrease significantly due to the natural aging process, increasing the risk of fractures). The resident's cognition was moderately impaired with a BIMS score of 8. The MDS reflected the resident received a scheduled pain medication regimen.<BR/>Record review of Resident #1's care plan, dated 08/15/24, reflected Resident #1 has Acute Pain / Chronic Pain. Goal:-she Will Report Satisfactory Pain Control. Interventions:- Educate Resident / Representative on prescribed analgesics and / or anti-inflammatory medications<BR/>Record review of Resident #1's May 2024 Physician Orders dated 1/24/2025 reflected the following: Lidocaine Pain Relieving External Patch 4% (Lidocaine). Apply to right hip 1 patch topically one time a day for PAIN and remove per schedule. <BR/>Record review of Resident #1's May 2025 MAR revealed reflected LVN C worked on 05/04/25 and had signed on the MAR that he had removed the resident's patch at 5:59 PM.<BR/>Observation on 05/06/25 at 11:40 AM revealed Resident #1 had two lidocaine external patches on her right hip, one was dated 05/04/25 and the other was dated 05/06/25. The resident's skin was intact.<BR/>Observation and interview with MA B on 05/06/25 at 11:50 AM revealed Resident #1 had two lidocaine patches on the right hip. MA B stated Resident #1s patch was supposed to be applied in the morning at 6:00 AM and then removed at 5:59 AM as per the order. She stated it was the responsibility of the nurse and herself to apply and remove the patch. She stated she worked on 05/04/25 and the patch was applied by the night shift nurse before she left after her shift and that evening she had left early. She expected the nurse to remove the patch because they use the same MAR and anytime the patch was due for application or removal it will pop on the electronic record showing as due. She stated she was the one that applied the patch on 05/05/25 and denied seeing the one dated 05/04/25. She stated failure to remove an old patch before applying a new could lead to overdose. She had done in-service on medication administration. <BR/>An interview was attempted via telephone with LVN C on 05/06/25 at 2:20 PM; however, the attempt was not successful. A voicemail message was left without a return call back from LVN C. <BR/>Interview with RN D on 05/06/25 at 2:57 PM revealed she was the one, who had removed the patch 05/05/25 in the evening, for Resident #1. She stated she did not see the old patch dated 05/04/25. RN D stated she was aware she was supposed to remove the old patch before administering the new one. She stated the risk of not removing the old patch was over medication and skin irritation. RN D stated she had done in-services on medication administration.<BR/>Interview with the DON on 05/06/25 at 4:34 PM revealed his expectation was that nurses and MAs should remove the old patch before applying the new patch. He stated failure to remove the old patch would lead to overdose and skin irritation. He stated facility had done in-service on medication administration but not on patches removal. <BR/>Record review of the facility medication administration in-service record, dated 04/23/25, reflected MA B, LVN C and RN D were in attendance.<BR/>Record review of the facility's current Pharmacy Services policy, dated April 2019, reflected: .4.Medications are administered in accordance with prescriber orders, including any required time frame The policy did not address patch administration and removal. The DON stated they did not have a policy that addressed patch removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for one (Resident #1) of five residents records reviewed for resident records, in that:<BR/>LVN A failed to accurately document the administration of Resident #1's hydrocodone and lorazepam on 09/04/23 on the resident's MAR.<BR/>This failure could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs. <BR/>Findings included:<BR/>Review of Resident #1's face sheet, dated 10/02/23, reflected the resident was admitted to the facility on [DATE]. Her diagnoses included anxiety disorder (a group of mental illnesses that cause constant fear and worry) and primary osteoarthritis (a condition that causes several different symptoms that can impact your function and affect your ability to perform your daily activities). <BR/>Review of Resident #1's Significant Change in Status MDS, dated [DATE], reflected she had a BIMS score of 03, indicating severe cognitive impairment. <BR/>Review of Resident #1's physician's orders, dated 10/02/23, reflected she was ordered Ativan oral tablet .5 mg (Lorazepam), give 1 tablet by mouth at bedtime related to anxiety disorder as of 07/17/23.<BR/>Review of Resident #1's physician's orders, dated 10/02/23, reflected she was ordered hydrocodone-acetaminophen oral tablet 5-325 mg, give 1 tablet by mouth every 4 hours as needed for Pain-Moderate: Pain-Severe as of 06/09/23.<BR/>Review of Resident #1's September 2023 MAR revealed on 09/04/23 the box was checked and initialed by LVN A that Resident #1 received her Ativan as ordered.<BR/>Review of Resident #1's September 2023 MAR revealed on 09/04/23 the boxes were blank, indicating there was no documentation that she received any hydrocodone-acetaminophen that day. <BR/>Review of Resident #1's controlled drug record form for her lorazepam (Ativan) reflected LVN A administered the medication on the following dates and times: 09/04/23 at 3:00 PM and 09/04/23 at 8:00 PM.<BR/>Review of Resident #1's controlled drug record form for her hydrocodone reflected LVN A administered the medication on the following dates and times: 09/04/23 at 8:00 AM, 09/04/23 at 12:00 PM, 09/04/23 at 4:00 PM, and 09/04/23 at 9:00 PM.<BR/>Review of the facility's Provider Investigation Report for Incident Intake ID: 449202 reflected the following under the investigation summary portion: On 9/4 [09/04/23] charge nurse (RN B) arrived for her 6-2 [6:00 AM-2:00 PM] shift and began her count. Charge nurse noticed medication for resident (Resident #1) was signed for by the 2-10 [2:00 PM-10:00 PM] shift nurse (LVN A). the medication was signed for at 8am and 12pm. Charge nurse (RN B) stated during her interview that these times immediately raised a red flag since the nurse in question only works the 2-10 shift. This employee then brought her findings to the DON. The DON began her investigation. The DON was able to determine that the medication was signed out at 8am and 12 pm by nurse, (LVN A). When the nurse in questions was interviewed she stated she had given to much. During the interview the nurse stated that she did not follow the MD orders. Nurse also stated that this resident has two orders for Ativan. This resident does not have a PRN order. The DON and HR requested a drug test from the nurse. The test came back positive for morphine. The nurse states that she did not have a prescription for the morphine. The DON explained to the nurse that she would be suspended pending an investigation due to the documented medication, drug test, and discrepancies in her interview. The employee was terminated. Interview with staff revealed that the nurse would sit at the nurse station for a long period of time and that there were no behaviors noted in regard to the staff. Interview statements also indicated that the resident was more confused. Nursing staff assessed resident and there were no adverse effects or injuries noted. Nursing facility to continue to proved care for resident. Safe surveys did not reveal any findings of abuse or neglect. [sic]<BR/>In an interview via phone on 10/02/23 at 10:56 AM with LVN A, she revealed she did not have any documentation in front of her and the situation regarding Resident #1's medications was a long time ago, but she would try her best to remember what happened on 09/04/23. LVN A said she did administer Resident #1 hydrocodone on 09/04/23 during her 2:00 PM-10:00 PM shift and documented the administration on the resident's narcotic count sheet. LVN A said Resident #1 had an order for hydrocodone which was for one tablet every six hours. LVN A said most people had an order for two tablets of hydrocodone every four hours so she got confused and accidentally administered Resident #1 too many hydrocodone pills because she had popped an extra pill each time. LVN A said Resident #1 was on hospice and had a lot of pain and was complaining of pain on 09/04/23 which was why she administered the hydrocodone to her. LVN A said she did document on the narcotic count sheet that the medication was administered at times when she was not working (referring to the 8:00 AM and 12:00 PM administrations). LVN A said that she documented it that way because she had administered too many pills to Resident #1 and should have been following the physician's order for just one tablet of the hydrocodone. LVN A said she also gave Resident #1 two pills of Ativan that day but could not remember why or what doctor's order she was following to administer it. LVN A said Resident #1 did not experience any adverse effects to the additional medications. LVN A said she did not take the medications for herself or administer them to any other residents. LVN A said she succumbed to the pressure and knew it was wrong to inaccurately document the wrong times of the medication administration. LVN A said she recognized her mistake and she should have asked another nurse to come and waste the medication and only administer Resident #1 what she was ordered by the doctor. LVN A said she administered Resident #1 hydrocodone and lorazepam on 09/04/23 during her 2:00 PM-10:00 PM shift and documented the administration on the resident's narcotic count sheet only. LVN A said she did not notate the medication administration on Resident #1's MAR because she forgot even though she knew she was supposed to do that. <BR/>In an interview on 10/02/23 at 3:36 PM with the DON, she revealed she expected staff to document on the resident's controlled drug sheet and on the resident's MAR when a medication was administered. <BR/>In an interview on 10/02/23 at 3:36 PM with the DON, she revealed all staff knew to document any medications administered on the resident's EMAR. <BR/>Review of the facility's Oral Medication Administration policy, dated September 2018, reflected: .9. Chart medication administration on the MAR (or eMAR) immediately following each resident's medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for daily living for two residents (Resident #24 and Resident #5) of eighteen residents reviewed for environmental concerns. <BR/>1. Resident #24's and Resident #5's room had a foul odor, the floor was sticky with debris, and the toilet was covered in feces. The two residents shared a room. <BR/>2. There was a pervasive foul odor on the Memory Care Unit (300 Hall).<BR/>These failures could place residents at risk of living with unclean, uncomfortable, un-homelike rooms and a diminished quality of life. <BR/>Findings included:<BR/>Record review of Resident #24's face sheet revealed the resident was an [AGE] year-old male, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included: dementia behavioral disturbance (loss of memory and thinking abilities), Type II diabetes, Parkinson's disease (nervous system disorder), anorexia (eating disorder), and atrial fibrillation (irregular heartbeat).<BR/>Record review of Resident #24's quarterly MDS, dated [DATE], revealed Resident #24 had severe cognitive impairment with a BIMS score of 2, required extensive assistance with ADLs, including toilet use, and was frequently incontinent of bowel and bladder.<BR/>Record review of Resident #24's care plan, dated 04/19/23, revealed he had an ADL self-care deficit and needed assistance and supervision with bathing, bed mobility, dressing, toileting, transfer, and walking. <BR/>Record review of Resident #5's face sheet revealed the resident was an [AGE] year-old female, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included: dementia without behavioral disturbance (loss of memory and thinking abilities), Type II diabetes, chronic kidney disease, age-related osteoporosis (weak bones), unsteadiness on feet, and heart disease. <BR/>Record review of Resident #5's quarterly MDS, dated [DATE], revealed Resident #5 severe cognitive impairment with a BIMS score of 3, required extensive assistance with ADLs, including toilet use, and was frequently incontinent of bowel and bladder.<BR/>Record review of Resident #5's care plan, dated 05/02/23, revealed she had limited physical mobility related to osteoporosis and required supportive care and assistance with mobility as needed. Resident #5 also had an ADL self-care performance deficit and required a one-person assist with bathing, bed mobility, dressing, and toilet use. Resident #5 used a wheelchair for mobility. <BR/>Observation on 06/20/23 at 11:10 AM revealed a foul odor immediately upon entering the Memory Care Unit. During a tour of all rooms on the unit, Residents #24's and Resident #5's room was found to have a strong odor of feces. The room floor was sticky and covered in debris, and the toilet was covered in feces. <BR/>Attempted interview on 06/20/23 at 11:15 AM with Residents #24 and #5 was unsuccessful due to their cognitive deficits and language barriers. <BR/>Interview on 06/20/23 with Residents #25's and Resident #5's family member revealed she was upset about the residents' living condition due to their room being unsanitary. The family member stated other family members visited more frequently than she did and had also reported that the room was often unclean and had an odor. She stated she was going to return later with cleaning supplies to clean the room herself because family had already complained to staff, and nothing had been done about it. <BR/>Observation on 06/21/23 at 9:30 AM revealed Residents #24's and Resident #5's room and bathroom were clean. There was no debris of the floor or feces on the toilet. <BR/>Interview on 06/22/23 at 1:25 PM with the Administrator revealed she was unaware Resident #24's and Resident #5's room was not cleaned properly or that there was feces on the toilet. She stated the residents' responsible party, who was not the family member who visited on 06/20/23, was satisfied with the care Residents #24 and #5 were receiving. The Administrator stated her expectation was for the Housekeeping Supervisor to be confident enough to delegate duties to the housekeepers to maintain sanitation and cleanliness of the facility, and for any concerns to be brought to her attention. She stated housekeepers were expected to follow a cleaning schedule implemented by the Housekeeping Supervisor. <BR/>Interview on 06/22/23 at 1:35 PM with the Housekeeping Supervisor revealed she had worked at the facility since March 2023. She stated the Memory Care Unit was considered a high traffic area and had an assigned housekeeper to remain on the unit for cleaning as needed. The Housekeeping Supervisor stated all rooms were generally cleaned at least once daily and as needed, which was more frequently on the memory care unit. She stated general cleaning included sweeping, mopping, wiping walls, fixtures, and handles, and cleaning the bathrooms. She stated the facility used non-acid cleaners from Medline, peroxide-based disinfectants and Odoban spray for odors. The Housekeeping Supervisor stated the staff and families had open communication with her about any concerns and dissatisfaction with the cleanliness of the facility. She denied being aware of any concerns other than minor ones such as dispensers needing paper towels. She also stated if there was ever a complaint about the assigned housekeepers, she would move them. She stated the residents' health could be at risk in an unclean environment. <BR/>Interview on 06/22/23 at 03:25 PM with LVN H revealed she worked at the facility for less than a month. She stated she worked on the memory care unit and was familiar with Residents #24 and #5. LVN H denied smelling any foul odors on the unit or coming from the residents' room, and she denied being made aware that the room was unsanitary with feces on the toilet. <BR/>A facility policy on housekeeping was requested on 06/22/23 at 3:45 PM from the Administrator, and she stated they did not have one. <BR/>Review of facility's daily census, dated 06/20/23, reflected there were 48 residents residing on the Memory Care Unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #32) of two residents reviewed for pressure ulcers. <BR/>The facility failed to ensure the Stage 4 pressure ulcer on Resident #32's sacrum was covered with a dressing as ordered by the physician. <BR/>This failure could affect the residents, who received pressure ulcer care, by placing them at risk for contamination of their wounds and causing unnecessary infections and worsening of pressure ulcers.<BR/>Findings included: <BR/>Record review of Resident #32's face sheet revealed the resident was a [AGE] year-old male who was admitted into the facility on [DATE] with diagnoses, unstageable pressure ulcer on right hip (refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) and Stage 4 pressure ulcer of sacral region (the large, triangle-shaped bone in the lower spine that forms part of the pelvis).<BR/>Record review of Resident #32's MDS, dated [DATE], revealed the resident had a BIMS score of 10 indicating the resident's cognition was moderately impaired. It also revealed the resident had pressure ulcers/injuries, and he was at risk of developing pressure ulcers. It also revealed the resident had one Stage 4 pressure ulcer.<BR/>Record review of Resident #32's care plan, dated 04/13/23, revealed Resident #32 had a Stage 4 pressure ulcer to the sacrum. The care plan interventions were to report loose or missing dressings to the nurse. The care plan also reflected to administer treatments as ordered and monitor effectiveness. Replace loose or missing dressings, assess, record, monitor wound healing at least weekly, measure length, width, and depth where possible, and to assess and document the status and perimeter, wound bed and healing process and report decline to doctor. The care plan also revealed Resident #32 required a low air loss mattress and used a lifting device, and drawsheet to reduce friction. <BR/>Record review of Resident #32's MAR on 06/22/23 revealed the last time wound care was performed was on 06/21/23.<BR/>Record review of Resident #32's physician's wound care notes and orders, dated 06/19/23, revealed the resident had a Stage 4 pressure wound on the sacrum measuring 22 cm x 28.6 cm x 5.7 cm, with a dressing treatment to cleanse Stage 4 sacrum wound with normal saline, pat dry apply calcium alginate and cover with a dry dressing once daily and every 4 hours as needed for soiled/dislodged dressings.<BR/>Observation on 06/22/23 at 2:03 PM revealed LVN A got wound care supplies ready outside of Resident #32's room. CNA D and LVN A washed their hands and put on new gloves. CNA D and LVN A positioned Resident #32 in bed and removed the positioning pillows. LVN A cleansed Resident #32's pressure ulcer on his sacrum with normal saline soaked gauze. There was no dressing observed on the wound prior to cleansing. She pat dried the wound, doffed gloves, and donned new gloves after performing hand hygiene. She applied calcium alginate, covered with abdominal pads, and then fastened with paper tape. She removed her gloves, performed hand hygiene, put on a new pair of gloves, and positioned Resident #32. LVN A and CNA D removed their gloves, and they performed hand hygiene.<BR/>Interview with Resident#32 on 06/21/23 at 12:28 PM revealed he had wounds that he admitted with to the facility. Resident #32 stated he received wound care every day, and the wound doctor came to see him weekly. Resident #32 stated the wounds were improving. <BR/>Interview with LVN A (Wound Care Nurse) on 06/22/23 at 2:46 PM revealed she also noticed Resident #32 did not have dressings on the sacrum wound when he was turned on his side. She stated she was the one who had performed wound care on Resident #32 on 06/21/23. She stated the wound was supposed to always be covered to prevent infection and promote healing. She stated she was not notified by staff that the dressing came off during bed bath or incontinence care.<BR/>Interview with the DON on 06/22/23 at 3:37 PM revealed her expectation was all wounds be covered as per the physician orders. She stated she had trained staff to report if the dressing dropped off or it got soiled during incontinence care for replacement. She stated failure to keep the wounds covered predisposed the resident to infection and prevented the wound from healing as expected. The DON stated she did not understand why Resident#32 was left with the wound uncovered since he has a colostomy and Foley catheter. <BR/>Interview with CNA C on 06/22/23 at 4:06 PM revealed she gave Resident #32 a bed bath during the 6:00 AM-2:00 PM shift and since the wound dressing was soaked with discharge it had fallen off and was on the brief. She removed the brief together with the dressing, and she discarded it. CNA C stated she notified the Wound Care Nurse (LVN A) on the hallway, and LVN A told her she would go attend to Resident #32. CNA C stated she was aware when the dressing fell off during incontinence care or bed bath, she was supposed to notify the nurse. She stated she been trained to notify the nurse if a dressing fell off, and she was aware if the wound was left uncovered it was likely to get infected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater on 3 errors of 33 opportunities for errors leading to 9.09% medication error rates for one (LVN B) of two staff observed for medication pass.<BR/>The facility failed to ensure LVN B administered all the crushed medication in the medication cups without leaving residue for Resident #2.<BR/>These failures resulted in a 9.09% medication error rate and could put residents at risk who received medications via g-tube for not receiving the correct dose of medication and getting intended therapy.<BR/>Findings included:<BR/>Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE]. Resident #2 had diagnoses which included difficulty in swallowing, oropharyngeal phase (middle part of the throat), and gastrostomy status (an opening into the stomach from the abdominal wall made surgically). Resident #2 had a BIMS status score of 99 indicating cognition was severely impaired. <BR/>Review of Resident #2's June 2023 MAR revealed physician orders to administer medications via g- tube (a tube inserted through the wall of the abdomen directly into the stomach).<BR/>Review of Resident #2's physician orders revealed the following medications were prescribed:<BR/>- Buspirone 15 mg (used to treat anxiety), <BR/>- Levothyroxine 150 mg (used treat an underactive thyroid gland),<BR/>- Tylenol with Codeine, Tylenol #3 (pain medication), <BR/>- Amiodarone 200 mg (used to treat life-threatening heart rhythm problems), <BR/>- Asa 81 mg (blood thinner), <BR/>- Baclofen 10 mg (muscle relaxant), <BR/>- Multi-Vite liquid 15 ml (multi-vitamin), <BR/>- Docusate 100 mg (constipation), <BR/>- Eliquis 5 mg (blood thinner), <BR/>- Lamotrigine 100 mg (mood stabilizer), <BR/>- Miralax 17 gm (laxative that provides relief from occasional constipation), <BR/>- Senna 8.6 mg (laxative), and <BR/>- Seroquel Tablet 150 mg (an antipsychotic medication) to be crushed. <BR/>Observation on 06/21/23 at 9:12 AM revealed LVN B crushed the following medications to administer to Resident #2 via g-tube in separate medication cups:<BR/>- Buspirone 15 mg, <BR/>- Levothyroxine 150 mg, <BR/>- Tylenol with Codeine, Tylenol #3, <BR/>- Amiodarone 200 mg,<BR/>- Asa 81 mg, <BR/>- Baclofen 10 mg, <BR/>- Multi-Vite liquid 15 ml, <BR/>- Docusate 100 mg, <BR/>- Eliquis 5 mg, <BR/>- Lamotrigine 100 mg, <BR/>- MiraLAX 17 gm, <BR/>- Senna 8.6 mg, and <BR/>- Seroquel Tablet 150 mg. <BR/>LVN B was observed mixing medications with 5 ml water in each cup wit crushed medication. She administered each of these thirteen medications via g-tube flushing the g-tube between each medication administration with 5 ml of water. Three cups were noted to have medication residue remaining in the cups.<BR/>Interview with LVN B on 06/21/23 at 10:12 AM revealed she was aware for good results she was supposed to stir the medication well and administer the whole dose to the resident, but she did not do that, and she had no reason for not rinsing the cups. She stated she was supposed to give all the contents in the cup for Resident #2 to get the full dose of those medications. She stated failure to administer the full doses to Resident #2 would lead to Resident #2 not getting the therapy needed. She stated she had been trained on g-tube medication administration by her DON.<BR/>Interview with the DON on 06/21/23 at 2:58 PM revealed her expectation was that nurses should try to give as much as possible of all the content in the medication cups. She stated she had done training on medication administration through g-tubes with all nurses one- onone, so she did not understand why the nurse did not administer all the medications. She stated failure to administer the full dose could lead to Resident #2 not getting the right therapy, and the medications would not be effective.<BR/>Record review of facility's general Guidelines for Administering Medication via Enteral Tube policy and procedure, revised August 2020, reflected the following: <BR/> .5 .b. Crushed medications are not mixed. The powder from each medication is mixed with 10 ml of water before administration. The souffl&eacute; cup is rinsed with water to get all the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for transfers.<BR/>The facility failed to ensure Resident #1 was transferred using a gait belt.<BR/>This failure could place residents at risk of not receiving adequate supervision and assistive devices to prevent injury.<BR/>Findings included:<BR/>Review of Resident #1's MDS assessment, dated 12/20/22, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, lack of coordination, unspecified abnormalities of gait and mobility, difficulty in walking, and unsteadiness on feet. The resident was totally dependent on one staff for transfers. The resident's cognitive skills for daily decision making were severely impaired. <BR/>Review of the comprehensive care plan, dated 03/14/22, reflected Resident #1 was at risk for falls due to wandering, unsteady gait and poor balance. Facility interventions included anticipate and meet the resident's needs. <BR/>An observation on 02/03/23 at 11:45 AM with RA A revealed she was transferring Resident #1 from her wheelchair to another wheelchair. RA A reached under the arms of the resident, lifted her, and struggled to move the resident to another wheelchair. The resident was barely moving her feet to assist. No gait belt was used. RA A took the resident and weighed her on a wheelchair scale. RA A then transferred the resident back to her original wheelchair using the same method. The resident was pushed to the dining table. An interview was attempted with the resident but was not successful due to the resident's cognitive status. <BR/>An interview on 02/03/23 at 11:50 AM with RA A, she said she did not transfer Resident #1 correctly. She said she was supposed to use a gait belt, but she did not have one with her. She said Resident #1 could help assist with the transfer. (Resident #1 did not assist with the transfer during the observation.) She said if a resident was not transferred correctly then they could get hurt. <BR/>An interview on 02/03/23 at 11:52 AM with LVN B, revealed she observed the transfer with Resident #1 by the RA A. She said RA A did not do the transfer correctly and that she should have had a gait belt and possibly another person to transfer Resident #1. She said she could have hurt the resident. LVN B said she did not intervene because RA A was already in the middle of the transfer, and she was trying to reach the physician on the phone. <BR/>An interview on 02/03/23 at 3:55 PM with the DON revealed all residents required a gait belt for transfer if they were not able to transfer independently. <BR/>Review of the Facility Restorative Specialty Skill Competency Verification Checklist, dated 12/23/22, for RA A reflected competency in:<BR/> .12. Begins each transfer and ambulation activity with gait belt.<BR/>Review of the Facility Policy and Procedure, Use of Gait Belt, dated 2020, reflected:<BR/>Policy: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety .<BR/>1. Each nursing department employee will be given a gait belt during orientation.<BR/>2. All employees will receive education on the proper use of gait belt during orientation and annually.<BR/>3. It will be the responsibility of each employee to ensure they have it available for use at all times when at work .<BR/>5. Failure to use gait belt properly may result in termination.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 5 of 40 residents (Residents #3, #5, #8, #9, and #10) and one unit reviewed for a clean environment. <BR/>1. The facility failed to keep the Memory Care Unit was free of offensive odors.<BR/>2. The facility failed to ensure Residents #3, #5, #8, #9, and #10 rooms were kept in a sanitary and comfortable manner. <BR/>This failure could place the residents at risk of exposure to infectious material and decreased feelings of self-worth.<BR/>Findings included:<BR/>Observation on 02/27/25 at 10:00 AM revealed upon entry to the Memory Care Unit there was a urine odor throughout the unit. Two housekeepers were cleaning rooms on the unit. <BR/>Observation on 02/27/25 from 10:00 AM-10:30 AM Residents #3, #5, #8, #9, and #10 rooms had dead bugs, food particles, dirt, and debris at the head of the beds and between the bed and the wall. <BR/>Observation on 02/27/25 at 10:30 AM a third housekeeper and the Housekeeping Supervisor joined the other two housekeepers in cleaning the unit. <BR/>Interview on 02/27/25 at 12:00 PM with the Housekeeper revealed there were two housekeeprs assigned to the unit every day. He stated they were responsible for cleaning the high touch items like handrails, sweeping and mopping the floors of the resident's rooms, emptying the trash and cleaning the bathrooms. He stated they usually did not pull all the furniture and beds and clean behind them unless they have been told to deep clean a specific room. <BR/>Interview on 02/27/25 at 12:27 PM with the Housekeeping Supervisor revealed there were two housekeepers assigned to the Memory Care Unit every day and they were responsible for cleaning each room and the common areas. Each housekeeper was also to do a deep clean in one room each day. A deep clean meant moving all furniture, beds, et cetera and cleaning under and behind them. She stated the residents deserved a clean room to prevent insect infestation and for their dignity. She stated she was responsible for following up on the housekeepers and which room they had deep cleaned that day, but she did not track them. <BR/>Record review of the facility's Resident Rights policy, dated February 2021 reflected:<BR/> .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/> a. a dignified existence .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 5 of 40 residents (Residents #3, #5, #8, #9, and #10) reviewed for effective pest control. <BR/>The facility failed to ensure Residents #3, #5, #8, #9, and #10 rooms were free of pests.<BR/>These failures could place residents at risk of exposure to bugs and bug bites.<BR/>Findings included:<BR/>Observation on 02/27/25 from 10:00 AM-10:30 AM revealed Resident #5's bathroom had two live cockroaches. Residents # 3, #8, #9, and #10 had dead cockroaches and other bugs at the head of their beds between the bed and the wall. <BR/>Record review of the facility's Pest Control log revealed cockroaches had been reported every month since May 2024. Pest control had treated for cockroaches every month. The last visit was on 02/20/25. <BR/>Interview on 02/27/25 at 5:04 PM with the Director of Plant Operations revealed bugs in the facility was an on-going problem. He stated it was an older building with multiple means of entry for bugs. He stated their pest control company treated the whole facility and any rooms that were identified by staff or residents as having live bugs. The pest control company also sealed up any openings they discovered during their treatments. He stated the dead bugs seen in the resident rooms were most likely related to the treatment on 02/20/25. He stated the residents deserved to have a bug and rodent free facility for their overall health. He stated he did not know of a policy for pest control other than they were required to have a pest control program. <BR/>Record review of the facility's Resident Rights policy, dated February 2021, reflected:<BR/> .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/> a. a dignified existence .<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for transfers.<BR/>The facility failed to ensure Resident #1 was transferred using a gait belt.<BR/>This failure could place residents at risk of not receiving adequate supervision and assistive devices to prevent injury.<BR/>Findings included:<BR/>Review of Resident #1's MDS assessment, dated 12/20/22, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, lack of coordination, unspecified abnormalities of gait and mobility, difficulty in walking, and unsteadiness on feet. The resident was totally dependent on one staff for transfers. The resident's cognitive skills for daily decision making were severely impaired. <BR/>Review of the comprehensive care plan, dated 03/14/22, reflected Resident #1 was at risk for falls due to wandering, unsteady gait and poor balance. Facility interventions included anticipate and meet the resident's needs. <BR/>An observation on 02/03/23 at 11:45 AM with RA A revealed she was transferring Resident #1 from her wheelchair to another wheelchair. RA A reached under the arms of the resident, lifted her, and struggled to move the resident to another wheelchair. The resident was barely moving her feet to assist. No gait belt was used. RA A took the resident and weighed her on a wheelchair scale. RA A then transferred the resident back to her original wheelchair using the same method. The resident was pushed to the dining table. An interview was attempted with the resident but was not successful due to the resident's cognitive status. <BR/>An interview on 02/03/23 at 11:50 AM with RA A, she said she did not transfer Resident #1 correctly. She said she was supposed to use a gait belt, but she did not have one with her. She said Resident #1 could help assist with the transfer. (Resident #1 did not assist with the transfer during the observation.) She said if a resident was not transferred correctly then they could get hurt. <BR/>An interview on 02/03/23 at 11:52 AM with LVN B, revealed she observed the transfer with Resident #1 by the RA A. She said RA A did not do the transfer correctly and that she should have had a gait belt and possibly another person to transfer Resident #1. She said she could have hurt the resident. LVN B said she did not intervene because RA A was already in the middle of the transfer, and she was trying to reach the physician on the phone. <BR/>An interview on 02/03/23 at 3:55 PM with the DON revealed all residents required a gait belt for transfer if they were not able to transfer independently. <BR/>Review of the Facility Restorative Specialty Skill Competency Verification Checklist, dated 12/23/22, for RA A reflected competency in:<BR/> .12. Begins each transfer and ambulation activity with gait belt.<BR/>Review of the Facility Policy and Procedure, Use of Gait Belt, dated 2020, reflected:<BR/>Policy: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety .<BR/>1. Each nursing department employee will be given a gait belt during orientation.<BR/>2. All employees will receive education on the proper use of gait belt during orientation and annually.<BR/>3. It will be the responsibility of each employee to ensure they have it available for use at all times when at work .<BR/>5. Failure to use gait belt properly may result in termination.

**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 for one (Resident #2) of one resident with a midline catheter for intravenous fluids. <BR/>The facility failed to change Resident #2's Midline Catheter's (a peripherally inserted catheter, a midline catheter is inserted in a larger vein than those used for standard I.V. therapy) dressing every 7 days per facility policy.<BR/>This failure could affect residents by placing them at risk for infections and cross-contamination.<BR/>Findings included:<BR/>Review of Resident #2's Minimum Data Set assessment dated , 01/06/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, and malnutrition. Her cognitive status was severely impaired. <BR/>Review of Resident #2's Order Summary Report dated January 2023 reflected:<BR/>01/04/23 May insert Midline for IVF. <BR/>There were no orders related to dressing changes for the midline catheter. <BR/>An observation on 02/03/23 at 12:35 PM revealed Resident #2 was asleep in bed. Her right upper arm had a midline catheter with a dressing dated 01/17/23. The dressing was clean, dry, and intact. <BR/>An interview on 02/03/23 at 12:40 PM with the ADON revealed Resident #2 had a midline catheter in her right upper arm for administration of weekly intravenous vitamins. The ADON said the date on the dressing was 01/17/22 and she thought the dressing was supposed to be changed weekly . She said she did not know why the dressing had not been changed.<BR/>An interview on 02/03/23 at 3:55 PM with the DON revealed Resident #2 had a midline catheter and the dressing was supposed to be changed every 7 days. She said she did not know why the dressing had not been changed since 01/17/23 or why she did not have orders to change the midline dressing. She said going forward, she and the ADON would be checking for new orders every morning. <BR/>Record review of the facility's policy for PICC Dressing Change, dated 2020, reflected:<BR/>Policy: It is the policy of this facility to change peripherally inserted central catheter dressings weekly or if soiled, in a manner to decrease potential for infection and/or cross contamination. Physician's orders will specify type of dressing and frequency of changes.

Based on observation, interview, and record review, the facility failed to equip rooms to assure full visual privacy for each resident for 4 of 20 residents (Residents #1, #2, #3, and #4) reviewed for privacy curtains.<BR/>The facility failed to ensure Residents #1, #2, #3, and #4 had full visual privacy. <BR/>This failure could place residents at risk of exposure while care was being provided.<BR/>Findings included:<BR/>Observation on 02/27/25 from 10:00 AM-10:30 AM of the Memory Care Unit revealed Resident #1's room had a privacy curtain that would not extend around the bed due to damage of the track. Residents #2, #3, and #4 had no privacy curtain at all. Residents were not in their rooms, staff kept residents in the dining area for observation. Residents were unable to give interviews.<BR/>Interview on 02/27/25 at 12:27 AM with the Housekeeping Supervisor revealed her Floor Tech was responsible for changing out privacy curtains when they were soiled or damaged. If the track was damaged, then maintenance would have to fix the track. She stated the reason the curtains were needed was to provide each resident with privacy and dignity. She stated the Floor Tech was on leave currently. <BR/>Interview on 02/27/25 at 5:04 PM with the Director of Plant Operations revealed curtains were not usually placed on his maintenace requests. He states staff would usually just notify him verbally when a curtain needed attention. He stated he did not know of any curtains that currently needed attention. <BR/>Record review of the facility's Resident Rights policy, dated February 2021, reflected: <BR/> .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/> a. a dignified existence;<BR/> .t. privacy and confidentiality .

Based on observation, interview, and record review, the facility failed to equip rooms to assure full visual privacy for each resident for 4 of 20 residents (Residents #1, #2, #3, and #4) reviewed for privacy curtains.<BR/>The facility failed to ensure Residents #1, #2, #3, and #4 had full visual privacy. <BR/>This failure could place residents at risk of exposure while care was being provided.<BR/>Findings included:<BR/>Observation on 02/27/25 from 10:00 AM-10:30 AM of the Memory Care Unit revealed Resident #1's room had a privacy curtain that would not extend around the bed due to damage of the track. Residents #2, #3, and #4 had no privacy curtain at all. Residents were not in their rooms, staff kept residents in the dining area for observation. Residents were unable to give interviews.<BR/>Interview on 02/27/25 at 12:27 AM with the Housekeeping Supervisor revealed her Floor Tech was responsible for changing out privacy curtains when they were soiled or damaged. If the track was damaged, then maintenance would have to fix the track. She stated the reason the curtains were needed was to provide each resident with privacy and dignity. She stated the Floor Tech was on leave currently. <BR/>Interview on 02/27/25 at 5:04 PM with the Director of Plant Operations revealed curtains were not usually placed on his maintenace requests. He states staff would usually just notify him verbally when a curtain needed attention. He stated he did not know of any curtains that currently needed attention. <BR/>Record review of the facility's Resident Rights policy, dated February 2021, reflected: <BR/> .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/> a. a dignified existence;<BR/> .t. privacy and confidentiality .

Based on observation, interview, and record review, the facility failed to ensure the menus were followed for 1 (the lunch meal on 07/09/25) of 1 meal reviewed for food and nutrition services.The facility did not serve the posted lunch menu of cornbread and seasoned okra. This failure could affect all residents in the facility, who eat from the kitchen, by placing them at risk of not knowing what was going to be served for that meal. Findings included:Observation on 07/09/25 at 10:15 AM of the menu posted in the dining room reflected for 07/09/25 the following: Sausage Jambalaya, Seasoned Okra, Cornbread, and a Brownie.Review of the facility's Week-At-A-Glance 2025 Week 3 for Wednesday reflected the following: Sausage Jambalaya, Seasoned Okra, Cornbread, Double Chocolate Brownie.Interview on 07/09/25 at 10:40 AM with Resident #1 revealed when he received his food, he was not sure what would be served because the menu did not match what was served to him often. Interview on 07/09/25 at 10:45 AM with Resident #2 revealed when she received her food, she was not sure what would be served because the menu did not match what was served to her. Observation and interview on 07/09/25 at 11:00 AM with the DM revealed the steamtables in the kitchen had the following food items which would be served for lunch: sausage jambalaya, sliced bread, and capri vegetables which included green beans, carrots, squash, and zucchini. Interview on 07/09/25 at 12:30 PM with the DM revealed she always tried to follow the menu and serve what was on it for the residents. The DM said for today's (07/09/25) lunch meal, she did substitute the cornbread with sliced bread and okra with capri vegetables. The DM said she had to do that because the cornbread box that was delivered appeared as if it was open so it was not usable and it was not replaced in time to serve it with the meal. The DM said as for the okra, it was used for another meal earlier in the week and she did not have enough to serve with lunch today (07/09/25). The DM said the if the kitchen did not serve what was posted on the menu, it could be confusing for residents because it did not match. The DM said the cook posted the menu, but if there were changes that needed to be made, she usually included that in the posted menu so residents knew what they would be served that day. The DM said she expected the menu to match what the residents were being served that day. The DM said all staff had been trained to make sure that the posted menu matched what was being served for that meal that day.Review of the facility's Menus policy, dated May 2014, reflected: .6. Menus are served as written, unless changed in response to preference, unavailability of an item, or a special meal.8. Menus are posted in the nutrition services department, dining rooms and resident/patient care areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 1 of 5 (Resident #80) residents reviewed for MDS assessments. <BR/>The facility failed to complete Resident #80's Quarterly MDS Assessment within three months of their most recent comprehensive assessment. <BR/>This failure could lead to residents not receiving care required for their individualized needs. <BR/>Findings included:<BR/>Record review of Resident #80's admission Record dated 08/29/2024 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. <BR/>Review of Resident #80's Significant Change in Status MDS assessment dated [DATE] reflected the resident had moderate cognitive impairment with a BIMS score of 11. Her diagnoses included diabetes (a chronic disease that affects how the body uses insulin and glucose), hypothyroidism (the thyroid gland does not make enough thyroid hormone), and dysphagia (difficulty swallowing that can be caused by various conditions that affect the throat or esophagus). <BR/>Review of Resident #80's electronic health record reflected there was not a more recent MDS Assessment submitted since 04/25/2024. <BR/>Interview on 08/28/24 at 2:25 PM the MDS Coordinator revealed she was responsible for completing MDS assessments. The MDS Coordinator said she thought Resident #80 had discharged from the facility and that her MDS was not showing it was due on her end. The MDS Coordinator said a resident's MDS asessment was due every three months from the date of the last completed MDS. The MDS Coordinator said Resident #80's MDS assessment should have been done by 07/25/2024. The MDS Coordinator said the purpose of the MDS assessment was that it told Medicaid and Medicare services what level of care the resident received and kept track of if they had a significant decline or listed what was going on with them in detail. The MDS Coordinator said there was a consultant that normally told her if an assessment was late, or he would bring things to her attention related to MDS assessments. <BR/>Follow-up interview on 08/28/2024 at 2:39 PM with the MDS Coordinator revealed Resident #80's MDS assessment was on the schedule but was missed.<BR/>Interview on 08/29/2024 at 3:23 PM, the DON revealed Resident #80's MDS assessment was missed and she was not sure why. The DON said it was a regulation that a resident's MDS assessment was supposed to be done every 92 days. <BR/>Interview on 08/29/2024 at 4:14 PM, the Administrator revealed the facility did not have a policy that addressed MDS assessments.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's one and only kitchen reviewed for food and nutrition services. The facility failed to ensure the four steamtable compartments in the kitchen were clean and free of debris before food was placed in them.This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included:Observation on 07/09/25 at 9:10 AM of the facility's only kitchen revealed the four steamtable compartments had food and debris floating in them.Observation on 07/09/25 at 11:00 AM of the facility's only kitchen revealed the four steamtable compartments had food and debris floating in them. The steamtables had the following: the first one had a tray of sausage jambalaya; the second one had capri vegetables and fortified mashed potatoes; the third one had mechanical soft sausage jambalaya and brown gravy; the fourth one had pureed vegetables, pureed bread, Salisbury steaks, and pureed jambalaya.Interview on 07/09/25 at 11:15 AM with the DM revealed she saw the food and debris in the steamtable compartments and mentioned that they would be cleaned after the lunch service had ended. Interview on 07/09/25 at 12:30 PM with the DM revealed normally the steamtable compartments were cleaned at the end of each shift, which would have been after lunch and after dinner. The DM said usually it was the cook who cleaned the steamtable compartments. The DM said the steamtable compartments did not get cleaned between breakfast and lunch services. The DM said she normally checked the steamtable compartments daily to ensure they were cleaned as they were supposed to be. The DM said she saw the food and debris floating in the steamtable compartments before the lunch service earlier, but the lunch meal was already on the line waiting to be served. The DM said the steamtable compartments should be cleaned before food was placed on it to be served. The DM said if the steamtable compartments were not cleaned, bacteria could get in the food. The DM said all staff had been trained to ensure the steamtable compartments were cleaned before service and that was her expectation. Review of the facility's Environment policy, dated May 2014, reflected: 1. The Food Service Director will insure [sic] that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces .

Based on observation, interview, and record review the facility failed to provide a private meeting space for the residents' monthly council meetings for 7 of 7 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.Findings included:During a confidential resident group interview with seven residents on 09/17/25 at 1:45 PM, the facility arranged for the meeting to be held in an open dining room located next to the facility kitchen and main entrance hall. There were no doors that could be closed to ensure the residents' privacy during the meeting. There were no signs indicating a resident council meeting was being held. During the meeting, staff were observed walking through the main hall while the meeting was in progress and kitchen staff stepping out of the kitchen to grab the tray carts. The seven residents in attendance all reported that their monthly resident council meetings were held in this open dining room area. The residents stated the monthly meetings were being held in the conference room, but the conference room was too cold for them. Interview on 09/18/25 at 2:21 PM with the Activity Assistant revealed resident council meetings were being held in the conference room, but residents began to complain about the room being cold. She stated the resident council meetings had been held in the dining room since June 2025. The Activity Assistant stated she would post signs or use the dry eraser board to notify facility staff of an active resident council meeting being held. She stated she was not aware of resident council meetings needed to be in a private setting. The Activity Assistant stated there was no risk to the residents if they were not provided with a private setting. Interview on 09/18/25 at 4:31 PM with the Administrator revealed resident council meetings had been held in the dining room area. She stated since the Activity Director left around May or June 2025 the resident council meetings had been in the dining room. The Administrator stated she was aware of the requirement of providing residents with a private area; however, she was not sure why it was not done. She stated a potential risk would be residents not having privacy to talk. Record review of the resident council minutes for May 2025 through August 2025 reflected there were no documented requests for a private meeting area. Record review of the facility's current, undated Statement of Resident Rights the following: .privacy, including privacy during visits and telephone calls. Record review of the facility Activity Programs, revised June 2018, reflected the following: Activity programs are designed to meet the interests of and support the physical, mental, and psychological well-being of each resident 14. Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. The facility's policy did not address resident council meetings.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's one and only kitchen reviewed for food and nutrition services. The facility failed to ensure the four steamtable compartments in the kitchen were clean and free of debris before food was placed in them.This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included:Observation on 07/09/25 at 9:10 AM of the facility's only kitchen revealed the four steamtable compartments had food and debris floating in them.Observation on 07/09/25 at 11:00 AM of the facility's only kitchen revealed the four steamtable compartments had food and debris floating in them. The steamtables had the following: the first one had a tray of sausage jambalaya; the second one had capri vegetables and fortified mashed potatoes; the third one had mechanical soft sausage jambalaya and brown gravy; the fourth one had pureed vegetables, pureed bread, Salisbury steaks, and pureed jambalaya.Interview on 07/09/25 at 11:15 AM with the DM revealed she saw the food and debris in the steamtable compartments and mentioned that they would be cleaned after the lunch service had ended. Interview on 07/09/25 at 12:30 PM with the DM revealed normally the steamtable compartments were cleaned at the end of each shift, which would have been after lunch and after dinner. The DM said usually it was the cook who cleaned the steamtable compartments. The DM said the steamtable compartments did not get cleaned between breakfast and lunch services. The DM said she normally checked the steamtable compartments daily to ensure they were cleaned as they were supposed to be. The DM said she saw the food and debris floating in the steamtable compartments before the lunch service earlier, but the lunch meal was already on the line waiting to be served. The DM said the steamtable compartments should be cleaned before food was placed on it to be served. The DM said if the steamtable compartments were not cleaned, bacteria could get in the food. The DM said all staff had been trained to ensure the steamtable compartments were cleaned before service and that was her expectation. Review of the facility's Environment policy, dated May 2014, reflected: 1. The Food Service Director will insure [sic] that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces .

Based on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 5 of 30 days (05/25/2024, 05/26/2024, 06/01/2024, 06/08/2024, and 06/15/2024) reviewed during a look back period from 05/25/2024 to 08/25/2024 for weekend coverage. <BR/>The facility failed to have RN coverage in the facility for eight consecutive hours on 05/25/2024, 05/26/2024, 06/01/2024, 06/08/2024, and 06/15/2024.<BR/>This failure could place residents at risk for not having their nursing and medical needs met and improper care.<BR/>Findings included: <BR/>Review of the facility's Time Detail Reports from 05/25/2024 to 08/25/2024 reflected the following:<BR/>- <BR/>RN C worked from 6:00 PM to 10:00 PM (4 total hours), clocked out for lunch, then resumed work from 10:30 PM to 12:00 AM (1.5 total hours) on 05/25/2024. RN E worked from 6:00 PM to 11:00 PM, clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 05/25/2024. RN D worked from 6:00 PM to 11:00 PM, clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 05/25/2024. <BR/>- <BR/>RN B worked from 12:00 AM to 6:30 AM (6.5 total hours) and 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 05/26/2024. RN D worked from 12:00 AM to 6:45 AM (6.75 total hours) and 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 05/26/2024.<BR/>- <BR/>RN B worked from 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 06/01/2024.<BR/>- <BR/>RN C worked from 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 06/08/2024. RN D worked from 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 06/08/2024. <BR/>- <BR/>RN C worked from 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 06/15/2024. RN B worked from 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 06/15/2024. RN F worked from 9:06 AM to 12:27 PM (3.5 total hours) on 06/15/2024.<BR/>Interview on 08/29/2024 at 3:23 PM, the DON revealed the RNs usually doubled up on the weekend shifts. The DON said she expected the RN to work 8 consecutive hours on the weekends. The DON said the purpose of this was for coverage reasons so there was always someone in the building to oversee everything. The DON said a lot of things can happen if an RN was not in the building working at least 8 consecutive hours each day. <BR/>Interview on 08/29/2024 at 4:14 PM, the Administrator revealed the facility did not have a policy that addressed RN coverage.

Based on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 5 of 30 days (05/25/2024, 05/26/2024, 06/01/2024, 06/08/2024, and 06/15/2024) reviewed during a look back period from 05/25/2024 to 08/25/2024 for weekend coverage. <BR/>The facility failed to have RN coverage in the facility for eight consecutive hours on 05/25/2024, 05/26/2024, 06/01/2024, 06/08/2024, and 06/15/2024.<BR/>This failure could place residents at risk for not having their nursing and medical needs met and improper care.<BR/>Findings included: <BR/>Review of the facility's Time Detail Reports from 05/25/2024 to 08/25/2024 reflected the following:<BR/>- <BR/>RN C worked from 6:00 PM to 10:00 PM (4 total hours), clocked out for lunch, then resumed work from 10:30 PM to 12:00 AM (1.5 total hours) on 05/25/2024. RN E worked from 6:00 PM to 11:00 PM, clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 05/25/2024. RN D worked from 6:00 PM to 11:00 PM, clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 05/25/2024. <BR/>- <BR/>RN B worked from 12:00 AM to 6:30 AM (6.5 total hours) and 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 05/26/2024. RN D worked from 12:00 AM to 6:45 AM (6.75 total hours) and 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 05/26/2024.<BR/>- <BR/>RN B worked from 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 06/01/2024.<BR/>- <BR/>RN C worked from 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 06/08/2024. RN D worked from 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 06/08/2024. <BR/>- <BR/>RN C worked from 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 06/15/2024. RN B worked from 6:00 PM to 11:00 PM (5 total hours), clocked out for lunch, then resumed work from 11:30 PM to 12:00 AM (.5 total hours) on 06/15/2024. RN F worked from 9:06 AM to 12:27 PM (3.5 total hours) on 06/15/2024.<BR/>Interview on 08/29/2024 at 3:23 PM, the DON revealed the RNs usually doubled up on the weekend shifts. The DON said she expected the RN to work 8 consecutive hours on the weekends. The DON said the purpose of this was for coverage reasons so there was always someone in the building to oversee everything. The DON said a lot of things can happen if an RN was not in the building working at least 8 consecutive hours each day. <BR/>Interview on 08/29/2024 at 4:14 PM, the Administrator revealed the facility did not have a policy that addressed RN coverage.