Paradigm Northwest

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 5 residents reviewed for notification of changes. The facility failed to establish contact with the NP after Resident#1 had an unwitnessed fall where he was found lying face down on the floor on 8/13/25 at 11am. LVN A sent the NP a text at 11:40 am but she was not aware until she received a second text notification at 12:44 pm. Resident #1 was transported to the hospital at 1:30 pm, after an induration formed above his left brow. An IJ was identified on 8/15/25 at 6:05 pm. The IJ template was provided to the facility on 8/15/25 at 7:10 pm. While the IJ was removed on 8/16/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or additional injury, paralysis or death. Finding included:Record review of Resident#1's face sheet revealed a fifty-six-year-old man who was admitted to the skilled nursing facility on [DATE]. His admitting diagnoses were hemiplegia and hemiparesis following cerebral infraction affecting the right dominant side (paralysis and weakness on one side of the body), paraplegia, cerebral aneurysm (blood vessel in the brain), a cerebral infraction (stroke), and the use of a tracheostomy. Record review of Resident #1's care plan disclosed that he utilized a feeding tube for meals and required supplemental oxygen. Record review of Resident #1's progress note dated 8/13/25 at 1:30 pm by LVN A documented unwitnessed fall, resident on floor next to bed in prone position with head turned to the left side. Bilateral arms straight and bilateral legs straight. Small swelling to left upper temporal noted upon assessment. Resident assisted back to bed x4. Vital signs obtained BP: 123/87 pulse: 89 respiratory: 20 temperature: 96.8. Neurological checks initiated per protocol. Physician and family notified. Resident mother stated resident tends to move a lot and he will try to get out of bed and this is not a new action for him. Precautions have been put in place. Two bedside mats or placed next to resident bed. Bed will continue to be lowered to ground call light within reach. In an interview with LVN A on 08/14/25 at 3:38 pm, she stated that Resident #1's mother alerted her that he was on the floor around 11am. She stated that she found him laying with his arms to his side and he did not have any signs of pain. The NP was notified, and she began neuro checks. After a few checks, she noticed a raised area forming above his brow and she alerted the NP who was also in the building at that time. The NP ordered Resident #1 to be sent out for further evaluation. LVN A explained that no fall protocols were put into place because he had not moved much since his admission, and they were not aware that he was able to move on his own. In an interview with Resident #1's family member on 08/15/25 at 10:50 am, she stated that when she entered his room at 11am, he was laying on the floor facedown with his trach still connected to his throat. LVN A was immediately alerted, and staff came inside the room and began assessments. She stated that she informed that staff amongst admission that Resident #1 could move and prior to him coming to the facility, he had done physical therapy at other facilities. EMS was called and he was transported to the hospital at 1:30 pm due to swelling above his left eyebrow. In an interview with CNA A on 8/15/25 at 11:53 am, she explained that she had worked with Resident #1 on 8/13/25 around 9:30 am to shower him. She stated that day, he was moving a lot. He would constantly move his legs up and down and he moved his head a lot. Resident #1 slept on an air mattress and before she left his room after his shower, she lowered his bed to the lowest position. She recalled that there was not a fall mat next to his bed because he was a new admit and she guessed nursing staff did not see a need for it at the time. In an interview with the Unit Manager on 8/15/25 at 12:16 pm, she stated that Resident #1 was nonverbal, but he could follow people with his eyes. She explained that he was able to move his arms and legs and described them as jerk like reactions. She stated that since Resident #1 was admitted , he had begun to move a lot more and his mother had also noticed his increase in movement. On that day of the fall, she was called to his room (time unknown) by LVN A and noticed that he was face down on the ground. There was no blood, and he was able to move his head. Initially there was no swelling, but after a few hours swelling began to appear on his left side. The Unit Manager recalled that the NP was in the building, but she could not recall if she assessed him immediately after the fall. The Unit Manager stated that the protocol after an unwitnessed depended on if it was a fall with an injury; then they would be sent out immediately. If there was an unwitnessed fall without injury, the facility's fall protocol was to notify the physician of NP and get an order to send them out. The surveyor asked that since Resident #1 had a history of head injuries, previously suffered from a stroke, and was found face down from an unwitnessed fall, would he be qualified to be sent out? Unit Manager took a long pause and said she was thinking and stated that he had no visible injuries, but he was a special situation and if the NP was in the building, she would have grabbed her to come see. In an interview with the DON on 8/15/25 at 12:35 pm, she stated that she did not know when the NP assessed Resident #1, but she was informed by LVN A when he fell, and she was informed when the swelling appeared. She stated that when LVN A noticed the swelling around 1-1:30 pm during neuro-checks and he was sent out afterwards. When the DON and Surveyor reviewed his orders, the DON confirmed that Resident #1 was on Aspirin, which was a blood thinner and the harm in not seeking emergency medical services post fall could be hemorrhaging or bleeding. She stated that no fall preventions were in place because Resident #1 was not able to move, and she believed he may have fell on the floor due to increased alertness. In an interview with the NP on 8/15/25 at 1:30 pm, she stated that LVN A sent her a text message on 8/13/25 at 11:40 am but she did not see the message. She could not give a definite time, but she stated that she entered the facility sometime between 12 pm and 2 pm to complete rounds. While she was there, LVN A sent her a second text message at 12:44 pm and informed her that Resident #1 had some swelling on his head post fall, and she went in to assess him. The NP found a little induration on the left side of his temple and stated that because he was on blood thinners, she ordered him to be sent out because she was concerned about internal bleeding. She stated that if someone had a fall where they hit their head, whether witnessed or unwitnessed, it would be best practice to send them out for a CT scan. This was especially significant for Resident #1 because he had a suspected head injury and was on blood thinners at the time. NP also noted that when she assessed Resident #1 that day, he was notably more alert, was able to shake his head, and seemed to understand her in conversation. Observation on 8/15/25 at 2:57 pm in the hospital, Resident #1 was sitting in bed at a 90-degree angle and his eyes were bright and alert. He seemed to have a smile on his face and followed the surveyor around the room as she spoke to him. He was nonverbal but attempted to make grunts and groans in response to conversation. In an interview with the HSW (Hospital Social Worker) on 8/15/25 at 2:59 pm, she explained that Resident #1 was admitted for a fall on 8/13/25. She stated that his admitting diagnoses were interval acute bleeding to the left side of the head, and he had new chronic appearing left frontal sub [NAME] hematoma Internal bleeding to the side. HSW stated that in addition to that, he was currently being treated for sepsis and pneumonia, which was present upon admittance. Record review of the facility's policy titled Fall Management revised July 2024 displayed that:1. The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medication review, and receive orders as indicated.2. If the resident's condition warrants, the charge nurse will arrange for appropriate emergency services or hospital transfer in collaboration with the Physician/Physician Extender. The ADM and DON were notified on 8/15/25 at 7:10 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 8/16/25 at 12:30 pm: Plan of Removal: F580 - Notification of ChangesAugust 16, 2025Immediate action:The facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or conditions or clinical conditions. Resident #1 was transferred on 8/13/2025 to the ER and remains in the hospital. Action: LVN A was immediately re-educated by the DON on 8/15/25 on the facility's fall protocol and notification procedures, including the requirement to make direct verbal communication with the provider NP/physician for all significant changes, and event escalation if the NP/Physician does not respond.Responsible: Director of Nursing Completion: August 16, 2025 The Administrator and Director of Nursing notified the Medical Director of the IJ F-0580.Responsible: Administrator/Director of NursingCompletion: August 16, 2025 Action: Ad Hoc QAPI conducted on 8/15/25 with Medical Director, Administrator, DON, & Unit Managers regarding IJ F0580 and F684.Responsible: Administrator/Director of NursingCompletion: August 16, 2025 Action: All license staff will be re-educated by the DON/Designee on the following: facility fall protocol to include immediate provider notification following all unwitnessed falls, regardless of visible injury. All license staff will be educated prior to the start of their next shift. Staff will not provide direct resident care until training/education has been completed. Staff should follow facility protocol and provide verbal communication to the provider.Escalation Protocol for Provider Notification:In the event of an unwitnessed fall and any other changes of condition from resident's baseline:1. Notify the Nurse Practitioner (NP) immediately.2. If the NP does not respond, contact the attending physician.3. If the attending physician does not respond, contact the Medical Director.4. If the Medical Director does not respond, contact the Administrator.Responsible: Director of Nursing/DesigneeCompletion: August 16,2025 Action: Administrator reviewed on 8/15/25 the facility falls policy and changes of conditions notification policy and no changes were needed. Responsible: AdministratorCompletion: August 16, 2025 The Surveyor monitored the POR on 8/16/25 as followed: Review of an in-service titled QAPI 8/15/25: Notification of Change and Quality of Care documented that all nursing staff had been educated on physician escalation notification, all unwitnessed or witnessed falls with a strike to head should be sent out immediately, and the physician or extending physician should be notified immediately. Attendees including the ADM, DON, and Unit Managers. Review of the in-services dated 8/15/25 titled Education Change of Condition, Physician Escalation Protocol for Provider Notification, and Fall management displayed that all nursing staff were educated. During interviews on 8/16/25 from 2:00 pm - 4:45 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-services. All staff stated that if a resident was experiencing a change in condition, the protocol would be to first assess the resident and if there was a deviation from their baseline, their NP or MD should be notified immediately. If the resident has interventions in place, nurses were to follow them or follow the orders given by the NP/MD. If the NP/MD is not available, 911 should be called so that the resident can receive a higher level of care. It was verbalized that the chain in notification would be that the NP would be notified first and if there was no answer, an attempt would be made to the MD, and the immediate scalation would be to call 911 and the ADM. All nurses should continue providing care until EMS arrives. Review of the Facility's QAPI Agenda, dated 8/15/25, reflected that the MD had reviewed and agreed with the plan. MD was interviewed and stated that a QAPI was held and the team developed a plan to address the issues of the IJs. LVN A was interviewed on 8/16/25 at 2:40 pm. She stated that she was in-serviced on fall management and escalation provider protocol. She said that if a resident has a fall, she was to contact the NP and MD, and if they didn't answer, she must call the administrator or EMS right away. The ADM and DON were notified on 8/16/25 6:05 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and based on the comprehensive assessment for 1 (Resident #87) of 8 residents reviewed for assessments. <BR/>-The facility (RN A) failed to complete an assessment, incident report, neuro-checks, and facility monitoring requirements after Resident #87 was said to have had an unwitnessed fall.<BR/>These failures placed the resident(s) at risk of harm for not receiving care and services.<BR/>Findings included:<BR/>Resident #87<BR/>Record review of Resident #87's face sheet dated 5/24/2022 revealed a [AGE] years old male, admitted on [DATE] and re-admitted on [DATE] and the following diagnoses included: Bi-polar disorder (mental illness with extreme mood swings), difficulty walking, cognitive communication deficit, cataracts (affecting the eye that causes clouding of the lens), ( hypothyroidism (decreased production of thyroid hormones), restless leg syndrome (disorder that causes an overwhelming urge to move legs), low back pain, unsteadiness on feet, and major depressive.<BR/>Record review of Resident #87's MDS dated [DATE] revealed a BIMS of 15 which indicated the resident was cognitively intact. Section J1800 did not indicate the resident had a fall history. <BR/>Record review of Resident #87's care plan dated 5/19/2022 (last care plan review completed) revealed the following in part:<BR/>Focus - I have had an actual fall with unsteadiness 11/14/2019 unwitnessed fall with no injuries, 2/9/2022 slide off the side of bed, 5/15/2022 suspected fall with bruising.<BR/>Goal - I will resume usual activities without further incident through the review date. (target date 7/23/2022)<BR/>Interventions - .Encourage resident to ask for assistance. Observe/document/report PRN x 72h MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. (date initiated 3/22/2022)<BR/>Focus - I am at risk for falls r/t poor balance; unsteady gait (date revised 3/22/2022)<BR/>Goal - My risk and injury potential will be minimized through the next review date. (revision date 4/25/2022).<BR/>Interventions - Anticipate and meet my needs. (revised 1/15/2019) Be sure my call light is within reach and encourage me to use it for assistance as needed. I need a prompt response to all request for assistance<BR/>Record review of facility nurses' note for Resident #87 written by RN A dated 5/15/2022 at unknown time (late entry for 5/14/2022) revealed the following: 5/14/2022 21:29 (11:29 p.m.) Nursing Note Late Entry: Note Text: This writer was informed of the recent incident of suspected fall to the resident. Nurse only heard the Rcs (RC X) and another Resident (Resident #10) talked about the fall. Nurse went into resident's (Resident #87) room to ask, resident denied fall. Nurse assessed patient from head to toe, no distress, discomfort or injury noted at the time of this assessment. V/signs checked; B/p--114/64, p-86, R-20. Resident asked to be changed, same done and given snack as requested. Resident in stable condition. In-coming Nurse (LVN P) notified to monitor resident.<BR/>Record review of nurses' note (written by LVN P on - 5/15/2022 at 7:42 a.m.) revealed the following in part:<BR/> .SBAR Summary:<BR/>Vitals Signs: BP 121/79 - 5/15/2022 8:07 a.m.<BR/>Position: Lying left /arm, P 64 - 5/15/2022 08:07 a.m.<BR/>Pulse Type: Regular R 16 - 5/15/2022 8:07 a.m.<BR/>Temperature 96.9 - 5/14/2022 8:09 a.m. Route: Axilla (armpit) <BR/>Weight 172.6 lb. - (last taken 4/20/2022)<BR/>O2 98.0 % - 5/14/2022 - Method: Room Air<BR/>RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: suspected of fall with possible head injury due to new bruising to left torso and back of right thigh. Decline in cognitive baseline, temp 95.3 Additional Nursing Notes as applicable: Received orders from Dr. to send to hospital for CT scan .<BR/>Record review of nurse's note (written by LVN P on 5/15/2022 at 9:27 a.m.) revealed the following in part:<BR/>Resident #87 transported to hospital ER for suspected fall with possible head injury .<BR/>Interview via telephone on 5/24/2022 at 11:37 a.m. with Resident #87's Guardian said he was told on 5/15/2022 by LVN P that Resident #87 was found on the floor and had vomited on 5/15/2022. The Guardian said Resident #87 was sent to the ER unresponsive. The Guardian said he was informed by the hospital staff that when Resident #87 arrived at the hospital he had bruising to his torso area. He said he last saw Resident #87 in April 2022 but could not remember the date. He said Resident #87 did not have bruising in April 2022. During this visit in April 2022, he said Resident #87 did have a rash in his groin area and complained about wait time for care needed. The Guardian said Resident #87 was impatient and wanted care immediately but this was talked about in his care plan.<BR/>Interview on 5/25/2022 at 10:17 a.m. the ER RN said when Resident #87 arrived at the hospital emergency room he had a bruised bilateral abdomen (midline of the stomach area). The ER RN said the emergency room doctor said Resident #87 had a traumatic inquiry not consistent with a fall .injury to his pancreas which was not consistent with a fall. The ER RN said Resident #87 was currently intubated (insertion of a tube either through the mouth or nose and into the airway to aid with breathing). She said she Resident #87 had bruising on the sides of his torso and one spot on his back the size of a fist. She said the bruises that Resident #87 had occurred within the last 24-48 hours. <BR/>Interview on 5/25/2022 at 11:07 a.m. with Resident #87's roommate (Resident #95) was attempted, and he was not able to answer questions or communicate what happened to Resident #87. <BR/>Record review of Resident #95's Quarterly MDS dated [DATE] revealed his BIMS was a 3 which indicated he had severe cognitive impairment. <BR/>Interview on 5/25/2022 2:56 p.m. with RN A said she had worked for the facility for approximately 2 months. RN A said she worked on 5/14/2022 from 2:00 p.m. - 10:00 p.m. She said as she was coming from assisting a resident with a fall, she overheard RC X say to Resident #10 that Resident #87 did not fall. RN A said she did not ask RC X and Resident #10 any questions and proceeded to Resident #87's room. RN A said she asked Resident #87 if he fell and he told her he did not. RN A said she completed an incontinent change and while doing so, she looked for injuries. RN A said she asked Resident #87 if he fell and she said he denied pain. RN A said she took Resident #87's vitals (signs checked; B/p--114/64, p-86, R-20) while he was in bed (she had this written in a person note book that she referred to during the interview). RN A said because Resident #87's vital were in normal range, he had no bruising and he said he did not fall. She said she disregarded protocol for unwitnessed falls based on Resident #87's response. She said when a resident had an unwitnessed fall, she had been trained to assess the resident, take vitals, check for pain, start neuro checks, complete incident report and follow the facility's fall management policy. She said the fall management policy was used to monitor if a resident had any change in condition which could be an indication of a decline in a resident's health. She said Resident #87 was sleep for the rest of her shift. RN A said she told LVN P to keep an eye on him (Resident #87). RN A did not provide an answer to why she said keep an eye on Resident #87 or what she meant. RN A said injuries or change in condition could present after the fall and may not show up immediately and that was why the fall management policy was used to monitor changes in the resident. She said she did not make any other notifications related to an unwitnessed fall for Resident #87. She said she later talked to Resident #10 on 5/16/2022 who said he picked up Resident #87 from the floor. She said RC X was the aide assigned to Resident #87 during her shift. <BR/>Interview on 5/25/2022 at 12:00 p.m. with the DON, she said she was not told Resident #87's had unwitnessed fall on 5/14/2022 until 5/16/2022 after she reviewed the 24 hour-report and was told by RN C (worked 6:00 a.m. - 2:00 p.m. on 5/15/2022). The DON said she was aware Resident #87 was sent out to the hospital but was not aware of Resident #87's possible unwitnessed fall prior to being sent out. The DON said RN C told her when he went to Resident #87 room at the beginning of his shift he saw vomit on the floor, the resident was in bed, vitals were taken, and his temperature had dropped and was low (95.3). Resident #87 was sent out to the hospital. The DON interviewed LVN P (worked 10:00 p.m. 5/14/2022 - 6:00 a.m. 5/15/2022). LVN P said Resident #87 had no changes throughout the night. The DON interviewed Resident #10 (BIMS 8) and he told her that he helped Resident #87 from the floor. The DON said Resident #10 said he snatched Resident #87 from the floor from behind to help him up to the bed. The DON interviewed NA J (worked on 5/14/2022 2:00 p.m. - 10:00 p.m.) and he told her Resident #10 said he picked up Resident #87 from the floor and put him back in the bed. The DON said NA J told her he did not report it to the nurse. The DON interviewed RC X. The DON said she was told by RC X that Resident #10 said he picked up Resident #87. The DON said the facility's policy on fall management was not followed. The DON said Resident #87 should have had neuro checks that would have been followed by a physical assessment to monitor for any change in condition that could detect injuries or change in mental status. The DON said a full and documented assessment should have been completed since there was a possible fall. The DON said there could be a delay in care without the assessments being completed. <BR/>Interview on 5/25/2022 at 4:17 p.m. with NA J (temporary nurse aide) said he worked on 5/14/2022 on the 2:00 p.m. -10:00 p.m. shift. NA J said he was not assigned to Resident #87. NA J said Resident #10 approached him in the hallway and said he had helped Resident #87 from the floor back into his bed. NA J said he went to Resident #87's room, pulled back the covers to see if the resident had any bruises. NA J said he did not see any visible bruises and went back to tell Resident #10 that he should not help a resident off the floor. NA J said he did not report the possible fall of Resident #87 to a nurse because he was busy doing something, did not see the nurse on the hall and forgot. NA J said the nurse on duty was RN A. NA J said he had been trained that if a had resident has a fall, then he should have reported it to the nurse so they could start their assessment. NA J said the nurse should check the resident for injuries, take the resident's vitals, and monitor the resident every 15-30 minutes and let the next nurse know. NA J said if a resident was not monitored after a fall it could lead to injuries that were not detected. <BR/>Interview on 5/26/2022 at 9:35 a.m. LVN P said he worked the 10:00 p.m. - 6:00 a.m. shift on 5/14/2022 - 5/15/2022. He said he completed shift change with RN A. LVN P said RN A did not inform him of a fall for Resident #87 or to monitor him. LVN P said RN A informed him of another resident who had a fall. LVN P said he completed the facility fall management protocol which was continue the neuro checks that had been started by RN A, but he had not been told to complete neuro checks for Resident #87. LVN P said the fall management protocol is was is started to assess the resident for injuries, check for pain, initiate neuro check to monitor a change in condition, document the incident and inform the next shift. LVN P said the protocol was to ensure if there is was a decline in the resident's health then it is was detected, and they receive the care that was needed. LVN P said during his shift he rounded and did not see bruising on Resident #87. LVN P said Resident #87 kept his overhead light on throughout the night. LVN P said he brought water to Resident #87. LVN P said there was no other interaction with Resident #87 and last saw him at the end of his shift around 5:30 a.m. LVN P said he did not see vomit in his room. LVN P said the fall management protocol should have been started if a resident said they picked up another resident from the floor and be treated as an unwitnessed fall. <BR/>Interview on 5/26/2022 at 9:50 a.m. with RC X said she worked a double shift from (5/14/2022 at 2:00 p.m. until 5/15/2022 at 6:00 a.m.) RC X said she clocked in at 2:35 p.m. and clocked out at 5:45 a.m. RC X said she worked with Resident #87 on the day shift and was assigned to him. RC X said Resident #87 had no problems during her day or night shift and provided normal care for him like incontinent changes and meal services. RC X said between 7:30 p.m. and 8:00 p.m. on 5/14/2022 she said Resident #10 said Resident #87 had fallen and he picked him up from the floor. RC X said Resident #10 was a strong able body man and would be able to pick up Resident #87. RC X said she told RN A that Resident #87 fell. RC X said RN A went to check on Resident #87 but RC X did not stay to see what RN A did. RC X said later in the evening she was asked to work a double shift around 9:30 p.m. and RN A asked her if the incident should be written up. RC X said she did not answer RN A. RC X said RN A should know the fall protocol. RC X said RN A should have assessed the resident physically, started neuro checks, monitored the resident for change in condition, documented on the neuro checks form and in PCC and advised the next nurse of the neuro checks that needed to continue. RC X said Resident #87 slept throughout the night and she last remembered checking in on him around 2:45 a.m. where he was asleep in bed. RC X said she did not inform the nurse on the next shift (RN C) of Resident #87's unwitnessed fall because that was RN A's job. RC X said she was to inform a nurse if a resident had a fall. <BR/>Resident #10<BR/>Record review of Resident #10's face sheet dated revealed at [AGE] year-old male admitted on [DATE] with the following diagnoses: hypertensions (elevated blood pressure), paranoid schizophrenia (delusions and hallucinations), anemia (deficiency of healthy red blood cells in blood), muscle weakness. <BR/>Record review of Resident #10's Quarterly MDS dated [DATE] revealed he had a BIMS of 8 which indicated he was moderately cognitively impaired. Further review of Section C1310 revealed Resident #10 had no evidence of acute change in mental status, no evidence of difficulty focusing, no evidence of disorganized thoughts. <BR/>Interview on 5/26/2022 at 10:34 a.m. with Resident #10 who said he heard Resident #87 hollering and yelling (not able to give a specific day and time). Resident #10 said it was a little over a week ago when he helped Resident #87 from the floor back into his bed. Resident #10 said when he heard Resident #87 yelling for help, he went towards Resident #87's room. Resident #10 said he was sitting in the common area of the hall 400 which is halfway down the hall. Resident #10 said his room was a few doors from Resident #87. Resident #10 said when he arrived at the room, Resident #87 was somewhat on his knees with his head under the bed and his wheelchair on the back of his legs. Resident #10 said he moved the wheelchair and attempted to pick up Resident #87 from the front with his arms under Resident 87's armpits. Resident #10 said he became weak and let Resident #87 back down and then picked him up from behind (described like the position a person would be in if giving the Heimlich maneuver). Resident #10 said he then laid him face down on the bed. Resident #10 said Resident #87's left arm was stuck under him and he helped him to free it. Resident #10 said he told NA J that he helped Resident #87 from the floor and later NA J came to his room and told him not to help a resident up from a fall and tell a staff. <BR/>Interview on 5/26/2022 at 11:49 a.m. RN A said she should have called the physician and made notification immediately to the RP, DON and the oncoming nurse but since she saw Resident #87 in the bed, and he denied he fell she did not go further with the fall management protocol. <BR/>Interview on 5/27/2022 at 10:45 a.m. the District Director of Clinical Services said she started on 5/10/2022 with the facility. She said she had not been able to facilitate trainings or in-services yet. She said her expectation after an unwitnessed fall was for a nurse to start the fall management protocol. She said the fall management protocol included the physical assessment for injuries, timely neuro check follow-ups, incident report, SBAR, skin assessment, and pain assessment by the nurse. She said if the neuro checks are not completed then a change in condition for the resident could be missed and result in a resident's decline and place the resident at risk for further decline or injury. She said even if the resident appears alert and oriented during the initial assessment, but it was said there could have been a fall then she expected it to be treated like a fall. She said the DON reviews the 24-hour report daily and falls are discussed in daily morning meetings. She said the DON is responsible for the training of staff on the fall management protocol. She said they use skill checks to ensure staff are following protocol. She said RN A had worked for approximately 2 months and her orientation and skills had been checked off for fall management. <BR/>Record review of Resident #87's hospital records dated 5/15/2022 revealed the following:<BR/> brought in from nursing home today. Patient found to be hypothermic (lower body temperature than normal body temperature) at 88 degrees Fahrenheit .vomiting in the ER .Patient had total body CT scan for trauma evaluation which revealed findings concerning for bowel contusion (bruising), left lateral chest wall and pulmonary contusion (bruising), and soft tissue contusions (bruising) left lateral hip and buttock.<BR/>Neurological - Awake, tired appearing very weak<BR/>Notes: <BR/> .found down on floor at a skilled nursing facility, suspected traumatic fall, presenting with multiple contusions visible on the left chest wall with severe abdominal guardian/discomfort on palpation (by touch).<BR/>Record review of witness statement from NA J dated 5/16/2022 revealed the following in part:<BR/>NA J said Resident #10 told him that he picked up Resident #87. NA J said he went to check on Resident #87. NA J said [Resident #10] was in the bed and didn't notice any changes. NA J said he did not report the fall to a nurse. <BR/>Record review of witness statement from LVN P dated 5/16/2022 revealed the following in part:<BR/>LVN P said on the off going nurse (RN A) told him about a fall for a resident but it was not Resident #87.<BR/>Record review of witness statement from RC R dated 5/16/2022 revealed the following in part:<BR/>RC R said she went into Resident #87's room on 5/15/2022 to provide incontinent care at the beginning of her 6:00 a.m. - 2:00 p.m. She said she noticed a bruise on his back and then she notified RN C.<BR/>Record review of witness statement from the DON dated 5/16/2022 revealed the following in part:<BR/>The DON said Resident #10 stopped her in the hallway. The DON said Resident #10 described Resident #87 physical and ethnic characteristics and said he put him back in the bed. The DON said Resident #10 said I heard a yell and got up to go check. Resident #10 said Resident #87 was on the floor with his right knee between the wheelchair and the bed . Resident #10 said he tried to untangle Resident #87's leg .Resident #87 said he snatched him up from the front Resident #10 said he got weak and then snatched him (Resident #87) up from the back and got him (Resident 87) back in the bed. Resident #10 said he told the boy with the gold hair and earring (later identified as NA J) that he picked up Resident #87. Resident #10 described RN A to the DON as a nurse having her skin color. <BR/>Interview on 6/25/21 at 4:40 p.m. with the Administrator, he said RN A should have assessed Resident #1 immediately after she though there was an unwitnessed fall, notified the physician, DON and the resident's responsible party. The Administrator said RN A should have documented the incident on an incident report and in the nurse's notes. The Administrator said RN A should have updated the next shift at shift change to ensure the resident was monitored. The Administrator said it was important to notify the physician after a fall for further care instruction the physician could have had. The Administrator said after an unwitnessed fall neuro checks were required to ensure there was not a change in condition. The Administrator said the protocol and policy was to call the DR, NP RP and to start the neuro checks, document in notes and incident reports. The Administrator said RN A did not tell us, and I was not aware of Resident #1's fall until 6/22/21. The Administrator said the DON is responsible for <BR/>Record review of Resident #87's Skin- Head to Toe Checks dated 5/16/2022 at 8:00 a.m. by RN C revealed the following in part:<BR/>Skin Integrity: <BR/>New Bruises<BR/>Site: <BR/>Chest, right gluteal fold<BR/>Record review of Resident #87's SBAR dated 5/15/2022 at 7:42 a.m. by RN C revealed the following in part:<BR/>Mental Status Changes - Increased confusion, decreased consciousness<BR/>GI/abdomen - Vomiting<BR/>Assessment: Suspected of fall with possible head injury due new bruising to left torso and back of right thigh. Decline in cognitive baseline, temp 95.3<BR/>Record review of facility policy Fall Management (revised on 7/2017) revealed the following in part:<BR/>Policy<BR/>The facility will assist each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision .<BR/>Falls defined:<BR/> .regarding falls state that a fall is defined as unintentionally coming to rest on the ground, floor or other lower level .<BR/>Clarification:<BR/>The presence or absence of a resultant injury is not a factor in the definition of a fall. A fall without injury is still a fall.<BR/>When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there .<BR/>Record review of facility flow chart Fall Management System (copyright 2017) revealed the following in part:<BR/>Resident Fall:<BR/>Complete Documentation:<BR/>Event reporting/Risk Console<BR/>Start IDT post fall review<BR/>SBAR communication form<BR/>24-hour report<BR/>Neuro checks .<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure that residents were free from accidents for 1 of 6 residents (Resident #76) reviewed for accident, hazards, and supervision. <BR/>The facility failed to ensure the emergency exit and patio exit in the secured unit were adequately secured which resulted in a resident elopement on 7/2/2023.<BR/>This failure could place residents at risk of injuries, hospitalization, pain and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #76's face sheet, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills), Severe Vascular Dementia (progressive loss of intellectual functioning with memory impairment), Bipolar Disorder (a mental illness that causes unusual shifts in mood, ranging from extreme highs to lows, and Cognitive Communication Deficit (difficulty with thinking and using language).<BR/>Record review of Resident #76's MDS assessment, dated 07/12/23, reflected a BIMS of 6 in Section C0500, indicating resident #76 had severe cognitive impairment. This means that the resident's ability to recall information, make decisions, and concentrate were impaired. <BR/>Record review of Resident #76's care plan dated 7/25/2023, reflected resident as elopement risk /wanderer related to impaired safety awareness (5/2/22). Listed interventions included: Orienting resident to her environment; Providing structured activities: toileting walking inside and outside, reorientation strategies including signs, pictures, and memory boxes; Reorient, validate, and redirect resident as needed.<BR/>Observation on 7/25/2023 at 9:50am revealed fire alarm being tested. When alarm sounded, CNA Y went to stand by the emergency exit door. When alarm stopped, CNA Y checked to ensure the emergency door was locked. The emergency exit was the only one observed to be checked by CNA Y at theis time.<BR/>During an interview with CNA Y on 7/25/2023 at 9:50am, she stated she has been working at the facility for one week. She denied having been trained on fire drill protocol at this current facility but knew from past experience elsewhere that during a drill, she should stand by an exit and then count residents. CNA Y did not know that in addition to monitoring the exits, secured unit staff was also responsible for securing the gates in the patio area. She said that failure to check the exits could result in a resident getting out of the facility. <BR/>During an interview with CNA QQ (former employee) on 7/28/2023 at 11:03am, she stated she was working the secured unit with LVN G on 7/2/2023 when Resident #76 pulled the fire alarm and eloped from the facility. She said that when the alarm went off, she was in another resident's room performing personal care. She said she stopped what she was doing and looked out of the door to see Resident #76 standing at the fire alarm near the locked, glass doors leading to the facility. CNA QQ said that she walked towards the resident who was being escorted by the unit manager. She said she directed the resident to the commons area where she started to do a headcount on residents. CNA QQ said that there were no procedures (to her knowledge) to address the patio exit and gates in the patio area. She said while doing the headcount, she realized Resident #76 was missing and notified the nurse and management. She said the staff went looking for the resident and found her when they went outside. CNA QQ said that a man told her that he saw a woman walking with one shoe and knocking door-to-door at the apartment complex right next to the facility. CNA QQ notified the other staff members outside looking and went next door and found Resident #76 sitting. She said that the resident was given water and assessed. <BR/>During an interview with LVN O (Secured Unit Nurse Manager) on 7/28/2023 at 11:40am, she stated that she was at the nurses station when she heard the fire alarm go off on 7/2/23. She said there was a fire alarm panel at the nurses station that alerts you as to where the fire alarm triggered. She said that saw the alarm was triggered on the 600 hall (secured unit) and looked up to see Resident #76 at the fire alarm. She said that she walked over to the unit and lead the resident away from the alarm and that CAN QQ and LVN G met her to get Resident #76 and took her back to the dining area. LVN O said she then left the unit to reset the alarm and notify the fire department that the alarm was false. LVN O did not say how long it took to reset the alarm. She said she then went back to 100 and 200 halls to check on those residents and to check the exits on those halls to ensure they were secured. LVN O was alerted by LVN G that Resident #76 was missing. She stated that nursing staff began to go room-to-room inside the facility to see if resident had wandered to an area outside of the secured unit. She said that when they could not find Resident #76 inside the facility, they expanded their search outside. LVN O said that she went out both exit doors of the secured unit to check because all the doors unlock when a fire alarm goes off until the panel was reset. She said when she walked out of the patio doors, she noticed 1 of the 2 gates outside was open. She and CNA QQ continued their search outside the gates while another staff member drove a car. CNA QQ yelled that she found Resident #76 at the apartment complex.<BR/>During an interview with LVN G on 7/28/2023 at 11:50am, she stated that Resident #76 pulled the fire alarm. She said prior to that, residents were roaming up and down the halls as they usually do. At the time when the alarm went off, she said she was in a room feeding a resident. She said that she and CNA QQ got everybody away from the doors in TV room to secure area, but she had to go back to the resident's room whom she was feeding to ensure her bed was in a safe position because she'd left abruptly. She was alerted by CNA QQ that a resident was missing. She then went to the unit doors and out to floor to alert LVN O. She said when they went outside to look for resident, one gate was closed and locked but the other gate was open. <BR/>During an interview with MS on 7/28/2023 at 12:30pm, he stated that the staff assigned to a given unit was responsible for checking the doors and securing exits for their unit after the fire alarm has been reset. All doors and gates lock when the alarm has been reset, but it is possible for an outside gate to remain open because it does not have automatic closing feature. He said when the gate lock is disengaged, the gate can be blown open by wind or pulled open. He said that every morning, maintenance makes rounds outside to pick up trash and ensure the grounds are clean. He said during the morning rounds, the outside gates are checked to make sure the facility is secure. He repeated, when the fire alarm goes off, staff assigned to the unit should secure their unit. MS said that he is responsible for training new staff and walks them through the building to show them. He stated that he does not train temporary staff and the regular staff should relay the information of how to respond to fire alarms, to temporary staff<BR/>During an interview with LVN R on 7/28/2023 at 12:45pm, she stated that during a fire drill or alarm, staff are expected to check the doors and count the residents. LVN R said she did not know to check the gates or why it is necessary.<BR/>During an interview with CNA FF on 7/28/2023 at 12:50pm, she stated that during a fire drill or alarm, staff should check the doors and count the residents. She said that she has worked for the facility for three days and has not had a walkthrough training with MS yet. She said that she did not know to check the gates and why it was necessary.<BR/>During an interview with the ADM on 7/28/2023 at 1:15pm, she said she was aware Resident #76 pulled the fire alarm and staff responded to that. She said while in the process of resetting the alarm, Resident #76 was seen sitting in the area across from the dining room in the secured unit but then went out of the patio door. When staff noticed Resident #76 missing, LVN O and administration were notified. They searched for the resident inside then expanded search outside and took bottled water because it was especially hot outside.<BR/>The ADM said the response to fire alarm should have been for the secured unit staff to go to the doors or keep them (residents) in their line of sight and count the residents to make sure all were present. She said that the secured unit staff were trying to count the residents, but it is difficult because many of them wander around and won't be still. She said that Resident #76 slipped away while they were counting. Doors should be manned or visually watched. She said there are 3 doors total from which a resident could leave the secured unit, 1 lead to the main facility and 2 lead outside. 1 door leads to the patio area which is enclosed by a fence and 2 gates. ADM says that she was not aware that the gates do not automatically shut and relock. She said failure to secure facility or gates could result in residents getting lost or being exposed to the elements.<BR/>During an interview with LVN I on 7/28/2023 at 1:30pm, she stated that when the fire alarm goes off, secured unit staff should check the doors and the gates to make sure residents stay in. She said that she was educated by MS as part of her orientation when she was hired 3 months ago.<BR/>During an interview with CNA EE on 7/28/2023 at 1:35pm, she stated when the fire alarm goes off, secured unit staff should count the residents while watching the doors. When it's over, check the doors and gates because the gates can swing open. She said that she received this training in response to Resident #76 getting out of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #1) reviewed for infection control. <BR/>1. RT A failed to wash her hands or use hand sanitizer between gloves changes while providing Tracheostomy (Trach) care for Resident #1.<BR/>2. RT A failed to ensure she did not double glove in placed of hand hygiene while providing Tracheostomy Care. <BR/>These failures could place residents at risk for spread of infection. <BR/>Findings include:<BR/>Record review Resident #1's face sheet, dated 03/05/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute respiratory failure with hypoxia (a condition where the lungs are unable to exchange oxygen and carbon dioxide properly, resulting in low oxygen levels in the blood), dependence of respirator (ventilator) status, hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high), diabetes (a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively, leading to high blood sugar levels), Chronic Obstructive Pulmonary Disease (a condition caused by damage to the airways or other parts of the lung), and Tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). <BR/>Record review of Resident #1's care plan, dated 12/31/24, reflected a focus area that Resident #1 had a tracheostomy and was at risk for changes in secretions, infection, and respiratory distress.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 01/04/25, reflected a BIMS score of 15, which indicated cognition was cognitively intact. Section O- Respiratory Treatment- E1. Tracheostomy Care.<BR/>During an observation on 03/05/25 at 10:59 AM revealed Trach Care was provided by RT A. RT A entered Resident #1's room and placed Trach supplies on the bedside table. RT A donned mask, gown, and gloves. RT A was observed donning another pair of gloves on top of the initial pair of gloves she already had on (RT A had 2 pair of gloves on). After suctioning Resident #1, RT A was observed removing the 2nd layer of gloves, and disposed of them. RT A was then observed opening a Trach care kit and putting sterile gloves on top of the initial pair of gloves she already had on. RT A was observed cleaning Resident #1's Trach site and doffing off after Trach care was completed and using hand sanitizer. Hand washing/ Hand sanitizer was not observed in between glove changes Trach Care. Resident #1's O2 Stat was monitored throughout Trach care and RT A engaged with Resident #1 throughout Trach care ensuring the resident was not in distress. <BR/>During an interview on 03/05/25 at 11:30 AM with RT A, she stated she was not seen sanitizing her hands while in Resident #1's room because she had just sanitized them before leaving the nurses station prior to entering the room. She stated they were supposed to sanitize their hands before and after suctioning the resident. She stated she did not sanitize her hand because she worked with a clean pair of gloves at all times and that was her purpose of having 2 pair of gloves on at all times. <BR/>During an interview on 3/05/25 at 12:57 PM, the DON stated hands should be washed or use of hand sanitizer used in between glove changes. She stated when trach care was being provided the staff were to sanitize or wash before care and to also let the patient know what was being done. She stated the staff were to use the Trach care kit with the sterile gloves. She stated staff were expected to sanitize or wash hands prior to beginning care, dispose of gloves, perform hand hygiene before putting on sterile gloves, dispose of gloves again and perform hand hygiene again. She stated she was unsure of why RT A used multiple pairs of gloves while providing care and stated it would have been appropriate for RT A to wash her hands or use hand sanitizer in between glove changes. She stated the risk of not performing hand hygiene was infection. <BR/>Record review of the facility's policy on Tracheostomy Care, revised date of 11/2022, reflected,<BR/>It is the policy of this facility that Tracheostomy care is performed aseptically for cleaning of the tracheostomy tube and stoma site, to prevent plugging of the tracheostomy tube, to prevent airway obstruction, to prevent infection of trach site, and to maintain a patent airway for suctioning .<BR/>Procedures: <BR/>1. <BR/>Review Orders for tracheostomy care (should contain the frequency & type of care) <BR/>2. <BR/>Gather necessary equipment<BR/>3. <BR/>Identify the resident, introduce self, and explain procedure to the resident.<BR/>4. <BR/>Wash hands prior to setting up equipment. <BR/>5. <BR/>Suction resident.<BR/>6. <BR/>Remove drain sponge and disposable inner cannula.<BR/>7. <BR/>Perform hand hygiene with soap and water.<BR/>8. <BR/>Prepare new inner cannula by opening slightly<BR/>9. <BR/>Open normal saline bottle and set aside<BR/>10. <BR/>Open trach care kit<BR/>11. <BR/>Aseptically DON sterile gloves<BR/>12. <BR/>Aseptically place drape on surface and dump contents of kit<BR/>13. <BR/>Place tray on the drape<BR/>14. <BR/>Pour normal saline into tray (may use wound cleanser as indicated)<BR/>15. <BR/>Place sponges / gauze into saline in the tray<BR/>16. <BR/>With a non-dominant hand, pick up new inner cannula and with the dominant hand, replace inner cannula. (Or follow instructions below for non-disposable inner cannula)<BR/>17. <BR/>Cleanse stoma with gauze / applicators<BR/>18. <BR/>Cleanse trach phalange with sponges<BR/>19. <BR/>Replace drain sponge<BR/>20. <BR/>Change tie if soiled<BR/>21. <BR/>NOTE: Monitor 02 saturation throughout procedure<BR/>22. <BR/>Monitor the patient's response to the procedure. If any adverse reaction is noted, discontinue the procedure, and notify physician.

Based on interviews and record review the facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 10 staff (Activities Director, and the Dietary Manager) reviewed for developing and implementing abuse and neglect policies.<BR/>- <BR/>The facility failed to ensure employee EMR checks were completed at least <BR/>once every 12 months for the Activities Director and the Dietary Manager. <BR/>These failures could place residents at risk of abuse, neglect, and misappropriation of property. <BR/>The findings included:<BR/>Record review of the facility's policy and procedure on Abuse, Neglect, and Exploitation (ANE) Prohibition (Revised: 4/2024) read in part: .This policy includes 7 key components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response. The Administrator or appointed designee serves as the ANE Prohibition Coordinator, overseeing the policy and investigations .The Facility screens potential employees for a history of abuse, neglect, or mistreatment of residents through licensure verifications and misconduct registry as required by applicable state or federal regulation. The Facility will conduct criminal history checks on applicants who will be offered a position pursuant to applicable state and federal regulations. The facility will review the criminal history reports pursuant to applicable state and federal regulations to determine whether employment is permitted. The Facility will ensure that prospective temporary/agency staff are screened through their employer pursuant to applicable state and federal regulations. The Facility will assess whether an employee's suitability to work aligns with the Facility's standards pursuant to applicable state and federal regulations, particularly in instances where disciplinary action is considered against an employee's professional license/certification due to substantiated cases of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property .<BR/>Record review of the Activities Director's personnel file revealed she was hired on 10/1/22. Her EMR was checked on 10/21/22. The next time her EMR was checked was on 8/8/24, which was 22 months later.<BR/>Record review of the Dietary Manager's personnel file revealed she was hired on 10/1/22. Her EMR was checked on 10/19/22. The next time her EMR was checked was on 8/8/24, which was 22 months later.<BR/>In an interview with the Human Resources Director on 9/26/24 at 11:30am, he said he started at the facility In August of 2023. He said he completed EMR checks on an annual basis and upon hire, and they were done through a third party. He said he determined when staff were eligible for EMR checks by keeping a complete facility roster, which showed who was due for their annual check, according to their hire date. The HR Director said he ensured all EMR's were completed timely by scanning the system every pay period. He stated he was unsure of when the Activities Director, and Dietary Manager's checks were last completed, but he did an audit when he was hired. He said his audit would have informed him of who was coming due and not who would have been overdue. He was not aware of any errors or anything overdue. He said if a background check was not completed, they would not know if the person had anything bad on their record. The HR Director said when he was hired, he was unsure of when background checks were to be performed and he asked for clarity, but no one really knew how often they were supposed to be done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #1) reviewed for infection control. <BR/>1. RT A failed to wash her hands or use hand sanitizer between gloves changes while providing Tracheostomy (Trach) care for Resident #1.<BR/>2. RT A failed to ensure she did not double glove in placed of hand hygiene while providing Tracheostomy Care. <BR/>These failures could place residents at risk for spread of infection. <BR/>Findings include:<BR/>Record review Resident #1's face sheet, dated 03/05/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute respiratory failure with hypoxia (a condition where the lungs are unable to exchange oxygen and carbon dioxide properly, resulting in low oxygen levels in the blood), dependence of respirator (ventilator) status, hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high), diabetes (a chronic condition where the body either doesn't produce enough insulin or doesn't use insulin effectively, leading to high blood sugar levels), Chronic Obstructive Pulmonary Disease (a condition caused by damage to the airways or other parts of the lung), and Tracheostomy status (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). <BR/>Record review of Resident #1's care plan, dated 12/31/24, reflected a focus area that Resident #1 had a tracheostomy and was at risk for changes in secretions, infection, and respiratory distress.<BR/>Record review of Resident 1's quarterly MDS assessment, dated 01/04/25, reflected a BIMS score of 15, which indicated cognition was cognitively intact. Section O- Respiratory Treatment- E1. Tracheostomy Care.<BR/>During an observation on 03/05/25 at 10:59 AM revealed Trach Care was provided by RT A. RT A entered Resident #1's room and placed Trach supplies on the bedside table. RT A donned mask, gown, and gloves. RT A was observed donning another pair of gloves on top of the initial pair of gloves she already had on (RT A had 2 pair of gloves on). After suctioning Resident #1, RT A was observed removing the 2nd layer of gloves, and disposed of them. RT A was then observed opening a Trach care kit and putting sterile gloves on top of the initial pair of gloves she already had on. RT A was observed cleaning Resident #1's Trach site and doffing off after Trach care was completed and using hand sanitizer. Hand washing/ Hand sanitizer was not observed in between glove changes Trach Care. Resident #1's O2 Stat was monitored throughout Trach care and RT A engaged with Resident #1 throughout Trach care ensuring the resident was not in distress. <BR/>During an interview on 03/05/25 at 11:30 AM with RT A, she stated she was not seen sanitizing her hands while in Resident #1's room because she had just sanitized them before leaving the nurses station prior to entering the room. She stated they were supposed to sanitize their hands before and after suctioning the resident. She stated she did not sanitize her hand because she worked with a clean pair of gloves at all times and that was her purpose of having 2 pair of gloves on at all times. <BR/>During an interview on 3/05/25 at 12:57 PM, the DON stated hands should be washed or use of hand sanitizer used in between glove changes. She stated when trach care was being provided the staff were to sanitize or wash before care and to also let the patient know what was being done. She stated the staff were to use the Trach care kit with the sterile gloves. She stated staff were expected to sanitize or wash hands prior to beginning care, dispose of gloves, perform hand hygiene before putting on sterile gloves, dispose of gloves again and perform hand hygiene again. She stated she was unsure of why RT A used multiple pairs of gloves while providing care and stated it would have been appropriate for RT A to wash her hands or use hand sanitizer in between glove changes. She stated the risk of not performing hand hygiene was infection. <BR/>Record review of the facility's policy on Tracheostomy Care, revised date of 11/2022, reflected,<BR/>It is the policy of this facility that Tracheostomy care is performed aseptically for cleaning of the tracheostomy tube and stoma site, to prevent plugging of the tracheostomy tube, to prevent airway obstruction, to prevent infection of trach site, and to maintain a patent airway for suctioning .<BR/>Procedures: <BR/>1. <BR/>Review Orders for tracheostomy care (should contain the frequency & type of care) <BR/>2. <BR/>Gather necessary equipment<BR/>3. <BR/>Identify the resident, introduce self, and explain procedure to the resident.<BR/>4. <BR/>Wash hands prior to setting up equipment. <BR/>5. <BR/>Suction resident.<BR/>6. <BR/>Remove drain sponge and disposable inner cannula.<BR/>7. <BR/>Perform hand hygiene with soap and water.<BR/>8. <BR/>Prepare new inner cannula by opening slightly<BR/>9. <BR/>Open normal saline bottle and set aside<BR/>10. <BR/>Open trach care kit<BR/>11. <BR/>Aseptically DON sterile gloves<BR/>12. <BR/>Aseptically place drape on surface and dump contents of kit<BR/>13. <BR/>Place tray on the drape<BR/>14. <BR/>Pour normal saline into tray (may use wound cleanser as indicated)<BR/>15. <BR/>Place sponges / gauze into saline in the tray<BR/>16. <BR/>With a non-dominant hand, pick up new inner cannula and with the dominant hand, replace inner cannula. (Or follow instructions below for non-disposable inner cannula)<BR/>17. <BR/>Cleanse stoma with gauze / applicators<BR/>18. <BR/>Cleanse trach phalange with sponges<BR/>19. <BR/>Replace drain sponge<BR/>20. <BR/>Change tie if soiled<BR/>21. <BR/>NOTE: Monitor 02 saturation throughout procedure<BR/>22. <BR/>Monitor the patient's response to the procedure. If any adverse reaction is noted, discontinue the procedure, and notify physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 of 77 residents (CR #1) reviewed for CPR. <BR/>1. <BR/>RN A failed to call a code blue and obtain assistance from available staff when CR #1 was found unresponsive. This led to a delay of approximately 1-2 minutes before CPR was started on CR #1.<BR/>2. <BR/>RN A initiated CPR with improper chest compressions and depth during CPR on CR #1 on [DATE].<BR/>3. <BR/>LVN A failed to place the mask over the resident's nose and mouth, ensuring a good seal.<BR/>4. <BR/>Staff failed to ensure the crash cart had AED pads and was ready for use during CPR on CR #1. This led to a delay of approximately 1-2 minutes before CPR was started on CR #1.<BR/>An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 9:45 a.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level of actual harm that was not immediate jeopardy because all staff had not been trained on [DATE]. <BR/>These failures placed residents at risk of experiencing worsening of condition, extended pain, and death from possible delays in the initiation of an emergency response and improper implementation of CPR. <BR/>Findings included:<BR/>Record review of CR #1's face sheet dated [DATE] revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. CR #1's diagnoses included respiratory failure, Crohn's disease (swelling and irritation of the tissues in the digestive tract), Asperger's syndrome (neurodevelopment disability that affects the ability to effectively interact and communicate with people), cirrhosis of the liver (liver damage from conditions such as hepatitis B or C, or chronic alcohol use), gastroesophageal reflux (condition in which stomach acid moves up into the esophagus, causing heartburn), pneumonia, and malnutrition. She was discharged to a medical examiner after she died on [DATE]. <BR/>Record review of CR #1's 5-day MDS dated [DATE] revealed she had a BIMS score of 00 (severe cognitive impairment); CR #1 ambulated via wheelchair; and CR #1 was dependent for ADL's (eating, toileting, shower, oral hygiene, and dressing). <BR/>Record review of CR #1's care plan meeting, dated [DATE] revealed the following in part:<BR/> .[ CR#1] will remain full code. [CR #1] does not have a POA .<BR/>Record review of progress notes dated [DATE] at 10:50 a.m. by MA A revealed the following:<BR/>cant [can't] swallow notified nurse [RN A]<BR/>Record review of progress notes dated [DATE] at 12:34 p.m. by RN A revealed the following in part:<BR/> .Change of Condition Identified: leukocytosis (above the normal range of white blood cells) . [PCP] present and visited resident [CR #1] . <BR/>What do you think is going on with the resident: Resident lab results show WBC 22.1. [PCP] present and visited resident. New orders received as follows:<BR/>1) CXR 1-V & UA w/ C&S<BR/>2) Ceftriazone (antibiotic that is used to treat many kinds of bacterial infections, including severe or life-threatening )1gm IV QD x7 days<BR/>3) May place midline for ABX therapy<BR/>4) Levothyroxine (used to treat hypothyroidism - underactive thyroid) 50mg PO QD<BR/> (RP ) notified of new orders and gave verbal consent for midline placement.<BR/>Physician Notified: [PCP], [DATE] 12:00 PM<BR/>Record review of CR #1's progress notes dated [DATE] by RN A revealed the follow in part:<BR/>[CR #1] was observed unresponsive sitting in wheelchair. [CR #1] was confirmed full code, transferred to bed, and CPR was called. 911 was called @1321 [1:21 p.m.] which EMS arrived to room shortly after. EMS continued life saving measures. [Family member] was notified of resident's condition [CR #1] was pronounced deceased @1351 [1:51 p.m.] per EMS personnel. Resident was last seen alive between 12-12:30 [12:00 p.m. - 12:30 p.m.] during lunchtime sitting in wheelchair .<BR/>Record review of CR #1's EMS Report dated [DATE] revealed: . Primary Impression: Cardiac - Cardiac Arrest . Call Received - 1:22 p.m. Dispatched - 1:23 p.m. On Scene - 1:24 p.m. At Patient - 1:42 p.m. Narrative: History - Nursing home staff stated they walked into the patient's room and found her unresponsive. The last time they saw . Assessment - On arrival, The pt was in bed in her room and nursing staff was doing very poor, slow CPR, and ventilating the pt on high flow oxygen via BVM . She was not conscious, not breathing, and without a pulse. There were no signs of rigor mortis. Her alive was one hour prior. The nursing home nurse states she has not been sick and does not know what could have caused it . Her airway appeared clear. Eyes appeared fixed, dilated, and non-reactive. Breath sounds: absent bi laterally. ABD: soft/nondistended. Skin: cool/dry. Rx/Treatment - Nursing home staff started CPR prior to arrival. 303 [EMS] arrived prior to 409 [FD ] and started ALS resuscitation. Upon contact, the nursing staff was doing low quality compressions and was corrected on proper rate and depth . After 20 minutes of high quality ALS resuscitation the family and POA called back and stated they wanted resuscitation terminated. Transport - The patient was not transported as resuscitation was terminated at 13:51 pm. Call complete. In service.<BR/>Record review of RN A's cell phone call history dated [DATE] revealed 911 was called at 1:21 p.m. <BR/>Record review of crash cart check list dated [DATE]st -18th 2024 revealed AED - function and ready. <BR/>Observation and interview of the facility's crash carts, with the DON and LVN E, on [DATE] at 4:11 p.m. revealed it was located at the front 300 hall, approximately 1-2 yards away from the nurse's station. The AED was in a case on the outside of the crash cart, after unlocking case mild pitch siren and blue light. The code status binder was on the cart. There were no pads located in the AED machine, but pads were in a zipped side pocket of the bag the AED was in. No extra pads were observed in the drawers of the crash cart. A second crash cart on 100 hall was observed and had a pad in the AED machine and extra pad in the bottom drawer of the crash cart. The DON said LVN E was responsible for checking the crash carts daily. The DON said if a resident was found unresponsive, the staff should call out code blue, direct another staff to call 911, and verify code status to start CPR as soon as possible. She said she was not at the facility on [DATE]. She said she would have preferred for the AED to be used because it would instruct the staff what to do if there was no pulse or heartbeat. She said RN A was not able to locate the AED pads. The DON said RN A should have stayed with CR #1. She said he could have directed CNAs and Nurses to call 911, get the crash cart, which she thought he had done. She said this was a part of the delegation process during a code blue. LVN E said she checked the carts daily and remembered seeing AED pads. <BR/>Interview on [DATE] at 9:11 a.m., with RN A said he worked the 6:00 a.m. - 2:00 p.m. on [DATE] when CR #1 expired. He said he was notified by CNA B who came and told him, CR #1 was unresponsive. He said he went to CR #1's room (on 500 hall) and checked her pulse and she did not have one. He said he left the room, went to get the crash cart (on 300 hall adjacent to the 500 hall). He said CNA B was left in the room with CR #1. RN A said on his way back with the crash cart, he looked at CR #1's code status in the binder on the crash cart and called 911. RN A said he left CNA B in the room with CR #1. RN A said when he returned to the room, CNA B assisted and placed CR #1 in the bed from her wheelchair. He said he did not yell out for help or code blue after CR#1's pulse was taken or instruct CNA B to get the crash cart. RN A said he told, CR #1's assigned CNA B, to get help. RN A said he placed the backboard under the resident. He said he attempted to use the AED and could not locate the pads. RN A said he started chest compressions. RN A said RT A and LVN A came in and assisted with the bag valve mask. He said he was not sure of the time when they both came in, but it was within a minute. RN A said he continued chest compressions until EMS arrived. He said he did not recall if EMS or the FD gave him direction on his CPR technique. He said he was CPR certified and was trained by the facility on the Code Blue protocol. He said code blue was called when a resident was unresponsive, without a pulse, and needed CPR . <BR/>Interview on [DATE] at 9:55 a.m. with CNA B said she worked 6:00 a.m. - 2:00 p.m. on [DATE]. She said she had not worked with CR #1 before. She said she saw therapy worked with CR #1 in the morning when they took her for a swallow test at approximately 7:00 a.m. CNA B said she was working on the hall next to CR #1's room, when HK A came to tell her CR #1 was not okay. CNA B went to CR #1's room, saw her sitting in her wheelchair. CNA B said she touched CR #1's leg, and CR #1 did not move. CNA B said CR #1's eyes were open, and her head faced toward the hallway. She said she left immediately and notified RN A. CNA B said RN A went to CR #1's room, checked for CR #1's pulse, and left to get the crash cart. CNA B said she waited with CR #1 until RN A came back with the crash cart. CNA B said she could not remember how much time past, but she said it was approximately a few minutes when RN A returned to the room. She said RN A opened the AED and a siren started. She said, less than a minute RT A and LVN A came in to assist and she left out of the room. She said she did not see if RN A used the AED and did not see CPR performed on CR #1. She said EMS arrived quickly but could not remember how long it took. He said he was CPR certified . He said his CPR trained him to complete 30 chest compression and two breaths. <BR/> In an interview on [DATE] at 12:58 p.m. CNA A said she had not worked with CR #1 prior to [DATE]. She said she recalled CR #1 had a swallow test around 7:00 a.m. on [DATE]. She said therapy assisted CR #1 with her meal. She said she saw CR #1 around 11:45 a.m. and assisted her with her lunch. She said CR #1 did not eat much. CNA A said she brought CR #1's roommate back to the room at approximately 12:30 p.m. CNA A said CR #1 was in her wheelchair looking out into the hallway. She said she saw staff running to CR #1's room and she stood at CR #1's door but left shortly after RN A and CNA A started to assist CR #1. She said EMS arrived approximately 5 minutes after the staff went in to assist CR #1. <BR/>In a telephone interview on [DATE] at 1:47 p.m. PCP A said she saw CR #1 on [DATE] at approximately 10:00 a.m. She said CR #1's vitals were within normal limits. PCP A described CR #1 as chronically ill, lungs were clear, sounds reduced, heart was regular, very pale, and malnourished. She said there were no acute care issues. She said the b/p was on the low side but no interventions were needed. In a further interview, PCP A said when a code blue was called the staff should response as a team. She said the staff who found the unresponsive resident should yell out for help from the other staff by asking them the resident code status, get the crash cart, call 911, and immediately start CPR. She said if one staff completed all of the task, a delay in CPR could happen.<BR/>In a telephone interview on [DATE] at 3:41 p.m. RT A said she was on another hall when she and LVN A were asked by (unknown CNA) to assist with CR #1. She said she could hear the AED siren as she ran down the hall. She said she did not hear anyone yell out code blue. She said she grabbed the O2 tank as she entered CR #1's room, LVN A grabbed the Ambu bag (manual resuscitator). She said LVN A placed the bag over CR #1's mouth without securing a tight seal. She said without a tight seal around the mouth and nose the resident would not get the full benefit of the manual breaths. RT A said she took over bagging CR #1 while RN A continued chest compressions until EMS took over. She said she did not remember if RN A said there were no pads for the AED or if she saw him search for them at some point and could not locate them. She said she saw a pulse oximeter on CR #1's finger but did not remember what the reading was. She said she did not remember if the paramedics educated RN A on the depth of his compressions. She said the facility had provided mock code blue trainings where the staff had to act out the code. She said she was CPR certified . She said a delay in CPR and use of the AED could negatively affect the resident.<BR/>In a telephone interview on [DATE] at 3:48 p.m. LVN A said he rushed down with RT A to assist with CR #1. He was asked how he assisted, and he continued to repeat I did what needed to be done as a team. He later said he initially placed the Ambu bag on CR #1 and then RT A took over. He said RT A connected the bag to the oxygen, he said he did not know why, and he left before EMS arrived, to get the paperwork ready for EMS. He said he was CPR certified . <BR/>In a second telephone interview at [DATE] at 8:59 a.m. PCP A said it should be a team effort when a code blue was called. She said the staff that found an unresponsive resident should have called out for help from several staff to bring the crash cart (which had the code status binder on it), get oxygen, call 911, and begin CPR. He should not have left the resident .<BR/>In a telephone interview on [DATE] at 1:42 p.m. the EMS Supervisor said the verbiage low quality chest compression and depth indicated in the EMS Run sheet indicated the CPR provided for CR #1 did not get the full effect or benefit of the chest compression to aid in life sustaining efforts He said the chest compressions should be 1-2 inches as referenced by the American Heart Association. He said he would have to get permission for this state surveyor to interview the paramedics that responded to CR #1.<BR/>Record review of American Heart Association dated [DATE] (https://cpr.heart.org/en/resources/what-is-cpr) revealed the following in part:<BR/>Automated External Defibrillators (AED)<BR/>AEDs can greatly increase a cardiac arrest victim's chances of survival .<BR/>For healthcare providers and those trained: conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to-breaths. In adult victims of cardiac arrest, it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min and to a depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches . Hands-Only CPR consists of two easy steps:<BR/>Call 9-1-1 (or send someone to do that)<BR/>Push hard and fast in the center of the chest .<BR/>About High-Quality CPR<BR/>High-quality CPR should be performed by anyone - including bystanders. There are five critical components:<BR/>Minimize interruptions in chest compressions,<BR/>Provide compressions of adequate rate and depth .<BR/>Record review of the facility's Policies and Procedures for CPR - Cardiopulmonary Resuscitation policy, revised [DATE] revealed, Policy The Facility will administer CPR per American Heart Association Guidelines and regulatory expectations for residents with a Full Code status, Procedure, <BR/>In the event of a medical emergency<BR/>2. <BR/>Check the resident for responsiveness.<BR/>3. <BR/>Validate the resident's code status.<BR/>a. <BR/>If the resident is a Full Code, proceed with step #4.<BR/>4. <BR/>Activate the Emergency Response System Code Blue and staff call 911.<BR/>5. <BR/>Assess respirations/pulse simultaneously (within 10 seconds).<BR/>a. <BR/>If NO respirations (or only gasping) and NO pulse<BR/>i. <BR/>Start CPR.<BR/>ii. <BR/>Apply AED as soon as available and follow the prompts.<BR/>iii. <BR/>Perform cycles of 30 compressions and 2 breaths via ambu-bag.<BR/>iv. <BR/>Continue until EMS providers take over, the resident regains pulse, or receives a Physician Order to cease rescue efforts. <BR/>6. <BR/>Document .Progress Notes .<BR/>AED Considerations<BR/>The Facility has an AED available for emergency use, is kept in a location easily accessible by staff, and is rescue-ready.<BR/>Crash Cart Considerations<BR/>Ensure the crash cart is ready for immediate use during a code situation .<BR/>Conduct daily checks to ensure all items are present and in working order and document these checks on a log attached to the cart and regularly check .<BR/>Ambu Bag Considerations<BR/>Place the mask over the resident's nose and mouth, ensuring a good seal.<BR/>Hold the mask with your thumb and index finger forming a C around the mask, while the other three fingers lift the jaw.<BR/>An IJ was identified on [DATE]. The IJ template was provided to the Administrator and the DON on [DATE] at 10:10 a.m. <BR/>The following Plan of Removal submitted by the facility was accepted on [DATE] at 6:57 p.m.:<BR/>Allegation: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice.<BR/>F678 CPR<BR/>IJ Plan of Removal for F678<BR/>[DATE]<BR/>According to the IJ Template: The facility failed to ensure that a resident received CPR in accordance with professional standards of practice.<BR/>The Administrator and DON notified the Medical Director of the IJ on [DATE] and held an ADHOC QAPI meeting to review the IJ template and POR .<BR/>On [DATE], the Director of Nursing conducted a 1:1 education with RN A. Topic: CPR Policies and Procedures highlighting: assessing the resident, calling for assistance code blue which activates the staff to assist and expedites the 911 response, validating the code status by a quick glance of the Code Status Binder, and initiating CPR with effective chest compressions (compression rate of 100-120 and a depth of 2 inches, Ambu-bag use (providing a seal), and applying the AED for residents with a Full Code status. <BR/>The DON initiated education on [DATE] with Nurses, and Respiratory Therapist on the CPR Policies and Procedures highlighting: assessing the resident, calling for assistance code blue which activates the staff to assist and expedites the 911 response, validating the code status by a quick glance of the Code Status Binder, and initiating CPR with effective chest compressions (compression rate of 100-120 and a depth of 2 inches, Ambu-bag use (providing a seal), and applying the AED for residents with a Full Code status. All Nurses and Respiratory Therapists will not be allowed to work their assigned shift until training is completed. Staff will verbalize understanding at of end of training session and further training will be provided as needed. Education will be provided in orientation for new hires. Completion date of [DATE].<BR/>The DON initiated education on [DATE] with CNA role and code blue situation. CNA will immediately report unresponsive residents to the charge nurse, can assist in announcing code blue and can respond with crash cart and AED to the CODE Blue site. CNA will not be allowed to worked their assigned shift until training is completed. Education will be provided in orientation for new hires. Completion date of [DATE].<BR/>The Regional RT and Clinical Team conducted a Mock Code on [DATE] with return demonstration with all staff on site during the 2nd shift. The RT and Clinical Team will conduct a Mock Code with return demonstration for the next 3 shifts with return demonstration to ensure understanding. The Regional RT and Clinical Team will conduct routine Mock Codes to ensure education compliance. Findings will be brought to QAPI and the facilities plan to maintain compliance will be updated as indicated.<BR/>The facility will maintain compliance with professional standards by treating residents who are Full Code and unresponsive (no pulse) by: assessing the resident, calling for assistance code blue which activates the staff to assist and expedites the 911 response, validating the code status by a quick glance of the Code Status Binder, and initiating CPR with effective chest compressions (compression rate of 100-120 and a depth of 2 inches, Ambu-bag use (providing a seal), and applying the AED. The Facility will update the code status binder with OOH DNRs as DNRs are implemented. Residents without OOH DNR forms will be considered Full Code. The facility inspects and replenish crash cart daily and after code events by DON/designee to ensure crash cart is rescue ready.<BR/>The Administrator reviewed the facility policy on [DATE] and no changes were required. <BR/>The plan of completion is [DATE].<BR/>Monitoring of the plan of removal included the following:<BR/>Record review of Education In-Service Attendance Record dated [DATE] - [DATE] revealed all nurses, CNAs (including RN A, LVN A) were provided education by LVN B - unit manager regarding nurses are responsible to ensure crash carts are restocked after code and CPR protocol. <BR/>Record review of Education In-Service Attendance Record - Mock Code dated [DATE] -[DATE] (2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m., and 6:00 a.m. - 2:00 p.m.) revealed all staff (nurses, CNAs, therapy staff, hk, were provided demonstration and return demonstration education by the Resp. Therapy Manager regarding Resident found unresponsive - What are our duties? (attachment: Policies and Procedures for CPR - Cardiopulmonary Resuscitation policy, revised [DATE])<BR/>Mock Code<BR/>o <BR/>Initiator: discovered resident, check vitals, called for help, started chest compressions.<BR/>o <BR/>Announcer: was code announced overhead<BR/>o <BR/>Leader: was control taken and directives given <BR/>o <BR/>Recorder: was documentation initiated<BR/>o <BR/>PPW (paperwork): was direction given to start paperwork for transfer? (copy of face sheet, etc.)<BR/>o <BR/>AED: was the AED initiated when bought [brought] to the scene?<BR/>o <BR/>Compressions: was compressions started at discovery and continued until arrival of AED?<BR/>o <BR/>Ventilations: was oxygen delivery via Ambu setup and started when emergency cart arrived<BR/>Observation on [DATE] at 1:30 p.m. of Mock Code Blue - regarding the CPR procedure, checking code status before initiating CPR, assessing resident's pulse before initiating CPR, initiating CPR on residents who are full code and are without pulse, not initiating CPR on residents with a faint pulse, and administering oxygen via Ambu bag . No concerns with the mock code.<BR/>Record review of Mock Code Blue inservice dated [DATE] at 9:30 a.m. revealed all facility staff were educated by a Regional Respiratory Manager regarding checking the crash cart, stocking the crash cart, AED use/location, steps of CPR, crash cart key location, clean up after and restocking, roles of staff during an emergency situation (all staff), and a mock code blue. <BR/>Record review of the facility's document Ad Hoc QAPI dated [DATE] revealed the interdisciplinary team met to discuss CPR, the crash cart, code statuses, staff roles, and the AED. <BR/>Observation of the two facility crash carts on [DATE] at 1:54 p.m. revealed both were fully stocked and code blue ready, including new AED chest pads visible in the AED and extras in the drawers. <BR/>Interviews were conducted on [DATE] - [DATE] with staff on all shifts (6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m., and 10:00 p.m. - 6:00 a.m. CNAs and Nurses) including the Administrator, the DON, RN A (morning shift), LVN A (morning shift), (morning shift), CNA A (morning shift), CNA B (morning shift), LVN C (evening shift), OT A (evening), Shower Tech A (morning shift), CNA C (night shift), CNA E (night shift) LVN F (night shift), LVN D (secure unit morning shift), RT A (morning shift) to verify the in-services were conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material, and expectations related to code blue, restock crash cart and CPR protocol. <BR/>The Administrator, the DON, were able to explain the importance of calling codes and using proper terminology when requesting assistance in the event of an emergency, prompt response to an emergency, retrieving the crash cart/AED, and appropriate implementation of the entire CPR process. <BR/>The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 3:01 p.m. The facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for 1 of 5 residents (Resident #1) reviewed for dignity. <BR/>The facility did not change the linen on Resident #1's bed after it had been soiled and stained with dark brown matter for the duration of the 6am-2pm shift on 05/08/24. <BR/>This failure could put residents who are incontinent and require ADL assistance at risk for a diminished quality of life, loss of dignity, and self-worth. <BR/>Findings included:<BR/>Record review of Resident#1's face sheet dated 05/08/24 revealed a [AGE] year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were multiple fractures to the ribs, Parkinson's disease (a condition that affects the brain and causes problems with movement, balance, and coordination), and hypertension (high blood pressure). <BR/>Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS Summary Score of 12 indicating he was moderately impaired . <BR/>Record review of Resident #1's care plan, last review dated 05/03/24 revealed he had an ADL self-care deficit and was at risk for further decline in ADL functioning. Resident #1's goal for the focus area reflected that he would be well dressed, groomed, cleaned, dignity maintained, and have no further decline in ADL functioning over the next 90 days. Further review of the care plan reflected that Resident #1 had bowel and bladder incontinence and was at risk for skin break down. The goal for the focus area reflected that Resident #1 would remain clean, dry, odor free, and no occurrence of skin break down. <BR/>In an observation on 05/08/24 at 11:05 am, Resident #1 was sitting in his wheelchair and he was hunched over asleep. The sheets on his bed were wet and there was a large brown tinged stain that was in the middle of the pull sheet (sheet used to adjust the resident in bed) and on the resident's top sheet. A smudge of dark brown matter was also left on the pull sheet and a faint smell of urine lingered in the air.<BR/>In an interview on 05/08/24 at 11:22 am with Resident #1, he stated that he required a lot of briefs, and the staff changed him when he needed to be changed. When asked about the linen on his bed, he explained that he had been out of bed since 9:30 am and had wet himself during the middle of the night. He did not know if staff were aware that his linen was wet, but he said that the CNA brought him his breakfast tray and removed it once he was finished. He explained that he had fallen asleep in his wheelchair after breakfast and did not request staff to change his linen. He could not recall if anyone checked on him. When asked if he was currently wet, he stated that the urine in his brief had dried up at that time due to the brief's absorbency. He could not recall if staff had preformed incontinent care for him when they helped him out of bed that morning. <BR/>In an observation on 05/08/24 at 1:15 pm, Resident #1 was sitting in the same position in his wheelchair next to his bed. He was wearing a different shirt and indicated that he changed it himself. The sheets still had a brown tinged stain that had begun to dry and a dark brown smudge. <BR/>In an interview with CNA A on 05/08/24 at 1:59 pm, she stated that she had worked at the facility for 2 years. Her shift on 05/08/24 was from 6am-2pm and she was working with Resident #1 on that day. She followed the investigator into Resident #1's room and she stated that she did not know he was up out of bed and she did not know that his sheets looked like that. She explained that linens were to be changed every time the residents were showered or on a as needed basis. She described as needed to be if the linens were dirty, had blood on them, or they were soiled. She agreed that his linens needed to be changed and she did not do it herself because she did not know that he was up . She could not recall when the last time she checked on him after breakfast, but stated that rounds were to be done every 2 hours. CNA A explained that the harm in not changing dirty linen when needed was that Resident #1 could get skin tears. <BR/>In an observation on 05/08/24 at 3:15 pm, the linen on Resident #1's bed had been changed. <BR/>In an interview with the DON on 05/08/24 at 3:32 pm, she stated the CNA's duties were to provide ADL care, incontinent care, help feed residents, and make up beds. She explained that a med aide was assigned to give Resident #1 his shower that day and she got him up out of the bed. The CNAs often gave showers to residents, but because the shower aide got the resident up that morning, she believed the linen change was overlooked by CNA A. She stated that the harm in not having clean linens on the bed was infection control and the risk for skin breakdowns. <BR/>Record review of the facility's Policies and Procedures titled Resident Rights revised 04/24 reflected that: The facility staff will uphold the resident's dignity and individuality, providing care that fosters their quality of life in a respectful environment. Procedure stated that the facility would provide a clean, safe, comfortable, and home-like environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain hygiene for 1 of 8 residents (Resident #5) reviewed for ADLs. <BR/>-The facility failed to provide nail trimming for Resident #5. <BR/>-The facility failed to provide beard grooming for Resident #5. <BR/>This failure placed residents at risk for injury, infection and decreased quality of life. <BR/>Findings include:<BR/>An electronic record review of Resident #5's Face Sheet revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses including chronic kidney disease, renal failure (kidney failure), diabetes mellitus (high blood glucose levels), malnutrition (lack of sufficient nutrients in the body), and hemiplegia(paralysis of one side of the body). <BR/>An electronic record review of Resident #5's MDS assessment, dated 2/8/22, revealed he was alert and oriented to person, place, and time and required extensive assistance of one-person physical assistance for personal hygiene. <BR/>An electronic record review Resident #5's Comprehensive Care Plan revealed an ADL self-care performance deficit and required limited to extensive assist by 1 staff for personal hygiene. Resident #5 had diabetes mellitus, refer to nurse to cut long nails and staff should always be cut straight across and file with emery board. <BR/>Record review of in-service provided on 5/25/22 for dignity and respect to include grooming, nail care and beard shaving. <BR/>Observation and interview on 5/24/22 at 9:54 a.m. revealed Resident #5 was lying in his bed alert and orientated. He appeared unkempt, long facial hair and had long dirty fingernails. Resident #5 said he had asked to have his nails trimmed for about 6 weeks, but no one would assist. <BR/>Observation and interview on 5/26/22 at 10:57 a.m. with Resident #5. He was sitting up in his bed alert and orientated to his surroundings. Resident #5's fingernails were long and jagged, and his beard was long and unkempt. He said he had asked for his fingernails to be cut again but staff have not been into his room to assist with cutting his nails. Resident #5 said he had not had his beard trimmed. <BR/>In an interview on 5/26/22 at 11:48 a.m. with RC J said she was the resident care provider for Resident #5 on that day. She said Resident #5 said he wanted his nails cut that morning. She said his nails appeared long and jagged. She said she had not cut his nails yet because she could not find a fingernail clippers. <BR/>In an interview on 5/26/22 at 11:50 a.m. with RC K (bath tech) said she gave Resident #5 his scheduled baths this week. She said she did not cut Resident #5's fingernails during his baths. She said it was a part of her job duty was to cut nails and trim hair on residents, but did not get around to do it today. She said Resident #5 never asked to have his nails cut and she was unsure if his fingernails were long. She said if a resident was diabetic then it was the nurse's duty to cut a resident's nails.<BR/>In an interview on 5/26/22 at 11:51 a.m. with LVN K said she was not aware Resident #5 needed his fingernails cut. She said she was unaware Resident #5 needed his nails cut. She said activities helped with cutting and filing fingernails for residents. <BR/>In an interview on 5/26/22 at 3:18 p.m. with DON said ultimately it was the bath technician's responsibility to make sure they take care of the resident ADL care needs while they are in the shower. The DON went on to say if the bath tech was not able to perform ADL's on a resident they were supposed to write it on the shower sheets and notify the nurse. She said she was not aware that Resident #5 needed his beard trimmed or nails cut. <BR/>Review of facility policy Routine Resident Care dated December 2021 read in part . Residents receive the necessary assistance to maintain good grooming and personal hygiene . Daily personal hygiene minimally includes assisting or encouraging residents with washing their faces and hands .<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for 1 of 5 residents (Resident #1) reviewed for dignity. <BR/>The facility did not change the linen on Resident #1's bed after it had been soiled and stained with dark brown matter for the duration of the 6am-2pm shift on 05/08/24. <BR/>This failure could put residents who are incontinent and require ADL assistance at risk for a diminished quality of life, loss of dignity, and self-worth. <BR/>Findings included:<BR/>Record review of Resident#1's face sheet dated 05/08/24 revealed a [AGE] year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were multiple fractures to the ribs, Parkinson's disease (a condition that affects the brain and causes problems with movement, balance, and coordination), and hypertension (high blood pressure). <BR/>Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS Summary Score of 12 indicating he was moderately impaired . <BR/>Record review of Resident #1's care plan, last review dated 05/03/24 revealed he had an ADL self-care deficit and was at risk for further decline in ADL functioning. Resident #1's goal for the focus area reflected that he would be well dressed, groomed, cleaned, dignity maintained, and have no further decline in ADL functioning over the next 90 days. Further review of the care plan reflected that Resident #1 had bowel and bladder incontinence and was at risk for skin break down. The goal for the focus area reflected that Resident #1 would remain clean, dry, odor free, and no occurrence of skin break down. <BR/>In an observation on 05/08/24 at 11:05 am, Resident #1 was sitting in his wheelchair and he was hunched over asleep. The sheets on his bed were wet and there was a large brown tinged stain that was in the middle of the pull sheet (sheet used to adjust the resident in bed) and on the resident's top sheet. A smudge of dark brown matter was also left on the pull sheet and a faint smell of urine lingered in the air.<BR/>In an interview on 05/08/24 at 11:22 am with Resident #1, he stated that he required a lot of briefs, and the staff changed him when he needed to be changed. When asked about the linen on his bed, he explained that he had been out of bed since 9:30 am and had wet himself during the middle of the night. He did not know if staff were aware that his linen was wet, but he said that the CNA brought him his breakfast tray and removed it once he was finished. He explained that he had fallen asleep in his wheelchair after breakfast and did not request staff to change his linen. He could not recall if anyone checked on him. When asked if he was currently wet, he stated that the urine in his brief had dried up at that time due to the brief's absorbency. He could not recall if staff had preformed incontinent care for him when they helped him out of bed that morning. <BR/>In an observation on 05/08/24 at 1:15 pm, Resident #1 was sitting in the same position in his wheelchair next to his bed. He was wearing a different shirt and indicated that he changed it himself. The sheets still had a brown tinged stain that had begun to dry and a dark brown smudge. <BR/>In an interview with CNA A on 05/08/24 at 1:59 pm, she stated that she had worked at the facility for 2 years. Her shift on 05/08/24 was from 6am-2pm and she was working with Resident #1 on that day. She followed the investigator into Resident #1's room and she stated that she did not know he was up out of bed and she did not know that his sheets looked like that. She explained that linens were to be changed every time the residents were showered or on a as needed basis. She described as needed to be if the linens were dirty, had blood on them, or they were soiled. She agreed that his linens needed to be changed and she did not do it herself because she did not know that he was up . She could not recall when the last time she checked on him after breakfast, but stated that rounds were to be done every 2 hours. CNA A explained that the harm in not changing dirty linen when needed was that Resident #1 could get skin tears. <BR/>In an observation on 05/08/24 at 3:15 pm, the linen on Resident #1's bed had been changed. <BR/>In an interview with the DON on 05/08/24 at 3:32 pm, she stated the CNA's duties were to provide ADL care, incontinent care, help feed residents, and make up beds. She explained that a med aide was assigned to give Resident #1 his shower that day and she got him up out of the bed. The CNAs often gave showers to residents, but because the shower aide got the resident up that morning, she believed the linen change was overlooked by CNA A. She stated that the harm in not having clean linens on the bed was infection control and the risk for skin breakdowns. <BR/>Record review of the facility's Policies and Procedures titled Resident Rights revised 04/24 reflected that: The facility staff will uphold the resident's dignity and individuality, providing care that fosters their quality of life in a respectful environment. Procedure stated that the facility would provide a clean, safe, comfortable, and home-like environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide routine and emergency drugs and biologicals and pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services.<BR/>-The facility failed to send Resident #1's insulin medications with him when he went out on pass/leave for two days. Resident returned back to the facility with a blood sugar level of 457.0 mg/dL.<BR/>-The facility failed to complete the Medication/Release Receipt form for Resident #1 when he went out on pass/leave for two days.<BR/>On 02/13/24 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/14/24, the facility remained out of compliance at no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>This deficient practice could place residents at risk of not receiving the desired therapeutic effect of their medications, result in worsening or exacerbation of chronic medical conditions due to missed doses, and/or death.<BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 02/13/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar). <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 01/26/24, revealed a BIMS score of 15, indicating resident was cognitively intact. Further review of Section I - Active Diagnoses, Metabolic, I2900., revealed diabetes mellitus was marked as an active diagnosis. Section N - Medications, N0300., Injections, N0350., Insulin, revealed resident received insulin injections .<BR/>Record review of Resident #1's undated physician orders, reflected in part .Lantus SoloStar subcutaneous solution pen-injector 100 unit/mL .inject 45 unit subcutaneously every 12 hours .start date: 01/30/24 .and Insulin Lispro (1 Unit Dial) subcutaneous solution pen-injector 100 unit/mL .inject 20 unit subcutaneously before meals .start date: 01/30/24 .<BR/>Record review of Resident #1's Medication Administration Record, dated 02/13/24, revealed he missed 4 doses of his Lantus SoloStar and 6 doses of his Insulin Lispro when he was out on pass. Further review revealed he received 1 of 2 doses of his Lantus SoloStar and 2 of 3 doses of his Insulin Lispro before he went out on leave on 02/10/24.<BR/>Record review of Resident #1's Blood Sugar Value, dated 2/12/24 at 16:57 (4:57 p.m.), revealed it was 457.0 mg/dL.<BR/>In an interview on 2/13/24 at 12:45 p.m., Nurse A said she had been working at the facility for approximately one year. She said Resident #1 was a diabetic and had an order for insulin. She said she did not pull and send the resident's insulin with him before he went out on pass on 02/10/24. She said she did not think about it and said the resident was in a hurry to leave. She said she worked Friday, 02/09/24, Saturday, 02/10/24, and Sunday, 02/11/24 and did not receive a telephone call or any messages about his insulin not being sent with him. She said a medication list was not sent with the resident. She said if a resident was not sent home with their insulin medications, they could become hyperglycemic (high blood sugar in the bloodstream) or hypoglycemic (condition in which your blood sugar is lower than the standard range).<BR/>In a telephone interview on 02/13/24 at 1:37 p.m., the DON said the Medication Release/Receipt form should have been completed by facility staff based on their policy .<BR/>Observation and interview on 02/13/24 at 4:15 p.m., revealed Resident #1 was awake and lying in bed. He said he went out on pass/leave Saturday morning, 02/10/24, at approximately 8:30 a.m. and returned back to the facility on Monday, 02/12/24, at approximately 1:30 p.m. He said a staff member (name unknown) packaged up his medications and put them inside his bag. He said he did not see what medications they put inside his bag. He said the facility's van driver dropped him off at his family member's home which was an hour and a half away from the facility. He said when his family member and he noticed his insulin medications were not sent, his family member called the facility and was told (name unknown) that his nurse was on lunch, and someone would call back. He said no one ever called them back.<BR/>In a follow-up interview on 02/14/24 at 2:13 p.m., Resident #1 said not having and taking his insulin medications while he was out on pass made him feel light-headed and said it made his stomach hurt. He said he thought about going to the hospital because of the way he was feeling but decided not to because he thought it was just him overreacting. He said when he returned to the facility on Monday, 02/12/24, he was feeling light-headed .<BR/>On 02/14/24 at 2:26 p.m., an attempted telephone interview was made with Resident #1's family member but there was no answer, and the voicemail box was full. <BR/>On 02/14/24 at 3:03 p.m., an attempted telephone interview was made with the facility's NP but there was no answer. A voicemail was left requesting a return phone call.<BR/>Record review of the facility's Day Outings/Therapeutic Leave of Absence policy, revised 6/2019, read in part .4) Facility staff will complete the Medication Release/Receipt if appropriate for resident/legal representative signature .<BR/>This was determined to be an Immediate Jeopardy (IJ). The Unit Managers were notified on 02/13/24 at 5:55 p.m. that an IJ was identified due to the above failures and the IJ template was presented to the facility at this time.<BR/>The facility's Plan of Removal was accepted on 02/14/24 at 9:42 a.m. and included:<BR/>[Facility Name] - IJ Plan of Removal for F755<BR/>2/13/2024<BR/>Allegation <BR/>F755: Pharmacy Services <BR/>The facility staff failed to follow their nursing policy and procedure Day Outings/Therapeutic Leave of Absence when Resident #1 went out on pass/leave for two days.<BR/>The facility failed to provide Resident #1 his insulin medications when he went out on pass/leave for two days.<BR/>Resident #1 returned from a leave of absence with family on 2/12/24 at 2:00pm. Resident's blood sugar was assessed by charge nurse on 2/12/24 @ 16:47 and was noted to be 457 and resident #1 received 20 units of Insulin Lispro for coverage. Resident #1's Nurse Practitioner was notified on 2/12/24 by the Unit Manager of 457 blood sugar and missed insulin doses while out on pass and no new orders were received. <BR/>Resident #1's concern that he was not provided with his insulin while out on pass was brought through the grievance process and investigated by nursing leadership on 2/12/24. Counseling was provided to the charge nurse who was over Resident #1's care at the time he was given his medication and left the faciity on 2/10/24. The investigation was completed on 2/13/24.<BR/>Resident #1 was assessed by the Nurse Practitioner on 2/13/24 with no adverse effects noted and no new orders received.<BR/>The Administrator notified the Medical Director of the IJ on 2/13/24.<BR/>The Unit Manager initiated education with Charge Nurses on 2/13/24. Topics included: Leave of Absence Policies and Procedure and Leave of Absence Medication Release form. The Charge Nurse will ensure that residents going out on pass are provided scheduled medications for the time frame they're predicted to be out on pass (including insulin) and that the quantities of medications provided, and medications received back are documented on the release form. The Charge Nurse should provide education on medication instructions, side effects, and signs or symptoms of missed doses. Charge nurses will be educated before starting their next shift. New Hires (Charge Nurses) will receive education in orientation. Completion date 2/14/24.<BR/>The IDT clinical leadership team will review residents who or on leave in the morning meeting for compliance with the leave of absence policies and procedures. Started on 2/13/14 and will be an ongoing practice.<BR/>On 2/13/24 The Unit Manager reviewed all residents who went on a leave of absence for the past 7 days with no adverse findings noted. Review was completed on 2/13/24.<BR/>The Administrator reviewed the Leave of Absence Policy and Procedure on 2/13/24 with no changes required.<BR/>Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 02/14/24 through 02/14/24.<BR/>Monitoring of the POR included: <BR/>During interviews on 02/14/24 between 10:53 a.m. and 3:10 p.m. with staff from all shifts, the following Nurses were able to verbalize an understanding of the Day Outings/Therapeutic Leave of Absence policy and procedures and steps to follow when a resident goes out on pass and requires their medications to be released: Unit Managers A and B and Nurses A, B, C, D, E, and F.<BR/>During an interview on 02/14/24 at 10:53 a.m., the DON said in-service trainings were started on 02/13/24 and completed in-person and over the telephone. She said the staff who completed the in-service trainings over the telephone would sign the in-service sheet when they returned for assignment.<BR/>During an interview on 02/14/24 at 1:26 p.m., Unit Manager B said during their morning meetings they would review which resident(s) who were on leave, their leave status, and if there were any changes.<BR/>During interviews on 02/14/24 at 1:48 p.m., Unit Manager A said she completed a review on all residents who went out on pass in the past 7 days. She said there was 1 resident who went on a leave of absence and took her medications with them.<BR/>Record review of Resident #2 who went out on leave of absence in the past 7 days was completed. The resident was not a diabetic and no concerns were found during review.<BR/>Record review of Resident #1's progress notes, dated 02/13/24, revealed he was assessed, the NP was notified, and no new orders were given. His blood sugar was noted to be 457 upon return. NP went to the facility on [DATE] and rounded on the resident. <BR/>Record review of Resident #1's grievance Concern Report, dated 02/12/24, revealed resident reported that his insulin medication was not sent home with him when he went out on pass. The investigation details revealed Nurse A said she did not provide the insulin medications to him. The findings on the facility's investigation included the following: Nurse A was educated, in-serviced, received 1:1 counseling, and the facility would provide his insulin when he goes out on pass.<BR/>Record review of Resident #1's NP's progress note, dated 02/13/24, revealed resident was seen and assessed by the NP. The NP assessed Resident #1 for a follow-up on elevated blood sugars reported upon return to facility from therapeutic pass. NP obtained permission from the resident to send in an order for a new medication since he had a change in insurance and resident agreed.<BR/>Record review of Education In-Service Attendance Records, topic OOP [out on pass] Medications, dated 02/12/24, revealed 6 nurse staff signatures.<BR/>Record review of Education In-Service Attendance Records titled Medications Released, dated 02/13/24, revealed 11 nurse staff signatures.<BR/>Record review of Education In-Service Attendance Record, topic Policy & Procedures, dated 02/13/24, revealed 15 nurse staff signatures.<BR/>Record review of Education In-Service Attendance Record, topic Request for Pass Medication/Leave of absence, dated 02/13/24, revealed 11 nurse staff signatures.<BR/>The Administrator was notified the Immediate Jeopardy (IJ) was removed on 02/14/24 at 3:23 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure that residents were free from accidents for 1 of 6 residents (Resident #76) reviewed for accident, hazards, and supervision. <BR/>The facility failed to ensure the emergency exit and patio exit in the secured unit were adequately secured which resulted in a resident elopement on 7/2/2023.<BR/>This failure could place residents at risk of injuries, hospitalization, pain and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #76's face sheet, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (brain disorder that slowly destroys memory and thinking skills), Severe Vascular Dementia (progressive loss of intellectual functioning with memory impairment), Bipolar Disorder (a mental illness that causes unusual shifts in mood, ranging from extreme highs to lows, and Cognitive Communication Deficit (difficulty with thinking and using language).<BR/>Record review of Resident #76's MDS assessment, dated 07/12/23, reflected a BIMS of 6 in Section C0500, indicating resident #76 had severe cognitive impairment. This means that the resident's ability to recall information, make decisions, and concentrate were impaired. <BR/>Record review of Resident #76's care plan dated 7/25/2023, reflected resident as elopement risk /wanderer related to impaired safety awareness (5/2/22). Listed interventions included: Orienting resident to her environment; Providing structured activities: toileting walking inside and outside, reorientation strategies including signs, pictures, and memory boxes; Reorient, validate, and redirect resident as needed.<BR/>Observation on 7/25/2023 at 9:50am revealed fire alarm being tested. When alarm sounded, CNA Y went to stand by the emergency exit door. When alarm stopped, CNA Y checked to ensure the emergency door was locked. The emergency exit was the only one observed to be checked by CNA Y at theis time.<BR/>During an interview with CNA Y on 7/25/2023 at 9:50am, she stated she has been working at the facility for one week. She denied having been trained on fire drill protocol at this current facility but knew from past experience elsewhere that during a drill, she should stand by an exit and then count residents. CNA Y did not know that in addition to monitoring the exits, secured unit staff was also responsible for securing the gates in the patio area. She said that failure to check the exits could result in a resident getting out of the facility. <BR/>During an interview with CNA QQ (former employee) on 7/28/2023 at 11:03am, she stated she was working the secured unit with LVN G on 7/2/2023 when Resident #76 pulled the fire alarm and eloped from the facility. She said that when the alarm went off, she was in another resident's room performing personal care. She said she stopped what she was doing and looked out of the door to see Resident #76 standing at the fire alarm near the locked, glass doors leading to the facility. CNA QQ said that she walked towards the resident who was being escorted by the unit manager. She said she directed the resident to the commons area where she started to do a headcount on residents. CNA QQ said that there were no procedures (to her knowledge) to address the patio exit and gates in the patio area. She said while doing the headcount, she realized Resident #76 was missing and notified the nurse and management. She said the staff went looking for the resident and found her when they went outside. CNA QQ said that a man told her that he saw a woman walking with one shoe and knocking door-to-door at the apartment complex right next to the facility. CNA QQ notified the other staff members outside looking and went next door and found Resident #76 sitting. She said that the resident was given water and assessed. <BR/>During an interview with LVN O (Secured Unit Nurse Manager) on 7/28/2023 at 11:40am, she stated that she was at the nurses station when she heard the fire alarm go off on 7/2/23. She said there was a fire alarm panel at the nurses station that alerts you as to where the fire alarm triggered. She said that saw the alarm was triggered on the 600 hall (secured unit) and looked up to see Resident #76 at the fire alarm. She said that she walked over to the unit and lead the resident away from the alarm and that CAN QQ and LVN G met her to get Resident #76 and took her back to the dining area. LVN O said she then left the unit to reset the alarm and notify the fire department that the alarm was false. LVN O did not say how long it took to reset the alarm. She said she then went back to 100 and 200 halls to check on those residents and to check the exits on those halls to ensure they were secured. LVN O was alerted by LVN G that Resident #76 was missing. She stated that nursing staff began to go room-to-room inside the facility to see if resident had wandered to an area outside of the secured unit. She said that when they could not find Resident #76 inside the facility, they expanded their search outside. LVN O said that she went out both exit doors of the secured unit to check because all the doors unlock when a fire alarm goes off until the panel was reset. She said when she walked out of the patio doors, she noticed 1 of the 2 gates outside was open. She and CNA QQ continued their search outside the gates while another staff member drove a car. CNA QQ yelled that she found Resident #76 at the apartment complex.<BR/>During an interview with LVN G on 7/28/2023 at 11:50am, she stated that Resident #76 pulled the fire alarm. She said prior to that, residents were roaming up and down the halls as they usually do. At the time when the alarm went off, she said she was in a room feeding a resident. She said that she and CNA QQ got everybody away from the doors in TV room to secure area, but she had to go back to the resident's room whom she was feeding to ensure her bed was in a safe position because she'd left abruptly. She was alerted by CNA QQ that a resident was missing. She then went to the unit doors and out to floor to alert LVN O. She said when they went outside to look for resident, one gate was closed and locked but the other gate was open. <BR/>During an interview with MS on 7/28/2023 at 12:30pm, he stated that the staff assigned to a given unit was responsible for checking the doors and securing exits for their unit after the fire alarm has been reset. All doors and gates lock when the alarm has been reset, but it is possible for an outside gate to remain open because it does not have automatic closing feature. He said when the gate lock is disengaged, the gate can be blown open by wind or pulled open. He said that every morning, maintenance makes rounds outside to pick up trash and ensure the grounds are clean. He said during the morning rounds, the outside gates are checked to make sure the facility is secure. He repeated, when the fire alarm goes off, staff assigned to the unit should secure their unit. MS said that he is responsible for training new staff and walks them through the building to show them. He stated that he does not train temporary staff and the regular staff should relay the information of how to respond to fire alarms, to temporary staff<BR/>During an interview with LVN R on 7/28/2023 at 12:45pm, she stated that during a fire drill or alarm, staff are expected to check the doors and count the residents. LVN R said she did not know to check the gates or why it is necessary.<BR/>During an interview with CNA FF on 7/28/2023 at 12:50pm, she stated that during a fire drill or alarm, staff should check the doors and count the residents. She said that she has worked for the facility for three days and has not had a walkthrough training with MS yet. She said that she did not know to check the gates and why it was necessary.<BR/>During an interview with the ADM on 7/28/2023 at 1:15pm, she said she was aware Resident #76 pulled the fire alarm and staff responded to that. She said while in the process of resetting the alarm, Resident #76 was seen sitting in the area across from the dining room in the secured unit but then went out of the patio door. When staff noticed Resident #76 missing, LVN O and administration were notified. They searched for the resident inside then expanded search outside and took bottled water because it was especially hot outside.<BR/>The ADM said the response to fire alarm should have been for the secured unit staff to go to the doors or keep them (residents) in their line of sight and count the residents to make sure all were present. She said that the secured unit staff were trying to count the residents, but it is difficult because many of them wander around and won't be still. She said that Resident #76 slipped away while they were counting. Doors should be manned or visually watched. She said there are 3 doors total from which a resident could leave the secured unit, 1 lead to the main facility and 2 lead outside. 1 door leads to the patio area which is enclosed by a fence and 2 gates. ADM says that she was not aware that the gates do not automatically shut and relock. She said failure to secure facility or gates could result in residents getting lost or being exposed to the elements.<BR/>During an interview with LVN I on 7/28/2023 at 1:30pm, she stated that when the fire alarm goes off, secured unit staff should check the doors and the gates to make sure residents stay in. She said that she was educated by MS as part of her orientation when she was hired 3 months ago.<BR/>During an interview with CNA EE on 7/28/2023 at 1:35pm, she stated when the fire alarm goes off, secured unit staff should count the residents while watching the doors. When it's over, check the doors and gates because the gates can swing open. She said that she received this training in response to Resident #76 getting out of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 9%, based on 3 errors out of 32 opportunities, which involved 3 (Residents #59, Resident #12, and Resident #101) of 5 residents reviewed for medication errors. <BR/>-The facility failed to ensure MA A administered one medication scheduled for 8:00 a.m. during Resident #59 medication administration.<BR/>-The facility failed to ensure MA A administered one medication scheduled for 8:00 a.m. during Resident #12 medication administration.<BR/>-RN D failed to administer the correct dose for one medication scheduled for 8:00 a.m. during Resident #101 medication administration.<BR/> This failure could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. <BR/>Findings include:<BR/>Resident #59<BR/>Record review of Resident #59's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), dysphagia (impairment or difficulty in swallowing), hypertension (blood is pumping with more force than normal through arteries) and vitamin deficiency (the condition of a long - term lack of vitamin). <BR/>Record review of Resident #59's quarterly MDS assessment, dated 06/10/23, revealed the BIMS score was 06, which indicated severely impaired cognition. Further review of the MDS revealed he required extensive assistance with one to two staff assist with all ADL.<BR/>Record review of Resident #59's order summary report for July 2023 revealed: Cholecalciferol 25 mcg(1000UT): give 1 tablet by mouth one time a day for vitamin D insufficiency. Start date 04/25/23<BR/>Record review of Resident #59's time stamp record revealed the medication was signed at 7:58 a.m. on 07/26/23.<BR/>During medication reconciliation on 07/26/23 at 11:00 a.m., it revealed Resident #59 Cholecalciferol Tablet 25 MCG (1000 UT) Give 1 tablet by mouth one time a day was not given during medication observation administration for 8:00 a.m.<BR/>During an observation on 07/26/23 at 7:55 a.m., revealed MA B prepped and administered medication for 8:00 a.m., to Resident #59 but did not administer the following medication: Cholecalciferol 25 mcg(1000UT): give 1 tablet by mouth one time a day.<BR/>During an interview on 07/26/23 at 12:50 p.m., MA B said she gave all the 8:00 a.m. medication when the surveyor observed medication administration this morning for Resident #59, and she had not gone back and administered any 8:00 a.m. to Resident #59.<BR/>During an observation on 07/26/23 at 12:55 p.m., it was revealed on the computer screen had a green check next to the medication, which Resident #59 did not receive. MA B the green check meant Cholecalciferol Tablet 25 MCG was administered. MA B said she did not manually check it off on the computer because it was automatically done. Then she said she must have given Cholecalciferol Tablet 25 MCG when she gave the 10:00 a.m. and 11:00 a.m. medication. Again, she said she could go and give it now, and when asked her if it was administered or not, she did not respond.<BR/>During an observation and interview on 07/26/23 at 1:00 p.m., LVN O pulled up Resident #59's time stamp on the computer screen and said MA B signed it at 7:58 a.m., which meant Cholecalciferol Tablet 25 MCG was given during medication pass. She stated that it was signed, and if it was not given, it was a medication error.<BR/>During an interview on 07/26/23 at 2:15 p.m., the DON said if Resident #59 did not receive Cholecalciferol Tablet 25 MCG medication and it was time-stamped by MA B, then it was a medication error. She said the unit managers monitor the medication aides by making random rounds during medication administration.<BR/>Resident #12<BR/>Record review of Resident #12's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes mellitus (elevated levels of blood glucose), atrial fibrillation (the top chamber of the heart twitch), hypertension (blood is pumping with more force than normal through arteries) and vitamin deficiency (the condition of a long - term lack of vitamin). <BR/>Record review of Resident #12's quarterly MDS assessment, dated 05/27/23, revealed the BIMS score was 13, which indicated intact cognition. Further review of the MDS revealed he required limited to extensive assistance with one staff assist with all ADLs.<BR/>Record review of Resident #12's order summary report for July 2023 revealed: Ascorbic Acid 500 mg, give 1 tablet by mouth one time a day. Initiated date 06/21/23.<BR/>Record review of Resident #12's time stamp record revealed the medication was signed at 8:36 a.m. on 07/26/23<BR/>During medication reconciliation on 07/26/23 at 11:05 a.m., it revealed Resident #12's Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth one time a day was not given during medication administration observation at 8:30 a.m.<BR/>During an observation on 07/26/23 at 8:30 a.m. revealed MA B prepped and administered medication for 8:00 a.m., to Resident #12 but did not administer the following medication: Ascorbic Acid 500 mg, give 1 tablet by mouth one time a day.<BR/>During an interview on 07/26/23 at 12:52 p.m., MA B said she gave all the 8:00 a.m. medication when the surveyor observed medication administration this morning for Resident # 12, and she had not gone back and administered any 8:00 a.m. to Resident # 12.<BR/>During an observation on 07/26/23 at 12:56 p.m., it was revealed on the computer screen had a green check next to the medication, which Resident #12 did not receive. MA B, the green check, meant Ascorbic Acid 500 mg. MA B said she did not manually check it off on the computer because it was automatically done. Then she said she must have given Ascorbic Acid 500 mg. when she gave the 10:00 a.m. and 11:00 a.m. medication. Again, she said she could go and give it now, and when asked if the drug was administered or not, she did not respond.<BR/>During an observation and interview on 07/26/23 at 1:02 p.m., LVN O pulled up the time stamp on the computer screen and said MA B signed off at 8:36 a.m., which meant Ascorbic Acid 500 mg was given during the medication pass. LVN O said MA B signed, and she did not administer it during the medication pass; it was another medication error.<BR/>During an interview on 07/26/23 at 2:17 p.m., the DON said MA B did not give Resident 12 her vitamin C during the medication pass time-stamped as given, then it was a medication error. The DON said Resident #12 would not get the desired therapeutic result when medication was not given.<BR/>Resident #101<BR/>Record review of Resident #101's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Parkinson's disease (brain disorder that cause unintended movements), conversion disorder (condition in which a person experiences physical or sensory problem), atherosclerotic heart disease (buildup of fats, cholesterol, and other substances in and on the artery walls) and acute respiratory failure (a serious condition that make it difficult to breathe on your own). <BR/>Record review of Resident #101's quarterly MDS assessment, dated 07/12/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed she required supervision to limited assistance with one to two staff assist with all ADL.<BR/>Record review of Resident # 101's MAR for July 2023 reflected: Symbicort Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT (Budesonide Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day. Initiated date:03/10/23 and discontinued date:07/11/23.<BR/>During medication administration on 07/26/23 at 11:05 a.m., RN D gave Resident #101 Budesonide-Formoterol Fumarate Inhalation Aerosol 80-4.5 MCG/ACT (Budesonide Formoterol Fumarate Dihydrate) and told her to inhale two puffs and the resident inhaled four puffs and RN D did not attempt the resident stop the resident from inhaling more puffs.<BR/>During an interview on 07/26/23 at 8: 55 a.m., RN D said he should have administered the medication by himself, and the resident would not have inhaled more than two puffs. He said the wrong dose was given because Resident #101 inhaled four puffs instead of 2 two puffs. He said he had skills check-off on medication administration, and the unit managers make random rounds during medication administration. He said it could have a negative effect, such as increased breathing or elevated heart rate for Resident #101.<BR/>During an interview on 07/26/23 at 3:30 p.m., the DON said RN D should have administered the medication unless Resident #101 had an order for self-medication administration and the resident was trained and monitored to ensure she could take the medicine safely. She said it was a medication error because the wrong dose was given. The DON said it was an overdose and could have a negative outcome, such as fast heartbeats or chest pain. She said the unit manager monitored the nurse by making rounds during medication rounds.<BR/>Record review of the facility policy on medication administration revised 6/2019 read in part . procedures . M. authorized licensed or certified/ permitted medication aide or by state regulatory guidelines staff, must understand: Indications and reason for therapy, effectiveness of the therapeutic goal, drug actions, . D. the eight rights for medication administration. 1. The right patient/resident 2. the right drug, 3. the right dose, 4. the right time, 5. the right route, 6. The right charting, 7 the right results, 8. The right reason . step III: administering the medication pass k. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines, staff documents that medication is given in the correct slot of MAR, before going to the next patient/resident .<BR/>Record review of MA B medication administration, tablet and capsules training revealed she signed it on 07/14/23.<BR/>Record review of RN D medication administration training revealed he signed it on 06/14/23.<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 (Resident #100) of 12 residents reviewed for environmental concerns in that:<BR/>-Resident #100's room had a pervasive urine odor.<BR/>These failures could place 21 residents who resided on hall 500 at risk of living in an unsafe, unsanitary, and uncomfortable environment.<BR/>Findings included<BR/>Record review of Resident #100's admission sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included huntingtin's disease, chronic obstructive pulmonary disease, dementia, constipation, anxiety disorder, adult failure to thrive, muscle wasting and atrophy, and other lack of coordination.<BR/>Record review of Resident #100's quarterly MDS assessment dated [DATE] revealed he had a BIMS score 03 indicating severely impaired. <BR/>During an observation and attempted interview on 7/26/2023 beginning at 9:44a.m. with Resident #100, revealed him lying in bed with feces on his sheet, shirt, and pillow. There was black cotton from his socks all over his bed and the floor. The room smelled like urine. There are two blankets on the bed and the bed is dirty and covered in feces. Resident #100 was lying in bed in a fetal position. He was talking to himself. There was a wheelchair facing the window. Resident #100's call light is not in reach. There were no trash bag liners in the trash can. The resident was not communicating with surveyor.<BR/>During an interview on 7/25/2023 at 9:54a.m. with MA B, said Resident #100 was a fighter. She said he will sometimes try to fight staff when they are providing incontinent care. She had linens in a plastic bag to change Resident #100 sheets.<BR/>During an interview on 7/25/2023 at 9:56a.m. Resident #100 complained about the bed being dirty and said he did not know how long he had been on the dirty sheets. His shirt was dirty.<BR/>During an observation and interview on 7/27/2023 beginning at 11:49a.m. with Resident #100, revealed him sitting at the bedside table in his room. There were no sheets or blankets on his bed. His room smelled like urine. He said he was waiting to eat lunch. He said he wanted to eat in his room. <BR/>During an interview on 7/27/2023 at 11:51a.m. with the RCS A, said she has been working at the facility since September 2022. She said it was her job to assist the residents by getting them up out of bed, to make sure they are fed, and to make sure they are comfortable overall. She said she is also responsible for getting the residents dressed and cleaned. She said she checks on the residents every 2 hours or when she sees that the call light was on. She said if she sees that a resident was covered in feces it will be a problem and it will be unsanitary and it was a health hazard. <BR/>During an interview on 7/27/2023 at 2:51p.m. with RCS B, said her job duties are to make sure the residents are safe and to make sure they are safe. She said she also makes sure the residents are clean, fed, and pay attention to warning signs and behaviors. She said it is important to make sure the residents are being changed in a timely manner so that there are no bacteria, skin break down, and no infections. <BR/>During an interview on at 12:30p.m. with RN D, said he has been working at the facility since April of last year. He said he was the charge nurse, and he was in charge of the CNAs on 400 hall and 500 hall. He said the CNAs are supposed to assist residents with incontinence care, feeding, activities, and assist with showers. He said they have shower techs as well. He said staff have tried to clean Resident #100 and can only do so if he let them. He said Resident #100 has been verbal with staff. He said when staff tells him about any incident, they have had with Resident #100, he notates it. He said if Resident #100 refuses care, he would encourage him to allow staff to change him. He said if staff are doing rounds, feces on the sheets is something they should see. <BR/>Record Review of the facility's policy titled Resident Right's revised on 06/2019 read in part . it is the policy of this facility that the Facility staff will provide the resident with the right to an environment that preserves dignity and contributes to a positive self-image. Create a home-like environment includes sufficient space with access to personal living space; appropriate furnishings, and equipment, including access to telephones; clean orderly comfortable, safe environment with clean bed and bath linen in good condition, and personal closet; appropriate environment adaptions to help residents with other specific/special needs when indicated and if able to provide .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain hygiene for 1 of 8 residents (Resident #5) reviewed for ADLs. <BR/>-The facility failed to provide nail trimming for Resident #5. <BR/>-The facility failed to provide beard grooming for Resident #5. <BR/>This failure placed residents at risk for injury, infection and decreased quality of life. <BR/>Findings include:<BR/>An electronic record review of Resident #5's Face Sheet revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses including chronic kidney disease, renal failure (kidney failure), diabetes mellitus (high blood glucose levels), malnutrition (lack of sufficient nutrients in the body), and hemiplegia(paralysis of one side of the body). <BR/>An electronic record review of Resident #5's MDS assessment, dated 2/8/22, revealed he was alert and oriented to person, place, and time and required extensive assistance of one-person physical assistance for personal hygiene. <BR/>An electronic record review Resident #5's Comprehensive Care Plan revealed an ADL self-care performance deficit and required limited to extensive assist by 1 staff for personal hygiene. Resident #5 had diabetes mellitus, refer to nurse to cut long nails and staff should always be cut straight across and file with emery board. <BR/>Record review of in-service provided on 5/25/22 for dignity and respect to include grooming, nail care and beard shaving. <BR/>Observation and interview on 5/24/22 at 9:54 a.m. revealed Resident #5 was lying in his bed alert and orientated. He appeared unkempt, long facial hair and had long dirty fingernails. Resident #5 said he had asked to have his nails trimmed for about 6 weeks, but no one would assist. <BR/>Observation and interview on 5/26/22 at 10:57 a.m. with Resident #5. He was sitting up in his bed alert and orientated to his surroundings. Resident #5's fingernails were long and jagged, and his beard was long and unkempt. He said he had asked for his fingernails to be cut again but staff have not been into his room to assist with cutting his nails. Resident #5 said he had not had his beard trimmed. <BR/>In an interview on 5/26/22 at 11:48 a.m. with RC J said she was the resident care provider for Resident #5 on that day. She said Resident #5 said he wanted his nails cut that morning. She said his nails appeared long and jagged. She said she had not cut his nails yet because she could not find a fingernail clippers. <BR/>In an interview on 5/26/22 at 11:50 a.m. with RC K (bath tech) said she gave Resident #5 his scheduled baths this week. She said she did not cut Resident #5's fingernails during his baths. She said it was a part of her job duty was to cut nails and trim hair on residents, but did not get around to do it today. She said Resident #5 never asked to have his nails cut and she was unsure if his fingernails were long. She said if a resident was diabetic then it was the nurse's duty to cut a resident's nails.<BR/>In an interview on 5/26/22 at 11:51 a.m. with LVN K said she was not aware Resident #5 needed his fingernails cut. She said she was unaware Resident #5 needed his nails cut. She said activities helped with cutting and filing fingernails for residents. <BR/>In an interview on 5/26/22 at 3:18 p.m. with DON said ultimately it was the bath technician's responsibility to make sure they take care of the resident ADL care needs while they are in the shower. The DON went on to say if the bath tech was not able to perform ADL's on a resident they were supposed to write it on the shower sheets and notify the nurse. She said she was not aware that Resident #5 needed his beard trimmed or nails cut. <BR/>Review of facility policy Routine Resident Care dated December 2021 read in part . Residents receive the necessary assistance to maintain good grooming and personal hygiene . Daily personal hygiene minimally includes assisting or encouraging residents with washing their faces and hands .<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and based on the comprehensive assessment for 1 (Resident #87) of 8 residents reviewed for assessments. <BR/>-The facility (RN A) failed to complete an assessment, incident report, neuro-checks, and facility monitoring requirements after Resident #87 was said to have had an unwitnessed fall.<BR/>These failures placed the resident(s) at risk of harm for not receiving care and services.<BR/>Findings included:<BR/>Resident #87<BR/>Record review of Resident #87's face sheet dated 5/24/2022 revealed a [AGE] years old male, admitted on [DATE] and re-admitted on [DATE] and the following diagnoses included: Bi-polar disorder (mental illness with extreme mood swings), difficulty walking, cognitive communication deficit, cataracts (affecting the eye that causes clouding of the lens), ( hypothyroidism (decreased production of thyroid hormones), restless leg syndrome (disorder that causes an overwhelming urge to move legs), low back pain, unsteadiness on feet, and major depressive.<BR/>Record review of Resident #87's MDS dated [DATE] revealed a BIMS of 15 which indicated the resident was cognitively intact. Section J1800 did not indicate the resident had a fall history. <BR/>Record review of Resident #87's care plan dated 5/19/2022 (last care plan review completed) revealed the following in part:<BR/>Focus - I have had an actual fall with unsteadiness 11/14/2019 unwitnessed fall with no injuries, 2/9/2022 slide off the side of bed, 5/15/2022 suspected fall with bruising.<BR/>Goal - I will resume usual activities without further incident through the review date. (target date 7/23/2022)<BR/>Interventions - .Encourage resident to ask for assistance. Observe/document/report PRN x 72h MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. (date initiated 3/22/2022)<BR/>Focus - I am at risk for falls r/t poor balance; unsteady gait (date revised 3/22/2022)<BR/>Goal - My risk and injury potential will be minimized through the next review date. (revision date 4/25/2022).<BR/>Interventions - Anticipate and meet my needs. (revised 1/15/2019) Be sure my call light is within reach and encourage me to use it for assistance as needed. I need a prompt response to all request for assistance<BR/>Record review of facility nurses' note for Resident #87 written by RN A dated 5/15/2022 at unknown time (late entry for 5/14/2022) revealed the following: 5/14/2022 21:29 (11:29 p.m.) Nursing Note Late Entry: Note Text: This writer was informed of the recent incident of suspected fall to the resident. Nurse only heard the Rcs (RC X) and another Resident (Resident #10) talked about the fall. Nurse went into resident's (Resident #87) room to ask, resident denied fall. Nurse assessed patient from head to toe, no distress, discomfort or injury noted at the time of this assessment. V/signs checked; B/p--114/64, p-86, R-20. Resident asked to be changed, same done and given snack as requested. Resident in stable condition. In-coming Nurse (LVN P) notified to monitor resident.<BR/>Record review of nurses' note (written by LVN P on - 5/15/2022 at 7:42 a.m.) revealed the following in part:<BR/> .SBAR Summary:<BR/>Vitals Signs: BP 121/79 - 5/15/2022 8:07 a.m.<BR/>Position: Lying left /arm, P 64 - 5/15/2022 08:07 a.m.<BR/>Pulse Type: Regular R 16 - 5/15/2022 8:07 a.m.<BR/>Temperature 96.9 - 5/14/2022 8:09 a.m. Route: Axilla (armpit) <BR/>Weight 172.6 lb. - (last taken 4/20/2022)<BR/>O2 98.0 % - 5/14/2022 - Method: Room Air<BR/>RN Assessment/LPN Appearance of resident - What I think is going on with the resident is: suspected of fall with possible head injury due to new bruising to left torso and back of right thigh. Decline in cognitive baseline, temp 95.3 Additional Nursing Notes as applicable: Received orders from Dr. to send to hospital for CT scan .<BR/>Record review of nurse's note (written by LVN P on 5/15/2022 at 9:27 a.m.) revealed the following in part:<BR/>Resident #87 transported to hospital ER for suspected fall with possible head injury .<BR/>Interview via telephone on 5/24/2022 at 11:37 a.m. with Resident #87's Guardian said he was told on 5/15/2022 by LVN P that Resident #87 was found on the floor and had vomited on 5/15/2022. The Guardian said Resident #87 was sent to the ER unresponsive. The Guardian said he was informed by the hospital staff that when Resident #87 arrived at the hospital he had bruising to his torso area. He said he last saw Resident #87 in April 2022 but could not remember the date. He said Resident #87 did not have bruising in April 2022. During this visit in April 2022, he said Resident #87 did have a rash in his groin area and complained about wait time for care needed. The Guardian said Resident #87 was impatient and wanted care immediately but this was talked about in his care plan.<BR/>Interview on 5/25/2022 at 10:17 a.m. the ER RN said when Resident #87 arrived at the hospital emergency room he had a bruised bilateral abdomen (midline of the stomach area). The ER RN said the emergency room doctor said Resident #87 had a traumatic inquiry not consistent with a fall .injury to his pancreas which was not consistent with a fall. The ER RN said Resident #87 was currently intubated (insertion of a tube either through the mouth or nose and into the airway to aid with breathing). She said she Resident #87 had bruising on the sides of his torso and one spot on his back the size of a fist. She said the bruises that Resident #87 had occurred within the last 24-48 hours. <BR/>Interview on 5/25/2022 at 11:07 a.m. with Resident #87's roommate (Resident #95) was attempted, and he was not able to answer questions or communicate what happened to Resident #87. <BR/>Record review of Resident #95's Quarterly MDS dated [DATE] revealed his BIMS was a 3 which indicated he had severe cognitive impairment. <BR/>Interview on 5/25/2022 2:56 p.m. with RN A said she had worked for the facility for approximately 2 months. RN A said she worked on 5/14/2022 from 2:00 p.m. - 10:00 p.m. She said as she was coming from assisting a resident with a fall, she overheard RC X say to Resident #10 that Resident #87 did not fall. RN A said she did not ask RC X and Resident #10 any questions and proceeded to Resident #87's room. RN A said she asked Resident #87 if he fell and he told her he did not. RN A said she completed an incontinent change and while doing so, she looked for injuries. RN A said she asked Resident #87 if he fell and she said he denied pain. RN A said she took Resident #87's vitals (signs checked; B/p--114/64, p-86, R-20) while he was in bed (she had this written in a person note book that she referred to during the interview). RN A said because Resident #87's vital were in normal range, he had no bruising and he said he did not fall. She said she disregarded protocol for unwitnessed falls based on Resident #87's response. She said when a resident had an unwitnessed fall, she had been trained to assess the resident, take vitals, check for pain, start neuro checks, complete incident report and follow the facility's fall management policy. She said the fall management policy was used to monitor if a resident had any change in condition which could be an indication of a decline in a resident's health. She said Resident #87 was sleep for the rest of her shift. RN A said she told LVN P to keep an eye on him (Resident #87). RN A did not provide an answer to why she said keep an eye on Resident #87 or what she meant. RN A said injuries or change in condition could present after the fall and may not show up immediately and that was why the fall management policy was used to monitor changes in the resident. She said she did not make any other notifications related to an unwitnessed fall for Resident #87. She said she later talked to Resident #10 on 5/16/2022 who said he picked up Resident #87 from the floor. She said RC X was the aide assigned to Resident #87 during her shift. <BR/>Interview on 5/25/2022 at 12:00 p.m. with the DON, she said she was not told Resident #87's had unwitnessed fall on 5/14/2022 until 5/16/2022 after she reviewed the 24 hour-report and was told by RN C (worked 6:00 a.m. - 2:00 p.m. on 5/15/2022). The DON said she was aware Resident #87 was sent out to the hospital but was not aware of Resident #87's possible unwitnessed fall prior to being sent out. The DON said RN C told her when he went to Resident #87 room at the beginning of his shift he saw vomit on the floor, the resident was in bed, vitals were taken, and his temperature had dropped and was low (95.3). Resident #87 was sent out to the hospital. The DON interviewed LVN P (worked 10:00 p.m. 5/14/2022 - 6:00 a.m. 5/15/2022). LVN P said Resident #87 had no changes throughout the night. The DON interviewed Resident #10 (BIMS 8) and he told her that he helped Resident #87 from the floor. The DON said Resident #10 said he snatched Resident #87 from the floor from behind to help him up to the bed. The DON interviewed NA J (worked on 5/14/2022 2:00 p.m. - 10:00 p.m.) and he told her Resident #10 said he picked up Resident #87 from the floor and put him back in the bed. The DON said NA J told her he did not report it to the nurse. The DON interviewed RC X. The DON said she was told by RC X that Resident #10 said he picked up Resident #87. The DON said the facility's policy on fall management was not followed. The DON said Resident #87 should have had neuro checks that would have been followed by a physical assessment to monitor for any change in condition that could detect injuries or change in mental status. The DON said a full and documented assessment should have been completed since there was a possible fall. The DON said there could be a delay in care without the assessments being completed. <BR/>Interview on 5/25/2022 at 4:17 p.m. with NA J (temporary nurse aide) said he worked on 5/14/2022 on the 2:00 p.m. -10:00 p.m. shift. NA J said he was not assigned to Resident #87. NA J said Resident #10 approached him in the hallway and said he had helped Resident #87 from the floor back into his bed. NA J said he went to Resident #87's room, pulled back the covers to see if the resident had any bruises. NA J said he did not see any visible bruises and went back to tell Resident #10 that he should not help a resident off the floor. NA J said he did not report the possible fall of Resident #87 to a nurse because he was busy doing something, did not see the nurse on the hall and forgot. NA J said the nurse on duty was RN A. NA J said he had been trained that if a had resident has a fall, then he should have reported it to the nurse so they could start their assessment. NA J said the nurse should check the resident for injuries, take the resident's vitals, and monitor the resident every 15-30 minutes and let the next nurse know. NA J said if a resident was not monitored after a fall it could lead to injuries that were not detected. <BR/>Interview on 5/26/2022 at 9:35 a.m. LVN P said he worked the 10:00 p.m. - 6:00 a.m. shift on 5/14/2022 - 5/15/2022. He said he completed shift change with RN A. LVN P said RN A did not inform him of a fall for Resident #87 or to monitor him. LVN P said RN A informed him of another resident who had a fall. LVN P said he completed the facility fall management protocol which was continue the neuro checks that had been started by RN A, but he had not been told to complete neuro checks for Resident #87. LVN P said the fall management protocol is was is started to assess the resident for injuries, check for pain, initiate neuro check to monitor a change in condition, document the incident and inform the next shift. LVN P said the protocol was to ensure if there is was a decline in the resident's health then it is was detected, and they receive the care that was needed. LVN P said during his shift he rounded and did not see bruising on Resident #87. LVN P said Resident #87 kept his overhead light on throughout the night. LVN P said he brought water to Resident #87. LVN P said there was no other interaction with Resident #87 and last saw him at the end of his shift around 5:30 a.m. LVN P said he did not see vomit in his room. LVN P said the fall management protocol should have been started if a resident said they picked up another resident from the floor and be treated as an unwitnessed fall. <BR/>Interview on 5/26/2022 at 9:50 a.m. with RC X said she worked a double shift from (5/14/2022 at 2:00 p.m. until 5/15/2022 at 6:00 a.m.) RC X said she clocked in at 2:35 p.m. and clocked out at 5:45 a.m. RC X said she worked with Resident #87 on the day shift and was assigned to him. RC X said Resident #87 had no problems during her day or night shift and provided normal care for him like incontinent changes and meal services. RC X said between 7:30 p.m. and 8:00 p.m. on 5/14/2022 she said Resident #10 said Resident #87 had fallen and he picked him up from the floor. RC X said Resident #10 was a strong able body man and would be able to pick up Resident #87. RC X said she told RN A that Resident #87 fell. RC X said RN A went to check on Resident #87 but RC X did not stay to see what RN A did. RC X said later in the evening she was asked to work a double shift around 9:30 p.m. and RN A asked her if the incident should be written up. RC X said she did not answer RN A. RC X said RN A should know the fall protocol. RC X said RN A should have assessed the resident physically, started neuro checks, monitored the resident for change in condition, documented on the neuro checks form and in PCC and advised the next nurse of the neuro checks that needed to continue. RC X said Resident #87 slept throughout the night and she last remembered checking in on him around 2:45 a.m. where he was asleep in bed. RC X said she did not inform the nurse on the next shift (RN C) of Resident #87's unwitnessed fall because that was RN A's job. RC X said she was to inform a nurse if a resident had a fall. <BR/>Resident #10<BR/>Record review of Resident #10's face sheet dated revealed at [AGE] year-old male admitted on [DATE] with the following diagnoses: hypertensions (elevated blood pressure), paranoid schizophrenia (delusions and hallucinations), anemia (deficiency of healthy red blood cells in blood), muscle weakness. <BR/>Record review of Resident #10's Quarterly MDS dated [DATE] revealed he had a BIMS of 8 which indicated he was moderately cognitively impaired. Further review of Section C1310 revealed Resident #10 had no evidence of acute change in mental status, no evidence of difficulty focusing, no evidence of disorganized thoughts. <BR/>Interview on 5/26/2022 at 10:34 a.m. with Resident #10 who said he heard Resident #87 hollering and yelling (not able to give a specific day and time). Resident #10 said it was a little over a week ago when he helped Resident #87 from the floor back into his bed. Resident #10 said when he heard Resident #87 yelling for help, he went towards Resident #87's room. Resident #10 said he was sitting in the common area of the hall 400 which is halfway down the hall. Resident #10 said his room was a few doors from Resident #87. Resident #10 said when he arrived at the room, Resident #87 was somewhat on his knees with his head under the bed and his wheelchair on the back of his legs. Resident #10 said he moved the wheelchair and attempted to pick up Resident #87 from the front with his arms under Resident 87's armpits. Resident #10 said he became weak and let Resident #87 back down and then picked him up from behind (described like the position a person would be in if giving the Heimlich maneuver). Resident #10 said he then laid him face down on the bed. Resident #10 said Resident #87's left arm was stuck under him and he helped him to free it. Resident #10 said he told NA J that he helped Resident #87 from the floor and later NA J came to his room and told him not to help a resident up from a fall and tell a staff. <BR/>Interview on 5/26/2022 at 11:49 a.m. RN A said she should have called the physician and made notification immediately to the RP, DON and the oncoming nurse but since she saw Resident #87 in the bed, and he denied he fell she did not go further with the fall management protocol. <BR/>Interview on 5/27/2022 at 10:45 a.m. the District Director of Clinical Services said she started on 5/10/2022 with the facility. She said she had not been able to facilitate trainings or in-services yet. She said her expectation after an unwitnessed fall was for a nurse to start the fall management protocol. She said the fall management protocol included the physical assessment for injuries, timely neuro check follow-ups, incident report, SBAR, skin assessment, and pain assessment by the nurse. She said if the neuro checks are not completed then a change in condition for the resident could be missed and result in a resident's decline and place the resident at risk for further decline or injury. She said even if the resident appears alert and oriented during the initial assessment, but it was said there could have been a fall then she expected it to be treated like a fall. She said the DON reviews the 24-hour report daily and falls are discussed in daily morning meetings. She said the DON is responsible for the training of staff on the fall management protocol. She said they use skill checks to ensure staff are following protocol. She said RN A had worked for approximately 2 months and her orientation and skills had been checked off for fall management. <BR/>Record review of Resident #87's hospital records dated 5/15/2022 revealed the following:<BR/> brought in from nursing home today. Patient found to be hypothermic (lower body temperature than normal body temperature) at 88 degrees Fahrenheit .vomiting in the ER .Patient had total body CT scan for trauma evaluation which revealed findings concerning for bowel contusion (bruising), left lateral chest wall and pulmonary contusion (bruising), and soft tissue contusions (bruising) left lateral hip and buttock.<BR/>Neurological - Awake, tired appearing very weak<BR/>Notes: <BR/> .found down on floor at a skilled nursing facility, suspected traumatic fall, presenting with multiple contusions visible on the left chest wall with severe abdominal guardian/discomfort on palpation (by touch).<BR/>Record review of witness statement from NA J dated 5/16/2022 revealed the following in part:<BR/>NA J said Resident #10 told him that he picked up Resident #87. NA J said he went to check on Resident #87. NA J said [Resident #10] was in the bed and didn't notice any changes. NA J said he did not report the fall to a nurse. <BR/>Record review of witness statement from LVN P dated 5/16/2022 revealed the following in part:<BR/>LVN P said on the off going nurse (RN A) told him about a fall for a resident but it was not Resident #87.<BR/>Record review of witness statement from RC R dated 5/16/2022 revealed the following in part:<BR/>RC R said she went into Resident #87's room on 5/15/2022 to provide incontinent care at the beginning of her 6:00 a.m. - 2:00 p.m. She said she noticed a bruise on his back and then she notified RN C.<BR/>Record review of witness statement from the DON dated 5/16/2022 revealed the following in part:<BR/>The DON said Resident #10 stopped her in the hallway. The DON said Resident #10 described Resident #87 physical and ethnic characteristics and said he put him back in the bed. The DON said Resident #10 said I heard a yell and got up to go check. Resident #10 said Resident #87 was on the floor with his right knee between the wheelchair and the bed . Resident #10 said he tried to untangle Resident #87's leg .Resident #87 said he snatched him up from the front Resident #10 said he got weak and then snatched him (Resident #87) up from the back and got him (Resident 87) back in the bed. Resident #10 said he told the boy with the gold hair and earring (later identified as NA J) that he picked up Resident #87. Resident #10 described RN A to the DON as a nurse having her skin color. <BR/>Interview on 6/25/21 at 4:40 p.m. with the Administrator, he said RN A should have assessed Resident #1 immediately after she though there was an unwitnessed fall, notified the physician, DON and the resident's responsible party. The Administrator said RN A should have documented the incident on an incident report and in the nurse's notes. The Administrator said RN A should have updated the next shift at shift change to ensure the resident was monitored. The Administrator said it was important to notify the physician after a fall for further care instruction the physician could have had. The Administrator said after an unwitnessed fall neuro checks were required to ensure there was not a change in condition. The Administrator said the protocol and policy was to call the DR, NP RP and to start the neuro checks, document in notes and incident reports. The Administrator said RN A did not tell us, and I was not aware of Resident #1's fall until 6/22/21. The Administrator said the DON is responsible for <BR/>Record review of Resident #87's Skin- Head to Toe Checks dated 5/16/2022 at 8:00 a.m. by RN C revealed the following in part:<BR/>Skin Integrity: <BR/>New Bruises<BR/>Site: <BR/>Chest, right gluteal fold<BR/>Record review of Resident #87's SBAR dated 5/15/2022 at 7:42 a.m. by RN C revealed the following in part:<BR/>Mental Status Changes - Increased confusion, decreased consciousness<BR/>GI/abdomen - Vomiting<BR/>Assessment: Suspected of fall with possible head injury due new bruising to left torso and back of right thigh. Decline in cognitive baseline, temp 95.3<BR/>Record review of facility policy Fall Management (revised on 7/2017) revealed the following in part:<BR/>Policy<BR/>The facility will assist each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision .<BR/>Falls defined:<BR/> .regarding falls state that a fall is defined as unintentionally coming to rest on the ground, floor or other lower level .<BR/>Clarification:<BR/>The presence or absence of a resultant injury is not a factor in the definition of a fall. A fall without injury is still a fall.<BR/>When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there .<BR/>Record review of facility flow chart Fall Management System (copyright 2017) revealed the following in part:<BR/>Resident Fall:<BR/>Complete Documentation:<BR/>Event reporting/Risk Console<BR/>Start IDT post fall review<BR/>SBAR communication form<BR/>24-hour report<BR/>Neuro checks .<BR/>.

Based on observation, interviews and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one (Medication Aide 400 /500 Halls Medication Cart) of four medication carts reviewed for storage of medications.<BR/>-The facility failed to ensure Medication Aide medication cart 400 /500 halls did not store medications with punctured or torn backs. <BR/>This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion.<BR/>Findings include:<BR/>Observation on 5/26/2022 at 1:21 PM of the medication aide medication cart for the 400/500 halls revealed narcotic storage of Tramadol 50mg tablet #15 of 30 tablets with a small pin size puncture on the back of the individual medication container.<BR/>Observation on 5/26/2022 at 1:26 PM of the medication aide medication cart for the 400/500 halls revealed narcotic storage of Lyrica 75 mg tablet #1 of 30 tablets with a tear on the back corner of the individual medication container.<BR/>In an interview on 5/26/2022 at 1:33 PM, MA B said the individual blister packs were checked each shift during the shift change narcotic count. If we find a torn back, we were to notify our nurse so the pill would be wasted. Risks of the backs being torn could be that the pill would come out and someone else could take it. It could mess up our narcotic count.<BR/>In an interview on 5/26/2022 at 1:40 PM, LVN K said the narcotic blister packs were checked every shift and the medication was to be wasted. The risk of a broken back was the pill could fall out and be taken by someone who should not have it.<BR/>In an interview on 5/26/2022 at 1:50 PM, Unit Manager LVN Z said the nurse managers check the carts weekly but the nurse and the medication aide who was on the cart was the one responsible for checking the carts each shift. The risk of having the torn back was a major problem even though the carts were double locked there can be an infection control issue, the pill could fall out and be taken by the wrong person. We have to waste the pill and notify the pharmacy because it can cause the medication to run out early.<BR/>In an interview on 5/26/2022 at 2:01 PM, the DON said the carts were checked every week by the unit managers. The nurses and the medication aides were to check the carts with every shift change narcotic count. The risk if the integrity of the blister pack was found to be altered was an infection control issue and a diversion risk. To prevent this from occurring again we will educate on the importance of checking the backs of the blister packs each shift. We have in-serviced on medication storage but will focus more on checking the backs of the blister packs.<BR/>In an interview on 5/26/2022 at 2:47 PM with the Administrator he said regarding the backs of the narcotics if we find anything that looks like it was tampered with, we would look in to it, do a count and cart audit. We have not had any tampering with medications or medication diversions.<BR/>Record review of the facility's policy titled Storage and Expiration Dating of Medications, Biologicals dated January 2022 read in part . Applicability: This policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles .13.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security .<BR/>.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans, in that: <BR/>-The facility failed to care plan Resident #1's diagnosis of type 2 diabetes mellitus and use of insulin. <BR/>This failure placed residents at risk of not having their individual care needs met and cause residents not to receive needed services.<BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 02/13/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar). <BR/>Record review of Resident #1's undated physician orders, reflected in part .Lantus SoloStar subcutaneous solution pen-injector 100 unit/mL .inject 45 unit subcutaneously every 12 hours .start date: 01/30/24 .and Insulin Lispro (1 Unit Dial) subcutaneous solution pen-injector 100 unit/mL .inject 20 unit subcutaneously before meals .start date: 01/30/24 .<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 01/26/24, revealed a BIMS score of 15, indicating resident was cognitively intact. Further review of Section I - Active Diagnoses, Metabolic, I2900., revealed diabetes mellitus was marked. Section N - Medications, N0300., Injections, N0350., Insulin, revealed resident received insulin injections.<BR/>Record review of Resident #1's care plan, undated, revealed it did not address his diagnosis of Type 2 diabetes and the use of insulin.<BR/>Observation and interview on 02/13/24 at 4:15 p.m., revealed Resident #1 was awake and lying in bed. He said he was a diabetic and took insulin . He said he went out on pass/leave Saturday morning, 02/10/24, at approximately 8:30 a.m. and returned back to the facility on Monday, 02/12/24, at approximately 1:30 p.m. He said the facility did not send his insulin medications with him.<BR/>In an interview on 02/14/24 at 3:50 p.m., the DON said the MDS nurse was responsible for developing and revising care plans, but she was on PTO. She said Resident #1's type 2 diabetes mellitus diagnosis should have been on his care plan. She said the purpose of the care plan was to tell them the resident's plan of care. She said not having the diagnosis on Resident #1's care plan did not affect his care. She said care plans were updated as needed but revised quarterly. She said the facility did not have a policy on comprehensive care plans.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for one of one facility for residents, staff, and the public as evidence by:<BR/>Gnats were observed on 100 hall, 200 hall, 300 hall, 500 hall, the nurse's station, and the conference room. <BR/>These failures could place 106 residents in the facility at risk of infection and decline in their health.<BR/>Findings included:<BR/>Observation on 7/25/2023 at 9:36a.m. revealed a gnat flying in the 500 hall, outside of the resident's rooms.<BR/>Observation and interview on 7/25/2023 at 10:34a.m, revealed, two gnats on 100 hall, flying in the hallway, outside of the resident's room. <BR/>Observation on 7/26/2023 at 1:15p.m., revealed a gnat flying around surveyor's food in the conference room.<BR/>Observation on 7/27/2023 at 2:00p.m. revealed several gnats on 200 hall near the resident's room.<BR/>Observation on7/28/2023 at 2:51p.m., revealed a gnat flying at the nurse's station.<BR/>Record review of the facility's Work Orders revealed that a work order had only been made one time for the janitor's closet and in the kitchen area regarding gnats, during 5/1/2023-7/26/2023.<BR/>During an interview on 7/27/2023 at 12:09p.m., with the DSS, said when there was an issue with insects and pest in the building, he calls the pest control company to service the building. He said he was responsible for making the call to the pest control company. He said he was training the new maintenance assistant and he helped with making rounds. He said the maintenance assistant started working for the facility a month ago. He said he called pest control about the gnats on yesterday. He said the gnats were everywhere in the facility. He said if he sees the gnats in the resident's room, he will remove the resident and spray the room. He said having gnats in the building is an infection control issue and it is an environmental issue. He said it can also spread diseases.<BR/>During an interview on 7/27/2023 at 2:51p.m., with the MA, said he has been working at the facility for 2 months. He said he was being trained to do general maintenance. He said it was important to clean and keep the building free of insects and pest and to keep the building in the healthiest condition. He said a clean environment was ideal for facility like this one. He said if he found any issues in the building regarding gnats or other insects, he would report it to his supervisor and the supervisor would report it to the ADM.<BR/>During an interview on 7/27/2023 at 3:30p.m., with the ADM, said the facility and the resident's rooms should be cleaned daily. She said the reason it should be cleaned was to have infection control, environmental control, to eliminate odors, pest control and good sanitation. She said pest control comes out monthly or as needed. She said called pest control to come and spray the building for gnats.<BR/>During an interview on 7/27/2023 at 12:54p.m., with HK H, said he has been working at the facility for 28 years. He said his job was to empty the trash, wax the floors, mop the hallways, and bring the supplies. He said he changes the trash 3x's a day. He said laundry does the trash at night. He said changing the trash will keep gnats from entering the resident's room.<BR/>Record Review of the facility's policy titled Pest Control revised on 06/2019 read in part . It is the policy of this facility that the facility will maintain an effective pest control program to prevent or eliminate infestation of pest and rodents. Director of Support Services is the designated Pest Management Coordinator for this facility. This person will act as a liaison between Facility and the pest management professional

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans, in that: <BR/>-The facility failed to care plan Resident #1's diagnosis of type 2 diabetes mellitus and use of insulin. <BR/>This failure placed residents at risk of not having their individual care needs met and cause residents not to receive needed services.<BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 02/13/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar). <BR/>Record review of Resident #1's undated physician orders, reflected in part .Lantus SoloStar subcutaneous solution pen-injector 100 unit/mL .inject 45 unit subcutaneously every 12 hours .start date: 01/30/24 .and Insulin Lispro (1 Unit Dial) subcutaneous solution pen-injector 100 unit/mL .inject 20 unit subcutaneously before meals .start date: 01/30/24 .<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 01/26/24, revealed a BIMS score of 15, indicating resident was cognitively intact. Further review of Section I - Active Diagnoses, Metabolic, I2900., revealed diabetes mellitus was marked. Section N - Medications, N0300., Injections, N0350., Insulin, revealed resident received insulin injections.<BR/>Record review of Resident #1's care plan, undated, revealed it did not address his diagnosis of Type 2 diabetes and the use of insulin.<BR/>Observation and interview on 02/13/24 at 4:15 p.m., revealed Resident #1 was awake and lying in bed. He said he was a diabetic and took insulin . He said he went out on pass/leave Saturday morning, 02/10/24, at approximately 8:30 a.m. and returned back to the facility on Monday, 02/12/24, at approximately 1:30 p.m. He said the facility did not send his insulin medications with him.<BR/>In an interview on 02/14/24 at 3:50 p.m., the DON said the MDS nurse was responsible for developing and revising care plans, but she was on PTO. She said Resident #1's type 2 diabetes mellitus diagnosis should have been on his care plan. She said the purpose of the care plan was to tell them the resident's plan of care. She said not having the diagnosis on Resident #1's care plan did not affect his care. She said care plans were updated as needed but revised quarterly. She said the facility did not have a policy on comprehensive care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans, in that: <BR/>-The facility failed to care plan Resident #1's diagnosis of type 2 diabetes mellitus and use of insulin. <BR/>This failure placed residents at risk of not having their individual care needs met and cause residents not to receive needed services.<BR/>The findings included:<BR/>Record review of Resident #1's admission Record, dated 02/13/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar). <BR/>Record review of Resident #1's undated physician orders, reflected in part .Lantus SoloStar subcutaneous solution pen-injector 100 unit/mL .inject 45 unit subcutaneously every 12 hours .start date: 01/30/24 .and Insulin Lispro (1 Unit Dial) subcutaneous solution pen-injector 100 unit/mL .inject 20 unit subcutaneously before meals .start date: 01/30/24 .<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 01/26/24, revealed a BIMS score of 15, indicating resident was cognitively intact. Further review of Section I - Active Diagnoses, Metabolic, I2900., revealed diabetes mellitus was marked. Section N - Medications, N0300., Injections, N0350., Insulin, revealed resident received insulin injections.<BR/>Record review of Resident #1's care plan, undated, revealed it did not address his diagnosis of Type 2 diabetes and the use of insulin.<BR/>Observation and interview on 02/13/24 at 4:15 p.m., revealed Resident #1 was awake and lying in bed. He said he was a diabetic and took insulin . He said he went out on pass/leave Saturday morning, 02/10/24, at approximately 8:30 a.m. and returned back to the facility on Monday, 02/12/24, at approximately 1:30 p.m. He said the facility did not send his insulin medications with him.<BR/>In an interview on 02/14/24 at 3:50 p.m., the DON said the MDS nurse was responsible for developing and revising care plans, but she was on PTO. She said Resident #1's type 2 diabetes mellitus diagnosis should have been on his care plan. She said the purpose of the care plan was to tell them the resident's plan of care. She said not having the diagnosis on Resident #1's care plan did not affect his care. She said care plans were updated as needed but revised quarterly. She said the facility did not have a policy on comprehensive care plans.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for one of one facility for residents, staff, and the public as evidence by:<BR/>Gnats were observed on 100 hall, 200 hall, 300 hall, 500 hall, the nurse's station, and the conference room. <BR/>These failures could place 106 residents in the facility at risk of infection and decline in their health.<BR/>Findings included:<BR/>Observation on 7/25/2023 at 9:36a.m. revealed a gnat flying in the 500 hall, outside of the resident's rooms.<BR/>Observation and interview on 7/25/2023 at 10:34a.m, revealed, two gnats on 100 hall, flying in the hallway, outside of the resident's room. <BR/>Observation on 7/26/2023 at 1:15p.m., revealed a gnat flying around surveyor's food in the conference room.<BR/>Observation on 7/27/2023 at 2:00p.m. revealed several gnats on 200 hall near the resident's room.<BR/>Observation on7/28/2023 at 2:51p.m., revealed a gnat flying at the nurse's station.<BR/>Record review of the facility's Work Orders revealed that a work order had only been made one time for the janitor's closet and in the kitchen area regarding gnats, during 5/1/2023-7/26/2023.<BR/>During an interview on 7/27/2023 at 12:09p.m., with the DSS, said when there was an issue with insects and pest in the building, he calls the pest control company to service the building. He said he was responsible for making the call to the pest control company. He said he was training the new maintenance assistant and he helped with making rounds. He said the maintenance assistant started working for the facility a month ago. He said he called pest control about the gnats on yesterday. He said the gnats were everywhere in the facility. He said if he sees the gnats in the resident's room, he will remove the resident and spray the room. He said having gnats in the building is an infection control issue and it is an environmental issue. He said it can also spread diseases.<BR/>During an interview on 7/27/2023 at 2:51p.m., with the MA, said he has been working at the facility for 2 months. He said he was being trained to do general maintenance. He said it was important to clean and keep the building free of insects and pest and to keep the building in the healthiest condition. He said a clean environment was ideal for facility like this one. He said if he found any issues in the building regarding gnats or other insects, he would report it to his supervisor and the supervisor would report it to the ADM.<BR/>During an interview on 7/27/2023 at 3:30p.m., with the ADM, said the facility and the resident's rooms should be cleaned daily. She said the reason it should be cleaned was to have infection control, environmental control, to eliminate odors, pest control and good sanitation. She said pest control comes out monthly or as needed. She said called pest control to come and spray the building for gnats.<BR/>During an interview on 7/27/2023 at 12:54p.m., with HK H, said he has been working at the facility for 28 years. He said his job was to empty the trash, wax the floors, mop the hallways, and bring the supplies. He said he changes the trash 3x's a day. He said laundry does the trash at night. He said changing the trash will keep gnats from entering the resident's room.<BR/>Record Review of the facility's policy titled Pest Control revised on 06/2019 read in part . It is the policy of this facility that the facility will maintain an effective pest control program to prevent or eliminate infestation of pest and rodents. Director of Support Services is the designated Pest Management Coordinator for this facility. This person will act as a liaison between Facility and the pest management professional

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for food and nutrition services.<BR/>-The facility failed to ensure the dumpster door was closed at all times when no one was dumping garbage. <BR/>This failure could place residents at risk of infection from improperly disposed garbage.<BR/>Findings include:<BR/>Observation on 09-24-24 at 8:45 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster &frac34; full of garbage and the dumpster door was open.<BR/>In an interview on 09-24-24 at 8:45 am, with the Food Service Manager, she stated the dumpster door were kept closed when not in use to keep vermin, pests, and insects out of the dumpster and from entering the facility. She stated housekeeping, and nursing also discarded their waste garbage in the dumpster. It was the responsibility of staff from dietary, nursing and housekeeping for ensuring the dumpster doors are kept closed when not in use.<BR/>Record review of facility's policy and procedure on waste disposal dated 6/2019, reflected trash containers, liners are secured and collected.<BR/> .5. Cover waste containers and close dumpster at all times.

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 in 1 of 1 kitchen reviewed for food procurement.<BR/> The facility failed to ensure/prepared food was discarded after 72 hours (3 days) per facility policy.<BR/>These failures could place residents at risk of food borne illness and disease. <BR/>Findings Include:<BR/>Observation of the facility kitchen on 09/24/24 at 8:15 AM revealed the following. <BR/>1. A plastic container of Shredded Monterey Cheese, dated 9/20/24.<BR/>2. A plastic container of gravy, dated 9/20/24.<BR/>3. A plastic bag of green salad, dated 9/15/24.<BR/>In an interview with the Dietary Food Service Manager on 09/24/24 at 8:30 AM, she stated the leftover food stored in the refrigerator should have been used or discarded prior to the use by date. She stated she or a designee, should be responsible for checking the refrigerator daily for food items that were expiring, and should be discarded prior to the expiration date.<BR/>Record review of facility's policies and procedures for Food Safety dated June 1, 2019 - reflected in part, .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded after 72 hours unless otherwise indicated.