Rosenberg Health & Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (CR#1) of 9 residents reviewed for professional standards. <BR/>The facility failed to follow physician orders postponing the resident's procedure on two occasions.<BR/>This failure could place residents at risk of inadequate care, decline in their health and or hospitalization.<BR/>The findings included: <BR/>Record review of CR#1's admission record dated October 5, 2023, revealed a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included acute kidney failure, cognitive communication, Dysphagia (medical term for having trouble swallowing), Hypertension (elevated blood pressure), malignant neoplasm of prostate (prostate cancer), Rhabdomyolysis (a breakdown of skeletal muscle due to direct or indirect muscle injury), Transient cerebral ischemic attack (is a temporary blockage of blood flow to the brain). The facility was unable to provide a care plan and a MDS for CR#1. During an interview on 10/06/2023 at 10:21a.m. ADM said she provided the surveyor with everything she could get from the computer for CR#1. <BR/>Record review of CR#1's Transfer/Discharge report dated October 5, 2023, revealed a CR#1 was transferred to another facility on September 27, 2023, at 3:00 p.m. <BR/>Record review of CR#1's active physician's order revealed in part: . to start the colon prep the day before the procedure on 9/11/2023. <BR/>Record review of CR#1's active physician's order revealed in part: .dated 9/12/2023 read No Solid Foods Only Clear Liquids from The Time You Wake Up, Stop All Liquids by Midnight.<BR/>Record review of CR#1's active physician order revealed in part: . dated 9/25/2023 read nothing by mouth after midnight, Colonoscopy : Clear Liquids only. No solid foods All Day, Failure to follow these guidelines may delay/cancel your procedure.<BR/>Record review of CR#1's Communication form from the facility Dietary department revealed in part: . dated 9/7/2023 at 1:45 p.m. Clear Liquid Diet on Mon 9/11/2023 signed by the dietary manager. <BR/>Record review of CR#1's Communication form from the facility dietary department revealed in part: . Clear Liquid Diet dated 9/24/2024 Sunday signed by the dietary manager. <BR/>During an interview on 10/05/2023 at 2:36 p.m., the CNA said on 9/11/2023 CR#1 was given clear liquids and was on a clear diet. The CNA said on 9/12/2023 she saw no orders for CR#1 therefore CR#1 was given a tray. The CNA said the date pertaining to 9/25/2023 the CNA received a text message from the LVN. The CNA said she saw the text message late from the LVN and CR#1 had eaten 25 percent of his food. <BR/>During an interview on 10/05/2023 at 2:47 p.m., the Driver said on 9/12/2023 CR#1 was eating candy and he had eaten his breakfast. She said on 9/24/2023 she called RN, Supervisor and asked about CR#1 and the RN, Supervisor replied saying she will start CR#1's prep at 6:00 p.m. She said on 9/25/2023 CR#1 had all types of snacks by his bedside and CR#1 did not drink all his fluid (GoLytely, a laxative solution to clean your colon before your colonoscopy). <BR/>During an interview on 10/05/2023 at 3:02 p.m., the LVN said on 9/11/2023 CR#1 was given clear liquids for CR#1 appointment dated 9/12/2023. The LVN said on 9/12/2023 CR#1 was not to eat anything. The LVN said CR#1 completed the prep for 6:00 p.m. The LVN said she gave CR#1 everything he was supposed to have but he kept having multiple bowel movements. The LVN said the driver took CR#1 to his appointment and returned saying CR#1 appointment was cancelled because the facility did not follow the physician orders dated 9/12/2023. The LVN said the appointment was set for 9/25/2023, she did not put NPO for Monday 9/25/2023 therefore CR#1 was given a breakfast tray. The LVN said she texted the CNA on 9/25/2023 at 9:19 a.m. telling her to make sure CR#1 did not eat anything. The LVN said the CNA returned her text message on 9/25/2023 at 9:27 a.m. saying she just read the text message and that CR#1 had eaten 25 percent of his food. The LVN said she was written up for not putting NPO on the communication form with the correct dates. <BR/>During an interview on 10/05/2023 at 3:56 p.m., the [NAME] said the nurses oversee the physician orders. The DON said she expects the nurses to follow the physician orders. She said by the nurses not following the physician orders could place the residents at risk of deteriorating and having a decline in their health. <BR/>During an interview on 10/06/2023 at 10:21 a.m., the ADM said if the nurses do not follow the physician orders it was a high risk to the residents. The ADM said it can cause the residents to decline in their health, it can cause a significant change in their condition, or it could cause the resident to be sent out to ER. <BR/>Record review of the LVN's Education In-Service revealed in part: . on 9/26/2023 Ensure the correct order and date is written on dietary communication form.<BR/>Record review of the RN Nurse Supervisor Disciplinary Memorandum revealed in part: . on 9/26/2023 not following physicians' orders per resident complaint. <BR/>Record review of the facility's policy and procedures for Following Physician Orders, dated 9/28/2021 read in part: . 2a. Document the order by entering the order and the time, date, and signature on the physician order sheet. 2b. Follow the facility procedures for verbal or telephone orders including noting the order .3c. Carry out and implement physician orders. 3d. Document resident response to physician order in the medical record as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 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 with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #1) reviewed for care plans. <BR/>The facility failed to develop and implement a comprehensive care plan including measurable objectives and timeframes to address Resident #1's medical, nursing, and mental and psychosocial needs related to his known history of signing himself out of the facility in a motorized wheelchair that did not belong to him, ambulating to nearby stores to drink alcohol until intoxicated/vomiting/lethargic and smoking marijuana in the surrounding community. As a result, the resident was ordered to be sent to the local ER on several occasions for treatment.<BR/>An IJ was identified on 05/29/2025. The IJ template was provided to the facility on [DATE] at 1:20 p.m. While the IJ was removed on 05/31/2025, the facility remained out of compliance at a scope of pattern with severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. <BR/>This failure placed residents with substance abuse issues at risk of sustaining serious injuries from possible accidents/incidents and an exacerbation/deterioration of health and wellness. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet dated 05/28/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. He was diagnosed with end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and excess fluid from the body), schizoaffective disorder (a chronic mental illness that combines systems of both schizophrenia and mood disorder), gastro-esophageal reflux (a chronic condition where stomach contents regularly flow back up into the esophagus), history of falling, difficulty walking, diabetes mellitus type II (chronic disease where the body either does not produce enough insulin or cannot properly use the insulin it produces) with hypoglycemia (when blood glucose levels drop too low), essential hypertension (persistently high blood pressure with no identifiable cause), chronic ischemic heart disease (long-term condition where the heart's blood supply is reduced due to a mismatch between oxygen supply and demand), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms in COPD patients), unspecified cirrhosis of liver (a type of chronic, progressive liver disease where healthy liver cells are replaced by scar tissue), acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the cystic duct), dependence on renal dialysis (treatment that cleans the blood when kidneys are unable to do so), and shortness of breath. Resident #1 was his own responsible party. <BR/>Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); Resident #1 exhibited behaviors related to rejection of care; Resident #1 used a manual wheelchair for mobility; Resident #1 was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers and required supervision or touching assistance for showers/bathing; Resident #1 was always continent of bowel and bladder; and Resident #1 was prescribed anticoagulant and antipsychotic medication. <BR/>Record review of Resident #1's care plan, revised on 05/25/2025 revealed the following care areas:<BR/>* <BR/>Resident has impaired visual function and is at risk for falls, injury, and a decline in functional ability. Goals included: Resident will maintain optimal quality of life and not experience a decline in ADL functional abilities, or an injury related to vision loss. Interventions included: Arrange consultation with eye care practitioner. Assist to ensure glasses are labeled and within reach.<BR/>* <BR/>Resistant to Care: Resident is resistant to care and at risk for injury, a decline in functional abilities, and not having his needs met. [He] refuses to take his scheduled medications and refuses to go to his scheduled dialysis days. Goal included: Resident will not be a danger to self or others. Interventions included: If refusals continue, notify MD and family, document in resident records. Give a clear explanation of complications of not having his dialysis. Encourage as much participation as possible. Provide resident with opportunities to make decisions about his treatment. <BR/>* <BR/>Falls: Patient is a fall risk due to weakness of both lower extremities. Resident has the potential for falls related to unsteadiness on feet, abnormalities of gait and mobility, unspecified lack of coordination, and generalized weakness. Fall: 01/04/2025, 02/01/2025. Goal included: Resident will not sustain a fall related injury by utilizing fall precautions. Interventions included: Encourage resident not to transfer without assistance. Anticipate and meet the resident's needs. Educate the resident about safety reminders and what to do if a fall occurs. Encourage socialization and activity attendance as tolerated. <BR/>* <BR/>Therapeutic Leave: Resident is cognitively able to sign out of the facility and make their own informed decisions while they are out. On 04/10/2025 while on therapeutic leave, resident made the decision to consume alcoholic beverages. Goals included: The resident will follow facility policy for out on pass. The resident will be safe and comfortable while out on pass. Interventions included: Educate the resident/family/caregivers about the potential risks associated with signing out on pass. Educate resident/family/caregivers on the facility's policy for therapeutic leave/out on pass. Resident is reminded of his health issues and treatment regimens and the recommendations to avoid the use of alcoholic beverages.<BR/>Further review of Resident #1's care plan revealed no care areas, goals, or interventions to address his substance abuse concerns. <BR/>Record review of Resident #1's, Elopement/Wandering Risk Assessment dated 05/24/2025, completed by LVN A revealed, A. Preliminary Data. 1. Is the resident physically able to leave the facility on their own? Yes. Continue assessment. B. Evaluation. Cognition: 1. Is the resident disoriented to place or intermittently confused? Yes . Further review of the assessment revealed Resident #1 scored a 1, which indicated low/no elopement risk. <BR/>Record review of Resident #1's nursing progress notes for April 2025 and May 2025 revealed:<BR/>* <BR/>On 04/02/2025, at 4:10 p.m., SW B wrote, Resident was educated with Administrator, ADON, DON, and SW on the policies for Therapeutic Leave and the expectations for the resident when he is on Therapeutic Leave. Resident verbalized understanding.<BR/>* <BR/>On 04/11/2025, at 12:10 a.m., RN E wrote, Resident came back on pass to the facility with alcohol intoxication, vitals and assessment done. All within normal baseline. NP notified. New order to transfer resident to the hospital for further evaluation but resident refused. Resident was monitored through the shift, comfort care provided to resident satisfaction.<BR/>* <BR/>On 04/11/2025, at 11:50 a.m., ADON F wrote, Late Entry: 04/10/2025 at 11:00 p.m. Upon resident's return to the facility, resident arrived propelling himself in his motorized wheelchair. Resident had a slurred speech, he was drooling, smiling, and laughing, slow to respond to questions, and lethargic. Resident said he was tired and wanted to lay down and go to sleep and was assisted back to his room and was unable to stand to assist with his transfer to his bed, so he was transferred to bed with two people assist. In speaking with the resident, he said that he had ingested alcohol, specifically three 40 oz bottles of [brand name of beer] and he would not say if he had ingested any other substances or drinks. Upon assessment by unit nurse, there was no evidence of trauma or physical injuries noted, no indications of any falls or any other incidents at the time of his return.<BR/>* <BR/>On 04/12/2025, at 7:17 p.m., LVN A wrote, Police officer called facility and said resident vomited and may have been drinking with his friend and they have called 911 for him to go to the ER and have him evaluated. They then came to the facility, and I gave him a face sheet and medication lists. I accompanied the officer to EMS parked on the street near the facility and found the patient inside the ambulance being attended to by two paramedics with patient leaning to his left side. I placed a call to the Administrator and ADON. Resident apparently signed out at about 12 noon and left the facility with another resident. They apparently went to a nearby store and purchased drinks. He drank until he vomited on himself and became very weak. I asked the paramedics where they were taking him, and they informed me that they were taking him to [a local hospital] ER. NP and RP notified.<BR/>* <BR/>On 04/14/2025, at 4:38 p.m., ADON F wrote, Resident was found to be in possession of a cigarette lighter. The resident was educated by the Administrator on the smoking policy and the lighter was placed in the smoker's box for the resident to have access to only when on smoke breaks. The Administrator educated the resident on use of another resident's electric wheelchair and encouraged to use his own, the resident verbalized understanding.<BR/>* <BR/>On 04/15/2025, at 2:11 p.m., RN H wrote, Resident signed himself out and came back vomiting. Happened a couple of times. NP notified. Lab work ordered. New order to transfer to ER for further evaluation.<BR/>* <BR/>On 04/16/2025, at 5:23 p.m., ADON G wrote, Final lab results received on the drug and alcohol screening, labs placed in NP binder for review . resident remains in the hospital at this time.<BR/>* <BR/>On 04/23/2025, at 9:46 p.m., RN E wrote, Resident, who went out on pass, returned to the facility alert but disoriented, drooling from alcohol intoxication also had multiple emesis (vomiting). Resident vitals and assessment done all vital signs were within normal baseline. NP contacted via telehealth/virtual service. New order for Ondansetron 4 MG 1 tablet PO q 6hours as needed .<BR/>* <BR/>On 05/01/2025, at 11:59 a.m., the SW wrote, The Social Worker and the Administrator witnessed [Resident #1] taking a power wheelchair without the permission of the resident who owns the power wheelchair. Resident was educated that he cannot take the belongings of other residents while they are out of the facility. Resident was also educated on the importance of not using someone else's wheelchair and the risks that can occur .<BR/>* <BR/>On 05/04/2025, at 4:41 p.m., RN H wrote, Resident exchanged wheelchair with his former roommate and resident was educated that it was not safe to do so, resident verbalized understanding.<BR/>Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/10/2025 at 11:17 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Complaint: Altered Mental Status . Per nurse, patient went out on pass and returned to facility lethargic, drooling from mouth and vomited once one hour ago. Per nurse, patient only knows his name, does not know where he is, and does not know the month, year. States at baseline patient is alert and oriented x 3 (a term that describes a patient's level of consciousness and cognitive function. Patient aware of person, place, and time). Per nurse, patient admitted to drinking 3 bottles of [brand of beer]. Per nurse, patient refused dialysis today and states patient did not go to dialysis yesterday . Patient seen with nurse . Physical Exam: Exam findings per nurse and video observation . Orders: Transfer to ER via 911: AMS/ESRD - missed HD/vomiting/possible alcohol intoxication . <BR/>Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/23/2025 at 10:02 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Chief Complaint: GI: Vomiting . Nurse notified clinician that the [AGE] year-old-male patient with history of ESRD on dialysis, Schizophrenia, falls, HTN, DM2, went out of the facility for an hour and came back intoxicated. The nurse stated this is a regular occurrence for him. He did have an episode of vomiting. Denies drinking alcohol. Will monitor him for now .<BR/>Record review of Resident #1's Lab Results Report collected on 04/11/2025 and reported on 04/16/2025 revealed Resident #1 was positive for THC (Cannabis).<BR/>Observation and interview with Resident #1 on 05/28/2025, at 2:30 p.m. revealed he was in his bed with his eyes closed. Resident #1 opened his eyes and was able to provide his name. Resident #1 stated he lived in the facility a couple of months and living there was alright. He said he went to dialysis. He said he fell out of his wheelchair about six months ago (he did not say why). Resident #1 did not answer questions related to drinking alcohol or taking drugs while outside the facility on pass. He closed his eyes and appeared to be asleep although he responded to questions unrelated to drinking or smoking. <BR/>In an interview with a random resident on 05/28/2025, at 1:45 p.m., they stated Resident #1 had a known history of taking his former roommate's motorized wheelchair without permission to sign himself out of the facility and drink at nearby stores. The resident stated Resident #1 frequently drank alcohol until he was intoxicated and smoked marijuana in the community around the facility. The resident said one time, Resident #1 was swerving (change or cause to change direction abruptly) all over the sidewalk on his way back to the facility after drinking and fell out of the motorized wheelchair onto the sidewalk. The resident stated the night nurse had to go and find Resident #1 on the sidewalk. <BR/>In an interview with the SW on 05/28/2025, at 3:24 p.m., she stated Resident #1 was capable of making his own decisions, but he just did not make the right decisions. She said Resident #1 went out on pass and did things he should not do. She said Resident #1 was vomiting once due to intoxication. She said the facility staff could not tell Resident #1 what he could and could not do outside of the facility, and they could only educate him. She said Resident #1 knew what he was doing. She said Resident #1 was his own RP and he did not have any family. She said to her knowledge, Resident #1 only went out twice and got drunk, but she was not there on weekends. She said she was not sure Resident #1's behaviors were addressed on his care plan, but they should have been so all staff are aware of any interventions. She stated she was not responsible for updating resident care plans. She stated she reviewed chart notes and assessed Resident #1's cognition to see if he could make his own decisions. She said Resident #1's BIMS score was high. She said possible negative outcomes of Resident #1 leaving the facility and getting drunk were that he could die, get injured, and go to the hospital.<BR/>In an interview with the Administrator on 05/28/2025, at 4:32 p.m., he stated the residents had rights. He said Resident #1's BIMS score was 15, but he did not make proper decisions. He said the facility staff had to make sure they did not infringe on the residents' rights. He said Resident #1 signed himself out and returned intoxicated between five and seven times. He said he had undocumented conversations with Resident #1 about how unsafe it was for him to leave the facility and get drunk. He said the conversations were not documented because he did not go into the facility's computer system to write progress notes. He said Resident #1 was still capable of wheeling himself down the road to the store in his own manual wheelchair. He said the residents previously went to the gas station at the end of the street (the residents still had to cross a busy two-lanes road), but the store staff said they could not go there anymore. He said now, the residents go down to a store further down the road. He said he did not know if Resident #1's behaviors were care planned, but they should have been. <BR/>In an interview with MDS Nurse C on 05/29/2025, at 12:25 p.m., she stated her duties included completing assessments and reviewing/updating resident care plans. She said she was responsible for residents whose last names began with A - K, so she did not update Resident #1's care plan. She said another MDS nurse who worked part-time was responsible for updating Resident #1's care plan. She said the MDS nurses reviewed and updated care plans every three months when they did quarterly MDS assessments. She said she was aware of Resident #1's behaviors related to smoking and drinking, and those behaviors should be a part of his care plan if the incidents happened. She said it was important to address those issues in Resident #1's care plan because if anything happened, they had the information in the care plan to show they were not giving him what he went outside to get (drugs and alcohol). She said negative outcomes of Resident #1's behaviors were possible if the facility did not intervene. She said Resident #1 could have serious health issues if the facility did not intervene. She said a resident's care plan should address all their behaviors. <BR/>In a telephone interview with Resident #1's physician on 05/30/2025, at 10:00 a.m., he stated he was familiar with Resident #1, and he was aware the resident frequently went out on pass to drink and smoke. He said Resident #1 denied drinking and smoking, but he had a history of noncompliance with dialysis and medications. He said Resident #1 was alert and oriented to be able to sign himself out. He said Resident #1 had recently been admitted to the hospital a lot and once, at the hospital, they found he had taken drugs. He said Resident #1 kept denying, so it was hard to address it. He said the negative outcome of Resident #1's behaviors were that one day, Resident #1 is fine, and then in a couple of days, he signs out and takes something (drugs or alcohol) and something happens that leads him back in the hospital. He said he asks the facility staff to do their best to monitor Resident #1. He said once Resident #1 was off drugs and was perfectly normal, it would be safe for him to be out alone. He stated when Resident #1 was in that state (under the influence of drugs and alcohol), it was not safe for him to be out alone. He said if a resident was alert, oriented, and making the right decisions, you could not tell them they could not go out because that would be restraining them. He said he would imagine it was not safe for Resident #1 to be out like that (under the influence of drugs and alcohol), but he had the right to sign himself out. He said the facility may have to get a contract with Resident #1 to say if he continued with these behaviors, they could not handle his needs because they do not want anything bad to happen. <BR/>In an interview with the VP of Operations on 05/30/2025, at 10:30 a.m., he stated the Administrator was no longer employed at the facility and Resident #1 called 911 and was transferred to the hospital related to stomach pains on 05/28/2025.<BR/>In an interview with LVN A on 05/31/2025, at 2:11 p.m., he stated on 04/12/2025, around 1:00 p.m., the police called the facility and said Resident #1 had fallen out of his wheelchair and was vomiting at the church next to the facility. He said the police went to the facility and then he (LVN A) followed them to see Resident #1. He said he thought the police saw Resident #1 on the ground and called 911. He said when he arrived at the scene, he saw Resident #1 inside the ambulance. He said Resident #1 said he had gone to the store. He said Resident #1 went to the hospital and returned to the facility about two days later. LVN A said he heard the motorized chair Resident #1 fell out of belonged to his friend. <BR/>In a telephone interview with MDS Nurse D on 06/02/2025, at 11:19 a.m., she stated she was responsible for updating care plans for residents whose last names began with J-Z. She said she made sure MDS assessments were done and care plans were updated. She said she got the information to update care plans by reading progress notes, reading physician's orders, talking to staff, and she observed and talked to the residents. She said she observed Resident #1 around the facility, and he was mostly independent. She even though she read through Resident #1's progress notes, she was not aware of his drinking or drug use. She said she knew he signed himself out of the facility because she saw him in the group when they went out. MDS Nurse D then said she heard Resident #1 smoked weed (marijuana). She said smoking marijuana would be something they needed to add to his care plan. She said it was her understanding that the ADON updated anything that was acute (not long-term issues). She said she only worked 20 hours per week, so she was not at the facility most days. She said she was aware of Resident #1's smoking, but not his drinking. She said she only looked at progress notes when it was time to update the MDS assessments. She said she never saw any notes about Resident #1's drinking alcohol. She said she did not have an answer for why she did not address Resident #1's smoking in his care plan. She said the ADON was at the facility more than she was and they should have updated Resident #1's care plan to address his drinking. She said in her opinion, anybody could update the care plan. She said it was important to address Resident #1's behaviors related to smoking and drinking because it was pertinent information and they needed to act on things like that to keep the resident safe. She said the nursing facility was not a place to get drunk and do drugs. She said the IDT needed to get together, call a care plan meeting, talk, and update things to make sure all Resident #1's behaviors were on his care plan. <BR/>In an interview with ADON F and ADON G on 06/02/2025, at 11:45 a.m., ADON G said MDS Nurse D was not in the building a lot, so she should review progress notes daily to ensure care plans were updated appropriately. ADON F said they handled (updated care plans) regarding things that were acute, but Resident #1's drinking and drug use were not acute because he had those behaviors a while. ADON G said it was important to address those behaviors in the care plan so all staff know what is going on. ADON G said a negative outcome of not having the behaviors care planned would be that the behaviors continued and but the resident's safety at risk. <BR/>Record review of the facility's policy, titled, Comprehensive care Plans revised on 09/04/2024 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. B. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . d. The resident's goals for admission, desired outcomes, and preferences for future discharge . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . <BR/>Record review of the facility's policy, titled, Behavior Management revised on 04/15/2014 revealed, Policy: The purpose of the policy is to optimize the quality of life and function of patients that experience behavioral symptoms that require person centered approaches to meet the health, physical, psychosocial, and behavioral health needs. Fundamental Information: Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for dementia patients. Fundamental principles of care for a patient with behaviors include an interdisciplinary approach that focus on the individualized needs of the patient . Procedure. Determine whether there is a medical, physical, functional, physiological, emotional, psychiatric, social, or emotional cause of the behaviors . Considerations: Person-Centered Care - evaluate if the environment is supportive and promotes comfort toward understanding, preventing, relieving, and recognizes individual needs and preferences . Evaluations are completed on new or worsening behaviors . Identify the frequency, intensity, duration, severity, and impact of behaviors, as well as the location, surroundings, or situation. Identify interventions or approaches to prevent, modify, relieve, or address the behaviors or distress. Patient behaviors or distress are documented as it occurs and the effectiveness of interventions. Individualized Care Plan Approaches - individualized approaches are used as a first line intervention (except in a documented emergency situation or if clinically contraindicated) . Consistent interventions are used that focuses on a patient's individual needs . Monitor and follow-up care plan is done by the interdisciplinary team who reviews the patient's progress towards goals. Summarize effectiveness of non-pharmacological and pharmacological interventions (quarterly and as indicated), for target behaviors and/or psychological symptoms and changes in a resident's level of distress or emergence of adverse consequences. Adjust interventions as needed and identified when care objectives are not met . <BR/>An IJ was identified on 05/29/2025 at 1:20 p.m. The IJ template was provided to the Administrator on 05/29/2025 at 1:20 p.m. and a Plan of Removal was requested. <BR/>The following Plan of Removal submitted by the facility was accepted on 05/31/2025 at 10:42 a.m.<BR/>Issue Cited: Care Plans<BR/>Failure to develop and implement a comprehensive person-centered care plan<BR/>5/30/25<BR/>1. <BR/>Immediate Action Taken<BR/> On 5-29-25 resident #1 is currently in hospital with diagnosis of gastroenteritis (inflammation of the lining of the stomach and intestines) and ESRD.<BR/>2. Identification of Residents Affected or Likely to be Affected: <BR/>A. On 5/29/25 by 3pm DON/designee identified 11 residents who sign out of the facility independently, had charts reviewed and determined by their capabilities according to their functional ability assessment (MDS section GG), and make their own choices and decisions according to their BIMs, they were reviewed for any behaviors, none were found, and care plan interventions are in place.<BR/>2. <BR/>Actions to Prevent Occurrence/Recurrence: <BR/>A. <BR/>On 5/30/25 by 10:00 am the RNC reviewed the policy on Comprehensive Care Plans with no changes made.<BR/>B. On 5/29/25 by 7:30pm DON/designee reviewed the care plans for those 11 residents identified as independently capable of signing out of the facility and making their own choices and decisions. None were found to have unsafe behaviors. Care plans were reviewed, and no updates were needed. If and when Resident #1 returns from hospital the care plan will be reviewed and updated with any unsafe behavior and the CNAs and Nurses will be in-serviced to the updated care plan at that time by DON/designee.<BR/>C. On 5/30/25 by 9am the Regional Nurse Consultant in-serviced the IDT on updating comprehensive care plans to include measurable objectives, timeframes, and interventions for those residents identified as independently signing themselves out of the facility with a focus on unsafe behaviors, goals, and interventions while out of facility. The Administrator/ or designee and DON/ or designee were in-serviced by the RNC beforehand.<BR/>D. DON/designee will monitor comprehensive care plans for all residents identified as capable of signing themselves out of the facility independently for any unsafe behaviors present and report findings to IDT in morning meeting and revise care plans as needed.<BR/>E. All findings will be discussed during QAPI monthly and plan of care will be revised as needed.<BR/>F. On 5/29/25 the facility's Administrator/ or designee notified the Medical Director regarding the Immediate Jeopardy the facility received related to Failure to Develop and Implement a Comprehensive Person-Centered Care Plan and reviewed plan to sustain compliance. <BR/>Monitoring of the plan of removal included the following:<BR/>Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/30/2025 revealed the IDT team (DON, Activity Director, ADON F, ADON G, MDS Nurse C, Treatment Nurse, , and a representative from the rehabilitation department) was educated by the RNC on comprehensive care plans, including measurable goals and individualized interventions. <BR/>Record review of the facility's, Comprehensive Care Plans policy revealed it was reviewed by the RNC on 05/29/2025. <BR/>Record review of the facility's plan of removal documentation revealed the MDS assessments and care plans for all eleven residents identified as independently capable of signing out of the facility and making their own choices and decisions were reviewed by the DON. <BR/>Interviews were conducted with staff on 05/31/2025 from 10:45 a.m. until 3:00 p.m. from all shifts (nurses and CNAs worked 12-hour shifts) including the VP of Operations, RNC, DON, ADON F, ADON G, LVN A (day shift), MDS Nurse C, RN P (day shift), CNA Q (day shift), RN R (night shift), Receptionist[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #1) of 5 residents reviewed for accident and hazards: <BR/>1. The facility failed to ensure Resident #1 had his floor mat by his bedside while lying asleep in his bed.<BR/>2. The facility failed to ensure Resident #1 wore his head helmet to prevent injuries from accidental falls.<BR/>These failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues as a result of accident hazards.<BR/>Findings included: <BR/>Record review of resident #1's face sheet revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were Hypertension (High blood pressure), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebellar ataxia (inability to control voluntary muscle movements). <BR/>Record review of resident #1's Comprehensive MDS dated [DATE] revealed Resident #1 had a BIMs score of 03 indicating the resident was severely cognitively impaired. The resident required extensive assistance with one person physical assist with bed mobility, locomotion on and off unit, eating, and personal hygiene. The resident required total dependence to walk in room, to walk in corridor, dressing, and toilet use. MDS did not code Resident #1 for helmet.<BR/>Record Review of Resident #1's Care Plan dated 12/26/2022 read in part , helmet to be worn while awake to aid in prevention of head injury related to falls. Fall Risk Screening upon admission and quarterly to identify risks factors and floor mat . <BR/>Record Review of Resident #1's Fall Prevention Protocol dated 05/18/2021 read in part . a near miss, also considered a fall, was when a resident would have fallen if someone else had not caught the resident from doing so. Each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. Implement at risk fall care plan; provide additional interventions as directed by resident's assessment, including but not limited to assistive devices, low bed, increased frequency of rounds and sitter if indicated .<BR/>Observation on 1/20/2023 at 11:20 a.m. revealed Resident #1 lying in bed asleep. The floor mat was not on the floor by resident #1's bedside.<BR/>Observation on 1/20/203 at 12:55 p.m., revealed Resident #1 awake and eating. Resident #1 was not wearing his preventive injury helmet. <BR/>Observation on 1/20/2023 at 1:20 p.m. revealed Resident #1 in his bed sitting up. He was not wearing helmet.<BR/>Observation on 1/20/2023 at 2:36 p.m. revealed Resident #1 in bed sitting up and alert. He was not wearing his preventive injury helmet. <BR/>Interview on 1/20/2023 at 10:23 a.m. with LVN A, she said Resident #1 had a couple of falls where he had hit his head on the floor . She said his last fall was on 1/7/2023. She said she did not know how Resident #1 received a black eye. <BR/>Observation and interview on 1/20/2023 at 3:00 p.m. with LVN A, she said she was informed by the surveyor that Resident #1's floor mat was behind his room door and was not put back on the floor by RA after feeding Resident #1. She said the last person to provide care or assist with helping Resident #1 was responsible for putting the floor mat back on the floor. She said she would speak with the RA about the floor mat not being place back on the floor for Resident #1.<BR/>Interview on 1/20/2023 at 3:39 p.m. with the RA, she said the importance of a floor mat was to protect a resident if in case they fell off their bed when residents were fall risks. She said she nursing staff was supposed to remove floor mats when performing patient care. She said she should have placed Resident #1's floor mat by resident's bedside but she had a lot going on and it slipped her mind. She said the helmet protected Resident #1's from head injuries due to resident #1 being a fall risk. She said the only time she had seen him with his helmet on was when he was sitting in his chair. She said the last time she was in-serviced for fall prevention was this month. She could not recall the exact. She said she was aware of fall prevention protocols because she had taken courses when she received her certification to become a CNA. She said when she was done feeding Resident #1, she kept him up for 30 minutes to avoid resident aspirating. She said she was supposed to placed the floor mat after feeding Resident #1. <BR/>Interview on 1/20/23 at 3:39 p.m. with LVN A, she said she nursing staff were supposed to conduct rounds on the residents at the facility every two hours. She said if she noticed nursing staff were not following policy and procedure, she would ask them what happened and remind them to adhere to the rules. She said the importance of the floor mat was to help with cushioning if someone fell to the floor. She said it also help avoid injuries and pain. She said Resident #1 wore a helmet because he had head injuries from falls in the past few months. She said he wore his helmet when he was in his wheelchair in common areas. She said when he was in his wheelchair, he had the ability to stand upright. She said Resident #1 did not seem restless today so she wasn't worried that he was not wearing his helmet. She said she had been working at the facility for 6 months. She said she did not know Resident #1's was care planned for wearing his preventive injury helmet while resident #1 was awake. She said she had oversight of the nursing staff in her Unit. She said the risk to the resident for not having floor mat by bedside while the resident was in bed was injury. She said the risk to Resident #1 for having his preventive injury helmet on while awake was risk of injury. She could not say why the failure occurred. She could not recall the last time staff was in-serviced for fall prevention or accidents and hazards.<BR/>Record Review of the facility's policy titled, Fall Management System revised on 1/03/2017 read in part . it is the policy of the facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on research on the resident's assessed needs. A fall occurs when there is an unintentional coming to rest on the floor, ground, or other lower level but not because of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. A fall is often the result of cumulative risk from both intrinsic (resident-related) and extrinsic (environmental) factors .

**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 the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, encompassing the resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders for 1 of 12 residents (Resident #1) reviewed for behavioral services. <BR/>The facility failed to ensure Resident #1 received adequate behavioral health care services to prevent and treat substance abuse disorder when Resident #1 frequently signed himself out of the facility to go to nearby stores and consume alcohol, resulting in intoxication, vomiting, and lethargy to the point of falling out of his wheelchair. Resident #1 was also known by staff to sign himself out and smoke marijuana in the community surrounding the facility, resulting in a positive laboratory finding for THC. <BR/>An IJ was identified on 05/29/2025. The IJ template was provided to the facility on [DATE] at 1:20 p.m. While the IJ was removed on 06/01/2025, the facility remained out of compliance at a scope of pattern with severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. <BR/>This failure could place residents who require behavioral health services at risk not receiving having their needs met and, deterioration of health<BR/> Findings include:<BR/>Record review of Resident #1's face sheet dated 05/28/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. He was diagnosed with end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and excess fluid from the body), schizoaffective disorder (a chronic mental illness that combines systems of both schizophrenia and mood disorder), gastro-esophageal reflux (a chronic condition where stomach contents regularly flow back up into the esophagus), history of falling, difficulty walking, diabetes mellitus type II (chronic disease where the body either does not produce enough insulin or cannot properly use the insulin it produces) with hypoglycemia (when blood glucose levels drop too low), essential hypertension (persistently high blood pressure with no identifiable cause), chronic ischemic heart disease (long-term condition where the heart's blood supply is reduced due to a mismatch between oxygen supply and demand), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms in COPD patients), unspecified cirrhosis of liver (a type of chronic, progressive liver disease where healthy liver cells are replaced by scar tissue), acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the cystic duct), dependence on renal dialysis (treatment that cleans the blood when kidneys are unable to do so), and shortness of breath. Resident #1 was his own responsible party. <BR/>Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); Resident #1 exhibited behaviors related to rejection of care; Resident #1 used a manual wheelchair for mobility; Resident #1 was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers and required supervision or touching assistance for showers/bathing; Resident #1 was always continent of bowel and bladder; and Resident #1 was prescribed anticoagulant and antipsychotic medication. <BR/>Record review of resident #1's care plan, revised on 05/25/2025 revealed the following care areas:<BR/>* <BR/>Behavioral Problem: Resident has a behavior problem as evidenced by: displaying verbal and sexually inappropriate behavior by exposing his private area to female residents and female staff. Goal included: Resident's inappropriate behavior will not result in harm or injury to self or others. Interventions included: Educate resident on the privacy issues associated with his behavior. Encourage as much as possible to detour injury. Intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of other. Resident will be receiving psychiatric visits with [Psychiatric Provider] to monitor his behaviors per physician orders.<BR/>* <BR/>Therapeutic Leave: Resident is cognitively able to sign out of the facility and make their own informed decisions while they are out. On 04/10/2025 while on therapeutic leave, resident made the decision to consume alcoholic beverages. Goals included: The resident will follow facility policy for out on pass. The resident will be safe and comfortable while out on pass. Interventions included: Educate the resident/family/caregivers about the potential risks associated with signing out on pass. Educate resident/family/caregivers on the facility's policy for therapeutic leave/out on pass. Resident is reminded of his health issues and treatment regimens and the recommendations to avoid the use of alcoholic beverages.<BR/>Further review of Resident #1's care plan revealed no care areas, goals, or interventions to address his substance abuse concerns. <BR/>Record review of Resident #1's nursing progress notes for April 2025 and May 2025 revealed:<BR/>* <BR/>On 04/02/2025, at 4:10 p.m., SW B wrote, Resident was educated with Administrator, ADON, DON, and SW on the policies for Therapeutic Leave and the expectations for the resident when he is on Therapeutic Leave. Resident verbalized understanding.<BR/>* <BR/>On 04/11/2025, at 12:10 a.m., RN E wrote, Resident came back on pass to the facility with alcohol intoxication, vitals and assessment done. All within normal baseline. NP notified. New order to transfer resident to the hospital for further evaluation but resident refused. Resident was monitored through the shift, comfort care provided to resident satisfaction.<BR/>* <BR/>On 04/11/2025, at 11:50 a.m., ADON F wrote, Late Entry: 04/10/2025 at 11:00 p.m. Upon resident's return to the facility, resident arrived propelling himself in his motorized wheelchair. Resident had a slurred speech, he was drooling, smiling, and laughing, slow to respond to questions, and lethargic. Resident said he was tired and wanted to lay down and go to sleep and was assisted back to his room and was unable to stand to assist with his transfer to his bed, so he was transferred to bed with two people assist. In speaking with the resident, he said that he had ingested alcohol, specifically three 40 oz bottles of [brand name of beer] and he would not say if he had ingested any other substances or drinks. Upon assessment by unit nurse, there was no evidence of trauma or physical injuries noted, no indications of any falls or any other incidents at the time of his return.<BR/>* <BR/>On 04/12/2025, at 7:17 p.m., LVN A wrote, Police officer called facility and said resident vomited and may have been drinking with his friend and they have called 911 for him to go to the ER and have him evaluated. They then came to the facility, and I gave him a face sheet and medication lists. I accompanied the officer to EMS parked on the street near the facility and found the patient inside the ambulance being attended to by two paramedics with patient leaning to his left side. I placed a call to the Administrator and ADON. Resident apparently signed out at about 12 noon and left the facility with another resident. They apparently went to a nearby store and purchased drinks. He drank until he vomited on himself and became very weak. I asked the paramedics where they were taking him, and they informed me that they were taking him to [a local hospital] ER. NP and RP notified.<BR/>* <BR/>On 04/14/2025, at 4:38 p.m., ADON F wrote, Resident was found to be in possession of a cigarette lighter. The resident was educated by the Administrator on the smoking policy and the lighter was placed in the smoker's box for the resident to have access to only when on smoke breaks. The Administrator educated the resident on use of another resident's electric wheelchair and encouraged to use his own, the resident verbalized understanding.<BR/>* <BR/>On 04/15/2025, at 2:11 p.m., RN H wrote, Resident signed himself out and came back vomiting. Happened a couple of times. NP notified. Lab work ordered. New order to transfer to ER for further evaluation.<BR/>* <BR/>On 04/16/2025, at 5:23 p.m., ADON G wrote, Final lab results received on the drug and alcohol screening, labs placed in NP binder for review . resident remains in the hospital at this time.<BR/>* <BR/>On 04/23/2025, at 9:46 p.m., RN E wrote, Resident, who went out on pass, returned to the facility alert but disoriented, drooling from alcohol intoxication also had multiple emesis (vomiting). Resident vitals and assessment done all vital signs were within normal baseline. NP contacted via telehealth/virtual service. New order for Ondansetron 4 MG 1 tablet PO q 6hours as needed .<BR/>* <BR/>On 05/01/2025, at 11:59 a.m., the SW wrote, The Social Worker and the Administrator witnessed [Resident #1] taking a power wheelchair without the permission of the resident who owns the power wheelchair. Resident was educated that he cannot take the belongings of other residents while they are out of the facility. Resident was also educated on the importance of not using someone else's wheelchair and the risks that can occur .<BR/>* <BR/>On 05/04/2025, at 4:41 p.m., RN H wrote, Resident exchanged wheelchair with his former roommate and resident was educated that it was not safe to do so, resident verbalized understanding.<BR/>Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/10/2025 at 11:17 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Complaint: Altered Mental Status . Per nurse, patient went out on pass and returned to facility lethargic, drooling from mouth and vomited once one hour ago. Per nurse, patient only knows his name, does not know where he is, and does not know the month, year. States at baseline patient is alert and oriented x 3 (a term that describes a patient's level of consciousness and cognitive function. Patient aware of person, place, and time). Per nurse, patient admitted to drinking 3 bottles of [brand of beer]. Per nurse, patient refused dialysis today and states patient did not go to dialysis yesterday . Patient seen with nurse . Physical Exam: Exam findings per nurse and video observation . Orders: Transfer to ER via 911: AMS/ESRD - missed HD/vomiting/possible alcohol intoxication . <BR/>Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/23/2025 at 10:02 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Chief Complaint: GI: Vomiting . Nurse notified clinician that the [AGE] year-old-male patient with history of ESRD on dialysis, Schizophrenia, falls, HTN, DM2, went out of the facility for an hour and came back intoxicated. The nurse stated this is a regular occurrence for him. He did have an episode of vomiting. Denies drinking alcohol. Will monitor him for now .<BR/>Record review of Resident #1's Lab Results Report collected on 04/11/2025 and reported on 04/16/2025 revealed Resident #1 was positive for THC (Cannabis).<BR/>Record review of Resident #1's, Psychiatric Subsequent Assessment dated 04/24/2025 revealed, . History of Presenting Illness: Last visit was on 03/24/2025 . Collateral Information: On 04/24/2025, I attended a multidisciplinary care conference meeting with the DON, ADON, MDS, administrator, medical records, and SW. The case was discussed in detail, and it was concluded; 1. Patient was sent to the hospital due to after the staff found him at the store unable to move. Patient was under the influence of alcohol. 2. Patient does not follow his dialysis schedule .<BR/>Record review of Resident #1's, Clinical Treatment Plan Review (Plan of Care) completed by the psychiatric provider and dated 04/29/2025 revealed, . History of Presenting Illness: . Patient was referred to psychological services for: Agitation, Irritability, Memory Loss, Short Term Memory Problems, Long Term Memory Problems, Noncompliance, Resistance to ADL/Medications, Sexually Inappropriate Behavior, Attention Seeking Behavior, Medication Evaluation, Other: Resident is refusing dialysis. In addition, he was touching himself in his genitals in an inappropriate way . Family/Social History: . Patient endorsed history of drug/alcohol abuse . Summary of Progress: Patient has been less active with therapy during this treatment cycle due to a new interpersonal relationship and frequent trips outside the facility . Treatment Plan: Treatment is expected to result in an improvement in condition or prevention of decline that would otherwise be expected. Treatment is expected to help improve patient's emotional, cognitive, social, behavioral functioning symptomatology. Psychotherapy in addition to psychotropic medication is the treatment of choice for this patient .<BR/>Further review of Resident #1's Clinical Treatment Plan Review (Plan of Care) revealed no mention of a plan to address Resident #1's substance abuse concerns.<BR/>Record review of Resident #1's, Psychiatric Subsequent Assessment dated 05/01/2025 revealed, . History of Presenting Illness: Last visit was on 04/24/2025 .<BR/>Further review of Resident #1's, Psychiatric Subsequent Assessment revealed no documentation to show his substance abuse issues were addressed. <BR/>Record review of Resident #1's, Psychiatric Subsequent Assessment dated 05/28/2025 revealed, . History of Presenting Illness: This is a post hospital follow up. After my last visit the patient was admitted into the hospital due to AMS, and general weakness. Psych meds were not changed. My last visit was on 05/01/2025 . Collateral Information: On 05/28/2025, I attended a multidisciplinary care conference meeting with the ADON, MDS, Medical records, DON, and SW. The case was discussed in detail, and it was concluded: 1. Patient has returned back from the hospital. Patient was drinking and using drugs while out on pass .<BR/>Observation and interview with Resident #1 on 05/28/2025, at 2:30 p.m. revealed he was in his bed with his eyes closed. Resident #1 opened his eyes and was able to provide his name. Resident #1 stated he lived in the facility a couple of months and living there was alright. He said he went to dialysis. He said he fell out of his wheelchair about six months ago (he did not say why). Resident #1 did not answer questions related to drinking alcohol or taking drugs while outside the facility on pass. He closed his eyes and appeared to be asleep although he responded to questions unrelated to drinking or smoking. <BR/>In an interview with the SW on 05/28/2025, at 3:24 p.m., she stated Resident #1 was capable of making his own decisions, but he just did not make the right decisions. She said Resident #1 went out on pass and did things he should not do. She said Resident #1 received psychiatric services to see why he refuses dialysis so much. She said she was not sure if Resident #1's substance abuse issues were discussed during his psychiatric sessions. She said Resident #1 was vomiting once due to intoxication. She said the facility staff could not tell Resident #1 what he could and could not do outside of the facility, and they could only educate him. She said Resident #1 knew what he was doing. She said Resident #1 was his own RP and he did not have any family. She said to her knowledge, Resident #1 only went out twice and got drunk, but she was not there on weekends. She said Resident #1's behavior of going out and getting drunk had decreased and he went out a lot less. She said Resident #1 had been sleeping a lot more recently and he had several hospitalizations. She said she spoke to Resident #1 about the risks of him going out drunk. She said possible negative outcomes of Resident #1 leaving the facility and getting drunk were that he could die, get injured, and go to the hospital. <BR/>In an interview with the Activity Director on 05/28/2025, at 3:45 p.m., she stated Resident #1 was known to take his former roommate's motorized wheelchair. She stated Resident #1 had been caught smoking weed (marijuana) and drinking beer. She said a group of residents were at a nearby store drinking and the store workers called the police. She said the police went to the facility and told them they had to keep the residents from going there, but once they sign out, the residents go their own way. She said the residents needed more things to do inside the facility. She said she left the facility at 5:00 p.m. daily and she had only observed Resident #1 return to the facility intoxicated a couple of times. She said Resident #1 was in the hospital about a week or so and yesterday (05/27/2025) or Monday (05/26/2025), he was sick and throwing up. She said Resident #1 refused dialysis a lot. She said Resident #1 used another resident's motorized wheelchair to go to the store because he could not physically wheel himself out to store in his manual wheelchair. She said Resident #1 kept taking his former roommate's wheelchair, so they moved Resident #1 to another room. She said she had no knowledge of Resident #1 falling out of a wheelchair but about 7-8 months ago, she observed him outside with his manual wheelchair stuck and leaning off a curb. She said she pulled over and pushed his wheelchair all the way back to the facility. She said Resident #1 was leaning over in his wheelchair and he kept saying he was sick. She said she did not know of he was intoxicated at that time. She said the residents had to pass a busy road and cross the road to get to the store. She said it was not safe for the residents to travel that way, but they had their rights. She said the Administrator told the staff that the residents had their rights. <BR/>In an interview with the Administrator on 05/28/2025, at 4:32 p.m., he stated the residents had rights. He said Resident #1's BIMS score was 15, but he did not make proper decisions. He said the facility staff had to make sure they did not infringe on the residents' rights. He said Resident #1 signed himself out and returned intoxicated between five and seven times. He said he had undocumented conversations with Resident #1 about how unsafe it was for him to leave the facility and get drunk. He said the conversations were not documented because he did not go into the facility's computer system to write progress notes. He stated Resident #1 received psychiatric services, but he sometimes refused to talk or participate during his sessions. He said he was not sure if Resident #1's smoking and drinking were addressed during the sessions. He said addressing Resident #1's smoking and drinking in his psychiatric sessions would be helpful to reinforce what the facility staff try to educate him on related to those behaviors. <BR/>In a telephone interview with Resident #1's physician on 05/30/2025, at 10:00 a.m., he stated he was familiar with Resident #1, and he was aware the resident frequently went out on pass to drink and smoke. He said Resident #1 denied drinking and smoking, but he had a history of noncompliance with dialysis and medications. He said Resident #1 had recently been admitted to the hospital a lot and once, at the hospital, they found he had taken drugs. He said Resident #1 kept denying, so it was hard to address it. He said the negative outcome of Resident #1's behaviors were that one day, Resident #1 is fine, and then in a couple of days, he signs out and takes something (drugs or alcohol) and something happens that leads him back in the hospital. <BR/>In an interview with LVN A on 05/31/2025, at 2:11 p.m., he stated on 04/12/2025, around 1:00 p.m., the police called the facility and said Resident #1 had fallen out of his wheelchair and was vomiting at the church next to the facility. He said the police went to the facility and then he (LVN A) followed them to see Resident #1. He said he thought the police saw Resident #1 on the ground and called 911. He said when he arrived at the scene, he saw Resident #1 inside the ambulance. He said Resident #1 said he had gone to the store. He said Resident #1 went to the hospital and returned to the facility about two days later. LVN A said he heard the motorized chair Resident #1 fell out of belonged to his friend. He said Resident never admitted to the drinking and always tried to hide it. He said Resident #1 usually returned to the facility late at night, so he (LVN A) was usually gone by that time (LVN worked the day shift, 7:00 a.m. - 7:00 p.m.). He said the negative outcome of Resident #1's behavior was that he was a dialysis patient and it interfered with his kidneys. He said Resident #1 falling out of the chair while intoxicated and going to the ER was a very negative effect. <BR/>Record review of the facility's policy, titled, Behavior Management revised on 04/15/2014 revealed, Policy: The purpose of the policy is to optimize the quality of life and function of patients that experience behavioral symptoms that require person centered approaches to meet the health, physical, psychosocial, and behavioral health needs. Fundamental Information: Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for dementia patients. Fundamental principles of care for a patient with behaviors include an interdisciplinary approach that focus on the individualized needs of the patient . Procedure. Determine whether there is a medical, physical, functional, physiological, emotional, psychiatric, social, or emotional cause of the behaviors . Considerations: Person-Centered Care - evaluate if the environment is supportive and promotes comfort toward understanding, preventing, relieving, and recognizes individual needs and preferences . Evaluations are completed on new or worsening behaviors . Identify the frequency, intensity, duration, severity, and impact of behaviors, as well as the location, surroundings, or situation. Identify interventions or approaches to prevent, modify, relieve, or address the behaviors or distress. Patient behaviors or distress are documented as it occurs and the effectiveness of interventions. Individualized Care Plan Approaches - individualized approaches are used as a first line intervention (except in a documented emergency situation or if clinically contraindicated) . Consistent interventions are used that focuses on a patient's individual needs . Monitor and follow-up care plan is done by the interdisciplinary team who reviews the patient's progress towards goals. Summarize effectiveness of non-pharmacological and pharmacological interventions (quarterly and as indicated), for target behaviors and/or psychological symptoms and changes in a resident's level of distress or emergence of adverse consequences. Adjust interventions as needed and identified when care objectives are not met . <BR/>An IJ was identified on 05/29/2025 at 1:20 p.m. The IJ template was provided to the Administrator on 05/29/2025 at 1:20 p.m. and a Plan of Removal was requested.<BR/>The following Plan of Removal submitted by the facility was accepted on 05/31/2025 at 5:20 p.m.<BR/>Issue Cited: Behavioral Services<BR/>Failure to provide behavioral services<BR/>5/31/25<BR/>6. <BR/>Immediate Action Taken<BR/> On 5-29-25 resident #1 is currently in hospital for diagnosis of gastroenteritis and ESRD.<BR/>2. Identification of Residents Affected or Likely to be Affected: <BR/> A. On 5/29/25 by 5:15pm DON/designee identified 66 residents are currently on behavioral services. The remaining 32 residents had no noted behaviors on admission or currently to warrant a referral for behavioral services. <BR/>3. Actions to Prevent Occurrence/Recurrence: <BR/>A. On 5/30/25, [Psychiatric Provider] Services begins performing a psych evaluation on those 32 residents identified to establish any behavioral service needs, ongoing. No residents are identified as using drugs/alcohol when leaving the facility. If any of the 32 residents are identified as having a need for psych behavioral services, then care plans will be updated to reflect the behavior services. If any of the 32 residents are found to need behavioral services then [Psychiatric Provider] will treat in-house, and the care plan will be updated and nursing staff will be educated. None of the 32 residents require behavioral services at this time.<BR/>B. Resident #1 is in hospital currently and has been on behavioral services but frequently refused visits. If and when resident #1 returns, psych behavioral services will be updated with his alcohol/drug behaviors and will be seen for appropriate service needs. Resident #1 has a history of refusing medical care including medications, dialysis, and psych services. If residents' refusals continue to jeopardize their health and the facility can no longer meet their needs, then the facility may discharge per HHSC guidelines.<BR/>C. On 5/30/25 at 9:00 am the RNC reviewed the Behavioral Management policy, with no revisions made.<BR/>D. On 5/30/25 by 12:00 PM the DON/ or designee will in-service nurses on Behavior Management policy, to include monitoring of behaviors each shift, documentation of any unsafe behaviors, notify physician of unsafe behaviors for new orders, and notify DON/ or designee of unsafe behaviors, no nurse will be able to work a shift without the in-service. The RNC in-serviced the Administrator/ or designee and DON/ or designee beforehand. On 5/30/25 by 6pm DON/designee in-serviced CNAs on Behavior Management policy including responding to behaviors and notifying charge nurse, no CNA will be able to work a shift without the in-service. <BR/> E. DON/designee will review future admissions for the need of psych services and notify physician for an order for behavioral services.<BR/>F. DON/designee will monitor 24-hour report for unsafe behaviors identified daily in morning stand-up meeting. <BR/>G. All findings will be discussed during the morning stand-up meeting with IDT team and report to QAPI and update plan of correction as needed.<BR/>H. On 5/29/25 the facility's Administrator/or designee notified the Medical Director regarding the Immediate Jeopardy the facility received related to Failure to Provide Behavioral Services and reviewed plans to sustain compliance.<BR/>Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ___5/31/25_________<BR/>Monitoring of the plan of removal included the following:<BR/>Record review of the facility's plan of removal documentation revealed a complete audit of the building was completed by the RNC on 05/29/2025 and 32 residents who did not receive behavioral health services were identified. <BR/>Further review of the facility's plan of removal documentation revealed psychiatric evaluations were completed on the 32 residents who did not previously receive behavioral health services beginning on 05/30/2025. No substance abuse issues were identified among the 32 residents evaluated. <BR/>Record review of the Behavior Management policy revealed it was reviewed by the RNC on 05/29/2025. <BR/>Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/29/2025 revealed the DON was educated by the RNC on the Behavior Management policy, including monitoring behaviors each shift, documentation of any unsafe behaviors, and notifying the doctor of any unsafe behaviors.<BR/>Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/30/2025 revealed the facility's nurses were educated by the RNC on the Behavior Management policy, including monitoring behaviors each shift, documentation of any unsafe behaviors, and notifying the doctor and DON of any unsafe behaviors.<BR/>Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/29/2025 revealed the facility's CNAs were educated by the DON, ADON F and ADON G on the Behavior Management policy, including how to respond to behaviors, redirection, providing a calm environment, and notifying the nurse of unsafe behaviors. <BR/>Interviews were conducted with staff on 06/01/2025 from 9:30 a.m. until 12:00 p.m. from all shifts (nurses and CNAs worked 12-hour shifts) including the VP of Operations, RNC, DON, ADON F, ADON G, RN H (day shift), Receptionist I, Receptionist J, LVN K (day shift), CNA L (day shift), CNA M (day shift), LVN N (night shift), and CNA O (night shift), to verify the in-services were conducted and to validate the staff understanding of requirements, training material, and expectations. The VP of Operations, RNC, DON, ADON F, ADON G, RN H, Receptionist I, Receptionist J, LVN K, CNA L (day shift), CNA M (day shift), LVN N (night shift), and CNA O were able to explain the importance of identifying and addressing unsafe behaviors (alcohol and drug abuse), notifying the nurses, DON, and physician of unsafe behaviors, documenting behaviors, responding appropriately to residents who exhibit behaviors, and monitoring residents who exhibit behaviors related to alcohol and drug abuse for their entire shift. <BR/>The RNC was informed the Immediate Jeopardy was removed on 06/01/2025 at 12:09 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate, acquiring, receiving, dispensing, and administering all of drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 4 residents reviewed for pharmacy services.<BR/>1. The facility failed to administer the medications Amlodipine Besylate medication had blanks in the MAR from 01/13/23- 01/17/23.; Digoxin Tablet 125 MCG 0.5 tablet had blanks in the MAR from 01/07/23- 01/17/23; Melatonin had blanks in the MAR from 01/07/23- 01/17/23; Metformin HCl Tablet 500 MG had blanks in the MAR from 01/07/23- 01/17/23; Artificial Tears Solution 1 % had blanks in the MAR from 01/07/23- 01/17/23 at 8AM, and 01/07/23- 01/16/23 for the 4PM; Cymbalta Capsule Delayed Release Particles 60 MG had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 5PM; Lidocaine Pain Relief 4 % Patch had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 8PM; and Tramadol HCl Tablet 50 MG had blanks in the MAR from 01/07/23- 01/17/23 at 7AM, and 01/07/23- 01/16/23 for the 7PM to Resident #1.<BR/>This deficient practice affected Resident #1 and placed other residents at risk of having missed medications that could lead to diseases getting worse and/or hospitalization.<BR/>Findings:<BR/>Record review of Resident #1's face sheet dated 01/20/2023 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were muscle weakness, pain in knee, unspecified osteoarthritis, pain in left hand, muscle wasting and atrophy, and osteoarthritis of the knee.<BR/>Record review of Resident #1's Entry MDS dated [DATE] reflected the resident had a BIMS score of 15 out of 15 indicating the resident was cognitively intact. The resident required oversight and encouragement with Bed mobility, Transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, eating with one person assist, toilet use, and personal hygiene.<BR/>Record review of Resident #1's Care Plan dated 12/15/2022 reflected in part . Focus: Has Delusions. Periods of isolation and depression. Resident takes Trazodone and Cymbalta daily related to diagnoses of Major Depression, anxiety and insomnia. Goal: Resident will not have delusions or hallucinations. She will have less episodes of isolation and will maintain the highest level of function possible. Intervention: Give medication and monitor for side effects. Focus: Resident has a diagnosis of diabetes and is at risk for unstable blood sugars and abnormal lab results. Goal: Resident will be free from the signs and symptoms of hyper (high blood glucose (blood sugar))/hypoglycemia (condition in which your blood sugar (glucose) level is lower than the standard range) and Resident will have a reduced risk for complications related to diabetes through the next review date. Intervention: Administer diabetic medications as ordered by the physician. Focus: The resident has depression and takes antidepressants. Goal: The resident will remain free of s/sx of distress, symptoms of depression, anxiety or sad mood X 90 Days. Administer medications as ordered. Focus: Digoxin, Resident is on digoxin therapy related to tachycardia (medical term for a heart rate over 100 beats a minute). Goal: Resident will be free from the potential adverse reactions. Interventions: Check peripheral pulse (the palpation of the high-pressure wave of blood moving away from the heart through vessels in the extremities following systolic ejection) prior to administration and hold if outside of acceptable parameters as set by the physician. Focus: Behavioral Problem: Resident has a behavior problem. Resident continues to believe that she has lice or bed bugs in her hair. She will become very upset with staff. Goal: Resident will be clean, well groomed, and episodes of physical behaviors will decrease to less than weekly through the next review date. Resident will have less episodes of stating she has lice and or dandruff and the medical staff will collaborate more with psych staff to reduce this situation causing her so much distress. Interventions: Administer medications as ordered. Focus: Hypertension: Resident has hypertension and is at risk for fluctuations in blood pressure. Goal: Resident will remain free of signs and symptoms of hypertension through the review date. Intervention: Administer antihypertensive medications as ordered. Focus: Resident takes psychotropic meds: Cymbalta, Vistaril, Seroquel, trazodone. Goal: Resident will maintain the highest level of function possible and not experience a decrease in functional abilities related to psychotropic use during the next 90 days. Interventions: Administer medications as ordered.<BR/>Record review of Resident #1's physician's orders dated 01/13/2023 reflected Amlodipine Besylate Give 10 mg by mouth in the morning related to Essential (Primary) Hypertension.<BR/>Record review of Resident #1's physician's orders dated 05/18/2021 reflected Digoxin Tablet 125 MCG 0.5 tablet 125 MCG, Give 0.5 tablet by mouth in the morning related to Tachycardia, unspecified.<BR/>Record review of Resident #1's physician orders dated 04/02/2021 reflected Melatonin Tablet 5 MG, Give 1 tablet by mouth at bedtime for insomnia.<BR/>Record review of Resident #1's physician's orders dated 01/13/2021 reflected Metformin HCl Tablet 500 MG Give 1 tablet by mouth in the morning related to Type 2 Diabetes Mellitus with Unspecified Complications.<BR/>Record review of Resident #1's physician orders dated 05/16/2022 reflected Artificial Tears Solution 1 % (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes two times a day for dry eyes.<BR/>Record review of Resident #1's physician orders dated 03/29/2022 reflected Cymbalta Capsule Delayed Release Particles 60 MG, Give 60 mg by mouth two times a day related to Major Depressive Disorder, Recurrent, Severe with Psychotic symptoms.<BR/>Record review of Resident #1's physician orders dated 11/19/2022 reflected Lidocaine Pain Relief 4 % Patch apply 1 patch transdermally every morning and at bedtime for pain.<BR/>Record review of Resident #1's physician orders dated 01/12/2021 reflected Tramadol HCl Tablet 50 MG Give 1 tablet by mouth every 12 hours related to pain related to Pain in Unspecified knee (M25.569); Pain in Left hand (M79.642); Unspecified Osteoarthritis unspecified site.<BR/>Record Review of Resident #1's MAR dated January 2023 revealed the following: Amlodipine Besylate medication had blanks in the MAR from 01/13/23- 01/17/23.; Digoxin Tablet 125 MCG 0.5 tablet had blanks in the MAR from 01/07/23- 01/17/23; Melatonin had blanks in the MAR from 01/07/23- 01/17/23; Metformin HCl Tablet 500 MG had blanks in the MAR from 01/07/23- 01/17/23; Artificial Tears Solution 1 % had blanks in the MAR from 01/07/23- 01/17/23 at 8AM, and 01/07/23- 01/16/23 for the 4PM; Cymbalta Capsule Delayed Release Particles 60 MG had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 5PM; Lidocaine Pain Relief 4 % Patch had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 8PM; and Tramadol HCl Tablet 50 MG had blanks in the MAR from 01/07/23- 01/17/23 at 7AM, and 01/07/23- 01/16/23 for the 7PM.<BR/>Observation and interview on 01/20/23 at 10:30 AM with Resident #1 revealed the resident lying in bed, dressed, and groomed with her call light within reach and water by her bedside table. The resident said she did not get her medications when she was in isolation a couple of weeks ago. She said she did not get her lactulose, dry eye drops, or lidocaine pain patch. She said she told staff she did not get her medications and she had pain, but did not know which staff she told. She did not say how staff responded after resident #1 told staff she didn't get her medications. At the time of the interview Resident #1 did not show any signs or symptoms of pain and did not report any pain. <BR/>Interview on 01/20/23 at 11:47 AM with CNA A, she said she had not seen or heard of residents missing medications. She said Medication Aides/LVNs were responsible for administering medications. She said the nurses had oversight of the Medication Aide to ensure medications were given. She said there was no reason why a resident would not get their medications. She said a resident not receiving their medications could lead to the resident getting sick or cause them harm.<BR/>Interview on 01/20/2023 at 1:35 PM with LVN A, she said she had worked at the facility for about seven months. She worked on Hall 100 and hall 500 as well. She said she worked with Resident #1. She said she put Voltaren gel on the resident's wrist for her osteoarthritis. She said a resident might not get their medications depending on parameters, or if it's PRN, according to orders. She said the MAR was blank 01/07/2023- 01/17/2023 because the resident was isolated due to COVID-19 and transferred to the COVID-19 wing. She said the facility did paper MARs for residents while they were in the COVID-19 wing.<BR/>Interview on 01/20/2023 at 1:40 PM with the ADON, she said Resident #1 had a paper MAR and she would locate it from the COVID-19 wing. <BR/>Interview with on 01/20/2023 at 2:00 PM with the Scheduler, she said the nurse administered medications to residents and LVN B was the nurse during the time Resident #1 was in the COVID-19 unit (01/07/2023- 01/17/2023). The Scheduler did not know when LVN B administered medications to Resident #1 while in the COVID-19 unit from 01/07/2023- 01/17/2023 because LVN B was scheduled to work during that time. The Scheduler did not know if LVN B had administered medications to Resident #1. <BR/>Phone interview on 01/20/2023 at 3:11 PM with LVN B, he said he gave medications to Resident #1. He said he left the COVID-19 unit on 11/17/2023 and Resident #1 was one of the last two people to arrive in the COVID-19 unit. He said he worked in the COVID-19 unit from 01/05/2023- 01/11/2023 and Resident #1 came into the COVID-19 unit on the 9th or 10th of January 2023. He said some of her medications were on a paper MAR. He said he administered Artificial tears, and Tramadol to the resident from 01/09/2023- 01/17/2023, but could not confirm he administered amlodipine Besylate, Digoxin Tablet, Melatonin, Metformin HCl Tablet, Cymbalta Capsule Delayed Release Particles 60 MG, or the Lidocaine Pain Relief 4 % Patch. He did not know why there were blanks on the MAR. <BR/>Interview on 01/20/2023 at 3:53 PM with the Scheduler, she said Resident #1 was in the COVID-19 unit from 01/7/2023- 01/17/2023. She said other nurses in the unit administered medications to Resident #1 were LVN C, and LVN D from 01/14/23 & 01/15/23, and LVN E and LVN F on 01/16/23 & 01/17/23.<BR/>A phone interview was attempted on 01/20/2023 at 4:15PM with LVN C and could not leave voicemail because the mailbox was full.<BR/>A phone interview was attempted on 01/20/2023 at 4:16PM with LVN D and left a voicemail asking her to call this survey back. <BR/>A phone interview was attempted on 01/20/2023 at 4:16PM with LVN E and left a voicemail asking her to call this survey back.<BR/>Phone interview on 01/20/2023 at 4:22PM LVN G said her shift was from 6PM- 6AM. She said she was familiar with Resident #1. She said she could not recall if Resident #1 received her medications from 01/07/2023- 01/17/2023. She said the risk to the residents when they didn't get their medications would be the resident getting worse and or hurting them. LVN G did not know the last time she was trained on medication administration.<BR/>Phone interview on 01/20/2023 at 4:26PM LVN D said she worked the 6PM- 6AM shift. She said she was familiar with Resident #1. She said she did not know if Resident #1 received her medications from 01/07/2023- 01/17/2023. She said the risk to the residents when they don't get their medications would be the resident getting sick or causing them pain. LVN D said she did not recall when she was last trained on medication administration.<BR/>Phone interview on 01/20/2023 at 4:30PM with LVN F said her shift is 6PM- 6AM and could not verify medications were administered during the day shift for Resident #1.<BR/>Interview on 01/20/2023 at 4:32 PM with the ADON, said she could not find the paper MAR for Resident #1. <BR/>Record review of the facility's Administration and Documentation guidelines dated 02/02/2014 reflected in part .Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. Circle initials or those medication or treatment that were not administered and document the reason for the non-administration on the back of the MAR or TAR .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish a grievance policy to ensure the prompt resolution of all grievances for 1 of 3 (Resident#1) residents reviewed for grievances. <BR/>-The facility failed to establish a grievance policy that includes the right to obtain a written decision regarding a resident's grievance.<BR/>-The facility did not provide a written decision to Resident #1 who filed grievances.<BR/>These failures could place residents at risk for feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness. <BR/>Findings included:<BR/>Observation on 09/27/2024 at 2:01p.m., of the posting near the Receptionist area titled Abuse, Neglect and Grievances revealed the posting included the Administrator's name, title, and phone number.<BR/>Record Review of Resident #1's face sheet, dated 9/27/2024, revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included cerebral palsy (a congenital disorder of movement, muscle tone, or posture), schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms) and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). <BR/>Record Review of Resident #1's quarterly MDS assessment, dated 8/13/2024, revealed Resident #1 had a BIMS score of 15 out of 15 which indicated Resident #1 was cognitively intact. <BR/>Record Review of Resident #1's care plan initiated 12/09/2023 and revised on 12/11/2023 revealed the following: <BR/>Focus: Resident is in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide selfcare and discharge planning is not needed. Either the family or the resident has requested that questions regarding return to the community only be asked on comprehensive assessments.Goal: Resident and family's wishes will be honored through next review date.<BR/>Interventions: Observe for change in conditions that may affect long-term care goals and notify the physician and responsible party as needed. Discuss the need for continuing long-term care placement with the resident or family as indicated or requested. Encourage and allow the resident or family to discuss feelings and concerns regarding long-term care placement. Discuss with the resident or family the level of care that would be needed to safely return to an assisted living facility, group home, or the community when indicated or<BR/>requested.<BR/>Record Review of the facility's Grievance log (June 2024 to September 2024) revealed Resident#1 filed a grievance on 09/03/2024 and 09/04/2024 with the facility that included patient care and medication administration. The resolution date for the grievance was 09/03/2024 and 09/04/2024 and documentation revealed that the resident was verbally informed of their decision regarding the grievance by the DON, SW, Administrator, but no documentation of written notification was given to Resident #1 or Resident #1's representative. <BR/>In an interview on 09/27/2024 at 9:30a.m., Resident #1 stated that she had filed two grievances with the facility on 09/03/24 and 09/04/24. Resident #1 stated she had made several attempts with the SW and the Administrator to request copies that the grievance was concluded but had not received any documentation. Resident#1 stated she was told by the Administrator that it was the company's policy not to provide written documentation of the decision regarding the grievance. Resident#1 stated she had filed grievances regarding insulin administration and patient care, and it was her right to view the resolution of the grievances. Resident#1 stated she felt ignored not getting written decisions about her grievances. <BR/>In an interview on 09/27/2024 at 11:46a.m., with the Administrator, he stated the grievance form was an internal document. Resident/family and not even state Surveyor can have access to the grievance form. It's company's policy. Surveyor asked what if the resident/family or Surveyor request to see the documentation of the decision regarding the grievance. The Administrator stated, they can't. <BR/>In an interview on 09/27/2024 at 1:10p.m., The SW stated Resident#1 had requested written explanation of the findings of the grievance several times. SW stated she did not give Resident #1 a written explanation of the findings of the grievance. SW stated they had a meeting with Resident#1, Regional Administrator, Administer and her as witness of the conversation. The Regional Administrator explained to the resident normally it's not what we practice. Grievance form is more of internal document, so it is not uploaded to the resident's file. It's not a medical record. SW stated the grievances form goes in the grievance file and when state surveyors ask for it, she was to give it in the form of the grievance log. SW said that a possible negative outcome for not giving a resident written notification for a filed grievance would be that a resident may not feel that the grievance was resolved.<BR/>In an interview on 09/27/2024 at 1:50 p.m., Interim DON stated the Administrator was the facility's abuse coordinator. Interim DON stated the process for grievance was interview staff/resident, investigate, resolve, and provide explanation to the resident if alert and or family. Interim DON stated, I don't think there is anything that would be preventing us from giving a copy. Interim DON stated that a possible negative outcome for not providing written documentation of the resolution would be that the resident would feel a lapse of communication in the facility, that a resident may forget that they were talked to about the grievance and feel that their grievance was not heard. <BR/>Record Review of facility's Grievance Policy (Revision Date: 11/19/2016, 7/22/2023) reflected in part: .The Administrator (grievances officer) is responsible for the following: Validates designee follows up with the resident/family regarding resolution or explanation. Ensure that residents either individually or through postings throughout the facility are aware of: The right to file grievances orally, or in writing in the language he/ she understands,<BR/>The right to file grievances anonymously,<BR/>The contact information of grievance official<BR/>Ensure that the grievance officer's information is posted to include: his/her name, business address (mailing and e-mail) and business phone number. <BR/>A reasonable expected time frame for completing the review of the grievance. <BR/>The contact information of independent entities with which grievances may be filed. E.g.: The pertinent state agency, Quality improvement Organization, State Survey Agency and State Long Term Care Ombudsman program or protection and advocacy system. Provide a copy of the grievance policy to the resident upon request . The grievance policy did not mention the right to obtain a written decision regarding his or her grievance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #1) of 5 residents reviewed for accident and hazards: <BR/>1. The facility failed to ensure Resident #1 had his floor mat by his bedside while lying asleep in his bed.<BR/>2. The facility failed to ensure Resident #1 wore his head helmet to prevent injuries from accidental falls.<BR/>These failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues as a result of accident hazards.<BR/>Findings included: <BR/>Record review of resident #1's face sheet revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were Hypertension (High blood pressure), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebellar ataxia (inability to control voluntary muscle movements). <BR/>Record review of resident #1's Comprehensive MDS dated [DATE] revealed Resident #1 had a BIMs score of 03 indicating the resident was severely cognitively impaired. The resident required extensive assistance with one person physical assist with bed mobility, locomotion on and off unit, eating, and personal hygiene. The resident required total dependence to walk in room, to walk in corridor, dressing, and toilet use. MDS did not code Resident #1 for helmet.<BR/>Record Review of Resident #1's Care Plan dated 12/26/2022 read in part , helmet to be worn while awake to aid in prevention of head injury related to falls. Fall Risk Screening upon admission and quarterly to identify risks factors and floor mat . <BR/>Record Review of Resident #1's Fall Prevention Protocol dated 05/18/2021 read in part . a near miss, also considered a fall, was when a resident would have fallen if someone else had not caught the resident from doing so. Each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. Implement at risk fall care plan; provide additional interventions as directed by resident's assessment, including but not limited to assistive devices, low bed, increased frequency of rounds and sitter if indicated .<BR/>Observation on 1/20/2023 at 11:20 a.m. revealed Resident #1 lying in bed asleep. The floor mat was not on the floor by resident #1's bedside.<BR/>Observation on 1/20/203 at 12:55 p.m., revealed Resident #1 awake and eating. Resident #1 was not wearing his preventive injury helmet. <BR/>Observation on 1/20/2023 at 1:20 p.m. revealed Resident #1 in his bed sitting up. He was not wearing helmet.<BR/>Observation on 1/20/2023 at 2:36 p.m. revealed Resident #1 in bed sitting up and alert. He was not wearing his preventive injury helmet. <BR/>Interview on 1/20/2023 at 10:23 a.m. with LVN A, she said Resident #1 had a couple of falls where he had hit his head on the floor . She said his last fall was on 1/7/2023. She said she did not know how Resident #1 received a black eye. <BR/>Observation and interview on 1/20/2023 at 3:00 p.m. with LVN A, she said she was informed by the surveyor that Resident #1's floor mat was behind his room door and was not put back on the floor by RA after feeding Resident #1. She said the last person to provide care or assist with helping Resident #1 was responsible for putting the floor mat back on the floor. She said she would speak with the RA about the floor mat not being place back on the floor for Resident #1.<BR/>Interview on 1/20/2023 at 3:39 p.m. with the RA, she said the importance of a floor mat was to protect a resident if in case they fell off their bed when residents were fall risks. She said she nursing staff was supposed to remove floor mats when performing patient care. She said she should have placed Resident #1's floor mat by resident's bedside but she had a lot going on and it slipped her mind. She said the helmet protected Resident #1's from head injuries due to resident #1 being a fall risk. She said the only time she had seen him with his helmet on was when he was sitting in his chair. She said the last time she was in-serviced for fall prevention was this month. She could not recall the exact. She said she was aware of fall prevention protocols because she had taken courses when she received her certification to become a CNA. She said when she was done feeding Resident #1, she kept him up for 30 minutes to avoid resident aspirating. She said she was supposed to placed the floor mat after feeding Resident #1. <BR/>Interview on 1/20/23 at 3:39 p.m. with LVN A, she said she nursing staff were supposed to conduct rounds on the residents at the facility every two hours. She said if she noticed nursing staff were not following policy and procedure, she would ask them what happened and remind them to adhere to the rules. She said the importance of the floor mat was to help with cushioning if someone fell to the floor. She said it also help avoid injuries and pain. She said Resident #1 wore a helmet because he had head injuries from falls in the past few months. She said he wore his helmet when he was in his wheelchair in common areas. She said when he was in his wheelchair, he had the ability to stand upright. She said Resident #1 did not seem restless today so she wasn't worried that he was not wearing his helmet. She said she had been working at the facility for 6 months. She said she did not know Resident #1's was care planned for wearing his preventive injury helmet while resident #1 was awake. She said she had oversight of the nursing staff in her Unit. She said the risk to the resident for not having floor mat by bedside while the resident was in bed was injury. She said the risk to Resident #1 for having his preventive injury helmet on while awake was risk of injury. She could not say why the failure occurred. She could not recall the last time staff was in-serviced for fall prevention or accidents and hazards.<BR/>Record Review of the facility's policy titled, Fall Management System revised on 1/03/2017 read in part . it is the policy of the facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on research on the resident's assessed needs. A fall occurs when there is an unintentional coming to rest on the floor, ground, or other lower level but not because of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. A fall is often the result of cumulative risk from both intrinsic (resident-related) and extrinsic (environmental) factors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident receives, and the facility provides food that accommodates resident allergies, intolerances, and preferences for 1 (Resident #2) of 5 residents reviewed, in that:<BR/> [NAME] A denied Resident #2, the 2 cheese flour tortillas requested on his breakfast meal ticket every morning. <BR/>This failure could place residents at risk for decreased quality of life and weight loss. <BR/>Findings included:<BR/>Record review of Resident #2's face sheet revealed a sixty-year-old man who was admitted to the facility on [DATE]. His admitting diagnoses was Parkinson's Disease (disorder that affects the nervous system and the parts of the body controlled by the nerves), kidney failure, reduced mobility, and obesity. <BR/>Record review of Resident #1's MDS assessment completed 07/03/24 revealed a cognitive score of a 15 (cognitively intact) out of 15. Cognitive functioning in relation to eating revealed that supervision and set up was required during meals. <BR/>Record review of Resident #2's care plan revised 01/14/20 that he was a regular diet, regular texture, and was to receive large portions. Interventions were to provide and serve diet as orders. <BR/>In an interview on 08/21/24 at 12:26 p.m., Resident #2 stated he had a problem with his meal ticket. He explained that every morning he was supposed to receive two flour tortillas with cheese but he never got them. Instead, he said he would be given two slices of toast. On the ticket, he explained that this order is always highlighted at the bottom and he informed DM A and the Admin about this occurrence. He could not detail how long his food preference had been denied, but he stated that it had been a long time. He felt that this was being done on purpose and it made him mad. <BR/>In an interview on 08/21/24 at 12:31 p.m., DM A was asked to go through the breakfast meal tickets to view what is requested by Resident #2. At the bottom of the meal ticket, it stated that he was to receive two flour tortillas with cheese and it was highlighted in green. She stated that he told her on 08/20/24 that he had not been receiving his tortillas and she had an in-service with [NAME] A. The in-service instructed her to follow exactly what was on the ticket. [NAME] A was sent home on [DATE] due to insubordination. DM A stated that the dietary staff have to give the residents what they have requested. <BR/>In an interview on 08/21/24 at 1:30 p.m., [NAME] A stated it was her fault that Resident #2 had not gotten his flour tortillas and she recognized that. She then stated that she did not know that he had cheese tortillas on his ticket because another dietary staff would read it out to her while she plated. She stated that on the morning on 08/21/24, the order for the tortillas was on the ticket but it was not read out to her. When asked when he liked those tortillas, she stated that he wanted them Monday-Sunday. She explained that some days he would want multiple tortillas but when they would bring his plate back, they would still be on his plate uneaten. She stated that going forward, she is going to start giving him the requested cheese tortillas. <BR/>In an interview on 08/21/24 at 2:22 p.m., DM A stated that on 08/20/24, she asked [NAME] A to make a requested item for a different resident and she stated she was not going to do it. She did not know what was wrong with [NAME] A, but she was sent home for insubordination. On the morning of 08/21/24, she asked [NAME] A if Resident #2 had his two cheese flour tortillas. She said no and [NAME] A was written up. DM A stated that every day, extra requests are highlighted on the ticket and she knew it be a fact that the dietary aid read the ticket out to her in full. She did not know why she did not make the tortillas for Resident #2. When told that [NAME] A denied knowing that Resident #2 requested the tortillas but later stated that he would not eat them, DM A stated Exactly. If he she didn't know he wanted them, then how does she know that he does not eat them?. <BR/>In an interview on 08/21/24 at 3:57 p.m., the Admin stated that Resident #2 told him on Friday that he had not been receiving his tortillas from his meal ticket. He told me to look at his meal ticket and it said that he was to receive two flour tortillas. He stated that he went to dietary and the DM said she would handle it, but apparently he did not receive flour tortillas on 08/21/24 or 08/20/24. <BR/>Record review of the Employment Action/Disciplinary Notice Form dated 08/21/24 revealed that [NAME] A was written up because Resident #2 had not received his 2 flour tortillas as it was written his tray ticket. The summary stated that her behavior was not acceptable and it would not be tolerated. <BR/>Record review of the Culinary Specialist Job responsibilities (not dated) displayed that they were to prepare quality food and baked goods according to the planned menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who needed colostomy (stool or urine collection pouch that is attached to the skin) care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (CR #1, R #2) of seven residents reviewed for colostomies and catheter care.<BR/>The facility failed to:<BR/>-Ensure CR #1 and R #2's catheter was emptied per shift as ordered by physician.<BR/>-This failure placed residents with a colostomy at risk of in delay in treatment/care, infection, discomfort, decreased quality of care.<BR/>Findings Included:<BR/>Record review of CR #1's undated face sheet revealed a [AGE] year-old who male who was initially admitted to the facility on [DATE] and re-admitted on [DATE] and discharged [DATE]. Resident had diagnoses of Paraplegia (paralysis that affects all or part of the trunk, legs and pelvic organs), Colostomy, chronic pain, and disease of spinal cord (Curving spine).<BR/>Record review of CR#1's quarterly MDS (assessment tool) dated 03/01/2024 revealed a BIMS Score of 15, indicating no Cognitive Impairment. Section H (Bladder and Bowel) reflected he had an Indwelling Catheter (held in the in the bladder by a water-filled balloon, which prevents it falling out) and Ostomy Bag (used to collect waste from surgical openings in the intestines or bladder).<BR/>Record review of CR#1's physician's order dated 2/23/2024 revealed, provide Urinary Catheter (flexible tube used to empty the bladder and collect urine) care every shift, change bag along with the catheter if visible soiled, to collect a urine specimen, or if the closed system has been compromised. <BR/>Record review of CR#1's Care Plan dated 2/23/2024 revealed CR#1 has a urinary catheter (flexible tube used to empty the bladder and collect urine) and is at risk for urinary tract infections and injury related to his suprapubic catheter (A hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen); monitor and document output; Change urinary catheter per routine schedule, if leaking, or if a blockage is present as ordered by the physician, provide urinary care per facility practice and provide incontinent care as needed. <BR/>Record review of CR#1's EMS records dated 3/13/2024 revealed, at contact CR#1 had over 2000ml of urine in the bag and told EMS staff would not help him. The report revealed colostomy and foley catheters were present. <BR/>Record review of CR#1's hospital record dated 3/13/2024 upon admittance records revealed, CR #1 presenting with foul odor in urine for a week. This is a 44 yo M with PMH HTN, HLD, paraplegia s/p GSW, with colostomy & SP catheter, here with lower abd pain, positive urine cultures. Pt with UA on 3/7, cultures came back but never got the abx from his facility - [name of facility]. Pt (Patient) with increasing abd (abdominal) pain, tremors in legs. Pt states his call light was taken away from him at his facility. A/w nausea.<BR/>Record review of R#2's undated face sheet reveal, [AGE] year-old who male who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident had diagnoses of Benign urinary tract symptoms (frequent or urgent need to urinate), Parkinson's Disease (central nervous system disorder), neuromuscular dysfunction of bladder (people who lack control of their bladder due to a brain, spinal cord or nerve problem), urinary tract infection (an infection in any part of your urinary system), and retention of urine.<BR/>Record review of R#2's MDS dated [DATE] revealed a BIMS Score of 15, indicating no Cognitive Impairment. Section H (Bladder and Bowel) reflected he has an Indwelling Catheter. <BR/>Record review of R#2's physician's order dated 5/22/2023 revealed, Catheter care should be secured in place every shift for Urinary Catheter use, change catheter if it becomes occluded, to obtain a urine specimen, or if the closed system has become compromised, every shift for urinary retention related to obstructive and reflux uropathy, Change the BSD (cover) bag along with the catheter if visibly soiled, to collect a urine specimen, or if the closed system has been compromised, as needed for care, <BR/>Record review of R#2's Care Plan dated 5/22/2023 revealed resident has a urinary foley catheter due to Neurogenic bladder. Monitor for and report to the physician any signs or symptoms of urinary tract infections. Change urinary catheter per routine schedule, if leaking, or if a blockage is present as ordered by the physician, provide urinary care per facility practice and provide incontinent care as needed. Monitor and document output. <BR/>Review of Nursing notes dated 3/12/2024 at 8:27am, CR#1 refused to allow staff to collect urine for C/S and also last night. <BR/>On 3/14/2024 at 6:30pm - Interview with CR#1, while he was in the hospital. CR#1 stated he had been in the facility for only six months and has not received proper medical care or medications. He further stated the facility does not communicate with him. CR#1 stated he has had a Urinary Tract Infection in the past. He stated his urine bag was always left full to the capacity the bag can hold and urine was always backing up in the tubes toward entry.<BR/>On 3/19/2024 at 11:00am Observation during rounds of the facility revealed R#2's foley bag to be full to its capacity. <BR/>On 3/19/2024 at 11:11am-Interview with R#2 stated no one has changed his foley bag today. He stated 3rd shift hardly changes his bag and its always full. He states he cannot remember the last time the bag has been changed. He stated his foley bag may have been changed yesterday during the day shift but can't remember. <BR/>On 3/19/2024 at 11:50am-Interview and observation with LVN A who stated she arrived on her shift this morning at 6:00am and did not observe his bag to be full. She stated the CNA usually empty the bag at the end of the shift and give the output numbers to the LVN. She stated the CNA has not emptied the bag today. LVN A was asked to look at the foley bag to see if the amount of urine in the foley bag was acceptable. LVN A stated it was not acceptable and the bag should have been emptied. She stated the results of a full foley bag can cause the resident to have a UTI. LVN A emptied the bag at this time. <BR/>On 3/19/2024 at 12:02pm-Interview with CNA A who stated CR#1 requires staff to allow him to be independent. She states he has an electric wheelchair and does for himself. He watches himself and he empty's his own foley bag. She stated nursing staff was aware of this. She stated he will also record his output and relay the information. She stated a lot of times you come in the room just to get the output numbers for nursing staff, and he has already emptied his bag. It depends on how he's feeling if he gives you the information or not. She stated management staff was aware of this issue. <BR/>Referenced to R#2, CNA A stated she has not emptied R#2's foley bag today. She stated she has not had a lot of time as she was responsible for another resident who has a higher level of care. However, CNA A stated it was important to empty foley bags before they were full because urine could back up and resident could get a UTI or another infection. <BR/>On 3/19/2024 at 1:30pm-Interview with LVN B who stated CR#1 was extremely difficult. LVN B stated he refuses to cooperate with staff regarding his treatment. LVN B stated he refused wound care and other care as well. <BR/>On 3/19/2024 at 3:50pm-Interview with CNA C who stated CR#1 refused care a lot. She stated she was very familiar with CR#1 and stated he has an electric wheelchair and would go to the bathroom and empty his own foley bag. She stated he refused to allow staff to empty his bag. Also, the foley bags were to be emptied at the end of the shift, then CNA gives the output number to nursing staff. CNA C stated a lot of the issues come because night shift does not empty the bags. <BR/>On 3/19/2024 at 4:25pm-Interview with the DON who stated the CNAs were to empty the bag and give the output to the nurse to be recorded. The DON stated there should not be any full catheter bags, which can back-up and cause infections. The DON stated, while the practice was to give the output numbers at the end of the shift, the CNAs were required to constantly monitor throughout all shifts. The DON stated, A full foley bag was unacceptable. <BR/>On 3/19/2024 at 4:34pm- during the exit interview, the Admin indicated the CNA's work 12-hour shifts. She further stated that throughout the shift all nursing staff should monitor the bags so they will not get full and suggested to the DON and ADON management staff would have to come into the facility during the night to monitor and ensure staff are attentive to residents as required. <BR/>Record review of the facility's policy and procedure dated 5/23/2014 and reviewed 2/10/2020 on Indwelling Foley Catheter Guidelines revealed, facility shall identify and access patients with an indwelling catheter or at risk for catheterization, provide appropriate treatment and services to prevent urinary tract infections and to achieve or maintain as much normal bladder function as possible, and ensure that indwelling catheters are medically necessary. Maintain unobstructed urine flow by changing indwelling catheters or drainage bags at routine. It is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 infection for 1 of 2 residents (Resident #1) reviewed for infection control.<BR/>-The facility failed to ensure CNA J performed hand hygiene during incontinent care on Resident #1.<BR/>This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. <BR/>Findings included:<BR/>Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit (trouble reasoning and making decisions while communicating) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 07/26/2024, revealed the BIMS score was 05 out of 15, which indicated her cognition was severely impaired. The MDS revealed she was dependent on staff with toileting, shower/baths, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS revealed .<BR/>Record review of Resident #1's care plan, initiated 02/17/2024 and revised on 06/06/24 revealed the following: <BR/>Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to muscle weakness. <BR/>Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. <BR/>Interventions: Bed Mobility: total x 1 assist. Transfers: total x 1 assist. Eating: set-up/ clean up<BR/>Toileting: dependent x 1 assist. Ambulation: n/a. Wheelchair: independent short distances --mostly propelled per staff. Dressing: dependent x 1 assist. Personal Hygiene: dependent x 1. Bathing: dependent x 1 assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Encourage resident to participate to the fullest extent possible with each interaction and praise when attempts are made.<BR/>Observation on 08/16/24 at 12:16 p.m., revealed CNA J provided Resident #1 with incontinence care. CNA J did not complete hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. CNA J unfasten Resident #1's brief and tucked it under the resident's buttocks. CNA J turned the Resident over and did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus. CNA J removed the soiled brief and discarded it into the trash can sitting near resident's foot of bed. CNA J wiped twice, removed her soiled gloves without washing or sanitizing her hands donned clean gloves. CNA J completed incontinent care and with the same soiled gloves touched the Resident's clean dress, brief, and sheets . <BR/>In an interview on 08/16/24 at 2:08 p.m., with CNA J, she said she started working full time at the facility last month. She said she did not recall doing CNA competency checks for incontinent care. CNA J said not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-services on infection control at the time of hire. <BR/>In an interview on 8/16/24 at 2:15 p.m., with the Wound Care Nurse, she said CNA J should have either washed or sanitized her hands in between gloves change as it placed the resident at risk for infections. <BR/>In an interview on 8/16/24 at 3:06p.m., with ADON B, she said she was the facility's infection preventionist. She said she provided mandatory infection control in-service to staff monthly, quarterly and as needed. She said CNA J was new to the building but not to long term care. She said staff should wash/sanitize their hands upon entering a resident's room, in between glove changes, and before leaving the resident's room. <BR/>In an interview on 08/16/24 at 4:48p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care each time they perform incontinent care. She said Wound Care Nurse brought it to her attention that CNA J failed to performed hand hygiene during incontinent care on Resident#1. She said the CNA should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said these failures were risk for infection control . <BR/>Record review of facility's In-Service Program Attendance Record dated 8/14/2024 revealed Topic: Hand Hygiene was signed by CNA J. <BR/>Record review of facility's Hand Hygiene Policy (Date implemented: 11/12/2017) revealed read in part: .Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6.Additional considerations: a. The use of antimicrobial-impregnated wipes (i.e. towelettes) are not a substitute for using an alcohol-based hand rub or antimicrobial soap. b. The use of gloves does not replace hand washing. Wash hands after removing gloves .<BR/>Record review of facility's infection control Guidelines (Revision Date: 9/22/2015) revealed read in part: .Anticipated Outcome: The purpose of this policy is to reduce and prevent the spread of infections by the use of evidence based techniques established infection control policies and procedures. 3.Hand Hygiene Protocol: a. Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty. b. Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing care to patients in isolation. c. For routine patient care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact. d. Hands shall be washed in accordance with our facility's established hand washing procedure .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement an effective discharge process that focused on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition them to post discharge care for 2 of 3 residents (CR # 1 and #2) reviewed for an effective discharge process.<BR/>-CR#1 was discharged on 05/17/2024 and a discharge summary was not completed.<BR/>-CR#2 was discharged on 06/04/2024 and a discharge summary was not completed.<BR/>These failures could affect residents who are discharged from the facility by not providing a recapitulation of the residents stay and a final summary of the residents' status for any continuation of care that may be required.<BR/>Findings included:<BR/>CR#1<BR/>Record review of CR#1's face Sheet (undated) revealed, a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included: cerebral infarction (refers to damage to tissue in the brain due to a loss of oxygen to the area), cerebral edema (swelling of the brain), and moyamoya disease (disorder of blood vessels in the brain). CR#1 was discharged on 05/17/2024.<BR/>Record review of CR#1's Care Plan initiated 11/19/2020 and updated on 05/30/2024 revealed the following: <BR/>Focus: Resident has an ADL Self Care Performance Deficit and was at risk for not having their needs met in a timely manner. Goal: Resident will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date. Interventions: Transfers: Per Hoyer x 2-person<BR/>Record review of CR#1's Discharge MDS dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognitively. Further review of Section A0310. Types of Assessment: F. Entry/discharge reporting coded-10: Discharge assessment-return not anticipated. Section A2105. Discharge Status coded-04: Short-Term General Hospital<BR/>Record review of CR#1's Social Worker notes dated 5/13/2024 at 12:04pm revealed read in part: .Social Worker spoke to [name] who is the RP and family member for [CR#1]. SW asked if he would like for a referral to be submitted to [facility name], and he stated that he would like the referral to be sent. Referral to [facility name] was sent to [name], the admissions coordinator .<BR/>Record review of CR #1's clinical record revealed no evidence of discharge planning and no discharge assessment. <BR/>Record review and interview on 06/21/24 at 1:37p.m., RN AA said nurses initiated the discharge summary and the DON reviewed and signed for completion. RN AA reviewed CR#1's electronic medical records with the State Surveyor. RN AA said, I don't see the discharge Summary for CR#1. <BR/>Record review and interview on 06/21/24 at 2:30p.m., ADON B said at the time of discharge nurses entered the DC orders and filled out the Discharge Summary form. The State Surveyor reviewed CR#1's EMR with ADON B. ADON B said she completed the functional abilities and goals discharge form today (6/21/24) but failed to complete the Discharge summary and plan of care form. ADON B said the expectation for the nurses were to fill these forms out within 24 to 72 hours of discharge.<BR/>CR#2<BR/>Record review of CR#2's face Sheet (undated) revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: heart failure ( a condition that develops when your heart doesn't pump enough blood for your body's needs), acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). CR#2 was discharged on 06/04/2024.<BR/>Record review of CR#2's Care Plan initiated 01/19/2024 and updated on 06/05/2024 revealed the following: <BR/>Focus: Resident was in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide selfcare and discharge planning was not needed. Goal: Resident and families wishes will be honored through the next review date. Interventions: Observe for change in conditions that may affect long-term care goals and notify the physician and responsible party as needed.<BR/>Record review of CR#2's Discharge MDS dated [DATE] revealed Section A0310. Types of Assessment: F. Entry/discharge reporting coded-10: Discharge assessment-return not anticipated. Section A2105. Discharge Status coded-04: Short-Term General Hospital.<BR/>Record review of CR#2 nurses noted dated 06/04/24 at 8:35p.m., revealed read in part: .Res found smoking marijuana in his car at the parking lot. Administrator confronted the res about this behavior, and the res was little aggressive. Administrator called 911. The police arrived, upon searching the res car, the police discovered that the res had a firearm in his car per Administrator. The police took the res. The writer notified the Md .<BR/>Record review of CR #2's clinical record revealed no evidence of discharge planning and no discharge assessment. <BR/>Record review and interview on 06/21/24 at 3:05p.m., ADON A said prior to being planned/unplanned discharge nurses initiated the discharge summary and each discipline were responsible for completing their own part. ADON A said he expected the interdisciplinary discharge summaries to be completed and sent with the resident at the time of discharge. ADON A said discharge assessments were important to be completed so the resident would know his or her limitations, and recommendations from other departments for example PT for discharge. ADON A said, usually the DON was responsible for closing out discharge documents, but the DON had been out for couple of days in training. ADON A said the ADONs and nurses could also go in assessments and complete/close the forms as well. ADON A said he completed the functional abilities and goals discharge form, discharge summary and plan of care form for CR#2 today (6/21/24). <BR/>In an interview on 06/21/24 at 3:38p.m., with the Administrator, she said she reviewed CR#1's Social Worker's notes and CR#1 was transferred to another facility. She said, I don't know where CR#2 went after the law enforcement took him from the facility. <BR/>Record review of facility's Discharge Planning policy dated (12/6/2016) revealed read in part: .Discharge Summary: Post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who needed colostomy (stool or urine collection pouch that is attached to the skin) care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (CR #1, R #2) of seven residents reviewed for colostomies and catheter care.<BR/>The facility failed to:<BR/>-Ensure CR #1 and R #2's catheter was emptied per shift as ordered by physician.<BR/>-This failure placed residents with a colostomy at risk of in delay in treatment/care, infection, discomfort, decreased quality of care.<BR/>Findings Included:<BR/>Record review of CR #1's undated face sheet revealed a [AGE] year-old who male who was initially admitted to the facility on [DATE] and re-admitted on [DATE] and discharged [DATE]. Resident had diagnoses of Paraplegia (paralysis that affects all or part of the trunk, legs and pelvic organs), Colostomy, chronic pain, and disease of spinal cord (Curving spine).<BR/>Record review of CR#1's quarterly MDS (assessment tool) dated 03/01/2024 revealed a BIMS Score of 15, indicating no Cognitive Impairment. Section H (Bladder and Bowel) reflected he had an Indwelling Catheter (held in the in the bladder by a water-filled balloon, which prevents it falling out) and Ostomy Bag (used to collect waste from surgical openings in the intestines or bladder).<BR/>Record review of CR#1's physician's order dated 2/23/2024 revealed, provide Urinary Catheter (flexible tube used to empty the bladder and collect urine) care every shift, change bag along with the catheter if visible soiled, to collect a urine specimen, or if the closed system has been compromised. <BR/>Record review of CR#1's Care Plan dated 2/23/2024 revealed CR#1 has a urinary catheter (flexible tube used to empty the bladder and collect urine) and is at risk for urinary tract infections and injury related to his suprapubic catheter (A hollow flexible tube that is used to drain urine from the bladder through a cut in the abdomen); monitor and document output; Change urinary catheter per routine schedule, if leaking, or if a blockage is present as ordered by the physician, provide urinary care per facility practice and provide incontinent care as needed. <BR/>Record review of CR#1's EMS records dated 3/13/2024 revealed, at contact CR#1 had over 2000ml of urine in the bag and told EMS staff would not help him. The report revealed colostomy and foley catheters were present. <BR/>Record review of CR#1's hospital record dated 3/13/2024 upon admittance records revealed, CR #1 presenting with foul odor in urine for a week. This is a 44 yo M with PMH HTN, HLD, paraplegia s/p GSW, with colostomy & SP catheter, here with lower abd pain, positive urine cultures. Pt with UA on 3/7, cultures came back but never got the abx from his facility - [name of facility]. Pt (Patient) with increasing abd (abdominal) pain, tremors in legs. Pt states his call light was taken away from him at his facility. A/w nausea.<BR/>Record review of R#2's undated face sheet reveal, [AGE] year-old who male who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident had diagnoses of Benign urinary tract symptoms (frequent or urgent need to urinate), Parkinson's Disease (central nervous system disorder), neuromuscular dysfunction of bladder (people who lack control of their bladder due to a brain, spinal cord or nerve problem), urinary tract infection (an infection in any part of your urinary system), and retention of urine.<BR/>Record review of R#2's MDS dated [DATE] revealed a BIMS Score of 15, indicating no Cognitive Impairment. Section H (Bladder and Bowel) reflected he has an Indwelling Catheter. <BR/>Record review of R#2's physician's order dated 5/22/2023 revealed, Catheter care should be secured in place every shift for Urinary Catheter use, change catheter if it becomes occluded, to obtain a urine specimen, or if the closed system has become compromised, every shift for urinary retention related to obstructive and reflux uropathy, Change the BSD (cover) bag along with the catheter if visibly soiled, to collect a urine specimen, or if the closed system has been compromised, as needed for care, <BR/>Record review of R#2's Care Plan dated 5/22/2023 revealed resident has a urinary foley catheter due to Neurogenic bladder. Monitor for and report to the physician any signs or symptoms of urinary tract infections. Change urinary catheter per routine schedule, if leaking, or if a blockage is present as ordered by the physician, provide urinary care per facility practice and provide incontinent care as needed. Monitor and document output. <BR/>Review of Nursing notes dated 3/12/2024 at 8:27am, CR#1 refused to allow staff to collect urine for C/S and also last night. <BR/>On 3/14/2024 at 6:30pm - Interview with CR#1, while he was in the hospital. CR#1 stated he had been in the facility for only six months and has not received proper medical care or medications. He further stated the facility does not communicate with him. CR#1 stated he has had a Urinary Tract Infection in the past. He stated his urine bag was always left full to the capacity the bag can hold and urine was always backing up in the tubes toward entry.<BR/>On 3/19/2024 at 11:00am Observation during rounds of the facility revealed R#2's foley bag to be full to its capacity. <BR/>On 3/19/2024 at 11:11am-Interview with R#2 stated no one has changed his foley bag today. He stated 3rd shift hardly changes his bag and its always full. He states he cannot remember the last time the bag has been changed. He stated his foley bag may have been changed yesterday during the day shift but can't remember. <BR/>On 3/19/2024 at 11:50am-Interview and observation with LVN A who stated she arrived on her shift this morning at 6:00am and did not observe his bag to be full. She stated the CNA usually empty the bag at the end of the shift and give the output numbers to the LVN. She stated the CNA has not emptied the bag today. LVN A was asked to look at the foley bag to see if the amount of urine in the foley bag was acceptable. LVN A stated it was not acceptable and the bag should have been emptied. She stated the results of a full foley bag can cause the resident to have a UTI. LVN A emptied the bag at this time. <BR/>On 3/19/2024 at 12:02pm-Interview with CNA A who stated CR#1 requires staff to allow him to be independent. She states he has an electric wheelchair and does for himself. He watches himself and he empty's his own foley bag. She stated nursing staff was aware of this. She stated he will also record his output and relay the information. She stated a lot of times you come in the room just to get the output numbers for nursing staff, and he has already emptied his bag. It depends on how he's feeling if he gives you the information or not. She stated management staff was aware of this issue. <BR/>Referenced to R#2, CNA A stated she has not emptied R#2's foley bag today. She stated she has not had a lot of time as she was responsible for another resident who has a higher level of care. However, CNA A stated it was important to empty foley bags before they were full because urine could back up and resident could get a UTI or another infection. <BR/>On 3/19/2024 at 1:30pm-Interview with LVN B who stated CR#1 was extremely difficult. LVN B stated he refuses to cooperate with staff regarding his treatment. LVN B stated he refused wound care and other care as well. <BR/>On 3/19/2024 at 3:50pm-Interview with CNA C who stated CR#1 refused care a lot. She stated she was very familiar with CR#1 and stated he has an electric wheelchair and would go to the bathroom and empty his own foley bag. She stated he refused to allow staff to empty his bag. Also, the foley bags were to be emptied at the end of the shift, then CNA gives the output number to nursing staff. CNA C stated a lot of the issues come because night shift does not empty the bags. <BR/>On 3/19/2024 at 4:25pm-Interview with the DON who stated the CNAs were to empty the bag and give the output to the nurse to be recorded. The DON stated there should not be any full catheter bags, which can back-up and cause infections. The DON stated, while the practice was to give the output numbers at the end of the shift, the CNAs were required to constantly monitor throughout all shifts. The DON stated, A full foley bag was unacceptable. <BR/>On 3/19/2024 at 4:34pm- during the exit interview, the Admin indicated the CNA's work 12-hour shifts. She further stated that throughout the shift all nursing staff should monitor the bags so they will not get full and suggested to the DON and ADON management staff would have to come into the facility during the night to monitor and ensure staff are attentive to residents as required. <BR/>Record review of the facility's policy and procedure dated 5/23/2014 and reviewed 2/10/2020 on Indwelling Foley Catheter Guidelines revealed, facility shall identify and access patients with an indwelling catheter or at risk for catheterization, provide appropriate treatment and services to prevent urinary tract infections and to achieve or maintain as much normal bladder function as possible, and ensure that indwelling catheters are medically necessary. Maintain unobstructed urine flow by changing indwelling catheters or drainage bags at routine. It is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 (Resident #203) of 4 residents reviewed for baseline care plans.<BR/>Resident #203 was admitted on [DATE] but the facility failed to ensure her baseline care plan was initiated until 12/29/23. <BR/>This failure could result in newly admitted residents not receiving person-centered care in a timely manner.<BR/>Findings include:<BR/>Record review of Resident #203's dated 12/19/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to Unspecified Dementia without behavioral disturbance (Dementia is the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Dysphagia, Oropharyngeal (swallowing problems occurring in the mouth and/or the throat) , Dysarthria and Anarthira (Dysarthria is a motor speech disorder resulting from impaired neuromuscular control over speech production [2]. The most severe form of dysarthria is anarthria meaning a complete loss of speech.), Demyelinating Disease of Central Nervous System (condition that causes a damage to the myelin in your brain, spinal cord and nerves.), Contracture of muscle (A contracture occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity.).<BR/>Record review of Resident #203's clinical records revealed that there was no Care Plan in the facility's electronic health records system. <BR/>During an interview on 12/29/32 at 1:45 PM, the Director of Nursing (DON) confirmed that the base line care plan was not initiated. The DON stated that baseline care plans should be completed within 48 hours of a resident's admission. The DON stated that the MDS Nurse was responsible for completing residents' care plans. <BR/>An Interview on 12/29/23 at 2:23 PM with the MDS Coordinator revealed she left early on the day Resident# 203 was admitted to the facility. She said, Care plans are considered part of the admitting and assessment process, and any nurse can initiate a baseline care plan. She stated that she was not tracking that this resident had not received a baseline care plan, and there was no Care Plan Meeting scheduled for Thursday, 12/28/23 or the upcoming Thursday. She stated that Thursdays are the usual scheduled day for Care Plan meetings with residents and their families, but she would contact them today to get it done as soon as possible. The MDS Coordinator stated that if a baseline care plan was not completed on a resident in 48 hours, the concern would be that a resident might not have gotten the care they needed, and it can cause delayed services and payments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 infection for 1 of 2 residents (Resident #1) reviewed for infection control.<BR/>-The facility failed to ensure CNA J performed hand hygiene during incontinent care on Resident #1.<BR/>This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. <BR/>Findings included:<BR/>Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit (trouble reasoning and making decisions while communicating) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 07/26/2024, revealed the BIMS score was 05 out of 15, which indicated her cognition was severely impaired. The MDS revealed she was dependent on staff with toileting, shower/baths, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS revealed .<BR/>Record review of Resident #1's care plan, initiated 02/17/2024 and revised on 06/06/24 revealed the following: <BR/>Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to muscle weakness. <BR/>Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. <BR/>Interventions: Bed Mobility: total x 1 assist. Transfers: total x 1 assist. Eating: set-up/ clean up<BR/>Toileting: dependent x 1 assist. Ambulation: n/a. Wheelchair: independent short distances --mostly propelled per staff. Dressing: dependent x 1 assist. Personal Hygiene: dependent x 1. Bathing: dependent x 1 assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Encourage resident to participate to the fullest extent possible with each interaction and praise when attempts are made.<BR/>Observation on 08/16/24 at 12:16 p.m., revealed CNA J provided Resident #1 with incontinence care. CNA J did not complete hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. CNA J unfasten Resident #1's brief and tucked it under the resident's buttocks. CNA J turned the Resident over and did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus. CNA J removed the soiled brief and discarded it into the trash can sitting near resident's foot of bed. CNA J wiped twice, removed her soiled gloves without washing or sanitizing her hands donned clean gloves. CNA J completed incontinent care and with the same soiled gloves touched the Resident's clean dress, brief, and sheets . <BR/>In an interview on 08/16/24 at 2:08 p.m., with CNA J, she said she started working full time at the facility last month. She said she did not recall doing CNA competency checks for incontinent care. CNA J said not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-services on infection control at the time of hire. <BR/>In an interview on 8/16/24 at 2:15 p.m., with the Wound Care Nurse, she said CNA J should have either washed or sanitized her hands in between gloves change as it placed the resident at risk for infections. <BR/>In an interview on 8/16/24 at 3:06p.m., with ADON B, she said she was the facility's infection preventionist. She said she provided mandatory infection control in-service to staff monthly, quarterly and as needed. She said CNA J was new to the building but not to long term care. She said staff should wash/sanitize their hands upon entering a resident's room, in between glove changes, and before leaving the resident's room. <BR/>In an interview on 08/16/24 at 4:48p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care each time they perform incontinent care. She said Wound Care Nurse brought it to her attention that CNA J failed to performed hand hygiene during incontinent care on Resident#1. She said the CNA should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said these failures were risk for infection control . <BR/>Record review of facility's In-Service Program Attendance Record dated 8/14/2024 revealed Topic: Hand Hygiene was signed by CNA J. <BR/>Record review of facility's Hand Hygiene Policy (Date implemented: 11/12/2017) revealed read in part: .Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6.Additional considerations: a. The use of antimicrobial-impregnated wipes (i.e. towelettes) are not a substitute for using an alcohol-based hand rub or antimicrobial soap. b. The use of gloves does not replace hand washing. Wash hands after removing gloves .<BR/>Record review of facility's infection control Guidelines (Revision Date: 9/22/2015) revealed read in part: .Anticipated Outcome: The purpose of this policy is to reduce and prevent the spread of infections by the use of evidence based techniques established infection control policies and procedures. 3.Hand Hygiene Protocol: a. Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty. b. Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing care to patients in isolation. c. For routine patient care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact. d. Hands shall be washed in accordance with our facility's established hand washing procedure .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate, acquiring, receiving, dispensing, and administering all of drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 4 residents reviewed for pharmacy services.<BR/>1. The facility failed to administer the medications Amlodipine Besylate medication had blanks in the MAR from 01/13/23- 01/17/23.; Digoxin Tablet 125 MCG 0.5 tablet had blanks in the MAR from 01/07/23- 01/17/23; Melatonin had blanks in the MAR from 01/07/23- 01/17/23; Metformin HCl Tablet 500 MG had blanks in the MAR from 01/07/23- 01/17/23; Artificial Tears Solution 1 % had blanks in the MAR from 01/07/23- 01/17/23 at 8AM, and 01/07/23- 01/16/23 for the 4PM; Cymbalta Capsule Delayed Release Particles 60 MG had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 5PM; Lidocaine Pain Relief 4 % Patch had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 8PM; and Tramadol HCl Tablet 50 MG had blanks in the MAR from 01/07/23- 01/17/23 at 7AM, and 01/07/23- 01/16/23 for the 7PM to Resident #1.<BR/>This deficient practice affected Resident #1 and placed other residents at risk of having missed medications that could lead to diseases getting worse and/or hospitalization.<BR/>Findings:<BR/>Record review of Resident #1's face sheet dated 01/20/2023 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were muscle weakness, pain in knee, unspecified osteoarthritis, pain in left hand, muscle wasting and atrophy, and osteoarthritis of the knee.<BR/>Record review of Resident #1's Entry MDS dated [DATE] reflected the resident had a BIMS score of 15 out of 15 indicating the resident was cognitively intact. The resident required oversight and encouragement with Bed mobility, Transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, eating with one person assist, toilet use, and personal hygiene.<BR/>Record review of Resident #1's Care Plan dated 12/15/2022 reflected in part . Focus: Has Delusions. Periods of isolation and depression. Resident takes Trazodone and Cymbalta daily related to diagnoses of Major Depression, anxiety and insomnia. Goal: Resident will not have delusions or hallucinations. She will have less episodes of isolation and will maintain the highest level of function possible. Intervention: Give medication and monitor for side effects. Focus: Resident has a diagnosis of diabetes and is at risk for unstable blood sugars and abnormal lab results. Goal: Resident will be free from the signs and symptoms of hyper (high blood glucose (blood sugar))/hypoglycemia (condition in which your blood sugar (glucose) level is lower than the standard range) and Resident will have a reduced risk for complications related to diabetes through the next review date. Intervention: Administer diabetic medications as ordered by the physician. Focus: The resident has depression and takes antidepressants. Goal: The resident will remain free of s/sx of distress, symptoms of depression, anxiety or sad mood X 90 Days. Administer medications as ordered. Focus: Digoxin, Resident is on digoxin therapy related to tachycardia (medical term for a heart rate over 100 beats a minute). Goal: Resident will be free from the potential adverse reactions. Interventions: Check peripheral pulse (the palpation of the high-pressure wave of blood moving away from the heart through vessels in the extremities following systolic ejection) prior to administration and hold if outside of acceptable parameters as set by the physician. Focus: Behavioral Problem: Resident has a behavior problem. Resident continues to believe that she has lice or bed bugs in her hair. She will become very upset with staff. Goal: Resident will be clean, well groomed, and episodes of physical behaviors will decrease to less than weekly through the next review date. Resident will have less episodes of stating she has lice and or dandruff and the medical staff will collaborate more with psych staff to reduce this situation causing her so much distress. Interventions: Administer medications as ordered. Focus: Hypertension: Resident has hypertension and is at risk for fluctuations in blood pressure. Goal: Resident will remain free of signs and symptoms of hypertension through the review date. Intervention: Administer antihypertensive medications as ordered. Focus: Resident takes psychotropic meds: Cymbalta, Vistaril, Seroquel, trazodone. Goal: Resident will maintain the highest level of function possible and not experience a decrease in functional abilities related to psychotropic use during the next 90 days. Interventions: Administer medications as ordered.<BR/>Record review of Resident #1's physician's orders dated 01/13/2023 reflected Amlodipine Besylate Give 10 mg by mouth in the morning related to Essential (Primary) Hypertension.<BR/>Record review of Resident #1's physician's orders dated 05/18/2021 reflected Digoxin Tablet 125 MCG 0.5 tablet 125 MCG, Give 0.5 tablet by mouth in the morning related to Tachycardia, unspecified.<BR/>Record review of Resident #1's physician orders dated 04/02/2021 reflected Melatonin Tablet 5 MG, Give 1 tablet by mouth at bedtime for insomnia.<BR/>Record review of Resident #1's physician's orders dated 01/13/2021 reflected Metformin HCl Tablet 500 MG Give 1 tablet by mouth in the morning related to Type 2 Diabetes Mellitus with Unspecified Complications.<BR/>Record review of Resident #1's physician orders dated 05/16/2022 reflected Artificial Tears Solution 1 % (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes two times a day for dry eyes.<BR/>Record review of Resident #1's physician orders dated 03/29/2022 reflected Cymbalta Capsule Delayed Release Particles 60 MG, Give 60 mg by mouth two times a day related to Major Depressive Disorder, Recurrent, Severe with Psychotic symptoms.<BR/>Record review of Resident #1's physician orders dated 11/19/2022 reflected Lidocaine Pain Relief 4 % Patch apply 1 patch transdermally every morning and at bedtime for pain.<BR/>Record review of Resident #1's physician orders dated 01/12/2021 reflected Tramadol HCl Tablet 50 MG Give 1 tablet by mouth every 12 hours related to pain related to Pain in Unspecified knee (M25.569); Pain in Left hand (M79.642); Unspecified Osteoarthritis unspecified site.<BR/>Record Review of Resident #1's MAR dated January 2023 revealed the following: Amlodipine Besylate medication had blanks in the MAR from 01/13/23- 01/17/23.; Digoxin Tablet 125 MCG 0.5 tablet had blanks in the MAR from 01/07/23- 01/17/23; Melatonin had blanks in the MAR from 01/07/23- 01/17/23; Metformin HCl Tablet 500 MG had blanks in the MAR from 01/07/23- 01/17/23; Artificial Tears Solution 1 % had blanks in the MAR from 01/07/23- 01/17/23 at 8AM, and 01/07/23- 01/16/23 for the 4PM; Cymbalta Capsule Delayed Release Particles 60 MG had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 5PM; Lidocaine Pain Relief 4 % Patch had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 8PM; and Tramadol HCl Tablet 50 MG had blanks in the MAR from 01/07/23- 01/17/23 at 7AM, and 01/07/23- 01/16/23 for the 7PM.<BR/>Observation and interview on 01/20/23 at 10:30 AM with Resident #1 revealed the resident lying in bed, dressed, and groomed with her call light within reach and water by her bedside table. The resident said she did not get her medications when she was in isolation a couple of weeks ago. She said she did not get her lactulose, dry eye drops, or lidocaine pain patch. She said she told staff she did not get her medications and she had pain, but did not know which staff she told. She did not say how staff responded after resident #1 told staff she didn't get her medications. At the time of the interview Resident #1 did not show any signs or symptoms of pain and did not report any pain. <BR/>Interview on 01/20/23 at 11:47 AM with CNA A, she said she had not seen or heard of residents missing medications. She said Medication Aides/LVNs were responsible for administering medications. She said the nurses had oversight of the Medication Aide to ensure medications were given. She said there was no reason why a resident would not get their medications. She said a resident not receiving their medications could lead to the resident getting sick or cause them harm.<BR/>Interview on 01/20/2023 at 1:35 PM with LVN A, she said she had worked at the facility for about seven months. She worked on Hall 100 and hall 500 as well. She said she worked with Resident #1. She said she put Voltaren gel on the resident's wrist for her osteoarthritis. She said a resident might not get their medications depending on parameters, or if it's PRN, according to orders. She said the MAR was blank 01/07/2023- 01/17/2023 because the resident was isolated due to COVID-19 and transferred to the COVID-19 wing. She said the facility did paper MARs for residents while they were in the COVID-19 wing.<BR/>Interview on 01/20/2023 at 1:40 PM with the ADON, she said Resident #1 had a paper MAR and she would locate it from the COVID-19 wing. <BR/>Interview with on 01/20/2023 at 2:00 PM with the Scheduler, she said the nurse administered medications to residents and LVN B was the nurse during the time Resident #1 was in the COVID-19 unit (01/07/2023- 01/17/2023). The Scheduler did not know when LVN B administered medications to Resident #1 while in the COVID-19 unit from 01/07/2023- 01/17/2023 because LVN B was scheduled to work during that time. The Scheduler did not know if LVN B had administered medications to Resident #1. <BR/>Phone interview on 01/20/2023 at 3:11 PM with LVN B, he said he gave medications to Resident #1. He said he left the COVID-19 unit on 11/17/2023 and Resident #1 was one of the last two people to arrive in the COVID-19 unit. He said he worked in the COVID-19 unit from 01/05/2023- 01/11/2023 and Resident #1 came into the COVID-19 unit on the 9th or 10th of January 2023. He said some of her medications were on a paper MAR. He said he administered Artificial tears, and Tramadol to the resident from 01/09/2023- 01/17/2023, but could not confirm he administered amlodipine Besylate, Digoxin Tablet, Melatonin, Metformin HCl Tablet, Cymbalta Capsule Delayed Release Particles 60 MG, or the Lidocaine Pain Relief 4 % Patch. He did not know why there were blanks on the MAR. <BR/>Interview on 01/20/2023 at 3:53 PM with the Scheduler, she said Resident #1 was in the COVID-19 unit from 01/7/2023- 01/17/2023. She said other nurses in the unit administered medications to Resident #1 were LVN C, and LVN D from 01/14/23 & 01/15/23, and LVN E and LVN F on 01/16/23 & 01/17/23.<BR/>A phone interview was attempted on 01/20/2023 at 4:15PM with LVN C and could not leave voicemail because the mailbox was full.<BR/>A phone interview was attempted on 01/20/2023 at 4:16PM with LVN D and left a voicemail asking her to call this survey back. <BR/>A phone interview was attempted on 01/20/2023 at 4:16PM with LVN E and left a voicemail asking her to call this survey back.<BR/>Phone interview on 01/20/2023 at 4:22PM LVN G said her shift was from 6PM- 6AM. She said she was familiar with Resident #1. She said she could not recall if Resident #1 received her medications from 01/07/2023- 01/17/2023. She said the risk to the residents when they didn't get their medications would be the resident getting worse and or hurting them. LVN G did not know the last time she was trained on medication administration.<BR/>Phone interview on 01/20/2023 at 4:26PM LVN D said she worked the 6PM- 6AM shift. She said she was familiar with Resident #1. She said she did not know if Resident #1 received her medications from 01/07/2023- 01/17/2023. She said the risk to the residents when they don't get their medications would be the resident getting sick or causing them pain. LVN D said she did not recall when she was last trained on medication administration.<BR/>Phone interview on 01/20/2023 at 4:30PM with LVN F said her shift is 6PM- 6AM and could not verify medications were administered during the day shift for Resident #1.<BR/>Interview on 01/20/2023 at 4:32 PM with the ADON, said she could not find the paper MAR for Resident #1. <BR/>Record review of the facility's Administration and Documentation guidelines dated 02/02/2014 reflected in part .Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. Circle initials or those medication or treatment that were not administered and document the reason for the non-administration on the back of the MAR or TAR .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 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 with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #1) reviewed for care plans. <BR/>The facility failed to develop and implement a comprehensive care plan including measurable objectives and timeframes to address Resident #1's medical, nursing, and mental and psychosocial needs related to his known history of signing himself out of the facility in a motorized wheelchair that did not belong to him, ambulating to nearby stores to drink alcohol until intoxicated/vomiting/lethargic and smoking marijuana in the surrounding community. As a result, the resident was ordered to be sent to the local ER on several occasions for treatment.<BR/>An IJ was identified on 05/29/2025. The IJ template was provided to the facility on [DATE] at 1:20 p.m. While the IJ was removed on 05/31/2025, the facility remained out of compliance at a scope of pattern with severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. <BR/>This failure placed residents with substance abuse issues at risk of sustaining serious injuries from possible accidents/incidents and an exacerbation/deterioration of health and wellness. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet dated 05/28/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. He was diagnosed with end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and excess fluid from the body), schizoaffective disorder (a chronic mental illness that combines systems of both schizophrenia and mood disorder), gastro-esophageal reflux (a chronic condition where stomach contents regularly flow back up into the esophagus), history of falling, difficulty walking, diabetes mellitus type II (chronic disease where the body either does not produce enough insulin or cannot properly use the insulin it produces) with hypoglycemia (when blood glucose levels drop too low), essential hypertension (persistently high blood pressure with no identifiable cause), chronic ischemic heart disease (long-term condition where the heart's blood supply is reduced due to a mismatch between oxygen supply and demand), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms in COPD patients), unspecified cirrhosis of liver (a type of chronic, progressive liver disease where healthy liver cells are replaced by scar tissue), acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the cystic duct), dependence on renal dialysis (treatment that cleans the blood when kidneys are unable to do so), and shortness of breath. Resident #1 was his own responsible party. <BR/>Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); Resident #1 exhibited behaviors related to rejection of care; Resident #1 used a manual wheelchair for mobility; Resident #1 was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers and required supervision or touching assistance for showers/bathing; Resident #1 was always continent of bowel and bladder; and Resident #1 was prescribed anticoagulant and antipsychotic medication. <BR/>Record review of Resident #1's care plan, revised on 05/25/2025 revealed the following care areas:<BR/>* <BR/>Resident has impaired visual function and is at risk for falls, injury, and a decline in functional ability. Goals included: Resident will maintain optimal quality of life and not experience a decline in ADL functional abilities, or an injury related to vision loss. Interventions included: Arrange consultation with eye care practitioner. Assist to ensure glasses are labeled and within reach.<BR/>* <BR/>Resistant to Care: Resident is resistant to care and at risk for injury, a decline in functional abilities, and not having his needs met. [He] refuses to take his scheduled medications and refuses to go to his scheduled dialysis days. Goal included: Resident will not be a danger to self or others. Interventions included: If refusals continue, notify MD and family, document in resident records. Give a clear explanation of complications of not having his dialysis. Encourage as much participation as possible. Provide resident with opportunities to make decisions about his treatment. <BR/>* <BR/>Falls: Patient is a fall risk due to weakness of both lower extremities. Resident has the potential for falls related to unsteadiness on feet, abnormalities of gait and mobility, unspecified lack of coordination, and generalized weakness. Fall: 01/04/2025, 02/01/2025. Goal included: Resident will not sustain a fall related injury by utilizing fall precautions. Interventions included: Encourage resident not to transfer without assistance. Anticipate and meet the resident's needs. Educate the resident about safety reminders and what to do if a fall occurs. Encourage socialization and activity attendance as tolerated. <BR/>* <BR/>Therapeutic Leave: Resident is cognitively able to sign out of the facility and make their own informed decisions while they are out. On 04/10/2025 while on therapeutic leave, resident made the decision to consume alcoholic beverages. Goals included: The resident will follow facility policy for out on pass. The resident will be safe and comfortable while out on pass. Interventions included: Educate the resident/family/caregivers about the potential risks associated with signing out on pass. Educate resident/family/caregivers on the facility's policy for therapeutic leave/out on pass. Resident is reminded of his health issues and treatment regimens and the recommendations to avoid the use of alcoholic beverages.<BR/>Further review of Resident #1's care plan revealed no care areas, goals, or interventions to address his substance abuse concerns. <BR/>Record review of Resident #1's, Elopement/Wandering Risk Assessment dated 05/24/2025, completed by LVN A revealed, A. Preliminary Data. 1. Is the resident physically able to leave the facility on their own? Yes. Continue assessment. B. Evaluation. Cognition: 1. Is the resident disoriented to place or intermittently confused? Yes . Further review of the assessment revealed Resident #1 scored a 1, which indicated low/no elopement risk. <BR/>Record review of Resident #1's nursing progress notes for April 2025 and May 2025 revealed:<BR/>* <BR/>On 04/02/2025, at 4:10 p.m., SW B wrote, Resident was educated with Administrator, ADON, DON, and SW on the policies for Therapeutic Leave and the expectations for the resident when he is on Therapeutic Leave. Resident verbalized understanding.<BR/>* <BR/>On 04/11/2025, at 12:10 a.m., RN E wrote, Resident came back on pass to the facility with alcohol intoxication, vitals and assessment done. All within normal baseline. NP notified. New order to transfer resident to the hospital for further evaluation but resident refused. Resident was monitored through the shift, comfort care provided to resident satisfaction.<BR/>* <BR/>On 04/11/2025, at 11:50 a.m., ADON F wrote, Late Entry: 04/10/2025 at 11:00 p.m. Upon resident's return to the facility, resident arrived propelling himself in his motorized wheelchair. Resident had a slurred speech, he was drooling, smiling, and laughing, slow to respond to questions, and lethargic. Resident said he was tired and wanted to lay down and go to sleep and was assisted back to his room and was unable to stand to assist with his transfer to his bed, so he was transferred to bed with two people assist. In speaking with the resident, he said that he had ingested alcohol, specifically three 40 oz bottles of [brand name of beer] and he would not say if he had ingested any other substances or drinks. Upon assessment by unit nurse, there was no evidence of trauma or physical injuries noted, no indications of any falls or any other incidents at the time of his return.<BR/>* <BR/>On 04/12/2025, at 7:17 p.m., LVN A wrote, Police officer called facility and said resident vomited and may have been drinking with his friend and they have called 911 for him to go to the ER and have him evaluated. They then came to the facility, and I gave him a face sheet and medication lists. I accompanied the officer to EMS parked on the street near the facility and found the patient inside the ambulance being attended to by two paramedics with patient leaning to his left side. I placed a call to the Administrator and ADON. Resident apparently signed out at about 12 noon and left the facility with another resident. They apparently went to a nearby store and purchased drinks. He drank until he vomited on himself and became very weak. I asked the paramedics where they were taking him, and they informed me that they were taking him to [a local hospital] ER. NP and RP notified.<BR/>* <BR/>On 04/14/2025, at 4:38 p.m., ADON F wrote, Resident was found to be in possession of a cigarette lighter. The resident was educated by the Administrator on the smoking policy and the lighter was placed in the smoker's box for the resident to have access to only when on smoke breaks. The Administrator educated the resident on use of another resident's electric wheelchair and encouraged to use his own, the resident verbalized understanding.<BR/>* <BR/>On 04/15/2025, at 2:11 p.m., RN H wrote, Resident signed himself out and came back vomiting. Happened a couple of times. NP notified. Lab work ordered. New order to transfer to ER for further evaluation.<BR/>* <BR/>On 04/16/2025, at 5:23 p.m., ADON G wrote, Final lab results received on the drug and alcohol screening, labs placed in NP binder for review . resident remains in the hospital at this time.<BR/>* <BR/>On 04/23/2025, at 9:46 p.m., RN E wrote, Resident, who went out on pass, returned to the facility alert but disoriented, drooling from alcohol intoxication also had multiple emesis (vomiting). Resident vitals and assessment done all vital signs were within normal baseline. NP contacted via telehealth/virtual service. New order for Ondansetron 4 MG 1 tablet PO q 6hours as needed .<BR/>* <BR/>On 05/01/2025, at 11:59 a.m., the SW wrote, The Social Worker and the Administrator witnessed [Resident #1] taking a power wheelchair without the permission of the resident who owns the power wheelchair. Resident was educated that he cannot take the belongings of other residents while they are out of the facility. Resident was also educated on the importance of not using someone else's wheelchair and the risks that can occur .<BR/>* <BR/>On 05/04/2025, at 4:41 p.m., RN H wrote, Resident exchanged wheelchair with his former roommate and resident was educated that it was not safe to do so, resident verbalized understanding.<BR/>Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/10/2025 at 11:17 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Complaint: Altered Mental Status . Per nurse, patient went out on pass and returned to facility lethargic, drooling from mouth and vomited once one hour ago. Per nurse, patient only knows his name, does not know where he is, and does not know the month, year. States at baseline patient is alert and oriented x 3 (a term that describes a patient's level of consciousness and cognitive function. Patient aware of person, place, and time). Per nurse, patient admitted to drinking 3 bottles of [brand of beer]. Per nurse, patient refused dialysis today and states patient did not go to dialysis yesterday . Patient seen with nurse . Physical Exam: Exam findings per nurse and video observation . Orders: Transfer to ER via 911: AMS/ESRD - missed HD/vomiting/possible alcohol intoxication . <BR/>Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/23/2025 at 10:02 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Chief Complaint: GI: Vomiting . Nurse notified clinician that the [AGE] year-old-male patient with history of ESRD on dialysis, Schizophrenia, falls, HTN, DM2, went out of the facility for an hour and came back intoxicated. The nurse stated this is a regular occurrence for him. He did have an episode of vomiting. Denies drinking alcohol. Will monitor him for now .<BR/>Record review of Resident #1's Lab Results Report collected on 04/11/2025 and reported on 04/16/2025 revealed Resident #1 was positive for THC (Cannabis).<BR/>Observation and interview with Resident #1 on 05/28/2025, at 2:30 p.m. revealed he was in his bed with his eyes closed. Resident #1 opened his eyes and was able to provide his name. Resident #1 stated he lived in the facility a couple of months and living there was alright. He said he went to dialysis. He said he fell out of his wheelchair about six months ago (he did not say why). Resident #1 did not answer questions related to drinking alcohol or taking drugs while outside the facility on pass. He closed his eyes and appeared to be asleep although he responded to questions unrelated to drinking or smoking. <BR/>In an interview with a random resident on 05/28/2025, at 1:45 p.m., they stated Resident #1 had a known history of taking his former roommate's motorized wheelchair without permission to sign himself out of the facility and drink at nearby stores. The resident stated Resident #1 frequently drank alcohol until he was intoxicated and smoked marijuana in the community around the facility. The resident said one time, Resident #1 was swerving (change or cause to change direction abruptly) all over the sidewalk on his way back to the facility after drinking and fell out of the motorized wheelchair onto the sidewalk. The resident stated the night nurse had to go and find Resident #1 on the sidewalk. <BR/>In an interview with the SW on 05/28/2025, at 3:24 p.m., she stated Resident #1 was capable of making his own decisions, but he just did not make the right decisions. She said Resident #1 went out on pass and did things he should not do. She said Resident #1 was vomiting once due to intoxication. She said the facility staff could not tell Resident #1 what he could and could not do outside of the facility, and they could only educate him. She said Resident #1 knew what he was doing. She said Resident #1 was his own RP and he did not have any family. She said to her knowledge, Resident #1 only went out twice and got drunk, but she was not there on weekends. She said she was not sure Resident #1's behaviors were addressed on his care plan, but they should have been so all staff are aware of any interventions. She stated she was not responsible for updating resident care plans. She stated she reviewed chart notes and assessed Resident #1's cognition to see if he could make his own decisions. She said Resident #1's BIMS score was high. She said possible negative outcomes of Resident #1 leaving the facility and getting drunk were that he could die, get injured, and go to the hospital.<BR/>In an interview with the Administrator on 05/28/2025, at 4:32 p.m., he stated the residents had rights. He said Resident #1's BIMS score was 15, but he did not make proper decisions. He said the facility staff had to make sure they did not infringe on the residents' rights. He said Resident #1 signed himself out and returned intoxicated between five and seven times. He said he had undocumented conversations with Resident #1 about how unsafe it was for him to leave the facility and get drunk. He said the conversations were not documented because he did not go into the facility's computer system to write progress notes. He said Resident #1 was still capable of wheeling himself down the road to the store in his own manual wheelchair. He said the residents previously went to the gas station at the end of the street (the residents still had to cross a busy two-lanes road), but the store staff said they could not go there anymore. He said now, the residents go down to a store further down the road. He said he did not know if Resident #1's behaviors were care planned, but they should have been. <BR/>In an interview with MDS Nurse C on 05/29/2025, at 12:25 p.m., she stated her duties included completing assessments and reviewing/updating resident care plans. She said she was responsible for residents whose last names began with A - K, so she did not update Resident #1's care plan. She said another MDS nurse who worked part-time was responsible for updating Resident #1's care plan. She said the MDS nurses reviewed and updated care plans every three months when they did quarterly MDS assessments. She said she was aware of Resident #1's behaviors related to smoking and drinking, and those behaviors should be a part of his care plan if the incidents happened. She said it was important to address those issues in Resident #1's care plan because if anything happened, they had the information in the care plan to show they were not giving him what he went outside to get (drugs and alcohol). She said negative outcomes of Resident #1's behaviors were possible if the facility did not intervene. She said Resident #1 could have serious health issues if the facility did not intervene. She said a resident's care plan should address all their behaviors. <BR/>In a telephone interview with Resident #1's physician on 05/30/2025, at 10:00 a.m., he stated he was familiar with Resident #1, and he was aware the resident frequently went out on pass to drink and smoke. He said Resident #1 denied drinking and smoking, but he had a history of noncompliance with dialysis and medications. He said Resident #1 was alert and oriented to be able to sign himself out. He said Resident #1 had recently been admitted to the hospital a lot and once, at the hospital, they found he had taken drugs. He said Resident #1 kept denying, so it was hard to address it. He said the negative outcome of Resident #1's behaviors were that one day, Resident #1 is fine, and then in a couple of days, he signs out and takes something (drugs or alcohol) and something happens that leads him back in the hospital. He said he asks the facility staff to do their best to monitor Resident #1. He said once Resident #1 was off drugs and was perfectly normal, it would be safe for him to be out alone. He stated when Resident #1 was in that state (under the influence of drugs and alcohol), it was not safe for him to be out alone. He said if a resident was alert, oriented, and making the right decisions, you could not tell them they could not go out because that would be restraining them. He said he would imagine it was not safe for Resident #1 to be out like that (under the influence of drugs and alcohol), but he had the right to sign himself out. He said the facility may have to get a contract with Resident #1 to say if he continued with these behaviors, they could not handle his needs because they do not want anything bad to happen. <BR/>In an interview with the VP of Operations on 05/30/2025, at 10:30 a.m., he stated the Administrator was no longer employed at the facility and Resident #1 called 911 and was transferred to the hospital related to stomach pains on 05/28/2025.<BR/>In an interview with LVN A on 05/31/2025, at 2:11 p.m., he stated on 04/12/2025, around 1:00 p.m., the police called the facility and said Resident #1 had fallen out of his wheelchair and was vomiting at the church next to the facility. He said the police went to the facility and then he (LVN A) followed them to see Resident #1. He said he thought the police saw Resident #1 on the ground and called 911. He said when he arrived at the scene, he saw Resident #1 inside the ambulance. He said Resident #1 said he had gone to the store. He said Resident #1 went to the hospital and returned to the facility about two days later. LVN A said he heard the motorized chair Resident #1 fell out of belonged to his friend. <BR/>In a telephone interview with MDS Nurse D on 06/02/2025, at 11:19 a.m., she stated she was responsible for updating care plans for residents whose last names began with J-Z. She said she made sure MDS assessments were done and care plans were updated. She said she got the information to update care plans by reading progress notes, reading physician's orders, talking to staff, and she observed and talked to the residents. She said she observed Resident #1 around the facility, and he was mostly independent. She even though she read through Resident #1's progress notes, she was not aware of his drinking or drug use. She said she knew he signed himself out of the facility because she saw him in the group when they went out. MDS Nurse D then said she heard Resident #1 smoked weed (marijuana). She said smoking marijuana would be something they needed to add to his care plan. She said it was her understanding that the ADON updated anything that was acute (not long-term issues). She said she only worked 20 hours per week, so she was not at the facility most days. She said she was aware of Resident #1's smoking, but not his drinking. She said she only looked at progress notes when it was time to update the MDS assessments. She said she never saw any notes about Resident #1's drinking alcohol. She said she did not have an answer for why she did not address Resident #1's smoking in his care plan. She said the ADON was at the facility more than she was and they should have updated Resident #1's care plan to address his drinking. She said in her opinion, anybody could update the care plan. She said it was important to address Resident #1's behaviors related to smoking and drinking because it was pertinent information and they needed to act on things like that to keep the resident safe. She said the nursing facility was not a place to get drunk and do drugs. She said the IDT needed to get together, call a care plan meeting, talk, and update things to make sure all Resident #1's behaviors were on his care plan. <BR/>In an interview with ADON F and ADON G on 06/02/2025, at 11:45 a.m., ADON G said MDS Nurse D was not in the building a lot, so she should review progress notes daily to ensure care plans were updated appropriately. ADON F said they handled (updated care plans) regarding things that were acute, but Resident #1's drinking and drug use were not acute because he had those behaviors a while. ADON G said it was important to address those behaviors in the care plan so all staff know what is going on. ADON G said a negative outcome of not having the behaviors care planned would be that the behaviors continued and but the resident's safety at risk. <BR/>Record review of the facility's policy, titled, Comprehensive care Plans revised on 09/04/2024 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. B. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . d. The resident's goals for admission, desired outcomes, and preferences for future discharge . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . <BR/>Record review of the facility's policy, titled, Behavior Management revised on 04/15/2014 revealed, Policy: The purpose of the policy is to optimize the quality of life and function of patients that experience behavioral symptoms that require person centered approaches to meet the health, physical, psychosocial, and behavioral health needs. Fundamental Information: Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for dementia patients. Fundamental principles of care for a patient with behaviors include an interdisciplinary approach that focus on the individualized needs of the patient . Procedure. Determine whether there is a medical, physical, functional, physiological, emotional, psychiatric, social, or emotional cause of the behaviors . Considerations: Person-Centered Care - evaluate if the environment is supportive and promotes comfort toward understanding, preventing, relieving, and recognizes individual needs and preferences . Evaluations are completed on new or worsening behaviors . Identify the frequency, intensity, duration, severity, and impact of behaviors, as well as the location, surroundings, or situation. Identify interventions or approaches to prevent, modify, relieve, or address the behaviors or distress. Patient behaviors or distress are documented as it occurs and the effectiveness of interventions. Individualized Care Plan Approaches - individualized approaches are used as a first line intervention (except in a documented emergency situation or if clinically contraindicated) . Consistent interventions are used that focuses on a patient's individual needs . Monitor and follow-up care plan is done by the interdisciplinary team who reviews the patient's progress towards goals. Summarize effectiveness of non-pharmacological and pharmacological interventions (quarterly and as indicated), for target behaviors and/or psychological symptoms and changes in a resident's level of distress or emergence of adverse consequences. Adjust interventions as needed and identified when care objectives are not met . <BR/>An IJ was identified on 05/29/2025 at 1:20 p.m. The IJ template was provided to the Administrator on 05/29/2025 at 1:20 p.m. and a Plan of Removal was requested. <BR/>The following Plan of Removal submitted by the facility was accepted on 05/31/2025 at 10:42 a.m.<BR/>Issue Cited: Care Plans<BR/>Failure to develop and implement a comprehensive person-centered care plan<BR/>5/30/25<BR/>1. <BR/>Immediate Action Taken<BR/> On 5-29-25 resident #1 is currently in hospital with diagnosis of gastroenteritis (inflammation of the lining of the stomach and intestines) and ESRD.<BR/>2. Identification of Residents Affected or Likely to be Affected: <BR/>A. On 5/29/25 by 3pm DON/designee identified 11 residents who sign out of the facility independently, had charts reviewed and determined by their capabilities according to their functional ability assessment (MDS section GG), and make their own choices and decisions according to their BIMs, they were reviewed for any behaviors, none were found, and care plan interventions are in place.<BR/>2. <BR/>Actions to Prevent Occurrence/Recurrence: <BR/>A. <BR/>On 5/30/25 by 10:00 am the RNC reviewed the policy on Comprehensive Care Plans with no changes made.<BR/>B. On 5/29/25 by 7:30pm DON/designee reviewed the care plans for those 11 residents identified as independently capable of signing out of the facility and making their own choices and decisions. None were found to have unsafe behaviors. Care plans were reviewed, and no updates were needed. If and when Resident #1 returns from hospital the care plan will be reviewed and updated with any unsafe behavior and the CNAs and Nurses will be in-serviced to the updated care plan at that time by DON/designee.<BR/>C. On 5/30/25 by 9am the Regional Nurse Consultant in-serviced the IDT on updating comprehensive care plans to include measurable objectives, timeframes, and interventions for those residents identified as independently signing themselves out of the facility with a focus on unsafe behaviors, goals, and interventions while out of facility. The Administrator/ or designee and DON/ or designee were in-serviced by the RNC beforehand.<BR/>D. DON/designee will monitor comprehensive care plans for all residents identified as capable of signing themselves out of the facility independently for any unsafe behaviors present and report findings to IDT in morning meeting and revise care plans as needed.<BR/>E. All findings will be discussed during QAPI monthly and plan of care will be revised as needed.<BR/>F. On 5/29/25 the facility's Administrator/ or designee notified the Medical Director regarding the Immediate Jeopardy the facility received related to Failure to Develop and Implement a Comprehensive Person-Centered Care Plan and reviewed plan to sustain compliance. <BR/>Monitoring of the plan of removal included the following:<BR/>Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/30/2025 revealed the IDT team (DON, Activity Director, ADON F, ADON G, MDS Nurse C, Treatment Nurse, , and a representative from the rehabilitation department) was educated by the RNC on comprehensive care plans, including measurable goals and individualized interventions. <BR/>Record review of the facility's, Comprehensive Care Plans policy revealed it was reviewed by the RNC on 05/29/2025. <BR/>Record review of the facility's plan of removal documentation revealed the MDS assessments and care plans for all eleven residents identified as independently capable of signing out of the facility and making their own choices and decisions were reviewed by the DON. <BR/>Interviews were conducted with staff on 05/31/2025 from 10:45 a.m. until 3:00 p.m. from all shifts (nurses and CNAs worked 12-hour shifts) including the VP of Operations, RNC, DON, ADON F, ADON G, LVN A (day shift), MDS Nurse C, RN P (day shift), CNA Q (day shift), RN R (night shift), Receptionist[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 of 1 resident (CR #1) reviewed for safe discharge. <BR/>-The facility failed to provide sufficient preparation to ensure safe and orderly discharge of CR #1.<BR/>This failure placed residents at risk of not receiving care and services to meet their needs upon discharge.<BR/>Findings include:<BR/>Record review of the admission sheet for CR #1 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on 10/23/23. Her diagnoses included hypertension (a condition in which the force of the blood against the artery walls is too high), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage) and aphasia (a language disorder that affects a person's ability to communicate). <BR/>Record review of the comprehensive Minimum Data Set (MDS), dated [DATE], revealed her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. She was dependent on staff physical assist with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. <BR/>Record review of CR#1's physician order dated 10/22/23 and discontinued on 10/23/23 revealed an order for Enteral Feed Order four times a day Intermittent Gravity (Bolus) Enteral Feeding: Formula Isosource 1.5 Amount: 250 ml Frequency QID Total mls/24 hours 1000 ml.<BR/>Record review of CR#1's Physician's order dated 10/24/23 revealed d/c to home with home health: PT, OT, Speech therapy, skilled nursing and wound care.<BR/>Record review of CR#1's progress notes written by the Social Worker on 10/24/23 at 6:54pm revealed read in part: .Note Text: Referral for Home Health was sent to the home health of RP's choice. [Home Health company name] was sent clinicals and home health orders per RP's request .<BR/>Record review of CR#1's progress notes written by the Social Worker on 10/25/23 at 11:49am revealed read in part: .Note Text: SW received an email from [insurance company name] that there is a pending authorization from the insurance of [CR#1]. SW informed RP that it can take a while for authorization to occur and it can take a while for the items to be delivered to her home .<BR/>In a telephone interview on 11/17/23 at 4:03 p.m., with CR#1's Responsible party, she said CR#1 had a feeding tube. She said 1 case of milk was provided from the facility which CR#1 ran out after few days of discharge. She said she had to go buy the milk which was costly on her. She said the nurse gave one syringe for the feedings. She said she had been boiling the syringe, so it did not get infected. She said the home health company was not set up. She said, luckily, I had the physician order for home health. I felt like I was a case manager/Social worker had to call the home health company and make arrangements. They finally came out last week. She said the facility should have assisted her and made sure the supplies were available for CR #1 when she went home. She said she had to contact facility's Social Worker several times to get the supplies. She said she received milk and other supplies on the 11/15/23 and CR#1 was discharged on 10/23/23. <BR/>In an interview on 11/20/23 at 1:11 p.m., with the Social Worker, she said CR#1 was admitted over the weekend. She said she saw CR #1 on either Monday (10/23/23) or Tuesday (10/24/23). It was her first-time seeing CR #1 at the time of discharge. She said the RP insisted on taking the resident home. She said it was not a planned discharge. She said she ordered the supplies, medical equipment to include bed, wheelchair, formula, and the nurse gave RP the meds. She said on 10/24/23 she ordered enteral formula and 5 other items. She said she received a response back on 10/25/23 that the insurance required additional documentation and to upload the latest progress notes relating the equipment being ordered. She said she attached the physician discharge progress note dated 10/23/23. She said CR #1's RP reached out to her several times via text inquiring regarding the status on DME. She said she followed up with insurance and they required additional documentation from the physician to include why resident needed equipment ordered. She said she called the physician and he made amendments on 11/7/23 to the progress note dated 10/24/23. She said she checked on the DME order status on 11/15/23 for enteral formula and 5 other items were ready for delivery.<BR/>In an interview on 11/20/23 at 4:34 p.m., with the Social Worker, she said on 11/08/23 CR #1's RP contacted her via text and informed her that she had no formula, syringe for the g-tube and home health. SW said she guided RP to go see PCP or to the hospital and not to pull resident out of the Nursing facility. SW said she had sent over the clinicals to the home health company which the RP had picked. SW said, I assumed home health was set up because the RP had good contact with the home health lady marketer. RP was the one who provided the home heath's company number to me. <BR/>In an interview on 11/20/23 at 4:50 p.m., with LVN B, she said at the time of discharge CR#1's RP was given the med list and the medications. She said the DON asked her to give a case of isosource to the RP. She said she had used 3 formulas out of that cartoon. She said she gave 1 syringe set to the RP. <BR/>In an interview on 11/20/23 at 2:39 p.m., with the DON, she said the Social Worker prepped and got everything ready for example if family needed assistance with home health the SW would arrange all of that. She said the nurse reviewed discharge medications, provided any education that needed to be done at the time of discharge. She said routine medications were sent home with family. The family should obtain that from home health which should be set up prior to discharge. The only thing the nursing home sent home with the resident was their routine medication and the family should obtain formula from home health. She said she was not aware home health was not set up. The DON said not setting up proper home health could have a negative outcome if proper care was not set up. Which could mean anything especially about wound care, g-tube care and overall health of the resident. She said she asked LVN B to give the formula to the RP because it was an unplanned discharge, and she did not want CR #1 to be without formula. She said the case of formula should have lasted 2 and a half weeks, depending on how often the resident took the formula. <BR/>In an interview on 11/20/23 at 6:16 p.m., with the Administrator and the DON, the Administrator said CR#1's was an unplanned discharge. Administrator said the RP wanted to take CR#1 home and had home health arranged from the hospital. But the resident ended up going to this facility. She said the facility asked if RP could give couple of hours for them to discharge CR#1 properly. She said with the planned discharge the SW ordered DME, made PCP appointment and set up home health. She said nothing was set up for CR#1 because the family did not wanted resident to be at the facility. At this time the Surveyors explained that CR#1's was out of formula, no DME no home health was set up. The Administrator said the SW was new and took it upon herself to assist but this was an unplanned discharge. The RP insisted on taking the CR#1 home. <BR/>Record review of facility's Transfer and Discharge (including AMA) policy (Review Date: 9/1/2023) revealed read in part: .9. Anticipated Transfers or Discharges - initiated by the resident. a. Obtain physicians' orders for transfer or discharge and instructions or precautions for ongoing care. b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. ii. A final summary of the resident's status. <BR/>iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). iv. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment. <BR/>c. Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. d. Assist with transportation arrangements to the new facility and any other arrangements as needed. e. The comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes and shall be in alignment with the discharge. f. Supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 infection for 1 of 2 residents (Resident #1) reviewed for infection control.<BR/>-The facility failed to ensure CNA J performed hand hygiene during incontinent care on Resident #1.<BR/>This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. <BR/>Findings included:<BR/>Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit (trouble reasoning and making decisions while communicating) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 07/26/2024, revealed the BIMS score was 05 out of 15, which indicated her cognition was severely impaired. The MDS revealed she was dependent on staff with toileting, shower/baths, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS revealed .<BR/>Record review of Resident #1's care plan, initiated 02/17/2024 and revised on 06/06/24 revealed the following: <BR/>Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to muscle weakness. <BR/>Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. <BR/>Interventions: Bed Mobility: total x 1 assist. Transfers: total x 1 assist. Eating: set-up/ clean up<BR/>Toileting: dependent x 1 assist. Ambulation: n/a. Wheelchair: independent short distances --mostly propelled per staff. Dressing: dependent x 1 assist. Personal Hygiene: dependent x 1. Bathing: dependent x 1 assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Encourage resident to participate to the fullest extent possible with each interaction and praise when attempts are made.<BR/>Observation on 08/16/24 at 12:16 p.m., revealed CNA J provided Resident #1 with incontinence care. CNA J did not complete hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. CNA J unfasten Resident #1's brief and tucked it under the resident's buttocks. CNA J turned the Resident over and did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus. CNA J removed the soiled brief and discarded it into the trash can sitting near resident's foot of bed. CNA J wiped twice, removed her soiled gloves without washing or sanitizing her hands donned clean gloves. CNA J completed incontinent care and with the same soiled gloves touched the Resident's clean dress, brief, and sheets . <BR/>In an interview on 08/16/24 at 2:08 p.m., with CNA J, she said she started working full time at the facility last month. She said she did not recall doing CNA competency checks for incontinent care. CNA J said not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-services on infection control at the time of hire. <BR/>In an interview on 8/16/24 at 2:15 p.m., with the Wound Care Nurse, she said CNA J should have either washed or sanitized her hands in between gloves change as it placed the resident at risk for infections. <BR/>In an interview on 8/16/24 at 3:06p.m., with ADON B, she said she was the facility's infection preventionist. She said she provided mandatory infection control in-service to staff monthly, quarterly and as needed. She said CNA J was new to the building but not to long term care. She said staff should wash/sanitize their hands upon entering a resident's room, in between glove changes, and before leaving the resident's room. <BR/>In an interview on 08/16/24 at 4:48p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care each time they perform incontinent care. She said Wound Care Nurse brought it to her attention that CNA J failed to performed hand hygiene during incontinent care on Resident#1. She said the CNA should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said these failures were risk for infection control . <BR/>Record review of facility's In-Service Program Attendance Record dated 8/14/2024 revealed Topic: Hand Hygiene was signed by CNA J. <BR/>Record review of facility's Hand Hygiene Policy (Date implemented: 11/12/2017) revealed read in part: .Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6.Additional considerations: a. The use of antimicrobial-impregnated wipes (i.e. towelettes) are not a substitute for using an alcohol-based hand rub or antimicrobial soap. b. The use of gloves does not replace hand washing. Wash hands after removing gloves .<BR/>Record review of facility's infection control Guidelines (Revision Date: 9/22/2015) revealed read in part: .Anticipated Outcome: The purpose of this policy is to reduce and prevent the spread of infections by the use of evidence based techniques established infection control policies and procedures. 3.Hand Hygiene Protocol: a. Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty. b. Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing care to patients in isolation. c. For routine patient care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact. d. Hands shall be washed in accordance with our facility's established hand washing procedure .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (CR#1) of 9 residents reviewed for professional standards. <BR/>The facility failed to follow physician orders postponing the resident's procedure on two occasions.<BR/>This failure could place residents at risk of inadequate care, decline in their health and or hospitalization.<BR/>The findings included: <BR/>Record review of CR#1's admission record dated October 5, 2023, revealed a [AGE] year-old-male admitted to the facility on [DATE]. His diagnoses included acute kidney failure, cognitive communication, Dysphagia (medical term for having trouble swallowing), Hypertension (elevated blood pressure), malignant neoplasm of prostate (prostate cancer), Rhabdomyolysis (a breakdown of skeletal muscle due to direct or indirect muscle injury), Transient cerebral ischemic attack (is a temporary blockage of blood flow to the brain). The facility was unable to provide a care plan and a MDS for CR#1. During an interview on 10/06/2023 at 10:21a.m. ADM said she provided the surveyor with everything she could get from the computer for CR#1. <BR/>Record review of CR#1's Transfer/Discharge report dated October 5, 2023, revealed a CR#1 was transferred to another facility on September 27, 2023, at 3:00 p.m. <BR/>Record review of CR#1's active physician's order revealed in part: . to start the colon prep the day before the procedure on 9/11/2023. <BR/>Record review of CR#1's active physician's order revealed in part: .dated 9/12/2023 read No Solid Foods Only Clear Liquids from The Time You Wake Up, Stop All Liquids by Midnight.<BR/>Record review of CR#1's active physician order revealed in part: . dated 9/25/2023 read nothing by mouth after midnight, Colonoscopy : Clear Liquids only. No solid foods All Day, Failure to follow these guidelines may delay/cancel your procedure.<BR/>Record review of CR#1's Communication form from the facility Dietary department revealed in part: . dated 9/7/2023 at 1:45 p.m. Clear Liquid Diet on Mon 9/11/2023 signed by the dietary manager. <BR/>Record review of CR#1's Communication form from the facility dietary department revealed in part: . Clear Liquid Diet dated 9/24/2024 Sunday signed by the dietary manager. <BR/>During an interview on 10/05/2023 at 2:36 p.m., the CNA said on 9/11/2023 CR#1 was given clear liquids and was on a clear diet. The CNA said on 9/12/2023 she saw no orders for CR#1 therefore CR#1 was given a tray. The CNA said the date pertaining to 9/25/2023 the CNA received a text message from the LVN. The CNA said she saw the text message late from the LVN and CR#1 had eaten 25 percent of his food. <BR/>During an interview on 10/05/2023 at 2:47 p.m., the Driver said on 9/12/2023 CR#1 was eating candy and he had eaten his breakfast. She said on 9/24/2023 she called RN, Supervisor and asked about CR#1 and the RN, Supervisor replied saying she will start CR#1's prep at 6:00 p.m. She said on 9/25/2023 CR#1 had all types of snacks by his bedside and CR#1 did not drink all his fluid (GoLytely, a laxative solution to clean your colon before your colonoscopy). <BR/>During an interview on 10/05/2023 at 3:02 p.m., the LVN said on 9/11/2023 CR#1 was given clear liquids for CR#1 appointment dated 9/12/2023. The LVN said on 9/12/2023 CR#1 was not to eat anything. The LVN said CR#1 completed the prep for 6:00 p.m. The LVN said she gave CR#1 everything he was supposed to have but he kept having multiple bowel movements. The LVN said the driver took CR#1 to his appointment and returned saying CR#1 appointment was cancelled because the facility did not follow the physician orders dated 9/12/2023. The LVN said the appointment was set for 9/25/2023, she did not put NPO for Monday 9/25/2023 therefore CR#1 was given a breakfast tray. The LVN said she texted the CNA on 9/25/2023 at 9:19 a.m. telling her to make sure CR#1 did not eat anything. The LVN said the CNA returned her text message on 9/25/2023 at 9:27 a.m. saying she just read the text message and that CR#1 had eaten 25 percent of his food. The LVN said she was written up for not putting NPO on the communication form with the correct dates. <BR/>During an interview on 10/05/2023 at 3:56 p.m., the [NAME] said the nurses oversee the physician orders. The DON said she expects the nurses to follow the physician orders. She said by the nurses not following the physician orders could place the residents at risk of deteriorating and having a decline in their health. <BR/>During an interview on 10/06/2023 at 10:21 a.m., the ADM said if the nurses do not follow the physician orders it was a high risk to the residents. The ADM said it can cause the residents to decline in their health, it can cause a significant change in their condition, or it could cause the resident to be sent out to ER. <BR/>Record review of the LVN's Education In-Service revealed in part: . on 9/26/2023 Ensure the correct order and date is written on dietary communication form.<BR/>Record review of the RN Nurse Supervisor Disciplinary Memorandum revealed in part: . on 9/26/2023 not following physicians' orders per resident complaint. <BR/>Record review of the facility's policy and procedures for Following Physician Orders, dated 9/28/2021 read in part: . 2a. Document the order by entering the order and the time, date, and signature on the physician order sheet. 2b. Follow the facility procedures for verbal or telephone orders including noting the order .3c. Carry out and implement physician orders. 3d. Document resident response to physician order in the medical record as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident's right to be free from neglect for 1 resident (Resident #1) of 10 residents reviewed for neglect in that:<BR/>1. The facility failed to have an effective system in place to monitor for STAT diagnostic/laboratory results, <BR/>2. The facility failed to ensure staff were trained on where to check for and follow up on diagnostic/laboratory results.<BR/>3. The facility failed to have a communication system in place to ensure timely continuity of care and interventions/treatment. <BR/>4. The facility failed to report to the ordering physician Resident #1's stat x-ray results of a fracture to the right hip, femur, and pelvis in a prompt manner.<BR/>An IJ was identified on 05/26/2023. The IJ template was provided to the facility Administrator on 05/26/2023 at 5:50pm. While the Administrator was notified at 11:50am on 05/29/2023 that the IJ was removed, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner.<BR/>This failure resulted in delayed diagnosis of sacral osteomyelitis and antibiotic administration for Resident #1 with the potential to place residents who received diagnostic testing at risk for neglect, delayed treatment, and hospitalization.<BR/>Findings:<BR/>Resident #1<BR/>Record review of Resident #1's face sheet dated 05/12/2023 revealed an [AGE] year-old male admitted to the NF on 04/02/2023 with the following diagnoses; cerebral infarction (disrupted blood flow to the brain), respiratory failure, hypertension (high blood pressure), dysphagia (difficulty swallowing), functional quadriplegia (loss of control of both arms and both legs), type two diabetes mellitus, heart disease, sacral (below the spine and above the tailbone) ulcer stage 4, pressure ulcer of left ankle, renal (kidney) disease, tracheostomy (opening created at the front of the neck so that a tube can be inserted in the windpipe to help one breathe), gastrostomy (opening in the stomach done surgically for the introduction of food), and colostomy (surgical operation creating an opening in the abdomen/stomach to expel waste). <BR/>Record review of Resident #1's admission assessment MDS dated [DATE] revealed BIMS score of 9 (cognition moderately impaired). Further review revealed that resident was totally dependent on staff with assistance of activities of daily living. <BR/>Record review of Resident #1's Nursing progress Notes dated 05/04/2023 documented by the Wound Care Nurse revealed in part:<BR/> .Resident visited per wound care docotor this a.m., upon observation stage 4 of the sacrum shows signs of improvement .Arterial wound of L(left) second toe is currently stable .wound has no noted exudate with 100% necrotic eschar noted to wound bed, tratement order for site continue as ordered, arterial wound of the L (left) 3rd toe is also stable .wound has no noted exudate with 100% necrotic eschar noted to wound bed, treatement order continue as ordered .no signs of infection noted to sites .<BR/>Record review of Resident #1's Care Plan dated 05/12/2023 revealed that resident was being care planned for falls and ADL performance deficit related to: impaired mobility and limited ROM. <BR/>Record review of Resident #1's Physician Progress Notes dated 05/04/2023 revealed in part:<BR/> .chief complaint/nature of presenting problem: Patient reports severe pain in right hip, right femur, patient has severe chronic comorbidities, patient's right lower extremity is seen over the left lower extremity. Patient appears more alert and verbal today, reports significant discomfort to the right hip, right femur .<BR/>Record review of Resident #1's Physician orders revealed the following orders:<BR/>-Dated 05/04/2023 X-ray right hip, pelvis, right femur STAT (right away)<BR/>-Dated 05/04/2023 Tylenol Extra Strength tablet 500mg 1 tablet every 8 hours for pain for 7 days crush via peg. <BR/>Record review of Resident #1's MAR for the month of May 2023 revealed that the NF was administering Tylenol extra strength as ordered by the physician. <BR/>Record review of Resident #1's STAT X-ray results of the right hip, pelvis, right femur dated 05/04/2023 revealed in part:<BR/> .Age-indeterminate (the radiologist cannot tell based on the x-rays alone if it is new or old) avulsion fracture at greater trochanter (any of two bones by which muscles are attached to the upper part of the thigh bone) of femur is noted. No other acute fracture or dislocation . <BR/>Record review of the NF 24-hour communication dated 05/04/2023 was documented that the STAT X-ray was done of the right hip, pelvis, and femur (there was no mention that the physician was notified of results). Further review of the 24-hour communication on 05/06/2023 was documented that Resident #1 refused dialysis, G-tube (gastrostomy) and trach (tracheotomy) care; colostomy bag changed. There was no further documentation regarding the results of Resident #1's STAT right hip X-ray or if the physician and been notified. <BR/>Further review of the results of Resident #1's STAT X-ray results of right hip, pelvis, right femur dated 05/04/2023 revealed that the weekend supervisor initialed on 05/07/2023 and that she notified the physician on 05/07/2023 with orders to send Resident #1 out for treatment and evaluation.<BR/>Record review of the NF Staff Time Sheet dated 05/04/2023 revealed that LVN F clocked in to work at 5:48pm and LVN C clocked in to work at 7:19pm.<BR/>Interview on 05/17/2023 at 4:15 pm via phone, LVN C said he worked on 05/04/2023 6pm-6am and was Resident #1's nurse. LVN C said he was not aware that Resident #1 had an X-ray done on his right hip. LVN C said he worked at the NF on a PRN basis and did not recall that he had received in report that resident had STAT X-ray done on right hip. LVN C said he received and gave shift report using the 24-hour communication form. <BR/>Interview on 05/28/2023 at 11:30 am via phone, LVN D said she was working on 05/04/2023 6am-6pm shift and that she was Resident #1's nurse on that day. LVN D said Resident #1's doctor came to the NF on 05/04/2023 and that she remembered resident complaining of pain to his right hip. LVN D said the NP had also come to the NF on 05/04/2023 and gave orders on multiple residents. LVN D said LVN C were the nurses to relieve her but were running late for work. Therefore, she had to give report to LVN F who was working another hall. LVN D said LVN F was upset that he had to take report for LVN C, and she just gave LVN F a verbal report not using the 24-hour communication form. LVN D said although she did not mention in her verbal report to LVN F that Resident #1 had a STAT order for an X-ray of the right hip that had been done, she did write it on the 24-hour communication form. LVN D said she knew she was supposed to utilize the 24-hour communication form, it was just a lot happening on 05/04/2023. <BR/>Interview on 05/28/2023 at 12:37 pm, LVN F said he worked at the NF part time during the evening shift 6pm-6am. LVN F said the normal process when clocking in to work was to count the narcotics cart. LVN F said he completed walking rounds along with verbal report utilizing the 24-hour report form. LVN F said he did not recall receiving a report from LVN D nor giving report to LVN C regarding Resident #1. <BR/>Record review of Resident #1's Nursing Progress Notes revealed the following documented by LVN D dated 05/04/2023 at 8:19 am:<BR/>incomplete documentation that read .9:49 am patient refused . <BR/>05/05/2023 documented by LVN C revealed in part at 7:11am: <BR/> .Refused dialysis MD/RP aware .<BR/>05/05/2023 documented by LVN O at 2:15pm: <BR/> .Resident refused dialysis. NP aware and educated patient about the importance of hemodialysis. Nurse attempted 3 times. Resident still refused .<BR/>05/07/2023 documented at 10:13 am by Weekend Supervisor read in part:<BR/> .Physician notified regarding x-ray results. Received new order to send out for evaluation of fracture. Resident resting quietly in bed at this time denies pain .<BR/>Record review of Resident #1's hospital records dated 05/07/2023 revealed in part:<BR/> XXX[AGE] year-old male who is bedbound, was sent from NH for evaluation of right hip pain. X-ray at outside facility was questionable for right hip fracture. Upon examination it was noted necrotic (death of living tissue) changes in his left 2nd and third toes. He also has a stage 4 sacral decubitus ulcer. CT pelvis was completed rising suspicion for sacral osteomyelitis (infection of bone). He did not meet the suspicion for sepsis .Right hip pain likely referred pain. No CT evidence of fracture .Noted Orthopedic Surgery input. No need for surgical intervention for hip or femur. Will start on empiric (therapy begun on the basis of a clinical or educated guess) Zyvox and Levaquin (antibiotics) . <BR/>Interview on 05/12/2023 at 11:14 am, The Administrator said Resident #1 was still in the hospital in ICU. The Administrator said she was not at the NF regarding the incident with Resident #1 and that she started working at the NF on 05/08/2023. The Administrator said she found out later the STAT X-rays done on Resident #1 right hip revealed a fracture. Further interview with the Administrator said she was not aware that there had been a delay in reporting Resident #1's STAT X-ray results of the right hip done on 05/04/2023 to the doctor until 05/07/2023. <BR/>Interview on 05/12/2023 at 3:42 pm, The Weekend Supervisor said she worked only on the weekends double shift 6am-10pm. The weekend supervisor said when she saw Resident #1's X-ray results of the right hip at the nurse's station on 05/07/2023, she was not sure if the physician had been notified and therefore texted the doctor on 05/07/2023. The weekend supervisor said when she contacted Resident #1's doctor, he had not been notified of the STAT X-ray results that he had ordered on 05/04/2023 until she had presented the results to him on 05/07/2023. The weekend supervisor said the doctor gave her orders to send Resident #1 out to the hospital for further evaluation and treatment. The weekend supervisor said she received reports on the residents at the NF from the ADON through text or facetime. The weekend supervisor said the ADON never mentioned to her that a STAT X-ray of the right hip, right femur, and pelvis had been ordered on Resident #1. The weekend supervisor said when she called the ADON on 05/07/2023, the ADON told her that she was not aware that a STAT X-ray had been order for Resident #1. The weekend supervisor said the nurses on duty on the weekend were not aware that a STAT X-ray of the right hip had been ordered on Resident #1. The weekend supervisor said she went to Resident #1's room to see if resident was in pain. She said resident said he was not in any pain.<BR/>Interview on 05/12/2023 at 4:40pm, LVN A said she worked Hall 500 and that Resident #1 resided on Hall 600. LVN A said when she reported to work, she went and checked on the residents before taking a verbal report from the nurse. LVN A said when she takes a verbal report from the nurse, she also utilized the 24-hour report sheet to ensure she was receiving all needed information to ensure the continuity of care. LVN A said not all the nurses utilized the 24-hour report sheet. LVN A said the 24-hour communication report sheet was kept at the nurse's station in a binder. <BR/>Interview on 05/12/2023 at 4:55pm, the ADON said the doctor was making rounds at the NF on 05/04/2023 and Resident #1 said he was in pain. The ADON said the doctor ordered an X-ray of the right hip on Resident #1. The ADON said honestly, she did not know that there had been a delay in notifying the physician regarding Resident #1 X-ray results taken of the right hip on 05/04/2023. The ADON said the X-ray of Resident #1's right hip was ordered STAT. The ADON said that radiology came to the NF late on 05/04/2023. The ADON said the nurses should have caught that and it should have been discussed in the shift-to-shift report. The ADON said when the weekend supervisor called her on 05/07/2023 she told the weekend supervisor to call the doctor. The ADON said there was a different DON working at the NF at that time of when the STAT X-ray was ordered for Resident #1. The ADON said she attended the morning meetings and that Resident #1's STAT X-rays done on 05/04/2023 (Thursday) was never discussed in the following morning meeting on 05/05/2023. Further interview with the ADON said the reason Resident #1's STAT X-ray of the right hip, pelvis, and femur was not discussed was because the NF Administrator was late arriving at the NF, and it was her last day working at the NF. Therefore the morning meeting on 05/05/2023 did not happen. The ADON said the NF at the time did not have a permanent DON as well, but an interim DON. The ADON said the NF did not have a policy that the nurses had to document on the 24-hour communication report sheet as a form of communication regarding the residents care. <BR/>Further interview on 05/12/2023 at 5:15 pm, the Administrator said regarding Resident #1, the NF had done in-services on abuse and neglect when she began work on 05/08/2023, documentation, level of pain assessment, shift reporting, notifying the Administrator/DON/Doctor before sending a resident out to the hospital. Further interview with the Administrator said the Regional Director of Operations called the incident regarding Resident #1 into the state and that the Regional Director of Operations was the one that completed the facility incident investigation regarding Resident #1 STAT X-ray results of fracture on right hip, right pelvis and femur. The Administrator was unable to provide a specific date as to when the Regional Director of Operations called the incident in to the state.<BR/>Interview on 05/12/2023 at 5:15pm. the DON said she started working at the NF on 05/08/2023 and what she knew about Resident #1 was that resident had a lot of contractures and complained of pain. The DON said the nurse medicated the resident for pain but it was not effective, and the doctor said to send resident to the hospital to be evaluated. The DON said it was discovered at the hospital that Resident #1 had a fracture but could not say where the fracture was. The DON said when Resident #1 went to the hospital on [DATE] the nurses called the hospital to see how the resident was doing. The DON said that was when the NF found out that Resident #1 had a fracture. The DON said she never read the NF Incident Investigation Report regarding Resident #1. <BR/>Interview on 05/17/2023 at 9:30 am via phone, Radiology said a STAT X-ray was done on Resident #1's right hip on 05/04/2023 and the results were called to the NF on 05/04/2023 spoke to a Staff Member XX. Radiology said they did not get a last name or title. Radiology said the results were verbally given to Staff Member XX at 9:54 pm and faxed to the NF on 05/04/2023. Radiology said the STAT X-ray results were faxed again to the NF on 05/07/2023 at 11:28am.<BR/>Interview on 05/17/2023 at 10:00am the Administrator said the NF had 3 fax machines in the NF<BR/>Further interview 05/17/2023 at 2:13 pm, the Administrator said the NF did not have an employee by the name of [Staff Member XX] that worked at the NF.<BR/>Observation on 05/17/2023 at 12:00 pm revealed Resident #1 on Hall-600 sitting in a Geri-chair that was in a reclined positioned. Resident was easily aroused and denied any pain at that time.<BR/>Interview on 05/17/2023 at 12:50 pm via phone Physician A of Resident #1 revealed he reviewed Resident #1' s hospital records on 05/16/2023. Physician A said the hospital records reached the conclusion, after a CT scan of the right pelvis, that resident did not have a fracture. Physician A said while Resident #1 was at the hospital, Resident #1 was seen by the Orthopedic doctor. Physician A said Resident #1 had multiple comorbidities and his prognosis was poor. Physician A said Resident #1 was a good candidate for hospice, but the family of the resident would have to make that choice. The physician said because resident had been assessed by the hospital would base his plan of care off the hospital conclusion and continue to monitor Resident #1.<BR/>Attempted interview via phone on 05/17/2023 at 1:47 pm with LVN O; no answer.<BR/>Interview on 05/17/2023 at 2:15 pm, the DON said the nurses were supposed to do verbal reports and look at the 24-hour communication report on the computer. The DON said the NF trying to get rid of paper, using only the computer to document resident care. The DON said she would have to look at the computer to see if the staff was charting on the 24-hour form on the computer. The DON said a STAT order should be followed up in 2 hours if results were not received. The DON said some of the nurses were timid when it came to calling the physician and not all nurses use critical thinking. The DON said she would be doing further in-service with staff on a lot of issues including notifying the doctor whenever there was a change in a resident (s) condition. The DON said she spoke with the Regional Nurse who informed her that whenever there is a change in a resident condition, the nurses should be using and INTERACT form. The DON said she had not been privy to reviewing the form, but it seems to be like a glorified SBAR. The DON said she had not reviewed Resident #1's chart at all because she had been busy with training and doing in-services with the Nursing Staff. The DON said the Administrator had reviewed Resident #1's medical records. The DON said she had learned that the NF had 3 different fax machines that consisted of an e-fax (send to the computer), fax in the medication room, and work room (copy room). The DON said she was unsure where the results for diagnostic testing would be faxed. The DON said it was the nurses that completed shift reports as well as the ADONs that was supposed to be reviewing the 24-hour communication form. The DON said the ADON was supposed to bring the 24-hour communication report sheet to the morning meetings. The DON said it was ultimately the DON that ensured that the 24-hour communication forms were being done. The DON said the 24-hour communication form was another form of communication that was relied upon to ensure the continuity of care for the residents. <BR/>Further interview on 05/17/2023 at 2:32 pm, The Administrator said when a resident had to be discharged to the hospital, she would do a look back for the past 72-hours that included reviewing the 24-hour communication reports that were kept in a binder at the nurse's station. The Administrator said she also reviewed what was documented in PCC to ensure that residents care was being met. The Administrator was not able to answer that if she had done those things, why did she not see that there was a delay in notifying Resident #1's physician of STAT X-ray results of the right hip. The Administrator said it was the ADONs that were responsible for reviewing the 24-hour communication form which were brought to the morning meetings to be further discussed. The Administrator said she was told by the ADON that all diagnostic results was faxed to the medication fax room (. The Administrator said even if a diagnostic result went to another fax room, the staff should have been following up on Resident #1's STAT X-ray results that were taken on 05/04/2023.<BR/>Interview on 05/17/2023 at 2:55 pm, LVN E said she thought the NF had 1 fax machine which was in the copy room. LVN E said diagnostics were good about calling the NF on anything that was critical and having the person's name who they spoke to; including the time they spoke with that person. <BR/>Interview on 05/17/2023 at 3:54 pm, the DON said the Weekend Supervisor was supposed to get the resident reports from the DON or ADON when they reported to work. The DON said she did not think that the NF had a permanent DON at the time of the incident regarding Resident #1, but an interim DON.<BR/>Interview on 05/27/2023 at 11:13 am, the Weekend Supervisor said she normally checked the fax machine in the copy room [ROOM NUMBER]-4 times while on duty. The Weekend Supervisor said STAT diagnostic testing should followed up in 2 hours for the results. The weekend supervisor said the laboratory was good about calling the NF with lab results but was not sure about radiology. The weekend supervisor said she was not sure how Resident #1 STAT X-ray results of the right hip went un-reported to Resident #1's physician. The weekend supervisor said the NF neglected to report to Resident #1's physician, right away, the results of resident STAT X-rays done on the resident's right hip. The Weekend Supervisor said resident was placed at risk for pain and further injury of the right hip. <BR/>A call was placed to LVN O on 05/27/2023 at 12:12pm with a female answering the phone denying that they were LVN O. It was confirmed with the NF that the number provided to the surveyor for LVN O was the number that they had on file for LVN O.<BR/>Attempted an interview on 05/27/2023 at 12:44pm via phone with LVN O; no answer, left voicemail with a call back number.<BR/>Interview on 05/27/2023 at 12:30pm, the ADON said LVN O was an agency nurse.<BR/>Interview on 05/27/2023 at 12:25 pm, LVN B said she worked at the NF PRN. LVN B said she worked at the NF over a year ago and had just started working back at the NF. LVN B said she did not know how many fax machines that the NF had. LVN B said she believed that diagnostic test results were retrieved from the fax machine in the medication room. LVN B said no one at the NF had in serviced her on all fax machine locations or how often to follow-up for diagnostic results.<BR/>Interview on 05/28/2023 at 11:20 am, the DON said the NF failed to follow up on Resident #1's STAT X-ray of right hip and report to the physician in a timely manner. The DON said the NF was not following their process. The DON said there was unstable staffing. The DON said there was no consistency with communication among the nursing staff regarding resident care.<BR/>Interview on 05/29/2023 at 11:08 am, the Administrator said when agency nurses worked at the NF, it was not a guarantee that they will be back the next day and things will go missed. The Administrator said the NF did not have any systems in place to follow-up on STAT Labs/diagnostic testing. The Administrator said everybody was just doing their own thing and not communicating with each other using the 24-hour communication form consistently regarding the residents' care, not following up regarding test results, and reporting the findings to the physician. Further interview with the Administrator said she did not do an investigation regarding Resident #1 stat x-ray of the right hip not being reported to the physician in a prompt manner because the Regional Director of Operations said that he would do the investigation.<BR/>Interview on 05/29/2023 at 12:55pm The Regional Director of Operations said regarding Resident #1's stat x-ray of the right hip not being reported to the attending physician at the NF in a prompt manner, said he called the incident in to the state and told the Administrator to do the facility investigation. <BR/>Record review of the NF Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/2022 revealed in part:<BR/> .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing an implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Neglect means failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .<BR/>Record review of the NF policy on Clinical Practice Guidelines Facility 24 Hour Report revised 02/04/2022 revealed in part:<BR/> .It is the policy of this facility to record relevant information on a 24-hour report form in order to promote continuity of care. The report form will be completed daily for a 24-hour period .Each nurse is responsible for reviewing the information on the shift report at the beginning of his/her shift to identify and prioritize resident needs. The ADON or designee, will review 24-hour shift reports daily in order to identify and prioritize resident needs .<BR/>An IJ was identified on 05/26/2023. The IJ template was provided to the facility Admministrator on 05/26/2023 at 5:50pm. While the Administrator was notified on 05/29/2023 at 11:50am that the IJ was removed, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner.<BR/>PLAN OF REMOVAL<BR/>F600<BR/>Name of facility<BR/>Date: 05/26/2023<BR/> Immediate Action<BR/>The DON or designee immediately reviewed all residents with recent Diagnostic testing to ensure that timely follow up on results of diagnostic testing, and physician notification were implemented if needed. No other issues identified. This was completed 05/26/2023.<BR/>The DON or designee immediately reviewed the 24 -hour nurse report to validate communication system is in use by licensed nurse to ensure continuity of care, treatment, and interventions as applicable. This was completed on 05/26/2023.<BR/>The DON or designee immediately validated that all licensed nurses were knowledgeable on location of fax machine designated to receive diagnostic results including frequency by providing in-service education. This was completed 05/27/2023. No licensed nurse will be allowed to work after 05/27/2023 until they have completed this education.<BR/>The DON or designee immediately implemented the Diagnostic Tracking tool on 05/27/2023 to effectively monitor diagnostic orders, results of diagnostic testing, and notification of Physician.<BR/>Facilities Plan to ensure compliance quickly<BR/>DON/designee began education Immediately on:<BR/>Diagnostic Tracking Guidelines Education with all licensed nurses including post-test<BR/>Use of Diagnostic Tracking tool to have an effective system in place to monitor for STAT diagnostic/laboratory results<BR/>Abuse and Neglect Education with all licensed nurses including post-test<BR/>24 Hour Report entry Guidelines Education to have a communication system in place to ensure timely continuity of care and interventions/treatment<BR/>Documentation Guidelines Education <BR/>Notification of Change in Condition Education including post-test<BR/>This education began 5/26/2023 and will end 5/27/2023. Any licensed nurse who has not received this education and post-test will not be allowed to work until this is completed.<BR/>The facility's Medical Director was notified of the Immediate Jeopardy on 5/26/2023.<BR/>On 5/27/2023 the facility will conduct an Ad Hoc QAPI meeting to review areas cited and plan for sustaining compliance.<BR/>The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following monitoring:<BR/>Interview on 05/28/2023 at 1:45 pm, the Weekend Supervisor said she had been in-service in the following areas: abuse/neglect, handwashing, how to access all diagnostic testing by looking in the computer to review and track physician orders. The weekend supervisor said by looking at the tracker, she could see if the order had been processed. That way, she could call the physician/doctor with the results in a timely manner. The weekend supervisor said she had also received in-service on receiving a verbal report using the 24-hour communication form from the unit nurses at the beginning of the shift and at the end of shift and her report would be provided to the ADON. The weekend supervisor said she had been in-serviced on all fax locations at the NF with the copy room being the fax machine for diagnostic results. <BR/>Interview on 05/28/2023 at 1:50 pm, RN I worked the 6am-6pm shift said she had been in-service on the following: abuse/neglect, tracking ordered diagnostic testing in the system and checking to see if the physician was notified of the results, documentation on all diagnostic testing in PCC and that the physician was notified, shift reporting providing a verbal report are porting using the 24-hour communication form, and the location of the fax machines at the NF.<BR/>Interview on 05/28/2023 at 2:03 pm, LVN E said she worked the 6am-6pm shift and had been in-serviced on all diagnostic testing, hand washing, abuse and neglect, notifying the physician in a timely manner on STAT diagnostic test results, checking on ordered diagnostic testing to ensure the order had been done and results provided to the physician, documentation, shift reporting using the 24-hour report form.<BR/>Interview on 05/28/2023 at 2:15 pm, LVN S said she worked full time at the NF 6am-6pm shift. LVN S said she received in-service on abuse and neglect, how to track ordered diagnostic testing in the computer using the tracker, reporting the test results to the physician and notifying the RP as well, document care provided to the residents in the Nursing Progress Notes in PCC as well as documenting on the 24-hour communication form, location of the fax machines at the NF, shift to shift report using the 24-hour communication form.<BR/>Interview on 05/28/2023 at 2:20 pm, LVN J said she worked the 6am-2pm shift and been in-serviced in the following areas: abuse and neglect, change in resident condition notifying and the RP, documentation, how to track all diagnostic testing using the tracker in the computer to see if the test had been done and reporting results to the physician, verbal shift to shift report with the 24-hour communication form, and location of fax machines with the test results being found on the fax machine in the copy room.<BR/>Interview on 05/28/2023 at 8:55 pm, LVN G said she worked at the NF part-time 6pm-6am shift. LVN G said she had received in-service on abuse and neglect, communicating all diagnostic testing results to the physician in a prompt manner, verbal shift to shift reporting using the 24-hour communication form, and location of fax machines with the copy room being the fax machine for designated diagnostic test results, and being sure to document actions taken in the care of the resident in PCC and on the 24-hour communication form.<BR/>Interview on 05/28/2023 at 9:02 pm, LVN K said she worked at the NF full time 6pm-6am. LVN K said she had been in-serviced on abuse and neglect, 24-hour communication shift to shift report, tracking STAT diagnostic testing as well as all diagnostic testing reporting to the doctor in a timely fashion, notifying the family when there is a change in the resident condition as well as the doctor, fax machine locations, and documentation.<BR/>Interview on 05/28/2023 at 9:15 pm, LVN L said she worked at the NF full time on the 6:00pm-6am shift. LVN L said she had been in-serviced on location of the fax machines with the copy room being the designated fax machine for diagnostic testing, documenting when a resident experience a change in condition notifying the physician and the RP and what was done, being sure to document on the 24-hour communication form, using the 24-hour communication form when giving verbal shift to shift report, reporting all diagnostic testing results to the physician in a timely manner, how to use the tracker in the computer to track diagnostic testing, abuse and neglect.<BR/>Interview on 05/28/2023 at 9:35pm LVN C, said he had been in-serviced on reporting all diagnostic testing results to the doctor in a timely manner, documenting in PCC and on the 24-hour communication fo[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician order for 1 (Resident #1) of 10 residents reviewed for radiology services in that: <BR/>-The facility failed to report Resident #1's stat x-ray results of a fracture of the right hip, femur, and pelvis in a prompt manner.<BR/>An IJ was identified on 05/26/2023. The IJ template was provided to the facility Administrator on 05/26/2023 at 5:50pm. While the Administrator was notified on 05/29/2023 at 11:50am that the IJ was removed, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner.<BR/>This failure has the potential to place residents who receive diagnostic testing for delayed treatment and hospitalizations.<BR/>Findings:<BR/>Resident #1<BR/>Record review of Resident #1's face sheet dated 05/12/2023 revealed an [AGE] year old male admitted to the NF on 04/02/2023 with the following diagnoses; cerebral infarction (disrupted blood flow to the brain), respiratory failure, hypertension (high blood pressure), dysphagia (difficulty swallowing), functional quadriplegia (loss of control of both arms and both legs), type two diabetes mellitus, heart disease, sacral (below the spine and above the tailbone) ulcer stage 4, pressure ulcer of left ankle, renal (kidney) disease, tracheostomy (opening created at the front of the neck so that a tube can be inserted in the windpipe to help one breathe), gastrostomy (opening in the stomach done surgically for the introduction of food), and colostomy (surgical operation creating an opening in the abdomen/stomach to expel waste). <BR/>Record review of Resident #1's admission assessment MDS dated [DATE] revealed BIMS score of 9 (cognition moderately impaired). Further review revealed that resident was totally dependent on staff with assistance of activities of daily living. <BR/>Record review of Resident #1's Care Plan dated 05/12/2023 revealed that resident was being care planned for falls and ADL performance deficit related to: impaired mobility and limited ROM. <BR/>Record review of Resident #1's Physician Progress Notes dated 05/04/2023 revealed in part:<BR/> .chief complaint/nature of presenting problem: Patient reports sever pain in right hip, right femur, patient has severe chronic comorbidities, patient's right lower extremity is seen over the left lower extremity. Patient appears more alert and verbal today, reports significant discomfort to the right hip, right femur .<BR/>Record review of Resident #1's Physician orders revealed the following orders:<BR/>-Dated 05/04/2023 X-ray right hip, pelvis, right femur STAT (right away)<BR/>Record review of Resident #1's MAR for the month of May 2023 revealed that the NF was administering Tylenol extra strength as ordered by the physician. <BR/>Record review of Resident #1's STAT X-ray results of the right hip, pelvis, right femur dated 05/04/2023 revealed in part:<BR/> .Age-indeterminate (the radiologist cannot tell based on the x-rays alone if it is new or old) avulsion fracture at greater trochanter of femur is noted. No other acute fracture or dislocation . <BR/>Record review of the NF 24-hour communication form dated 05/04/2023 was documented that the STAT X-ray was done of the right hip, pelvis, and femur but not that the physician was notified of results. Further review of the 24-hour communication on 05/06/2023 was documented that Resident #1 refused dialysis, G-tube (gastrostomy)and trach (tracheotomy) care; colostomy bag changed. There was no further documentation regarding the results of Resident #1's STAT right hip X-ray or if the physician and been notified. <BR/>Further review of the results of Resident #1's STAT X-ray results of right hip, right pelvis, and right femur dated 05/04/2023 revealed that the weekend supervisor initialed on 05/07/2023 that she notified the physician on 05/07/2023 with orders to send Resident #1 out for treatment and evaluation.<BR/>Record review of the NF Staff Time Sheet dated 05/04/2023 revealed that LVN F clocked in to work at 5:48pm and LVN C clocked in to work at 7:19pm.<BR/>Interview on 05/17/2023 at 4:15pm via phone LVN C said he worked on 05/04/2023 6pm-6am and was Resident #1's nurse. LVN C said he was not aware that Resident #1 had an X-ray done on his right hip. LVN C said he worked at the NF on a PRN basis and did not recall that he had received in report that resident had STAT X-ray done on right hip. LVN C said he received and gave shift report using the 24-hour communication form. <BR/>Interview on 05/28/2023 at 11:30am via phone LVN D said she was working on 05/04/2023 6am-6pm shift and that she was Resident #1's nurse on that day. LVN D said resident doctor came to the NF on 05/04/2023 and that she remembered resident complaining of pain to his right hip. LVN D said the NP had also come to the NF on 05/04/2023 and gave orders on multiple residents. LVN D said LVN C was the nurse to relieve her, but was running late for work therefore, she had to give report to LVN F who was working another hall. LVN D said LVN F was upset that he had to take report for LVN C, and she just gave LVN F a verbal report not using the 24-hour communication form. LVN D said although she did not mention in her verbal report to LVN F that Resident #1 had a STAT order for an X-ray of the right hip that had been done, she did write it on the 24-hour communication form. LVN D said she knew she was supposed to utilize the 24-hour communication form it was just a lot happening on 05/04/2023. <BR/>Interview on 05/28/2023 at 12:37pm LVN F said he worked at the NF part time the evening shift 6pm-6am. LVN F said the normally process when clocking in to work at the NF was to count the narcotic cart. LVN F said he done walking rounds along with verbal report utilizing the 24-hour report form. LVN F said he did not recall receiving report from LVN D nor giving report to LVN C regarding Resident #1. <BR/>Record review of Resident #1's Nursing Progress Notes revealed the following documented by LVN D dated 05/04/2023 at 8:19am documentation incomplete read as follows:<BR/> .9:49am patient refused . <BR/>05/05/2023 documented by LVN C revealed in part at 7:11am: <BR/> .Refused dialysis MD/RP aware .<BR/>05/05/2023 documented by LVN O at 2:15pm Resident refused dialysis. NP aware and educated patient about the importance of hemodialysis. Nurse attempted 3 times. Resident still refused .<BR/>05/07/2023 documented at 10:13am by weekend supervisor read in part:<BR/> .Physician notified regarding x-ray results. Received new order to send out for evaluation of fracture. Resident resting quietly in bed at this time denies pain .<BR/>Record review of Resident #1's hospital records dated 05/07/2023 revealed in part:<BR/> XXX[AGE] year-old male who is bedbound, was sent from NH for evaluation of right hip pain. X-ray at outside facility was questionable for right hip fracture. Upon examination it was noted necrotic (death of living tissue) changes in his left 2nd and third toes. He also has a stage 4 sacral decubitus ulcer. CT pelvis was completed rising suspicion for sacral osteomyelitis (infection of bone). He did not meet the suspicion for sepsis .Right hip pain likely referred pain. No CT evidence of fracture .Noted Orthopedic Surgery input. No need for surgical intervention for hip or femur. Will start on empiric (therapy begun on the basis of a clinical or educated guess) Zyvox and Levaquin (antibiotics) .<BR/>Interview on 05/12/2023 at 11:14am Administrator said Resident #1 was still in the hospital in ICU. The Administrator said she was not at the NF regarding the incident with Resident #1 and that she started working at the NF on 05/08/2023. The Administrator said she found out later the STAT X-rays done on Resident #1 right hip revealed a fracture. Further interview with the Administrator said she was not aware that there had been a delay in reporting Resident #1's STAT X-ray results of the right hip done on 05/04/2023 to the doctor until 05/07/2023. <BR/>Interview on 05/12/2023 at 3:42pm The Weekend Supervisor said she worked only on the weekends double shift 6am-10pm. The Weekend Supervisor said when she saw Resident #1's X-ray results of the right hip at the nurse's station on 05/07/2023, she was not sure if the physician had been notified and therefore text the doctor on 05/07/2023. The Weekend Supervisor said when she contacted Resident #1's doctor, he had not been notified of the STAT X-ray results that he had ordered on 05/04/2023 until she had presented the results to him on 05/07/2023. The Weekend Supervisor said the doctor gave her orders to send Resident #1 out to the hospital for further evaluation and treatment. The Weekend Supervisor said she received report on the residents at the NF from the ADON through text or facetime. The Weekend Supervisor said the ADON never mentioned to her that a STAT X-ray of the right hip, right femur, and pelvis had been ordered on Resident #1. The Weekend Supervisor said when she called the ADON on 05/07/2023, the ADON told her that she was not aware that a STAT X-ray had been order for Resident #1. The Weekend Supervisor said the nurses on duty on the weekend were not aware that a STAT X-ray of the right hip had been ordered on Resident #1. The Weekend Supervisor said she went to Resident #1's room to see if resident was in pain. She said resident said he was not in any pain.<BR/>Interview on 05/12/2023 at 4:40pm LVN A said she worked Hall 500 and that Resident #1 resided on Hall 600. LVN A said when she reported to work, she observed the residents first before taking a verbal report from the nurse. LVN A said when she took a verbal report from the nurse, she also utilized the 24-hour report sheet to ensure she was receiving all needed information to ensure the continuity of care. LVN A said not all the nurses utilized the 24-hour report sheet. LVN said the 24-hour report sheet was kept at the nurse's station in a binder. <BR/>Interview on 05/12/2023 at 4:55pm ADON said the doctor was making rounds at the NF on 05/04/2023 and Resident #1 said he was in pain. The ADON said the doctor ordered an X-ray of the right hip on Resident #1. The ADON said honestly, she did not know that there had been a delay in notifying the physician regarding Resident #1 X-ray results taken of the right hip on 05/04/2023. The ADON said the X-ray of Resident #1's right hip was ordered STAT. The ADON said that radiology came to the NF late on 05/04/2023. The ADON could not give the time that Radiology came to the NF to do an X-ray of Resident #1's right hip. The ADON said the nurses should have caught that and it should have been discussed in shift-to-shift report. The ADON said when the weekend supervisor called her on 05/07/2023 regarding Resident #1's X-ray of the right hip she told the weekend supervisor to call the doctor. The ADON said there was a different DON working at the NF at that time when the STAT X-ray was ordered for Resident #1 right hip. The ADON said she attended the morning meetings and that Resident #1 STAT X-rays done on 05/04/2023 (Thursday) was never discussed in the following morning meeting on 05/05/2023. Further interview with the ADON said the reason Resident #1's STAT X-ray of the right hip, pelvis, and femur was not discussed was because the NF Administrator was late arriving at the NF, and it was her last day working at the NF therefore the morning meeting on 05/05/2023 did not happen. The ADON said the NF at the time did not have a permanent DON as well, but an interim DON. The ADON said the NF did not have a policy that the nurses had to document on the 24-hour communication report sheet as a form of communication regarding the resident (s) care. <BR/>Further interview on 05/12/2023 at 5:15pm Administrator said regarding Resident #1, the NF had done in-services on abuse and neglect, documentation, level of pain assessment, shift reporting, notifying the Administrator/DON/Doctor before sending a resident out to the hospital. Further interview with the Administrator said the Regional Director of Operations called the incident regarding Resident #1 into the state and that the Regional Director of Operations was the one that done the facility incident investigation regarding Resident #1 STAT X-ray results of a fracture to resident right hip. <BR/>Interview on 05/12/2023 at 5:15pm DON said she started working at the NF on 05/08/2023 and what she knew about Resident #1 was that resident had a lot of contractures and complained of pain. The DON said the nurse did medicate resident for pain but was not effective and the doctor said to send resident to the hospital to be evaluated. The DON said it was discovered at the hospital that Resident #1had a fracture but could not say where the fracture was. The DON She said when Resident #1 went to the hospital on [DATE] the nurses called the hospital to see how resident was doing. The DON said that was when the NF found out that Resident #1 had a fracture. The DON said she never read the NF Incident Investigation Report regarding Resident #1. <BR/>Interview on 05/17/2023 at 9:30am via phone Radiology regarding Resident #1 said a STAT X-ray was done on resident right hip on 05/04/2023 and the results were called to the NF on 05/04/2023 spoke to a staff member XX. Radiology said they did not get a last name or title. Radiology said the results were verbally given to XX at 9:54pm and faxed to the NF on 05/04/2023. Radiology said the STAT X-ray results were faxed again to the NF on 05/07/2023 at 11:28am.<BR/>Interview on 05/17/2023 at 10:00am the Administrator said the NF had 3 fax machines in the NF that consisted of the following:<BR/>1)Copy Room<BR/>2)Medication Room<BR/>3)e-fax<BR/>Further interview 05/17/2023 at 2:13pm the Administrator said the NF did not have an employee by the name of XX that worked at the NF.<BR/>Observation on 05/17/2023 at 12:00pm Resident #1 on Hall-600 sitting in a Geri-chair that was in a reclined positioned. Resident was easily aroused and denied any pain at the present time.<BR/>Interview on 05/17/2023 at 12:50pm via phone Physician A of Resident #1 at the NF said regarding Resident #1 he reviewed resident hospital records on 05/16/2023. Physician A said the hospital records reached the conclusion after a CT scan of the right pelvis was done that resident did not have a fracture. Physician A said while resident was at the hospital was seen by the Orthopedic doctor. Physician A said resident had multiple comorbidities and prognosis was poor, resident was a good candidate for hospice, but the family of resident would have to make that choice. Physician A said because resident had been assessed by the hospital would base his plan of care off the hospital conclusion and continue to monitor Resident #1.<BR/>Attempted interview via phone on 05/17/2023 at 1:47pm with LVN O; no answer.<BR/>Interview on 05/17/2023 at 2:15pm DON said the nurses supposed to do verbal report and use their computer looking at the 24-hour communication report on the computer. The DON said the NF trying to get rid of paper using only the computer to document resident care. The DON said she would have to look at the computer to see if the staff was charting on the 24-hour form on the computer. The DON said a STAT order should be followed up in 2 hours if results not received. The DON said some of the nurses are timid when it came to calling the physician and that not all nurses use critical thinking. The DON said she would be doing further in-service with staff on a lot of issues including notifying the doctor whenever there was a change in a resident (s) condition. The DON said she spoke with the Regional Nurse who informed her that whenever there is a change in a resident condition the nurses should be using and INTERACT form. The DON said she had not been privy to reviewing the form, but it seems to be like a glorified SBAR. The DON said she had not reviewed Resident #1's chart at all because she had been busy with training and doing in-services with the Nursing Staff when she started working at the NF on 05/08/2023. The DON said the Administrator had reviewed Resident #1's medical records. The DON said she learned today that the NF had 3 different fax machines that consisted of an e-fax (send to the computer), fax in the medication room, and work room (copy room). The DON said she was unsure where the results for diagnostic testing would be faxed too. The DON said it was the nurses that done shift report as well as the ADON's that was supposed to be reviewing the 24-hour communication form. The DON said the ADON supposed to bring the 24-hour communication report sheet to the morning meetings. The DON said it was ultimately the DON that ensure that the 24-hour communication forms were being done. The DON said the 24-hour communication forms was another form of communication that was relied upon to ensure the continuity of care for the residents. <BR/>Further interview on 05/17/2023 at 2:32pm Administrator said when a resident had to be discharged to the hospital, she would do a look back for the past 72-hours that included reviewing the 24-hour communication reports that were kept in a binder at the nurse's station. The Administrator said she also reviewed what was documented in PCC to ensure that residents care was being met. The Administrator was not able to answer that if she done these things why did she not see that there was a delay in notifying Resident #1's physician of STAT X-ray results of the right hip? The Administrator said it was the ADON's that were responsible for reviewing the 24-hour communication form which were brought to the morning meetings to be further discussed. The Administrator said she was told by the ADON that all diagnostic results was faxed to the medication fax room (281-633-9594). The Administrator said even if a diagnostic result went to another fax room, the staff should have been following up on Resident #1's STAT X-ray results that were taken on 05/04/2023.<BR/>Interview on 05/17/2023 at 2:55pm LVN E said she thought the NF had 1 fax machine which was in the copy room. LVN E said diagnostics were good about calling the NF on anything that was critical and got the person's name who they spoke too including the time they spoke with that person. <BR/>Interview on 05/17/2023 at 3:54pm DON said the weekend supervisor supposed to get report from the DON or ADON when they report to work. The DON said she did not think that the NF had a permanent DON at the time of the incident regarding Resident #1, but an interim DON.<BR/>Interview on 05/27/2023 at 11:13am Weekend Supervisor said she normally checked the fax machine in the copy room [ROOM NUMBER]-4 times while on duty. The Weekend Supervisor said STAT diagnostic testing she followed up in 2 hours for the results. The weekend supervisor said laboratory was good about calling the NF with lab results but was not sure about radiology. The Weekend Supervisor said she was not sure how Resident #1 STAT X-ray results of the right hip went un-reported to Resident #1's physician. The Weekend Supervisor said the NF neglected to report to Resident #1's physician right away the results of resident STAT X-rays done on resident right hip. The Weekend Supervisor said this placed resident at risk for pain and further injury of the right hip. <BR/>A call was placed to LVN O on 05/27/2023 at 12:12pm with a female answering the phone denying that they were LVN O. It was confirmed with the NF that the number provided to the surveyor for LVN O was the number that they had on file for LVN O.<BR/>Interview on 05/27/2023 at 12:30pm ADON said LVN O was an agency nurse.<BR/>Attempted interview on 05/27/2023 at 12:44pm via phone with LVN O, no answer, left voicemail with a call back number.<BR/>Interview on 05/27/2023 at 12:25pm LVN B said she worked at the NF PRN. LVN B said she worked at the NF over a year ago and had just started working back at the NF. LVN B said she did not know how many fax machines that the NF had. LVN B said she believed that diagnostic test results were retrieved from the fax machine in the medication room. LVN B said no one at the NF had in serviced her on all fax machine locations at the NF or how often to follow-up for diagnostic results.<BR/>Interview on 05/28/2023 at 11:20am DON said she thought the immediate jeopardy occurred because the NF failed to follow up on Resident #1's STAT X-ray of right hip and report to the physician in a timely manner. The DON said the NF was not following their process. The DON said another reason she believes was due to unstable staffing not that she was blaming the previous DON. The DON said there was no consistency with communication among the nursing staff regarding Resident #1's care.<BR/>Interview on 05/29/2023 at 11:08am Administrator said IJ occurred at the NF because when agency nurses work at the NF not a guarantee that they will be back the next day and things will go missed. The Administrator said the NF did not have any systems in place to follow-up on STAT Labs/diagnostic testing. The Administrator said everybody was just doing their own thing and not communicating with each other using the 24-hour communication form consistently regarding the resident (s) care, not following up regarding test results, and reporting the findings to the physician. <BR/>Record review of the NF Policy on Diagnostic's Tracking Guidelines dated 08/2013 revealed in part:<BR/>Purpose: To establish a clinical practice model to track the completion, reporting and monitoring of diagnostic tests (labs, x-rays, Doppler studies etc.) and results .Abnormal Radiology results are communicated to the physician or medical director immediately . <BR/>Record review of the NF policy on Clinical Practice Guidelines Facility 24 Hour Report revised 02/04/2022 revealed in part:<BR/> .It is the policy of this facility to record relevant information on a 24-hour report form in order to promote continuity of care. The report form will be completed daily for a 24-hour period .Each nurse is responsible for reviewing the information on the shift report at the beginning of his/her shift to identify and prioritize resident needs. The ADON or designee, will review 24-hour shift reports daily in order to identify and prioritize resident needs .<BR/> An IJ was identified on 05/26/2023. The IJ template was provided to the facility on [DATE] at 5:50pm. While the IJ was removed on 05/29/2023, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner.<BR/>PLAN OF REMOVAL<BR/>F 773<BR/>Name of facility<BR/>Date: 5/26/2023<BR/>Immediate action:<BR/>The DON or designee immediately reviewed all residents with recent Diagnostic testing to ensure that timely follow up on results of diagnostic testing, and physician notification were implemented if needed. No other issues identified. This was completed 5/26/2023<BR/>The DON or designee immediately reviewed the 24 -hour nurse report to validate communication system is in use by licensed nurse to ensure continuity of care, treatment, and interventions as applicable. This was completed 5/26/2023<BR/>The DON or designee immediately validated that all licensed nurses were knowledgeable on location of fax machine designated to receive diagnostic results including frequency by providing in-service education. This was completed 5/27/2023. No licensed nurse will be allowed to work after 5/27/2023 until they have completed this education.<BR/>The DON or designee provided 1:1 education with ADON and all charge nurses that failed to update the 24-hour report regarding the impending results of the stat X-Ray and for not following up on results timely. This was completed 5/27/2023.<BR/>The DON or designee immediately validated that facility did not fail to notify physician regarding any recent diagnostic testing. This was completed 5/27/2023.<BR/>Facilities Plan to ensure compliance quickly<BR/>DON/designee began education Immediately with all licensed nurses on:<BR/>Reviewing the 24-hour report in morning meeting <BR/>Policy & Procedure: Diagnostic Tracking Guidelines Education with all licensed nurses including post-test<BR/>Use of Diagnostic Tracking tool to have an effective system in place to monitor for STAT diagnostic/laboratory results for timely tracking of Diagnostic testing 7 days a week. All ordered diagnostic testing will be recorded on the tracking log in the 24- hour report book, and reviewed 3 times a shift by charge nurses/ADON until results are received and Physician notification of results. If stat results not received within 4 hours, physician will be notified for appropriate orders<BR/>The lab tracking log will be reviewed in the daily morning meeting and on weekends by the weekend supervisor.<BR/>Policy & Procedure: Abuse and Neglect Education with all licensed nurses including post-test<BR/>Policy & Procedure: 24 Hour Report entry Guidelines Education to have a communication system in place to ensure timely continuity of care and interventions/treatment<BR/>Policy & Procedure: Documentation Guidelines Education <BR/>Policy & Procedure: Notification of Change in Condition Education including post-test<BR/>Beginning 5/27/2023 DON or designee will provide this education to all licensed Agency staff, PRN staff, and new hires prior to working<BR/>On 5/27/2023 the DON or designee will provide 1:1 education with the weekend supervision on all education to ensure oversight of systems on weekends<BR/>This education began 5/26/2023 and will end 5/27/2023. Any licensed nurse who has not received this education and post-test will not be allowed to work until this is completed.<BR/>The facility DON or designee conducted a root cause analysis on 5/27/2023 and will take to QAPI committee for review<BR/>The facility's Medical Director was notified of the Immediate Jeopardy on 5/26/2023.<BR/>On 5/27/2023 the facility will conduct an Ad Hoc QAPI meeting to review areas cited and plan for sustaining compliance.<BR/>The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following:<BR/>Interview on 05/28/2023 at 1:45pm Weekend supervisor said she had been in-service in the following areas: abuse/neglect, handwashing, how to access all diagnostic testing by looking in the computer to review and track physician orders. The weekend supervisor said by looking at the tracker, she could see if the order had been processed that way, she could call the physician/doctor with the results in a timely manner. The weekend supervisor said she had also received in-service on receiving a verbal report using the 24-hour communication form from the unit nurses at the beginning of the shift and at the end of shift and her report would be provided to the ADON. The weekend supervisor said she had been in-serviced on all fax locations at the NF with the copy room being the fax machine for diagnostic results. <BR/>Interview on 05/28/2023 at 1:50pm RN I worked the 6am-6pm shift said she had been in-service on the following: abuse/neglect, tracking ordered diagnostic testing in the system and checking to see if the physician was notified of the results, documentation on all diagnostic testing in PCC and that the physician was notified, shift reporting providing a verbal report are porting using the 24-hour communication form, and the location of the fax machines at the NF.<BR/>Interview on 05/28/2023 at 2:03pm LVN E said she worked the 6am-6pm shift and had been in-serviced on all diagnostic testing, hand washing, abuse and neglect, notifying the physician in a timely manner on STAT diagnostic test results, checking on ordered diagnostic testing to ensure the order had been done and results provided to the physician, documentation, shift reporting using the 24-hour report form.<BR/>Interview on 05/28/2023 at 2:15pm LVN S said she worked full time at the NF 6am-6pm shift. LVN S said she received in-service on abuse and neglect, how to track ordered diagnostic testing in the computer using the tracker, reporting the test results to the physician and notifying the RP as well, document care provided to the residents in the Nursing Progress Notes in PCC as well as documenting on the 24-hour communication form, location of the fax machines at the NF, shift to shift report using the 24-hour communication form.<BR/>Interview on 05/28/2023 at 2:20pm LVN J said she worked the 6am-2pm shift and been in-serviced in the following areas: abuse and neglect, change in resident condition notifying and the RP, documentation, how to track all diagnostic testing using the tracker in the computer to see if the test had been done and reporting results to the physician, verbal shift to shift report with the 24-hour communication form, and location of fax machines with the test results being found on the fax machine in the copy room.<BR/>Interview on 05/28/2023 at 8:55pm LVN G said she worked at the NF part-time 6pm-6am shift. LVN G said she had received in-service on abuse and neglect, communicating all diagnostic testing results to the physician in a prompt manner, verbal shift to shift reporting using the 24-hour communication form, and location of fax machines with the copy room being the fax machine for designated diagnostic test results, and being sure to document actions taken in the care of the resident in PCC and on the 24-hour communication form.<BR/>Interview on 05/28/2023 at 9:02pm LVN K said she worked at the NF full time 6pm-6am. LVN K said she had been in-serviced on abuse and neglect, 24-hour communication shift to shift report, tracking STAT diagnostic testing as well as all diagnostic testing reporting to the doctor in a timely fashion, notifying the family when there is a change in the resident condition as well as the doctor, fax machine locations, and documentation.<BR/>Interview on 05/28/2023 at 9:15pm LVN L said she worked at the NF full time on the 6:00pm-6am shift. LVN L said she had been in-serviced on location of the fax machines with the copy room being the designated fax machine for diagnostic testing, documenting when a resident experience a change in condition notifying the physician and the RP and what was done, being sure to document on the 24-hour communication form, using the 24-hour communication form when giving verbal shift to shift report, reporting all diagnostic testing results to the physician in a timely manner, how to use the tracker in the computer to track diagnostic testing, abuse and neglect.<BR/>Interview on 05/28/2023 at 9:35pm LVN C said he had be in-serviced on reporting all diagnostic testing results to the doctor in a timely manner, documenting in PCC and on the 24-hour communication form relaying the information in shift report, documenting when there was a change in resident (s) condition, location of the fax machines, and how to track the results of ordered diagnostic testing in the computer.<BR/>Interview on 05/29/2023 at 9:00am LVN H said he worked the 6:00pm-6:00am shift part time at the NF and been in-service in the following areas: abuse and neglect, timeliness of report STAT diagnostic testing results to the physician, following up on all diagnostic testing results by tracking the ordered test results in the computer, location of all fax machines at the NF and the one designated for diagnostic t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #1) of 5 residents reviewed for accident and hazards: <BR/>1. The facility failed to ensure Resident #1 had his floor mat by his bedside while lying asleep in his bed.<BR/>2. The facility failed to ensure Resident #1 wore his head helmet to prevent injuries from accidental falls.<BR/>These failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues as a result of accident hazards.<BR/>Findings included: <BR/>Record review of resident #1's face sheet revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were Hypertension (High blood pressure), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebellar ataxia (inability to control voluntary muscle movements). <BR/>Record review of resident #1's Comprehensive MDS dated [DATE] revealed Resident #1 had a BIMs score of 03 indicating the resident was severely cognitively impaired. The resident required extensive assistance with one person physical assist with bed mobility, locomotion on and off unit, eating, and personal hygiene. The resident required total dependence to walk in room, to walk in corridor, dressing, and toilet use. MDS did not code Resident #1 for helmet.<BR/>Record Review of Resident #1's Care Plan dated 12/26/2022 read in part , helmet to be worn while awake to aid in prevention of head injury related to falls. Fall Risk Screening upon admission and quarterly to identify risks factors and floor mat . <BR/>Record Review of Resident #1's Fall Prevention Protocol dated 05/18/2021 read in part . a near miss, also considered a fall, was when a resident would have fallen if someone else had not caught the resident from doing so. Each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. Implement at risk fall care plan; provide additional interventions as directed by resident's assessment, including but not limited to assistive devices, low bed, increased frequency of rounds and sitter if indicated .<BR/>Observation on 1/20/2023 at 11:20 a.m. revealed Resident #1 lying in bed asleep. The floor mat was not on the floor by resident #1's bedside.<BR/>Observation on 1/20/203 at 12:55 p.m., revealed Resident #1 awake and eating. Resident #1 was not wearing his preventive injury helmet. <BR/>Observation on 1/20/2023 at 1:20 p.m. revealed Resident #1 in his bed sitting up. He was not wearing helmet.<BR/>Observation on 1/20/2023 at 2:36 p.m. revealed Resident #1 in bed sitting up and alert. He was not wearing his preventive injury helmet. <BR/>Interview on 1/20/2023 at 10:23 a.m. with LVN A, she said Resident #1 had a couple of falls where he had hit his head on the floor . She said his last fall was on 1/7/2023. She said she did not know how Resident #1 received a black eye. <BR/>Observation and interview on 1/20/2023 at 3:00 p.m. with LVN A, she said she was informed by the surveyor that Resident #1's floor mat was behind his room door and was not put back on the floor by RA after feeding Resident #1. She said the last person to provide care or assist with helping Resident #1 was responsible for putting the floor mat back on the floor. She said she would speak with the RA about the floor mat not being place back on the floor for Resident #1.<BR/>Interview on 1/20/2023 at 3:39 p.m. with the RA, she said the importance of a floor mat was to protect a resident if in case they fell off their bed when residents were fall risks. She said she nursing staff was supposed to remove floor mats when performing patient care. She said she should have placed Resident #1's floor mat by resident's bedside but she had a lot going on and it slipped her mind. She said the helmet protected Resident #1's from head injuries due to resident #1 being a fall risk. She said the only time she had seen him with his helmet on was when he was sitting in his chair. She said the last time she was in-serviced for fall prevention was this month. She could not recall the exact. She said she was aware of fall prevention protocols because she had taken courses when she received her certification to become a CNA. She said when she was done feeding Resident #1, she kept him up for 30 minutes to avoid resident aspirating. She said she was supposed to placed the floor mat after feeding Resident #1. <BR/>Interview on 1/20/23 at 3:39 p.m. with LVN A, she said she nursing staff were supposed to conduct rounds on the residents at the facility every two hours. She said if she noticed nursing staff were not following policy and procedure, she would ask them what happened and remind them to adhere to the rules. She said the importance of the floor mat was to help with cushioning if someone fell to the floor. She said it also help avoid injuries and pain. She said Resident #1 wore a helmet because he had head injuries from falls in the past few months. She said he wore his helmet when he was in his wheelchair in common areas. She said when he was in his wheelchair, he had the ability to stand upright. She said Resident #1 did not seem restless today so she wasn't worried that he was not wearing his helmet. She said she had been working at the facility for 6 months. She said she did not know Resident #1's was care planned for wearing his preventive injury helmet while resident #1 was awake. She said she had oversight of the nursing staff in her Unit. She said the risk to the resident for not having floor mat by bedside while the resident was in bed was injury. She said the risk to Resident #1 for having his preventive injury helmet on while awake was risk of injury. She could not say why the failure occurred. She could not recall the last time staff was in-serviced for fall prevention or accidents and hazards.<BR/>Record Review of the facility's policy titled, Fall Management System revised on 1/03/2017 read in part . it is the policy of the facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on research on the resident's assessed needs. A fall occurs when there is an unintentional coming to rest on the floor, ground, or other lower level but not because of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. A fall is often the result of cumulative risk from both intrinsic (resident-related) and extrinsic (environmental) factors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate, acquiring, receiving, dispensing, and administering all of drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 4 residents reviewed for pharmacy services.<BR/>1. The facility failed to administer the medications Amlodipine Besylate medication had blanks in the MAR from 01/13/23- 01/17/23.; Digoxin Tablet 125 MCG 0.5 tablet had blanks in the MAR from 01/07/23- 01/17/23; Melatonin had blanks in the MAR from 01/07/23- 01/17/23; Metformin HCl Tablet 500 MG had blanks in the MAR from 01/07/23- 01/17/23; Artificial Tears Solution 1 % had blanks in the MAR from 01/07/23- 01/17/23 at 8AM, and 01/07/23- 01/16/23 for the 4PM; Cymbalta Capsule Delayed Release Particles 60 MG had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 5PM; Lidocaine Pain Relief 4 % Patch had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 8PM; and Tramadol HCl Tablet 50 MG had blanks in the MAR from 01/07/23- 01/17/23 at 7AM, and 01/07/23- 01/16/23 for the 7PM to Resident #1.<BR/>This deficient practice affected Resident #1 and placed other residents at risk of having missed medications that could lead to diseases getting worse and/or hospitalization.<BR/>Findings:<BR/>Record review of Resident #1's face sheet dated 01/20/2023 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were muscle weakness, pain in knee, unspecified osteoarthritis, pain in left hand, muscle wasting and atrophy, and osteoarthritis of the knee.<BR/>Record review of Resident #1's Entry MDS dated [DATE] reflected the resident had a BIMS score of 15 out of 15 indicating the resident was cognitively intact. The resident required oversight and encouragement with Bed mobility, Transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, eating with one person assist, toilet use, and personal hygiene.<BR/>Record review of Resident #1's Care Plan dated 12/15/2022 reflected in part . Focus: Has Delusions. Periods of isolation and depression. Resident takes Trazodone and Cymbalta daily related to diagnoses of Major Depression, anxiety and insomnia. Goal: Resident will not have delusions or hallucinations. She will have less episodes of isolation and will maintain the highest level of function possible. Intervention: Give medication and monitor for side effects. Focus: Resident has a diagnosis of diabetes and is at risk for unstable blood sugars and abnormal lab results. Goal: Resident will be free from the signs and symptoms of hyper (high blood glucose (blood sugar))/hypoglycemia (condition in which your blood sugar (glucose) level is lower than the standard range) and Resident will have a reduced risk for complications related to diabetes through the next review date. Intervention: Administer diabetic medications as ordered by the physician. Focus: The resident has depression and takes antidepressants. Goal: The resident will remain free of s/sx of distress, symptoms of depression, anxiety or sad mood X 90 Days. Administer medications as ordered. Focus: Digoxin, Resident is on digoxin therapy related to tachycardia (medical term for a heart rate over 100 beats a minute). Goal: Resident will be free from the potential adverse reactions. Interventions: Check peripheral pulse (the palpation of the high-pressure wave of blood moving away from the heart through vessels in the extremities following systolic ejection) prior to administration and hold if outside of acceptable parameters as set by the physician. Focus: Behavioral Problem: Resident has a behavior problem. Resident continues to believe that she has lice or bed bugs in her hair. She will become very upset with staff. Goal: Resident will be clean, well groomed, and episodes of physical behaviors will decrease to less than weekly through the next review date. Resident will have less episodes of stating she has lice and or dandruff and the medical staff will collaborate more with psych staff to reduce this situation causing her so much distress. Interventions: Administer medications as ordered. Focus: Hypertension: Resident has hypertension and is at risk for fluctuations in blood pressure. Goal: Resident will remain free of signs and symptoms of hypertension through the review date. Intervention: Administer antihypertensive medications as ordered. Focus: Resident takes psychotropic meds: Cymbalta, Vistaril, Seroquel, trazodone. Goal: Resident will maintain the highest level of function possible and not experience a decrease in functional abilities related to psychotropic use during the next 90 days. Interventions: Administer medications as ordered.<BR/>Record review of Resident #1's physician's orders dated 01/13/2023 reflected Amlodipine Besylate Give 10 mg by mouth in the morning related to Essential (Primary) Hypertension.<BR/>Record review of Resident #1's physician's orders dated 05/18/2021 reflected Digoxin Tablet 125 MCG 0.5 tablet 125 MCG, Give 0.5 tablet by mouth in the morning related to Tachycardia, unspecified.<BR/>Record review of Resident #1's physician orders dated 04/02/2021 reflected Melatonin Tablet 5 MG, Give 1 tablet by mouth at bedtime for insomnia.<BR/>Record review of Resident #1's physician's orders dated 01/13/2021 reflected Metformin HCl Tablet 500 MG Give 1 tablet by mouth in the morning related to Type 2 Diabetes Mellitus with Unspecified Complications.<BR/>Record review of Resident #1's physician orders dated 05/16/2022 reflected Artificial Tears Solution 1 % (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes two times a day for dry eyes.<BR/>Record review of Resident #1's physician orders dated 03/29/2022 reflected Cymbalta Capsule Delayed Release Particles 60 MG, Give 60 mg by mouth two times a day related to Major Depressive Disorder, Recurrent, Severe with Psychotic symptoms.<BR/>Record review of Resident #1's physician orders dated 11/19/2022 reflected Lidocaine Pain Relief 4 % Patch apply 1 patch transdermally every morning and at bedtime for pain.<BR/>Record review of Resident #1's physician orders dated 01/12/2021 reflected Tramadol HCl Tablet 50 MG Give 1 tablet by mouth every 12 hours related to pain related to Pain in Unspecified knee (M25.569); Pain in Left hand (M79.642); Unspecified Osteoarthritis unspecified site.<BR/>Record Review of Resident #1's MAR dated January 2023 revealed the following: Amlodipine Besylate medication had blanks in the MAR from 01/13/23- 01/17/23.; Digoxin Tablet 125 MCG 0.5 tablet had blanks in the MAR from 01/07/23- 01/17/23; Melatonin had blanks in the MAR from 01/07/23- 01/17/23; Metformin HCl Tablet 500 MG had blanks in the MAR from 01/07/23- 01/17/23; Artificial Tears Solution 1 % had blanks in the MAR from 01/07/23- 01/17/23 at 8AM, and 01/07/23- 01/16/23 for the 4PM; Cymbalta Capsule Delayed Release Particles 60 MG had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 5PM; Lidocaine Pain Relief 4 % Patch had blanks in the MAR from 01/07/23- 01/17/23 at 9AM, and 01/07/23- 01/16/23 for the 8PM; and Tramadol HCl Tablet 50 MG had blanks in the MAR from 01/07/23- 01/17/23 at 7AM, and 01/07/23- 01/16/23 for the 7PM.<BR/>Observation and interview on 01/20/23 at 10:30 AM with Resident #1 revealed the resident lying in bed, dressed, and groomed with her call light within reach and water by her bedside table. The resident said she did not get her medications when she was in isolation a couple of weeks ago. She said she did not get her lactulose, dry eye drops, or lidocaine pain patch. She said she told staff she did not get her medications and she had pain, but did not know which staff she told. She did not say how staff responded after resident #1 told staff she didn't get her medications. At the time of the interview Resident #1 did not show any signs or symptoms of pain and did not report any pain. <BR/>Interview on 01/20/23 at 11:47 AM with CNA A, she said she had not seen or heard of residents missing medications. She said Medication Aides/LVNs were responsible for administering medications. She said the nurses had oversight of the Medication Aide to ensure medications were given. She said there was no reason why a resident would not get their medications. She said a resident not receiving their medications could lead to the resident getting sick or cause them harm.<BR/>Interview on 01/20/2023 at 1:35 PM with LVN A, she said she had worked at the facility for about seven months. She worked on Hall 100 and hall 500 as well. She said she worked with Resident #1. She said she put Voltaren gel on the resident's wrist for her osteoarthritis. She said a resident might not get their medications depending on parameters, or if it's PRN, according to orders. She said the MAR was blank 01/07/2023- 01/17/2023 because the resident was isolated due to COVID-19 and transferred to the COVID-19 wing. She said the facility did paper MARs for residents while they were in the COVID-19 wing.<BR/>Interview on 01/20/2023 at 1:40 PM with the ADON, she said Resident #1 had a paper MAR and she would locate it from the COVID-19 wing. <BR/>Interview with on 01/20/2023 at 2:00 PM with the Scheduler, she said the nurse administered medications to residents and LVN B was the nurse during the time Resident #1 was in the COVID-19 unit (01/07/2023- 01/17/2023). The Scheduler did not know when LVN B administered medications to Resident #1 while in the COVID-19 unit from 01/07/2023- 01/17/2023 because LVN B was scheduled to work during that time. The Scheduler did not know if LVN B had administered medications to Resident #1. <BR/>Phone interview on 01/20/2023 at 3:11 PM with LVN B, he said he gave medications to Resident #1. He said he left the COVID-19 unit on 11/17/2023 and Resident #1 was one of the last two people to arrive in the COVID-19 unit. He said he worked in the COVID-19 unit from 01/05/2023- 01/11/2023 and Resident #1 came into the COVID-19 unit on the 9th or 10th of January 2023. He said some of her medications were on a paper MAR. He said he administered Artificial tears, and Tramadol to the resident from 01/09/2023- 01/17/2023, but could not confirm he administered amlodipine Besylate, Digoxin Tablet, Melatonin, Metformin HCl Tablet, Cymbalta Capsule Delayed Release Particles 60 MG, or the Lidocaine Pain Relief 4 % Patch. He did not know why there were blanks on the MAR. <BR/>Interview on 01/20/2023 at 3:53 PM with the Scheduler, she said Resident #1 was in the COVID-19 unit from 01/7/2023- 01/17/2023. She said other nurses in the unit administered medications to Resident #1 were LVN C, and LVN D from 01/14/23 & 01/15/23, and LVN E and LVN F on 01/16/23 & 01/17/23.<BR/>A phone interview was attempted on 01/20/2023 at 4:15PM with LVN C and could not leave voicemail because the mailbox was full.<BR/>A phone interview was attempted on 01/20/2023 at 4:16PM with LVN D and left a voicemail asking her to call this survey back. <BR/>A phone interview was attempted on 01/20/2023 at 4:16PM with LVN E and left a voicemail asking her to call this survey back.<BR/>Phone interview on 01/20/2023 at 4:22PM LVN G said her shift was from 6PM- 6AM. She said she was familiar with Resident #1. She said she could not recall if Resident #1 received her medications from 01/07/2023- 01/17/2023. She said the risk to the residents when they didn't get their medications would be the resident getting worse and or hurting them. LVN G did not know the last time she was trained on medication administration.<BR/>Phone interview on 01/20/2023 at 4:26PM LVN D said she worked the 6PM- 6AM shift. She said she was familiar with Resident #1. She said she did not know if Resident #1 received her medications from 01/07/2023- 01/17/2023. She said the risk to the residents when they don't get their medications would be the resident getting sick or causing them pain. LVN D said she did not recall when she was last trained on medication administration.<BR/>Phone interview on 01/20/2023 at 4:30PM with LVN F said her shift is 6PM- 6AM and could not verify medications were administered during the day shift for Resident #1.<BR/>Interview on 01/20/2023 at 4:32 PM with the ADON, said she could not find the paper MAR for Resident #1. <BR/>Record review of the facility's Administration and Documentation guidelines dated 02/02/2014 reflected in part .Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration. Circle initials or those medication or treatment that were not administered and document the reason for the non-administration on the back of the MAR or TAR .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect and exploitation for 2 (Residents #26 and #61) of 2 residents reviewed for abuse, neglect, and misappropriation of property, in that;<BR/>1. The facility failed to implement their policy to report an injury of unknown source and failed to have evidence that a thorough investigation was conducted following the injury for Resident #26.<BR/>2. The facility failed to implement their policy to report to State an allegation of abuse reported by Resident #61. <BR/>These failures could place residents at risk for not having incidents reported and investigated as required and continued abuse and neglect which could result in diminished quality of life.<BR/>The findings were: <BR/>1. Record review of Resident #26's face sheet, dated 09/30/2022 revealed Resident #26 had an initial admission on [DATE] and was re-admitted on [DATE] with diagnoses that included: unspecified fracture of shaft of humerus, right arm (fracture of the long bone between the shoulder and the elbow), expressive language disorder (a condition that affects the ability to express oneself clearly, both verbally and non-verbally), hematemesis (vomiting of blood), and vascular dementia with behavioral disturbance (deterioration of memory, language, and other thinking abilities with agitation and anxiety).<BR/>Record review of Resident #26's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 03, indicating resident's cognition was severely impaired. Further review revealed Resident #26's functional level for transfers and ambulation with a walker was supervision to independent and balance to be not steady but able to stabilize without human assistance.<BR/>Record review of Resident #26's Care Plan, undated, revealed an entry initiated on 09/28/2022 and revised on 09/29/2022, Focus: 9/20/22 res. Had a actual fall with injury fx of right humerus. Intervention: Bed in lowest position. Fall mat to the bedside. Frequently used items within the resident's reach. Further review revealed an entry on 09/28/2022, Focus: [Resident #26] noncompliant with fall safety precaution refused fall mat/bed in low position x 3 attempts.<BR/>Record review of Resident #26's Nurses' Note, dated 09/20/2022, revealed, AROUND 0045 (12:45am) HEARD [RESIDENT #26] YELLING FOR HELP. NOTED ALERT LYING ON LEFT SIDE ON FLOOR WITH RT ARM BEHIND HIS BACK. CHECK FOR INJURY NOTED HIS RT ARM IN PAIN. V/S BP 169/99 P76 R20, [Telehealth Physician service] WAS CALLED, SPOKE TO MD, SEND OUT 911. RP WAS NOTIFIED AND D.O.N. WAS TEXTED. TOOK TO [hospital name].<BR/>Record review of the facility's Incidents by Incident Type report, dated 09/27/2022, revealed Resident #26's fall to have occurred at 12:45 a.m. in the resident's room. Further review revealed the fall occurred while ambulating and staff were unable to determine an injury.<BR/>Record review of the hospital report for Resident #26, revealed a note, dated 09/20/2022, 12:06 a.m., Complaint: fall at nursing home, vomiting blood. Information is limited as patient has some confusion. Further review revealed a History and Physical Note, ASSESSMENT AND PLAN: 1. Acute Right humerus fracture 2. Hematemesis (vomiting blood) concerning for Acute upper GI bleed 3. S/p mechanical ground level fall at nursing home.<BR/>Record review in TULIP (an online system for submitting long-term care licensure applications) revealed a self-report was made regarding Resident #26's fall with injury by the Administrator dated 09/26/2022, six days following the incident. <BR/>In an attempted interview with Resident #26 on 09/27/2022 at 11:44 a.m., Resident #26 struggled communicating the words and was unable to tell this writer how the resident's arm had been hurt.<BR/>During an interview with the Administrator on 09/28/2022 at 3:08 p.m., the Administrator stated he had not been told about Resident #26's injury until 09/26/2022 at which time he reported the incident to the state. The Administrator was asked if he was aware of the timelines required for reporting and he stated he was but the hospital did not call us and we only found out on Friday (09/23/22), I think it was when the resident returned. The Administrator confirmed the resident re-admitted on [DATE] (Friday) and stated, it was late, I found out about it Monday (09/26/22) morning and reported it.<BR/>During an interview on 09/29/2022 at 10:40 a.m., the DON stated she had been texted by the charge nurse on the night of the resident's fall however stated, we didn't know if there was an injury or not until he returned. The DON was asked if the facility called for updates on residents who were transferred out or if the hospital called to give a report and the DON stated, No, not until they are re-admitted . The DON was asked who at the facility could call in a report of abuse, neglect or injury of unknown injury and she stated, The Administrator does because he is the Abuse Coordinator, but I guess I could.<BR/>Record review of a training certificate Six Keys to Self-Reporting ANE and other Incidents (NF), provided by Texas Health and Human Services, dated 02/07/2022, revealed the DON had been trained in self-reporting regulations.<BR/>2. Record review of Resident #61's face sheet, dated 09/30/2022 revealed Resident #61 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses that included: end-stage renal (kidney) disease, anemia and pressure ulcer of sacral region (located below the lumbar spine and above the tailbone), stage 4.<BR/>Record review of Resident #61's admission MDS, dated [DATE], revealed the resident had a BIMS score of 12, indicating resident's cognition was moderately impaired. Further review of Resident #61's MDS assessments for 08/04/22, 08/25/22 and 08/30/22 revealed the resident did not exhibit any behavior problems during these assessment periods. <BR/>Record review of Resident #61's Care Plan, undated, revealed an entry initiated on 09/15/2022 and revised on 09/27/2022, Focus: Verbal Behaviors: Resident exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner. Res.(resident) yells at staff at times. <BR/>During an interview with the complainant on 09/29/2022 at 2:56 p.m., the complainant stated during a VA health check 09/20/2022, Resident #61 informed her that a female nurse aide hit him a few weeks ago. Neither the complainant nor the resident knew her name however the complainant stated she visited with the Administrator on the same day of the outcry, 09/20/22, and he assured her he would investigate the situation. She stated she was later informed he suspended a nurse aide one day, felt there to be no concerns and let her return to work. The VA advocate stated she was told by the Administrator he would not be reporting the situation to the state because it was not substantiated.<BR/>During an interview with Resident #61 on 09/29/2022 at 3:45 p.m., Resident #61stated he had talked to that VA lady when she was here about my therapy. He then added, And I talked to that man in charge here, but they all stick together. The resident was asked if he could explain what he had reported and if he remembered who the staff was at that time. He stated he did not know her name and had not seen her since but that she was rude and rough with him the afternoon of the incident. Resident #61 denied any physical abuse. He added, the girls get mad because I need extra help, but I am not like most of the other folks around here. I know my rights and I am not afraid to make sure the staff and man in charge know when I need something. Resident #61 stated he felt safe and that he knew how to report any issues he may encounter in the future. <BR/>Record review in TULIP on 09/29/2022 revealed no self-report was made for the allegation of abuse made by Resident #61.<BR/>Record review of the facility grievance reports for April 2022-[DATE] revealed a grievance was not completed regarding the allegation of abuse for Resident #61.<BR/>During an interview with the Administrator on 09/29/2022 at 4:13 p.m., the Administrator stated he had completed an internal investigation on the allegation of abuse made by resident #61 and VA worker however he did not report it the allegation to State. The Administrator stated, The situation with [Resident #61] is special. He always complains of the African girls. The Administrator continued that the resident is verbally abusive to the staff and that on occasions other nurses have heard the conversations and reported CNAs responded appropriately. The Administrator produced a folder and referred to it as his soft file that he had kept on the investigation because I knew someday someone would come asking for it. When asked why he chose not to file a self-report the Administrator responded, I should have reported it. I have nothing to hide.<BR/>Record review of the soft file provided by the Administrator revealed progress notes and witness statements from staff and family members gathered by the Administrator to unsubstantiate Resident #61's allegation.<BR/>Record review of an Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime, provided by Texas Health and Human Services, dated 09/15/2021, revealed the Administrator's signature acknowledging he was aware of self-reporting responsibilities to regulatory services.<BR/>Record review of the facility's policy titled, Resident Protection: Abuse Policy, reviewed 02/1/2021, revealed, Fundamental Information: (c.) All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. (d.) each employee, agent or contractor of this facility is individually responsible for reporting any reasonable suspicion of a crime committed against a resident of, or an individual receiving care from, a long-term care facility. (e.) the report is made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities). V. INVESTIGATION: A. Investigate different types of incidents; and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. C. the results of the investigation must be reported to the Administrator and to other officials in accordance with state law (including the State survey and certification agency) within 5 working days of the incident. If the alleged violation is verified, appropriate corrective and disciplinary action will be taken. VII. REPORTING AND RESPONSE TO ALLEGED INCIDENTS: A. Incidents of alleged abuse, neglect or misappropriation, exploitation of resident property must be reported to the appropriate local, state, and federal agencies. B. All alleged violations involving mistreatment neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administrator or the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, 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, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Residents #26 and #61) of 2 residents reviewed for abuse, neglect, and misappropriation of property, in that;<BR/>1. The facility failed to report an injury of unknown source for Resident #26. <BR/>2. The facility failed to report an allegation of abuse by Resident #61. <BR/>These failures could place residents at risk for not having incidents reported as required and continued abuse and neglect which could result in diminished quality of life.<BR/>The findings were: <BR/>1. Record review of Resident #26's face sheet, dated 09/30/2022 revealed Resident #26 had an initial admission on [DATE] and was re-admitted on [DATE] with diagnoses that included: unspecified fracture of shaft of humerus, right arm (fracture of the long bone between the shoulder and the elbow), expressive language disorder (a condition that affects the ability to express oneself clearly, both verbally and non-verbally), hematemesis (vomiting of blood), and vascular dementia with behavioral disturbance (deterioration of memory, language, and other thinking abilities with agitation and anxiety).<BR/>Record review of Resident #26's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 03, indicating resident's cognition was severely impaired. Further review revealed Resident #26's functional level for transfers and ambulation with a walker was supervision to independent and balance to be not steady but able to stabilize without human assistance.<BR/>Record review of Resident #26's Care Plan, undated, revealed an entry initiated on 09/28/2022 and revised on 09/29/2022, Focus: 9/20/22 res. Had a actual fall with injury fx of right humerus. Intervention: Bed in lowest position. Fall mat to the bedside. Frequently used items within the resident's reach. Further review revealed an entry on 09/28/2022, Focus: [Resident #26] noncompliant with fall safety precaution refused fall mat/bed in low position x 3 attempts.<BR/>Record review of Resident #26's Nurses' Note, dated 09/20/2022, revealed, AROUND 0045 (12:45am) HEARD [RESIDENT #26] YELLING FOR HELP. NOTED ALERT LYING ON LEFT SIDE ON FLOOR WITH RT ARM BEHIND HIS BACK. CHECK FOR INJURY NOTED HIS RT ARM IN PAIN. V/S BP 169/99 P76 R20, [Telehealth Physician service] WAS CALLED, SPOKE TO MD, SEND OUT 911. RP WAS NOTIFIED AND D.O.N. WAS TEXTED. TOOK TO [hospital name].<BR/>Record review of the facility's Incidents by Incident Type report, dated 09/27/2022, revealed Resident #26's fall to have occurred at 12:45 a.m. in the resident's room. Further review revealed the fall occurred while ambulating and staff were unable to determine an injury.<BR/>Record review of the hospital report for Resident #26, revealed a note, dated 09/20/2022, 12:06 a.m., Complaint: fall at nursing home, vomiting blood. Information is limited as patient has some confusion. Further review revealed a History and Physical Note, ASSESSMENT AND PLAN: 1. Acute Right humerus fracture 2. Hematemesis (vomiting blood) concerning for Acute upper GI bleed 3. S/p mechanical ground level fall at nursing home.<BR/>Record review in TULIP (an online system for submitting long-term care licensure applications) revealed a self-report was made regarding Resident #26's fall with injury by the Administrator dated 09/26/2022, six days following the incident. <BR/>In an attempted interview with Resident #26 on 09/27/2022 at 11:44 a.m., Resident #26 struggled communicating the words and was unable to tell this writer how the resident's arm had been hurt.<BR/>During an interview with the Administrator on 09/28/2022 at 3:08 p.m., the Administrator stated he had not been told about Resident #26's injury until 09/26/2022 at which time he reported the incident to the state. The Administrator was asked if he was aware of the timelines required for reporting and he stated he was but the hospital did not call us and we only found out on Friday (09/23/22), I think it was when the resident returned. The Administrator confirmed the resident re-admitted on [DATE] (Friday) and stated, it was late, I found out about it Monday (09/26/22) morning and reported it.<BR/>During an interview on 09/29/2022 at 10:40 a.m., the DON stated she had been texted by the charge nurse on the night of the resident's fall however stated, we didn't know if there was an injury or not until he returned. The DON was asked if the facility called for updates on residents who were transferred out or if the hospital called to give a report and the DON stated, No, not until they are re-admitted . The DON was asked who at the facility could call in a report of abuse, neglect or injury of unknown injury and she stated, The Administrator does because he is the Abuse Coordinator, but I guess I could.<BR/>Record review of a training certificate Six Keys to Self-Reporting ANE and other Incidents (NF), provided by Texas Health and Human Services, dated 02/07/2022, revealed the DON had been trained in self-reporting regulations.<BR/>2. Record review of Resident #61's face sheet, dated 09/30/2022 revealed Resident #61 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses that included: end-stage renal (kidney) disease, anemia and pressure ulcer of sacral region (located below the lumbar spine and above the tailbone), stage 4.<BR/>Record review of Resident #61's admission MDS, dated [DATE], revealed the resident had a BIMS score of 12, indicating resident's cognition was moderately impaired. Further review of Resident #61's MDS assessments for 08/04/22, 08/25/22 and 08/30/22 revealed the resident did not exhibit any behavior problems during these assessment periods. <BR/>Record review of Resident #61's Care Plan, undated, revealed an entry initiated on 09/15/2022 and revised on 09/27/2022, Focus: Verbal Behaviors: Resident exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner. Res.(resident) yells at staff at times. <BR/>During an interview with the complainant on 09/29/2022 at 2:56 p.m., the complainant stated during a VA health check 09/20/2022, Resident #61 informed her that a female nurse aide hit him a few weeks ago. Neither the complainant nor the resident knew her name however the complainant stated she visited with the Administrator on the same day of the outcry, 09/20/22, and he assured her he would investigate the situation. She stated she was later informed he suspended a nurse aide one day, felt there to be no concerns and let her return to work. The VA advocate stated she was told by the Administrator he would not be reporting the situation to the state because it was not substantiated.<BR/>During an interview with Resident #61 on 09/29/2022 at 3:45 p.m., Resident #61stated he had talked to that VA lady when she was here about my therapy. He then added, And I talked to that man in charge here, but they all stick together. The resident was asked if he could explain what he had reported and if he remembered who the staff was at that time. He stated he did not know her name and had not seen her since but that she was rude and rough with him the afternoon of the incident. Resident #61 denied any physical abuse. He added, the girls get mad because I need extra help, but I am not like most of the other folks around here. I know my rights and I am not afraid to make sure the staff and man in charge know when I need something. Resident #61 stated he felt safe and that he knew how to report any issues he may encounter in the future. <BR/>Record review in TULIP on 09/29/2022 revealed no self-report was made for the allegation of abuse made by Resident #61.<BR/>Record review of the facility grievance reports for April 2022-[DATE] revealed a grievance was not completed regarding the allegation of abuse for Resident #61.<BR/>During an interview with the Administrator on 09/29/2022 at 4:13 p.m., the Administrator stated he had completed an internal investigation on the allegation of abuse made by resident #61 and VA worker however he did not report it the allegation to State. The Administrator stated, The situation with [Resident #61] is special. He always complains of the African girls. The Administrator continued that the resident is verbally abusive to the staff and that on occasions other nurses have heard the conversations and reported CNAs responded appropriately. The Administrator produced a folder and referred to it as his soft file that he had kept on the investigation because I knew someday someone would come asking for it. When asked why he chose not to file a self-report the Administrator responded, I should have reported it. I have nothing to hide.<BR/>Record review of the soft file provided by the Administrator revealed progress notes and witness statements from staff and family members gathered by the Administrator to unsubstantiate Resident #61's allegation.<BR/>Record review of an Acknowledgement of Responsibility for Reporting Abuse, Neglect and Exploitation and Reasonable Suspicion of Crime, provided by Texas Health and Human Services, dated 09/15/2021, revealed the Administrator's signature acknowledging he was aware of self-reporting responsibilities to regulatory services.<BR/>Record review of the facility's policy titled, Resident Protection: Abuse Policy, reviewed 02/1/2021, revealed, Fundamental Information: (c.) All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. (d.) each employee, agent or contractor of this facility is individually responsible for reporting any reasonable suspicion of a crime committed against a resident of, or an individual receiving care from, a long-term care facility. (e.) the report is made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities). V. INVESTIGATION: A. Investigate different types of incidents; and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. C. the results of the investigation must be reported to the Administrator and to other officials in accordance with state law (including the State survey and certification agency) within 5 working days of the incident. If the alleged violation is verified, appropriate corrective and disciplinary action will be taken. VII. REPORTING AND RESPONSE TO ALLEGED INCIDENTS: A. Incidents of alleged abuse, neglect or misappropriation, exploitation of resident property must be reported to the appropriate local, state, and federal agencies. B. All alleged violations involving mistreatment neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administrator or the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violation of abuse and neglect were thoroughly investigated for 1 (Resident #26) of 2 residents reviewed for abuse, neglect, and misappropriation of property, in that;<BR/>The facility failed to have evidence that a thorough investigation was conducted following the injury of an unknown source for Resident #26.<BR/>This failure could place residents at risk for abuse and neglect.<BR/>The findings were: <BR/>Record review of Resident #26's face sheet, dated 09/30/2022 revealed Resident #26 had an initial admission on [DATE] and was re-admitted on [DATE] with diagnoses that included: unspecified fracture of shaft of humerus, right arm (fracture of the long bone between the shoulder and the elbow), expressive language disorder (a condition that affects the ability to express oneself clearly, both verbally and non-verbally), hematemesis (vomiting of blood), and vascular dementia with behavioral disturbance (deterioration of memory, language, and other thinking abilities with agitation and anxiety).<BR/>Record review of Resident #26's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 03, indicating resident's cognition was severely impaired. Further review revealed Resident #26's functional level for transfers and ambulation with a walker was supervision to independent and balance to be not steady but able to stabilize without human assistance.<BR/>Record review of Resident #26's Care Plan, undated, revealed an entry initiated on 09/28/2022 and revised on 09/29/2022, Focus: 9/20/22 res. Had a actual fall with injury fx of right humerus. Intervention: Bed in lowest position. Fall mat to the bedside. Frequently used items within the resident's reach. Further review revealed an entry on 09/28/2022, Focus: [Resident #26] noncompliant with fall safety precaution refused fall mat/bed in low position x 3 attempts.<BR/>Record review of Resident #26's Nurses' Note, dated 09/20/2022, revealed, AROUND 0045 (12:45am) HEARD [RESIDENT #26] YELLING FOR HELP. NOTED ALERT LYING ON LEFT SIDE ON FLOOR WITH RT ARM BEHIND HIS BACK. CHECK FOR INJURY NOTED HIS RT ARM IN PAIN. V/S BP 169/99 P76 R20, [Telehealth Physician service] WAS CALLED, SPOKE TO MD, SEND OUT 911. RP WAS NOTIFIED AND D.O.N. WAS TEXTED. TOOK TO [hospital name].<BR/>Record review of the facility's Incidents by Incident Type report, dated 09/27/2022, revealed Resident #26's fall to have occurred at 12:45 a.m. in the resident's room. Further review revealed the fall occurred while ambulating and staff were unable to determine an injury.<BR/>Record review of the hospital report for Resident #26, revealed a note, dated 09/20/2022, 12:06 a.m., Complaint: fall at nursing home, vomiting blood. Information is limited as patient has some confusion. Further review revealed a History and Physical Note, ASSESSMENT AND PLAN: 1. Acute Right humerus fracture 2. Hematemesis (vomiting blood) concerning for Acute upper GI bleed 3. S/p mechanical ground level fall at nursing home.<BR/>Record review in TULIP (an online system for submitting long-term care licensure applications) revealed a self-report was made regarding Resident #26's fall with injury by the Administrator dated 09/26/2022, six days following the incident. <BR/>In an attempted interview with Resident #26 on 09/27/2022 at 11:44 a.m., Resident #26 struggled communicating the words and was unable to tell this writer how the resident's arm had been hurt.<BR/>During an interview with the Administrator on 09/28/2022 at 3:08 p.m., the Administrator stated he had not been told about Resident #26's injury until 09/26/2022 at which time he reported the incident to the state. The Administrator was asked if he was aware of the timelines required for reporting and he stated he was but the hospital did not call us and we only found out on Friday (09/23/22), I think it was when the resident returned. The Administrator confirmed the resident re-admitted on [DATE] (Friday) and stated, it was late, I found out about it Monday (09/26/22) morning and reported it.<BR/>During an interview on 09/29/2022 at 10:40 a.m., the DON stated she had been texted by the charge nurse on the night of the resident's fall however stated, we didn't know if there was an injury or not until he returned. The DON was asked if the facility called for updates on residents who were transferred out or if the hospital called to give a report and the DON stated, No, not until they are re-admitted . The DON was asked who at the facility could call in a report of abuse, neglect or injury of unknown injury and she stated, The Administrator does because he is the Abuse Coordinator, but I guess I could.<BR/>Record review of the facility's policy titled, Resident Protection: Abuse Policy, reviewed 02/1/2021, revealed, Fundamental Information: (c.) All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. (d.) each employee, agent or contractor of this facility is individually responsible for reporting any reasonable suspicion of a crime committed against a resident of, or an individual receiving care from, a long-term care facility. (e.) the report is made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities). V. INVESTIGATION: A. Investigate different types of incidents; and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. C. the results of the investigation must be reported to the Administrator and to other officials in accordance with state law (including the State survey and certification agency) within 5 working days of the incident. If the alleged violation is verified, appropriate corrective and disciplinary action will be taken. VII. REPORTING AND RESPONSE TO ALLEGED INCIDENTS: A. Incidents of alleged abuse, neglect or misappropriation, exploitation of resident property must be reported to the appropriate local, state, and federal agencies. B. All alleged violations involving mistreatment neglect, or abuse, including injuries of unknown source, and misappropriation of resident property shall be reported immediately to the Administrator or the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that an assessment was completed for residents within 14 days after a significant change in the resident's status for 1 of 24 residents (Resident #60) reviewed for MDS assessments, in that:<BR/>The facility failed to complete a Significant Change MDS for Resident #12 within 14 days after the resident was admitted to hospice services. <BR/>This deficient practice could place residents admitted to hospice services at-risk of not having their individual needs met. <BR/>The findings were:<BR/>Record review of Resident # 60's face sheet dated 9/28/2022, revealed a [AGE] year-old male with an admission date of 10/21/2021 with a diagnosis that included: Cerebral infarct - occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients, which can cause parts of the brain to die off. Dysphagia - difficulty or discomfort in swallowing, as a symptom of disease and muscle wasting - A weakening, shrinking, and loss of muscle caused by disease or lack of use. <BR/>Record review of Resident # 60's quarterly MDS dated [DATE], revealed a BIMS undocumented, indicating the resident was unable to complete the interview. Further review revealed the resident had a life expectancy of fewer than six months and had received hospice care, while a resident at the facility's record revealed the resident did not have any Significant Change MDS initiated or completed after receiving hospice care . <BR/>Record Review of Resident #60's Order Summary Report for Active Orders, dated 09/28/2022, did reveal an active order for admission to hospice on 9/9/2022. <BR/>During an interview with MDS Coordinator C , on 09/29/2022 at 2:05 p.m., MDS Coordinator C confirmed the significant change in MDS should have been completed within the 14 days and further stated, I don't know what happened, but it wasn't done; I don't even see it in the incomplete ones. She revealed that no harm to the patient happened by her not updating the MDS but that she would update it now after the surveyor intervention. <BR/>During an interview with the DON on 09/29/2022 at 2:35 p.m., the DON confirmed that the MDS Coordinator should have completed the significant change in MDS within 14 days. She stated the facility follows the RAI manual as a policy for completing resident assessments and she did not have a specific policy to address this. <BR/>Record review of CMS's RAI Version 3.0 Manual, dated 10/2019, pages 2-23 and 2-24, revealed that a Significant Change in Status Assessment is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA (Significant Change Status Assessment) must be performed regardless of whether an assessment was recently conducted on a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 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 with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #1) reviewed for care plans. <BR/>The facility failed to develop and implement a comprehensive care plan including measurable objectives and timeframes to address Resident #1's medical, nursing, and mental and psychosocial needs related to his known history of signing himself out of the facility in a motorized wheelchair that did not belong to him, ambulating to nearby stores to drink alcohol until intoxicated/vomiting/lethargic and smoking marijuana in the surrounding community. As a result, the resident was ordered to be sent to the local ER on several occasions for treatment.<BR/>An IJ was identified on 05/29/2025. The IJ template was provided to the facility on [DATE] at 1:20 p.m. While the IJ was removed on 05/31/2025, the facility remained out of compliance at a scope of pattern with severity level at potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. <BR/>This failure placed residents with substance abuse issues at risk of sustaining serious injuries from possible accidents/incidents and an exacerbation/deterioration of health and wellness. <BR/>Findings include:<BR/>Record review of Resident #1's face sheet dated 05/28/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. He was diagnosed with end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and excess fluid from the body), schizoaffective disorder (a chronic mental illness that combines systems of both schizophrenia and mood disorder), gastro-esophageal reflux (a chronic condition where stomach contents regularly flow back up into the esophagus), history of falling, difficulty walking, diabetes mellitus type II (chronic disease where the body either does not produce enough insulin or cannot properly use the insulin it produces) with hypoglycemia (when blood glucose levels drop too low), essential hypertension (persistently high blood pressure with no identifiable cause), chronic ischemic heart disease (long-term condition where the heart's blood supply is reduced due to a mismatch between oxygen supply and demand), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms in COPD patients), unspecified cirrhosis of liver (a type of chronic, progressive liver disease where healthy liver cells are replaced by scar tissue), acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the cystic duct), dependence on renal dialysis (treatment that cleans the blood when kidneys are unable to do so), and shortness of breath. Resident #1 was his own responsible party. <BR/>Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); Resident #1 exhibited behaviors related to rejection of care; Resident #1 used a manual wheelchair for mobility; Resident #1 was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers and required supervision or touching assistance for showers/bathing; Resident #1 was always continent of bowel and bladder; and Resident #1 was prescribed anticoagulant and antipsychotic medication. <BR/>Record review of Resident #1's care plan, revised on 05/25/2025 revealed the following care areas:<BR/>* <BR/>Resident has impaired visual function and is at risk for falls, injury, and a decline in functional ability. Goals included: Resident will maintain optimal quality of life and not experience a decline in ADL functional abilities, or an injury related to vision loss. Interventions included: Arrange consultation with eye care practitioner. Assist to ensure glasses are labeled and within reach.<BR/>* <BR/>Resistant to Care: Resident is resistant to care and at risk for injury, a decline in functional abilities, and not having his needs met. [He] refuses to take his scheduled medications and refuses to go to his scheduled dialysis days. Goal included: Resident will not be a danger to self or others. Interventions included: If refusals continue, notify MD and family, document in resident records. Give a clear explanation of complications of not having his dialysis. Encourage as much participation as possible. Provide resident with opportunities to make decisions about his treatment. <BR/>* <BR/>Falls: Patient is a fall risk due to weakness of both lower extremities. Resident has the potential for falls related to unsteadiness on feet, abnormalities of gait and mobility, unspecified lack of coordination, and generalized weakness. Fall: 01/04/2025, 02/01/2025. Goal included: Resident will not sustain a fall related injury by utilizing fall precautions. Interventions included: Encourage resident not to transfer without assistance. Anticipate and meet the resident's needs. Educate the resident about safety reminders and what to do if a fall occurs. Encourage socialization and activity attendance as tolerated. <BR/>* <BR/>Therapeutic Leave: Resident is cognitively able to sign out of the facility and make their own informed decisions while they are out. On 04/10/2025 while on therapeutic leave, resident made the decision to consume alcoholic beverages. Goals included: The resident will follow facility policy for out on pass. The resident will be safe and comfortable while out on pass. Interventions included: Educate the resident/family/caregivers about the potential risks associated with signing out on pass. Educate resident/family/caregivers on the facility's policy for therapeutic leave/out on pass. Resident is reminded of his health issues and treatment regimens and the recommendations to avoid the use of alcoholic beverages.<BR/>Further review of Resident #1's care plan revealed no care areas, goals, or interventions to address his substance abuse concerns. <BR/>Record review of Resident #1's, Elopement/Wandering Risk Assessment dated 05/24/2025, completed by LVN A revealed, A. Preliminary Data. 1. Is the resident physically able to leave the facility on their own? Yes. Continue assessment. B. Evaluation. Cognition: 1. Is the resident disoriented to place or intermittently confused? Yes . Further review of the assessment revealed Resident #1 scored a 1, which indicated low/no elopement risk. <BR/>Record review of Resident #1's nursing progress notes for April 2025 and May 2025 revealed:<BR/>* <BR/>On 04/02/2025, at 4:10 p.m., SW B wrote, Resident was educated with Administrator, ADON, DON, and SW on the policies for Therapeutic Leave and the expectations for the resident when he is on Therapeutic Leave. Resident verbalized understanding.<BR/>* <BR/>On 04/11/2025, at 12:10 a.m., RN E wrote, Resident came back on pass to the facility with alcohol intoxication, vitals and assessment done. All within normal baseline. NP notified. New order to transfer resident to the hospital for further evaluation but resident refused. Resident was monitored through the shift, comfort care provided to resident satisfaction.<BR/>* <BR/>On 04/11/2025, at 11:50 a.m., ADON F wrote, Late Entry: 04/10/2025 at 11:00 p.m. Upon resident's return to the facility, resident arrived propelling himself in his motorized wheelchair. Resident had a slurred speech, he was drooling, smiling, and laughing, slow to respond to questions, and lethargic. Resident said he was tired and wanted to lay down and go to sleep and was assisted back to his room and was unable to stand to assist with his transfer to his bed, so he was transferred to bed with two people assist. In speaking with the resident, he said that he had ingested alcohol, specifically three 40 oz bottles of [brand name of beer] and he would not say if he had ingested any other substances or drinks. Upon assessment by unit nurse, there was no evidence of trauma or physical injuries noted, no indications of any falls or any other incidents at the time of his return.<BR/>* <BR/>On 04/12/2025, at 7:17 p.m., LVN A wrote, Police officer called facility and said resident vomited and may have been drinking with his friend and they have called 911 for him to go to the ER and have him evaluated. They then came to the facility, and I gave him a face sheet and medication lists. I accompanied the officer to EMS parked on the street near the facility and found the patient inside the ambulance being attended to by two paramedics with patient leaning to his left side. I placed a call to the Administrator and ADON. Resident apparently signed out at about 12 noon and left the facility with another resident. They apparently went to a nearby store and purchased drinks. He drank until he vomited on himself and became very weak. I asked the paramedics where they were taking him, and they informed me that they were taking him to [a local hospital] ER. NP and RP notified.<BR/>* <BR/>On 04/14/2025, at 4:38 p.m., ADON F wrote, Resident was found to be in possession of a cigarette lighter. The resident was educated by the Administrator on the smoking policy and the lighter was placed in the smoker's box for the resident to have access to only when on smoke breaks. The Administrator educated the resident on use of another resident's electric wheelchair and encouraged to use his own, the resident verbalized understanding.<BR/>* <BR/>On 04/15/2025, at 2:11 p.m., RN H wrote, Resident signed himself out and came back vomiting. Happened a couple of times. NP notified. Lab work ordered. New order to transfer to ER for further evaluation.<BR/>* <BR/>On 04/16/2025, at 5:23 p.m., ADON G wrote, Final lab results received on the drug and alcohol screening, labs placed in NP binder for review . resident remains in the hospital at this time.<BR/>* <BR/>On 04/23/2025, at 9:46 p.m., RN E wrote, Resident, who went out on pass, returned to the facility alert but disoriented, drooling from alcohol intoxication also had multiple emesis (vomiting). Resident vitals and assessment done all vital signs were within normal baseline. NP contacted via telehealth/virtual service. New order for Ondansetron 4 MG 1 tablet PO q 6hours as needed .<BR/>* <BR/>On 05/01/2025, at 11:59 a.m., the SW wrote, The Social Worker and the Administrator witnessed [Resident #1] taking a power wheelchair without the permission of the resident who owns the power wheelchair. Resident was educated that he cannot take the belongings of other residents while they are out of the facility. Resident was also educated on the importance of not using someone else's wheelchair and the risks that can occur .<BR/>* <BR/>On 05/04/2025, at 4:41 p.m., RN H wrote, Resident exchanged wheelchair with his former roommate and resident was educated that it was not safe to do so, resident verbalized understanding.<BR/>Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/10/2025 at 11:17 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Complaint: Altered Mental Status . Per nurse, patient went out on pass and returned to facility lethargic, drooling from mouth and vomited once one hour ago. Per nurse, patient only knows his name, does not know where he is, and does not know the month, year. States at baseline patient is alert and oriented x 3 (a term that describes a patient's level of consciousness and cognitive function. Patient aware of person, place, and time). Per nurse, patient admitted to drinking 3 bottles of [brand of beer]. Per nurse, patient refused dialysis today and states patient did not go to dialysis yesterday . Patient seen with nurse . Physical Exam: Exam findings per nurse and video observation . Orders: Transfer to ER via 911: AMS/ESRD - missed HD/vomiting/possible alcohol intoxication . <BR/>Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/23/2025 at 10:02 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Chief Complaint: GI: Vomiting . Nurse notified clinician that the [AGE] year-old-male patient with history of ESRD on dialysis, Schizophrenia, falls, HTN, DM2, went out of the facility for an hour and came back intoxicated. The nurse stated this is a regular occurrence for him. He did have an episode of vomiting. Denies drinking alcohol. Will monitor him for now .<BR/>Record review of Resident #1's Lab Results Report collected on 04/11/2025 and reported on 04/16/2025 revealed Resident #1 was positive for THC (Cannabis).<BR/>Observation and interview with Resident #1 on 05/28/2025, at 2:30 p.m. revealed he was in his bed with his eyes closed. Resident #1 opened his eyes and was able to provide his name. Resident #1 stated he lived in the facility a couple of months and living there was alright. He said he went to dialysis. He said he fell out of his wheelchair about six months ago (he did not say why). Resident #1 did not answer questions related to drinking alcohol or taking drugs while outside the facility on pass. He closed his eyes and appeared to be asleep although he responded to questions unrelated to drinking or smoking. <BR/>In an interview with a random resident on 05/28/2025, at 1:45 p.m., they stated Resident #1 had a known history of taking his former roommate's motorized wheelchair without permission to sign himself out of the facility and drink at nearby stores. The resident stated Resident #1 frequently drank alcohol until he was intoxicated and smoked marijuana in the community around the facility. The resident said one time, Resident #1 was swerving (change or cause to change direction abruptly) all over the sidewalk on his way back to the facility after drinking and fell out of the motorized wheelchair onto the sidewalk. The resident stated the night nurse had to go and find Resident #1 on the sidewalk. <BR/>In an interview with the SW on 05/28/2025, at 3:24 p.m., she stated Resident #1 was capable of making his own decisions, but he just did not make the right decisions. She said Resident #1 went out on pass and did things he should not do. She said Resident #1 was vomiting once due to intoxication. She said the facility staff could not tell Resident #1 what he could and could not do outside of the facility, and they could only educate him. She said Resident #1 knew what he was doing. She said Resident #1 was his own RP and he did not have any family. She said to her knowledge, Resident #1 only went out twice and got drunk, but she was not there on weekends. She said she was not sure Resident #1's behaviors were addressed on his care plan, but they should have been so all staff are aware of any interventions. She stated she was not responsible for updating resident care plans. She stated she reviewed chart notes and assessed Resident #1's cognition to see if he could make his own decisions. She said Resident #1's BIMS score was high. She said possible negative outcomes of Resident #1 leaving the facility and getting drunk were that he could die, get injured, and go to the hospital.<BR/>In an interview with the Administrator on 05/28/2025, at 4:32 p.m., he stated the residents had rights. He said Resident #1's BIMS score was 15, but he did not make proper decisions. He said the facility staff had to make sure they did not infringe on the residents' rights. He said Resident #1 signed himself out and returned intoxicated between five and seven times. He said he had undocumented conversations with Resident #1 about how unsafe it was for him to leave the facility and get drunk. He said the conversations were not documented because he did not go into the facility's computer system to write progress notes. He said Resident #1 was still capable of wheeling himself down the road to the store in his own manual wheelchair. He said the residents previously went to the gas station at the end of the street (the residents still had to cross a busy two-lanes road), but the store staff said they could not go there anymore. He said now, the residents go down to a store further down the road. He said he did not know if Resident #1's behaviors were care planned, but they should have been. <BR/>In an interview with MDS Nurse C on 05/29/2025, at 12:25 p.m., she stated her duties included completing assessments and reviewing/updating resident care plans. She said she was responsible for residents whose last names began with A - K, so she did not update Resident #1's care plan. She said another MDS nurse who worked part-time was responsible for updating Resident #1's care plan. She said the MDS nurses reviewed and updated care plans every three months when they did quarterly MDS assessments. She said she was aware of Resident #1's behaviors related to smoking and drinking, and those behaviors should be a part of his care plan if the incidents happened. She said it was important to address those issues in Resident #1's care plan because if anything happened, they had the information in the care plan to show they were not giving him what he went outside to get (drugs and alcohol). She said negative outcomes of Resident #1's behaviors were possible if the facility did not intervene. She said Resident #1 could have serious health issues if the facility did not intervene. She said a resident's care plan should address all their behaviors. <BR/>In a telephone interview with Resident #1's physician on 05/30/2025, at 10:00 a.m., he stated he was familiar with Resident #1, and he was aware the resident frequently went out on pass to drink and smoke. He said Resident #1 denied drinking and smoking, but he had a history of noncompliance with dialysis and medications. He said Resident #1 was alert and oriented to be able to sign himself out. He said Resident #1 had recently been admitted to the hospital a lot and once, at the hospital, they found he had taken drugs. He said Resident #1 kept denying, so it was hard to address it. He said the negative outcome of Resident #1's behaviors were that one day, Resident #1 is fine, and then in a couple of days, he signs out and takes something (drugs or alcohol) and something happens that leads him back in the hospital. He said he asks the facility staff to do their best to monitor Resident #1. He said once Resident #1 was off drugs and was perfectly normal, it would be safe for him to be out alone. He stated when Resident #1 was in that state (under the influence of drugs and alcohol), it was not safe for him to be out alone. He said if a resident was alert, oriented, and making the right decisions, you could not tell them they could not go out because that would be restraining them. He said he would imagine it was not safe for Resident #1 to be out like that (under the influence of drugs and alcohol), but he had the right to sign himself out. He said the facility may have to get a contract with Resident #1 to say if he continued with these behaviors, they could not handle his needs because they do not want anything bad to happen. <BR/>In an interview with the VP of Operations on 05/30/2025, at 10:30 a.m., he stated the Administrator was no longer employed at the facility and Resident #1 called 911 and was transferred to the hospital related to stomach pains on 05/28/2025.<BR/>In an interview with LVN A on 05/31/2025, at 2:11 p.m., he stated on 04/12/2025, around 1:00 p.m., the police called the facility and said Resident #1 had fallen out of his wheelchair and was vomiting at the church next to the facility. He said the police went to the facility and then he (LVN A) followed them to see Resident #1. He said he thought the police saw Resident #1 on the ground and called 911. He said when he arrived at the scene, he saw Resident #1 inside the ambulance. He said Resident #1 said he had gone to the store. He said Resident #1 went to the hospital and returned to the facility about two days later. LVN A said he heard the motorized chair Resident #1 fell out of belonged to his friend. <BR/>In a telephone interview with MDS Nurse D on 06/02/2025, at 11:19 a.m., she stated she was responsible for updating care plans for residents whose last names began with J-Z. She said she made sure MDS assessments were done and care plans were updated. She said she got the information to update care plans by reading progress notes, reading physician's orders, talking to staff, and she observed and talked to the residents. She said she observed Resident #1 around the facility, and he was mostly independent. She even though she read through Resident #1's progress notes, she was not aware of his drinking or drug use. She said she knew he signed himself out of the facility because she saw him in the group when they went out. MDS Nurse D then said she heard Resident #1 smoked weed (marijuana). She said smoking marijuana would be something they needed to add to his care plan. She said it was her understanding that the ADON updated anything that was acute (not long-term issues). She said she only worked 20 hours per week, so she was not at the facility most days. She said she was aware of Resident #1's smoking, but not his drinking. She said she only looked at progress notes when it was time to update the MDS assessments. She said she never saw any notes about Resident #1's drinking alcohol. She said she did not have an answer for why she did not address Resident #1's smoking in his care plan. She said the ADON was at the facility more than she was and they should have updated Resident #1's care plan to address his drinking. She said in her opinion, anybody could update the care plan. She said it was important to address Resident #1's behaviors related to smoking and drinking because it was pertinent information and they needed to act on things like that to keep the resident safe. She said the nursing facility was not a place to get drunk and do drugs. She said the IDT needed to get together, call a care plan meeting, talk, and update things to make sure all Resident #1's behaviors were on his care plan. <BR/>In an interview with ADON F and ADON G on 06/02/2025, at 11:45 a.m., ADON G said MDS Nurse D was not in the building a lot, so she should review progress notes daily to ensure care plans were updated appropriately. ADON F said they handled (updated care plans) regarding things that were acute, but Resident #1's drinking and drug use were not acute because he had those behaviors a while. ADON G said it was important to address those behaviors in the care plan so all staff know what is going on. ADON G said a negative outcome of not having the behaviors care planned would be that the behaviors continued and but the resident's safety at risk. <BR/>Record review of the facility's policy, titled, Comprehensive care Plans revised on 09/04/2024 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. B. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . d. The resident's goals for admission, desired outcomes, and preferences for future discharge . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . <BR/>Record review of the facility's policy, titled, Behavior Management revised on 04/15/2014 revealed, Policy: The purpose of the policy is to optimize the quality of life and function of patients that experience behavioral symptoms that require person centered approaches to meet the health, physical, psychosocial, and behavioral health needs. Fundamental Information: Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for dementia patients. Fundamental principles of care for a patient with behaviors include an interdisciplinary approach that focus on the individualized needs of the patient . Procedure. Determine whether there is a medical, physical, functional, physiological, emotional, psychiatric, social, or emotional cause of the behaviors . Considerations: Person-Centered Care - evaluate if the environment is supportive and promotes comfort toward understanding, preventing, relieving, and recognizes individual needs and preferences . Evaluations are completed on new or worsening behaviors . Identify the frequency, intensity, duration, severity, and impact of behaviors, as well as the location, surroundings, or situation. Identify interventions or approaches to prevent, modify, relieve, or address the behaviors or distress. Patient behaviors or distress are documented as it occurs and the effectiveness of interventions. Individualized Care Plan Approaches - individualized approaches are used as a first line intervention (except in a documented emergency situation or if clinically contraindicated) . Consistent interventions are used that focuses on a patient's individual needs . Monitor and follow-up care plan is done by the interdisciplinary team who reviews the patient's progress towards goals. Summarize effectiveness of non-pharmacological and pharmacological interventions (quarterly and as indicated), for target behaviors and/or psychological symptoms and changes in a resident's level of distress or emergence of adverse consequences. Adjust interventions as needed and identified when care objectives are not met . <BR/>An IJ was identified on 05/29/2025 at 1:20 p.m. The IJ template was provided to the Administrator on 05/29/2025 at 1:20 p.m. and a Plan of Removal was requested. <BR/>The following Plan of Removal submitted by the facility was accepted on 05/31/2025 at 10:42 a.m.<BR/>Issue Cited: Care Plans<BR/>Failure to develop and implement a comprehensive person-centered care plan<BR/>5/30/25<BR/>1. <BR/>Immediate Action Taken<BR/> On 5-29-25 resident #1 is currently in hospital with diagnosis of gastroenteritis (inflammation of the lining of the stomach and intestines) and ESRD.<BR/>2. Identification of Residents Affected or Likely to be Affected: <BR/>A. On 5/29/25 by 3pm DON/designee identified 11 residents who sign out of the facility independently, had charts reviewed and determined by their capabilities according to their functional ability assessment (MDS section GG), and make their own choices and decisions according to their BIMs, they were reviewed for any behaviors, none were found, and care plan interventions are in place.<BR/>2. <BR/>Actions to Prevent Occurrence/Recurrence: <BR/>A. <BR/>On 5/30/25 by 10:00 am the RNC reviewed the policy on Comprehensive Care Plans with no changes made.<BR/>B. On 5/29/25 by 7:30pm DON/designee reviewed the care plans for those 11 residents identified as independently capable of signing out of the facility and making their own choices and decisions. None were found to have unsafe behaviors. Care plans were reviewed, and no updates were needed. If and when Resident #1 returns from hospital the care plan will be reviewed and updated with any unsafe behavior and the CNAs and Nurses will be in-serviced to the updated care plan at that time by DON/designee.<BR/>C. On 5/30/25 by 9am the Regional Nurse Consultant in-serviced the IDT on updating comprehensive care plans to include measurable objectives, timeframes, and interventions for those residents identified as independently signing themselves out of the facility with a focus on unsafe behaviors, goals, and interventions while out of facility. The Administrator/ or designee and DON/ or designee were in-serviced by the RNC beforehand.<BR/>D. DON/designee will monitor comprehensive care plans for all residents identified as capable of signing themselves out of the facility independently for any unsafe behaviors present and report findings to IDT in morning meeting and revise care plans as needed.<BR/>E. All findings will be discussed during QAPI monthly and plan of care will be revised as needed.<BR/>F. On 5/29/25 the facility's Administrator/ or designee notified the Medical Director regarding the Immediate Jeopardy the facility received related to Failure to Develop and Implement a Comprehensive Person-Centered Care Plan and reviewed plan to sustain compliance. <BR/>Monitoring of the plan of removal included the following:<BR/>Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/30/2025 revealed the IDT team (DON, Activity Director, ADON F, ADON G, MDS Nurse C, Treatment Nurse, , and a representative from the rehabilitation department) was educated by the RNC on comprehensive care plans, including measurable goals and individualized interventions. <BR/>Record review of the facility's, Comprehensive Care Plans policy revealed it was reviewed by the RNC on 05/29/2025. <BR/>Record review of the facility's plan of removal documentation revealed the MDS assessments and care plans for all eleven residents identified as independently capable of signing out of the facility and making their own choices and decisions were reviewed by the DON. <BR/>Interviews were conducted with staff on 05/31/2025 from 10:45 a.m. until 3:00 p.m. from all shifts (nurses and CNAs worked 12-hour shifts) including the VP of Operations, RNC, DON, ADON F, ADON G, LVN A (day shift), MDS Nurse C, RN P (day shift), CNA Q (day shift), RN R (night shift), Receptionist[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain most recent hospice Plan of Care, Hospice Consent and Election Form, Physician Certification of Terminal Illness, names and contact information for hospice personnel involved in hospice care of each resident, documentation by specific interdisciplinary hospice staff providing services to the resident, and hospice medication information specific to each resident for 4 of 24; Residents #9, #15, # 29, and# 60 reviewed for hospice services, in that:<BR/>The facility failed to ensure they had most recent hospice Plan of Care, Hospice Consent and Election Form, Physician Certification of Terminal Illness, names and contact information for hospice personnel involved in hospice care of each resident, documentation by specific interdisciplinary hospice staff providing services to the resident, and hospice medication information specific to each resident including Residents #9, #15, #29, and #60. <BR/>This deficient practice could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. <BR/>The findings include:<BR/>1. Record Review of Residents # 9 face sheet, dated 9/28/2022, revealed a [AGE] year-old male admitted to the facility on [DATE], with a diagnoses that included: Type two diabetes - (condition in which the body either doesn't produce enough insulin, or it resists insulin), calculus in bladder (bladder stones are solid calculi that are primarily found in the urinary bladder), and essential hypertension (defined as high blood pressure in which secondary causes such as renovascular disease), renal failure- condition in which the kidneys lose the ability to remove waste and balance fluids , <BR/>Record review of Resident #9's admission MDS dated [DATE], revealed, a BIMS undocumented, indicating the resident was unable to complete the interview. Further review revealed the resident had a life expectancy of fewer than six months and had received hospice care while a resident at the facility.<BR/>Record review of Resident #9's electronic medical record Physician's Orders, dated 9/28/2022, revealed orders for: Admit to [Hospice Company]<BR/>Record review of Resident #9's hospice binder revealed the following information was not in the resident's record: <BR/>- Hospice Consent and Election Form<BR/>- Physician Certification of Terminal Illness<BR/>- Names and contact information for hospice personnel involved in hospice care of the resident<BR/>- Documentation by specific interdisciplinary hospice staff providing services to the resident<BR/>Observation on 09/28/2021 at 1:55 p.m. revealed a [Hospice Company] binder in the resident's room. <BR/>Record review of Resident #9's hospice binder revealed: <BR/>- a cover sheet with no resident name<BR/>- a welcome letter [Hospice Company], reflecting the intent of the binder to make sure that everyone involved will be kept up to date on our patient's conditions.<BR/>2. Record review of Resident #15's Face Sheet, dated 09/28/2022, revealed a [AGE] year-old male with an admission date of 08/04/2022 with diagnoses that included: Chronic pain syndrome - (chronic pain as pain that lasts for longer than 3 months), and anxiety disorder (medical condition includes symptoms of intense panic). <BR/>Record review of Resident #15's admission MDS dated [DATE], revealed, a BIMS of 15, indicating intact cognition. Further review revealed the resident had a life expectancy of fewer than six months and had received hospice care while a resident at the facility.<BR/>Record review of Resident #15's electronic medical record Physician's Orders, dated 9/28/2022, revealed orders for: Admit to [Hospice Company] <BR/>Record review of Resident #15's hospice binder revealed the following information was not in the resident's record: <BR/>- Most recent hospice Plan of Care<BR/>- Hospice Consent and Election Form<BR/>- Physician Certification of Terminal Illness<BR/>- Names and contact information for hospice personnel involved in hospice care of the resident<BR/>- Documentation by specific interdisciplinary hospice staff providing services to the resident<BR/>- Hospice medication information specific to the resident. <BR/>Observation on 09/28/2021 at 09:45 a.m. revealed a [Hospice Company] binder at the nurse's station.<BR/>Record review of Resident #15's hospice binder revealed: <BR/>- a face sheet for [Hospice Company]<BR/>3. Record review of Resident #29's Face sheet dated 9/28/2022, revealed an [AGE] year-old female with an admission date of 4/9/2022 with a diagnoses that included: senile degeneration of the brain (is the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age),and constipation (a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces) and pain.<BR/>Record review of Resident #29's MDS dated [DATE], revealed a BIMS of 03, indicating severe cognitive impairment. Further review revealed the resident had a life expectancy of fewer than six months and had received hospice care while a resident at the facility.<BR/>Record review of Resident #29's electronic medical record Physician's Orders, dated 9/28/2022, revealed orders for: Admit to [Hospice Company] <BR/>Record review of Resident #29's hospice binder revealed the following information was not in the resident's record: <BR/>- Hospice Consent and Election Form<BR/>- Physician Certification of Terminal Illness<BR/>- Hospice medication information specific to the resident <BR/>Observation on 09/28/2021 at 10:55 a.m. revealed a [Hospice Company] binder in the resident's room. <BR/>Record review of Resident #29's hospice binder revealed: <BR/>- a cover sheet with no resident name<BR/>4. Record review of Resident #60's face sheet dated 9/28/2022, revealed a [AGE] year-old male with an admission date of 10/21/2021 with a diagnoses that included: cerebral infarct (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it. A lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients, which can cause parts of the brain to die off), dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use). <BR/>Record review of Resident #60's MDS dated [DATE], revealed a BIMS undocumented, indicating the resident was unable to complete the interview. Further review revealed the resident had a life expectancy of fewer than six months and had received hospice care while a resident at the facility.<BR/>Record review of Resident #60's electronic medical record Physician's Orders, dated 9/28/2022, revealed orders for: Admit to [Hospice Company] <BR/>Record review of Resident #60's hospice binder revealed the following information was not in the resident's record: <BR/>- Most recent hospice Plan of Care<BR/>- Hospice Consent and Election Form<BR/>- Physician Certification of Terminal Illness<BR/>Observation on 09/28/2021 at 1:15 p.m. revealed a [Hospice Company] binder at the nurse's station.<BR/>Record review of Resident #60's hospice binder revealed: <BR/>- a face sheet for [Hospice Company] which included outdated medication orders<BR/>During an interview with the DON, on 9/28/2021 at 3:11 p.m., the DON confirmed Resident #9's, # 29's ,15 and #60's hospice binders did not include the required documentation. The Surveyor asked DON if she was aware of when hospice visits and services were provided and DON revealed usually once a week. When asked who coordinates hospice services the DON revealed the Social Worker speaks with the families to organize the admission for hospice services. DON further revealed after admission the hospice staff would probably just talk to one of the nurses working that day.the DON was unaware of who would be responsible for updating the hospice binder with the resident's current plan of care and hospice staff's progress notes.<BR/>During an interview with the Social Worker on 9/28/2022 at 11:10 a.m., she stated she was responsible for coordinating services with hospice and families to ensure documentation was in place. She did not know why documentation was not in place but would ensure it would be in a binder moving forward. <BR/>Record review of the facility's policy titled, Coordination of hospice services, dated 04/21/11, revealed, The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the residents care . <BR/>Record review of the facility's hospice services agreement with [Hospice Company], effective 9/02/2015, revealed, in Section III; 3.1, admission to hospice program (a) If nursing facility elects to receive hospice services, and if the nursing facility requests hospice to provide hospice services to that resident, the hospice shall assess such resident and the resident's family shall notify the nursing facility of the results of the assessment. If the hospice agrees to perform services for the resident, the hospice shall complete and submit to the appropriate agency all necessary forms, including Texas Medicaid hospice recipient election/cancelation, discharge notice, physician certification of terminal illness and provide copies to nursing facility to be kept in nursing facility clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 infection for 1 of 2 residents (Resident #1) reviewed for infection control.<BR/>-The facility failed to ensure CNA J performed hand hygiene during incontinent care on Resident #1.<BR/>This failure could lead to the spread of infection to residents, resident illness, and/or resident distress. <BR/>Findings included:<BR/>Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which include Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cognitive communication deficit (trouble reasoning and making decisions while communicating) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 07/26/2024, revealed the BIMS score was 05 out of 15, which indicated her cognition was severely impaired. The MDS revealed she was dependent on staff with toileting, shower/baths, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS revealed .<BR/>Record review of Resident #1's care plan, initiated 02/17/2024 and revised on 06/06/24 revealed the following: <BR/>Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to muscle weakness. <BR/>Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. <BR/>Interventions: Bed Mobility: total x 1 assist. Transfers: total x 1 assist. Eating: set-up/ clean up<BR/>Toileting: dependent x 1 assist. Ambulation: n/a. Wheelchair: independent short distances --mostly propelled per staff. Dressing: dependent x 1 assist. Personal Hygiene: dependent x 1. Bathing: dependent x 1 assist. Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. Encourage resident to participate to the fullest extent possible with each interaction and praise when attempts are made.<BR/>Observation on 08/16/24 at 12:16 p.m., revealed CNA J provided Resident #1 with incontinence care. CNA J did not complete hand hygiene prior to entering the resident's room, nor prior to donning clean gloves. CNA J unfasten Resident #1's brief and tucked it under the resident's buttocks. CNA J turned the Resident over and did not spread Resident #1's labia to thoroughly clean the area and the resident's urinary meatus. CNA J removed the soiled brief and discarded it into the trash can sitting near resident's foot of bed. CNA J wiped twice, removed her soiled gloves without washing or sanitizing her hands donned clean gloves. CNA J completed incontinent care and with the same soiled gloves touched the Resident's clean dress, brief, and sheets . <BR/>In an interview on 08/16/24 at 2:08 p.m., with CNA J, she said she started working full time at the facility last month. She said she did not recall doing CNA competency checks for incontinent care. CNA J said not performing hand hygiene while changing gloves could result in cross contamination. She said she had completed in-services on infection control at the time of hire. <BR/>In an interview on 8/16/24 at 2:15 p.m., with the Wound Care Nurse, she said CNA J should have either washed or sanitized her hands in between gloves change as it placed the resident at risk for infections. <BR/>In an interview on 8/16/24 at 3:06p.m., with ADON B, she said she was the facility's infection preventionist. She said she provided mandatory infection control in-service to staff monthly, quarterly and as needed. She said CNA J was new to the building but not to long term care. She said staff should wash/sanitize their hands upon entering a resident's room, in between glove changes, and before leaving the resident's room. <BR/>In an interview on 08/16/24 at 4:48p.m., with the DON, she said she expected staff to make sure they provided complete and proper incontinent care each time they perform incontinent care. She said Wound Care Nurse brought it to her attention that CNA J failed to performed hand hygiene during incontinent care on Resident#1. She said the CNA should have either washed or sanitized her hands after touching a dirty area prior to moving to a clean area when performing incontinent care. She said these failures were risk for infection control . <BR/>Record review of facility's In-Service Program Attendance Record dated 8/14/2024 revealed Topic: Hand Hygiene was signed by CNA J. <BR/>Record review of facility's Hand Hygiene Policy (Date implemented: 11/12/2017) revealed read in part: .Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. 6.Additional considerations: a. The use of antimicrobial-impregnated wipes (i.e. towelettes) are not a substitute for using an alcohol-based hand rub or antimicrobial soap. b. The use of gloves does not replace hand washing. Wash hands after removing gloves .<BR/>Record review of facility's infection control Guidelines (Revision Date: 9/22/2015) revealed read in part: .Anticipated Outcome: The purpose of this policy is to reduce and prevent the spread of infections by the use of evidence based techniques established infection control policies and procedures. 3.Hand Hygiene Protocol: a. Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty. b. Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing care to patients in isolation. c. For routine patient care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact. d. Hands shall be washed in accordance with our facility's established hand washing procedure .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen.<BR/>-Thirteen 8 oz glasses of juice were not labeled and not dated in the facility refrigerator. <BR/>-Nine 4 oz glasses of apple sauce were not labeled and not dated in the facility kitchen.<BR/>This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness.<BR/>Findings included:<BR/>Observation in the facility kitchen on 2/25/25 at 06:30 am revealed thirteen 8 oz glasses of juice and nine 4 oz glasses of apple sauce were not labeled (attach a label to something) or dated.<BR/>Interview with the Dietary Manager on 2/26/25 at 4:01 pm, she said she starts her workday by making sure everything is correctly labeled and dated . She said she make sure the date and use by date are on each food item. She said if the item used is not labeled or dated the residents can get sick or have an allergic reaction. <BR/>Interview with the [NAME] on 2/27/25 at 1:39 pm, she said all food items should be labeled and dated. She said if the items are not labeled and dated, she had no idea how long the item had been sitting there. She said if she was to use the item and it's not dated or labeled it can make the residents sick. <BR/>Interview with the Tray-aide on 2/27/25 at 1:45 pm, he said all the food items should be labeled and dated always. He said if the items are not labeled and dated, and the food is used it can put the residents at risk of getting sick.<BR/>Record review of the Facility's Nutrition Policies and Procedures dated December 5, 2017, read in part . proper labeling with an expiration or use by date .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen.<BR/>-Thirteen 8 oz glasses of juice were not labeled and not dated in the facility refrigerator. <BR/>-Nine 4 oz glasses of apple sauce were not labeled and not dated in the facility kitchen.<BR/>This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness.<BR/>Findings included:<BR/>Observation in the facility kitchen on 2/25/25 at 06:30 am revealed thirteen 8 oz glasses of juice and nine 4 oz glasses of apple sauce were not labeled (attach a label to something) or dated.<BR/>Interview with the Dietary Manager on 2/26/25 at 4:01 pm, she said she starts her workday by making sure everything is correctly labeled and dated . She said she make sure the date and use by date are on each food item. She said if the item used is not labeled or dated the residents can get sick or have an allergic reaction. <BR/>Interview with the [NAME] on 2/27/25 at 1:39 pm, she said all food items should be labeled and dated. She said if the items are not labeled and dated, she had no idea how long the item had been sitting there. She said if she was to use the item and it's not dated or labeled it can make the residents sick. <BR/>Interview with the Tray-aide on 2/27/25 at 1:45 pm, he said all the food items should be labeled and dated always. He said if the items are not labeled and dated, and the food is used it can put the residents at risk of getting sick.<BR/>Record review of the Facility's Nutrition Policies and Procedures dated December 5, 2017, read in part . proper labeling with an expiration or use by date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #1) of 5 residents reviewed for accident and hazards: <BR/>1. The facility failed to ensure Resident #1 had his floor mat by his bedside while lying asleep in his bed.<BR/>2. The facility failed to ensure Resident #1 wore his head helmet to prevent injuries from accidental falls.<BR/>These failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues as a result of accident hazards.<BR/>Findings included: <BR/>Record review of resident #1's face sheet revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were Hypertension (High blood pressure), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), cerebellar ataxia (inability to control voluntary muscle movements). <BR/>Record review of resident #1's Comprehensive MDS dated [DATE] revealed Resident #1 had a BIMs score of 03 indicating the resident was severely cognitively impaired. The resident required extensive assistance with one person physical assist with bed mobility, locomotion on and off unit, eating, and personal hygiene. The resident required total dependence to walk in room, to walk in corridor, dressing, and toilet use. MDS did not code Resident #1 for helmet.<BR/>Record Review of Resident #1's Care Plan dated 12/26/2022 read in part , helmet to be worn while awake to aid in prevention of head injury related to falls. Fall Risk Screening upon admission and quarterly to identify risks factors and floor mat . <BR/>Record Review of Resident #1's Fall Prevention Protocol dated 05/18/2021 read in part . a near miss, also considered a fall, was when a resident would have fallen if someone else had not caught the resident from doing so. Each resident would be assessed for the risks of falling and would receive care and services in accordance with the level of risk to minimize the likelihood of falls. Implement at risk fall care plan; provide additional interventions as directed by resident's assessment, including but not limited to assistive devices, low bed, increased frequency of rounds and sitter if indicated .<BR/>Observation on 1/20/2023 at 11:20 a.m. revealed Resident #1 lying in bed asleep. The floor mat was not on the floor by resident #1's bedside.<BR/>Observation on 1/20/203 at 12:55 p.m., revealed Resident #1 awake and eating. Resident #1 was not wearing his preventive injury helmet. <BR/>Observation on 1/20/2023 at 1:20 p.m. revealed Resident #1 in his bed sitting up. He was not wearing helmet.<BR/>Observation on 1/20/2023 at 2:36 p.m. revealed Resident #1 in bed sitting up and alert. He was not wearing his preventive injury helmet. <BR/>Interview on 1/20/2023 at 10:23 a.m. with LVN A, she said Resident #1 had a couple of falls where he had hit his head on the floor . She said his last fall was on 1/7/2023. She said she did not know how Resident #1 received a black eye. <BR/>Observation and interview on 1/20/2023 at 3:00 p.m. with LVN A, she said she was informed by the surveyor that Resident #1's floor mat was behind his room door and was not put back on the floor by RA after feeding Resident #1. She said the last person to provide care or assist with helping Resident #1 was responsible for putting the floor mat back on the floor. She said she would speak with the RA about the floor mat not being place back on the floor for Resident #1.<BR/>Interview on 1/20/2023 at 3:39 p.m. with the RA, she said the importance of a floor mat was to protect a resident if in case they fell off their bed when residents were fall risks. She said she nursing staff was supposed to remove floor mats when performing patient care. She said she should have placed Resident #1's floor mat by resident's bedside but she had a lot going on and it slipped her mind. She said the helmet protected Resident #1's from head injuries due to resident #1 being a fall risk. She said the only time she had seen him with his helmet on was when he was sitting in his chair. She said the last time she was in-serviced for fall prevention was this month. She could not recall the exact. She said she was aware of fall prevention protocols because she had taken courses when she received her certification to become a CNA. She said when she was done feeding Resident #1, she kept him up for 30 minutes to avoid resident aspirating. She said she was supposed to placed the floor mat after feeding Resident #1. <BR/>Interview on 1/20/23 at 3:39 p.m. with LVN A, she said she nursing staff were supposed to conduct rounds on the residents at the facility every two hours. She said if she noticed nursing staff were not following policy and procedure, she would ask them what happened and remind them to adhere to the rules. She said the importance of the floor mat was to help with cushioning if someone fell to the floor. She said it also help avoid injuries and pain. She said Resident #1 wore a helmet because he had head injuries from falls in the past few months. She said he wore his helmet when he was in his wheelchair in common areas. She said when he was in his wheelchair, he had the ability to stand upright. She said Resident #1 did not seem restless today so she wasn't worried that he was not wearing his helmet. She said she had been working at the facility for 6 months. She said she did not know Resident #1's was care planned for wearing his preventive injury helmet while resident #1 was awake. She said she had oversight of the nursing staff in her Unit. She said the risk to the resident for not having floor mat by bedside while the resident was in bed was injury. She said the risk to Resident #1 for having his preventive injury helmet on while awake was risk of injury. She could not say why the failure occurred. She could not recall the last time staff was in-serviced for fall prevention or accidents and hazards.<BR/>Record Review of the facility's policy titled, Fall Management System revised on 1/03/2017 read in part . it is the policy of the facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on research on the resident's assessed needs. A fall occurs when there is an unintentional coming to rest on the floor, ground, or other lower level but not because of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. A fall is often the result of cumulative risk from both intrinsic (resident-related) and extrinsic (environmental) factors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit a resident assessment within the required time frame for 1 of 1 discharged residents (Resident #1) reviewed for data encoding and transmission in that: <BR/>Resident #1's discharge MDS dated [DATE] was not transmitted to CMS within 14 days of completion. <BR/>This failure could affect residents who were discharged from the facility and place them at risk of not having their assessments transmitted timely. <BR/>The findings were:<BR/>Record review of Resident #1's face sheet, dated 09/30/2022 revealed an admission date of 04/29/2022 and discharge date of 05/17/2022 with diagnoses included: encephalopathy (any diffuse disease of the brain that alters brain function or structure), sepsis (body's extreme response to an infection), myocardial infarction (heart attack), and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs).<BR/>Record review of Resident #1's completed MDS in the electronic chart revealed a Discharge MDS was completed on 05/17/2022 but was not transmitted.<BR/>During an interview with MDS Nurse C on 09/29/2022 at 3:55 p.m., MDS Nurse C revealed Resident #1 had a discharge MDS that was not transmitted to CMS and stated the corporate RN who had completed the MDS at that time had not unlocked it so that it could be submitted.<BR/>During an interview with MDS Nurse C and the DON on 09/29/2022 at 4:10 p.m., MDS Nurse C confirmed the discharge MDS should been submitted within 14 days. The DON unlocked the entry so MDS Nurse C could complete the submission.<BR/>Record review of the RAI (Resident Assessment Instrument) Manual OBRA Assessment Summary, dated October 2019, revealed OBRA Discharge assessments consist of discharge return anticipated and discharge return not anticipated. The same record also revealed the Discharge MDS must be completed within 14 days after the discharge date and must be submitted within 14 days after the MDS completion date.

Based on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for eight (CNA G, CNA L, CNA M, MA N, CNA O, CNA P, MA Q, and CNA R) of eight CNAs reviewed for demonstration of skills and techniques necessary for residents' needs. <BR/>The facility had not conducted competency assessments for all eight CNAs reviewed.<BR/>These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety.<BR/>The findings were:<BR/>Record review of personnel file for CNA G with hire date 03/03/2021 reflected no evidence of skill competency checkoffs.<BR/>Record review of personnel file for CNA L with hire date 05/04/2021 reflected no evidence of skill competency checkoffs.<BR/>Record review of personnel file for CNA M with hire date 07/02/1998 reflected no evidence of skill competency checkoffs.<BR/>Record review of personnel file for MA N with hire date 05/16/2002 reflected no evidence of skill competency checkoffs.<BR/>Record review of personnel file for CNA O with hire date 10/13/2016 reflected no evidence of skill competency checkoffs.<BR/>Record review of personnel file for CNA P with hire date 09/09/2019 reflected no evidence of skill competency checkoffs.<BR/>Record review of personnel file for MA Q with hire date 05/25/2021 reflected no evidence of skill competency checkoffs.<BR/>Record review of personnel file for CNA R with hire date 06/11/2021 reflected no evidence of skill competency checkoffs.<BR/>In an interview with the DON and Payroll Coordinator on 09/30/2022 at 12:22 p.m., the DON (hire date 06/27/2022) stated she thought after CNA competency evaluations were completed the form would go to HR. The Payroll Coordinator stated CNA competency evaluations were not part of the employee file and she had never been part of that process. The DON further stated she was not aware the checkoffs were not being completed and would immediately ensure there was a process.<BR/>In an interview and record review with the Administrator and Payroll Coordinator on 09/30/2022 at 1:15 p.m., the Administrator provided a blank CNA Competency Evaluation document that he stated was just received from the corporate office and would be putting in place right away a process for CNA competency checkoffs.<BR/>Record review of the facility's Facility Assessment 2021 revealed Skills validations are performed upon hire, and on an annual basis, to gauge competency and evaluate the need for additional educational offerings.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 garbage dumpsters (dumpsters #1 and #2) reviewed for disposal of garbage.<BR/>The facility failed to ensure 2 of 2 dumpster lids were secured.<BR/>This failure could place residents at risk of infection for exposure to germs and diseases carried by rodents from improperly disposed garbage.<BR/>Finding included:<BR/>Observation on 2/25/25 at 7:15 am revealed Dumpster #1 and Dumpster #2 had their lids completely open with the garbage exposed. The cook said they were not the only ones using the dumpsters in the facility. <BR/>Interview with the Nutrition Director on 2/26/25 at 4:01 pm, she said she had worked at the facility for seven years. The Nutrition Director said the dietary staff were responsible for the dumpster lids remaining closed. She said if the dumpster lid was open the residents are at risk for potential rodents that could come into the building and make the residents sick.<BR/>Interview with the [NAME] on 2/27/25 at 1:39 pm, she said she had worked at the facility for eight months. She said the kitchen staff responsible for making sure the dumpster lids closed. She said when the lid of the dumpster did not close it can cause the rodents, flies, and gnats to enter the facility which can cause the residents to become sick. <BR/>Interview with the Tray-Aide on 2/27/25 at 1:45pm, he said he had worked for the facility for one year. He said the kitchen responsible for the dumpster lids remaining closed. He said if the dumpster lids remain open it can put the residents at risk. He said the resident can be put at risk once rodents surround the dumpster. He said the residents can get rabies and become sick.<BR/>Record review of the Facility's Nutrition Policies and Procedures dated December 2017 read in part . dumpsters must be covered with lids . dumpster doors and lids must be kept closed when not in use . <BR/>Record review of the Facility's Food-Related Garbage and Rubbish Disposal policy, revised April 2006 revealed . 2. All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be covered when stored or not in continuous use. 5. Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin. 7. Outside dumpsters provided by garbage pick-up services will be kept closed and free of surrounding litter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 (Resident #1) out of 3 residents reviewed for privacy, in that:<BR/>Facility failed to provide privacy for Resident #1 during personal care on 05/01/2023.<BR/>This failure could result in residents having their bodies exposed to the public and loss of dignity and embarrassment due to lack of privacy.<BR/>Findings include<BR/>Record review of Resident #1's face sheet revealed a [AGE] years old male, admitted to 07/12/2022. His diagnoses included cerebral infarction, type 2 diabetic mellitus (high levels of sugar in the blood), hypertension (high blood pressure), end stage renal (kidney) disease, and chronic obstructive pulmonary disease.<BR/>Record review of a video dated 05/01/2023 at 05:11AM showed an employee providing care for Resident #1, the door to Resident #1's room was widely opened while Resident #1 was undressed and Resident #1's bed was closest to the door.<BR/>On 05/03/2023 at 1:08PM Surveyor attempted to interview the Agency Staff A who was taking care of Resident #1 on 05/01/2023 at 05:11AM when she failed to provide privacy. There was no response to the call, surveyor left voice message but there was no return call from the Agency Staff A.<BR/>On 05/03/2023 at 1:23PM during interview with LVN A, she stated she was trained about resident privacy during the time she was hired by the facility. she stated that this deficient practice was a dignity issue and it can embarrass the resident and cause them to be ashamed.<BR/>On 05/03/2023 at 1:26PM during interview with CNA B, she stated she was trained on residents' right to privacy and she stated this deficient practice can embarrass resident and affect their dignity.<BR/>On 05/03/2023 at 2:09PM during interview with Resident #1, Surveyor showed him the picture of him being cared for by a staff with Resident #1 undressed while the door was wide opened. Resident #1 shrugged his shoulder and stated I couldn't do nothing, they just do what they do.

Based on interview and record review, the facility failed to refer a resident with a serious mental disorder for a level 2 PASSAR review for 1 of 24 residents reviewed (Resident # 4) in that<BR/>The facility did not complete a level 2 PASSAR review whenever Resident #4 received a new mental health diagnosis on 3/28/22.<BR/>This deficient practice could place residents at risk of not receiving necessary mental health services.<BR/>The findings include:<BR/>Record review of Resident #4 face sheet dated 09/28/22 revealed she was admitted to the facility with diagnosis of fibromyalgia (a condition noted by widespread musculoskeletal pain), histrionic personality disorder ( a mental health disorder noted by a pattern of exaggerated emotionality), and osteoarthritis of the knee, (a degenerative joint disease of the knee.)<BR/>Record review of the MDS assessment for Resident #4 indicated a BIMS score of 14.<BR/>Record review of the care plan for Resident #4 revised on 12/18/19 revealed she had cognitive impairment and was at risk for further decline in cognitive and functional abilities.<BR/>Record review of the diagnosis report dated 9/28/22 for Resident # 4 revealed a diagnosis of paranoid schizophrenia was given on 3/28/22 during the resident's stay.<BR/>During an interview on 09/28/22 at 4:30 PM with the SW she stated Resident # 4, who had a PASSAR level 1 determination, was given a new diagnosis on 3/28/22 of paranoid schizophrenia. She stated a PASSAR level 2 referral should have been made to the local mental health authority to further assess for mental health needs and she forgot to do so.<BR/>During an interview on 09/29/22 at 10:35AM with MDS Coordinator_C stated that the SW was responsible for PASSAR updates and notifications.<BR/>Record review of the facility's PASSAR rules and guidelines dated 04/26/16 and revised on 6/3/20 revealed a new resident PASSAR notification needs to be completed with a new serious mental disorder diagnosis.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen.<BR/>-Thirteen 8 oz glasses of juice were not labeled and not dated in the facility refrigerator. <BR/>-Nine 4 oz glasses of apple sauce were not labeled and not dated in the facility kitchen.<BR/>This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness.<BR/>Findings included:<BR/>Observation in the facility kitchen on 2/25/25 at 06:30 am revealed thirteen 8 oz glasses of juice and nine 4 oz glasses of apple sauce were not labeled (attach a label to something) or dated.<BR/>Interview with the Dietary Manager on 2/26/25 at 4:01 pm, she said she starts her workday by making sure everything is correctly labeled and dated . She said she make sure the date and use by date are on each food item. She said if the item used is not labeled or dated the residents can get sick or have an allergic reaction. <BR/>Interview with the [NAME] on 2/27/25 at 1:39 pm, she said all food items should be labeled and dated. She said if the items are not labeled and dated, she had no idea how long the item had been sitting there. She said if she was to use the item and it's not dated or labeled it can make the residents sick. <BR/>Interview with the Tray-aide on 2/27/25 at 1:45 pm, he said all the food items should be labeled and dated always. He said if the items are not labeled and dated, and the food is used it can put the residents at risk of getting sick.<BR/>Record review of the Facility's Nutrition Policies and Procedures dated December 5, 2017, read in part . proper labeling with an expiration or use by date .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen.<BR/>-Thirteen 8 oz glasses of juice were not labeled and not dated in the facility refrigerator. <BR/>-Nine 4 oz glasses of apple sauce were not labeled and not dated in the facility kitchen.<BR/>This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness.<BR/>Findings included:<BR/>Observation in the facility kitchen on 2/25/25 at 06:30 am revealed thirteen 8 oz glasses of juice and nine 4 oz glasses of apple sauce were not labeled (attach a label to something) or dated.<BR/>Interview with the Dietary Manager on 2/26/25 at 4:01 pm, she said she starts her workday by making sure everything is correctly labeled and dated . She said she make sure the date and use by date are on each food item. She said if the item used is not labeled or dated the residents can get sick or have an allergic reaction. <BR/>Interview with the [NAME] on 2/27/25 at 1:39 pm, she said all food items should be labeled and dated. She said if the items are not labeled and dated, she had no idea how long the item had been sitting there. She said if she was to use the item and it's not dated or labeled it can make the residents sick. <BR/>Interview with the Tray-aide on 2/27/25 at 1:45 pm, he said all the food items should be labeled and dated always. He said if the items are not labeled and dated, and the food is used it can put the residents at risk of getting sick.<BR/>Record review of the Facility's Nutrition Policies and Procedures dated December 5, 2017, read in part . proper labeling with an expiration or use by date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who needed colostomy care were provided such care, consistent with professional standards of practice for 1 of 24 residents (Resident #15) reviewed for colostomy care in that:<BR/>Resident #15 had a colostomy and did not have an order for treatment/care to be provided.<BR/>This deficient practice could place residents with a colostomy at risk of delay in treatment/care.<BR/>The findings were:<BR/>Record review of Resident #15's Face Sheet, dated 09/27/2022, revealed a [AGE] year-old male with an admission date of 08/04/2022 with diagnoses that included: Chronic pain syndrome (chronic pain as pain that lasts for longer than 3 months) and anxiety disorder ( medical condition includes symptoms of intense panic). <BR/>Record review of Resident #15's electronic record of a progress note signed by the physician, dated 9/23/2022, revealed, colostomy - a surgical opening in which a piece of the colon is diverted to an artificial opening, under the section of the history of present illness. <BR/>Record review of Resident #15's admission MDS dated [DATE], revealed, a BIMS of 15, indicating intact cognition. <BR/>Record review of Resident #15's care plan dated 8/18/2022 did not reveal any focus area for colostomy care. <BR/>Record review of Resident #15's physician's orders dated 08/27/2022, revealed no physician's order for colostomy care.<BR/>Record review of Resident #15's treatment administration record dated 08/27/2022, revealed no documentation of colostomy care/treatment provided. <BR/>Record review of Resident #15's progress notes dated 8/4/2022 to 9/28/2022 revealed no documentation of colostomy care/treatment provided.<BR/>Observation and interview on 9/27/2022 at 12:55 p.m. of Resident #15 revealed a colostomy bag in place on the left lower abdomen. Resident #15 stated he had an opening on his left lower abdomen that secreted stool, and staff placed a colostomy bag over it so that stool did not leak all over the bed. <BR/>Record review of the physician's history and physical, dated 9/22/2022, revealed a colostomy was present. <BR/>During an interview on 09/27/2022 at 9:45 a.m. the Wound Care, Nurse stated Resident #15 had a colostomy, colostomy care, and teaching had been provided by nurses but not documented. The Wound Care Nurse stated there was no physician's order for colostomy care. The Wound Care Nurse stated there should have been an order and was unsure why there was no order.<BR/>During an interview on 9/28/2022 at 11:38 a.m. ADON A stated Resident #15 had a colostomy. She stated she could not remember if there was an order for colostomy care and treatment for Resident #15 . <BR/>During an interview at 11:48 a.m., the DON stated Resident #15 had a colostomy. The DON stated the facility had standing orders for colostomy care and treatment, and this should have been placed on Resident #15's physician's orders to ensure the colostomy care and treatment were performed and documented. The DON was unsure why there was no order on Resident #15's chart.<BR/>During an interview on 12/9/2021 at 12:00 p.m., the DON stated, We have a policy for colostomy care and treatment; however, we don't have an order for the care. <BR/>Review of the facility's admission checklist, undated revealed in part . Admitting nurse must complete the following, and ensure the following are included in the admission assessment head to toe assessment, to include any wounds, bowel sounds and lung sounds.<BR/>Review of facility's colostomy/ileostomy care, dated 8/29/2014, revised 2/10/2020, revealed a colostomy or ileostomy is an artificial opening in the abdomen that is created as a means for evacuation of bowel contents.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for one (Hall 500) of four halls observed for environment, in that: <BR/>The door to the paint supply closet on 500 Hall with paint cans and supplies was unsecured.<BR/>This deficient practice could place residents at risk of living in an unsafe environment.<BR/>The findings were:<BR/>An observation on 09/27/22 at 11:45 a.m. on Hall 500 revealed a paint supply closet with the door cracked slightly open. The closet contained approximately 15 cans of paint and various other paint supplies such as brushes and rags. Further observation revealed a sign on the inside of the door that read, Leave vent on. Do not turn off light switch, and signed by Maintenance. Both the vent was off, and the light switch was off at this time.<BR/>In an interview with LVN E on 09/27/22 at 11:52 a.m., LVN E stated the closet door should be locked and she would go find one of the guys with maintenance.<BR/>An observation on 09/27/22 at 11:54 a.m on the 500 Hall revealed two residents walking in the hallway and another resident ambulating down the hall independently in her wheelchair.<BR/>Record review of the resident roster dated 09/27/22 revealed there were 23 residents on the 500 Hall. Additional record review revealed 12 of the 23 residents on 500 Hall had severe cognitive impairments.<BR/>In an interview with the Maintenance Assistant on 09/27/22 at 11:59 a.m., the Maintenance Assistant stated, It was opened this morning and we probably got in a rush and didn't lock it back. We know to always keep it locked. When asked about the sign on the back of the door, the Maintenance Assistant stated, That is from a long time ago, before I started. I don't think we do that anymore.<BR/>In an interview with the Maintenance Director on 09/27/22 at 12:05 p.m., the Maintenance Director stated the door should have been locked and the vent should be on for the fumes. When asked what the harm to residents would be, the Maintenance Director stated a resident could wander into the room creating a dangerous situation.<BR/>In an interview with the Administrator on 09/27/22 at 12:10 p.m., the Administrator confirmed the paint supply closet door should always be kept locked.<BR/>Review of the Policy and Procedure provided Incident/Accident Reporting and Supervision revised 11/07 reflected It is the policy of this facility to provide an environment that is free from hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Avoidable Accident: means that an accident occurred because the facility failed to: identify environmental hazards and individual resident risk of an accident, including the need for supervision; and/or evaluate/analyze the hazards and risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for 1 of 13 resident rooms reviewed for homelike environment.<BR/>1. The facility failed to clean the floor and wall in Resident #29's room.<BR/>2. The facility failed to provide clean linens for Resident #29's bed.<BR/>These failures could affect all residents by decreasing their sense of self-worth.<BR/>Findings include:<BR/>Review of Resident #29's electronic face sheet dated 12/30/23 revealed he was admitted to the facility on [DATE] with diagnosis of osteomyelitis (inflammation of bone caused by infection), pressure ulcer of sacral (the bottom of the spine and lies between the fifth segment of the lumbar spine and the tailbone) region, paraplegia, neuromuscular dysfunction of bladder, and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).<BR/>During an observation on 12/27/23 at 11:20 AM of Resident #29's room, on the floor there were candy wrappers, food crumbs, droplets of a dried brown substance, and a jacket. The wall behind the resident's bed had about 7 round yellowish-brown stains. There was also a dried red substance on the resident's sheets.<BR/>During an observation and interview on 12/28/23 at 3:25 PM, Resident #29's floor was clean, there were new bed sheets on the bed, the round yellowish-brown stains were on the wall behind the resident's bed. Resident #29 said the room was finally cleaned after the state came in. He said the yellowish-brown substance on the wall was hot sauce and housekeeping staff did not attempt to clean the wall.<BR/>During an interview on 12/29/23 at 4:50 PM with the Housekeeper, she said each employee has a hall and all the rooms were cleaned once a day. She said the cleaning staff were not supposed to touch personal items, and if the bed linens were soiled, the CNAs were responsible for changing the bed sheets. She said Resident #29 got upset if staff touched his personal belongings. She said when Resident #29 used to live on Hall 500, which was her assigned hallway, she would make sure Resident #29's floor was cleaned. She said she was not sure who was assigned to hall 200 where he currently lived but did state housekeeping had been short staffed due to COVID.<BR/>Record review of the Statement of Resident Rights not dated read in part . residents have the right to safe, decent, and clean conditions <BR/>A housekeeping policy was requested on 12/29/23 at 4:58 pm but was never received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have assessments that accurately reflect the status 1 of 24 residents (Resident #15) reviewed for resident assessments in that: <BR/>Resident #15's admission MDS incorrectly documented the resident as not having a colostomy while a resident at the facility.<BR/>This deficient practice could place residents at risk for inadequate care due to inaccurate assessments. <BR/>The Findings were: <BR/>Record review of Resident #15's Face Sheet, dated 09/27/2022, revealed a [AGE] year-old male with an admission date of 08/04/2022 with diagnoses that included: Chronic pain syndrome - chronic pain as pain that lasts for longer than 3 months; and anxiety disorder - Medical condition includes symptoms of intense panic. <BR/>Record review of Resident #15's electronic record of a progress note signed by the physician, dated 9/23/2022, revealed, colostomy - a piece of the colon that is diverted to an artificial opening in the abdominal wall . under the section of the history of present illness. <BR/>Record review of Resident #15's admission MDS dated [DATE], revealed, a BIMS of 15, indicating intact cognition. The MDS indicated Resident #15 had no colostomy.<BR/>Record review of Resident #15's active physician's orders, dated 9/27/2022, revealed no orders for colostomy care.<BR/>During an observation and interview with Resident #15 on 09/27/2022 at 12:40 p.m., Resident #15 revealed a colostomy bag in place on the abdomen. Resident #15 stated the nurses placed a colostomy bag over the lower part of the abdomen to keep it from leaking stool . <BR/>Record review of Resident #15's electronic record of a progress note signed by the physician, dated 9/23/2022, revealed a : colostomy under the section of the history of present illness. <BR/>During an interview with the MDS nurse C, on 9/27/2022 at 12:12 p.m., stated Resident #15's active physician's orders reflected no orders for colostomy care . MDS nurse C stated the resident was wearing a colostomy bag but did not know this prior to surveyor intervention. <BR/>During an interview with the DON on 9/27/2022 at 1230 p.m. the DON stated Resident #15's physician's orders did not address colostomy care, and she stated the resident was wearing a colostomy bag. The DON stated she did not know how these were missed on the nursing assessments and did not have a policy for nursing assessments. <BR/>Review of the facility's admission checklist, undated revealed, in part . Admitting nurse must complete the following, and ensure the following are included in the admission assessment head to toe assessment, to include any wounds, bowel sounds and lung sounds.<BR/>Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, October 2019, revealed Responsibilities of Nursing Homes for Completing Assessments, Steps for Assessment:<BR/>Review the medical record for bowel records and incontinence flow sheets, nursing assessments and progress notes, physician history and physical examination.

Based on interview and record review, the facility failed to provide dementia management and resident abuse prevention training for 12 of 14 staff (Administrator, DON, ADON A, MDS Nurse C, MDS Nurse D, LVN S, LVN H, RN I, LVN E, CNA J, CNA K and AD) reviewed for training, in that:<BR/>The Administrator, DON, ADON A, MDS Nurse C, MDS Nurse D, LVN S, LVN H, RN I, LVN E, CNA J, CNA K and AD had not received dementia and abuse training.<BR/>These failures could place the residents at risk of by being cared for by staff who are not adequately trained. <BR/>The findings were: <BR/>Record review of the Facility Staff Roster, undated, revealed:<BR/>Administrator - date of hire 04/05/2021<BR/>DON - date of hire 06/27/2022<BR/>ADON A - date of hire 07/13/2022<BR/>MDS Nurse C - date of hire 09/24/2012<BR/>MDS Nurse D - date of hire 01/19/2020<BR/>LVN S - date of hire 08/24/2018<BR/>LVN H - date of hire 09/20/2022<BR/>RN I - date of hire 09/13/2022<BR/>LVN E - date of hire 05/26/2022<BR/>CNA J - date of hire 06/14/2022<BR/>CNA K - date of hire 07/19/2022<BR/>AD - date of hire 08/02/2022<BR/>In-service sign-in sheets, dated 09/29/2022 for trainings on Dementia (via phone) and Abuse/Neglect were provided by the Payroll Coordinator. The Payroll Coordinator was unable to provide a training transcript for the Administrator, DON, ADON A, MDS nurse C, MDS nurse D, LVN S, LVN H, RN I, LVN E, CNA J, CNA K and AD.<BR/>During an interview with the Payroll Coordinator on 09/30/2022 at 10:44 a.m., the Payroll Coordinator stated we are working to get the training to where it needs to be. She said she had tried to get as many done as possible yesterday, by calling them on the phone, but then realized that wasn't really much of a training. <BR/>In an interview with the Administrator on 09/30/2022 at 11:05 a.m., the Administrator revealed the facility used a web-based computerized training program and the staff always had access to the program. The Administrator stated the facility would be able to correct the failure easily. <BR/>Record review of the facility's Facility Assessment 2021 revealed using the [training program] web-based education platform, an annual calendar has been established to include training required to meet basic industry regulatory compliance. <BR/>Record review of the facility's policy titled, Abuse Policy, review date 02/01/2021, revealed, II. Training Employees: Prevention, Intervention, Detection, Reporting and Employee Rights. Train employees, through orientation and on-going sessions on issues related to abuse prohibition practices. III. Prevention of Abuse: C. In addition to freedom from abuse, neglect, and exploitation requirements in facilities will provide training at the minimum upon hire and annually to their staff on the following topics - (1) activities that constitute abuse, neglect, exploitation, and misappropriation of resident property (2) procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (3) dementia management and resident abuse prevention.