Every finding on record at Accel at College Station

Based on observation, interview, and record review the facility failed to ensure that residents receive care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcers for 1 of 5 residents (Resident #2) reviewed for skin integrity. The facility failed to initiate treatment for Resident #2's unstageable pressure ulcer to his right heel when it was found during a skin assessment on 08/09/2026 with the treatment order not being obtained until 08/13/2026 and not started prior to Resident #2 being discharged home on [DATE] and the family not finding the unstageable pressure ulcer until 36 hours after returning home and finding a second unstageable ulcer to his left heel at that time. This failure could lead to residents developing preventable ulcers and skin breakdowns. Findings included: Review of Resident #2's face sheet dated 08/20/2026 reflected an [AGE] year old male admitted to the facility on [DATE] and discharged on 08/13/2026 with the following diagnoses venous insufficiency chronic peripheral (decreased circulation of the legs) diabetes mellitus type 2 (A condition results from insufficient production of insulin, causing high blood sugar.) and non-pressure chronic ulcers to right and left calf. Review of Resident #2's admission MDS dated [DATE] reflected he was assessed to have a BIMS score of 8 indicating moderate cognitive impairment. Resident #2 was assessed to be at risk for pressure ulcers and to have one unhealed stage 3 pressure ulcer. He was further assessed to have 2 venous and arterial ulcers, and MASD. Review of Resident #2's comprehensive care plan reflected a focus area initiated on 07/20/2026 [Resident #2 has actualimpairment to skin integrity related to fragile skin. Interventions included; Administer treatment as ordered; Follow facility protocols for treatment of injury and Keep skin clean and dry. Use lotion on dry skin. Resident #2's care plan did not address pressure ulcers, or other skin impairments. Further review of Resident #2's care plan reflected a focus area initiated 08/06/2026 [Resident #2] has peripheral vascular disease related to venous insufficiency chronic peripheral, atherosclerotic heart disease. Interventions included Observe/document/report to MD PRN any signs or symptoms of complications of extremities: coldness of extremity, pallor, rubor, cyanosis and pain. Observe/document/report to MD PRN any signs or symptoms of skin problems related to PVD: Redness, Edema, Blistering, Itching, Burning, Bruises, Cuts, other skin lesions. Review of the complaint narrative reported on 08/19/2026 reflected Resident #2's family reported the resident had pressure ulcers develop during his stay. The family member stated that 36 hours after he was home they found the pressure ulcers. The report noted that no one at the facility reported to them that he had the pressure ulcers. Review of the photos provided by the family member reflected unstageable pressure injuries to his right and left heel both approximately 6cm by 4cm. Attempts to contact the complainant on 08/20/2026 at 3:24 pm and 4:50 pm and on 08/24/2026 at 3:18 pm via email were unsuccessful. Review of Resident #2's weekly skin review assessments reflected he had weekly skin assessments preformed. His last skin assessment done on 08/09/2026 reflected a new area identified to his right heel. No measurements or other descriptions were documented. No area was documented for his left heel. The skin assessment was signed by RN D. Review of Resident #2's wound evaluation and management summary dated 08/12/2026 by the wound doctor reflected an unstageable pressure ulcer (due to necrosis) of the right heel with the ulcer being 6 cm x 4cm x 0.2 cm. The wound care MD ordered alginate calcium with silver daily and general recommendations of off-load wounds, reposition per facility protocol, float heels in bed and elevate legs. Review of Resident #2's consolidated physician orders reflected an order dated 08/13/2026 with a start date of 08/14/2026 Location of wound: Right heel unstageable PI (pressure injury) Cleanse PI to the right heel with ns, pat dry, apply calcium alginate AG to thewound bed, cover with ABD pad and wrap with kerlix. Review of Resident #2's TAR for August 2026 reflected no treatments preformed on Resident #2's right heel pressure injury. In an interview on 08/20/2026 at 2:43 pm the DON stated the weekend supervisor (RN D) did the skin assessment on Resident #2 on 08/09/2026 and she was not sure if she reported it to anyone. She stated Resident #2 was seeing the wound care physician. After the DON reviewed Resident #2's EMR she stated it looks like the treatment was not started on his right heel pressure ulcer. She stated they should have obtained treatment orders on 08/09/26 when the ulcer was found. In an interview on 08/20/2026 at 4:05 pm Resident #2's NP stated the facility floated all residents' heels; she stated the old treatment nurse (stated no longer working at facility) stayed on top of the residents' wounds. She stated Resident #2 he had a lot of issues with his legs and circulation. She stated his wounds were unavoidable due to multiple comorbidities. She stated she expected treatments for wounds to start as soon as they are discovered and that interventions such as floating the heels should be on the resident's care plan. She stated she did not know about the DTI to his right heel she stated he had his legs wrapped from his feet to his knees. In an interview on 08/20/2026 at 5:02 pm RN D stated Resident #2 did not have an open area that he had a dark area DTI to right heel. She stated he did not have a pressure ulcer to his left heel on 08/09/2026 when she did the skin assessment. She stated she reported the pressure ulcer to treatment nurse (no longer at the facility). She stated she did not call the doctor or get orders for the pressure ulcer at that time. RN D stated she thought the wound care doctor was coming the next day. Stated she should have called the doctor, but she thought the NP was supposed to come the next day. Review of the facility's policy pressure ulcers/ skin breakdown clinical protocol dated 04/2027 reflected 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. 1.The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 1.During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds. 2. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions.

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #1) reviewed for nutrition status. The facility failed to provide dietary interventions for Resident #1 when she had 16.48 % weight loss from 04/10/2026 to 05/11/2026 (152.3 lbs. to 127.2 lbs.) and a decreased ability to feed herself and a decline in oral intake secondary to Resident #1 increased Parkinsonian features (refer to a group of motor symptoms, rigidity, tremor, and postural instability that resemble those seen in Parkinson's disease) and swallowing problems. Interventions for weight loss did not start until 06/05/2026. Resident #1 had a continued weight loss at three months 06/10/2026 (115 lbs.) 24.49 % and continued to experience weight loss at 6 months from 04/10/2026 to 08/10/2026 of (152.3 lbs. to 92.8 lbs.) 39.7% (59.5 lbs.). These failures could place residents at risk for malnutrition, muscle loss, weakened immunity and increased hospitalization risk.Findings Included: Review of Resident #1's face sheet dated 08/19/2026 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses malignant neuroleptic syndrome (a rare and life-threatening reaction to the use of any neuroleptic medication. Neuroleptics, also known as antipsychotic medications, treat and manage symptoms of many psychiatric conditions.), spastic quadriplegic cerebral palsy (It is characterized by increased muscle tone. This makes muscles stiff and movements jerky and awkward.) and mild intellectual disabilities (involves both reduced cognitive abilities and challenges in adaptive functioning skills needed for daily life.) Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 4 indicating severe cognitive impairment. Resident #1was assessed to require supervision or touching assist with eating. She was assessed to have complaints of difficulty or pain with swallowing and to have a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months and to not be on a physician-prescribed weight-loss regimen. Review of Resident #1's comprehensive care plan reflected a focus area dated as initiated on 05/10/2026 and revised on 07/20/2026 reflected [Resident #1] is at risk for weight fluctuations d/t (due to) changes in appetite and depression. 7/10/26- -3.0% change over 30 day(s) -7.5% change. The goal listed was Will maintain adequate nutritional status as evidenced by maintaining weight within baseline, no signs or symptoms of malnutrition, and consuming at least 75% of meals served daily, Date Initiated: 05/21/2026 Target Date: 11/01/2026. Interventions listed: Monitor weights as per facility protocol, Date Initiated: 05/10/2026; New order Add Resource 2.0 60 ml TID Date Initiated: 07/20/2026; RD to evaluate and treat, Date Initiated: 05/10/2026; Report to MD PRN no signs or symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months and >10% in 6 months Date Initiated: 05/10/2026; Weekly weights for 4 week, Date Initiated: 07/20/2026. Further review of her comprehensive care plan reflected a focus area dated 11/26/2025. The goal was for resident to maintain adequate nutritional status through review date. Interventions listed were: Administer medications as ordered. Observe/Document for side effects and effectiveness. Date Initiated: 11/26/2025; Observe/document/report to MD PRN for s/sx (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, holding food in mouth, several attempts at swallowing, refusing to eat, Appears concerned during meals. Date Initiated: 11/26/2025; Provide, serve diet as ordered. Monitor intake and record q meal. Date Initiated: 11/26/2025. No other interventions were listed. Further review of Resident #1's comprehensive care plan reflected a focus area dated 11/26/2025 [Resident #1] has a swallowing problem related to DYSPHAGIA, OROPHARYNGEAL PHASE. The goal was for Resident #1 to have clear Lungs, no signs and symptoms of aspiration through the review date. The only intervention listed was Observe/document/report to nurse/dietitian and MD PRN for difficulty swallowing, holding food in mouth, prolonged swallowing time, repeated swallows per bite, coughing, throat clearing, drooling, pocketing food in mouth Date Initiated: 11/26/2025 Review of Resident #1's consolidated physician orders for August 2026 reflected the following orders with dates for weight loss interventions: Remeron (mirtazapine) 30 mg one tablet by mouth at bedtime for major depressive disorder start date 11/05/2025; HS (night time) snack at bed time with start date 11/05/2025; Health shake or equivalent two times a day with start date 06/05/2026; Liquid protein supplement two times a day for wound healing give 30 ml BID start date 06/11/2026; resource 2.0 or equivalent three times a day for supplement give 60 ml start date 07/14/2026. ST (speech therapy) five times a week for 30 days for dysphagia therapy, patient/caregiver education, and/or discharge planning start date 07/29/2026; Regular diet puree (dysphasia pureed level 1) texture regular consistency start date 08/05/2026. Review of Resident #1's weights from 04/10/2026 through 08/10/2026:04/10/2026 152.3 lbs.05/10/2026 121.4 lbs.05/11/2026 127.2 lbs.06/05/2026 118.4 lbs.06/10/2026 115 lbs.07/10/2026 110 lbs.08/10/2026 92.8 lbs. Review of Resident #1's nursing progress note dated 05/10/2026 signed by the ADON reflected her weight was 121.4 lbs. indicating a 5% change over 30 days [20.4%, 31 lbs.]; 10% change over 180 days [22.9%, 36 lbs.]; 7.5% change [20.9%, 32 lbs.]. continue POC (plan of care) WNL (within normal limits). In an interview on 08/19/2026 at 11:50 am the DON stated the ADON was in charge of doing the weights and inputting them into the resident record. She stated she would need to review Resident #1's record to see why her weight loss was not addressed in May. She stated the facility did a PIP (performance improvement plan) in April due to people not doing their job and them having a problem with the resident weights not being right. In an interview on 08/19/2026 at 12:22 pm Resident #1's NP stated he did not have Resident #1's records in front of him but he knows they addressed her weight loss but not sure when they started addressing it. He stated Resident #1 stopped eating and needed more assistance. He stated he saw her on 04/29/2026 but her weight was not an issue at that point. He stated the next time he saw her was o6/25/2026 and been addressing her weight since then. He stated she had tardive dyskinesia due to her psychotropic drugs, and it was causing a decline in her mobility, and she was having a lot of behaviors when she was up and was no longer able to sit in her wheelchair. He stated he was not able to say if interventions had been started in May would have prevented her decline he would have to look at his notes. Observation and interview on 08/19/2026 at 12:52 pm revealed Resident #1 in room in bed with a family member at bedside. The family member was preparing to feed Resident #1 and took the lid off her meal tray to reveal a regular diet. The family member stated this tray is wrong because she is supposed to be on a pureed diet. CNA A entered the room and Resident #1's family member told her the tray was wrong. CNA A stated yes she is supposed to be on a pureed diet. Resident #1's family member told CNA A that she is supposed to get at milkshake too. CNA A told the family member she would bring another tray and left with the meal tray. Resident #1 was in bed unable to verbalize needs. Her tremors were very prominent with both her arms and legs shaking and she had a consistent verbalization of incoherent sounds. Resident #1 was on her back with her arms and legs drawn up into the fetal position. Resident #1's family member stated she had drug induced Parkinson's. She stated she thinks Resident #1's decline and weight loss started at the end of June or early July. She stated she fed her lunch a couple days a week and she usually eats pretty good on the pureed diet. CNA A entered the room with the new meal tray and placed it on the over bed table; no milk shake was observed. Resident #1's family member again asked for a milk shake from CNA A. ST entered the room. ST stated Resident #1 required total assist with feeding. ST stated she caught Resident #1's weight loss during a quarterly screening she stated the facility staff did not request a ST eval and she did not pick her up until the end of July. She stated the facility should have contacted her in May when the weight loss and eating decline started. ST stated Resident #1 could eat regular food and would not choke if she ate regular food she just consumes more because it is easier to eat. She stated looking at the diet card on Resident #1's food tray that the diet order is confusing on the card. She stated it starts with Regular then pureed comes after that and it is abbreviated. She stated that might be why she got the wrong tray. Resident #1's family member stated that it was the first time she has seen the wrong meal tray. In an interview on 08/19/2026 at 1:22 pm the MDS Coordinator stated that she did not do a significant change assessment on Resident #1 in July due to a PIP being in place due to the weights being wrong and the facility needing to redo the weights. She stated that once the weight loss was confirmed in July and Resident #1 developed sores a significant change assessment should have been done. In an interview on 08/19/2026 at 2:40 pm the ADON provided dietitian recommendation summary for Resident #1 for May, June and July 2026. She stated that the facility had weekly weight meetings and they reviewed the weights. She stated she had weekly weights in another binder they were not in PCC and she would provide them. Review of the facility's Dietitian Recommendation Summary dated 05/20/2026 reflected Resident #1 name was listed. The assessment type was listed as Wt. Var (weight variance) with recommendation of Continue current POC. BMI WNL. Handwritten on the form was on Remeron. (Resident #1 with a 25.1 lb. weight loss; 16.48%) Review of the facility's Dietitian Recommendation Summary dated 06/03/2026 reflected Resident #1 name was listed. The assessment type was listed as quarterly with recommendation of add health shake BID with no follow-up needed. (Resident #1 with a continued weight loss of another 8.8 lbs.) Review of the facility's Dietitian Recommendation Summary dated 07/12/2026 reflected Resident #1 name was listed. The assessment type was listed as weight loss with recommendation of add resource 2.0 60 ml TID (three times daily) with no follow-up needed. (Resident #1 with a continued weight loss of another 8.4 lbs. 24.49%) Review of Resident #1's quarterly nutritional screening dated 06/03/2026 signed by the RD reflected her most recent weight was 127.2 lbs., her BMI was 22.5, she was checked for significant weight loss and was checked that her average meal intake was from 26-50%. Resident #1's supplements were listed as HS snack. The assessment of her feeding ability was left blank, it indicated she had a chewing/ swallowing problem, and she did not have pressure sores. The summary/plan reflected Res for quarterly nutrition assessment. Res pending SLP eval for issues with liquids. Res consumes 25-50% of meals. Res with hx of wt loss 152-127#, BMI 22.5, WNL. Rec health shake BID for nutrition support. REs to consume >50% of meals and supplements to meet EEN. Skin: intact Labs: None Meds: reviewed Goals- no s/s dehydration; no sig wt changes through next review; Continue current nutrition POC. In an interview on 08/19/2026 at 2:55 pm the RD stated they do a weight meeting and that her notes do not go into PCC she stated she only does the quarterly assessment in PCC and that the facility would need to document the weight meeting notes under progress notes. The RD stated regarding Resident #1 she thinks, but she does not have her notes to be sure that she was put on a supplement with the meal tray, then resource for the goal of consistent intake. She stated at some point her diet was downgraded. She stated that other interventions that could have been done were a magic cup with the meal tray and weekly weights. She stated she was not sure if they did weekly weights for Resident #1. She stated no interventions were done for Resident #1 in May because her BMI was within normal limits, so she did not have concerns about her weight at that point. She stated she did not see Resident #1 before the 06/03/2026 that was when her quarterly assessment was due. She stated she had been at the facility since the end of March 2026, and they started interventions on Resident #1 when she went below BMI. Review of the website dietitianmentor.com on 08/19/2026 reflected In long-term care, unintentional weight loss (UWL) is defined by CMS as a loss of 5% of body weight in the past 30 days or 10% in the past 90 days, regardless of BMI. This means that even if a resident's BMI is within normal range, a 16.48% loss over a short period is clearly in the UWL category and should trigger immediate intervention. In an interview on 08/19/2026 at 3:00 pm Resident #1's Psych NP stated she had noticed a recent decline in Resident #1 physical and mental health and stated she felt she had hallucinations and voices telling her not to eat. She stated she was going to add Seroquel to help with the hallucinations. She stated she felt her decline was mostly related to her multiple diagnoses. In an interview on 08/19/2026 at 3:15 pm CNA A stated she frequently works with Resident #1 and stated she has noted she has been in a decline for about 3 months. She stated she for about 3 months she would refuse to eat and say no all the time. She stated she was aware of her new status of being a feeder. She stated they could no longer get Resident #1 up in her chair any longer due to her sloughing forward in her chair and was not able to sit up straight. CNA A stated she would not drink and they had to give her IV's a couple of times. She stated she did not know she needed a milk shake she did not think was on her diet card. In an interview on 08/19/2026 at 3:20 PM CNA B stated she had noticed a decline in Resident #1 she stated Resident #1 had stopped eating. She stated Resident #1 would refuse to eat and they were no longer able to get her up in the wheelchair because she would just fall forward. Review of the facility's policy Nutrition (impaired) /unplanned weight loss- clinical protocol dated 12/2008 reflected The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100]:1. 1 month - 5% weight loss is significant; greater than 5% is severe. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe.1. The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: 1. Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals. 1. Evaluating the resident's response to interventions should be based on defined criteria for improvement/worsening of nutritional status; for example, stabilization of weight, laboratory values, or food/fluid intake. 2. The Physician, with input from the staff, will determine the most appropriate intervals for weight assessments.

Based on observation, interview and record review, the facility failed to make a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within 14 days after the facility determines, or should have determined, that there had been a significant change in the resident's physical or mental condition for 1 of 7 residents (Resident #1) reviewed for a change in condition. The facility failed to complete a significant change assessment after Resident #1 had a significant weight loss of 16.48 % from 04/10/2026 to 05/11/2026 (152.3 lbs. to 127.2 lbs.) a decreased ability to feed herself, get out of bed and the development of skin breakdown on 06/20/2026. The failure could place residents at risk of not having their needs met and further decline.Findings included: Review of Resident #1's face sheet dated 08/19/2026 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses malignant neuroleptic syndrome (a rare and life-threatening reaction to the use of any neuroleptic medication. Neuroleptics, also known as antipsychotic medications, treat and manage symptoms of many psychiatric conditions.), spastic quadriplegic cerebral palsy (It is characterized by increased muscle tone. This makes muscles stiff and movements jerky and awkward.) and mild intellectual disabilities (involves both reduced cognitive abilities and challenges in adaptive functioning skills needed for daily life.) Review of Resident #1's comprehensive care plan reflected a focus area dated as initiated on 05/10/2026 and revised on 07/20/2026 reflected [Resident #1] is at risk for weight fluctuations d/t (due to) changes in appetite and depression. 7/10/26- -3.0% change over 30 day(s) -7.5% change. The goal listed was Will maintain adequate nutritional status as evidenced by maintaining weight within baseline, no signs or symptoms of malnutrition, and consuming at least 75% of meals served daily, Date Initiated: 05/21/2026 Target Date: 11/01/2026. Interventions listed: Monitor weights as per facility protocol, Date Initiated: 05/10/2026; New order Add Resource 2.0 60ml TID Date Initiated: 07/20/2026; RD to evaluate and treat, Date Initiated: 05/10/2026; Report to MD PRN no signs or symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months and >10% in 6 months Date Initiated: 05/10/2026; Weekly weights for 4 week, Date Initiated: 07/20/2026. Further review of her comprehensive care plan reflected a focus area dated 06/26/2026 [Resident #1] has actual impairment of skin integrity related to right1st toe DTI. The care plan also reflected a focus are dated 06/26/2026 for an impairment of skin integrity related to non-pressure wound to left 1st toe. Review of Resident #1's weights from 04/10/2026 through 08/10/2026:04/10/2026 152.3 lbs.05/10/2026 121.4 lbs.05/11/2026 127.2 lbs.06/05/2026 118.4 lbs.06/10/2026 115 lbs.07/10/2026 110 lbs.08/10/2026 92.8 lbs. Review of Resident #1's MDS assessments reflected a quarterly MDS was done on 05/20/2026 and on 07/10/2026. No significant change MDS assessment was initiated until 08/19/2026. Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 4 indicating severe cognitive impairment. Resident #1was assessed to require supervision or touching assist with eating. She was assessed to have complaints of difficulty or pain with swallowing and to have a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months and to not be on a physician-prescribed weight-loss regimen. Resident #1 was assessed to have skin tears and applications of dressing to her feet. Review of Resident #1's consolidated physician orders dated 08/19/2026 reflected an order dated 06/20/2026 location of wound Left 1st toe clean with wound cleanser, pat dry, apply calcium alginate and cover with a dry dressing. And an order with original start date 06/20/2026 for Right 1st toe cleanse with wound cleanser, pat dry apply calcium alginate and cover with dry dressing. Observation and interview on 08/19/2026 at 12:52 pm revealed Resident #1 in room in bed with a family member at bedside. The family member was preparing to feed Resident #1. Resident #1's family member stated she had drug induced Parkinson's. She stated she thinks Resident #1's decline and weight loss started at the end of June or early July. She stated she fed her lunch a couple days a week and she usually eats pretty good on the pureed diet. Resident #1's family member pulled back Resident #1's covers to reveal her feet and the presence of a DTI on her right and left big toe. Resident #1's toes were digging into the mattress (hammer toes) Resident #1's family member stated they try to get her to use the boots, but she does not like them. She stated Resident #1 sees the wound care doctor all the time and feels like her toes are getting better. ST (speech therapy) entered the room. ST stated Resident #1 required total assist with feeding. ST stated she caught Resident #1's weight loss during a quarterly screening she stated the facility staff did not request a ST eval and she did not pick her up until the end of July. She stated the facility should have contacted her in May when the weight loss and eating decline started. In an interview on 08/19/2026 at 3:15 pm CNA A stated she frequently works with Resident #1 and stated she has noted she has been in a decline for about 3 months. She stated she for about 3 months she would refuse to eat and say no all the time. She stated she was aware of her new status of being a feeder. She stated they could no longer get Resident #1 up in her chair any longer due to her sloughing forward in her chair and was not able to sit up straight. In an interview on 08/19/2026 at 1:22 pm the MDS Coordinator stated that she did not do a significant change assessment on Resident #1 in July due to a PIP being in place due to the weights being wrong and the facility needing to redo the weights. She stated that once the weight loss was confirmed in July and Resident #1 developed sores a significant change assessment should have been done. In an interview on 08/19/2026 at 1:34 pm the DON stated the facility was working on a pip in May and June related to the resident weights she stated she was not sure if significant change assessment should have been done for Resident #1 and stated they are working on one for her now. Review of the facility's policy comprehensive assessments and the care delivery process dated 12/2016 reflected Comprehensive assessments will be conducted to assist in developing person-centered care plans. 1. Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. 2. Complete the Minimum Data Set within 14 days after admission, within 14 days after it is determined that the resident has had a significant change in physical or mental condition, and annually. 4. Decision making leading to a person-centered plan of care includes1. Selecting and implementing interventions, based on the results of the above.

Based on observations, interviews, and reviews, the facility failed to provide food that was prepared in a form designed to meet individual needs for 1 of 3 residents (Resident #1) reviewed for nutrition status. The facility failed to ensure that Resident #1 was provided with her correct diet on 08/19/2026 when she was provided with a regular textured diet when she was ordered a pureed diet. This failure could affect residents at risk for diminished or altered nutritional status and potential weight loss.Findings included: Review of Resident #1's face sheet dated 08/19/2026 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses malignant neuroleptic syndrome (a rare and life-threatening reaction to the use of any neuroleptic medication. Neuroleptics, also known as antipsychotic medications, treat and manage symptoms of many psychiatric conditions.), spastic quadriplegic cerebral palsy (It is characterized by increased muscle tone. This makes muscles stiff and movements jerky and awkward.) and mild intellectual disabilities (involves both reduced cognitive abilities and challenges in adaptive functioning skills needed for daily life.) Review of Resident #1's quarterly MDS dated [DATE] reflected she was assessed to have a BIMS score of 4 indicating severe cognitive impairment. Resident #1was assessed to require supervision or touching assist with eating. She was assessed to have complaints of difficulty or pain with swallowing and to have a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months and to not be on a physician-prescribed weight-loss regimen. Resident #1 was assessed to be on a mechanically altered diet. Review of Resident #1's comprehensive care plan reflected a focus area dated 11/26/2025. The goal was for resident to maintain adequate nutritional status through review date. Interventions included Provide, serve diet as ordered. Monitor intake and record q meal. Date Initiated: 11/26/2025. Review of Resident #1's consolidated physician orders for August 2026 reflected Regular diet puree (dysphasia pureed level 1) texture regular consistency start date 08/05/2026. Observation and interview on 08/19/2026 at 12:52 pm revealed Resident #1 in room in bed with a family member at bedside. The family member was preparing to feed Resident #1 and took the lid off her meal tray to reveal a regular diet. The family member stated this tray is wrong because she is supposed to be on a pureed diet. CNA A entered the room and Resident #1's family member told her the tray was wrong. CNA A stated yes she is supposed to be on a pureed diet. ST entered the room. ST stated Resident #1 required total assist with feeding. ST stated Resident #1 could eat regular food and would not choke if she ate regular food she just consumes more because it is easier to eat. She stated looking at the diet card on Resident #1's food tray that the diet order is confusing on the card. She stated it starts with Regular then pureed comes after that and it is abbreviated. She stated that might be why she got the wrong tray. In an interview on 08/19/2026 at 3:25 pm CNA A stated she took Resident #1's tray to her room. She stated her family member was in the room and she just placed the tray on the overbed table. She stated she did not check the tray. In an interview on 08/19/2026 at 3:30 pm LVN B stated she was working on Resident #1's hall. She stated, I don't work here I am agency. When asked if she checked the hall trays before they went down to the resident rooms she stated No, nobody told me I had to. In an interview on 08/19/2026 at 3:45 pm the DON stated the nursing staff were supposed to check meal trays before they are passed out to make sure everyone has the correct diet. Review of the facility policy Therapeutic diets dated 12/2008 reflected Therapeutic diets shall be prescribed by the Attending Physician. The facility will strive for the fewest possible dietary restrictions. 2. A therapeutic diet must be prescribed by the resident's Attending Physician. The physician's diet order should match the terminology used by Food Services.

Based on observation, interview, and record review the facility failed to ensure the residents receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident ' s comprehensive assessment and plan of care for 3 of 3 (Resident #7, Resident #63, and Resident #120) residents reviewed for call light response. The facility failed to ensure staff answered Resident #7, Resident #63, and Resident #120's call light timely. This failure puts all residents at risk of not getting their need met and staff not responding in case of an emergency.Findings included 1. Record review of Resident #7's face sheet, dated 08/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included streptococcal arthritis (is a rare complication that occurs when the immune system reacts to a recent infection), sepsis ((a life-threatening complication of an infection), moderate protein- calorie malnutrition (inadequate intake of both protein and calories), muscle weakness, chronic kidney disease (a serious condition where the kidneys are severely damaged), and heart failure. Record review of Resident #7's admission MDS assessment, dated 06/26/2026, reflected Resident #7 had a BIMS score of 15, which indicated intact cognitive response. The MDS also revealed resident was set up/clean up assist for toileting. She was also a partial/moderate assist on picking up items. Record review of Resident #7's care plan dated 06/25/2026 revealed it did not have any information on call lights. During an interview with Resident #7 on 08/04/2026 at 2:30 p.m., she said staff did not answer her call light until an hour after she turned it on. She said staff did not answer her call light timely irritated her. She said it happened all the time. She said she did reported to the ADM, but nothing had been done. She said the thought of pushing her call light and having something serious wrong and having to wait an hour was horrible. 2. Record review of Resident #63's face sheet, dated 08/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #63 had diagnoses which included chronic kidney disease (a serious condition where the kidneys are severely damaged), anemia (not enough healthy red blood cells), hypokalemia (low potassium), hypertension (high blood pressure), type 2 diabetes mellitus with diabetic kidney disease (kidney damage due to diabetes), and heart failure. Record review of Resident #63's quarterly MDS assessment, dated 06/26/2026, reflected Resident #63 had a BIMS score of 10, which indicated moderate impairment. The MDS also stated that Resident #63 was substantial/maximal assistance with all ADLS. Record review of Resident #63's care plan dated 06/03/2026 revealed Focus: [Resident #63] is at risk for falls r/t incontinent, weakness, confusion. Goal: Will be free from major injury d/t fall through the review date.Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.During an interview with Resident #63 on 08/04/2026 at 10:47 a.m., she said staff took a while to answer her call light. She said she did not know how long she had to wait. She said it happened all the time. She said she did reported to the ADM, but nothing had been done. She did not answer how she felt about staff taking a while to answer her call light. Observation of Resident #63's call light on 08/04/2026 at 9:45p.m., revealed RN N walked past Resident #63's room while the call light was on twice and did not answer the call light. Observation of Resident #63's call light on 08/04/2026 at 9:53p.m., revealed RN N walked past Resident #63's room and did not answer the call light. 3. Record review of Resident #120's face sheet, dated 08/05/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #120 had diagnoses which included chronic kidney disease (a serious condition where the kidneys are severely damaged), sepsis (a life-threatening complication of an infection), end stage renal disease (kidney failure), dependency on renal dialysis (when the kidneys can no longer filter waste or extra fluid from the blood and regular dialysis treatment is required to sustain life), muscle weakness, and heart failure.Record review of Resident #120's quarterly MDS assessment, dated 08/01/2026, reflected Resident #120 had a BIMS score of 10, which indicated moderate impairment. The MDS also revealed Resident #1 was dependent on staff for toileting, showers, and transfers. Record review of Resident #120's care plan dated 07/31/2026 revealed Focus: [Resident #120] is at risk for falls.Goal: Will not sustain serious injury through the review date.Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.An interview was attempted with Resident #120 on 08/04/2027 at 10:25 a.m., 08/04/2026 at 2:32 p.m., and on 08/05/2026 at 8:43 a.m. All attempts were unsuccessful.Observation of Resident #120's call light on 08/04/2026 at 9:56p.m., revealed RN N walked past Resident #120's room while the call light was on twice and did not answer the call light. During a confidential meeting at a confidential location with confidential resident group revealed staff do not answer the call lights timely. The resident group said it happened all the time on all shifts. The confidential resident groups said at times it took over an hour for staff to answer the call lights. During an interview with RN N on 08/04/2026 at 10:07 p.m., she said she had been trained on answering the residents call lights. She said all staff were responsible for answering the call lights. She said staff were to answer the call light as soon as possible. She said if staff were walking by a resident's room and saw the call light the staff were to answer the call light. She said if the residents call lights were not answered timely the resident could have a delay in services. She said the nurse monitored to ensure staff were answering the call lights. She said the nurse monitored through observation and monitoring the call light box (a box at the nurses station that shows what call light was on). She said she did not answer Resident #63 and Resident #120's call light because she was talking. During an interview with CNA K on 08/07/2026 at 12:45 p.m., she said she had been trained on answering the call lights. She said the policy was to answer the call light as soon as possible. She said everyone was responsible for answering the call lights. She said if staff saw a call light on when they were passing by the staff should answer the call light. She added if the resident needed something the CNA or nurse needed to do the staff member was to inform the aide or the nurse. She said the call light should not be turned off until staff completed what the resident needed. She said if the staff did not answer the call light timely it could be neglect to the resident. She said the nurses monitored to ensure staff were answering the call light. She said the nurses monitored by watching the call light box. She said she did not know why there were so many complaints about call lights not being answered. During an interview with the DON on 08/07/2026 at 2:54 p.m., She said she had been trained on call lights. She said the policy was for staff to answer the call lights as soon as possible. She said all staff could answer the call lights. She said staff should not turn off the call light until after they have provided the care the resident needed. She said if the call light was not answered timely it could cause the resident emotional stress, and the resident may worry about their needs not being met. She said all staff monitored to ensure the call lights were answered. She said staff monitored by walking by and seeing the call light on and responding to the call light. During an interview with the ADM on 08/07/2026 at 3:50 p.m., he said he had been trained on resident right. He said the policy was to answer the call light as quickly as possible. He said anyone could answer the call light. He said the call light should only be turned off when the care was completed. He said if staff did not answer the call lightly, depending on the circumstances the resident could try to get up and walk or try to do something by themselves. He said if staff were walking by a call light that was on the staff should answer the call light unless they were providing care to another resident. He said typically the nurse on the floor monitored to ensure staff were answering the call lights. He said the nurse monitored by walking around and monitoring the call light box. He said he did not know why RN N walked past Resident #63 and Resident #120's call light without answering it. Record review of the Answering Call Lights Policy dated 10/2010 revealed Answer the resident's call as soon as possible. Be courteous in answering the resident's call.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to have paper towels and a trash receptacle at the kitchen handwashing station.2. The facility failed to properly store, label, and date all food items located in the facility refrigerator, freezer and in the dry food pantry area on 08/04/2026, and 08/05/2026. 3. The facility failed to discard outdated food items located in the refrigerators, freezer, and dry food pantry on 08/04/2026 and 08/05/2026. 4. The facility failed to discard dented cans of vegetables and fruit in dry food pantry on 08/05/2026.These failures could place residents who received meals from the kitchen at risk of foodborne illnesses.Findings:Observation during the initial tour of the kitchen on 08/04/2026 beginning at 9:00 AM revealed the following:Kitchen open areaHandwashing station observed with no paper towels and no trash can, surveyors had to ask for the items to complete the handwashing process.2 large trash cans not in use with no lids.Walk in Refrigerator:1 prepared container, labeled mechanical ham with prep date of 7/1/26 and use by date of 8/8/261 prepared container labeled lasagna with prep date of 7/3/26 and discard date of 7/10,no year1 pan of quiche(about 3 servings remained) labeled broccoli cheese, with prep date of 7/2/26 and use by date of 7/13/262 pans of quiche labeled ham cheese, with prep date of 7/2/26 and use by date of 7/13/261 prepared container labeled vegetable lasagna with prep date of 7/3/26 and discard date of 7/10,no year 1 container of corn labeled with prep date of 7/1/26 and use by date of 8/8/261 plastic bag with thawed fries, not labeled nor dated1container of bell peppers with prep date of 7/27/26 and use by date of 8/3/261 container of sliced tomatoes with prep date of 7/1/26 and use by date of 8/8/26 Walk in Freezer: 1 plastic wrapped item labeled roast beef with prep date of 7/1/2026, discard date of 7/12/26 1 large package labeled sweet potato with prep date of 7/21/26 and discard date of 7/25/26 1 large pan covered with foil labeled cinnamon rolls with prep date of 7/29/26 and discard date of 7/29/27 Dry Food Pantry area:3 gallon containers(1 opened) of Worcestershire sauce with expiration date of 02/04/20261 large gallon of opened red pepper sauce, labeled 9/2/2025, it had a manufacture best by date of 9/1/20254 packages of granola, labeled 11/7/2025, expiration date of 6/11/20261 opened package of muffin mix, with prep date of 7/2/26 and use by date of 7/13/26 Observation during the follow up tour of the kitchens on 08/05/2026 beginning at 11:12 AM, revealed the following: Walk in Refrigerator :1 prepared container labeled lasagna from the previous day with tag changed to reflect prep date of 8/3/26 and discard date of 8/10, no year 1 prepared container labeled vegetable lasagna with prep date of 7/3/26 and discard date of 7/10, no year1 container labeled turkey with prep date of 08/03, no use by date1container of bell peppers with prep date of 7/27/26 and use by date of 8/3/261 container labeled porkchop with prep date of 7/26/26 and use by date 7/31 1 container labeled chopped meat on top with prep date of 7/30/26 with discard date of 8/6/26, on side the label indicated celery with prep date of 7/14/26 and use by date of 7/20/26 1 container labeled egg on one side with prep date of 7/27/26, use by date of 8/1/26, the other side of container was labeled coleslaw with pre date of 7/28/26 and use by date of 8/5/26 Walk in Freezer: 1 large package labeled sweet potato with prep date of 7/21/26 and discard date of 7/25/26 1 large pan covered with foil labeled cinnamon rolls with prep date of 7/29/26 and discard date of 7/29/27 Dry Food Pantry area:3-gallon containers (1 opened) of Worcestershire sauce with expiration date of 02/04/20261 large gallon of opened red pepper sauce, labeled 9/2/2025, it had a manufacture best by date of 9/1/20254 packages of granola, labeled 11/7/2025, expiration date of 6/11/20263 large, dented cans of sauerkraut, spinach, and apples.Interview conducted with [NAME] A on 08/06/2026 at 2:10 PM. [NAME] A stated she has been employed at the facility since April 2026. She stated all staff were responsible for labeling and dating food items. [NAME] A stated she has received conflicted information on the food labeling and dating process. She stated one dietary staff instructed her to label food with the current date as the prep date and discard date of after 3 days while another dietary staff instructed her to count five days from the current date before discarding a food item. [NAME] A stated she was unsure which process is correct. [NAME] A stated expired foods were discarded and prepared foods that were past 3-7 days were thrown out. [NAME] A stated the trash cans should always remain covered. She further stated the handwashing station should have a trash can and paper towels. [NAME] A stated the station was often out of paper towels. [NAME] A stated residents could become ill if served expired food items.Interview conducted with Dietary Aide D on 08/06/2026 at 2:23 PM. Dietary Aide D stated he has been employed at the facility for 3 weeks. She stated she was initially trained by a previous dietary worker who was no longer with the facility. Dietary Aide D stated all staff were responsible for labeling and dating food items. She reported staff were expected to write the name of the food item, the date opened and time, employee name or initials, and the use date. She stated prepped foods were discarded after 3 days. Dietary Aide D stated dented cans were returned to the supplier. Dietary Aide D stated a resident could become very sick if they ate expired foods and food from dented cans.Interview conducted with [NAME] B on 08/06/2026, at 3:12 PM. [NAME] B stated she has been employed with the facility for seven months and she moved from dietary aide to cook about three months ago. [NAME] B stated she was trained on kitchen protocols by a previous cook and the DTSM. [NAME] B stated food labels should include the food name, preparation date, discard date, and employee name. She stated the discard date for prepared food was 3 days and expired food should be discarded. [NAME] B stated the facility has a designated area on the shelf for dented cans. She stated that expired food or food prepared from compromised cans could cause a resident to become ill or potentially result in a more serious outcome.Interview conducted on 08/07/2026 at 10:06 AM, the DTSM stated she had been with the facility since November 2025. The DTSM stated she came to the facility with extensive dietary experience. She stated the label and dating process included food items be marked with the date received, the date prepared, and a use by date of 3 day after prepared. She stated each employee was expected to place their initials on the food labels. When advised of expired items in the pantry, the DTSM stated the dry pantry was thoroughly checked over the weekends for expired foods and food is rotated. She stated the facility no longer used the large cereal bags, she stated they use individual packages now and the old ones had not been discarded. The DTSM stated the food items in the refrigerator had been labeled incorrectly by one staff member who was used to a different labeling system. She further stated that she knew the surveyors had looked at the quiche and lasagna and that the dates were incorrect and she had changed the lasagna date to reflect the correct date. The DTSM stated the trash cans were required to have lids when not in use. She stated the trash can located in the handwashing station should be foot-operated and that paper towels should be available.Record review 08/07/2026 of the facility's policy named Food Receiving Policy and Procedure undated reflected: Policy StatementThis policy establishes guidelines for the safe handling of all food items during transport, delivery, and storage, with a focus on maintaining strict time and temperature controls to ensure food safety. Procedures.4. Canned Goods Inspection: Canned goods will be examined for signs of damage, such as dents, rust, or bulges. Any compromised cans will be isolated and marked for return to the supplier or for safe disposal, as required.5. Labeling and Dating: All food items must be clearly labeled and dated, using either the manufacturer's packaging information or manual staff entries, to ensure traceability and freshness.6. Storage Practices: All food items are to be stored following the first in, first out (FIFO) principle to optimize inventory rotation and usage.Record review 8/07/2026 of facility policy named Sanitation Conditions Policy and Procedure, undated, reflected: Policy Statement[Company] recognizes the paramount importance of maintaining safe and sanitary conditions in all aspects of food storage, preparation, and service within healthcare facilities. Therefore, the Dietary Service Director will ensure that these activities are conducted in compliance with rigorous sanitation standards to safeguard the health and well-being of residents, staff, and visitors. Planning: -The Dietary Services Director will be responsible for maintaining an appropriate inventory of supplies necessary for safe food handling, warewashing, and surface sanitizing.- Regular assessments of inventory levels will be conducted to ensure that an adequate supply of sanitation supplies is available at all times.

Based on observations, interviews, and record reviews, the facility failed to provide food that was prepared in a form designed to meet individual needs and by methods that conserve nutritive value and flavor for 4 residents (Residents #6,12,85, and 102) who ate pureed diets from 1 of 1 kitchen reviewed for food and nutrition services.The facility failed to ensure the DTSM refrained from adding an unmeasured amount of liquid to green beans pureed meal during lunch service on 8/05/2026. The facility failed to ensure the DTSM followed the recipe for the hamburger pureed meal during lunch service on 08/05/2026.The facility failed to ensure that the lunch meal on 08/05/2026 was served at the correct temperature and was palatable. This failure could affect residents at risk for diminished or altered nutritional status and potential weight loss.Findings included:Diet Type Report received from the Administrator on 08/05/2026 at 9:05 AM revealed 4 residents (Residents #6,12,85, and 102) at the facility received a pureed diet. Observation and interview conducted on 08/05/2026 at 11:25 AM revealed DTSM placed an unmeasured amount of liquid into the puree blender with the green beans. She did not measure the liquid. DTSM proceeded to puree the green beans. She stated there were 4 residents on puree diets, but she made enough for 5. The pureed green beans were of a runny consistency. The DTSM indicated the greens were ready and she proceeded to demonstrate the puree process of one hamburger and bun; she stated the other servings had been prepared earlier. The DTSM proceeded to prepare the bun and meat, she poured the two items into the blender with broth from the meat. The broth was not measured. The DTSM did not refer to a recipe during the puree process. Surveyor asked the DTSM for the recipe book, she replied there was not one. She was asked about the puree diet recipe source, she initially stated she did not have a recipe for the green beans. The DTSM then stated she would have to find the recipes and print them. The recipes were eventually provided, and they reflected that the green beans should add thickener, if needed to make the consistency of applesauce, thick mashed potatoes, pudding or yogurt. The recipe for the hamburger reflected that it should be pureed with 2 percent milk and margarine. Observation conducted 08/05/2026 beginning at 12:37 PM, the State Survey Team participated in sampling of the Lunch Meal which included 3 Test Trays (regular, mechanical, and puree). The lunch meal was cheeseburger on bun, fries, and relish tray (lettuce tomatoes, onions, pickles), the pureed meal served was cheeseburger, mashed potatoes, and green beans. The pureed cheeseburger on a bun was covered in a significant amount of brown gravy it did not taste like a cheeseburger. Interview via telephone conducted on 08/06/2026 at 11:55 AM, the Dietician stated she had been with the facility since the end of March 2026. She stated she visited the facility every other week. She stated that she signs the substitution forms for the menus and completed assessments. She stated once a month she completed meal observations. The Dietician stated if training was warranted, she will complete it with the DTSM, however the contracted company completed the training with staff on therapeutic diets. Interview conducted on 08/06/2026 at 2:10 PM [NAME] A stated she has been employed at the facility since April 2026. She stated she had been trained on pureed diets at previous employment. [NAME] A stated she has not seen any recipe books at the facility and that staff just recently showed her how to prepare the puree meals at this facility. She stated there were about 5 residents who received a puree diet. [NAME] A stated they have packaged thickener for the pureed foods, but when they prepared pureed vegetables, staff used the juice from the cooked vegetables. [NAME] A stated pureed food should have a pudding-like consistency and not be watery. She further explained that if puree food was too thin or watery, a resident could choke. Interview conducted on 08/06/2026 at 3:12 PM [NAME] B stated she has been employed with the facility for seven months and she moved from dietary aide to cook about three months ago. [NAME] B stated she was trained on kitchen protocols by a previous cook and the DTSM. Regarding the puree diet, [NAME] B stated the pureed foods should be blended until they reach a pudding-like consistency. [NAME] B stated the kitchen does not have a recipe book readily available. She stated that if a recipe was needed, the DTSM could print one for the dietary staff; however, she stated recipes for the pureed diets are not consistently followed. [NAME] B stated that failing to follow the appropriate recipe or achieving the correct consistency could potentially cause a resident to choke and she emphasized the importance of preparing pureed foods to the correct consistency. Interview conducted on 08/07/2026 at 9:56 AM [NAME] C stated she was trained by the DTSM. She stated the puree diet was prepared to make it easier for residents to swallow who required a pureed diet to eat. She stated that residents could choke if the consistency was too loose. Interview conducted on 08/07/2026 at 10:06 AM, the DTSM stated she had been with the facility since November 2025. The DTSM stated she came to the facility with extensive dietary experience. The DTSM stated she was taught to always use the stock from the food item when preparing pureed foods. She stated physicians order pureed diets for residents who had chewing or swallowing difficulties. The DTSM acknowledged that when she pureed green beans the previous day, the product did not have a pudding-like consistency and was somewhat runny, she also stated she realized later she was supposed to use milk and margarine for the cheeseburger. The DTSM stated that a resident provided with food that does not have the correct pureed consistency could potentially result in the resident choking and possible death.Interview conducted 08/07/2026 at 10:39 AM, the DON stated physician-ordered diets (such as pureed diets) are communicated to nursing and dietary staff. She stated it is entered into the facility's computer system, and a yellow communication slip is provided to the kitchen. The DON stated the nurses check the trays prior to them being served to the residents. She stated that the diet order was on the meal ticket and nurses were trained to review the tickets. The DON further stated that nursing staff will notify dietary if the consistency of a pureed diet meal was too loose. Review of the facility's policy named Modified Consistency Diet, undated, reflected: Modified Consistency DietsAt [company], we specialize in providing dietary and clinical RD services tailored to theunique needs of healthcare facilities. One essential aspect of our service is offering modifiedconsistency diets, which involve altering the texture of foods to facilitate safe consumptionfor residents/patients with specific health conditions. Pureed:Our commitment to nutritional adequacy remains paramount, guided by menu planningand therapeutic diet guides. For instance, our pureed consistency diet, adapted from theNational Dysphagia Diet level 1, offers homogenous and cohesive food options suitable forindividuals with oral health/dentition issues or dysphagia.Review of the facility's policy named Therapeutic Diets Policy and Procedure, undated, reflected: Policy StatementAt [company], all residents are provided with customized diet plans, including regular,therapeutic, and texture-modified diets, prescribed by their attending physician, physicianextender, or qualified practitioner, in accordance with regulatory guidelines.

Based on observation, interview and record review, the facility failed to provide food that was palatable and at a safe and appetizing temperature for 1 of 1 meal reviewed for dietary services. 1. The facility failed to serve food that was palatable and at an appetizing temperature for the lunch meal on 08/04/2026 for the regular, mechanical soft and pureed meals. This failure could place residents who consumed food prepared in the kitchen at risk for reduced meal satisfaction, diminished nutritional intake, weight loss and a decreased quality of life.Findings included:In confidential resident interviews at an undisclosed date and time, the residents stated that their food was often served cold.In an interview conducted on 08/05/2026 at 11:15 AM, a request was made to the Dietary Manager to provide sample trays with regular, mechanical soft and pureed meal items, same portions and resident set up. It was also requested that the sample trays would be the last tray served on Halls 100 and 500. During a group confidential interview on an undisclosed date and time, 6 of 11 confidential residents stated meals were served cold often. Several of the residents stated the food was very bland and not seasoned. 3 residents stated the breakfast was always cold and the sausage does not appear cooked, it was stated, it looks like they just take it out of a package to thaw, the sausage should have some kind of browning. One of the residents also stated, there is a hit or miss with the food and 1 resident stated the carts sit in front of the nurse's station for about 20-30 minutes before the trays are passed out. The resident reported that sometimes staff get distracted by conversations with other staff causing them to temporarily stop passing the trays and then staff would return to handing out the trays, but by that time the food is cold.Observation conducted 08/05/2026 beginning at 12:37 PM, the State Survey Team participated in sampling of the Lunch Meal which included 3 Test Trays (regular, mechanical, and puree). The regular and mechanical tray consisted of cheeseburger on bun, fries, and relish tray (lettuce tomatoes, onions, pickles), the pureed was cheeseburger, mashed potatoes, and green beans. The first test tray received was the regular diet, the fries were cold to touch and rubbery in texture, they did not taste good. The temperature for the fries was 86.5 degrees Fahrenheit. The cheeseburger meat patty was 121.6 degrees Fahrenheit. The Administrator was advised of the cold food and was offered to test the regular test tray, he declined. The other two test trays were tested, and the food was not hot and was not tasty. The pureed cheeseburger on a bun was covered in brown gravy that did not taste like a cheeseburger.Interview conducted with [NAME] B on 08/06/2026, at 3:12 PM. [NAME] B stated she has been employed with the facility for seven months and she moved from dietary aide to cook about three months ago. [NAME] B stated she was trained on kitchen protocols by a previous cook and the DTSM. [NAME] B stated food was seasoned with a salt free seasoning. She stated the temperatures were checked when the meals were sent from the kitchen. [NAME] B stated the resident's food could become cold if they are not distributed in a timely manner on the hallways, she stated she is unsure where the breakdown has occurred when the residents complain of cold food. In an interview conducted 08/07/2026 at 10:06 AM, with the DTSM, she stated she was not aware the test trays were not hot. She stated she has spoken to a few residents about food temperatures. The DTSM stated that dietary staff assembled the meal trays and checked the temperature of the food on all the trays before they left the kitchen. She stated the trays were then delivered to the hallways, and the CNAs and nurses have been instructed to pass trays to residents as quickly as possible. The DTSM stated that the food was hot when it leaves the kitchen; however, she believes the trays become cold when they were not passed promptly to the residents. The DTSM further stated the facility's plate warmers had been out of service since Monday, day before State arrived. She stated the plate warmers started smoking and that the maintenance department was working on repairing them today. She stated her supervisor had spoken with the Administrator about the possibility of obtaining insulated carts. She stated the carts currently being used to deliver food were preparation carts. The DTSM stated the potential harm associated with residents receiving cold food was that they may become dissatisfied and choose not to eat the food. She stated this could result in residents losing their appetite and could potentially contribute to weight loss. In an interview conducted 08/07/2026 at 4:08 PM, the Administrator stated, there has been some complaints of cold food to some degree, not a large amount, maybe one to four a month. He stated if he heard a resident had received cold food, he would observe the meal and pull the trays and ask the residents. The Administrator stated the residents usually do not report cold food when he observes the meal, he stated if so, he would have the kitchen to remake the plate. The Administrator stated he was just notified yesterday of the plate warmers not working, and he was assessing the situation to see if the warmers could be fixed and if not, they will be replaced. Record review conducted 08/05/2026 of a facility grievance date 6/11/2026, revealed there was a complaint for the dietary department on food temperatures. Record review conducted 08/05/2026 of the facility Resident Council meetings revealed that on 07/09/2026 there were concerns of cold food and no communication that trays are brought out. Record review of the facility's, undated, policy, Food Preparation Policy and Procedure, revealed: Policy Statement:At [company], we uphold the highest standards of food safety and quality by strictly adhering to the FDA Food Code in all aspects of food preparation.ProcedurePreparation Guidelines10. Temperature Control for Safety (TCS) Foods: TCS foods are cooked to specifiedminimum internal temperatures for 15 seconds to guarantee safety.11. Hot Service Reheating: Mechanically altered foods in the danger zone are reheatedto 165 F for 15 seconds before hot service.12. Rapid Reheating: Foods are reheated to 165 F for 15 seconds within two hours ordiscarded.13. Temperature Holding: Foods are maintained at safe temperatures-above 135 F forhot items and below 41 F for cold items, as required by state regulation.14. Temperature Monitoring: Temperatures of TCS foods are logged at service time andmonitored periodically during service.

Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 residents (Resident #7, Resident #23, and Resident #72) reviewed for pharmacy services. 1. The facility failed to ensure medications were administered in a timely manner to Resident #7. 2. The facility failed to ensure medications were administered in a timely manner to Resident #23. 3. The facility failed to ensure medications were administered in a timely manner to Resident #72. These failures could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. Findings include: 1. Record review of Resident #7's face sheet, dated 08/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included streptococcal arthritis (is a rare complication that occurs when the immune system reacts to a recent infection), sepsis ((a life-threatening complication of an infection), moderate protein- calorie malnutrition (inadequate intake of both protein and calories), muscle weakness, chronic kidney disease (a serious condition where the kidneys are severely damaged), and heart failure. Record review of Resident #7's admission MDS assessment, dated 06/26/2026, reflected Resident #7 had a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #7's physician orders, dated 07/07/2026, Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every six hours for pain for 7 days. Record review of Resident #7's physician orders, dated 07/29/2026, Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth two times a day for pain. Record review of Resident #7's Medication Administration Audit Report dated 08/05/2026 reflected Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth two times a day for pain to be given at 03:00 a.m. Resident #7's Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth one time a day for PAIN was scheduled at 09:00 a.m. and Resident #7 did not get it until 01:35 p.m., on 07/25/2026. The MAR also revealed Resident #7 her Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) was scheduled at 03:00 a.m., and she did not get it until 05:34 a.m. on 08/03/2026. Record review of Resident #7's Care Plan, dated 06/25/2026, reflected Focus: [Resident #7] At risk for pain/discomfort r/t muscle weakness. Goal: Will report reduction in pain with interventions through next review date. Interventions: Administer prescribed pain medications as ordered by physician. Monitor for side effects and effectiveness of medications. During an interview with Resident #7 on 08/04/2026 at 10:14 a.m., she said that there were times when she needed her pain medication and could not get it. She said there had been times when she was in severe pain and she could not get her pain medication on time. She said it was frustrating and she was tired of it all. 2. Review of Resident #23's face sheet, dated 08/05/2026, reflected an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses that included: sepsis due to anaerobes (an extreme immune response that can damage tissues and organs caused by bacteria in the bloodstream that can live without oxygen), acute respiratory failure with hypoxia (when the lungs are not able to provide enough oxygen to the blood), aortitis in disease classified elsewhere (an inflammation of the largest blood vessel in the body caused by other diseases).Record review of Resident #23's admission MDS assessment, dated 07/09/2026, reflected Resident #23 had a BIMS score of 03, which indicated severe cognitive impairment. Record review of Resident #23's physician orders, dated 07/24/2026, Infusions for Penicillin G Potassium Injection Solution Reconstituted 5000000 UNIT (Penicillin G Potassium). Use 1 dose intravenously every 6 hours for emphysematous aortitis (a rare life-threatening infection) until 08/13/2026. Record review of Resident #23's Medication Administration Audit Report dated 08/05/2026 reflected Infusions for Penicillin G Potassium Injection Solution Reconstituted 5000000 UNIT (Penicillin G Potassium). Use 1 dose intravenously every 6 hours for emphysematous aortitis was scheduled at 09:00 p.m. and Resident #23 did not get it until 02:16 a.m., on 07/29/2026. The MAR also revealed staff did not give Resident #23 his Infusions for Penicillin G Potassium Injection Solution Reconstituted 5000000 UNIT (Penicillin G Potassium) that was scheduled at 03:00 p.m. until 04:51 p.m on 07/30/2026. Record review of Resident #23's Care Plan, dated 07/09/2026, reflected Focus [Resident #23 is on IV therapy r/t infection SEPSIS DUE TO ANAEROBES. Goal: Will not have any complications related to IV therapy through the review date. Interventions: Change IV site dressing as ordered. Check dressing at site daily. Flush IV catheter for patency as ordered. Observe for signs and symptoms of infiltration at the site: Edema at the insertion site, Taut or stretched skin, Blanching or coolness of skin, Slowing or stopping of the infusion, Leaking of IV fluid out of the insertion site. If infiltrated, stop infusion. Notify physician if indicated. Observe/document/report to MD PRN signs and symptoms of infection at the site: Drainage, Inflammation, Swelling, Redness, Warmth. Obtain and monitor lab work. Report results to MD and follow up as indicated. During an interview with Resident #23 on 08/04/2026 at 09:47 a.m., he said staff never gave him his IV antibiotics on time. He said they leave him plugged up to the IV for hours after it finished. He said he gets agitated when the staff leave him plugged up to the IV for hours after it had finished. He added he was worried the blood in the tube would cause a blood clot if left in the tube too long. 3. Record review of Resident #72 face sheet, dated 08/05/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #72 had diagnoses which included Parkinson's disease (movement disorder of the nervous system that worsen over time), hyperlipidemia (high cholesterol), hypertension (high blood pressure), muscle weakness, history of falls, need for assistance with personal care and lack of coordination. Record review of Resident #72's admission MDS assessment, dated 07/16/2026, reflected Resident #72 had a BIMS score of 12, which indicated moderate impairment. Record review of Resident #72's physician orders, dated 07/14/2026, Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 2 tablet by mouth three times a day for PARKINSON'S Disease. Record review of Resident #72's Medication Administration Audit Report dated 08/05/2026 reflected Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 2 tablet by mouth three times a day for PARKINSON'S Diseases was scheduled at 09:00 p.m. on 07/15/2026 and Resident #72 did not get it until 07:13 a.m., on 07/16/2026. The MAR also revealed staff did not give Resident #72 his Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) was scheduled at 03:00 p.m. until 05:44 p.m on 07/16/2026. Resident #72's Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) was scheduled for 9:00 p.m., on 07/17/2026 and Resident #72 did not get it until 11:27 p.m. On 07/18/2026 Resident #72's Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) was scheduled at 3:00 p.m. and he did not get it until 5:16 p.m. On 07/23/2026 Resident #72's Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) was scheduled for 9:00 p.m., he did not get it until 12:27 a.m. on 07/24/2026. Record review of Resident #72's Care Plan, dated 07/16/2026, reflected Focus: [Resident #72] Resident #72 has potential nutritional problem related to PARKINSON'S, TYPE 2 DIABETES. Goal: Will maintain adequate nutritional status through review date.Interventions: Observe/document/report to MD PRN for signs and symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. Provide, serve diet as ordered. Monitor intake and record every meal. Administer medications as ordered.During an interview with Resident #72 on 08/04/2026 at 10:09a.m., he said staff did not give him his mediations on time. He said he was supposed to get his Parkinson's medication on time. He said if he did not get the medication for his Parkinson's on time he would start to shake. He said it upsets him when he does not get his medication on time. During an interview with the NP on 08/05/2026 at 3:07p.m., he said the medication aides and nurses should be giving medication on time for the medication to be affective. He said all medications were to be given within one hour of the prescribed time. He said if medication was not given timely the resident may be at higher risk of falls, or other side effects. He said he was not aware that residents were not getting their medications on time. During an interview with MA P on 08/06/2026 at 4:30 p.m., revealed she was trained on medication administration. She said the policy was medications had to be given within one hour before and one hour after the scheduled time. She said the nurses or the medication aides were responsible for giving the medication to the residents on time. She said if medication was not given on time the resident could have side effect. She said the nurse monitored to ensure medication was given timely. She said the nurse monitored by checking the resident's chart to ensure they got their medication on time. She was late passing medications to Resident #7, Resident #23, and Resident #72 due to having three halls and the medication load just got heavier recently. She said she felt the facility needed more medication aides to be able to get medications out on time.An attempted telephone interview with LVN R on 08/07/2026 at 2:46 p.m., was unsuccessful. During an interview with the DON on 08/07/2026 at 3:08 p.m., she said she was trained on medication administration. She said the policy was to give medication as ordered, medication was to be given an hour before and an hour after the prescribed time. She said the nurses and the medication aides were responsible for ensuring the residents were getting their medication on time. She said if the resident was not given their medication on time; depending on what medication it was it could take the medication longer to act. She said the nurses monitored to ensure the residents were getting their medication on time. She said the nurses monitored by pulling a report showing late medication. She said she did not know why MA P, MA Q and LVN R were not giving medications on time to residents. During an interview with MA Q on 08/07/2026 at 3:19 p.m., she said she was trained on medication administration. She said the policy was medication was supposed to be given within an hour of the scheduled time. She said the medication aide was responsible for giving medication to the residents on time. She said if medication was not given timely some medication may not be affective. She said the nurse was responsible for monitoring to ensure medication was given on time. She said the nurse monitored by checking the MAR and seeing what time the medication was given. She said she was late giving Resident #7, Resident #23 and Resident #72 medication late because she may had been helping in another area. She said she felt like the facility had enough staff to get medications passed on time. During an interview with the ADM on 08/07/2026 at 4:03 p.m., he said he was not trained on medication administration. He said his expectation was medication be administered on time, safely and within parameter. He said he did not know the time frame staff had to get medication to the resident. He said the nurses or medication aides were responsible for giving medication on time. He said if the medication was not given on time it could be critical and the medication might not be affective. He said the nursing manager monitored to ensure staff were giving medication on time. He said the nursing manager monitored by running the medication audit report. He said he did not know why MA P, MA Q and LVN R were not passing medication on time. He said he felt like the facility had enough staff to get medication passed on time. Record review of the Administering Medications Policy, dated 12/2012, reflected Medications shall be administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frames. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview and record review the facility failed to ensure prompt resolution of grievances regarding the resident's right to file a grievance for 3 of 3 residents (Resident #7, Resident #63, and Resident #120) reviewed for grievances.The facility failed to notify residents in writing of the findings and actions of the grievances they filed. This failure could affect resident's right to a written decision regarding the resolution of their grievance.Findings Included:1. Record review of Resident #7's face sheet, dated 08/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included streptococcal arthritis (is a rare complication that occurs when the immune system reacts to a recent infection), sepsis ((a life-threatening complication of an infection), moderate protein- calorie malnutrition (inadequate intake of both protein and calories), muscle weakness, chronic kidney disease (a serious condition where the kidneys are severely damaged), and heart failure. Record review of Resident #7's admission MDS assessment, dated 06/26/2026, reflected Resident #7 had a BIMS score of 15, which indicated intact cognitive response. Resident #7's MDS also revealed resident was set up/clean up assist for toileting. She was also a partial/moderate assist on picking up items. Record review of Resident #7's care plan dated 06/25/2026 revealed it did not have any information on call lights. During an interview with Resident #7 on 08/04/2026 at 2:30 p.m., she said staff did not answer her call light until an hour after she turned it on. She said staff did not answer her call light timely irritated her. She said this happened on all shifts at different times. She said the thought of pushing her call light and having something serious wrong and having to wait an hour was horrible. She said she had told the ADM and DON but did not do a formal grievance. 2. Record review of Resident #63's face sheet, dated 08/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #63 had diagnoses which included chronic kidney disease (a serious condition where the kidneys are severely damaged), anemia (not enough healthy red blood cells), hypokalemia (low potassium), hypertension (high blood pressure), type 2 diabetes mellitus with diabetic kidney disease (kidney damage due to diabetes), and heart failure. Record review of Resident #63's quarterly MDS assessment, dated 06/26/2026, reflected Resident #63 had a BIMS score of 10, which indicated moderate impairment. The MDS also stated that Resident #63 was substantial/maximal assistance with all ADLS. Record review of Resident #63's care plan dated 06/03/2026 revealed Focus: [Resident #63] is at risk for falls r/t incontinent, weakness, confusion. Goal: Will be free from major injury d/t fall through the review date.Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.During an interview with Resident #63 on 08/04/2026 at 10:47 a.m., she said staff took a while to answer her call light. She said she did not know how long she had to wait. She did not answer how she felt about staff taking a while to answer her call light. She said she had filed grievances. Observation of Resident #63's call light on 08/04/2026 at 9:45p.m., revealed RN N walked past Resident #63's room while the call light was on twice and did not answer the call light.Observation of Resident #63's call light on 08/04/2026 at 9:53p.m., revealed RN N walked past Resident #63's room and did not answer the call light. 3. Record review of Resident #120's face sheet, dated 08/05/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #120 had diagnoses which included chronic kidney disease (a serious condition where the kidneys are severely damaged), sepsis (a life-threatening complication of an infection), end stage renal disease (kidney failure), dependency on renal dialysis (when the kidneys can no longer filter waste or extra fluid from the blood and regular dialysis treatment is required to sustain life), muscle weakness, and heart failure. Record review of Resident #120's quarterly MDS assessment, dated 008/01/2026, reflected Resident #120 had a BIMS score of 10, which indicated moderate impairment. The MDS also revealed Resident #1 was dependent on staff for toileting, showers, and transfers. Record review of Resident #120's care plan dated 07/31/2026 revealed Focus: [Resident #120] is at risk for falls.Goal: Will not sustain serious injury through the review date.Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. An interview was attempted with Resident #120 on 08/04/20267 at 10:25 a.m., 08/04/2026 at 2:32 p.m., and on 08/05/2026 at 8:43 a.m. All attempts were unsuccessful. Observation of Resident #120's call light on 08/04/2026 at 9:56p.m., revealed RN N walked past Resident #120's room while the call light was on twice and did not answer the call light. During a confidential meeting at a confidential location with confidential resident group revealed staff do not answer the call lights timely. The confidential resident groups said at times it took over an hour for staff to answer the call lights. During an interview with RN N on 08/04/2026 at 10:07 p.m., she said she had been trained on answering the residents call lights. She said all staff were responsible for answering the call lights. She said staff were to answer the call light as soon as possible. She said if staff were walking by a resident's room and saw the call light the staff were to answer the call light. She said if the residents call lights were not answered timely the resident could have a delay in services. She said the nurse monitored to ensure staff were answering the call lights. She said the nurse monitored through observation and monitoring the call light box (a box at the nurses station that shows what call light was on). She said she did not answer Resident #63 and Resident #120's call light because she was talking. During an interview with the local Ombudsman on 08/06/2026 at 8:42 a.m., she said she had gotten a lot of complaints from residents and family members regarding staff ignoring the call light and not answering the call lights. During an interview with the DON on 08/07/2026 at 2:54 p.m., She said she had been trained on call lights. She said the policy was for staff to answer the call lights as soon as possible. She said the grievances were discussed in the morning meetings. She said she was responsible for handling the grievances about call lights. She said when she does handle a call light grievance it was mostly handled by in-services. She said if the residents still had an issue with call light the facility could escalate the response and make verbal and written warnings with staff. She said the facility monitored the grievances for patterns. She said if a pattern was noticed the facility would find out what rotation or shift the problem was on. She said she had not noticed a trend with call light responses. She said she had not had an increase for call light grievances. During an interview with the ADM on 08/07/2026 at 3:54 p.m., he said he had been trained on resident right. He said the policy was to answer the call light as quickly as possible. He said the DON was responsible for addressing the grievances for call lights. He said a grievance should be handled in 72 hours. He said if a grievance was filed for call lights the DON would do a call light test and have a manager push the call light and see how long it took staff to respond. He said if the staff response time was unacceptable the DON would reeducate to ensure the issue was resolved. He said if staff did not address the grievances the resident could be dissatisfied and frustrated. He said he had seen an increase in grievances since he started because the grievances were not addressed before. He said to resolve a call light grievance he would identify the tread. He said he would see if the call light not being answered was on a specific day or time, see who was working and see what the worker said about the call light response time. He said he did not know call lights were still an issue. Record review of Grievances dated 04/2026 to 07/2026 revealed in April of 2026 there was a grievance from the resident council regarding call light response. In May 2026, the grievance for call light responses increased to nine grievances for call light responses. In June 2026 there were also nine grievances regarding call light response times. In July 2026 there were six complaints about call light response times. There were also no grievances from Resident #7, 63 or 120. Record review of the Filing Grievances/Complaints Policy dated 08/2008 revealed Upon receipt of a grievance and/or complaint, the designated staff member will investigate or delegate the investigation accordingly to the responsible department head who will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The designated Grievance Official will oversee the grievance process, receiving and tracking grievances to ensure corrective action if needed.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 2 medication carts (MC #1) reviewed for drug storage and labeling.The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors on 08/04/2026.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings include:During an observation on 08/04/2026 at 9:51 p.m. on 500-hall, revealed MC #1 was against the walls across from the nurse's station unattended and unlocked. LVN O was on the other side of the facility at the other nurses station. MC #1 contained residents' prescription drugs, over the counter medications, and narcotics in a locked box. RN N had just come in for her shift and did not say anything when the drawers were being opened, and pictures taken.During an interview with LVN O on 08/04/2026 at 09:54 p.m., she said she was trained on medication storage. She said the policy was staff must lock the medication carts at all times. She said the nurse was responsible for locking the medication cart. She said if staff left the medication cart unlocked and unattended a resident could get into the medication cart and take medications. She said the supervisor monitored to ensure the medication carts were locked. She said the supervisor monitored the medication carts through observation. She said she had left the medication cart unlocked because she forgot she had two medication carts and she thought she had pushed the lock in.During an interview with the DON on 08/07/2026 at 03:08 p.m., she said she was trained on medication storage. She said the policy was the medication cart was to be clean and locked. She said the nurse or medication aide who was on the medication cart was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked and unattended someone could take medications or medication could be misplaced. She said the DON and ADM monitored to ensure staff locked the medication cart. She said the DON and ADM monitored by doing observations. She said she did not know why LVN O left the medication carts unlocked.During an interview with the ADM on 08/07/2026 at 4:01 p.m., revealed he was not trained on medication storage. He said the policy for medication storage was that the medication cart was to be locked when not in use. He said the person in charge of the medication cart was responsible for ensuring it was locked. He said if the medication cart was left unlocked and unattended the facility could have a medication theft. He said all the managers monitored to ensure the staff were locking the medication cart. He said all the managers monitored by doing observations. He said she did not know why LVN O left the medication cart unlocked.Record review of Storage of Medications Policy, dated April 2007, reflected The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available others.Record review of Security of Medication Cart Policy dated April 2007, reflected: Policy Statement: The medication cart shall be secured during medication passes. Policy Interpretation and Implementation:The nurse must secure the medication cart during the medication pass to prevent unauthorized entry.The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room.When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway against the wall with doors and drawers facing the wall. The cart must be locked before the nurse enters the resident's room.Medication carts must be securely locked at all times when out of the nurse's view.When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #23) reviewed for infection prevention.The facility failed to ensure LVN H wore a gown on 08/05/2026 when she administered medications through an IV (administration of fluids or medications directly into the vein) to Resident #23.This failure could place residents at risk for cross contamination and the spread of infection.Findings included:Review of Resident #23's admission record, dated 08/05/2026, reflected an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses that included: sepsis due to anaerobes (an extreme immune response that can damage tissues and organs caused by bacteria in the bloodstream that can live without oxygen), acute respiratory failure with hypoxia (when the lungs are not able to provide enough oxygen to the blood), aortitis in disease classified elsewhere (an inflammation of the largest blood vessel in the body caused by other diseases).Review of Resident #23's comprehensive MDS, dated [DATE], reflected a BIMS score of 03, which indicated severe cognitive impairment. Section O - Special Treatments, Procedures, and Programs reflected Resident #23 received IV antibiotics while at the facility.Review of Resident #23's care plan, dated 07/09/2026, reflected a focus of Enhanced Barrier Precautions - At risk for infection r/t Indwelling Medical Device with interventions that included Wear gloves and gown during high-contact care activities for resident with indwelling medical devices, wounds and colonized or infection with a CDC targeted MDRO.Review of Resident #23's order summary, dated 08/05/2026, reflected Penicillin G Potassium Injection Solution Reconstituted 5000000 UNIT Use 1 dose intravenously every 6 hours for emphysematous aortitis [the presence of gas around the inflamed vessel wall] until 08/13/2026 23:59 [11:59 PM] with a start date of 07/07/2026. There were no orders for enhanced barrier precautions.Observation on 08/05/2026 at 09:16 am revealed there was a sign which indicated Enhanced Barrier Precautions on the door to Resident #23's room. There was a supply of PPE availed inside of the room in a container at the door. LVN H had her gloves on to administer IV Penicillin G Potassium Injection Solution through a PICC line, but she did not wear a gown.During an interview on 08/05/2026 at 09:28 AM, LVN H stated, after reviewing the sign on the door, she was supposed to wear a gown while providing care to Resident #23. She stated she forgot to put a gown on. LVN H stated she had received training on infection control and enhanced barrier precautions. She stated she was supposed to wear a gown to protect herself and the resident from diseases.During an interview on 08/07/2026 at 01:23 PM, LVN G stated she had received training on infection control and enhanced barrier precautions. She stated enhanced barrier precautions were used for residents with wounds, foley catheters or any indwelling tubes and the residents were identified by a sign on the door. LVN G stated PPE was stored in a bin by the resident's door and all staff entering the room were responsible for wearing the PPE. LVN G stated by not wearing a gown, cross contamination could occur and the residents would be at an increased risk for infection.During an interview on 08/07/2026 at 02:20 PM, CNA F stated she had received training on infection control and enhanced barrier precautions. She stated the residents that required enhanced barrier precautions were identified by the sign on their door and the supplies just inside the door. She stated she was sure that staff were required to wear gloves when providing care but was not sure if a gown was required. CNA F stated she was unsure how it could affect a resident if a gown was not worn while providing direct care to a resident that required enhanced barrier precautions.During an interview on 08/07/2026 at 02:35 PM, CNA E stated she had received training on infection control and enhanced barrier precautions. She stated enhanced barrier precautions were put in place for residents that had a feeding tube, a weakened immune system, or were on dialysis. CNA E stated the residents who required enhanced barrier precautions were identified by the sign hanging on their door and the bins with supplies just inside their door. She stated by not wearing a gown and gloves when providing care to the residents identified by the sign, the resident could get sick.During an interview on 08/07/2026 at 02:55 PM, the DON stated she was also the infection preventionist. She stated she had received training on infection control and enhanced barrier precautions. She stated enhanced barrier precautions were precautions that were used as a second line of protection for any resident that had an opening in their skin or an invasive line like a foley catheter, IV, PEG tube (a tube surgically inserted through the abdomen directly to the stomach to provide nourishment and medications) or wound. The DON stated the residents were identified by staff by the sign that was hung on the resident's door and the plastic bin just inside their door with supplies. She stated staff were responsible for wearing a gown and gloves when providing direct care to residents identified by the signs. The DON stated herself and other managers monitored for staff wearing the proper PPE during their rounds. She stated if staff did not wear a gown, then their second layer of protection would not be there, and the residents could potentially get an infection. The DON stated LVN H was probably nervous and forgot to wear a gown while administering antibiotics through Resident #23's IV.During an interview on 08/07/2026 at 03:50 PM, the ADM stated he had received brief training on infection control and enhanced barrier precautions. He stated residents that required enhanced barrier precautions had an invasive line and staff were required to wear a gown and gloves when providing care. He stated staff were able to identify the residents that required enhanced barrier precautions by the sign on their door and the orange sticker next to their name. The ADM stated management monitored by observing for staff wearing the proper PPE during their rounds. He stated residents would be exposed to bacteria if staff did not wear the proper PPE for direct contact with residents that required enhanced barrier precautions. The ADM stated he was unsure why LVN H did not wear a gown while providing direct care to Resident #23.Review of facility policy titled Enhanced Barrier Precautions - Policy, dated 04/01/2024, reflected: PurposeThis policy outlines the guidelines to implement enhanced barrier precautions to prevent the spread of infectious diseases among residents and staff .PolicyEBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing.EBP are indicated for residents with any of the following: . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: . Device care or use: central line, urinary catheter, feeding tube.

Based on interview and record review, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 4 residents reviewed for discharge planning. 1. The facility failed to inform Resident #1's FM about his discharge to another facility on 06/04/2026. 2. The facility failed to inform the Ombudsman of Resident #1's discharge on [DATE] to another facility. This failure could place residents at risk of not receiving care and services to meet their needs at discharge to the other facility due to the receiving facility not getting Resident #1's medications, and diet orders. Findings included: Record review of Resident #1's face sheet dated 07/27/2026 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included sepsis (a life-threatening complication of an infection), cholecystitis (inflammation of the gallbladder), heart failure, cerebral infraction (stroke), lack of coordination, muscle weakness, and end stage renal disease (kidney failure). Record review of Resident #1's discharge MDS dated [DATE] revealed Resident #1 had a BIMS score of 09, which indicated moderate cognitive impairment. Record review of Resident #1's care plan dated 05/21/2026 revealed Resident #1 did not have any information on discharge planning. Record review of Resident #1's medical records revealed Resident #1's payor source was commercial insurance. During an interview with the Ombudsman on 07/27/2026 at 8:54a.m., she said she did not know about Resident #1 being discharged . She also said she did not get a 30-day notice for Resident #1. She said that Resident #1's FM told her that she did not know Resident #1 was discharged . She said the facility did not send any paperwork or medication with Resident #1 from what Resident #1's FM told her. During an interview with Resident #1's FM on 07/27/2026 at 10:11a.m., she said the facility told her they were not an SSI pending facility. She said on 05/20/2026 the SW texted her with a list of facilities in the area that were SSI pending. She said that the facility sent her a text message on 06/04/2026 saying they were transferring Resident #1 that day to a facility out of the area. She said when she talked to the SW through text she was told that he would not be transferred to the other facility. She said when she went to the facility on [DATE] Resident #1 was not there, and staff told her he was transferred. During an interview with the SW on 07/27/2026 at 11:20a.m., she said that Resident #1 and his FM wanted to switch to long term care. She said Resident #1 wanted the FM to take care of everything. She said a lot of the facilities she tried to get Resident #1 into had denied him. She said she contacted the FM about the out-of-town facility that accepted Resident #1. She said she informed the FM he would be moved that day. She said later that day the facility informed her that he would not be accepted because the facility did not want to transport the resident to dialysis. She said she canceled the transport to the other facility. She said she did not document the cancelation to the other facility. She said she got a call on 06/05/2026 in the morning that Resident #1 was at the out-of-town facility. She said the out-of-town facility decided at that time they would go ahead and keep the resident. She said she was off on 06/05/2026 but she went to the facility to send his medical records to the out-of-town facility. She said there was a miscommunication between dispatch and the transportation driver. She said Resident #1 was transported on 06/04/2026 to the out-of-town facility. She said she was not sure who was notified of him being picked up by transportation. She said the nurse on duty was notified that Resident #1 was not going to transfer to the out-of-town facility. During an interview with LVN A on 07/27/2026 at 1:30p.m., she said she was the nurse on duty when Resident #1 left. She said Resident #1 was scheduled to go to dialysis and from there he was to transfer to the out-of-town facility. She said she was not informed Resident #1 was not supposed to transfer on 06/04/2026. She said she knew the FM did not want Resident #1 to go to the other facility. She said the last she had heard before her shift ended at 6p.m., was Resident #1 was transferring to the other facility. During an interview with the ADM on 07/27/2026 at 2:03p.m., he said originally Resident #1 was supposed to transfer to the out-of-town facility after his dialysis. He said Resident #1 had already left for dialysis. He said the SW canceled the transport to the other facility. He said the transport company could confirm the cancelation. He said there was a miscommunication and the transport ended up taking Resident #1 to the other facility. He said he offered to go pick the resident up but the ADM at the other facility said they would keep him. He said the staff knew Resident #1 was not transferring. When asked if the staff knew Resident #1 was not transferring to the other facility, why did no one look for Resident #1 when he did not return from dialysis, he did not answer. During an interview with the FD at the dialysis company on 07/27/2026 at 5:05p.m., she said on 06/04/2026 Resident #1 got dialysis from 1:52p.m. until 6:22p.m. She said there were no notes on the treatment sheet that Resident #1 was not going to the out-of-town facility. She said on 06/03/2026 the dialysis clinic was trying to transfer Resident #1 to another facility. She said when he showed up to dialysis on 06/04/2026 they were under the impression he was going to the out-of-town facility after his session. During an interview with the Owner of the transportation company on 07/27/2026 at 5:22p.m., he said the facility called him today and informed him he would be getting a call from the State. He said the facility claimed they called him the day of 06/04/2026 to cancel the transportation to the out-of-town facility. He said the facility called him a few days later to inform him that Resident #1 was not supposed to go to the out-of-town facility. He said he did not get any information on not taking Resident #1 to the out-of-town facility. He said he chopped it up to miscommunication. He said when the transport company dropped off Resident #1 at the out-of-town facility they received him. Record review of text messages between the SW and FM of Resident #1 revealed: 05/20/2026 at 12:58p.m. Hi [FM] the is [SW] the following facilities accept SSI pending (she lists 3 facilities). FM: Thanks SW: you're welcome 06/04/2026 at 11:05a.m. SW: Good morning, Resident #1 will be transferred to [out-of-town] facility today after his dialysis. They will transfer his dialysis to [out-of-town] dialysis location for further dialysis treatments. We will transfer him to the [out-of-town] facility located at (address in text). FM: Good morning there is no facility over here? What happened to [facility name]? SW: no ma'am, no other facility has accepted him. This is the one that has accepted him. FM: what about all his stuff and have you told him this? SW: no ma'am, no other facility has accepted him. This is the one that has accepted him. FM: what about his belongings and have you told him this? And not even the one in [city] of the highway. And what happened to [facility name]. SW: no ma'am no other facility has accepted, I sent the referral to every facility possible. We will send his personal belongings with him. FM: Did you ever find his blankets and black shirt? What days and times is the dialysis now? SW: we have informed him and he is okay with it and understands this is a part of him needing care at this time. The dialysis center will be able to give the new dialysis chair time information. The housekeeping supervisor was look to locate the items; I will follow up with him and get back with you.[sic] FM: what is their information? Please be sure all his items go with him especially his phone and charger and items in the closet. SW: yes ma'am I am packing his belongings now. FM: thank you what is the information for the dialysis center? SW: I do not have the information for that clinic but once I get it from the current dialysis social worker I will give it to you. FM: Thanks can you write his name on his clothes since I won't be able to go to [city] every day for his clothes to be washed? SW: I am currently in a meeting, but I will let the accepting facility know. FM: ok. We cannot wait a couple of more days to see if a place here will accept him? That is really too far, and he will not have visitors. I know I said we did not want [facility name] but will they accept him and accommodate him or [Facility name]? We will would prefer him to stay in town, so he will not be by himself.[sic] SW: Unfortunately no other facility has accepted. FM: So tried [Facility name]? SW: We have not tried [Facility name] due to you stating you did not want that facility. They are sister facilities with [facility name]. and have the same referral process and they have not accepted. I will continue to follow up. Are you able to come to our facility today to speak further about this please before 5pm. FM: I am unable to come since I am at work but will call you in a little bit. Please try [Facility name]. SW: The marketer said they will need 3 months bank statements. FM: for which one? Who is the marketer? SW: [facility name and facility name] (inserted name and phone number). FM: I can provide his bank statements do I call [staff name] or send to you? SW: you can email them to me, and I will get them to her. FM: is he still moving to [out-of-town facility]? SW: no ma'am he will not transfer to [out-of-town facility]. FM: Ok thank you SW: Yes ma'am 06/06/2026 10:51a.m. FM: why was [Resident #1] moved without me knowing and with [out-of-town] facility not even knowing he was coming without any information on his medications or anything? Record review of the Dialysis Centers team chat dated 06/04/2026 at 2:43p.m. I texted [name] again about doing his history and physical. I am going to call [out-of-town facility] when I get in to discuss transportation. What date is he moving? 06/04/2026 5:51p.m., tonight vs tomorrow. Soon. 06/05/2026 at 2:47p.m., [Resident #1] is now at [out-of-town] facility permanently working with his transportation transfer to [dialysis center] is on hold until further notice.Record review of an email sent from the Dialysis Center FD on 07/27/2026 at 9:03p.m., 6/3/26: records state internal transfer was created for [dialysis center]. Our facility has previously worked with [facility name] and are aware of the transportation constraints plus preference to travel to [city] vs [city] for resident appointments, therefore it was known transportation would be an issue should [Resident #1] transfer to [facility name]. The screenshot of messages sent on 6/4/26 indicate transportation to dialysis treatments were not arranged prior to patient moving.6/4/26: patient's treatment was initiated at 1:52p.m., and discontinued at 06:22p.m. My charge nurse completed the post treatment assessment at 7:07p.m., stating patient left the facility via stretcher. Upon brief interview this afternoon following our phone call, my staff stated they were notified upon EMS transport picking patient up on 6/4/26 that he was moving immediately after dialysis. Two of my technicians stated EMS seemed surprised/confused about the transfer as well. We did have the transfer request initiated at that time, but patient was not accepted at [out-of-town-dialysis clinic]. Screenshot from message sent to staff on 6/5/26 states we were aware patient moved on the prior evening, but transportation arrangements were still in progress. Record review of the Discharge Policy dated 09/2025 revealed When a resident is discharged , a discharge plan shall be provided to the resident, and/or his or her representative. When the facility anticipates a resident's discharge to a private residence or to another nursing care facility (skilled, intermediate care), a discharge plan will be developed to help the resident adjust to his or her new living environment. The care plan team will collaborate with the resident and his or her family to develop the discharge plan. Advance notice of discharge should be provided to the extent possible to assure that an adequate discharge plan can be developed. When a 2 to 3 days' advance notice is not possible (because of managed care limitations or the unexpected availability of a bed in a transfer setting), staff will document reasons for a more limited discharge plan. The discharge plan will include at least the following:The identity of specific resident needs after discharge (personal care, sterile dressings, physical therapy) A description of the resident's and family's preferences for care.A description of how the resident and family will access and pay for such services.A description of how the care should be coordinated if continuing treatment involves multiple caregivers; andA description of how the resident and family need to prepare for the discharge or for subsequent service provision in the next setting.Social services will review the plan with the resident and family at least twenty-four (24) hours prior to discharge, whenever possible.The staff will give a copy of the discharge plan to the resident and the receiving facility and will also file a copy in the resident's medical records.

Based on interview and record review, the facility failed to ensure residents remained free of any significant errors for one of four residents (Resident #1) reviewed for medications and pharmacy services.The facility failed to ensure the physician's orders were followed for Resident #1 when MA A administered 3 different medications that could affect the heart when the orders stated to hold the medications for heart rate/pulse less than 60 and Resident #1's heart rate was documented to be less than 60 on 06/19/2026 and 06/20/2026.This failure could place residents at risk of not receiving the intended therapeutic benefits of the medication and symptomatic changes in vital signs.Findings included:Review of Resident #1's admission record, dated 07/08/2026, reflected a [AGE] year-old female, admitted to the facility on [DATE] and discharged on 06/21/2026 with diagnoses that included Unspecified fall, essential hypertension (high blood pressure), and paroxysmal atrial fibrillation (the heart suddenly starts beating irregularly and fast, but goes back to beating normally on its own again).Review of Resident #1's Comprehensive MDS, dated [DATE], reflected a BIMS score was 99 which indicated she was unable to complete the BIMS assessment. The staff assessment for mental status reflected she had short-term and long-term memory problems. Section I - Active Diagnoses reflected Resident #1 had hypertension and atrial fibrillation (an irregular heart rhythm).Review of Resident #1's care plan, dated 06/08/2026, revealed no documentation related to high blood pressure or atrial fibrillation.Review of Resident #1's Medication Administration Record for June 2026 reflected: Amiodarone Hcl [a medication used to prevent and treat fast or irregular heartbeats] Oral Tablet 200 MG Give 1 tablet by mouth one time a day for Arrhythmia [irregular heart rhythm] hold if pulse less than 60 with a start date of 06/17/2026. The June 2026 medication administration record reflected MA A administered Amiodarone on 06/20/2026 with Resident #1's pulse documented as 43. Metoprolol Succinate ER [a slow-release medication used to treat heart rhythm disorders and high blood pressure] Oral Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day for HTN hold if sbp[top number in the blood pressure] is less than 110 or hr less than 60 with a start date of 05/21/2026. The June 2026 medication administration record reflected MA A administered Metoprolol on 06/19/2026 with Resident #1's heart rate documented as 43. It reflected MA A administered Metoprolol on 06/20/2026 with Resident #1's heart rate documented as 43. Lisinopril [a medication administered for the treatment of high blood pressure] Oral tablet 10 MG Give 1 tablet by mouth two times a day for HTN hold if sbp is less than 110 or hr less than 60 with a start date of 05/20/2026. The June 2026 medication administration record reflected MA A administered a dose on 06/19/2026 between 6 AM - 1 PM to Resident #1 with a documented heart rate of 43. She administered a dose on 06/20/2026 between 6 AM - 1 PM with Resident #1's documented heart rate of 43. MA A administered a dose of Lisinopril on 06/20/2026 between 6 AM - 1 PM with Resident #1's documented heart rate was 56. Review of Resident #1's documented heart rates/pulses for June 2026 reflected the following: 06/19/2026 08:01 AM - 43 bpm documented by MA A;06/19/2026 08:11 AM - 46 bpm documented by RN C;06/19/2026 02:32 PM - 54 bpm documented by RN C;06/19/2026 05:58 PM - 67 bpm documented by MA A;06/19/2026 06:00 PM - 55 bpm documented by RN C;06/20/2026 09:10 AM - 43 bpm documented by MA A;06/20/2026 09:11 AM - 43 bpm documented by MA A;06/20/2026 09:11 AM - 43 bpm documented by MA A;06/20/2026 05:05 PM - 56 bpm documented by MA A;06/21/2026 08:22 AM - 60 bpm documented by MA A.Review of Resident #1's order summary, dated 07/08/2026, for active orders as of 06/21/2026, reflected the following: Amiodarone HCl Oral Tablet 200 MG Give 1 tablet by mouth one time a day for Arrhythmia hold if pulse less than 60 with a start dated of 06/17/2026; Lisinopril Oral Tablet 10 MG Give 1 tablet by mouth two times a day for HTN hold if sbp is less than 110 or hr less than 60 with a start date of 05/20/2026; and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG Give 1 tablet by mouth one time a day for HTN hold if sbp is less than 110 or hr less than 60 with a start date of 05/21/2026.During an interview on 07/09/2026 at 09:15 AM, MA A stated she had been trained to administer medication. She stated her last training was in June 2026. She stated she was trained to follow the seven rights of medications administration. MA A stated she was trained to check the resident's vital signs first, if indicated, and if the vital signs were out of range, then she was expected to hold the medication and report it to the charge nurse right away. MA A stated the staff member administering medication was responsible for assessing the vital signs first. She stated if the medication was required to be held due to the parameters set forth by the doctor, then she would have the nurse do an assessment and administer the medication, if necessary. MA A stated if the medication was administered to the resident even if the vital signs were outside of the parameter, then their heartrate could bottom out and the resident could pass out. She stated on 6/19/2026 she assessed Resident #1's vital signs and her heartrate was 43. She stated she documented the heart rate but did not know how to document the medication was not administered but still document the vital signs so she signed it off as administered, but she told the RN C the vital signs and gave her the medication so that she could reassess Resident #1's vital signs and RN C could administer the medications, if necessary. She stated the same thing happened on 06/20/2026 two different times, both in the morning and the afternoon. MA A stated she held all the medications with parameters on 6/19/2026 and 6/20/2026 due to the low heart rate. She stated she did prepare the medications each time, but she did not administer the medication. She stated she handed the medications to RN C. She stated she documented the notification to RN C on 6/19/2026 but she forgot to write a progress note on 6/20/2026 stating that she notified RN C.During an interview on 07/09/2026 at 09:34 AM, RN C stated she had been trained to administer medications. She stated her last in-service related to medication administration was in May 2026. She stated it was the facility's policy to check the blood pressure and heart rate prior to administering medication that could affect the heart. RN C stated the medications that affect the heart had parameters to hold for a systolic blood pressure less than 110 and/or a heart rate less than 60. She stated the medication aide was responsible for holding the medication and notifying the nurse if the resident's blood pressure or heart rate were not within the parameters. RN C stated she would then be responsible to reassess the resident's blood pressure and heart rate. She stated the medication aide was responsible for documenting the medication was held and the nurse was notified and the nurse was responsible for documenting the reassessment of the blood pressure and heart rate and, if necessary because the reassessment revealed the heart rate and/or blood pressure were out of range, the notification of the doctor. RN C stated if the medications were not held and the blood pressure and/or heart rate were outside of the parameters, then the blood pressure and/or heart rate to drop. RN C reviewed the electronic health record for Resident #1 on 06/19/2026 and 06/20/2026 and stated she did not remember MA A notifying her of the low heart rate on 06/19/2026, but she performed a reassessment of her heart rate 10 minutes after MA A did an assessment, so she must have been aware of the heart rate. She stated she did not document that she notified the doctor or nurse practitioner about the low heart rate, so she was not sure if she did or not. She stated she was not told on 06/19/2026 that the medications with parameters were administered. RN C stated she was not notified on 06/20/2026 that Resident #1's heart rate was 43 or that it was 56 or that any medications were held on that day. She stated if she had been notified, she would have documented the reassessment of the heart rate when she did it.During an interview on 07/09/2026 at 10:25 AM, the NP stated she could not recall if she was notified about Resident #1's heart rate on 06/19/2026 and 06/20/2026. She stated the practice she worked for ensured standing orders were placed for medications that affected the heart. She stated anything outside of the parameters she expected the medication to be held. She stated if the medication was not held then the resident could experience low blood pressure.During an interview on 07/09/2026 at 12:26 PM, the MD stated he was aware that Resident #1's heart rate/pulse would drop into the 40's and her medications were being adjusted. He stated for a heart rate under 60 he would have recommended holding the Amiodarone, but he would not have held the Lisinopril for the heart rate alone.During an interview on 07/09/2026 at 04:23 PM, the DON stated the facility's policy for administering medication that affected the heart was to check the blood pressure and heart rate prior to administering the medication and hold the medication if the heart rate or blood pressure was not within the parameters. She stated the medication aide was responsible for checking the blood pressure and heart rate and the charge nurse was responsible for reassessing the blood pressure and heart rate. The DON stated she expected the medication aide to notify the charge nurse. She stated the charge nurse was responsible for notifying the doctor or nurse practitioner if the charge nurse's assessment revealed the blood pressure or heart rate was not within the parameters on the order. She stated she expected the medication aide to document on the medication administration record and in the progress notes if the medication was held because of the parameters. She stated if a medication that affects the heart is administered even though the blood pressure and/or heart rate were not within parameters, then the residents heart rate and/or blood pressure could drop even lower.During an interview on 07/09/2026 at 05:57 PM, the ADM stated he expected the medication aides to notify the charge nurse if the residents vital signs are outside of the parameters ordered by the provider. He stated he would then expect the charge nurse to notify the provider of the vital sign that was not within the parameter.Review of facility policy titled Administering Oral Medications, dated 2001 and revised October 2010, reflected, PurposeThe purpose of this procedure is to provide guidelines for the safe administration of oral medications.Steps in the Procedure.13. Perform any pre-administration assessments.Reporting.2. Report other information in accordance with facility policy and professional standards of practice.

Based on interview and record review, the facility failed to ensure weekly skin assessments were accurately documented for 1 of 8 (Resident #1) residents reviewed for skin assessments.The facility failed to ensure LVN D provided accurate documentation of skin assessments when she documented a skin assessment on Resident #1 on 06/23/2026. Resident #1 was discharged to the hospital on [DATE], had not returned and was not in the facility on 06/23/2026.This failure could place residents at risk of worsening skin issues, infection, and not receiving appropriate care.Findings included:Review of Resident #1's admission record, dated 07/08/2026, reflected a [AGE] year-old female, admitted to the facility on [DATE] and discharged on 06/21/2026 with diagnoses that included Unspecified fall, essential hypertension (high blood pressure), and paroxysmal atrial fibrillation (the heart suddenly starts beating irregularly and fast, but goes back to beating normally on its own again).Review of Resident #1's Comprehensive MDS, dated [DATE], reflected a BIMS score was 99 which indicated she was unable to complete the BIMS assessment. The staff assessment for mental status reflected she had short-term and long-term memory problems.Review of Resident #1's care plan, dated 05/21/2026, reflected a focus of [Resident #1] has actual impairment to skin integrity r/t surgical wound at R medial [inner] knee and interventions that included Observe skin injury for abnormalities, failure to heal, s/sx of infection, maceration [skin damage due to prolonged exposure to liquid] etc. and report to MD.During an interview and record review on 07/09/2026 at 03:43 PM, LVN D stated she was responsible for completing the weekly skin assessment and documenting them in the electronic health record. She stated she completed the skin assessment for Resident #1 on 06/23/2026 after reviewing the electronic health record. Record review of the skin assessment, dated 06/23/2026, reflected Resident #1 had bruising to her bilateral upper extremities (arm) and bilateral lower extremities (legs). She stated she apparently just clicked the bubbles and went on to the next resident when asked how she completed the skin assessment for Resident #1 after she was discharged from the facility on 06/21/2026. LVN D stated she was overwhelmed with completing her assignments and so she just completed the weekly skin assessment in the electronic health record. She stated she did the physical skin assessment the week prior on an unknown day but documented it on 06/23/2026. LVN D stated documenting skin assessments days after they were completed could affect the residents because they could develop a new skin issue and it would be unknown when the skin issue actually occurred.During an interview on 07/09/2026 at 04:23 PM, the DON stated the facility's policy for skin assessments was for the charge nurse to do a skin assessment upon admission and LVN D was responsible for the weekly skin assessments after admission. She stated she expected the weekly skin assessments to be performed and documented every 7 days or as soon as the resident is available. She stated she expected LVN D to document her assessments when they were performed and not at a later date. She stated if an assessment was not documented when it was performed then a new skin issue could arise that would not be identified.During an interview on 07/09/2026 at 05:57 AM, the ADM stated he expected LVN D to do skin assessments regularly. He stated he was unsure how often they were required to be completed. He stated he had previously had discussions with LVN D about her work responsibilities and had adjusted her other responsibilities and granted overtime to allow LVN D the resources to complete her work responsibilities. He stated there were a lot of variables that needed to be considered to determine how a resident could be affected if a skin assessment was documented but was not actually performed at that time.Review of facility policy titled Pressure Ulcer Risk Assessment, dated 2001 and last revised March 2005, reflected Purpose.The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers.General Guidelines.10. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor.Assessment.2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated.3. Monitoring:.c. Nurses will conduct skin assessments at least weekly to identify changes.Step in the Procedure.5. Document the procedure.

Based on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for two of eight (Resident #2 and Resident #3) residents reviewed for reasonable accommodation of needs.The facility failed to ensure RN B was not on her cell phone while sitting at the dining room table with Resident #2 and Resident #3 during breakfast on 07/08/2026.This failure had the potential to place all residents at risk of not having their needs met timely and decreased dignity.Findings included:Resident #2Record review of Resident #2's admission record, dated 07/08/2026, reflected an [AGE] year-old female, admitted to the facility on [DATE], with diagnoses that included unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), lack of coordination, and dysphagia (difficulty swallowing).Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 00, which indicated severe cognitive impairment. Section GG - Functional Abilities reflected Resident #2 required Supervision or touching assistance for eating.Record review of Resident #2's care plan, dated 04/30/2024 and last revised on 06/07/2026, reflected a focus of [Resident #2] has an ADL Self Care Performance Deficit r/t Dementia with interventions that included EATING: The resident requires (x 1) staff participation to eat.Resident #3Record review of Resident #3's admission record, dated 07/08/2026, reflected a [AGE] year-old female, admitted to the facility on [DATE] and most recently readmitted on [DATE], with diagnoses that included dysphagia, oropharyngeal phase (difficulty swallowing), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), and cognitive communication deficit (problems with communication).Record review of Resident #3's Comprehensive MDS, dated [DATE], reflected a BIMS score of 00, which indicated severe cognitive impairment. Section GG - Functional Abilities reflected Resident #3 required Substantial/maximal assistance for eating.Record review of Resident #3's care plan, dated 03/19/2019 and last revised on 07/07/2026, reflected a focus of [Resident #3] Exhibits ADL Self Care Performance Deficit, requires assistance; cognitive deficit secondary to dementia disease progression with interventions that included Eating: requires extensive assist x 1 staff participation assist.During an observation on 07/08/2026 at 08:13 AM revealed RN B was sitting at the dining room table looking at the screen of her cellular phone. Resident #2 was sitting at the table to the left of RN B with her breakfast plate in front of her and Resident #3 was sitting at the table to the right of RN B with her breakfast plate in front of her.Attempted to interview RN B at 07/08/2026 at 08:13 AM and she stated she was tired and walked away.During an interview on 07/09/2026 at 04:23 PM, the DON stated the facility's policy for cellular phone use at the facility was that the staff were not allowed to use their personal cellular phones in patient care areas. She stated the nurse was allowed to use her personal cellular phone to contact the doctor or nurse practitioner, but they needed to step away from the residents. The DON stated she had a talk with RN B and RN B reported that she was listening to music on her phone in the dining room. She stated personal cellular phones were not allowed to be used in resident care areas because it may make the residents feel like the staff's cellular phone was more important than the residents.During an interview on 07/09/2026 at 05:57 PM, the ADM stated the facility's policy for cellular phone use by employees at the facility was staff were not allowed to use their personal cellular phones in patient care areas. He stated staff would not be able to supervise the residents if they are on their phones. The ADM stated if staff were on their cellular phones, then residents might get irritated and feel like their phones are more important than the residents.Review of an unnamed facility policy, dated 04/2019, reflected 10.3 COUNSELING: In all cases regarding the application of discipline, constructive counseling will be used, as necessary, to inform you of the nature of the infraction, the form of corrective action needed to improve, and the likely consequence of your failure to correct the misconduct, or if you continue to repeat the misconduct. You will receive copies of all disciplinary actions, with originals kept in your personnel file. The following is a general outline providing examples of employee violations subject to disciplinary measures: .Personal Cell phone use while on duty.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 5 (200-hall nurse cart) medication carts reviewed for drug storage and labeling.The facility failed to ensure the 200-hall nurse cart was locked, medications secured, and not accessible to other staff, residents, or visitors.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.Findings include:During an observation of the area between the nurses' station and the dining room on 07/08/2026 at 08:12 AM, revealed RN B was sitting at a dining room table with 2 residents. Her nurse medication cart was positioned up against the wall that divided the nurse's station from the dining room, and was unlocked, the locking mechanism was left sticking out. Staff and residents were observed walking past the unlocked medication cart.During an interview on 07/08/2026 at 08:13 AM, RN B stated she was responsible for the 200-hall nurse cart. She stated the policy for medication storage was to ensure all medication carts were locked at all times. She stated she forgot to lock the cart because she got distracted with helping residents with breakfast. She stated it was required to keep the medication carts locked because the residents could get into the cart and take something that could make them sick.During an interview on 07/09/2026 at 04:23 PM, the DON stated the policy for medication storage was to secure the cart with a lock anytime the cart was not in use. She stated it was the responsibility of the person who had the keys for the medication cart to lock the cart. She stated all staff were responsible for monitoring to ensure the medication carts were locked by observing during their rounds. The DON stated if the medication cart was left unlocked and unattended then a resident could get into the cart and take something they were allergic to.During an interview on 07/09/2026 at 05:57 PM, the ADM stated the policy for medication storage in the medication cart was to lock the medication cart when not in use. He stated the person with the keys to the cart was responsible for ensuring the cart was locked before they left it unattended. The ADM stated nursing management was responsible for monitoring to ensure the medication carts were locked when they did their rounds. He stated if the cart were left unlocked then a resident or family member could take something out of the medication cart and it would possibly cause a drug diversion. Review of facility policy titled Storage of Medications, dated 2001 and last revised April 2007, reflected Policy StatementThe facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation.2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on interview, observation, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person -centered care plan, and the residents' choice for one (Resident #1) of 5 residents reviewed for quality of care.The facility failed to promptly identify and intervene for an acute change in Resident #1's condition related to congestive heart failure (CHF), resulting in the family calling 911 to transport the resident to the hospital. The resident was admitted to the hospital with respiratory distress and pulmonary edema.An Immediate Jeopardy (IJ) was identified on 01/28/2026. The IJ template was provided to the facility on [DATE] at 12:16 PM. While the IJ was removed on 01/29/2026, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm due to staff needing more time to monitor the plan of removal for effectiveness.This failure placed residents at risk for not being provided the care and treatment required to meet their needs.Findings included: Review of Resident #1's face sheet, dated 01/14/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: generalized anxiety disorder ( a chronic mental health condition marked by excessive, persistent, and uncomfortable worry about everyday things like health, work, and family that's hard to control and interfere with daily life), unspecified diastolic congestive heart failure (heart's main pumping chamber is stiff and cannot relax or fill properly with blood between beats, causing fluid backup (congestion), essential hypertension ( high blood pressure with no single identifiable cause), paroxysmal atrial fibrillation ( a type of irregular heartbeat where episodes start and stop suddenly, usually resolving on their own or with treatment within seven days, often ending within minutes to hours), nonrheumatic aortic valve stenosis ( the heart's aortic valve narrows, most commonly age-related or a congenital defect, restricting blood flow from the heart to the body and forcing the heart to work harder, potentially leading to heart failure), end stage of renal disease ( your kidneys have failed and can no longer effectively filter waste from your blood, requiring dialysis or a kidney transplant for survival, as kidneys lose their ability to function, leading to waste buildup and serious body-wide problems). Review of Resident #1's Medicare MDS Assessment, dated 11/18/2025, reflected Resident #1 had a BIMS score of 15 which indicated her cognition was intact. She required assistance with dressing, personal hygiene, bed mobility, transfers, and bathing. She did not have any shortness of breath or difficulty with breathing . Review of Resident #1's Comprehensive Care Plan, dated 01/08/2026 reflected: Resident #1 had altered cardiovascular status related to congestive heart failure . Interventions: Give oxygen as ordered by the physician. Assess fingers and toes for warmth and color. Resident #1 had the potential for signs and symptoms and complication related to hypertension. Intervention: Avoid taking blood pressure reading after physical or emotional distress. Document and report to the MD as needed any signs or symptoms of malignant hypertension: headache, difficulty breathing, seizure activity, irritability, lethargic, confusion and/or visual problems. Give medications as ordered. Resident #1 needed hemodialysis ( a life-sustaining medical treatment for kidney failure that uses a machine with an artificial kidney to filter waste products, excess fluids, and toxins from the blood, mimicking healthy kidney function) related to renal failure. Interventions: Report significant changes in pulse, respirations and blood pressure immediately. Resident #1 was on diuretic therapy. Interventions: Administer medications as ordered. Resident #1 had CHF ( congestive heart failure- ( a long-term condition where the heart muscle weakens and cannot pump enough blood to meet the body's needs.) and is on dialysis. Resident #1 uses anti-depressant medication. Interventions: Monitor for side effects such as agitation, emotional blunting (a mental state characterized by a significant reduction in the intensity of emotions, leading to feelings of numbness, detachment, or indifference to both positive and negative events), dry mouth , and restlessness. Review of Resident #1's Late Entry Nurses Notes, dated 01/13/2026 at 7:30 AM reflected new order for Oxygen. Primary Care Provider feedback responded family called 911. Primary Care Physician approved for transferring resident to emergency room. Review of Resident #1's Nurses Notes, dated 01/13/2026 at 8:16 a.m. reflected ADON A entered Resident #1's room approximately at 7:45 a.m. Resident #1 was sitting upright in bed on 2 L/min oxygen via nasal cannula. SpO2 94%, Respirations 20. Room Temperature was 74 degrees Fahrenheit. Resident #1's family member was on phone and repeatedly instructed staff to call 911. Attempted to reposition Resident #1; Resident #1 refused. Breathing treatment was offered and declined. When asked what exacerbated or relieved symptoms, Resident #1 declined to answer and did not engage with staff (ADON A) Resident #1 closed eyes and vocalized softly. When family member asked if Resident #1 was okay, Resident #1 responded clearly and without difficulty stating No, I just need you to do something or come here to help. Resident #1 looked at this nurse (ADON A) and stated 911. Resident #1 remained upright in bed. Resident #1 was offered breathing treatment and refused. Resident #1 was restless. Signed by ADON A. Review of Resident #1's Physician Orders, dated12/01/2025, reflected Resident #1 was on medication for depression. O2 at 2L/minute via PRN as needed for shortness of breath. Review of O2 Sats Summary dated 01/13/2026 at 7:35 am reflected Resident O2 SATS was 92 percent at room air. Resident #1's O2 Sats from 10/16/2025 to 01/13/2026 averaged between 91 percent to 98 percent at room air. Observation of video in Resident #1's room revealed on 01/13/2026 at 7:26 AM Resident #1 asked LVN B for oxygen. LVN B stated, You are right. You may need oxygen. Your face looks flushed . LVN B obtained vital signs, blood pressure and O2 saturation, and stated her O2 Sat was 92 percent. Resident #1 continued to ask for oxygen. The television was on in the room, and there were times when the television was loud, and it was difficult to hear all the conversation. Resident #1 began to become very anxious. She had grimacing facial expression and began to breathe heavier ( her chest was moving faster). Resident #1 continued to ask for oxygen. LVN B stated to Resident #1, do you want another nurse to take care of you. Resident #1's tone of voice changed to a crying sound, and she was having difficulty with talking and held her chest. She kept repeating I need oxygen. LVN B collected her medical devices, and exited the room at 7:31 a.m. Observation of video of Resident #1 in her room on 1/13/2026 at 7:33 a.m. revealed Resident #1 was talking on her phone, and it was difficult to understand what she was saying due to the television being loud and she having difficulty talking. Resident #1 continued to breathe heavier, and her chest was moving faster when she would speak. Observation of video of Resident #1 in her room on 01/13/2026 at 7:37 a.m. revealed LVN B returned to the room with oxygen and stated your O2 Sat is 97 percent. LVN B placed oxygen on Resident #1 at 7:39 a.m. and exited the room at 7:40 a.m. Observation of video of Resident #1 in her room on 01/13/2026 at 7:40 a.m. revealed Resident #1 was moaning and making crying sounds. She had her personal phone on her chest. ADON A entered Resident #1's room at 7:41 a.m. Resident #1 was crying and stated she could not breathe. ADON stated, You can't breathe? You are on oxygen Is the O2 not helping you ? Resident stated, call 911. ADON stated you want to call 911. Resident #1 stated she couldn't breathe. ADON A stated she needed to assess her. ADON A did not assess Resident #1, and asked Resident #1 why are you not talking to me? You are talking to your family member. Resident #1 became more frustrated and anxious. Her chest was moving faster and she could barely speak. ADON A asked, what can we do to help you right now. Resident #1 did not respond to the question. ADON A stated, you are talking to your [family member] and won't talk to me. Resident #1 stated I can't breathe. ADON A asked Resident #1 if she wanted a breathing treatment. Resident #1 did not respond. ADON did not check her O2 sats, blood pressure, oxygen tank, or tubing. She exited the room at 7:44 a.m. ADON A re-entered Resident #1's room at 7:51 a.m. and she checked the temperature of the room. ADON A stated you need to speak to me. you are talking to your [family member] on the phone but won't speak to me. Resident #1 stated call 911 I can't breathe. ADON A removed Resident #1's phone from her chest and placed it on the rolling table, where Resident #1 was unable to reach the phone. ADON A stated your O2 Sats is 94. ADON A did not check her O2 Sats. EMS entered Resident #1's room at 7:52 a.m. Resident #1 was attempting to reach her cell phone and was stating to the EMS her [family member] was on the phone. She was unable to reach her cell phone to give it to the EMS. EMS picked up the phone and asked if Resident #1 was complaining of shortness of breath. EMS stated to family member via cell phone, we are checking her on our monitor. Does she have any other issues other than Congestive Heart Failure? . EMS stated Her O2 Sat is 79 %. I can understand why she was having shortness of breath. EMS explained to the family member on the phone and to Resident #1 they would be transferring her to the hospital and asked their hospital preference. Observation and interview on 01/14/2026 at 5:40 PM of five residents' ( Resident # 3, Resident #4, Resident #5, Resident #6 and Resident #7) oxygen tanks in their rooms revealed there were no concerns with oxygen tanks. Residents did not have any concerns of receiving oxygen or having issues with their oxygen tanks. Record review of Resident #1's hospital records reflected Resident #1 arrived at the ER on [DATE] at 8:15 a.m. [Resident #1] had history of CKD, CAD, presents the emergency department with respiratory distress, [Resident #1] gets hemodialysis Tuesday, Thursday and Saturday. She woke up this morning having respiratory distress she tried to have the nursing facility call EMS to bring her to the hospital and the facility declined. Resident #1 called her [family member] and he called EMS to bring [Resident #1] to the emergency department at that point EMS reports that she was on 2 L nasal cannula and oxygen saturations were in the 70's. [Resident #1] placed on CPAP with improvement. [Resident #1] did not have any other complaints at this time. Resident #1 was admitted to the hospital for respiratory distress in setting of volume overload. Resident #1's chest radiographs revealed findings consistent with volume overload with trace right pleural effusion ( an early or mild buildup of excess fluid throughout the body that has resulted in a tiny, minimal amount of fluid collecting in the membrane space surrounding the right lung). Resident #1 was admitted to the hospital. In an attempted interview on 1/14/2026 at 11:05 AM attempted to contact Resident #1 via phone but was unable to leave a message. Resident #1 was in the hospital. In an interview on 01/14/2026 at 12:01 p.m., ADON A stated she entered Resident #1's room approximately 7:45 a.m. on 01/13/ 2026, upon request of LVN B. She stated Resident #1 was sitting upright in the bed and she was on 2 liter(s per minute) of oxygen. She stated Resident #1 was upset and she could not understand what Resident #1 was saying to her. ADON A stated Resident #1 did state she was having shortness of breath. ADON A stated she complained about that a lot. She stated she began to assess her. ADON A stated she checked her O2 sats, blood pressure, oxygen tank, and the room temperature. ADON A stated she was only in Resident #1's room one time. She stated Resident #1 would say she was having difficulty with breathing, and her family member was on Resident #1's cell phone. She stated her oxygen saturation was 94 percent . She stated she used the pulse oximeter three times when she checked Resident #1's O2 sats and it was 94 percent each time. ADON A stated she checked the oxygen tubing in Resident #1's nose to ensure it was secure. ADON A stated Resident #1 became more frustrated and anxious with the questions she was asking about what she could do to help her. ADON A stated Resident #1 stated 911. ADON A stated she removed the cell phone from Resident #1's chest and placed it on the bedside table right beside her bed where she could reach it. ADON A stated Resident #1's family member was on the phone when she removed it from Resident #1's chest. She stated she did not speak to the family member. ADON A stated EMS entered the room and took over with assessing Resident #1. ADON A stated if a Resident asked for 911 to be called, the facility staff was expected to call 911. She stated she did not call 911 or anyone about Resident #1's complaints of having shortness of breath.ADON A did not respond why she did not call 911. ADON A did not reply why she did not call 911. She stated she did not call the physician or report the resident's complaint of having difficulty with breathing and wanting to go to hospital to anyone. ADON A stated she had been in-serviced on resident rights and change of condition, and she was expected to contact the physician and to call 911 if a resident requested to go to the hospital. She stated LVN B called 911 and that was when EMS came to the facility to transport Resident #1 to the hospital. She stated the family did not call 911, and the facility staff called 911. In an interview on 01/14/2026 at 3:03 p.m., LVN B stated she entered Resident #1's room at approximately 7:15 a.m. after it was reported to her that Resident #1 was complaining of having shortness of breath. LVN B stated Resident #1 did request oxygen several times during the assessment. She stated the oxygen tank in Resident #1 was not working. LVN B stated Resident #1 became frustrated and anxious when she was assessing Resident #1. She stated Resident #1 continued to ask for oxygen. She stated she felt she was frustrating Resident #1 and was making Resident #1 worse due to her color becoming flushed and her becoming upset due to wanting oxygen. LVN B stated she did not call 911 or the physician. She stated she did not think it was necessary to contact the physician or call 911 until she finished her assessment. LVN B stated she re- entered Resident #1's room approximately 10 minutes later with an oxygen tank and placed the oxygen on Resident #1. She stated when she checked Resident #1's O2 sat, it was 94 percent at room air. LVN B stated after she placed the oxygen on Resident #1, she exited the room and asked ADON A to assess Resident #1. LVN B stated she asked Resident #1 if she wanted another nurse to give her care and she became upset after this question was asked of her. LVN B did not respond to why Resident #1 became upset after this question was asked. She stated Resident #1's family member called 911 for EMS to come to the facility and Resident #1 was transferred to the emergency room and was admitted to the hospital with shortness of breath and respiratory distress. LVN B stated if a resident requested for 911 to be called, and complained of shortness of breath, the facility was expected to call 911, the physician, and the family. She stated Resident #1's family member was on the phone when she was in the room. LVN B stated she did not have anything else to report about the situation with Resident #1. In an interview on 01/14/2026 at 4:00 p.m., the Director of Nurses stated anytime a resident was complaining about shortness of breath and requested for the nurse to call 911, her expectation was for the nurse to call 911 immediately. She stated Resident #1 did have a history of having shortness of breath and had heart conditions. Director of Nurses stated Resident #1 was placed on oxygen prior to EMS entering the facility. She stated that occurred on 01/13/2026 approximately 7:30 a.m. The Director of Nurses stated ADON A was in the room with Resident #1. She stated they were investigating exactly what occurred with Resident #1 on 01/13/2026. She stated ADON A needed to call 911 when the resident first stated she had shortness of breath and wanted 911 to be called instead of the family having to call 911. She stated it was the facility's responsibility to ensure the resident's wishes were honored and not neglect what Resident #1 was requesting. The Director of Nurses stated she would need to review the hospital records to determine Resident #1's condition when she arrived at the hospital to determine if it was an emergency for Resident #1 to be admitted to the hospital. She stated she would need to investigate more into the situation with Resident #1 before answering any further questions. Review of the facility's Change in a Resident's Condition or Status, dated 2016 , reflected Our facility shall promptly notify the resident , his or her Attending Physician, and representative (sponsor) of changes in the resident's medical, mental condition and /or status (e.g. changes in level of care, billing/payments, resident rights etc.) or need to transfer the resident to the hospital/treatment center . The Director of Nurses was notified on 01/28/2026 at 12:16 pm that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/28/2026 at 9:30 pm. Letter of Credible AllegationFor Removal of Immediate Jeopardy Attention Sir or Madam On 1/28/2026 an abbreviated survey was initiated at facility. On 1/28/2026 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusion set for in the verbal and written notice of immediate jeopardy and/ or any subsequent Statement of Deficiencies. The immediate jeopardy allegations are as follows: F684 Quality of Care The facility failed to ensure Resident #1 received treatment and care in accordance with professional standards of practice. Resident #1 remains in the hospital and does not expect to return to the facility related to new health concern with heart as stated by the family member. Actions for Resident Involved Resident #1 was discharged to the hospital on [DATE]. Investigation completed on 01/14/2026, ADON A received disciplinary action and one on one re-education. Identification of Others On 1/28/2026 an Inservice was initiated with the licensed nurses, nurses' aides, and medication aides, regarding honoring resident wishes when requesting 911 to be called, comprehension will be verified by posttest after in servicing completed. Director of Nurses was in serviced on honoring residents wishes when requesting 911 to be called by Clinical Service Director with a post test. Start date was 01/28/2026 and completion date was 01/28/2026. The Director of Nurses and/ or designee was responsible for these in-services. On 1/28/2026 interview able residents will be interviewed to ensure staff are honoring their wishes. Any identified concerns will be addressed immediately . Non-interview able residents will be observed to ensure no change in condition is present. It will be documented on life satisfaction survey forms and reviewed by the administrator and any concerns will be addressed immediately. The start date was 01/28/2026 and completion date was 01/28/2026. The administrator and/ or designee was responsible for interviewing the residents. System Monitoring The Director of Nurses or designee will continue with in servicing newly hired staff including PRN staff and agency( if utilized), regarding honoring residents' wishes when wanting 911 called during the orientation process.The department heads will conduct rounds ( documented on life satisfaction survey forms) on their assigned rooms daily to interview able residents to ensure staff are honoring their wishes to include if requesting to call 911. Non-interview able residents will be observed to ensure no change in condition was present. It will determine all the documented-on life satisfaction survey forms and reviewed by the administrator and any concerns will be addressed immediately. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 1/28/2026 with the Medical Director. The Medical Director has reviewed and agrees with this plan. We respectfully submit this action plan for the removal of Immediate Jeopardy. The Surveyor monitored the POR ( Plan of Removal) on 01/29/2026 as follows: In an interview and observation on 01/29/2026 at 9:50 am Resident #3 stated she is on oxygen, and the staff checks her oxygen several times a day. She stated she does not have any issues with her care at the facility, and she feels safe and confident in the abilities of the nursing staff to give her the care she needs. There were no concerns with her oxygen. In an interview on 01/29/2026 at 10:05 am Resident #4 stated anytime she needed help someone always came to her room and assisted her. She complained about her back hurting and had reported this concern to MA D. She stated her back pain was chronic and anytime she asked for pain medication if it was time for her to have it the nurse always brought the pain medication to her room. She stated she felt safe at the facility and did not worry about not receiving good care from the nurses. In an interview on 01/29/2026 at 10:12 am ADON B stated she did give Resident #4 her pain medication for her back. In an interview on 01/29/2026 at 10:15 am Resident #4 verified she did receive her pain medication. In an interview on 01/29/2026 at 10:24 am Resident #5 stated anytime she asked for a nurse for medicine or for any help the nurse came to her room within a reasonable time. She stated she never had to wait very long to speak to a nurse. Resident #5 stated she felt safe at the facility and the care she received. She stated she did not have any concerns about her care or the nurses giving care to her. In an interview and observation on 01/29/2026 at 10:30 am Resident #6 stated he was on oxygen continuously. He stated the nurses checked his oxygen every day. He stated he has never had any issues with his oxygen. Resident #6 stated he had confidence in the staff to give him the care he needed, and he felt safe in the facility. Did not observe any issues with Resident #6's oxygen. In an interview and observation on 01/29/2026 at 10:40 am Resident #7 stated she loved the nurses at the facility. She stated when she asked for assistance with anything a nurse would come in and check on her. She stated a nurse checked her oxygen every day and she did not have any issues with not receiving her oxygen. Resident #7 stated she felt safe at the facility and felt safe receiving the needs she required to get the care the doctor wanted her to have while living at this facility. There were no concerns with her oxygen. In an interview and observation on 01/29/2026 at 10:47 am Resident #8 stated she received oxygen at night, and she did not have any issues of not receiving her oxygen on time. She stated the nurses were very good to assist her with oxygen and anything else she may need. Resident #8's oxygen was in her room. She stated she had only been at the facility a few weeks and she felt comfortable and safe with the care she has received from nursing staff and from all the staff. Did not observe any concerns with her oxygen. In an interview on 01/29/2026 at 12:00 pm MA F ( 6 am to 6 pm) stated she had been in serviced on resident rights and change of condition. She stated she received in-service on 1/28/2026. She stated anytime a resident requested to go to the hospital she was expected to immediately report it to the nurse. She stated it was a resident right to request for 911 to be called. MA F stated anytime a resident was having a change of condition such as physical, behaviors, or mentally, she would report the change to the nurse. She stated she did take a quiz on resident rights and change of condition. She stated she learned the resident had a right to call 911 on their personal cell phone and the staff was not to interfere with resident's request to go to the hospital. MA F stated if a resident had a cell phone it was not to be taken away from resident and placed in an area where the resident was unable to reach the phone. She stated the resident had a right for privacy when speaking to their family. She stated if staff removed the cell phone away from a resident while their family was on the phone and placed it where resident was unable to speak to their family , she would consider this resident neglect and she would report it immediately. She stated the Administrator was the abuse/ neglect coordinator. In an interview on 01/29/2026 at 12:10 pm ADON E ( 6 am to 6 pm ) stated she was in serviced on 01/28/2026 on resident rights and change of condition of a resident. She stated after she received in-service she was given a written quiz on resident rights and change of condition. She stated anytime a resident requests for 911 to be called due to any type of physical concern, she would call 911 and would assess the resident until EMS came to the facility. She stated it was a resident right for 911 to be called for health reasons such as difficulty of breathing. She stated if a resident was complaining of having shortness of breath and asked for 911 to be contacted she would contact 911 immediately. ADON E stated she would call the physician and responsible party. She stated it was resident rights for 911 to be contacted upon their request when the resident was having a change of condition in their physical condition, behaviors, and mental status. She stated residents had a right to voice their opinion about their care. ADON E stated anytime a resident is requesting oxygen related to shortness of breath the nurse is expected to check physician orders to ensure the resident has orders for oxygen and provide the oxygen for resident after assessing the resident. She stated if the resident repeats to call 911 this is her resident right for 911 to be called and nurse is expected to call 911 and the physician. ADON E stated a resident's cell phone was never to be taken away from the resident especially if the family was on the phone speaking to resident. She stated this was a resident right to speak to family in private and to have the phone where the resident had access to the cell phone. She stated the department heads have assigned residents they make satisfaction rounds and beginning yesterday ( 01/28/2026) began asking about their care and their resident rights. If a resident was not interview able they made observations of the residents to determine if the resident was in any type of distress such as grimacing expression , moaning, or change in complexion. In an interview on 01/29/2026 at 12:30 pm LVN G ( 6 pm to 6 am) stated he was in-serviced on resident rights and change of condition on 01/28/2026. He stated when a resident is in physical distress and asking for 911 to be called the nurse was expected to honor resident rights and contact 911. LVN G stated it was resident rights to be transferred to the hospital upon resident request. He stated a resident has the right to be treated with dignity and respect. LVN G stated anytime a resident had a cell phone it was their resident right to have the cell phone within reach of the resident. LVN stated if a resident was speaking to a family member on the cell phone the resident had a right for privacy, and the cell phone was not to be taken away from the resident and placed where the resident was unable to reach the phone. He stated he did receive a quiz after the in-service on resident rights and change of condition. He stated the quiz was about giving examples of resident rights and what to do observe if a resident had a change of condition such as physical, mental , behaviors, etc. He stated anytime he suspected a resident being neglected he would report it immediately to the Administrator who was the abuse coordinator. In an interview on 01/29/2026 at 1:10 pm CNA H (6 am to 6 pm) stated if a resident was not at their baseline mentally, physically or with their behaviors she would immediately report it to the nurse. She stated she had been in-serviced on resident rights and change of condition. She stated she did take a quiz after she was in-serviced. CNA H stated she learned if a resident complains a lot about the same thing do not ignore their complaints and always report any health complaints to the nurse. She stated anytime a resident stated they wanted 911 to be called she was to report this immediately to the nurse. CNA H stated it was resident neglect to take a cell phone away from a resident while family was on the phone and place the phone where the resident was not able to reach the phone. She stated it was also considered against resident rights. CNA H stated she received in-service on 1/28/2026. She stated she learned the resident had a right to call 911. She stated anytime there was any changes with a resident, and a resident was not at their baseline to report it immediately to the nurse. She stated if she noticed anything unusual with oxygen she would report this immediately to the nurse, such as the concentrator not working properly or there was no air coming out of the tubing. She stated anytime there was anything unusual with the resident no matter what it was to always report to the nurse. In an interview on 01/29/2026 at 3:00 pm the Director of Nurses stated she was in-serviced on quality of care, change of condition, respecting resident wishes and when a resident wants to go to the hospital. She stated residents are to be treated respectfully and explain the care to the resident and report any type of concern of the resident immediately to the nurse and if the nurse is the one observing the concern, the nurse was to immediately call the physician or 911 according to the circumstance of the resident. She stated quality of care meets professional standards and supports residents' highest level of well-being. The Director of Nurses stated when a resident had a change of condition this was when a new physical, mental or emotional change occurred, or an existing concern deteriorated. She stated the staff was expected to recognize the change, call the physician, report to the nurse, or call 911. She stated the resident was to be monitored until EMS came to the facility. The Director of Nurses stated delaying reporting can cause serious harm or delay calling 911. She stated if a resident refused care the nurse was to document it in the nurses notes.In an interview on 01/29/2026 at 3:30 pm the Administrator stated all staff except for 8 had been in-serviced on change of condition, resident rights and quality of care. She stated the 8 staff would not be eligible to work until they receive in-service. The Administrator stated ADON A was suspended on 01/28/2026. She stated they had a QAPI meeting and reviewed the POR and the concern with Quality of Care. The Administrator stated they had already began monitoring process such as the department heads make rounds on the residents they are assigned to and ensure there is no new or past issues with the residents. She stated in-services would be ongoing and anyone new would receive the in-service on resident rights, quality of care and change in condition prior to working at the facility. She stated the facility was continuing with their investigation of the situation with Resident #1. She stated the facility staff would randomly be monitored by the Director of Nurses or designee of their overall care for the r[TRUNCATED]

Based on interviews and record reviews, the facility failed to ensure a comprehensive care plan was reviewed and revised by theinterdisciplinary team after each assessment for 1 of 5 (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's care plan was revised to reflect Resident #2 was on Enhanced Barrier Precautions . This failure could place residents at risk of not receiving appropriate care to meet their needs. Findings included: Review of Resident #2's Face sheet, dated 01/14/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of sepsis, unspecified organism (a serious medical conditions characterized by the body's extreme response to an infection, where the specific organism causing the infection is not identified. It can lead to organ failure), perforation of intestine ( a hole or tear in the intestinal wall, allowing digestive contents like food, bacteria, bile, and acid to leak into the abdominal cavity, causing severe infection and potentially life-threatening sepsis), colostomy status (a surgically created opening in the abdominal wall that connects the colon to the outside of the body, allowing waste to bypass a damaged or diseased part of the lower bowel), and malignant neoplasm of rectum (cancer forming in the tissues of the rectum). Review of Resident #2's MDS Assessment, dated 01/01/2026, reflected Resident #2 had a BIMS score of 13 indicated his cognition was intact. Resident #2 had a colostomy. He had diagnosis of septicemia (body's extreme response to an infection that enters the bloodstream) and sepsis. Review of Resident #2's Comprehensive Care Plan, revised on 01/07/2026, reflected Resident #2 had an ostomy secondary to bowel perforation. He was at risk for complications including but not limited to stoma, irritation and bleeding. Interventions: Colostomy care every shift as needed. Monitor for signs of infections such as edema, redness, increased pain around the stoma area. There was not a care plan for Resident #2 to be on enhance barrier precautions. Interview on 01/16/2026 at 4:00 pm, the Director of Nurses stated Resident #2's care plan should have been revised on 01/07/2026. She stated either the ADON or DON was responsible for updating care plans. The Director of Nurses stated they hired an MDS nurse, however, she would begin working next week. She stated if a Resident had an order for enhanced barrier precautions, the nurse reviewing the physician order could have added it to the care plan. The Director of Nurses stated all information about a resident was to be care planned, including enhanced barrier precautions. She stated the interdisciplinary team, and all staff was to follow what was documented on the plan of care for each resident, and if enhanced barrier precautions was not on the care plan, there was a possibility if a nurse reviewed the care plan, the nurse may not know how to use PPE prior to entering the resident's room, if the enhanced barrier precaution sign fell off the door of the resident's room. Interview on 01/16/2026 at 4:35 pm, the Administrator stated she expected any time there was a change of condition or change of treatment, it was to be immediately added to the resident's care plan. She stated if a resident had a new order for enhanced barrier precautions, she expected the nurse, DON, or the Interim nurse completing care plans, to implement this on the resident's care plan. She stated if enhanced barrier precautions were not on a resident's care plan, there was the potential for a nurse, or any staff who may review the care plan, not realize to follow the facility's enhanced barrier precautions protocols. She stated if a staff did not follow enhance barrier precautions, there was a possibility bacteria could be spread to another resident. She stated ultimately, the Director of Nurses was responsible for ensuring the care plans were completed and revised until the new MDS nurse began working next week. She did not recall the exact hire date for the new MDS nurse. Record review of the facility's policy on Comprehensive Care plan, dated December 2015, reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.The Interdisciplinary Team must review and update the care plan:1. When there has been a significant change in the resident's condition.2. When the desired outcome is not met;3. When the resident has been readmitted to the facility from a hospital stay; and4. At least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 5 residents (Resident #1 observed for resident rights. The facility failed to ensure Resident #1 was treated with respect when Resident #1's personal cell phone was placed on the bedside rolling table, where she could not reach it, by ADON A when she was talking to her son while she was in respiratory distress. This failure could place residents at risk lack of advocacy and frustration. Findings included: Review of Resident #1's face sheet, dated 01/14/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses unspecified diastolic congestive heart failure (heart's main pumping changer is stiff and cannot relax or fill properly with blood between beats, causing fluid backup (congestion), essential hypertension ( high blood pressure with no single identifiable cause), paroxysmal atrial fibrillation ( a type of irregular heartbeat where episodes start and stop suddenly, usually resolving on their own or with treatment withing seven days, often ending within minutes to hours), generalized anxiety disorder (a mental health disorder that produces fear, worry and a constant feeling of being overwhelmed), recurrent depressive disorder ( caused by traumatic or stressful life events), nonrheumatic aortic valve stenosis ( the hearts aortic valve narrows, most commonly age-related or a congenital defect, restricting blood flow from the heart to the body and forcing the heart to work harder, potentially leading to heart failure), Review of Resident #1's Medicare MDS Assessment, dated 11/18/2025, reflected Resident #1 had a BIMS score of 15 indicated her cognition was intact. Resident #1 had diagnosis of anxiety and depression. Review of Resident #1's Comprehensive Care Plan, dated 01/08/2026 reflected Resident #1 was taking anti-depressant medication. Intervention: Psych services as indicated. Social Services to evaluate and provide emotional support as needed. Observation of Resident #1's video from her room dated 01/13/2026 at 7:51 am, revealed ADON A stated I am going to remove your phone from your chest and Resident #1 nodded her head no and held up her left hand. She became more frustrated and ADON A left the room when she removed the phone from Resident #1. Resident #1's family member was on the phone, and Resident #1 attempted to reach the phone. The phone was placed on rolling bedside table where Resident #1 was unable to reach it. The bedside rolling table was not beside Resident #1. The bedside rolling table was to the right side of the bed, approximately 10 feet from Resident #1, towards the middle of the right side of the bed. Approximately 8 minutes later, EMS walked into the room and picked up the cell phone and began talking to Resident #1 son. During the time the cell phone was removed from Resident #1's chest, Resident #1's hands were not shaking. Resident #1 was holding the cell phone in her left hand prior to laying it on her chest. In an interview on 01/14/2026 at 12:01 p.m., ADON A stated Resident #1 was having difficulty with breathing, and her phone was near her chest. She stated the phone had an effect on Resident #1's breathing. ADON A stated the phone lying on Resident #1 chest was not good for breathing. She stated Resident #1's son was on the phone talking to Resident #1 when she removed the phone from Resident #1 chest and placed it on the bedside table, within reach of Resident #1. She stated Resident #1 was able to reach the cell phone from where she was lying in bed. ADON A stated the bedside rolling table was not located on the right side of the bed and was not toward the middle of the bed, instead it was directly beside Resident #1, at the head of the bed. ADON A stated it was Resident #1's right to have her cell phone when her son was on the phone speaking to Resident #1. She stated Resident #1 was not able to hold the cell phone with her hand. ADON A stated Resident #1's hands were shaking, and she was not capable of holding a cell phone. ADON A stated she was expected to follow resident rights and had been in-service on resident rights. She stated she did not recall the time or date of the in-service. ADON A stated she did not have anything else to say about the cell phone, that was all she knew to report about the situation of the phone. In an interview on 01/16/2026 at 4:00 pm, the Director of Nurses stated anytime a Resident was on their personal cell phone with a family member, and they find comfort having their family member on the cell phone when they are in distress or not in distress it was against resident rights for a staff to remove the cell phone from the resident. She stated ADON A was not to remove the cell phone from Resident #1 and place it where Resident #1 could not reach it. The Director of Nurses stated a resident had a right to speak to their family anytime they choose, and to have their cell phone within reach. She stated all staff had been in-service on resident rights. She stated she had not interviewed ADON A about the incident with Resident #1, and the facility was going to conduct a full investigation of what occurred with Resident #1 on 01/13/2026. In an interview on 01/16/2026 at 4:35 pm, the Administrator stated all residents had a right to have access to using phone to contact family. She stated if a resident had a personal cell phone and a family member was on the phone with the resident, it did not matter what the situation was, the staff was not to take the cell phone away from a resident while family was on the phone. The Administrator stated if a resident had a cell phone, and not using it, the staff was not to place a resident's cell phone outside of the reach of the resident. She stated a resident's personal cell phone was expected to be within reach of the resident at all times, especially when the resident's family was talking to the resident on the phone. She stated that was against the resident's rights. The Administrator stated all staff had been in-serviced on resident rights, and she did not recall the date or time of the in-service. She stated the facility was completing an investigation of what occurred with Resident #1 on 01/13/2026. The Administrator stated she would be conducting further investigation about the situation with the cell phone incident that occurred on 01/13/2026. Record review of the facility's policy on Resident Rights, dated 2009, reflected Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident to use a telephone in privacy. Residents are entitled to exercise their rights and privileges to the fullest extent possible. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of ten residents reviewed for care plans. The facility failed to ensure staff followed Resident #1's care plan on 03/26/25 when CNA A was giving her a bed bath alone and she slid from the bed onto the floor sustaining a severe laceration to her right hip and fracture to her left hip. An IJ was identified on 04/09/25. The IJ template was provided to the facility on [DATE] at 5:36 pm. While the IJ was removed on 04/09/25, 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. This failure placed residents at risk for negligence, injury, and hospitalization . Findings included: Review of Resident #1's face sheet, dated 04/09/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE], readmitted on [DATE] and 07/07/23 with diagnoses including Congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs, leading to fluid buildup in the body, particularly in the lungs and extremities), varicose veins (swollen, twisted, and enlarged veins, usually seen on the legs), and body mass index BMI 45.0 - 49.9 (indicates Class III obesity, also known as morbid obesity). Review of Resident #1's quarterly MDS assessment, dated 01/27/25, reflected a BIMS of 15, indicating resident had intact cognition. Review of Resident #1's quarterly care plan, revised on 11/24/21, reflected ADL performance deficit related to immobility, pain, and poor vision with interventions of: Toilet use - Resident #1 required (X2) staff participation to use toilet revised on 11/24/21 Transfer - Resident #1 required (X2) staff participation with transfers revised on 11/24/21 Bed Mobility - Resident #1 required (X2) staff participation to reposition and turn in bed revised on 11/24/21 Bathing - Resident #1 required (X2) participation with bathing revised on 11/24/21 Review of Resident #1's hospital HPI dated 03/26/25 reflected Resident #1 presented to the ER after a fall. Resident lived at a nursing home and reportedly when they were changing the sheets she fell out of bed. In the ER she was found to have a left comminuted intertrochanteric fracture (a break in the femur (thigh bone) that occurs in the intertrochanteric region, specifically between the greater and lesser trochanters. This fracture type is often seen in older adults and can result from a fall or impact. The comminuted aspect means the fracture has multiple bone fragments making it a more unstable fracture) and a large V-shaped skin tear that was stabled in the ER. A review of the Texas Unified Licensure Information Portal for the facility revealed that on 03/26/25 the facility reported that on 03/26/25 CNA A administered ADL care to Resident #1 and rolled her to her right side. Resident #1 slid out of bed onto the floor. Resident #1 received a laceration to her right lower extremity and was sent to the emergency room . The facility later received notification that Resident #1 had a left hip fracture. Review of unsigned facility statement from CNA A dated 03/26/25 reflected, I [CNA A] was giving [Resident #1] a bed bath, when I turned her over to clean the other side of her she slid out of her bed on to the Floor. I ran fast to tell nurse. we came back with help to get her off the floor. her legs were bleeding bad, so the nurse called 911, the nurses wrapped her legs to slow some of the bleeding. By then the paramedics/EMT Came and took her to the hospital. A review of Resident #1's Progress Note by LVN B reflected he was called to Resident #1's room by staff and found resident on floor at bedside closest to window. Resident #1 was nude from ADL care and her lower extremities lay across the legs of the bedside table, while her head was partially resting against wheels of bed. Resident #1 was alert and oriented and able to converse about her condition. After returning resident to bed with assistance of staff and mechanical devise it was determined that the laceration on the upper part of right thigh required a physician's intervention. While additional staff nurses remained with resident to help control bleeding RN B returned to desk and called EMS and reported to hospital ER of impending transfer. Resident was transferred to [hospital] by EMS, MD was made aware, and DON was informed. Resident #1 was her own responsible party and concurred with the treatment plan. Review of facility statement by the Administrator dated 03/27/25 9:15 am revealed she spoke with CNA A regarding the incident with Resident #1 and asked if she know how to read the Kardex (a concise nursing documentation system that summarizes key patient information, including medications, treatments, and daily care plans) and CNA said she did. Administrator asked her if she read it the morning of the incident with Resident #1 and CNA A said she did not. The Administrator asked CNA A how many people it took to assist Resident #1 and with peri care (cleaning the genital and anal areas to maintain hygiene and prevent infections) as well as other ADL's and CNA A said 2 (two). The Administrator asked CNA A if she used another person to assist Resident #1 and CNA A replied no, that the other aides were assisting other residents. The Administrator revealed she educated CNA A on the importance of reading the Kardex as well as following the Kardex and that it was to prevent any injuries to the resident. Review of facility statement by the Administrator dated 03/27/25 9:15 am revealed she asked CNA A to go to Resident #1's room and show her how the incident occurred. The Administrator said CNA A raised the bed to the position it was at the time of the incident and CNA A stated that when she got ready to turn [Resident #1] she pulled the sheet up and turned [Resident #1] on her right side. This is when [Resident #1's] left leg swung over the side of the bed causing [Resident #1] to slide off the bed landing on her stomach. [Resident #1's] head was by the front wheels of the bed and her legs were by the back wheels of the bed. [CNA A] stated that [Resident #1's] lower right leg was laying on the top of the bottom of the over the bed table. This table has a metal frame that holds the table with the bottom of the bedside table where [Resident #1's] right lower extremity landed. CNA A told the Administrator that there was blood at the bottom of the bedside table where [Resident #1's] right lower extremity landed. The Administrator said she asked if Resident #1 complained of pain to either of her hips and CNA A stated that [Resident #1] did not. Review of signed statement dated 03/26/25 of CNA C who stated I was sitting at the nurse's station when we were approached by [RN B] to assist with [Resident #1] that fell out of bed. I went to assist with the fall of [Resident #1]. I came to help get [Resident #1] off the floor. Review of signed statement dated 03/26/25 of CNA D who stated, I was sitting at the nurse's station when we were approached by [RN B] to assist with [Resident #1] that fell out of bed. I went to assist with the fall of [Resident #1]. I came and grabbed the [assistive device] to help assist until no longer needed. Attempted interview on 04/09/25 with Resident #1 at 11:42 am, who discharged to another facility after she discharged from the hospital, reflected, when phoning Resident #1, received a voice mail that the number requested could not be dialed and unable to interview Resident #1. Interview on 04/09/25 with a Family Member of Resident #1 at 11:25 am revealed Resident #1 no longer had a telephone. Family Member reported the facility staff, rolled [Resident #1] right off the bed. The Family member said there was a policy in place for Resident #1 to have 2 (two) people always go in and assist Resident #1 when she needed to be changed. The Family member reported Resident #1 had, 30 staples and 7 stitches and a broken hip. An interview on 04/09/25 with CNA A at 12:36 pm reflected she felt like the facility was short staffed and she did not want to bother the other staff and ask for help. She said she had helped Resident #1 alone previously and Resident #1 had been sitting in urine and needed to be changed. CNA A said she did not purposely hurt Resident #1, but she did not ask for help to assist Resident #1. She said she had not been asked to return to work at the facility. CNA A said when Resident #1 fell , she ran to get a nurse and he assessed with getting Resident #1, using an assistive devise, off the floor. CNA A she was not trained on how to use the Kardex but did know that Resident #1 was a 2 (two) person assist when changing or moving Resident #1. A phone call interview on 04/10/25 with LVN B at 02:12 pm revealed he was the nurse on shift at time of Resident #1's fall on 03/26/25 and, to his knowledge the resident was a 2 (two) person assist. He said the Kardex contained information about Resident #1's ADLs and transfer status. LVN B stated the CNAs referred to the Kardex to determine the care needs of a resident and the Kardex was available to all CNAs. LVN B stated, he was not aware, at the time of the incident, that CNA A was providing care alone. LVN B stated he was informed by staff (staff name unknown) that Resident #1 had a large bowl movement and CNA A wanted to bath her after but stated that CNA A should have gotten help and that there was plenty of staff that night to assist and no reason for her to not ask for help. CNA B revealed, Why she chose not to do that I don't know, I was at the nurses station charting when she came to get me for help after. He stated if CNA A had told him that she was going to bathe Resident #1 he would have gotten up to help CNA A, but she did not inform him that she needed a second staff member to help her with Resident #1. He stated he was the charge nurse that night. He stated the caregiver was ultimately responsible for asked for assistance with residents because they knew the rules when they were given their assignments. LVN B stated anyone would be crazy to take a resident her size on by themselves and he did not know why to this day CNA A did not ask for help. LVN B recalled the resident's weight to be in the area of 260 plus pounds. Resident #1 was in a bariatric bed, and it was hard for LVN B to imagine that someone would attempt changing and cleaning her alone. When LVN B walked into the room to help after CNA A called him, he said it looked like she [CNA A] was getting ready to change the oil on the bed- that was never safe at any time for any patient especially someone with Resident #1's weight to have a bed that high. The aide should have gotten help, the call light was available there was always a way to get help. An interview on 04/10/25 with CNA C at 2:33 pm revealed she was at the nurses' station on the rehabilitation side of the facility when LVN B came to get her stating they needed help getting a resident off the floor. CNA C stated she saw the resident on the floor in between the wall and the bed and Resident #1's bed was pretty high up. CNA C stated prior to this event, she never worked with Resident #1 but upon seeing Resident #1, because of Resident #1 was a big woman, she would have known that Resident #1 was a 2 (two) person assist. CNA C stated that the number of staff assistance a resident required for safe resident care was in the Kardex located in EMR. A CNA could click on the Kardex to see if the resident was a one or two person assist. The CNA C said if there was not another person to assist a resident who was a 2 (two) person assist, she would ask a nurse to help or wait for a coworker to get help before assisting the resident. She said she did not recall how many staff members were working that night but said there were plenty of people listing herself, two aides, a nurse, and a nurse trainee. CNA C stated that CNA A could have also asked the people in the rehabilitation side of the facility for help. CNA C stated it was never appropriate to proceed with just one person if the resident was listed in the Kardex as a 2 (two) person assist. If the Kardex says the Resident require a 2 (two) person assist, you wait until you have 2 (two) people to assist. CNA C stated, you never know the condition or if they just had hip surgery, you always wait to have the amount of people you need. CNA C stated she has no idea why the CNA A did not ask for help that night. A phone interview on 04/10/25 with CNA D at 2:50 pm revealed LVN B asked for help with a resident. CNA D she walked into Resident #1's room and saw Resident #1 on the floor and she went to grab the mechanical devise to lift help get Resident #1 off the floor. CNA D stated they needed a mechanical device due to Resident#1's size and also because of Resident #1's ADL abilities. CNA D stated she had worked with Resident #1 in the past and stated it was very obvious for anyone, even working with Resident #1 for the first time, to see that Resident #1 was a 2 (two) person assist based on her size and appearance. CNA D stated she would look at the Kardex to determine the level of assistance needed for residents. CNA D stated if she did not have the 2nd person needed to assist a resident, she would go find help and stated, you just have to ask for help. CNA D Stated it was never appropriate to proceed to assist without the help of others if they require 2 (two) or more even assist if it appeared manageable. CNA D stated it was everyone's responsibility to ensure the residents received the level of care they need. She stated she referred to the Kardex daily because something could change. She stated she would report any Kardex issues to her nurse or the Administrator as needed. In an interview on 04/10/25 with ADON at 6:02 pm she stated CNAs were ultimately responsible for ensuring the correct level of care for residents because they were trained and knew the procedures. She stated that agency and PRN staff also have access to the Kardex. She stated she was responsible for the PRN and new hire staff be aware of where to locate the Kardex which displays the care needs of the residents. She stated it was her expectation that they provided the highest level of care, that all residents needs were met in a safe, respectful, and dignified manner. The ADON stated that level of resident care and resident transfer status understanding was the knowledge that kept patients safe. She said that if staff knew the level of resident care needs it helped to makes sure residents remained safe. She stated that if the person was aware of the transfer status of a resident and did not follow the resident transfer status when providing resident care she would consider it negligence because they did not provide the safest level of care. An interview on 04/10/25 with the DON at 6:20 pm revealed she had been the DON at the facility for a week and a half and it was her expectation that the CNAs follow the Kardex that they have been trained to follow. She stated she would consider it negligence if a CNA knew the transfer status of a resident and failed to follow it and stated that CNA would require retraining. She stated that training for Kardex occurred frequently. An interview on 04/10/25 with the Administrator at 2:33 pm revealed staff needed to ensure the physical abilities and the level of the ADL care needed for residents when providing assistance. The CNAs can find out if residents require a 1 (one) or 2 (two) person level of assistance by referring to the Kardex. If there is not a 2nd staff member available, they need to wait until a 2nd staff member is available to provide resident care. An interview on 04/10/25 with the Administrator at 6:45 pm revealed it was the CNAs responsibility to ensure they were providing the care the resident required. She stated all PRN staff had access to the Kardex and knew how to locate it. She stated it was important to follow the transfer status due to resident safety as well as staff safety. She stated that when she asked CNA A why she didn't ask for help CNA A said that other CNAs were busy, and Resident #1 was impatient. Review of facility Falls and Fall Risk, Managing Policy dated April 2007 reflected based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent resident from falling and try to minimize complications from falling. Review of the facility Falls - Clinical Protocol dated April 2007 based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Review of the facility Abuse and Neglect - Clinical Protocol Assessment and Recognition policy dated April 2007 reflected neglect means failure to provide good and services necessary to avoid physical harm, mental anguish, or mental illness. Treatment/Management -The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The ADM was notified on 04/09/25 at 5:36 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 04/10/25 at 2:27 pm: The POR included: PLAN OF REMOVAL Date: April 9, 2025 The Texas Department of Health and Human Services entered facility on April 9, 2025 for a Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited regarding F656 Develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. The facility failed to follow Resident # 1's care plan when care was provided by one staff member only. Immediate action: What corrective actions have been implemented for the identified residents? Resident #1 discharged from the facility on 3-26-25 to the hospital and did not return to the facility. On 4-9-25, the Clinical Service Director in-serviced the nurse managers to include the DON to refer to the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care. On 4-9-25, DON/designees in-serviced all direct care (full-time, part-time, and PRN) nursing staff to utilize Kardex to determine the level of assistance required to provide care. On 3-27-25, the Administrator educated CNA A to refer to the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care. CNA A last day worked was 3-31-25. All direct care nursing staff (full-time, part-time, and PRN) will demonstrate and acknowledge that they are aware of how to identify and utilize the Kardex to review resident's care plan to identify the level of assistance: including 2 person assistance) required to provide ADL care. The Kardex was in the POC dashboard which is accessible by all direct care nursing staff in the facility. To access the employee will log into their POC, select the resident and then select the Kardex button located on the right-hand side of their screen. This will then display the level of care required to provide care as directed in their care plan including 2 person assistance. On 4-10-25, DON/designees audited residents' Kardex to ensure the level of required assistance was stated as directed by resident's care plan. 13 residents were identified as needing 2-person assistance for bed mobility. On 4-10-25, DON/designees audited employee roster to ensure 100% of direct care nursing staff (full-time, part-time, and PRN) are in-serviced to refer to the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care. The training regarding to refer the Kardex for the level of assistance: including 2 person assistance required to provide ADL care will be ongoing. Continuous training to be conducted during the orientation of newly hired direct care nursing staff (full-time, part-time, and PRN). The DON/designees provide oversight and ensure compliance. No direct care nursing staff will be allowed to work without receiving the in-service on the utilization of the residents' Kardex to determine the level of assistance that is required to provide care. DON/designees will conduct random direct care observation audit for compliance with the utilization of the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care daily for 1 week, weekly for 1 month and monthly thereafter until compliance is sustained for 3 consecutive months. Noncompliance identified will be corrected immediately. On 4/9/25, the facility Administrator notified the Medical Director via phone. Items discussed were: IJ (Immediate Jeopardy) was cited on 4/9/25 as evidenced by facility's failure to: F656 - Develop and implement a comprehensive person-centered care plan The facility failed to follow Resident # 1's care plan when care was provided by one staff member only. All direct care nursing staff is to identify and utilize the Kardex to review resident's care plan to determine the level of assistance required to provide care. All direct care nursing staff will demonstrate and acknowledge that they are aware of how to identify and utilize the Kardex to review resident's care plan to identify the level of assistance required to provide care. The Kardex is in the POC dashboard which is accessible by all direct care nursing staff in the facility. To access the employee will log into their POC, select the resident and then select the Kardex button located on the right-hand side of their screen. This will then display the level of care required to provide care as directed in their care plan. DON/designees audited residents' Kardex to ensure the level of required assistance is stated as directed by resident's care plan. DON/designees audited employee roster to ensure 100% of direct care nursing staff are in-serviced regarding identification and utilization of the Kardex. The training regarding to refer the Kardex for the level of assistance: including 2 person assistance required to provide ADL care will be ongoing. Continuous training to be conducted during the orientation of newly hired direct care nursing staff (full-time, part-time, and PRN). The DON/designees provide oversight and ensure compliance No direct care nursing staff will be allowed to work without receiving the in-service on the utilization of the residents' Kardex to determine the level of assistance that is required to provide care. Random direct care observation audit will be conducted by DON/designees for compliance with the utilization of the Kardex to determine the level of assistance that is required to provide care to the residents daily for 1 week, weekly for 1 month and monthly thereafter until compliance is sustained for 3 consecutive months. Noncompliance identified will be corrected immediately. This will be reviewed monthly in QAPI until sustained compliance is achieved. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 4/09/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. While the IJ was removed on 04/10/25 at 7:10 pm, the facility remained out of compliance at a level of no actual harm at a scope of widespread because the facility's need to evaluate the effectiveness of the corrective systems. Monitoring: Record review completed on 04/10/25 of inservice dated 04/09/25 by clinical services director - refer to Kardex on level of assistance required by residents with ADL care including residents that require a 2 person assist, signed by the DON. Record review completed on 04/10/25 of log dated 04/09/25 used to complete training for staff, indicated who was trained over the phone or in person. Of 77 direct care staff, 75 were inserviced which is 97 percent. 2 which have not are PRN staff not scheduled to work, but per the clinical services director, they will be inserviced when they are scheduled prior to their shift. During interviews on 04/10/25 from 12:40 pm - 3:20 pm, two LVNs, one MA, and 9 CNAs from different shifts all stated they were in-serviced before working their shift on utilization of the residents' Kardex to determine the level of assistance that is required to provide care and observed the CNA's ability to locate the Kardex and care requirements for ADLS and transfers. Record review completed on 04/10/25 of in-service dated 03/27/25 at 9:00 am presented by Administrator to CNA A you must refer to the Kardex prior to providing assistance to residents so that you can ensure you are providing the appropriate level of care. Observed signature by CNA A. Record review completed on 04/10/25 of audit done on all residents dated 04/10/25 for bed mobility and level of assist and Kardex accuracy. Audit was completed of all residents, of 15 that had a x2 status- 2 were corrected which no longer required x2 assistance and changed to x1 assist, condition improved. Record review completed on 04/10/25 of audit of employee rooster to ensure 100% of direct care (full-time, part-time, and PRN) were in-serviced to refer to the Kardex for the level of assistance: including 2 person assistance required by residents with ADL care. Record review completed on 04/10/25 of adhoc QAPI dated 04/09/25 with sign in sheet that included 7 staff; Administrator, Regional VP of Ops, DON, ADON E, ADON F, Clinical Services Director, and facility MD. While the IJ was removed on 04/10/25 at 7:10 pm, the facility remained out of compliance at a level of no actual harm at a scope of widespread because the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards, in that: The facility failed to protect Resident #1, who required a two person assist for toilet, transfers, bed mobility and bathing, when CNA A, acting alone on 03/26/2025, assisted Resident #1 with ADL care. Resident #1 slid off her bed, sustained a severe laceration (a tear or cut in the skin or other tissues caused by trauma) to her right hip and a fracture to her left hip. An IJ was identified on 04/09/25. The IJ template was provided to the facility on [DATE] at 5:36 pm. While the IJ was removed on 04/09/25, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk for negligence, injury, and hospitalization . Findings included: Review of Resident #1's face sheet, dated 04/09/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE], readmitted on [DATE] and 07/07/23 with diagnoses including Congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs, leading to fluid buildup in the body, particularly in the lungs and extremities), varicose veins (swollen, twisted, and enlarged veins, usually seen on the legs), and body mass index BMI 45.0 - 49.9 (indicates Class III obesity, also known as morbid obesity). Review of Resident #1's quarterly MDS assessment, dated 01/27/25, reflected a BIMS of 15, indicating resident had intact cognition. Review of Resident #1's quarterly care plan, revised on 11/24/21, reflected ADL performance deficit related to immobility, pain, and poor vision with interventions of Toilet use - Resident #1 required (X2) staff participation to use toilet revised on 11/24/21. Transfer - Resident #1 required (X2) staff participation with transfers revised on 11/24/21. Bed Mobility - Resident #1 required (X2) staff participation to reposition and turn in bed revised on 11/24/21. Bathing - Resident #1 required (X2) participation with bathing revised on 11/24/21. Review of Resident #1's hospital HPI dated 03/26/25 reflected Resident #1 presented to the ER after a fall. Resident lived at a nursing home and reportedly, when they were changing the sheets she fell out of bed . In the ER she was found to have a left comminuted intertrochanteric fracture (a break in the femur (thigh bone) that occurs in the intertrochanteric region, specifically between the greater and lesser trochanters. This fracture type was often seen in older adults and can result from a fall or impact. The comminuted aspect means the fracture has multiple bone fragments making it a more unstable fracture) and a large V-shaped skin tear that was stabled in the ER. A review of the Texas Unified Licensure Information Portal for the facility revealed that on 03/26/25 the facility reported that on 03/26/25 CNA A was administering ADL care to Resident #1 and rolled her to her right side. Resident #1 slid out of bed onto the floor. Resident #1 received a laceration to her right lower extremity and was sent to the emergency room . The facility later received notification that Resident #1 had a left hip fracture. Review of unsigned facility statement from CNA A dated 03/26/25 reflected, I [CNA A] was giving [Resident #1] a bed bath, when I turned her over to clean the other side of her, she slid out of her bed on to the Floor. I ran fast to tell nurse. we came back with help to get her off the floor. her legs were bleeding bad, so the nurse called 911, the nurses wrapped her legs to slow some of the bleeding. By then the paramedics/EMT Came and took her to the hospital. A review of Resident #1's Progress Note dated 03/26/25 by LVN B reflected he was called to Resident #1's room by staff and found resident on floor at bedside closest to window. Resident #1 was nude from ADL care and her lower extremities lay across the legs of the bedside table, while her head was partially resting against wheels of bed. Resident #1 was alert and oriented and able to converse about her condition. After returning resident to bed with assistance of staff and mechanical lift it was determined that the laceration on the upper part of right thigh required a physician's intervention. While additional staff nurses remained with resident to help control bleeding RN B returned to desk and called EMS and reported to hospital ER of impending transfer. Resident was transferred to [hospital] by EMS, MD was made aware, and DON was informed. Resident #1 was her own responsible party and concurred with the treatment plan. Review of facility statement by the Administrator dated 03/27/25 9:15 am revealed she spoke with CNA A regarding the incident with Resident #1 and asked if she knew how to read the Kardex (a concise nursing documentation system that summarizes key patient information, including medications, treatments, and daily care plans) and CNA said she did. Administrator asked her if she read it the morning of the incident with Resident #1 and CNA A said she did not. The Administrator asked CNA A how many people it took to assist Resident #1 and with peri care (cleaning the genital and anal areas to maintain hygiene and prevent infections) as well as other ADL's and CNA A said 2 (two). The Administrator asked CNA A if she used another person to assist Resident #1 and CNA A replied no, that the other aides were assisting other residents. The Administrator revealed she educated CNA A on the importance of reading the Kardex as well as following the Kardex and that it was to prevent any injuries to the resident. Review of facility statement by the Administrator dated 03/27/25 9:15 am revealed she asked CNA A to go to Resident #1's room and show her how the incident occurred. The Administrator said CNA A raised the bed to the position it was at the time of the incident and CNA A stated that when she got ready to turn [Resident #1] she pulled the sheet up and turned [Resident #1] on her right side. This was when [Resident #1's] left leg swung over the side of the bed causing [Resident #1] to slide off the bed landing on her stomach. [Resident #1's] head was by the front wheels of the bed and her legs were by the back wheels of the bed. [CNA A] stated that [Resident #1's] lower right leg was laying, on the top of the bottom of the over the bed table. This table has a metal frame that holds the table with the bottom of the bedside table where [Resident #1's] right lower extremity landed. CNA A told the Administrator that there was blood at the bottom of the bedside table where [Resident #1's] right lower extremity landed. The Administrator said she asked if Resident #1 complained of pain to either of her hips and CNA A stated that [Resident #1] did not. Review of signed statement dated 03/26/25 of CNA C who stated I was sitting at the nurse's station when we were approached by [RN B] to assist with [Resident #1] that fell out of bed. I went to assist with the fall of [Resident #1]. I came to help get [Resident #1] off the floor. Review of signed statement dated 03/26/25 of CNA D who stated, I was sitting at the nurse's station when we were approached by [RN B] to assist with [Resident #1] that fell out of bed. I went to assist with the fall of [Resident #1]. I came and grabbed the [mechanical lift] to help assist until no longer needed. Attempted interview on 04/09/25 with Resident #1, who discharged to another facility from the hospital after the incident, at 11:42 am reflected, when phoning Resident #1, received a voice mail that the number requested could not be dialed and unable to interview Resident #1. Interview on 04/09/25 with a Family Member of Resident #1 at 11:25 am who stated Resident #1 no longer had a telephone. Family Member reported the facility staff, rolled [Resident #1] right off the bed. The Family member said there was a policy in place for Resident #1 to have 2 (two) people always go in and assist Resident #1 when she needed to be changed. The Family member reported Resident #1 had, 30 staples and 7 stitches and a broken hip. An interview on 04/09/25 with CNA A at 12:36 pm she stated she felt like the facility was short staffed and she did not want to bother the other staff and ask for help. She said she had helped Resident #1 alone previously and Resident #1 had been sitting in urine and needed to be changed . CNA A said she did not purposely hurt Resident #1, but she did not ask for help to assist Resident #1 with ADL care. She said she had not been asked to return to work at the facility since the incident. CNA A said when Resident #1 fell , she ran to get a nurse and he assisted with getting Resident #1 off the floor, using a mechanical assistive devise. CNA A stated she was not trained on how to use the Kardex but did know that Resident #1 was a 2 (two) person assist when changing or moving Resident #1. A phone call interview on 04/10/25 with LVN B at 2:12 pm revealed he was the nurse on shift at time of Resident #1's fall on 03/26/25 and, to his knowledge the resident was a 2 (two) person assist. He said the Kardex contained information about Resident #1's ADLs and transfer status. LVN B stated the CNAs referred to the Kardex to determine the care needs of a resident and the Kardex was available to all CNAs. LVN B stated, he was not aware, at the time of the incident, that CNA A was providing care alone. LVN B stated he was informed by staff (staff name unknown) that Resident #1 had a large bowl movement and CNA A wanted to bath her after but stated that CNA A should have gotten help and that there was plenty of staff that night to assist and no reason for her to not ask for help. CNA B revealed, Why she chose not to do that I don't know, I was at the nurses station charting when she came to get me for help. He stated if CNA A had told him that she was going to provide ADL assistance for going to bathe Resident #1 he would have gotten up to help CNA A, but she did not inform him that she needed a second staff member to help her with Resident #1. He stated he was the charge nurse that night. He stated the caregiver was ultimately responsible to ask for assistance with residents because they knew the rules when they were given their assignments. LVN B stated anyone would be crazy to take a resident her size on by themselves and he did not know why to this day CNA A did not ask for help. LVN B recalled the resident's weight to be in the area of 260 plus pounds. Resident #1 was in a bariatric bed, and it was hard for LVN B to imagine that someone would attempt changing and cleaning her alone. When LVN B walked into the room to help after CNA A called him, he said it looked like she [CNA A] was getting ready to change the oil on the bed- that was never safe at any time for any patient especially someone with Resident #1's weight to have a bed that high. The aide should have gotten help, the call light was available and there was always a way to get help. An interview on 04/10/25 with CNA C at 2:33 pm revealed she was at the nurses' station on the rehabilitation side of the facility when LVN B came to get her stating they needed help getting a resident off the floor. CNA C stated she saw the resident on the floor in between the wall and the bed and Resident #1's bed was pretty high up. CNA C stated prior to this event, she never worked with Resident #1 but upon seeing Resident #1, because of Resident #1 was a big woman, she would have known that Resident #1 was a 2 (two) person assist. CNA C stated that the number of staff assistance a resident was required for safe resident care and the information was in the Kardex located in EMR. A CNA could click on the Kardex to see if the resident was a one or two person assist. CNA C said if there was not another person to assist a resident who was a 2 (two) person assist, she would ask a nurse to help or wait for a coworker to get help before assisting the resident. She said she did not recall how many staff members were working that night but said there were plenty of people listing herself, two aides, a nurse, and a nurse trainee. CNA C stated that CNA A could have also asked the people in the rehabilitation side of the facility for help. CNA C stated it was never appropriate to proceed with just one person if the resident was listed in the Kardex as a 2 (two) person assist. If the Kardex says the Resident require a 2 (two) person assist, you wait until you have 2 (two) people to assist. CNA C stated, you never know the condition or if they just had hip surgery, you always wait to have the amount of people you need. CNA C stated she has no idea why the CNA A did not ask for help that night. A phone interview on 04/10/25 with CNA D at 2:50 pm revealed LVN B asked for help with a resident. CNA D stated she walked into Resident #1's room and saw Resident #1 on the floor and she went to grab the mechanical lift to lift help get Resident #1 off the floor. CNA D stated they needed a mechanical lift due to Resident#1's size and also because of Resident #1's ADL abilities. CNA D stated she had worked with Resident #1 in the past and stated it was very obvious for anyone, even working with Resident #1 for the first time, to see that Resident #1 was a 2 (two) person assist based on her size and appearance. CNA D stated she would look at the Kardex to determine the level of assistance needed for residents. CNA D stated if she did not have the 2nd person needed to assist a resident, she would go find help and stated, you just have to ask for help. CNA D stated it was never appropriate to proceed to assist without the help of others if they require 2 (two) or more even assist if it appeared manageable. CNA D stated it was everyone's responsibility to ensure the residents received the level of care they need. She stated she referred to the Kardex daily because something could change. She stated she would report any Kardex issues to her nurse or the Administrator as needed. An interview on 04/10/25 with ADON at 6:02 pm stated stated CNAs were ultimately responsible for ensuring the correct level of care for residents because they were trained and knew the procedures. She stated that agency and PRN staff also have access to the Kardex. She stated she was responsible for the PRN and new hire staff be aware of where to locate the Kardex which displays the care needs of the residents. She stated it was her expectation that they provided the highest level of care, that all residents needs were met in a safe, respectful, and dignified manner. The ADON stated that level of resident care and resident transfer status understanding was the knowledge that kept patients safe. She said that if staff knew the level of resident care needs it helped to makes sure residents remained safe. She stated that if the person was aware of the ADL transfer status of a resident and did not follow the resident ADL transfer status when providing resident care she would consider it negligence because they did not provide the safest level of care. An interview on 04/10/25 with the DON at 6:20 pm revealed she had been the DON at the facility for a week and a half and it was her expectation that the CNAs follow the Kardex that they have been trained to follow. She stated she would consider it negligence if a CNA knew the ADL transfer status of a resident and failed to follow it and stated that CNA would require retraining. DON stated that training for Kardex occurred frequently. An interview on 04/10/25 with the Administrator at 2:33 pm revealed staff needed to ensure the physical abilities and the level of the ADL care needed for residents when providing assistance. The CNAs can find out if residents require a 1 (one) or 2 (two) person level of assistance by referring to the Kardex. If there was not a 2nd staff member available, they need to wait until a 2nd staff member was available to provide resident care. An interview on 04/10/25 with the Administrator at 6:45 pm revealed it was the CNAs responsibility to ensure they were providing the care the resident required. She stated all PRN staff had access to the Kardex and knew how to locate it. She stated it was important to follow the ADL transfer status due to resident safety as well as staff safety. She stated that when she asked CNA A why she didn't ask for help CNA A said that other CNAs were busy, and Resident #1 was impatient. Review of facility Falls and Fall Risk, Managing Policy dated April 2007 reflected based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent resident from falling and try to minimize complications from falling. Review of the facility Falls - Clinical Protocol dated April 2007 based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. Review of the facility Abuse and Neglect - Clinical Protocol Assessment and Recognition policy dated April 2007 reflected neglect means failure to provide good and services necessary to avoid physical harm, mental anguish, or mental illness. Treatment/Management -The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The ADM was notified on 04/09/25 at 5:36 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 04/10/25 at 2:27 pm: The POR included the following: F- 600 IJ Template provided to entity: 04/09/25 5:36pm F-600 Plan of Removal Date: April 9, 2025 The Texas Department of Health and Human Services entered the facility on April 9, 2025, for a Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited regarding F600 -The resident has the right to be free from neglect . The facility failed to ensure Resident #1 had two staff members assisting her during care as outlined in Resident #1's care plan. What corrective actions have been implemented for the identified residents? A. On 3/26/2025 Resident #1 involved in alleged deficient practice was discharged to the hospital resident did not return to the facility. B. On 3/26/2025 CNA A was in-serviced on Referring to the Kardex for the level of assistance required by residents with ADL care and the Abuse and Neglect Policy by the administrator. C. On 3/26/025 CNA A was suspended on 3/26/2025 pending investigation findings. D. On 4/09/2025 at 7:20 pm the Administrator notified the Medical Director of the alleged deficient practice. Record review completed on 04/10/25 of screenshot showing call made to the MD 04/09/25 at 7:20 pm. E. CNA A last day employed was on 3/31/2025. F. On 4/09/2025 the Corporate Clinical Service Director re-educated the nurse management team on referring to the Kardex for the level of assistance required with ADL care including residents needing 2-person assistance and the Abuse and Neglect Policy. The completion date was 4/09/2025. G. On 4/09/2025 the Administrator and Nurse Managers re-educated the nursing staff on referring to the Kardex for the level of assistance required with ADL care including residents needing 2-person assistance and the Abuse and Neglect Policy. The completion date was 4/10/2025. H. On 4/10/2025 an audit was conducted by the Corporate Clinical Service Director and the nurse management team to ensure the level of ADL care required, including residents needing 2-person assistance was noted in the Kardex. There were 13 residents identified that require 2-person assistance with bed mobility. Discrepancies found were immediately corrected on 04/10/2025. I. The Corporate Clinical Service Director reviewed facility policy on 04/09/2025 regarding change in condition and no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. All residents have the potential to be affected by the alleged deficient practice. On 4/10/2025 the Regional Nurse completed Resident Life Satisfactory Surveys for residents that require 2-person assistance, no concerns were noted. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. On 4/09/2025 the nurse management team re-educated the nursing staff (Full-time, Part-time, and PRN) on referring to the Kardex for the level of assistance required, including residents needing 2-person assistance with ADL care and the Abuse and Neglect Policy. Nursing staff will not be allowed to return to work until they receive this in-service. The completion date was 4/10/2025. B. Newly hired nursing staff will be in-serviced upon hire during staff orientation by nurse management/designee on referring to the Kardex for the level of assistance required, including residents needing 2-person assistance with ADL care and the Abuse and Neglect Policy. C. DNS /designee will conduct random observations of ADL care including residents needing 2-person assistance is being provided daily for one week, then weekly for one month, and monthly thereafter until compliance is sustained for three consecutive months. Noncompliance identified will be addressed immediately. How will the system be monitored to ensure compliance? A. The ADONs will review the change in condition daily x 3 months for any changes in residents' ADL level of assistance requirements and ensure the Kardex is updated as applicable. Discrepancies noted during reviews will be immediately corrected. Further training will be provided as identified by the nurse manager who identified the discrepancy when and if necessary. The review will be documented on an audit report form. B. The Administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction for three months. The review will be documented on an audit report form. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 4/09/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Record review completed of adhoc QAPI dated 04/09/25 with sign in sheet that included 7 staff; Administrator, Regional VP of Ops , DON, both ADONs, Clinical Services Director, and facility MD. Monitoring: Monitoring: Record review completed on 04/10/25 of in-service dated 03/27/25 at 9:00 am presented by Administrator to CNA A you must refer to the Kardex prior to providing assistance to residents so that you can ensure you are providing the appropriate level of care. Observed signature by CNA A. Record review completed on 04/10/25 of disciplinary action for CNA C dated 03/31/25 with violation date of 03/26/25 reflecting termination for not following proper protocol in regard to providing care to resident, the resident sustained a laceration and fractured hip. Record review completed on 04/10/25 of screenshot showing call made to the MD 04/09/25 at 7:20 pm notifying the Medical Director of the alleged deficient practice Record review completed on 04/10/25 of disciplinary action for CNA C dated 03/31/25 with violation date of 03/26/25 reflecting termination for not following proper protocol in regard to providing care to resident as 2x staff, the resident sustained a laceration and fractured hip. Record review completed on 04/10/25 of in-service dated 04/09/25 by clinical services director to nurse management - refer to Kardex on level of assistance required by residents with ADL care including residents that require a 2 person assist, and ANE signed by DON, two ADONs, LVN MDS, and treatment nurse. Record review completed on 04/10/25 of log used to complete training for staff, dated 04/09/25, that indicated who was trained over the phone or in person. Of 77 direct care staff, 75 were in-serviced which was 97 percent. 2 which are PRN staff not scheduled to work, but per the clinical services director, they will be in-serviced when they are scheduled prior to their shift. During interviews on 04/10/25 from 12:40 pm - 3:20 pm, two LVNs, one MA, and 9 CNAs from different shifts all stated they were in-serviced before working their shift on utilization of the residents' Kardex to determine the level of assistance that is required to provide care and observed the CNA's ability to locate the Kardex and care requirements for ADLS and transfers. Record review completed on 04/10/25 of audit done on all residents dated 04/10/25 for bed mobility and level of assist for Kardex accuracy. Audit was completed of all residents, of 15 that had a x2 status- 2 were corrected which no longer required x2 assistance and changed to x1 assist, condition improved. Record review completed on 04/10/25 of the in-serviced dated 04/09/25 on re-education of the nursing staff on referring to the Kardex for the level of assistance required with ADL care including residents needing 2-person assistance and the Abuse and Neglect Policy. Record review completed on 04/10/25 of adhoc QAPI dated 04/09/25 with sign in sheet that included 7 staff; Administrator, Regional VP of Ops , DON, both ADONs, Clinical Services Director, and facility MD. While the IJ was removed on 04/10/25 at 7:10 pm, the facility remained out of compliance at a level of no actual harm at a scope of widespread because the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluid were administered consistent with professional standards of practice in accordance with physician orders, the comprehensive-centered care plan, and the resident's goals and preferences for two (Resident #1 and Resident #2) of two residents reviewed for parenteral fluids. 1. The facility failed to ensure Resident #1's PICC line dressing was changed every 7 days or as needed as Resident #1 went 27 days without a dressing change. Resident #1's dressing was dated 2/20/2025 and was not changed on 02/27/2025, 03/06/2025, and 03/13/2025. 2. The facility failed to ensure Resident #1, and Resident #2 were on enhanced barrier precautions for PICC lines. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 03/18/2025 at 2:25 PM and an IJ template was provided. While the IJ was removed on 03/19/2025 at 6:30 PM, the facility remained out of compliance at no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents with central lines at risk for serious infection, impaired nutrition, and hospitalization . Findings included: Review of Resident #1 face sheet reflected a [AGE] year-old man readmitted on [DATE] with diagnoses of other acute osteomyelitis, left femur, sepsis due to Escherichia coli, type 2 diabetes mellitus, unspecified dementia, malignant neoplasm of prostate, and abscess of bursa. Review of Resident #1 quarterly MDS reflected a BIMS score of 06. Further review reflected Resident #1 had septicemia and received intravenous, antibiotics. Review of Resident #1's physician orders dated 02/20/2025 reflected Resident #1 had a PICC inserted for IV access until 03/19/2025. Review of Resident #1's physician orders dated 02/11/2025 reflected to change IV dressing every seven days and as needed. Resident #1's dressing should have been changed on 02/27/2025, 03/06/2025, and 03/13/2025 and/or as needed. Review of Resident #1's physician orders dated 02/11/2025 reflected to administer cefazolin sodium intravenous solution every 8 hours for sepsis until 03/19/2025 through PICC line. Further review reflected orders dated 02/12/2025 to flush IV line before and after administration of IV medication. Observation on 03/18/2025 at 9:53 AM, revealed there were no EBP signage or PPE available for Resident #1. Further observation revealed Resident #1's PICC line dressing was dated 02/20/2025. There was no signs of redness or odor observed at site. During an observation and interview on 03/18/2025 at 11:26 AM, LVN A stated that Resident #1's dressing was dated 02/20/2025. LVN A stated dressings were supposed to be changed at least once a week and if it was not changed the resident could get an infection. LVN A stated she was not sure what residents were supposed to be on EBP. LVN A was observed flushing Resident #1's PICC line with gloves on and no gown. LVN A stated the nurse who was assigned to the resident should change the dressing. LVN A stated she thought she should use a gown and gloves if you were flushing or doing anything with a PICC line. During an observation and interview on 03/18/2025 at 11:43 AM, ADON B stated EBP should have been used on residents who have direct line in or out of the body and any major wound. ADON B stated you should use EBP when you changed dressings or provided personal care. ADON B stated residents who had a PICC line should have been on EBP. ADON B stated he needed to double check whether staff needed to wear a gown to flush the line. ADON B observed Resident #1's dressing and stated, I can tell you right now, that isn't good. ADON B stated that Resident #1's dressing was dated 02/20/2025. During a subsequent interview on 03/18/2025 at 12:23 PM, ADON B stated that he was informed that central supply ran out of dressings two weeks ago and their order was backordered for some time. ADON B stated they should get a new delivery today. ADON B stated he was not aware the facility was out of the dressings. Review of Resident #2's face sheet reflected a [AGE] year-old man admitted on [DATE] with diagnoses of other specified sepsis, infection and inflammatory reaction due to internal right hip prosthesis, abscess of [NAME], staphylococcal arthritis, and hearth failure. Review of Resident #2's physician order dated 03/13/2025 reflected to change foley catheter as needed, and provide catheter care every shift or as needed. Further review reflected to change IV dressing every seven days or as needed. Observation on 03/18/2025 at 10:49 AM, revealed no EBP signage or PPE in or outside of Resident #2's door. Observation on 03/18/2025 at 10:50 AM, revealed facility staff posted EBP sign on Resident #2's door. Observation on 03/18/2025 at 10:55 PM, revealed LVN C flushed Resident #2's line with gloves on and did not have a gown on. During an interview on 03/18/2025 at 11:26 AM, LVN C stated that dressings were supposed to be changed every 7days and if there were not an infection could occur. LVN C stated residents who had a PICC line were usually on EBP. LVN C started EBP was used to provide personal care such as showers. LVN C stated that only gloves could be used for flushing, and it was not considered personal care. During an interview on 03/18/2025 at 1:38 PM, DON stated that EBP should have been used on residents with a foley, PICC, IVs and wounds. She stated that this included using gloves, gown and mask when care was provided. DON stated resident with PICC lines should be on EBP. She stated PPE should have been just inside or just outside of the resident's room. She stated that when staff handled the PICC lines they should have implemented EBP. DON stated the purpose of EBP was to possibly prevent infection. DON stated she was not aware that Resident #1's dressing had not been changed since 02/20/2025. DON stated the nurse was responsible for putting in the orders and changing the dressing when it was needed. DON stated ADONs should have monitored that orders were initiated and PICC dressings were changed. DON stated dressings should be changed every seven days. She stated the potential outcome of not changing the dressing or using EBP was possible introducing an infection. DON stated central supply was responsible for ordering supplies and that PICC line dressings were on back order. DON stated they had one dressing in the facility today and she just learned that there was a PICC dressing shortage. During an interview on 03/18/2025 at 1:18 PM, MD stated that dressing was supposed to be every seven days and as needed. MD stated there was a risk for infection if the dressing was not changed but it was not anything outrageous and stated Resident #1's dressing should have been changed. MD stated there are no standing orders for EBP, but she would expect the staff to have EBP PPE on such as gown and gloves. Review of facility policy titled Central Venous Catheter Dressing Changes with revision date of April 2016 reflected the purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Further reviewed reflected general guidelines included to change dressings at least every 5-7 days and PRN. Review of facility policy titled Enhanced Barrier Precautions - Policy dated 04/01/2024 reflected the use of gown and gloves during high-contact resident care activities were required. High-contact resident care activities included device care or use such as central line or urinary catheter. Further review reflected indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. The ADM and DON were notified on 03/18/2025 at 2:25 PM, that an IJ had been identified. An IJ template was provided, and a POR was requested. The following POR was approved on 03/19/2025 at 12:19 PM and indicated: Plan of Removal A. On 3/18/25, an abbreviated survey was initiated at the facility. The surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy stating the facility failed to ensure resident #1's PICC line dressing was changed every 7 days. The facility failed to ensure resident #1 and resident#2 were on enhanced barrier precautions for PICC line. What corrective actions have been implemented for the identified residents? B. On 3/18/2025 at 2:25pm, resident #1's PICC line dressing change was done by Nurse Manager A. C. On 3/18/2025 at 2:25pm, resident #1 was placed on enhanced barrier precautions and signage posted on resident #1's door by Nurse Manager A. D. On 3/18/25 at 2:30pm, resident #2 was placed on enhanced barrier precautions and signage posted on resident #2's door by Nurse Manager A. E. On 03/18/2025 at 2:40pm the Administrator notified the Medical Director of the alleged deficient practice. F. The Corporate Clinical Service Director in-serviced the Nurse Managers on 3/18/25 at 3:30pm on ensuring PICC line dressing change is done every 7 days. G. On 3/18/25 at 4pm Nurse Manager A and B completed an assessment of 2 residents with PICC line to ensure the dressing change date is less than 7 days, and no concerns were identified. H. Nurse Managers completed a 100% audit of residents residing in the facility to assess the need for barrier precautions, no concerns were identified. I. On 3/18/2025 licensed nurses were in-serviced on ensuring PICC line dressing change is done every 7 days by Nurse Manager A and B. The facility audited all residents with PICC line for dressing change dates less than 7 days old, no concerns were identified by Nurse Manager A and B. J. The Corporate Clinical Service Director reviewed facility policy on 3/18/2025 regarding PICC line dressing change and no revisions were deemed necessary. K. The Corporate Clinical Service Director reviewed facility policy on 3/18/2025 regarding enhanced barrier precautions and no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. All residents have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. An in-service was completed on 3/18/2025 by the Corporate Clinical Service Director with the Director of Nursing on ensuring residents PICC line dressing change is done every 7 days. B. An in-service was completed on 3/18/25 by the Corporate Clinical Service Director with the Director of Nursing on ensuring residents requiring enhanced barrier precautions have signage posted on the door. C. The Director of Nursing completed an in-service on 3/18/2025 with the licensed nursing staff on ensuring PICC line dressing change is done every 7 days. D. The Director of Nursing completed an in-service on 3/18/2025 with the licensed nursing staff on ensuring residents requiring enhanced barrier precautions have signage posted on the door. E. Nurses will not be allowed to return to work until they receive this in-service. Nursing staff who are unable to physically attend the in-service training in person will be in-serviced via phone by Nurse Manager A. The completion date is 3/19/2025. F. Newly hired nurses will be in-serviced by the Director of Nursing or designee to ensure PICC line dressing change is done every 7 days during facility orientation upon hire. G. Newly hired nurses will be in-serviced by the Director of Nursing or designee to ensure residents requiring enhanced barrier precautions have signage placed on the door during facility orientation upon hire. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the removal was completed on 3/18/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Surveyor monitored the POR on 03/19/2025 as followed: Observation on 03/19/2025 at 11:32 AM revealed Resident #1's dressing was changed and dated for 03/18/2025. No odor or redness was observed. Observation revealed EBP signage on door and PPE such as gown and gloves in bind inside of Resident #1's room. Observation on 03/19/2025 at 11:39 AM, revealed EBP signage posted on Resident #2's door and bin of PPE such as gown and gloves outside of Resident #2's door. Review of facility in-service dated 03/18/2025 completed by corporate nurse reflected EBP signage must be posted on door and PICC line dressing change was done every 7 days was completed with DON, ADON B and ADON D. Review of in-services dated 03/18/2025 and 03/19/2025 by ADON D reflected 56 staff were educated on EBP. Review of in-services dated 03/18/2025 and 03/19/2025 by ADON D reflected 8 nurses were in-serviced on PICC line dressing changes. Review QAPI sign-in sheet undated reflected medical director, ADM, DON and ADONs attended. During an interview on 03/19/2025 at 4:47 PM, ADON B stated that facility nursing staff (CNAs and nurses) work 12-hour shifts. ADON B stated that all nursing staff was called yesterday and if they answered they were in-serviced via telephone or left a voicemail requesting a return phone call. ADON B stated that staff would be in-serviced prior starting their shift if they had not already been in-serviced. During interviews conducted on 03/19/2025 between 3:45 PM and 6:12 PM, 2 RNs, 2 ADONS, DON, 3 LVNs and 6 CNAs it was revealed that staff received an in-service either on 03/18/2025 or 03/19/2025 or prior to their shift by ADON D or ADON B. Staff stated that in-service included that EBP were to be used with residents who have an open wound, catheter, PICC line, or feeding tube to prevent infection from staff to the resident. Staff stated that EBP included to use PPE such as gown and gloves when they provided direct care such as flushing the line, changing the dressing, peri care and/or showers. Staff stated they can tell to use EBP with a resident on signage that was posted and PPE bin in or outside the resident's room. Licensed nurses stated that PICC line dressings were to be changed every 7 days or as needed to prevent infection to the resident. Licensed nurses stated that they should wear a gown and gloves when changing the dressings or flushing the line for residents with PICC lines. Licensed nurses stated that upon admission they can post EBP signage and get PPE needed or if they notice a resident was supposed to be on EBP. The ADM and DON were notified on 03/19/2025 at 6:30 PM that the IJ had be lowered. While the IJ was lowered, the facility remained out of compliance at a level of no actual harm that was not immediate jeopardy at a score of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for two of two residents reviewed for care plans. (Residents #1, and #2) A) The facility failed to ensure Resident #1's fall care plan intervention were followed by not placing a fall mat in his room. Resident #1 had a fall and died . B) The facility failed to implement Resident #2's fall care plan intervention by not placing a fall mat in her room. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00 pm. While the IJ was removed on [DATE], the facility remained at a level of actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical well-being, serious injury, serious harm, serious impairment, or death. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed an original admitted [DATE], initial admitted [DATE] and admitted [DATE] revealed [AGE] year-old-male with diagnoses of Parkinson's disease without dyskinesia (uncontrolled, involuntary movement), fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 day). Resident #1's care plan focus initiated [DATE] and revised on [DATE] revealed: Resident #1 is high risk for fall, Gait/balance problems, unaware of safety needs, history of multiple falls, orthostatic hypotension (a condition in which your blood pressure suddenly drops when you stand up from a seated or lying position), and confusion. Resident #1's care plan goal initiated [DATE] and target date [DATE] Resident #1 will be free of falls through the review date. Resident #1's care plan interventions were the falling star program initiated [DATE], CNA and CN to anticipate and meet the resident's needs date initiated [DATE], CNA and CN to be sure the resident #1's call light was within reach and encourage the resident to use it for assistance as needed, resident needed prompt response to all requests for assistance date Initiated [DATE], encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility date Initiated [DATE] revised on [DATE], falling mats date initiated [DATE]. Resident #1's MDS dated [DATE] revealed a BIMS score of 8 suggesting mild cognitive impairment. Functional status reflected extensive assistance - resident involved in activity, staff provide weight-bearing support and 1-person physical assist and mobility devise of use of a wheelchair. Resident #1's fall risk assessment dated [DATE] revealed he was a high risk for falls, reason for assessment recent falls, had fallen 1 - 2 times within the last 6 months, he was disoriented, he was unable to independently come to a standing position and used an assistive device, e.g., cane, walker, etc. Resident #1's Visual/Bedside Kardex Report revealed SAFETY - [DATE] anti-roll back on wheelchair, [DATE] drop wheelchair seat, [DATE] scoop mattress, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt responses to all requests for assistance, encourage the resident to use [NAME] to call for assistance, falling mats. Resident #1's hospital records dated [DATE] revealed, chief complaint of fall of [AGE] year-old man with a hx of Parkinson's disease and advanced dementia, previously on hospice and presents after a fall in his nursing home. He was down on the ground for some about of time. The facility reported they are not exactly sure why he fell , but he did fall frequently. It was revealed he most likely fell from his bed. Physical exam revealed soft tissue contusion (a region of injured tissue or skin in which blood capillaries have been ruptured) with 2-centimeter laceration (cut referring to a skin wound) over the left eyebrow. He struck his head on the ground, was alert disoriented at his neurologic baseline. CT impression large acute left cerebral convexity subdural (the aspect of the cerebral hemisphere that lies in contact with the flat bones of the skull) hematoma (a bad bruise that happens when an injury causes blood to collect and pool under the skin) with 10 millimeter rightward midline shift (most epidural, subdural, or intracerebral hematomas associated with a midline shift of 5 mm or more are surgically evacuated). Resident had a chronic indwelling right parietal ventriculostomy catheter. He was on hospice, but it was discontinued. He had a significant brain bleed and operating room visit may not benefit the patient if he were to decline. Final dx of traumatic subdural hematoma and intraparenchymal hematoma of brain (blood pools in the tissues of the brain) due to trauma, fall from a height of less than 3 feet. Resident #1's hospital records dated [DATE] revealed worsening of intracranial hemorrhage, was transitioned to comfort measures and passed away. Resident #2's face sheet dated [DATE] with admitted [DATE] revealed [AGE] year-old female with diagnoses of fracture of upper end of right humerus (the bone of the upper arm or forelimb), hyperosmolality (a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances common electrolyte problem) and hypernatremia (common electrolyte problem). Resident #2's MDS dated [DATE] revealed a BIMS score of 10 suggesting moderately impaired cognition. Functional status reflected limited assistance needed resident highly involved in activity; staff provided guided maneuvering and one-person physical assist. Resident #2's care plan focus revealed she had an actual fall on [DATE] as the result of cognitive impairment and poor safety awareness and an actual fall on [DATE] fall with injury with laceration (a deep cut or tear in skin or flesh). Resident #2's care plan goal initiated on [DATE] reflected inflicted injured areas will resolve without complication by review date and resident will resume usual activities without further incident through [DATE]. Resident #2's care plan interventions included falling star program initiated [DATE], CNA and CN to perform frequent safety checks to assess and assist resident with needs initiated [DATE], therapy to work on safety awareness and use of assistive devices, CALL DO NOT FALL sign in room initiated [DATE], CNA and CN to place fall mats initiated [DATE], psych eval for increase confusion and refusal of care initiated: [DATE]. Resident #2's Visual/Bedside Kardex Report revealed SAFETY - [DATE] falling star program, [DATE] frequent safety checks to assess and assist with needs, [DATE] therapy to work on safety awareness and use of assistive devices, [DATE] call do not fall sign in room, [DATE] fall mats while patient is in bed, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance, sling to right arm. Facility progress note dated [DATE] reflected Resident #2 was admitted to the facility after fall that occurred on [DATE]. Facility progress note dated [DATE] reflected Resident #2 had a fall and was sent to the emergency room and sustained a laceration to her forehead that required 4 staples and a contusion to her left hip. DX recurrent falls and continued to attempt to ambulate on her own. Interview on [DATE] at 11:55 am CNA A revealed she initially discovered Resident #1 laying in the floor. She revealed she went to his room because his call light was on. She revealed there was no fall mat in Resident #1's room but a wheelchair was beside his bed. When asked a second time if a fall mat was present, she said there was no fall mat anywhere and said she could say for sure there was no fall mat. She revealed she did see Resident #1's bed was lowered. Interview on [DATE] at 11:19 am with RN/CN revealed she was the nurse who assessed Resident #1 after he was found by the CNA, and he appeared to have tried to get out of the bed and fell . She said he had fall interventions of a lowered bed, but he did not have a fall matt because it was a trip hazard when he attempted to get out of bed. RN/CN revealed there was no fall mat when she assessed him after his fall on [DATE]. Interview on [DATE] at 1:20 pm with Resident #1's family member said he visited Resident #1 the Friday before Resident #1's fall on [DATE] and there was no mat in the room and there had been no mat in the resident's room for a least two months. The family member said initially, when Resident #1 first had a fall, there was a mat then it was folded up in the corner of the room, but he had not seen it anywhere for about 2 months. Interview on [DATE] at 1:20 pm with who said she visited Resident #1 the Thursday before resident's fall [DATE]. She said resident was sleeping/dozing when she entered his room, and there was no floor mat. She said when the resident first fell , there was a mat for a while, then it was folded and put in a corner of the room, and she had not seen it for about 1 or 2 months. Interview on [DATE] at 3:20 pm with the facility MD revealed that if Resident #1's care plan listed fall mats as an intervention, ideally the fall mat should have been in place. The MD said he can't recall if there was a fall mat in place when he last visited with Resident #1. Interview and observation on [DATE] at 6:47 am with LVN A revealed Resident #2 did not have a fall mat in her room. Surveyor observed the falling star placard on the outside of Resident #1's room and entered room with LVN A. LVN A expressed that all fall interventions were in place and pointed out the saddle seat in the wheelchair for Resident #1's roommate and lowered bed for Resident #1. No fall mat was observed in any area of the room. LVN A told surveyor that all interventions for the falls were in place. Interview on [DATE] at 1:46 pm surveyor told LVN A that when she went to Resident #2's room on [DATE] with LVN A there was no fall mat, and the surveyor went into Resident #2's room later the same day and looked all over the room and on both sides of the room there was no fall mat. Surveyor asked how the staff caring for the resident were informed of resident fall interventions. LVN A said that there was a Kardex Report that listed all fall interventions. Surveyor showed LVN A Resident #2's Kardex Report where the report revealed, under SAFETY on [DATE] fall mats. LVN A revealed she did not know that Resident #2 had an intervention for a fall mat. She said she missed the fall mat because she did not see it on the doctor's orders for Resident #2 but agreed, after looking at the Kardex Report, that Resident #2 should have had a fall mat. LVN A revealed that if a fall intervention was not in place, it was horrible to contemplate what could happen. The resident could break their hip, they could get bruised, and get a hematoma. When the surveyor went into Resident #2's room with her on [DATE] she said she did not mention the fall mats as an intervention for Resident #2 because she did not see the mats in the room to point them out to the surveyor as an intervention in place. Interview on [DATE] at 11:06 pm with the LVN MDS Coordinator revealed care plans tell a story about the resident care needs from medications to dietary needs and resident requests and it was in place to keep resident's safe. The care plan was an integral part to all resident care. If a staff member does not carry out something in a care plan, it could be detrimental to the resident and the resident could receive a physical injury. If the care plan says there should be a fall mat in place for the resident, then, there should be a fall mat for the resident. The MDS Coordinator said that every staff member who goes into the resident's room should know that the resident was care planned for a fall mat and should make sure that a fall mat was there . She revealed that every resident who comes into the facility should have received a fall assessment and the fall assessment would be used to decide any necessary care planned fall interventions. Residents who were at high risk for falls were in the falling star program. Interview a t 12:06 pm with RN A revealed that to learn about resident interventions, staff could look at both or either the residents' care plan located in the EHR or the visual/bedside Kardex Report, also located in the EHR. The Kardex Report listed all resident care plan needs, including fall interventions, and both the nurses and CNAs can access the care plans and the Kardex Report. She revealed she checked that all the interventions were in place at the start of her shifts. She revealed that if there was not a fall mat in a resident's room and the resident was care planned for a fall mat there could be injury to the resident. It was extremely important to make sure fall mats were in place because it can minimize the risk of injury. RN A revealed staff should follow the intervention that was in place. Interview on [DATE] at 4:35 with the DON revealed the entire nursing staff, including the DON, were responsible for the care plans, including fall interventions, and it was the responsibility of the DON to make sure accurate interventions were in place and were being carried out. Interview on [DATE] at 2:46 pm with the DON revealed the facility absolutely has the responsibility to follow the interventions that were in the residents' care plans. A care plan guides the care of a patient and was in place to prevent falls or injuries due to falls. At this time the Surveyor informed him that she had observed on three different occasions that Resident #2, who was care planned for a fall mat, did not have a fall mat in her room and he responded that if it was in her care plan, it should have been in there. He revealed that every nurse should know the plan of care for their patients, that was why they do the plan of care. He revealed that if care planned interventions were not in place, residents could fall and become injured. Interview on [DATE] at 1:26 pm with the ADM revealed facilities have care plans to develop an appropriate plan of care when a resident was receiving services at the facility. She revealed it was necessary to the safety of the residents to do anything possible to prevent them from falling or having injuries and it would jeopardize the safely of the resident if fall interventions were not in place. She revealed that it was the responsibility of the DON and the ADM to ensure interventions were in place. Review of facility Fall Risk assessment dated ,d+[DATE] reflected Facility Nursing will document the following in the nursing note, full assessment and/or approaches in the care plan. Rationale for the fall precautions, falling star program placement, all steps taken to aid in the safety of the resident, education of the resident and responsible party, consult request. Fall status will be documented in the resident care guide and communicated between shifts and disciplines. Review of facility Care Planning - Interdisciplinary Team Policy Statement dated ,d+[DATE] reflected Policy Statement our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation 1. A comprehensive crew plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary team which includes but is not necessarily limited to the following personnel: a. the resident's attending physician b. the registered nurse who has responsibility for resident c. the dietary manager d. the social services worker responsible for the resident e. the activity director f. therapists g. consultants h. the director of nursing i. the charge nurse responsible for resident care j. nursing assistants responsible for the resident's care plan and k. others as appropriate or necessary to meet the needs of the resident. Review of facility Care Plans - Comprehensive dated ,d+[DATE] reflected: Policy Statement - An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility's care planning/interdisciplinary team in coordination with the resident, his/her family or representative develops and maintains a person-centered comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain through establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and other factors related to effectiveness of the plan of care. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS, Assessments of residents are ongoing and cre plans are revised as information about the resident and the resident's condition change. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. c. Build on the resident's strengths. d. Reflect treatment goals, timetables, and objectives in measurable outcomes. e. Identify the professional services that are responsible for each element of care. f. Aid in prevention or reducing declines in the resident's functional status and/or functional levels. g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program and h. Reflect currently recognized standards of practice for problems areas and conditions. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:00 PM. The ADM and the DOW were notified. The ADM as provided with the IJ template on [DATE] at 5:00 pm. [name of facility]PLAN OF REMOVAL F656 Name of Facility: Date: [DATE] Residents residing in the facility have the potential to be affected by not developing and implementing a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. What corrective actions have been implemented for the identified resident? Resident #1 No longer resides in the building. Resident #2 careplan was reviewed by the DON to ensure careplan was updated to meet the resident fall risk. DON ensure resident had fall matt placed in proper location. What corrective actions were taken? 1. The following actions were initiated immediately on [DATE]. a. On [DATE] an audit was completed by DON and/or designee to identify residents care planned for fall mats, all residents currently requiring fall mats careplaned was reviewed and careplans updated by the DON/designee to address patients fall needs. Those care planned for fall mats a check of the residents' room was completed by Don/Designee during the clinical morning meeting. DON/Designee will review 5 days a week and will round to ensure fall mats are in place. The weekend manager/Nurse on duty on the weekend will round to ensure fall mats that are care planned are in place. b. On [DATE], the Director of Nursing (DON) initiated an in-service session for the licensed nursing staff (Nurses,CNA,CMA). The focus of the in-service was to review patient fall interventions and ensure their proper implementation. All untrained Nursing staff (Nurses,CNA,CMA) staff will not be allowed to work on the floor without receiving the in-service c. On [DATE] an in-service was initiated for the facility Nursing Management by the DON on the importance of updating and reviewing care plan of resident at risk for fall to ensure proper interventions are placed to meet the residents' needs. The MDS/PPS coordinator, unit manager, ADON and DON will update resident care plans with new/changed orders, changes in condition, falls, etc. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Surveyor monitored the POR on [DATE] as followed: During interviews on [DATE] from 12:06 pm through 1:46 pm with two CNAs and two LVNs, they all stated they were in-serviced before their shifts on reporting abuse, neglect, and exploitation, patient fall interventions and to ensure their proper implementation and updating and reviewing care plan of resident at risk for fall to ensure proper interventions were placed to meet the residents' needs. Reviewed in-service for the licensed nursing staff (Nurses,CNA,CMA) subject patient fall interventions and ensure their proper implementation. Reviewed in-service for the facility Nursing Management by the DON on the importance of updating and reviewing care plan of resident at risk for fall to ensure proper interventions are placed to meet the residents' needs. Surveyor observed that Resident #2 had a fall mat placed by her bed. The ADM and DON were informed the Immediate Jeopardy was removed on [DATE] at 4:06 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, inteviews, and record reviews the facility failed to ensure it provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents for 2 (Resident #1 and Resident #2) out of 15 residents reviewed for accidents and hazards. The facility failed to provide the necessary fall care planned service to Resident #1 by falling to provide the intervention of a fall mat. Resident #1 had a fall, was taken to the hospital, and died . The facility failed to implement interventions for Resident #2 by not placing a fall mat in her room after she had two previous falls, one that resulted in an injury requiring medical intervention. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00 pm. While the IJ was removed on [DATE], the facility remained at a level of actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of injury, a decline in physical well-being, serious injury, serious harm, serious impairment, or death. Findings Include: Resident #1's face sheet dated [DATE] with original admitted [DATE], initial admitted [DATE] and admitted [DATE] revealed [AGE] year-old-male with diagnoses of Parkinson's disease without dyskinesia (uncontrolled, involuntary movement), fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 day). Resident #1's care plan focus initiated [DATE] and revised on [DATE]: Resident #1 is high risk for fall, Gait/balance problems, unaware of safety needs, history of multiple falls, orthostatic hypotension (a condition in which your blood pressure suddenly drops when you stand up from a seated or lying position), and confusion. Resident #1's care plan goal initiated [DATE] and target date [DATE] Resident #1 will be free of falls through the review date. Resident #1's care plan interventions were the falling star program initiated [DATE], CNA and CN to anticipate and meet the resident's needs date initiated [DATE], CNA and CN to be sure the resident #1's call light was within reach and encourage the resident to use it for assistance as needed, resident needed prompt response to all requests for assistance date Initiated [DATE], encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility date Initiated [DATE] revised on [DATE], falling mats date initiated [DATE]. Resident #1's MDS dated [DATE] revealed a BIMS score of 8 suggesting mild cognitive impairment. Functional status reflected extensive assistance - resident involved in activity, staff provide weight-bearing support and 1-person physical assist and mobility devise of use of a wheelchair. Resident #1's fall risk assessment dated [DATE] revealed he was a high risk for falls, reason for assessment recent falls, had fallen 1 - 2 times within the last 6 months, he was disoriented, he was unable to independently come to a standing position and used an assistive device, e.g., cane, walker, etc. Resident #1's Visual/Bedside Kardex Report revealed SAFETY - [DATE] anti-roll back on wheelchair, [DATE] drop wheelchair seat, [DATE] scoop mattress, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt responses to all requests for assistance, encourage the resident to use [NAME] to call for assistance, falling mats. Resident #1's hospital records dated [DATE] revealed chief complaint of fall of [AGE] year-old man with a hx of Parkinson's disease and advanced dementia, previously on hospice and presents after a fall in his nursing home. He was down on the ground for some about of time. The facility reported they are not exactly sure why he fell , but he did fall frequently. It was revealed he most likely fell from his bed. Physical exam revealed soft tissue contusion (a region of injured tissue or skin in which blood capillaries have been ruptured) with 2-centimeter laceration (cut referring to a skin wound) over the left eyebrow. He struck his head on the ground, was alert disoriented at his neurologic baseline. CT impression large acute left cerebral convexity subdural (the aspect of the cerebral hemisphere that lies in contact with the flat bones of the skull) hematoma (a bad bruise that happens when an injury causes blood to collect and pool under the skin) with 10 millimeter rightward midline shift (most epidural, subdural, or intracerebral hematomas associated with a midline shift of 5 mm or more are surgically evacuated). Resident had a chronic indwelling right parietal ventriculostomy catheter. He was on hospice, but it was discontinued. He had a significant brain bleed and operating room visit may not benefit the patient if he were to decline. Final dx of traumatic subdural hematoma and intraparenchymal hematoma of brain (blood pools in the tissues of the brain) due to trauma, fall from a height of less than 3 feet. Resident #1's hospital records dated [DATE] revealed worsening of intracranial hemorrhage, was transitioned to comfort measures and passed away. Resident #2's face sheet dated [DATE] with admitted [DATE] revealed [AGE] year-old female with diagnoses of fracture of upper end of right humerus (the bone of the upper arm or forelimb), hyperosmolality (a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances common electrolyte problem) and hypernatremia (common electrolyte problem). Resident #2's MDS dated [DATE] revealed a BIMS score of 10 suggesting moderately impaired cognition. Functional status reflected limited assistance needed resident highly involved in activity; staff provided guided maneuvering and one-person physical assist. Resident #2's care plan focus revealed she had an actual fall on [DATE] as the result of cognitive impairment and poor safety awareness and an actual fall on [DATE] fall with injury with laceration (a deep cut or tear in skin or flesh). Resident #2's care plan goal initiated on [DATE] reflected inflicted injured areas will resolve without complication by review date and resident will resume usual activities without further incident through [DATE]. Resident #2's care plan interventions included falling star program initiated [DATE], CNA and CN to perform frequent safety checks to assess and assist resident with needs initiated [DATE], therapy to work on safety awareness and use of assistive devices, CALL DO NOT FALL sign in room initiated [DATE], CNA and CN to place fall mats initiated [DATE], psych eval for increase confusion and refusal of care initiated: [DATE]. Resident #2's Visual/Bedside Kardex Report revealed SAFETY - [DATE] falling star program, [DATE] frequent safety checks to assess and assist with needs, [DATE] therapy to work on safety awareness and use of assistive devices, [DATE] call do not fall sign in room, [DATE] fall mats while patient is in bed, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance, sling to right arm. Facility progress note dated [DATE] reflected Resident #2 was admitted to the facility after fall that occurred on [DATE]. Facility progress note dated [DATE] reflected Resident #2 had a fall and was sent to the emergency room and sustained a laceration to her forehead that required 4 staples and a contusion to her left hip. DX recurrent falls and continued to attempt to ambulate on her own. Resident #2 osteopathic progres notes dated [DATE] reflected she had a fall on [DATE] and was transported to the emergency departrment. X-ray revealed a right humeral (upper arm) fracture, laceration to head that required four staples, and burising to her left hip. Diagnoses recurrent falls, continues to attempt to ambulate on her own, last fall required a trip to the emergency department. Interview at 11:55 am CNA A on [DATE] revealed she initially discovered Resident #1 laying in the floor. She revealed she went to his room because his call light was on. She revealed there was no fall mat in Resident #1's room but a wheelchair was beside his bed. When asked a second time if a fall mat was present, she said there was no fall mat anywhere and said she could say for sure there was no fall mat. She revealed she did see Resident #1's bed was lowered. Interview at 11:19 am with RN/CN on [DATE] revealed she was the nurse who assessed Resident #1 after he was found by the CAN, and he appeared to have tried to get out of the bed and fell . She said he had fall interventions of a lowered bed, but he did not have a fall matt because it was a trip hazard when he attempted to get out of bed. RN/CN revealed there was no fall mat when she assessed him after his fall on [DATE]. Interview at 1:20 pm with Resident #1's son on [DATE] who said he visited his father the Friday before Resident #1's fall on [DATE] and there was no mat in the room and there had been no mat in his father's room for a least two months. Resident #1's son said initially, when his father first had a fall, there was a mat then it was folded up in the corner of the room, but he had not seen it anywhere for about 2 months. Interview at 1:20 pm with resident's former wife on [DATE] who said she visited Resident #1 the Thursday before resident's fall [DATE]. She said resident was sleeping/dozing when she entered his room and there was no floor mat. She said when the resident first fell , there was a mat for a while, then it was folded and put in a corner of the room, and she had not seen it for about 1 or 2 months. Interview at 3:20 pm with the facility MD on [DATE] revealed that if Resident #1's care plan listed fall matts as an intervention, ideally the fall mat should have been in place. MD said he can't recall if there was a fall mat in place when he last visited with Resident #1. Interview and observation on [DATE] at 6:47 am with LVN A revealed Resident #2 did not have a fall mat in her room. Surveyor observed the falling star placard on the outside of Resident #1's room and entered room with LVN A. LVN A expressed that all fall interventions were in place and pointed out the saddle seat in the wheelchair for Resident #1's roommate and lowered bed for Resident #1. No fall mat was observed in any area of the room. LVN A told surveyor that all interventions for the falls were in place. Observations on [DATE] at 2:00 pm and 3:30 pm of Resident #2's room revealed no floor mats. Interview on [DATE] at 1:46 pm surveyor told LVN A that when she went to Resident #2's room on [DATE] with LVN A there was no fall mat, and the surveyor went into Resident #2's room later the same day and looked all over the room and on both sides of the room there was no fall mat. Surveyor asked how the staff caring for the resident were informed of resident fall interventions. LVN A said that there was a Kardex Report that listed all fall interventions. Surveyor showed LVN A Resident #2's Kardex Report where the report revealed, under SAFETY on [DATE] fall mats. LVN A revealed she did not know that Resident #2 had an intervention for a fall mat. She said she missed the fall mat because she did not see it on the doctor's orders for Resident #2 but agreed, after looking at the Kardex Report, that Resident #2 should have had a fall mat. LVN A revealed that if a fall intervention was not in place, it was horrible to contemplate what could happen. The resident could break their hip, they could get bruised, and get a hematoma. When the surveyor went into Resident #2's room with her on [DATE] she said she did not mention the fall mats as an intervention for Resident #2 because she did not see the mats in the room to point them out to the surveyor as an intervention in place. Interview at 11:06 pm with LVN MDS Coordinator on [DATE] revealed care plans tell a story about the resident care needs from medications to dietary needs and resident requests and it is in place to keep resident's safe. The care plan is an integral part to all resident care. If a staff member does not carry out something in a care plan, it could be detrimental to the resident and the resident could receive a physical injury. If the care plan says there should be a fall mat in place for the resident, then, there should be a fall mat for the resident. The MDS Coordinator said that every staff member who goes into the resident's room should know that the resident was care planned for a fall mat and should make sure that a fall mat is there. She revealed that every resident who comes into the facility should have received a fall assessment and the fall assessment would be used to decide any necessary care planned fall interventions. Residents who were at high risk for falls were in the falling star program. Interview at 12:06 pm with RN A revealed that to learn about resident interventions staff could look at both or either the residents' care plan located in the EHR or the visual/bedside Kardex Report, also located in the EHR. The Kardex Report listed all resident care plan needs, including fall interventions, and both the nurses and CNAs can access the care plans and the Kardex Report. She revealed she checked that all the interventions were in place at the start of her shifts. She revealed that if there is not a fall mat in a resident's room and the resident is care planned for a fall mat there could be injury to the resident. It is extremely important to make sure fall mats are in place because it can minimize the risk of injury. RN A revealed staff should follow the intervention that is in place. Interview at 4:35 with the DON on [DATE] revealed the entire nursing staff, including the DON, were responsible for the care plans, including fall interventions, and it is the responsibility of the DON to make sure accurate interventions were in place and were being carried out. 2:46 pm with the DON on [DATE] revealed the facility absolutely has the responsibility to follow the interventions that are in the residents' care plans. A care plan guides the care of a patient and are in place to prevent falls or injuries due to falls. He revealed that every nurse should know the plan of care for their patients that is why they do the plan of care. He revealed that if care planned interventions are not in place, residents could fall and become injured. Interview at 1:26 pm with the ADM on [DATE] revealed facilities have care plans to develop an appropriate plan of care when a resident is receiving services at the facility. She revealed it is necessary to the safety of the residents to do anything possible to prevent them from falling or having injuries and it would jeopardize the safely of the resident if fall interventions were not in place. She revealed that it is the responsibility of the DON and the ADM to ensure interventions were in place. Review of facility Fall Risk assessment dated ,d+[DATE] reflected Facility Nursing will document the following in the nursing note, full assessment and/or approaches in the care plan. Rationale for the fall precautions, falling star program placement, all steps taken to aid in the safety of the resident, education of the resident and responsible party, consult request. Fall status will be documented in the resident care guide and communicated between shifts and disciplines. Review of facility fall and fall risk managing policy dated [DATE] revealed based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff, with the input of the attending physician, identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of the residence fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions as applicable to try to minimize serious consequences of falling. The staff will monitor and document each resident's responses to interventions intended to reduce falling or the risks of falling. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the interventions has resolved. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to prevent a risk for falling or injury due to falls. Review of facility falling star program protocol dated February 2012 policy statement based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Purpose and implementation to identify residents at high risk for falls and to attempt to prevent these falls through an interdisciplinary approach in cooperation with nursing, the resident, the family or significant others and facility staff period to assist in preventing resident falls by frequent monitoring of residents need for assistance while in the facility period to implement preventative measures in order to minimize the degree of injury sustained by a resident resulting from a fall. Intrinsic risk factors for falls include changes that are part of normal aging as well as certain acute or chronic conditions and medications. The following are samples of intrinsic risk factors Parkinson's disease and conductive impairments. Extrinsic risk factors for falls are part of their resident environment and are most likely to be seen in areas such as the resident room, bathroom, dining room, and hallways. Policy all residents admitted to the facility will be assessed for risk of falling on admission and at least quarterly or whenever is necessary secondary to a change in resident status. All residents will be assessed for risk of falls on admission, after a fall, after a change of condition, quarterly. Resident identified at a high risk for falling will be placed on the protocol falling star program which includes - consider therapy consult, educate resident and responsible party regarding the risk of falls, provide tips to avoid falls. Ensure adequate lighting and remove clutter from room, provide non slip footwear, observe sleep and elimination and offer assistance, please call light, phone, and personal items within reach, bed in low position, wheels locked, consider a pharmacy consult, consider timing of diuretic and laxative administration, place resident on the falling star program, anticipate toileting needs, consider bed/chair alarm, consider low bed, move resident close to nursing station, if possible, restroom light on in the evening and night, place internal pumps, Avi poles, Foley and other equipment on the side of the bed the resident exits, consider disease processes during room selection, admit process. Overview - interdisciplinary fall teams are a key success factors in fall prevention programs. This section will cover the following information choosing the right people, responsibilities of the team members, options for facilities of various sizes, functions of the interdisciplinary team. Choosing the right people - the interdisciplinary fall team should have people with administrative and direct care functions. We recommend the following people to be involved in the interdisciplinary fall team: Clinical staff - fall clinical nurse specialist (or similar position) if available or applicable, nurse manager, nursing assistant, pharmacy, rehab team, physician or nurse practitioner. Nonclinical staff patient safety manager/quality manager coordinator, facility management manager, central supply manager, environmental manager, transportation, and activities. They should be clearly defined in the policy charter. Clinical staff - fall clinical nurse specialist- not all facilities have a fall clinical nurse specialist. Some facilities have a particular nurse manager, generally in the long term or extended care wards that have an interest in falls and fall related injuries prevention. This person will generally facilitate team meetings, ensure fall prevention measures are being used (this is a responsibility of the entire team), elicit comments from staff regarding the program and other fall related activities. Nurse manager - due to their management responsibilities, they can enforce the interventions taken by the interdisciplinary team. Due to their management responsibilities, they can enforce the interventions taken by the interdisciplinary teams and ensure that interventions become the standard of care for high fall risk residents. Nursing assistant - nursing assistants are generally the most affected by the interventions implemented by the fall team. They can help educate their peers on the interventions. They can also act as fall prevention advocates and collect data for the aggregate reviews submitted. Pharmacy - pharmacy review medications of all high fall risk residents when they are identified and following a fall. Pharmacy help to identify issues with the medications and notify physicians that medication need to be adjusted. This is very important because many falls are the result of medication side effects. Rehabilitation staff - occupational therapy and physical therapies provide balance and strength assessments for high fall risk residents. They can also assess the ability of a resident to use specific interventions taking into account grip strength and other factors. Physician slash nurse practitioner - the physician looks at the medical history and stability of the high fall- risk residents when admitted and following a fall. He or she should identify aspects of the medical history that could contribute to falls. Nonclinical staff - residents safety manager/quality management coordinator - the resident safety manager can facilitate the team if there is no falls clinical specialist. He or she can also act as a liaison between the team and the management of the facility. He or she can provide data to the team to help determine the impact of the intervention taken. Facility management member - the facility management member can help to ensure that the environment of care is set up to reduce falls. they can train the janitorial staff to perform environmental assessments to remove cutter from rooms, ensure that spills are cleaned up promptly and other things. The facility management person can also identify fall hazards related to cleaning supplies, such as a particular cleaning agent causing floor to be sticky. They may assess the environment in common rooms to ensure that furniture is safe for people who are at risk for falls. Central supply manager - the central supply manager can help facilities purchase items to reduce the risk of falls- related injuries. They can also ensure that the supply is adequate and ensure that the correct products are purchased. Environmental manager - the environmental manager can ensure that all devices used are in working order to prevent residents from falling. They can also look into devices that were involved in falls, such as wheelchairs or walkers. Options for facilities of various sizes. Smaller facilities can integrate the falls team into their interdisciplinary treatment teams. The treatment teams for high fall risk residents should include: physician or nurse practitioner, physical or occupational therapist, pharmacy, nurse manager for residents unit, the other suggested members can serve as resources for the treatment team. Responsibilities of the fall team - develop/review facility fall prevention protocols, implement fall prevention strategies across the facility, act as a resource for interdisciplinary treatment teams treating a high fall-risk residents, review fall on a case by case basis and make recommendations to treatment teams, collect and analyze data on falls to see if there are any common factors and determine if the interventions are working to reduce falls and fall-related injuries. Logistics of the fall team - fall teams operate differently depending on the facility: however, once the team is established, they need to decide the following things: when and how often they are going to meet (i.e., monthly, biweekly), where are they going to meet, what their relationship is to the treatment team (i.e., hi fall-risk residents are referred to the falls team or the interdisciplinary treatment team ask for help with specific residence. Tips to avoid falls - for residents and responsible parties - medications such as tranquilizers, sleeping aids, pain relievers, blood pressure pills or diuretics may make you dizzy and disoriented, your illness, and the most common laxatives, long periods without food may leave you weak and unsteady, the nursing facility is born and unfamiliar to you, especially when you wake up at night, some falls, as those associated with illness or therapy, cannot be avoided, however, by following the safety guidelines you and your family can help reduce the risk of falling. Residents attempting to climb out of bed over side rails. Safety guidelines for preventing falls - when you need assistance, use your call light by the bed and/or restroom and wait for assistance. It is recommended that you wear rubber sold or [NAME] sold slippers or shoes whenever you walk in the facility. Ask the nurse or assistant for help if you feel dizzy or weak getting out of bed. Remember you are most likely to feel dizzy after sitting or lying for a long time period before you get up, sit in bed for a while before standing then rise carefully and slowly. Walk carefully and slowly. Do not attempt yourself on rolling objects, always follow your physician's orders and caregivers instructions whether you must stay in bed or require assistance to get up or go to use the restroom. Do not bring excessive amounts of furnishings from home ask administration prior to bringing in outside furniture observe what signs in the hallway or other areas. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:00 PM. The ADM and the DOW were notified. The ADM as provided with the IJ template on [DATE] at 5:00 pm. [name of facility]PLAN OF REMOVAL QOC-600 Name of Facility: [name of facility] Date: [DATE] Residents residing in the facility have the potential to be affected and should free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. What corrective actions have been implemented for the identified resident? Resident #1 no longer resides in the building. Observations on [DATE] at 2:00 pm and 3:30 pm of Resident #2's room revealed o What corrective actions were taken? 2. The following actions were initiated immediately on [DATE]. d. On [DATE] an audit was completed by DON and/or designee to identify residents care plan for fall mats. Those care planned for fall mats, a check of the resident's room was completed by DON/Designee to ensure the fall mat was in place. Going forward the Don/Designee will review careplans during the clinical morning meeting 5 days a week and will round to ensure fall mats are in place. The weekend manager/Nurse on duty on the weekend will round to ensure fall mats that are care planned are in place. e. Don was in serviced on ,d+[DATE] by the regional nurse consultant on importance of reviewing and updating residents fall careplans to ensure proper interventions are put into place to prevent falls. f. On [DATE], the Director of Nursing (DON) initiated an in-service session for the licensed nursing staff (Nurses,CNA,CMA). The focus of the in-service was to review patient fall interventions and ensure their proper implementation. All untrained Nursing staff, PRN Nursing Staff and Agency nursing staff (Nurses,CNA,CMA) will not be allowed to work on the floor without receiving the in-service to be completed [DATE]. g. On [DATE] an in-service was initiated for the facility Nursing Management by the DON on the importance of updating and reviewing the care plan of residents with falls to ensure care planned interventions such as fall mats are in place. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Surveyor monitored the POR on [DATE] as followed: Reviewed in service of by the regional nurse consultant on importance of reviewing and updating residents fall careplans to ensure proper interventions are put into place to prevent falls. Reviewed in-services for the licensed nursing staff (Nurses,CNA,CMA) for patient fall interventions and ensure their proper implementation. Reviwed in-service for the facility Nursing Management by the DON on the importance of updating and reviewing the care plan of residents with falls to ensure care planned interventions such as fall mats are in place. During interviews on [DATE] from12:06 pm through 1:46 pm two CNAs and two LVNs they all stated they were in-serviced before their shifts on reporting abuse, neglect, and exploitation, patient fall interventions and to ensure their proper implementation and updating and reviewing care plan of resident at risk for fall to ensure proper interventions are placed to meet the residents' needs. Observed floor mat in Resident #2's room. The ADM and DON were informed the Immediate Jeopardy was removed on [DATE] at 4:06 pm. The facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for one (Resident #1) of three residents reviewed for discharges, in that: The facility failed to provide or document sufficient preparation for an orderly discharge when they did not allow Resident #1 to return to the facility after being sent to a behavioral health hospital on 06/30/23. He was discharged to his FM's home where he had two falls, was not bathed, his wounds worsened, and he subsequently required hospitalization . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/23/23 at 3:15 PM. While the IJ was removed on 08/25/23 at 4:00 PM, the facility remained at a level of actual harm at a scope of isolation that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge, injury, and hospitalization . Findings Included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, stage IV pressure ulcer of right heel, history of heart attack, and repeated falls. Review of Resident #1's quarterly MDS assessment, dated 05/30/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section E (Behaviors) reflected he had verbal behavioral symptoms directed toward others. Functional Status (G) reflected he utilized a wheelchair. Section GG (Functional Abilities and Goals) reflected he required partial/maximal assistance with most ADLs. Section H (Bladder and Bowel) reflected he was occasionally incontinent of bladder and bowel. Section M (Skin Conditions) reflected he had one or more unhealed pressure ulcers/injuries. Review of Resident #1's quarterly care plan, r evised 03/09/23, reflected he had potential/actual impairment to skin integrity related to surgical wound to the right foot 3rd digit amputation and stage IV pressure ulcer to his right heel with an intervention of administering treatment as ordered. Review of Resident #1's nursing note in his EMR, dated 06/30/23, reflected the following: [Resident #1] discharged to (behavioral hospital) in stable condition . [Resident #1] was accepted for physical and verbal aggression . There were no further nursing notes documented. Review of Resident #1's medical documentation from the behavioral health hospital, from 06/30-23 - 07/20/23, reflected there was no documentation or orders from the facility on discharge planning or orders for alternate placement upon discharge. Review of Resident #1's medical documentation from the ER, dated 07/24/23, reflected he presented to the ER with complaints of running out of his diabetes medication, an elevated blood sugar (232), four recent falls, and pain to the wound on his right heel. During an interview on 07/26/23 at 10:05 AM, the facility's Ombudsman stated she received a call the previous Monday, 07/17/23, from the MRC requesting recommendations for other nursing facilities for Resident #1. She stated she explained to the MRC that it was the facility's responsibility to accept the resident back after his hospitalization and if they felt they could not meet his needs, she could be of assistance in the discharge process. She stated she explained 30-day discharge letter would also need to be given to Resident #1. She stated she received a call the previous Thursday, 07/20/23, from Resident #1's FM stating that Resident #1 had been discharged to her home and she was not able to care for him and did not have his medications. During an interview on 07/26/23 at 10:55 AM, the MRC stated they had been without a SW for a long time so for three weeks she had been assisting with resident discharges. She stated Resident #1 was admitted to the behavioral hospital due to his verbal abuse towards staff. She stated he would cuss and call the staff derogatory names and had hit a resident. She stated after she spoke with the Ombudsman on the phone, she related the message to their old ADM (he was no longer working for the facility). She stated if he had been discharged home that would have been inappropriate as he was unable to care for himself and was in a wheelchair. She stated she knew it was the facility's due diligence to accept all residents back after hospitalization . She stated she was not informed of the situation and thought he was still at the behavioral hospital. During a telephone interview on 07/26/23 at 11:03 AM, Resident #1's FM stated the behavioral hospital called her last Thursday, 07/20/23, and informed her the nursing facility was not allowing Resident #1 back. She stated she told them it would not be a good idea but agreed because she did not want him to be homeless. She stated attempting to care for him had made her physically sick and she now had a pinched nerve in her back. She stated she was not able to bathe him and had a hard time changing his brief. She stated he came with some medications and a walker. She stated he was not able to walk well due to the wounds on his feet and his amputated toes. She stated he had two falls during the week he was at her home. She stated the wounds to his heels and amputated toes started to cause him a lot of pain and have a foul odor, so she had her family member take him to the ER and he was admitted to the hospital where he remained. During an interview on 07/26/23 at 11:32 AM, the AC stated Resident #1 had been having a lot of problems at the facility, such has hitting a resident and calling staff names, so he was sent to the behavioral hospital. She stated she received a call from the behavioral hospital on 07/17/23 informing her he was ready to be discharged . She stated she notified the old ADM, and he told her they could not accept him back without giving her a reason. She stated she knew it was unacceptable to not accept a resident back after a hospitalization , but since he was the ADM, she had not known did not know what else to do. She stated she was not aware he was discharged to his FM's home. She stated she was aware that they were having a hard time getting him Medicaid because he was refusing to provide his SS benefits, and was reminded that even in that instance, a 30-day discharge letter was necessary. During an interview on 07/26/23 at 1:18 PM, the DON stated she had been working at the facility for about a week and was not aware of the situation with Resident #1. She stated if they were to discharge a resident to the hospital, they were expected to accept them back. She stated there could be some instances, such as a resident needing a secured unit, in which they may not accept them back. During an interview on 07/26/23 at 2:34 PM, the ADM stated she had started working at the facility that Monday, 07/24/23, and was not aware of the situation with Resident #1. She stated not accepting a resident back to the facility after hospitalization could be considered hospital dumping. She stated yes, generally a resident would be accepted back, but she did not know the whole story with Resident #1. She stated a possible negative outcome of not accepting a resident back after hospitalization could be deterioration in their health. During an interview on 08/23/23 at 3:00 PM, the CSD stated she was involved with all admissions and discharges. She stated she spoke with Resident #1 before he was discharged to the behavioral health hospital and he told her he wanted to be discharged from the hospital to where his FM was residing at another facility. She stated she did not know the name of the facility, nor did she notify the hospital of his wishes, because he was his own RP and could make those decisions as it was his right. She stated once a resident was discharged to a hospital/behavioral health hospital, the facility was no longer responsible for their care. She stated the former ADM did not deny him of being readmitted to their facility and she had text messages to prove it. She stated if the behavioral health hospital was not able to find him placement, they could have brought him back to their facility. Review of the text messages between the former ADM and the CSD, dated 07/18/23, reflected the following: ADM: They're trying to send [Resident #1] back to us from (behavioral health hospital). Do y'all want us to tell them that we don't have a bed for him? Or should we take him back and seek other placement? CSD: Will they not help to send him somewhere else? He is Medicare and easy to find placement at this time. ADM: I'm sure they will if we tell them we can't or won't take him. CSD: Yes tell them and if they can't then we will accept but you will appreciate if they can help us. Review of the facility's Discharge a Resident Policy, revised December of 2016, reflected the following: Purpose: The purpose of this procedure is to provide guidelines for the discharge process. Preparation: 1. The resident should be consulted about the discharge. . 3. If discharging the resident to another long-term care facility tell the resident where the new facility is located. 4. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions. 5. If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed and telephone report is called to the receiving facility. The ADM and CSD were notified on 08/23/23 at 3:15 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 08/25/23 at 12:00 PM: Impact Statement: On 8/23/23 a health survey was initiated at (facility). On 8/23/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to identify and provide treatment and care to resident #1. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all discharges to behavioral hospital completed in the last 30 days for safe discharge plans. All residents sent to behavioral hospital have the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to behavioral hospital on 06/30/23. What corrective actions were taken? 1. The following actions were initiated immediately on 8/23/23 a. On 8/23/23 an audit was completed by CSD (Clinical Services Director) and/or designee to identify all residents who had a discharge to behavior hospital in the last 30 days. No residents were identified to be discharged to behavioral hospital in the last 30 days. b. Social worker/discharge planner was educated on 8/23/23 by Clinical Services Director on discharge process of residents to behavioral hospital and readmission process of these residents to facility. c. Admissions Coordinator in-serviced by Clinical Services Director/Designee on readmission of residents sent to behavioral hospital on 8/23/23. 2. How will the system be monitored to ensure compliance? a. The Director of Nurses/Administrator will review discharges to behavioral hospital in the morning meeting beginning on 8/24/23 and ongoing to ensure safe discharge process. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The Director of Nurses/Administrator will include the residents discharged to behavioral hospital on daily census list which will be reviewed during weekdays in the morning meeting for re-admission to facility. Any discharges that did not re-admit will be followed up by Social Worker/Admission Coordinator/Designee to ensure safe discharge was set up for resident(s). This was started on 8/24/23 and will be monitored 5 days a week for 4 weeks and then ongoing. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 8/23/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Surveyor monitored the Plan of Removal from 08/24/23 - 08/25/23 as followed: During interviews on 08/24/23 from 9:15 AM - 9:50 AM, the SW, two medication aides, three LVN's and one CNA all stated they had been in-serviced on resident discharges and readmissions. They all stated nurses were to handle all discharge planning, with assistance from the SW. They stated that discharges to the hospital or a behavioral health hospital were no different than a discharge home or to another facility. During interviews on 08/25/23 from 1:52 PM - 2:20 PM, three RN's and one CNA all stated they had been in-serviced on resident discharges and readmissions. They all stated nurses were to handle all discharge planning, with assistance from the SW. They stated that discharges to the hospital or a behavioral health hospital were no different than a discharge home or to another facility. Review of the facility's Admission/Discharges in-service, dated 08/23/23, reflected staff were being in-serviced before the start of their shifts. The ADM and CSD were notified 08/25/23 at 4:00 PM that the IJ had been lowered. While the IJ was lowered, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #1) of three residents reviewed for behavioral health services., in that: The facility failed to ensure alternate interventions were attempted such as psychiatric care or medication for Resident #1 until admission to a behavioral health hospital for treatment was necessary. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/23/23 at 3:15 PM. While the IJ was removed on 08/25/23 at 4:00 PM, the facility remained at a level of actual harm at a scope of isolation that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving needed services and treatments and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the hospital on 02/23/23 with diagnoses including type II diabetes, stage IV pressure ulcer of right heel, history of heart attack, and repeated falls. Review of Resident #1's quarterly MDS assessment, dated 05/30/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section E (Behaviors) reflected he had verbal behavioral symptoms directed toward others. Review of Resident #1's quarterly care plan, revised 04/17/23, reflected he had potential to demonstrate verbally abusive behaviors related to saying racist remarks to the staff with an intervention of assessing his coping skills and support system. Review of Resident #1's EMR, on 07/26/23, reflected no assessments or treatment notes by a psychiatrist or psychologist. Review of Resident #1's physician orders in his EMR, on 07/26/23, reflected he was not prescribed any psychiatric medication. Review of Resident #1's behavior nursing note in his EMR, dated 06/28/23, reflected the following: [Resident #1] was in dining room and was slapping (resident) on the side of his head. Nonpharmacological interventions: N/A PRN medications: N/A Results: sent [Resident #1] out of dining room. Review of Resident #1's behavioral nursing note in his EMR, dated 06/29/23 at 12:46 PM, reflected the following: [Resident #1] verbal aggressive to sitter and this nurse during lunch, stated he did not want to be guarded, he felt like a dog in the pound, stated he is unable to eat while being watched . This behavior continued throughout lunch in the dining room. Resident behavior unchanged PRN medications: N/A Review of Resident #1's incident report, dated 06/28/23, reflected was seen hitting another resident on the head and was put on 1:1 and a referral to behavioral hospital was made to receive appropriate treatment in a controlled environment. Review of Resident #1's nursing note in his EMR, dated 06/30/23 at 2:48 PM, reflected the following: [Resident #1] discharged to (behavioral hospital) in stable condition . [Resident #1] was accepted for physical and verbal aggression . Review of Resident #1's medical documentation from the behavioral health hospital, dated 07/01/23 and signed by their MD, reflected the following: Inpatient Psychiatric Evaluation: History of Present Illness: Per (facility) report, [Resident #1] has been verbally/physically aggressive with peers and staff. [Resident #1] has been hitting peers, difficult to redirect, not always taking meds, decreased sleep. Review of Symptoms: Irritability and Mood Swings Liabilities: Cognitive Impairment, Depression, Psychosis Assessment and Plan: Major depressive disorder recurrent moderate. Major neurocognitive disorder Alzheimer's type mild to moderate with behavioral disturbance. Unspecified psychosis. Complexity of [Resident #1]'s mental condition is severe. Plan: Medication changes on 07/01/2023: Start Aricept 10 mg p.o. every morning Start Zoloft 25 mg p.o. daily Review of Resident #1's medical documentation from the behavioral health hospital, from 06/30/23-23 - 07/20/23, reflected the following additional medications were ordered: 06/30/23 - Hydroxyzine - 50 mg (1 capsule) by mouth every six orders PRN for anxiety 07/02/23 - Sertraline HCL, 25 mg (1 tablet) by mouth for major depressive disorder. 07/02/23 - Donepezil HCL - 5 mg (tablet) by mouth daily for mild to moderate Alzheimer's type dementia. 07/10/23 - Trazodone - 50 mg by mouth at bedside for major depressive disorder. 07/14/23 - Abilify, 10 mg (1 tablet) by mouth daily for major depressive disorder. Review of Resident #1's medical documentation from the behavioral health hospital, dated 07/16/23 and signed by a nurse, reflected the following: Problem from Plan of Care: Alteration in Thought Processes Psychosis related to psychotropic disease process as evidenced by paranoid behavior, sleep disturbance, decreased impulse control, delusional thoughts, withdrawn behaviors, decreased focus and concentration. Disease process that interferes with ability to function appropriately in social situations. Review of Resident #1's medical documentation from the behavioral health hospital, dated 07/016/23 and signed by their MD, reflected the following: Assessment and plan: [Resident #1 is adherent with the treatment recommendations. Gradual dose reduction not recommended due to potential risk of returning psychosis, depression, or manic symptoms. Complexity of [Resident #1]'s mental condition is severe. Current medications are helping. Plan to increased Abilify soon and switch to long-acting injectable before discharge. During an interview on 07/26/23 at 10:55 AM, the MRC stated Resident #1 was admitted to the behavioral hospital due to his verbal abuse towards staff, and the fact that he recently hit a resident. She stated he would cuss and call the staff derogatory names. She stated she was unaware if he was receiving psych services while at the facility. During an interview on 07/26/23 at 1:18 PM, the DON stated she had been working at the facility for about a week and was not aware of the situation with Resident #1. She stated before a resident was sent to a psychiatric hospital, there should be interventions attempted, such as psych services or medication. She stated normally the nurse managers would make the psych referrals. She stated if a resident who needed psychiatric care and/or medication went without, it would lead to the deterioration of their mental health. During an interview on 08/07/23 at 10:12 AM, Resident #1's MD stated he was seeing the resident monthly when he was residing at the facility. He stated the last time he saw Resident #1 back in May, he was notified by staff of his increased verbal aggressive episodes. He stated he ordered a psych consult but had to assume the staff did not get to it in time before Resident #1 needed in-patient psychiatric help. When asked if he thought it was necessary to discharge Resident #1 to a behavioral health hospital before other interventions was appropriate, he stated, That was a facility choice, I will just leave it at that. During an interview on 08/23/23 at 3:00 PM, the CSD stated they attempted psychiatric care with Resident #1, but would tell them, I don't need that, I'm not crazy. She stated there was not any documentation of those attempts. She stated they did provide interventions such as re-direction, and he was placed on 1:1 after he hit another resident on 06/29/23. Review of the facility's Behavior Assessment and Monitoring policy, revised April of 2007, reflected the following: Policy Statement: 1. Problematic behavior will be identified and managed appropriately Management: 1. The staff will identify and discuss with the practitioner situations where nonpharmacologic approaches are indicated and will institute such measures to the extent possible. The ADM and CSD were notified on 08/23/23 at 3:15 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 08/25/23 at 12:00 PM: Impact Statement: On 8/23/23 an abbreviated survey was initiated at (facility). On 8/23/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to ensure immediate actions to ensure residents are receiving mental/behavior health. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all discharges to behavioral hospital completed in the last 30 days to ensure alternate behavioral interventions were implemented. All residents sent to behavioral hospital have the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to behavioral hospital on 06/30/23. What corrective actions were taken? 1. The following actions were initiated immediately on 8/23/23 a. On 8/23/23 an audit was completed by CSD (Clinical Services Director) and/or designee to identify all residents who had a discharge to behavior hospital in the last 30 days to ensure alternate behavioral interventions were implemented prior discharge. No residents were identified to be discharged to behavioral hospital in the last 30 days. b. Social worker was educated on 8/23/23 by Clinical Services Director on referral process to in-house mental/behavioral services for all residents with behaviors. c. Initiated in-services on 8/23/23 with licensed nurses by Clinical Services Director/Designee to report behavioral changes to Director of Nurses /Designee and initiate non-pharmacological and pharmacological behavioral interventions. 2. How will the system be monitored to ensure compliance? a. The Director of Nurses/Administrator will review behavioral changes in conditions in the morning meeting starting on 8/24/23 and ongoing to ensure behaviors are appropriately addressed. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The Director of Nurses/Administrator will review during weekdays in the daily stand down meetings all interventions that have been implemented for residents identified in morning meeting experiencing behaviors. Any identified concerns will be addressed to ensure immediate alternative intervention were implemented. This was started on 8/24/23 and will be monitored 5 days a week for 4 weeks and then ongoing. c. The weekend supervisor and/or designee was in-serviced on 8/23/23 by Clinical Services Director/ Designee on identifying all residents experiencing behaviors on Saturdays and Sundays and ensure that any resident with behaviors receive immediate pharmacological and or non-pharmacological behavioral interventions. d. Newly hired staff, agency, and PRN staff will be educated by Clinical Services Director/Designee on implementing immediate pharmacological and or non-pharmacological behavioral interventions. Staff unable to come to receive education will be required to completed training before their next scheduled shift. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 8/23/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Surveyor monitored the Plan of Removal from 08/24/23 - 08/25/23 as followed: During interviews on 08/24/23 from 9:15 AM - 9:50 AM, the SW, two medication aides, three LVN's and one CNA all stated they had been in-serviced on resident behaviors and dealing with aggressive residents. They stated interventions such as re-directing, offering food, notifying the charge nurse, and ensuring they were receiving their prescribed psych meds as ordered. During interviews on 08/25/23 from 1:52 PM - 2:20 PM, three RN's and one CNA all stated they been in-serviced on resident behaviors and dealing with aggressive residents. They stated interventions such as re-directing, offering food, notifying the charge nurse, and ensuring they were receiving their prescribed psych meds as ordered. Review of the facility's Resident Behaviors in-service, dated 08/23/23, reflected staff were being in-serviced before the start of their shifts. The ADM and CSD were notified 08/25/23 at 4:00 PM that the IJ had been lowered. While the IJ was lowered, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is not immediate jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-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 one (Resident #1) of 15 residents reviewed for change in condition. The facility failed to notify the physician of a change in condition in Resident #1 when she became increasingly lethargic, unarousable, unresponsive, experienced high blood sugar and required emergency transfer to the hospital. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. This failure put residents a risk of decline, serious injury and death. Findings included: Review of Resident #1 face sheet dated [DATE] revealed Resident #1 was an [AGE] year old female admitted to the facility on [DATE] with a diagnoses of heart disease, hypertension, UTI and a history of falling. Review of Resident #1 Baseline Care Plan dated [DATE] revealed Resident #1 had a diabetic alert with the goal to manage symptoms and no interventions listed or medications. Resident #1 was noted to be at risk for dehydration with the goal to provide adequate fluids and interventions included determine likes/dislikes and monitor signs/symptoms. Review of Resident #1 eInteract Change in Condition Evaluation dated [DATE] revealed Resident #1 had sign and symptoms of abnormal vital signs, other change in condition and talk/communicates less. An additional change noted was high blood sugar and the change started on [DATE] in the afternoon. It was noted that since the change in condition occurred have the symptoms or signs gotten: worse and the symptoms had not occurred before. Resident #1 had an altered level of consciousness and it was noted to be a sudden change. Resident #1's functional status was noted to be have general weakness. Resident #1 had a blood pressure of ,d+[DATE] and the blood sugar noted was from [DATE] at 117.0. The physician was notified at 5:06 PM on [DATE] and Resident #1 was sent to the ER. Respiratory status was noted to be labored or rapid breathing which was recent intermittent change from usual pattern. Resident #1 was not noted to have pain. In an interview on [DATE] at 9:36 AM, JP #1 stated he pronounced the death at [HOSPITAL] for Resident #1 who was sent from [FACILITY] when she was found unresponsive after having high blood sugar. He stated Resident #1 was diabetic and had high blood sugar way above her normal routine blood sugars at the facility. He stated the cause of death he wrote on the death certificate was acute cardiac failure caused by atherosclerotic heart disease related to blood sugar levels were allowed to rise to 334 without medication being given. He stated the responsible party for Resident #1 told him Resident #1's Hemoglobin A1C was a five (to indicate good control of diabetes mellitus with insulin). He stated the RP #1 said Resident #1 had good control on insulin of her diabetes mellitus and rarely had blood sugars higher than 150. He stated he reviewed records from Resident #1 and was concerned Resident #1 had a high blood sugar when she died and was not given any interventions to prevent her blood sugar from continuing to rise. He stated Resident #1's RP reported having to ask the facility staff to send Resident #1 to the ER after she declined and became unresponsive. In an interview on [DATE] at 9:50 AM, RP #1 stated he was the responsible party for Resident #1 who died after being admitted to the facility for 48 hours. He stated Resident #1 lived independently prior to being hospitalized due to a UTI and dehydration. He stated Resident #1 was going to an assisted living facility after the hospital but they decided to have her complete a couple of weeks at the SNF to strengthen her because she was weak after the hospitalization . He stated Resident #1 was not on hospice and no one thought she was close to dying. He stated he was with Resident #1 when she was admitted on [DATE] and though Resident #1 was weak and in a wheelchair (when Resident #1 previously ambulated using a walker at home), Resident #1 was alert and oriented times three. He stated on [DATE] he spoke with Resident #1 and Resident #1 had a good day, went to physical therapy at the facility and was feeling well. He stated Resident #1 spoke easily to him on the phone around 4:00 PM on [DATE]. He stated on [DATE] he tried to call Resident #1 multiple times in the morning and received no answer. He stated he assumed Resident #1 was at therapy. He stated in the afternoon on [DATE] he was unable to reach Resident #1 on her phone so he called the nurse's station and could not reach anyone multiple times. He stated around 4:00 PM on [DATE] he was able to speak with Resident #1's nurse and asked that LVN A check on Resident #1. He stated LVN A said Resident #1 was tired today and refused physical therapy today. He said LVN A told him Resident #1 did not want to do nothing today. He stated LVN A tried to wake Resident #1 during that phone call and Resident #1 was sleeping and would not wake up. He stated he told LVN A he would check back in an hour. He stated he called back around 5:00 PM and LVN A said Resident #1 is laying here making rattling noises and told him to listen. He stated he could hear through the phone Resident #1 making unusual loud breathing noises. He stated LVN A told him Resident #1 would not wake up and he told LVN A to check Resident #1's blood sugar. He stated LVN A checked her blood sugar and blood pressure. LVN A said Resident #1's blood pressure was ,d+[DATE], which was low for her. LVNA said Resident #1's blood sugar was 334 which was very high for Resident #1. He stated he told LVN A to call an ambulance since Resident #1 was unresponsive with high blood sugar and low blood pressure. He stated LVN A told him she thought about calling an ambulance but the facility did not have anyone to sit with Resident #1 at the hospital so she did not call an ambulance. He stated he told LVN A to call an ambulance at that time and LVN A hung up. He stated approximately 30 minutes later he received a phone call from the ER physician who said Resident #1 passed away. He stated the ER physician told him Resident #1 was expired upon arrival at the ER. Resident #1's RP stated he was told Resident #1 died of cardiac arrest because she was in a diabetic coma. He stated he does not believe they were monitoring Resident #1's blood sugar closely and did not understand why he had to direct the nurse to check her blood sugar and call 911. He said LVN A did tell her that Resident #1's blood sugar was high that morning at 262 prior to insulin administration. He said LVN A told him she did not re-check Resident #1's blood sugar after administering the insulin to see if Resident #1's blood sugar went down. He stated he did not understand how Resident #1 died within 48 hours of admission to the facility when she was only admitted for a short term stay for weakness. In an interview on [DATE] at 1:00 PM, LVN A stated she worked with Resident #1 on [DATE] - [DATE]. She stated on [DATE] Resident #1 was alert and oriented times three and went to therapy without a problem. She stated on [DATE] Resident #1 was tired and did not want to go to therapy. She stated she checked Resident #1's blood sugar prior to administering her insulin but did not document the result. She stated Resident #1's blood sugar was 262 that morning so she administered the ordered insulin. She said she did not re-check Resident #1's blood sugar later in the day to ensure the blood sugar returned to normal range. She stated Resident #1 did not have a physician order for routine blood sugar checks. She stated Resident #1 did not have routine blood sugar checks because the nurse who admitted Resident #1 did not obtain the order from her physician. She stated normally the admitting nurse would obtain routine blood sugar checks from the resident's physician upon admission. She stated it was an oversight that routine blood sugar checks were not ordered for Resident #1. She stated when Resident #1's RP called later in the day on [DATE], he wanted LVN A to check Resident #1's blood sugar and it was 343. She stated she did not document the high blood sugar or notify the physician as Resident #1's RP wanted Resident #1 sent to the ER. She stated she did not know how long Resident #1 had been experiencing high blood sugar as it had not been monitored since Resident #1 was admitted . She stated if a resident had high blood sugar above their routine readings she would notify their physician for further orders. LVN A was unsure of what blood sugar level she should have notified Resident #1's physician. She stated Resident #1 had no additional symptoms of high blood sugar besides being sleepy, lethargic and arouseable. She stated CNA B came and got her after Resident #1's RP called the first time on [DATE] and said Resident #1 was breathing funny. She stated Resident #1 was breathing faster, shallower and had a rattle. She said she did not notify the doctor at that time or start life saving measures. She stated Resident #1's RP called back and she had him listen to Resident #1's breathing and told Resident #1's RP that Resident #1 would not wake up. She stated she did not notify Resident #1's physician at that time that Resident #1 would not wake up. She stated she called 911 upon direction from Resident #1's RP. She stated she did not start CPR or other life saving measures because Resident #1 was a DNR even though the facility did not have the paperwork at the facility to confirm Resident #1 was an OOH-DNR. In an interview on [DATE] at 1:20 PM, the interim DON stated she was new to the facility and had only been at the facility since [DATE]. She stated she was not very familiar with Resident #1 but knew that she was a new admit that passed away at the hospital on [DATE]. She stated she was called to her room on [DATE] because Resident #1 was unresponsive and she assisted with Resident #1's care while they waited for EMS response. She stated she checked Resident #1's blood sugar approximately 10 minutes after LVN A checked it and Resident #1's blood sugar had increased to 376. She said EMS arrived after that and took over Resident #1's care. She stated the facility had a hypoglycemic protocol for residents that experience low blood sugar but the facility did not have a hyperglycemic protocol (for high blood sugar). She stated for residents with high blood sugar, the physician would need to be notified per physician order at parameters set by the physician for high blood sugar. For instance, the physician would be notified for any blood sugar over 400. She stated she did not know why Resident #1 did not have an order for routine blood sugar checks since she was on insulin. She stated it was likely an oversight by the nurse that admitted Resident #1. She stated Resident #1 should have had her blood sugar checked at least once daily since she was on insulin. She stated she could not say that the reason Resident #1 was unarouseable on [DATE] was because of high blood sugar and/or a diabetic coma. She stated when Resident #1 was admitted routine blood sugar checks should have been ordered. She stated LVN A should have re-checked Resident #1's blood sugar after administering the insulin on [DATE] to ensure Resident #1's blood sugar returned to normal range. She stated the nurse should have recognized the change in condition in Resident #1 on [DATE] and notified her physician. She stated interventions could have put into place sooner to address Resident #1's symptoms. In an interview on [DATE] at 1:30 PM, Resident #1's NP stated he had not examined or seen Resident #1 since she was admitted . He stated based on Resident #1's blood sugar readings and history of well controlled diabetes, he could not rule out that she was in diabetic coma when she was sent to theER on [DATE] and passed away. He stated he should have been notified and routine blood sugar checks should have been ordered upon admission for Resident #1 with parameters to notify him or the attending physician when results were abnormal. In an interview on [DATE] at 1:12 PM, the ER PHYSICIAN stated she treated Resident #1 upon arrival at the ER. She stated Resident #1 was in full cardiac arrest upon arrival and when they confirmed with Resident #1's RP that Resident #1 had a DNR order, they stopped all life saving measures. She stated Resident #1 was deceased upon arrival and the EMS life saving measures was what kept her showing signs of life. She stated it is unclear what exactly caused Resident #1's death but Resident #1 experienced a rapid decline that day [DATE] that should have been detectable to healthcare staff at the facility. In an interview on [DATE] at 3:00 PM, CNA B stated on [DATE] she notified LVN A that Resident #1 was complaining of pain in the morning and could not even hold a cup to her mouth. She stated she told LVN A Resident #1 had increased weakness and wanted additional pain medication. She stated she told LVN A twice and was not sure if LVN A did anything for Resident #1. She was going to give Resident #1 a bed bath and Resident #1 was too sleepy and lethargic and declined a bed bath. She stated Resident #1 was not voiding normally and did not require routine incontinent care as her brief was dry. She stated later in the day around 1:00 PM she notified LVN A Resident #1 was breathing differently in that Resident #1 was breathing faster and shallower. She stated she did not see LVN A do an assessment on Resident #1. She stated Resident #1 became increasingly less responsive through out the day and she did not see any interventions put into place to address her change in condition. She stated she did as required and notified Resident #1's nurse and did not know what else to do for Resident #1. In an interview on [DATE] at 3:20 PM, PT E stated she went to check on Resident #1 on [DATE] and Resident #1 was weak and reported being in a lot of pain. PT E said she told Resident #1's nurse LVN A. She stated on [DATE] she worked with Resident #1 as her PT and Resident #1 was alert and oriented times three and was able to complete all exercises. She stated Resident #1 did report being tired after her exercises but was otherwise okay. She said on the morning of [DATE] Resident #1 reported to PT A Resident #1's abdomen was sore and Resident #1 was noted to be grimacing in pain. She said Resident #1 could not sit up on the side of the bed as Resident #1 could the day before easily. She said she reported this to LVN A without any interventions noted before she exited the room. In a follow-up interview on [DATE] at 1:23 PM, the interim DON stated the change in condition should have been detected by LVN A sooner in Resident #1 and the physician should have been notified immediately the morning of [DATE] instead of after 911 was called on the evening of [DATE]. She stated any significant change in condition would require physician notification and notification of the resident's RP. She stated she was not aware that Resident #1 had complained of pain to CNA B and PT E. She stated moving forward if staff do not see an appropriate intervention when they notify a charge nurse of a resident change in condition, they should contact her or one of her designees to intervene. Review of Resident #1's progress notes dated [DATE] did not reveal any notes regarding the nurse being notified of Resident #1's change in condition, complaints of pain or change in breathing. There were no notes regarding Resident #1 being increasingly sleepy and refusing therapy. Review of Change in a Resident's Condition or Status Policy dated [DATE] revealed our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been: . d. significant change in the resident's physical/emotional/mental condition . The Administrator was notified of the Immediate Jeopardy on [DATE] at 2:30 PM and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 9:45 AM and included the following: Impact Statement: On [DATE] an abbreviated survey was initiated at [FACILITY]. On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to identify and provide needed care and services after a change in condition to resident #1. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address potential change of conditions on all residents using the ,d+[DATE]-hour report on [DATE]. All residents had the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to hospital on [DATE]. What corrective actions were taken? 3. The following actions were initiated immediately on [DATE] d. On [DATE] an audit was completed by traveling DON and/or designee to identify all residents who were at risk for having a change of condition related to their disease process including those receiving insulin. No residents were identified to be affected including those who receive insulin. Interim DON and ADON were educated on [DATE] by CSD (Clinical Service Director) on identification of change of condition, e-interact stop and watch tool, and notification to physician when changes of condition are observed in residents. e. On [DATE] an in-service was initiated for all staff to include housekeeping, therapy, dietary, and agency/contract staff by the traveling DON on change of condition, notification of the nurse on duty, notifying the physician of changes, verifying orders, and s/s of hypo/hyper glycemia. In-service was completed on [DATE] and all staff who was unable to attend will be required to complete training before their next scheduled shift. f. On [DATE] an in-service was initiated for all staff by the DON and/or designee on the importance of completing stop and watch forms when there are changes of condition noticed in residents. In-service was completed on [DATE] and all staff including agency who was unable to attend will be required to complete training before their next scheduled shift. 4. How will the system be monitored to ensure compliance? f. The ADON, Interim DON and/or designee will review the facilities ,d+[DATE] hour summary report in PCC 5 days per week in the morning clinical meeting starting on [DATE] for 4 weeks and then ongoing to identify any resident who has had a change in condition or has symptoms that may trigger an acute decline requiring medical attention. Licensed and trained nursing staff will ensure the physician has been notified and interventions implemented. Any identified concerns will be addressed immediately, and additional training will be provided as needed. g. The acting DON or designee will review new daily telephone orders, and new/readmit orders after being entered by licensed nursing staff into PCC to ensure anyone with an insulin order has accuchecks in place and parameters of when to call the physician. This was started on [DATE] and will be monitored 5 days a week for 4 weeks and then ongoing. h. The Interim DON and Nurse Manager will review all stop and watch forms completed by all staff in morning meetings to help identify observed changes in condition and to ensure the physician has been notified. Starting on [DATE] and will be ongoing. i. The weekend supervisor and/or designee was in-serviced on [DATE] by acting DON on how to review the ,d+[DATE]-hour report from PCC and the stop and watch tools on Saturdays and Sundays to ensure that any residents with a change in condition are identified. Nursing staff will contact the physician and ensure appropriate orders and interventions are in place. j. Newly hired staff, agency, and PRN staff will be trained on the stop and watch tools, changes in condition, verification of orders, notification to physician and s/s of hyper hypoglycemia during orientation by the acting DON or designee. Staff unable to come to receive training will be required to complete training before their next scheduled shift. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring was completed on [DATE] and [DATE]: In an observation on [DATE] at 1:00 PM, Resident #2 and Resident #3, both diagnosed with insulin dependent diabetes mellitus, were observed with no issues or complications related to diabetes mellitus. Review of inservices completed [DATE] - [DATE] revealed all current staff inserviced on change in condition reporting and interventions. In an interview on [DATE] at 12:15 PM, CNA G stated she received education regarding a resident change in condition, who should notify and what to do if an appropriate intervention was not put into place for the resident. She stated she would notify the charge nurse and if the charge did not put an acceptable intervention into place she would notify the ADON, DON or administrator. In an interview on [DATE] at 12:22 PM, CAN H stated she received education to notify the charge immediately if a resident had a change in condition and if an appropriate intervention was not put into place she would follow the chain of command. She stated a change in condition could a mental change like a cognitive decline or a physical change. In an interview on [DATE] at 12:30 PM, MA J stated she received education about what to do if a resident had a change in condition and she would notify their charge nurse. She stated if the charge nurse did not evaluate the resident and ensure an appropriate intervention was put into place, she would notify the ADON or DON. In an interview on [DATE] at 12:43 PM, RN D stated she received education on resident change in condition and appropriate interventions to put into place and who to notify immediately. She stated if an intervention was not effective she would notify the physician for additional interventions. In an interview [DATE] at 1:23 PM, the interim DON stated all staff were educated regarding what to do if a resident experienced a change in condition, who to notify and what to do if interventions implemented were not effective. She stated new staff or agency staff would be educated prior to working with residents. Review of 24 hour summary report dated [DATE] and no residents were identified as at risk for related to not having blood sugar checks routinely. Review of Stop and Watch form dated [DATE] revealed the form would identify residents at risk for blood sugar issues and change in condition.

Based on interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for one (Resident #1) of 15 residents reviewed for quality of care. The facility failed to obtain orders to check/monitor Resident #1's blood sugar levels/parameters related to her diabetes upon admission. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk of not receiving the care and treatment needed Findings included: Review of Resident #1 face sheet dated [DATE] revealed Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of heart disease, hypertension, UTI and a history of falling. Review of Resident #1 Baseline Care Plan dated [DATE] revealed Resident #1 had a diabetic alert with the goal to manage symptoms and no interventions listed or medications. Resident #1 was noted to be at risk for dehydration with the goal to provide adequate fluids and interventions included determine likes/dislikes and monitor signs/symptoms. Review of Resident #1 Blood Sugar vital sign documentation dated [DATE] - [DATE] revealed one blood sugar documented on [DATE] at 6:50 PM and the ready reading was documented as 117.0 mg/dL. There were not additional blood sugars documented during this time period. Review of Resident #1's physician orders dated [DATE] - [DATE] revealed no physician orders for blood sugar checks for Resident #1. Review of Resident #1's physician orders dated [DATE] revealed Resident #1 was ordered Insulin Detemir Subcutaneous Solution Pen-injector 100 unit/mL with orders to inject 12 unit subcutaneously one time a day for Hyperglycemia. In an interview on [DATE] at 9:36 AM, JP #1 (Justice of the Peace) stated he pronounced the death at [HOSPITAL] for Resident #1 who was sent from [FACILITY] when she was found unresponsive after having high blood sugar. He stated Resident #1 was diabetic and had high blood sugar way above her normal routine blood sugars at the facility. He stated the cause of death he wrote on the death certificate was acute cardiac failure caused by atherosclerotic heart disease related to blood sugar levels were allowed to rise to 334 without medication being given. He stated the responsible party (RP) for Resident #1 told him Resident #1's Hemoglobin A1C was a five (to indicate good control of diabetes mellitus with insulin). He stated the RP #1 said Resident #1 had good control on insulin of her diabetes mellitus and rarely had blood sugars higher than 150. He stated he reviewed records from Resident #1 and was concerned Resident #1 had a high blood sugar when she died and was not given any interventions to prevent her blood sugar from continuing to rise. In an interview on [DATE] at 9:50 AM, RP #1 stated he was the responsible party for Resident #1 who died after being admitted to the facility for 48 hours. He stated Resident #1 lived independently prior to being hospitalized due to a UTI and dehydration. He stated Resident #1 was going to an assisted living facility after the hospital but they decided to have her complete a couple of weeks at the SNF to strengthen her because she was weak after the hospitalization . He stated Resident #1 was not on hospice and no one thought she was close to dying. He stated he was with Resident #1 when she was admitted on [DATE] and though Resident #1 was weak and in a wheelchair (when Resident #1 previously ambulated using a walker at home), Resident #1 was alert and oriented times three. He stated on [DATE] he spoke with Resident #1 and Resident #1 had a good day, went to physical therapy at the facility and was feeling well. He stated Resident #1 spoke easily to him on the phone around 4:00 PM on [DATE]. He stated on [DATE] he tried to call Resident #1 multiple times in the morning and received no answer. He stated he assumed Resident #1 was at therapy. He stated in the afternoon on [DATE] he was unable to reach Resident #1 on her phone so he called the nurse's station and could not reach anyone multiple times. He stated around 4:00 PM on [DATE] he was able to speak with Resident #1's nurse and asked that LVN A check on Resident #1. He stated LVN A said Resident #1 was tired today and refused physical therapy today. He said LVN A told him Resident #1 did not want to do nothing today. He stated LVN A tried to wake Resident #1 during that phone call and Resident #1 was sleeping and would not wake up. He stated he told LVN A he would check back in an hour. He stated he called back around 5:00 PM and LVN A said Resident #1 is laying here making rattling noises and told him to listen. He stated he could hear through the phone Resident #1 making unusual loud breathing noises. He stated LVN A told him Resident #1 would not wake up and he told LVN A to check Resident #1's blood sugar. He stated LVN A checked her blood sugar and blood pressure. LVN A said Resident #1's blood pressure was ,d+[DATE], which was low for her. LVN A said Resident #1's blood sugar was 334 which was very high for Resident #1. He stated he told LVN A to call an ambulance since Resident #1 was unresponsive with high blood sugar and low blood pressure. He stated LVN A told him she thought about calling an ambulance but the facility did not have anyone to sit with Resident #1 at the hospital so she did not call an ambulance. He stated he told LVN A to call an ambulance at that time and LVN A hung up. He stated approximately 30 minutes later he received a phone call from the ER physician who said Resident #1 passed away. He stated the ER physician told him Resident #1 was expired upon arrival at the ER. Resident #1's RP stated he was told Resident #1 died of cardiac arrest because she was in a diabetic coma. He stated he does not believe they were monitoring Resident #1's blood sugar closely and did not understand why he had to direct the nurse to check her blood sugar and call 911. He said LVN A did tell her that Resident #1's blood sugar was high that morning at 262 prior to insulin administration. He said LVN A told him she did not re-check Resident #1's blood sugar after administering the insulin to see if Resident #1's blood sugar went down. He stated he did not understand how Resident #1 died within 48 hours of admission to the facility when she was only admitted for a short term stay for weakness. In an interview on [DATE] at 1:00 PM, LVN A stated she worked with Resident #1 on [DATE] - [DATE]. She stated on [DATE] Resident #1 was alert and oriented times three and went to therapy without a problem. She stated on [DATE] Resident #1 was tired and did not want to go to therapy. She stated she checked Resident #1's blood sugar prior to administering her insulin but did not document the result. She stated Resident #1's blood sugar was 262 that morning so she administered the ordered insulin. She said she did not re-check Resident #1's blood sugar later in the day to ensure the blood sugar returned to normal range. She stated Resident #1 did not have a physician order for routine blood sugar checks. She stated Resident #1 did not have routine blood sugar checks because the nurse who admitted Resident #1 did not obtain the order from her physician. She stated normally the admitting nurse would obtain routine blood sugar checks from the resident's physician upon admission. She stated it was an oversight that routine blood sugar checks were not ordered for Resident #1. She stated when Resident #1's RP called later in the day on [DATE], he wanted LVN A to check Resident #1's blood sugar and it was 343. She stated she did not document the high blood sugar or notify the physician as Resident #1's RP wanted Resident #1 sent to the ER. She stated she did not know how long Resident #1 had been experiencing high blood sugar as it had not been monitored since Resident #1 was admitted . She stated if a resident had high blood sugar above their routine readings she would notify their physician for further orders. LVN A was unsure of what blood sugar level she should have notified Resident #1's physician. She stated Resident #1 had no additional symptoms of high blood sugar besides being sleepy, lethargic and arousable. In an interview on [DATE] at 1:20 PM, the interim DON stated she was new to the facility and had only been at the facility since [DATE]. She stated she was not very familiar with Resident #1 but knew that she was a new admit that passed away at the hospital on [DATE]. She stated she was called to her room on [DATE] because Resident #1 was unresponsive and she assisted with Resident #1's care while they waited for EMS response. She stated she checked Resident #1's blood sugar approximately 10 minutes after LVN A checked it and Resident #1's blood sugar had increased to 376. She said EMS arrived after that and took over Resident #1's care. She stated the facility had a hypoglycemic protocol for residents that experience low blood sugar but the facility did not have a hyperglycemic protocol (for high blood sugar). She stated for residents with high blood sugar, the physician would need to be notified per physician order at parameters set by the physician for high blood sugar. For instance, the physician would be notified for any blood sugar over 400. She stated she did not know why Resident #1 did not have an order for routine blood sugar checks since she was on insulin. She stated it was likely an oversight by the nurse that admitted Resident #1. She stated Resident #1 should have had her blood sugar checked at least once daily since she was on insulin. She stated she could not say that the reason Resident #1 was unarouseable on [DATE] was because of high blood sugar and/or a diabetic coma. She stated when Resident #1 was admitted routine blood sugar checks should have been ordered. She stated LVN A should have re-checked Resident #1's blood sugar after administering the insulin on [DATE] to ensure Resident #1's blood sugar returned to normal range. In an interview on [DATE] at 1:30 PM, Resident #1's NP stated he had not examined or seen Resident #1 since she was admitted . He stated based on Resident #1's blood sugar readings and history of well controlled diabetes, he could not rule out that she was in diabetic coma when she was sent to theER on [DATE] and passed away. He stated he should have been notified and routine blood sugar checks should have been ordered upon admission for Resident #1 with parameters to notify him or the attending physician when results were abnormal. In an interview on [DATE] at 3:00 PM, CNA B stated she worked with Resident #1 on [DATE] and reported to LVN A Resident #1 had a change in condition. She stated she saw LVN A check her blood sugar prior to insulin administration but did not see her check Resident #1's blood sugar again until Resident #1's RP requested it via phone later that afternoon around 4:00 PM. In an interview on [DATE] at 11:05 AM, LVN C stated any new admit with a diagnosis of diabetes mellitus would require an order for routine blood sugar checks. She stated new residents on insulin would typically have morning and bedtime blood sugar checks unless the resident was unstable and then it would be more frequently. She stated if a resident experienced a high blood sugar greater than 160 she would notify their physician for further orders. She stated the admitting nurse would be responsible for obtaining the orders and ensuring it was in the EMR. In an interview on [DATE] at 11:20 AM, RN D stated she would ask the admitting physician for an order for routine blood sugar checks and it would be dependent on whether the resident received insulin or oral medication for diabetes mellitus. RN D stated for a resident on insulin the order would typically be for twice daily in the morning and at bedtime. She stated it was likely an oversight by the admitting nurse that Resident #1 did not have a routine order for blood sugar checks. She stated the charge nurses should have checked Resident #1's blood sugar at least daily prior to insulin administration to make sure her blood sugar was not low prior to insulin administration. The Administrator was notified of the Immediate Jeopardy on [DATE] at 2:30 PM and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 9:45 AM and included the following: Impact Statement: On [DATE] an abbreviated survey was initiated at [FACILITY]. On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to identify and provide treatment and care to resident #1. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address potential change of conditions on all residents using the ,d+[DATE]-hour report on [DATE]. All residents had the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to hospital on [DATE]. What corrective actions were taken? 1. The following actions were initiated immediately on [DATE] a. On [DATE] an audit was completed by traveling DON and/or designee to identify all residents who were at risk for having a change in condition related to their disease process including those receiving insulin. No residents were identified to be affected including those who receive insulin. Interim DON and ADON were educated on [DATE] by CSD (Clinical Service Director) on identification of change of condition, e-interact stop and watch tool, and notification to physician when changes of condition are observed in residents. b. On [DATE] an in-service was initiated for all staff to include housekeeping, therapy, dietary, and agency/contract staff by the traveling DON on change of condition, notification of the nurse on duty, notifying the physician of changes, verifying orders, s/s of altered mental status, and s/s of hypo/hyper glycemia. In-service was completed on [DATE] and all staff who was unable to attend will be required to complete training before their next scheduled shift. c. On [DATE] an in-service was initiated for all staff by the DON and/or designee on the importance of completing stop and watch forms when there are changes of condition noticed in residents. In-service was completed on [DATE] and all staff including agency who was unable to attend will be required to complete training before their next scheduled shift. 2. How will the system be monitored to ensure compliance? a. The ADON, Interim DON and/or designee will review the facilities ,d+[DATE] hour summary report in EMR 5 days per week in the morning clinical meeting starting on [DATE] for 4 weeks and then ongoing to identify any resident who has had a change in condition or has symptoms that may trigger an acute decline requiring medical attention. Licensed and trained nursing staff will ensure the physician has been notified and interventions implemented. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The acting DON or designee will review new daily telephone orders and new/readmits orders after being entered by licensed nursing staff into EMR to ensure anyone with an insulin order has blood sugar checks in place and parameters of when to call the physician. This was started on [DATE] and will be monitored 5 days a week for 4 weeks and then ongoing. c. The Interim DON and Nurse Manager will review all stop and watch forms completed by all staff in morning meetings to help identify observed changes in condition and to ensure the physician has been notified. Starting on [DATE] and will be ongoing. d. The weekend supervisor and/or designee was in-serviced on [DATE] by DON on how to review the ,d+[DATE]-hour report from EMR and the stop and watch tools on Saturdays and Sundays to ensure that any residents with a change in condition are identified. Nursing staff will contact the physician and ensure appropriate orders and interventions are in place. e. Newly hired staff, agency, and PRN staff will be trained on the stop and watch tools, changes in condition, verification of orders, notification to physician and s/s of hyper hypoglycemia during orientation by the acting DON or designee. Staff unable to come to receive training will be required to completed training before their next scheduled shift. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. Monitoring was completed on [DATE] and [DATE]: In an observation on [DATE] at 1:00 PM, Resident #2 and Resident #3, both diagnosed with insulin dependent diabetes mellitus, were observed with no issues or complications related to diabetes mellitus. Review of 24 hour summary report dated [DATE] and no residents were identified as at risk for related to not having blood sugar checks routinely. Review of Stop and Watch form dated [DATE] revealed the form would identify residents at risk for blood sugar issues and change in condition. In an interview on [DATE] at 12:23 PM, RN D stated she received education regarding entering orders for routine blood sugar checks for diabetic residents who require insulin. She stated she would notify the physician if there was not an order specified for routine blood sugar checks. She said most of the time diabetic residents on insulin require a morning and bedtime blood sugar check unless the resident's diabetes was unstable and then the physician may order more frequent blood sugar checks. In an interview on [DATE] at 12:45 PM at LVN F stated she received education regarding routine blood sugar checks that should be ordered by the resident's physician upon admission. She stated most of the time if the resident's diabetes was stable the resident would only require twice daily, in the morning before breakfast and at bed time blood sugar checks. She stated she was educated on parameters to notify a resident's physician if the resident's blood sugar was low or high above the normal range. She stated there was also orders for when a resident experienced low blood sugar called the hypoglycemia protocol. Review of Routine Blood Sugar Orders Inservice dated [DATE] - [DATE] revealed all required staff were educated regarding a new admission and asking resident physician for routine blood sugar orders. In an interview [DATE] at 1:23 PM, the interim DON stated all nurses were educated regarding obtaining order upon admission for residents on insulin for blood sugar checks. She stated the nurses should also obtain parameters for which the physician should be notified for abnormal blood sugar levels. The DON stated agency and PRN staff will not be allowed to work until they have received the education.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care, in that: The facility failed to properly assess or provide effective pain management to Resident #1 after she fell and injured her hip on [DATE], resulting in uncontrolled pain, decline in health, and ultimately death on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 3:30 PM. While the IJ was removed on [DATE] at 4:30 PM, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] for respite care with diagnoses of history of falling, chronic respiratory failure, type II diabetes, hypertensive (high blood pressure) heart disease, seizures, and other specified anxiety disorders. Review of Resident #1's fall risk assessment, dated [DATE], reflected a score of 16, indicating she was a high risk for falls. Review of Resident #1's discharge MDS assessment, dated [DATE], reflected she died in the facility. Review of Resident #1's initial baseline care plan, dated [DATE], reflected she had an actual fall (on [DATE]) with no injury related to cognitive impairment and poor balance with interventions of frequent rounding and checking range of motion. Review of Resident #1's progress notes in her EMR documented by RN K, dated [DATE] at 6:59 PM, reflected the following: [Resident #1] admitted into (facility) on respite care per (hospice agency) . care giver will be at beside daily from 8:00 AM - 6:00 PM . clear adequate speech, adequate vision, adequate hearing . Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 7:45 AM, reflected the following: During monitoring rounds observed [Resident #1] attempting to self-ambulate and fell to floor. Unable to reach [Resident #1] before she fell to the floor. [Resident #1] did not hit her head and landed on her bottom. Assessed [Resident #1] and assisted back into wheelchair and assisted back into bed. [Resident #1] does not display any signs of pain/discomfort, with no injuries observed at this time. Review of text messages sent by CG C to Resident #1's RP B reflected the following: [DATE]: 8:28 AM - Soon as I arrived, I asked if [Resident #1] wanted breakfast and she said no . I noticed her making a face and I asked what was wrong and she said her left leg hurts. 9:39 AM - I got [Resident #1] up in the chair and had to ask for help to change her brief . [Resident #1] was asking to get back in bed because her leg was hurting. When breakfast arrived, [Resident #1] did not want to eat because she was nauseated. 1:01 PM - She ate a little (lunch). She's really out of it. Not sure what to do. I don't wanna put her in bed and she doesn't want to do anything else. I had her in the living room but she kept hollering for help . She's also tilted all the way forward (in her wheelchair). 1:11 PM - The hospice nurse arrived and was just told that [Resident #1] fell at 6am. Now we know the reason for the pain. Review of text messages sent by CG D to Resident #1's RP B reflected the following: [DATE]: 2:29 PM - . [Resident #1] isn't talking much today and when they put her in the wheelchair she just stated hunched over. This is not normal for her at all . They put her on oxygen today. 3:29 PM - . HN G told me she was going to figure out why they did not treat [Resident #1] right away because she was in pain. 7:23 PM - . I requested Morphine so I could change her brief . [LVN H] never brought the Morphine so I changed her the best I could. She cried out yelling it hurts. [DATE]: 8:57 AM - I asked for the morphine and other morning meds but [LVN H] still hasn't brought them so [Resident #1] won't stop getting loud saying please let it work, please let it work. Her leg is hurting her a lot and she can't move it. 10:24 AM - [LVN H] came in at 9:57 AM and asked [Resident #1] if she needed anything and I told her she needs her morphine to help with the pain. So she asked [Resident #1] what was hurting and where and she told her she doesn't have any pain so the nurse said ok if you need it hit the red button. So she didn't give her morphine. As soon as [LVN H] left, [Resident #1] starts saying it hurts please help. Review of Resident #1's hospice notes documented by HN G, dated [DATE] (no time documented), reflected the following: New complaints, problems or concerns: [Resident #1] fell this morning and her hip hurts. Objective findings: [Resident #1] on respite and in room with paid caregiver. [Resident #1] lethargic but answering some questions. [Resident #1] is now total assist [Resident #1] was in wheelchair in room with head hung forward and most of her body limp when RN arrived. CG C was at beside and stated she is not herself today and does not know what's wrong. RN asked if she was aware that [Resident #1] had fallen this morning and CG C she was not told of any fall. RN asked [Resident #1] to lift her head but she stated she was not able to. [Resident #1] stated she was SOB and oxygen was applied via nasal canula at 3 L however oxygen sat was not obtainable. [Resident #1] was breathing comfortably with nasal canula and RN continued assessment. RN had to use both hands to gently lift [Resident #1]'s head to examine her eyes and face . [Resident #1] complained of slight pain with left leg lifting at hip only . Once laying in bed, [Resident #1] did call out in pain with movement of left leg especially at hip joint . RN educated facility staff on medication management and use of PRN Morphine for [Resident #1]'s pain if Tylenol is not enough. LVN H verbalized understanding. Assessment: [Resident #1] is possibly at start of decline in status. She has been more lethargic, not eating much, and had a recent fall . [Resident #1] may have fracture or deep injury of left hip or coccyx. RN also spoke with HA who confirmed they were not notified of [Resident #1] having a fall that morning when she and another aide came to bathe her. She reports it took both of them to transfer [Resident #1] but they were able to shower her . HA recalls that [Resident #1] would groan from time to time but they thought it had something to do with her being medicated because she was less alert than usual. Review of Resident #1's hospice notes documented by an on-call nurse, dated [DATE] at 4:24 PM, reflected the following: CG D would like to speak with the on-call nurse regarding [Resident #1] falling that morning and is experiencing a lot of pain on her left side. She was provided 1 Tylenol and it's not working. Review of Resident #1's hospice notes documented by HN G, dated [DATE] (no time documented), reflected the following: Objective findings: [Resident #1] complained of pain on left side when is moved or touched on that side . Her left leg was straight, and foot dropped to the left . [Resident #1] had pain when leg was gently turned to point foot up towards ceiling. Anytime left hip was touched or leg slightly moved or lifted she complained of paint. RN got LVN H and had her administer morphine IR 15 MG at 10:20 AM. Per LVN H she had just been in the room and [Resident #1] did not have any s/s of pain . This RN educated LVN H on [Resident #1]'s confusion and that she has pain anytime she moves or is moved for brief changes, and she may need to have caregiver help with administration of meds since [Resident #1] is familiar with her and she may be able to facilitate [Resident #1] accepting needed meds. She verbalized understanding. RN obtained order to schedule Morphine Q4 hours for pain. Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 11:12 AM, reflected the following: Hospice nurse and [CG C] of [Resident #1] c/o left hip pain and wanted MS administered. During assessment of [Resident #1], asked if in any pain or if she needed any medication, she responded no . Hospice nurse enters room and states to [Resident #1] that the nurse is going to give you medication, the resident states okay. MS administered per Hospice. Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 11:56 AM, reflected the following: Hospice in facility, new orders for Morphine sulfate 15mg q4 hours for pain. Hospice nurse/sitter reported [Resident #1] to have pain to her left leg . Review of Resident #1's progress notes in her EMR documented by RN I, dated [DATE] at 12:05 AM, reflected the following: CNA notified the Nurse that [Resident #1] is unresponsive. On assessment, resident unresponsive to verbal and tactile stimulation. No visible breathing, no pulse, pupils dilated and fixed, [Resident #1] has expired . Review of a documented Interview between a Hospice State Surveyor and the hospice agency's Alternate Administrator regarding the timeline of Resident #1, dated [DATE] at 1:30 PM, reflected the following: On [DATE] at approximately 6:30 AM, [Resident #1] was found on the floor by facility staff. [Resident #1]'s private caregiver arrived at 8:00 AM. From 11:30 AM - 12:30 PM, hospice aides assisted [Resident #1] with her shower and personal care. At 12:57 PM, HN G arrived to conduct a skilled nursing visit. It was at that time a facility nurse reported the fall to her. This was the first notification of a fall. Review of a documented Interview between a Hospice State Surveyor and Resident #1's HN G, dated [DATE] at 2:50 PM, reflected the following: Surveyor asked [HN G] to discuss what she recalled about what occurred when she arrived at the facility on [DATE]. [HN G] stated when arrived at the facility to conduct a visit, the client was sitting in a wheelchair with her head hung down. Surveyor asked if this was unusual. [HN G] stated, That was very unusual. I asked her to lift her head and she said she couldn't. I was concerned she had injured her head or neck when she fell. During a telephone interview on [DATE] at 11:22 AM, CG D stated CG C would sit with Resident #1 from 8:00 AM - 2:00 PM and she would relieve her at 2:00 PM - 6:00 PM. She stated CG C contacted her in the morning of [DATE] and asked if Resident #1 had fallen the day prior ([DATE]). She stated she told her no and asked her why. CG C told her Resident #1 was complaining of left hip/leg pain. She stated when she arrived at 2:00 PM on [DATE], Resident #1 was still in pain, and that was when HN G learned of the fall from the facility staff; CG C was never notified during her entire shift. She stated Resident #1 was able to verbalize pain and would yell, Owe! when she attempted to change her brief or reposition her. She stated she had worked with Resident #1 for over two months, and new her tendencies well. The day before, [DATE], when she was admitted , she ate a big breakfast, was able to self-transfer to the toilet, and even ambulated independently into the nursing facility via walker. She stated on [DATE] she was lethargic, was not eating, required oxygen, and needed full assistance. She stated she told LVN H that Resident #1 needed Morphine as she was in pain and her hip appeared swollen. She stated when LVN H came into the room and asked her if she was in pain, she said no. She stated she tried to explain that when Resident #1 was not familiar/comfortable with a person, she would appear as though everything was fine and would not verbalize her pain. She stated she may have been on hospice, but she drastically changed after the fall, and was not at end-of-life stages when she was admitted to the facility. During a telephone interview on [DATE] at 12:12 PM, Resident #1's RP A stated the Justice of the Peace and police were now involved because the death was suspicious/questionable. He stated Resident #1 was completely fine two days before her death and after being admitted to the facility. During a telephone interview on [DATE] at 1:12 PM, a Judge with the Justice of the Peace stated he had contacted the funeral home Resident #1 was sent to and was able to view her body. He stated there had been an abrasion on her left forehead and her left hip was black and blue. He stated he gave legal authority for an autopsy to be conducted due to the questionable death of Resident #1. During an interview on [DATE] at 10:46 AM, LVN H stated she witnessed Resident #1's fall. She stated she saw Resident #1 attempting to stand up out of her wheelchair when she fell to her bottom. She stated she did not hit her head. She stated CNA E assisted her with getting Resident #1 up and into her wheelchair. She stated Resident #1 was guarding her left hip/thigh and moaned a little, so they laid her down in bed. She stated when she did her full-body assessment, she touched her left thigh, she groaned a little bit, so she did not conduct a ROM assessment for this reason. She stated in the early morning sometime on [DATE], Resident #1's sitter (CG C) notified her that she was in pain. She stated around that time, Resident #1's hospice nurse arrived and administered her Tylenol after she informed her about the fall. She stated she had not notified HN G sooner because she was doing her rounds. She stated she had not notified the sitter, as that was not normal protocol. She stated when the sitter continued to notify her that she was in pain later that day, she called her hospice nurse who changed the order to Tylenol 3x/day instead of PRN. She stated she was aware she had an order for PRN Morphine, but when she asked the resident if she was in pain, she would say no. She stated although there were indications of pain, Resident #1 continued to deny pain when asked, and she was not going to administer Morphine to a resident who said they were not in pain. She stated Resident #1 did appear more lethargic on [DATE] during the day, but believed it was from all the medications. She stated she did not know if there was a decline in her health because she had not been at the facility that long. She stated she was not aware if she was eating or drinking normally because she always had a sitter with her during the day, and no one had reported it to her. LVN H denied Resident #1 utilizing oxygen throughout her time at the facility and denied hearing her hollering out in pain from her room. During an interview on [DATE] at 10:35 AM, the DON stated she had not heard anything abnormal about the death of Resident #1. She stated her expectations were that a full fall assessment be conducted after every fall - including a ROM, even if the resident denies pain. She stated if the fall was unwitnessed, neuros would be conducted; if fall was witnessed and the resident had not hit their head, neuros would not be conducted. She stated Resident #1's HN should have been notified immediately and LVN H should have conducted a full fall assessment to ensure proper care was initiated for pain management. During an interview on [DATE] at 11:03 AM with RN J, she stated after a fall, an assessment on a resident should be conducted. She stated this included a head-to-toe assessment, vitals, ROM, pain level, and neuro checks. She stated a ROM should be conducted even if the resident claims of no pain. She stated she would notify the resident's RP, DON, NP immediately after the fall. She stated if the resident was on hospice services, she would call the hospice nurse immediately after the incident as well. During an interview on [DATE] at 11:32 AM, CNA E stated she did not witness Resident #1's fall. She stated LVN H asked for her assistance to get her up. She stated when she entered the room, Resident #1 was on her bottom. She stated she did not believe she had hit her head. She stated she had not seen any bumps or redness on her head. During a telephone interview on [DATE] at 11:02 AM, RP B stated she was still in shock with the quick decline and death of Resident #1. She stated Resident #1 was herself the day of admission to the facility, [DATE]. She stated she ate breakfast, was able to transfer from her wheelchair to the toilet, and even walked into the facility with her walker. She stated although she was sometimes confused, she was able to make her needs known and have a conversation. She stated being lethargic and refusing to eat was definitely not her baseline. She stated no family member should have to go through something like that - they should feel comfortable and at ease dropping their loved one off at a skilled nursing facility for a few days without fear of not being properly cared for. Review of Resident #1's Medication Administration Audit, on [DATE], reflected she was administered Tylenol Extra Strength, 500 MG (order was for three times a day), once on [DATE] at 7:31 PM. It also reflected Resident #1 was not administered PRN Morphine Sulfate, 15 MG until [DATE] at 10:17 AM by LVN H (when HN G mandated her to administer it). Review of the facility's Assessing Falls Policy, Revised [DATE], reflected the following: Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Identify the resident's current medications and active medical conditions. . General Guidelines: 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. 2. Approximately 50 percent of residents fall annually and 10 percent of these falls result in serious injury. Review of the facility's Pain Assessment and Management Policy, revised [DATE], reflected the following: Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing for potential pain b. Effectively recognizing the presence of pain c. Identifying the characteristics of pain d. Addressing the underlying causes of the pain e. Developing and implementing approaches to pain management f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring for the effectiveness of interventions h. Modifying approaches as necessary Steps in the procedure: Recognizing Pain: 1. Observe the reside (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming b. Facial expressions such as grimacing, frowning, flinching of the jaw, etc. c. Changes in gait, skin color and vital signs d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities e. Limitations in his or her level of activity due to the presence of pain f. Guarding, rubbing, or favoring a particular part of the body g. Difficulty eating or loss of appetite The ADM and DON were notified on [DATE] at 3:30 PM that an Immediate Jeopardy had been identified due to the above failures. The IJ template was provided to the ADM and DON [DATE] at 3:30 PM. A Plan of Removal was accepted on [DATE] at 5:40 PM: Impact Statement On [DATE] a health complaint survey was initiated at (facility) at (address). On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to the failure to take immediate action to ensure residents are treated for acute injuries and pain effectively. What corrective actions have been implemented for the identified residents? Resident with the deficient practice expired on [DATE]. How were other residents at risk to be affected by this deficient practice identified? All residents (92) residing in the facility on [DATE] are at risk for the same deficient practice. All residents residing in facility on [DATE] were audited by Director of Nursing (DON) and nurse managers for effectiveness of pain management and if acute injuries present and treated effectively. No residents with acute injuries not treated effectively with pain management identified. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? An in-service was initiated to licensed nurses on [DATE], by the Director of Nursing (DON) on assessing residents effectively for pain and acute injuries using Numerical/ Painad Scale and head to toe assessment post injuries. Residents will be assessed by licensed nurses immediately for injuries and will be treated with pain medications based on level of pain assessed. Licensed nurses will assess effectiveness of pain management within 30-45 minutes post pain medication administration to ensure the pain medication was effective. If the resident does not have a PRN pain medication ordered or if the current pain medication prescribed by hospice to the resident is not effective in managing the resident's pain, the nurse is to contact the resident's physician to obtain guidance on how to address the pain and notify DON/Designee. Facility in-serviced licensed nurses by DON on [DATE] on calling the hospice resident's responsible party (RP) to notify for changes in condition. If facility unable to reach RP the facility will leave voicemail indicating the RP needs to call facility back and collaborate with hospice company to use all the efforts to contact RP for further direction in plan of care of resident. Licensed nurses educated to notify [NAME] or Administrator when RP is unable to be reached for further direction. All notification attempts will be documented into resident's chart. Nurses that are unable to come to the facility by [DATE] will be educated via phone by the DON by [DATE]. Nurses unable to contacted will be kept on employee roster list and will be educated upon their return prior to starting their shift by DON or a nurse manager who as previously been in serviced on the topic. Daily staffing sheets will be audited prior to each scheduled shift starting on [DATE] by staffing coordinator or nurse manager daily for one week or until determined effective to ensure all staff who have worked are in service prior to their shift. Facility will in-service new license nurse hires during orientation. Start Date: [DATE] End Date: ongoing Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Facility's DON contacted on [DATE] the contracted hospice companies to notify that all changes in conditions of hospice residents will be directly notified to the DON/designee and will be documented on the change in condition log at the nursing station after each hospice nurse visit and will include the facility's identified changes of condition for communication between hospice staff and facility's staff. Hospice residents will have change in condition log implemented to use for all hospice visits to log and communicate changes on [DATE]. Hospice change in condition log will be daily reviewed by DON/Designee to ensure all changes in condition identified by hospice are effectively communicated and addressed. Administrator will review the Hospice Change in Condition Log twice a week for four weeks to ensure intervention implemented is effective. Start Date: [DATE] End Date: ongoing Who is Responsible: DON/Designee Who will Monitor: Administrator/Designee An in-service was initiated to certified nurse aides (CNAs) on [DATE], by the Director of Nursing (DON) on pain management. CNAs were in-serviced on reporting any pain needs reported by resident, noted during ADL care, or pain treated but not effective to change nurses. CNAs in-serviced to report to DON/Designee when residents continue to complain of pain post pain treatment and no interventions implemented by nurse. CNAs that are unable to come to the facility by [DATE] will be educated via phone by the DON by [DATE]. CNAs unable to be contacted will be kept on employee roster list and will be educated upon their return prior to starting their shift by DON or a nurse manager who as previously been in serviced on the topic. Daily staffing sheets will be audited prior to each scheduled shift starting on [DATE] by staffing coordinator or nurse manager daily for one week or until determined effective to ensure all staff who have worked are in service prior to their shift. The new CNA hires will be in-serviced on pain management during orientation process. Start Date: [DATE] End Date: ongoing Who is Responsible: DON or Nurse Managers Who will Monitor: Administrator/Designee How will the system be monitored to ensure compliance? The DON or nurse manager will review daily all pain assessments in the residents' eMAR and assess all residents with injuries to ensure all assessments are completed and document by the licensed nurse appropriately in addressing patients' acute injuries and pain for 2 weeks starting [DATE]. Any discrepancies identified will be addressed immediately and further education by the DON or nurse manager. Start Date: [DATE] End Date: until metrics met Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Starting [DATE] the DON or nurse manager will interview 10 residents daily for 2 weeks to ensure the licensed charge nurses are assessing and addressing pain and acute injuries effectively. Post the daily monitoring the DON/nurse manager will review pain assessments of 10 residents and acute injuries twice weekly for 4 weeks to ensure acute injuries are effectively treated for pain. Any discrepancies identified will be addressed immediately by the nurse manager and further education provided by the DON or designee when necessary. Administrator will review the pain assessment auditing and rounding on patients on a weekly basis to ensure nurse managers are following the plan of correction for six weeks or until it is determined the metric is met starting [DATE] Start Date: [DATE] End Date: until metrics met Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Survey team monitored the Plan of Removal from [DATE] - [DATE] as followed: During interviews on [DATE] from 5:51 PM - 6:21 PM, three RN's, two LVN's, one MA, and one CNA stated they had been in-serviced on resident falls, assessments, and pain management. They were able to identify different indicators of pain - groaning, wincing, grimacing, clenching fists. All stated if when providing care, the resident voices pain or shows indicators of pain, care should be stopped immediately, and a nurse should be notified. During interview on [DATE] from 1:15 PM - 3:00 PM, two LVN's and on RN stated they had received education regarding assessing for pain and effective pain management, education regarding communication with hospice agencies/staff and addressing acute injuries, and non-verbal indicators of pain. During an interview on [DATE] at 1:45 PM, the DON stated she had finished the in-services for all staff for the completion of the POR. She stated staff that were unable to be reached would be in-serviced before working the floor. She stated there were currently no resident with acute injuries or unmanaged pain. Review of an in-service conducted to all staff by the DON, dated [DATE], reflected education was provided on ADL Care and Pain: When providing ADL care, if resident complains of pain or shows signs/symptoms of pain, notify nurse immediately. If nurse does not administer medication, notify DON/ADON. If resident is in pain, you must stop ADL care until pain is addressed. Review of an in-service conducted to all staff by the DON, dated [DATE], reflected education was provided on Acute Injury Incidents and Pain: - Assessing residents effectively for pain and injuries using numerical/painAD sale with head-to-toe assessment pot injuries - Assess immediately after fall and medicate based on pain level - Assess effectiveness of pain management within 30-45 minutes post pain medications The ADM and DON were notified [DATE] at 4:30 PM that the IJ had been lowered. While the IJ was lowered on [DATE] at 4:30 PM, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated identified due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care, in that: The facility failed to properly assess or provide effective pain management to Resident #1 after she fell and injured her hip on [DATE], resulting in uncontrolled pain, decline in health, and ultimately death on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 3:30 PM. While the IJ was removed on [DATE] at 4:30 PM, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] for respite care with diagnoses of history of falling, chronic respiratory failure, type II diabetes, hypertensive (high blood pressure) heart disease, seizures, and other specified anxiety disorders. Review of Resident #1's fall risk assessment, dated [DATE], reflected a score of 16, indicating she was a high risk for falls. Review of Resident #1's discharge MDS assessment, dated [DATE], reflected she died in the facility. Review of Resident #1's initial baseline care plan, dated [DATE], reflected she had an actual fall (on [DATE]) with no injury related to cognitive impairment and poor balance with interventions of frequent rounding and checking range of motion. Review of Resident #1's progress notes in her EMR documented by RN K, dated [DATE] at 6:59 PM, reflected the following: [Resident #1] admitted into (facility) on respite care per (hospice agency) . care giver will be at beside daily from 8:00 AM - 6:00 PM . clear adequate speech, adequate vision, adequate hearing . Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 7:45 AM, reflected the following: During monitoring rounds observed [Resident #1] attempting to self-ambulate and fell to floor. Unable to reach [Resident #1] before she fell to the floor. [Resident #1] did not hit her head and landed on her bottom. Assessed [Resident #1] and assisted back into wheelchair and assisted back into bed. [Resident #1] does not display any signs of pain/discomfort, with no injuries observed at this time. Review of text messages sent by CG C to Resident #1's RP B reflected the following: [DATE]: 8:28 AM - Soon as I arrived, I asked if [Resident #1] wanted breakfast and she said no . I noticed her making a face and I asked what was wrong and she said her left leg hurts. 9:39 AM - I got [Resident #1] up in the chair and had to ask for help to change her brief . [Resident #1] was asking to get back in bed because her leg was hurting. When breakfast arrived, [Resident #1] did not want to eat because she was nauseated. 1:01 PM - She ate a little (lunch). She's really out of it. Not sure what to do. I don't wanna put her in bed and she doesn't want to do anything else. I had her in the living room but she kept hollering for help . She's also tilted all the way forward (in her wheelchair). 1:11 PM - The hospice nurse arrived and was just told that [Resident #1] fell at 6am. Now we know the reason for the pain. Review of text messages sent by CG D to Resident #1's RP B reflected the following: [DATE]: 2:29 PM - . [Resident #1] isn't talking much today and when they put her in the wheelchair she just stated hunched over. This is not normal for her at all . They put her on oxygen today. 3:29 PM - . HN G told me she was going to figure out why they did not treat [Resident #1] right away because she was in pain. 7:23 PM - . I requested Morphine so I could change her brief . [LVN H] never brought the Morphine so I changed her the best I could. She cried out yelling it hurts. [DATE]: 8:57 AM - I asked for the morphine and other morning meds but [LVN H] still hasn't brought them so [Resident #1] won't stop getting loud saying please let it work, please let it work. Her leg is hurting her a lot and she can't move it. 10:24 AM - [LVN H] came in at 9:57 AM and asked [Resident #1] if she needed anything and I told her she needs her morphine to help with the pain. So she asked [Resident #1] what was hurting and where and she told her she doesn't have any pain so the nurse said ok if you need it hit the red button. So she didn't give her morphine. As soon as [LVN H] left, [Resident #1] starts saying it hurts please help. Review of Resident #1's hospice notes documented by HN G, dated [DATE] (no time documented), reflected the following: New complaints, problems or concerns: [Resident #1] fell this morning and her hip hurts. Objective findings: [Resident #1] on respite and in room with paid caregiver. [Resident #1] lethargic but answering some questions. [Resident #1] is now total assist [Resident #1] was in wheelchair in room with head hung forward and most of her body limp when RN arrived. CG C was at beside and stated she is not herself today and does not know what's wrong. RN asked if she was aware that [Resident #1] had fallen this morning and CG C she was not told of any fall. RN asked [Resident #1] to lift her head but she stated she was not able to. [Resident #1] stated she was SOB and oxygen was applied via nasal canula at 3 L however oxygen sat was not obtainable. [Resident #1] was breathing comfortably with nasal canula and RN continued assessment. RN had to use both hands to gently lift [Resident #1]'s head to examine her eyes and face . [Resident #1] complained of slight pain with left leg lifting at hip only . Once laying in bed, [Resident #1] did call out in pain with movement of left leg especially at hip joint . RN educated facility staff on medication management and use of PRN Morphine for [Resident #1]'s pain if Tylenol is not enough. LVN H verbalized understanding. Assessment: [Resident #1] is possibly at start of decline in status. She has been more lethargic, not eating much, and had a recent fall . [Resident #1] may have fracture or deep injury of left hip or coccyx. RN also spoke with HA who confirmed they were not notified of [Resident #1] having a fall that morning when she and another aide came to bathe her. She reports it took both of them to transfer [Resident #1] but they were able to shower her . HA recalls that [Resident #1] would groan from time to time but they thought it had something to do with her being medicated because she was less alert than usual. Review of Resident #1's hospice notes documented by an on-call nurse, dated [DATE] at 4:24 PM, reflected the following: CG D would like to speak with the on-call nurse regarding [Resident #1] falling that morning and is experiencing a lot of pain on her left side. She was provided 1 Tylenol and it's not working. Review of Resident #1's hospice notes documented by HN G, dated [DATE] (no time documented), reflected the following: Objective findings: [Resident #1] complained of pain on left side when is moved or touched on that side . Her left leg was straight, and foot dropped to the left . [Resident #1] had pain when leg was gently turned to point foot up towards ceiling. Anytime left hip was touched or leg slightly moved or lifted she complained of paint. RN got LVN H and had her administer morphine IR 15 MG at 10:20 AM. Per LVN H she had just been in the room and [Resident #1] did not have any s/s of pain . This RN educated LVN H on [Resident #1]'s confusion and that she has pain anytime she moves or is moved for brief changes, and she may need to have caregiver help with administration of meds since [Resident #1] is familiar with her and she may be able to facilitate [Resident #1] accepting needed meds. She verbalized understanding. RN obtained order to schedule Morphine Q4 hours for pain. Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 11:12 AM, reflected the following: Hospice nurse and [CG C] of [Resident #1] c/o left hip pain and wanted MS administered. During assessment of [Resident #1], asked if in any pain or if she needed any medication, she responded no . Hospice nurse enters room and states to [Resident #1] that the nurse is going to give you medication, the resident states okay. MS administered per Hospice. Review of Resident #1's progress notes in her EMR documented by LVN H, dated [DATE] at 11:56 AM, reflected the following: Hospice in facility, new orders for Morphine sulfate 15mg q4 hours for pain. Hospice nurse/sitter reported [Resident #1] to have pain to her left leg . Review of Resident #1's progress notes in her EMR documented by RN I, dated [DATE] at 12:05 AM, reflected the following: CNA notified the Nurse that [Resident #1] is unresponsive. On assessment, resident unresponsive to verbal and tactile stimulation. No visible breathing, no pulse, pupils dilated and fixed, [Resident #1] has expired . Review of a documented Interview between a Hospice State Surveyor and the hospice agency's Alternate Administrator regarding the timeline of Resident #1, dated [DATE] at 1:30 PM, reflected the following: On [DATE] at approximately 6:30 AM, [Resident #1] was found on the floor by facility staff. [Resident #1]'s private caregiver arrived at 8:00 AM. From 11:30 AM - 12:30 PM, hospice aides assisted [Resident #1] with her shower and personal care. At 12:57 PM, HN G arrived to conduct a skilled nursing visit. It was at that time a facility nurse reported the fall to her. This was the first notification of a fall. Review of a documented Interview between a Hospice State Surveyor and Resident #1's HN G, dated [DATE] at 2:50 PM, reflected the following: Surveyor asked [HN G] to discuss what she recalled about what occurred when she arrived at the facility on [DATE]. [HN G] stated when arrived at the facility to conduct a visit, the client was sitting in a wheelchair with her head hung down. Surveyor asked if this was unusual. [HN G] stated, That was very unusual. I asked her to lift her head and she said she couldn't. I was concerned she had injured her head or neck when she fell . During a telephone interview on [DATE] at 11:22 AM, CG D stated CG C would sit with Resident #1 from 8:00 AM - 2:00 PM and she would relieve her at 2:00 PM - 6:00 PM. She stated CG C contacted her in the morning of [DATE] and asked if Resident #1 had fallen the day prior ([DATE]). She stated she told her no and asked her why. CG C told her Resident #1 was complaining of left hip/leg pain. She stated when she arrived at 2:00 PM on [DATE], Resident #1 was still in pain, and that was when HN G learned of the fall from the facility staff; CG C was never notified during her entire shift. She stated Resident #1 was able to verbalize pain and would yell, Owe! when she attempted to change her brief or reposition her. She stated she had worked with Resident #1 for over two months, and new her tendencies well. The day before, [DATE], when she was admitted , she ate a big breakfast, was able to self-transfer to the toilet, and even ambulated independently into the nursing facility via walker. She stated on [DATE] she was lethargic, was not eating, required oxygen, and needed full assistance. She stated she told LVN H that Resident #1 needed Morphine as she was in pain and her hip appeared swollen. She stated when LVN H came into the room and asked her if she was in pain, she said no. She stated she tried to explain that when Resident #1 was not familiar/comfortable with a person, she would appear as though everything was fine and would not verbalize her pain. She stated she may have been on hospice, but she drastically changed after the fall, and was not at end-of-life stages when she was admitted to the facility. During a telephone interview on [DATE] at 12:12 PM, Resident #1's RP A stated the Justice of the Peace and police were now involved because the death was suspicious/questionable. He stated Resident #1 was completely fine two days before her death and after being admitted to the facility. During a telephone interview on [DATE] at 1:12 PM, a Judge with the Justice of the Peace stated he had contacted the funeral home Resident #1 was sent to and was able to view her body. He stated there had been an abrasion on her left forehead and her left hip was black and blue. He stated he gave legal authority for an autopsy to be conducted due to the questionable death of Resident #1. During an interview on [DATE] at 10:46 AM, LVN H stated she witnessed Resident #1's fall. She stated she saw Resident #1 attempting to stand up out of her wheelchair when she fell to her bottom. She stated she did not hit her head. She stated CNA E assisted her with getting Resident #1 up and into her wheelchair. She stated Resident #1 was guarding her left hip/thigh and moaned a little, so they laid her down in bed. She stated when she did her full-body assessment, she touched her left thigh, she groaned a little bit, so she did not conduct a ROM assessment for this reason. She stated in the early morning sometime on [DATE], Resident #1's sitter (CG C) notified her that she was in pain. She stated around that time, Resident #1's hospice nurse arrived and administered her Tylenol after she informed her about the fall. She stated she had not notified HN G sooner because she was doing her rounds. She stated she had not notified the sitter, as that was not normal protocol. She stated when the sitter continued to notify her that she was in pain later that day, she called her hospice nurse who changed the order to Tylenol 3x/day instead of PRN. She stated she was aware she had an order for PRN Morphine, but when she asked the resident if she was in pain, she would say no. She stated although there were indications of pain, Resident #1 continued to deny pain when asked, and she was not going to administer Morphine to a resident who said they were not in pain. She stated Resident #1 did appear more lethargic on [DATE] during the day, but believed it was from all the medications. She stated she did not know if there was a decline in her health because she had not been at the facility that long. She stated she was not aware if she was eating or drinking normally because she always had a sitter with her during the day, and no one had reported it to her. LVN H denied Resident #1 utilizing oxygen throughout her time at the facility and denied hearing her hollering out in pain from her room. During an interview on [DATE] at 10:35 AM, the DON stated she had not heard anything abnormal about the death of Resident #1. She stated her expectations were that a full fall assessment be conducted after every fall - including a ROM, even if the resident denies pain. She stated if the fall was unwitnessed, neuros would be conducted; if fall was witnessed and the resident had not hit their head, neuros would not be conducted. She stated Resident #1's HN should have been notified immediately and LVN H should have conducted a full fall assessment to ensure proper care was initiated for pain management. During an interview on [DATE] at 11:03 AM with RN J, she stated after a fall, an assessment on a resident should be conducted. She stated this included a head-to-toe assessment, vitals, ROM, pain level, and neuro checks. She stated a ROM should be conducted even if the resident claims of no pain. She stated she would notify the resident's RP, DON, NP immediately after the fall. She stated if the resident was on hospice services, she would call the hospice nurse immediately after the incident as well. During an interview on [DATE] at 11:32 AM, CNA E stated she did not witness Resident #1's fall. She stated LVN H asked for her assistance to get her up. She stated when she entered the room, Resident #1 was on her bottom. She stated she did not believe she had hit her head. She stated she had not seen any bumps or redness on her head. During a telephone interview on [DATE] at 11:02 AM, RP B stated she was still in shock with the quick decline and death of Resident #1. She stated Resident #1 was herself the day of admission to the facility, [DATE]. She stated she ate breakfast, was able to transfer from her wheelchair to the toilet, and even walked into the facility with her walker. She stated although she was sometimes confused, she was able to make her needs known and have a conversation. She stated being lethargic and refusing to eat was definitely not her baseline. She stated no family member should have to go through something like that - they should feel comfortable and at ease dropping their loved one off at a skilled nursing facility for a few days without fear of not being properly cared for. Review of Resident #1's Medication Administration Audit, on [DATE], reflected she was administered Tylenol Extra Strength, 500 MG (order was for three times a day), once on [DATE] at 7:31 PM. It also reflected Resident #1 was not administered PRN Morphine Sulfate, 15 MG until [DATE] at 10:17 AM by LVN H (when HN G mandated her to administer it). Review of the facility's Assessing Falls Policy, Revised [DATE], reflected the following: Preparation: 1. Review the resident's care plan to assess for any special needs of the resident. 2. Identify the resident's current medications and active medical conditions. . General Guidelines: 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes. 2. Approximately 50 percent of residents fall annually and 10 percent of these falls result in serious injury. Review of the facility's Pain Assessment and Management Policy, revised [DATE], reflected the following: Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. General Guidelines: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing for potential pain b. Effectively recognizing the presence of pain c. Identifying the characteristics of pain d. Addressing the underlying causes of the pain e. Developing and implementing approaches to pain management f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring for the effectiveness of interventions h. Modifying approaches as necessary Steps in the procedure: Recognizing Pain: 1. Observe the reside (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming b. Facial expressions such as grimacing, frowning, flinching of the jaw, etc. c. Changes in gait, skin color and vital signs d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities e. Limitations in his or her level of activity due to the presence of pain f. Guarding, rubbing, or favoring a particular part of the body g. Difficulty eating or loss of appetite The ADM and DON were notified on [DATE] at 3:30 PM that an Immediate Jeopardy had been identified due to the above failures. The IJ template was provided to the ADM and DON [DATE] at 3:30 PM. A Plan of Removal was accepted on [DATE] at 5:40 PM: Impact Statement On [DATE] a health complaint survey was initiated at (facility) at (address). On [DATE] the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to the failure to take immediate action to ensure residents are treated for acute injuries and pain effectively. What corrective actions have been implemented for the identified residents? Resident with the deficient practice expired on [DATE]. How were other residents at risk to be affected by this deficient practice identified? All residents (92) residing in the facility on [DATE] are at risk for the same deficient practice. All residents residing in facility on [DATE] were audited by Director of Nursing (DON) and nurse managers for effectiveness of pain management and if acute injuries present and treated effectively. No residents with acute injuries not treated effectively with pain management identified. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? An in-service was initiated to licensed nurses on [DATE], by the Director of Nursing (DON) on assessing residents effectively for pain and acute injuries using Numerical/ Painad Scale and head to toe assessment post injuries. Residents will be assessed by licensed nurses immediately for injuries and will be treated with pain medications based on level of pain assessed. Licensed nurses will assess effectiveness of pain management within ,d+[DATE] minutes post pain medication administration to ensure the pain medication was effective. If the resident does not have a PRN pain medication ordered or if the current pain medication prescribed by hospice to the resident is not effective in managing the resident's pain, the nurse is to contact the resident's physician to obtain guidance on how to address the pain and notify DON/Designee. Facility in-serviced licensed nurses by DON on [DATE] on calling the hospice resident's responsible party (RP) to notify for changes in condition. If facility unable to reach RP the facility will leave voicemail indicating the RP needs to call facility back and collaborate with hospice company to use all the efforts to contact RP for further direction in plan of care of resident. Licensed nurses educated to notify Don or Administrator when RP is unable to be reached for further direction. All notification attempts will be documented into resident's chart. Nurses that are unable to come to the facility by [DATE] will be educated via phone by the DON by [DATE]. Nurses unable to contacted will be kept on employee roster list and will be educated upon their return prior to starting their shift by DON or a nurse manager who as previously been in serviced on the topic. Daily staffing sheets will be audited prior to each scheduled shift starting on [DATE] by staffing coordinator or nurse manager daily for one week or until determined effective to ensure all staff who have worked are in service prior to their shift. Facility will in-service new license nurse hires during orientation. Start Date: [DATE] End Date: ongoing Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Facility's DON contacted on [DATE] the contracted hospice companies to notify that all changes in conditions of hospice residents will be directly notified to the DON/designee and will be documented on the change in condition log at the nursing station after each hospice nurse visit and will include the facility's identified changes of condition for communication between hospice staff and facility's staff. Hospice residents will have change in condition log implemented to use for all hospice visits to log and communicate changes on [DATE]. Hospice change in condition log will be daily reviewed by DON/Designee to ensure all changes in condition identified by hospice are effectively communicated and addressed. Administrator will review the Hospice Change in Condition Log twice a week for four weeks to ensure intervention implemented is effective. Start Date: [DATE] End Date: ongoing Who is Responsible: DON/Designee Who will Monitor: Administrator/Designee An in-service was initiated to certified nurse aides (CNAs) on [DATE], by the Director of Nursing (DON) on pain management. CNAs were in-serviced on reporting any pain needs reported by resident, noted during ADL care, or pain treated but not effective to change nurses. CNAs in-serviced to report to DON/Designee when residents continue to complain of pain post pain treatment and no interventions implemented by nurse. CNAs that are unable to come to the facility by [DATE] will be educated via phone by the DON by [DATE]. CNAs unable to be contacted will be kept on employee roster list and will be educated upon their return prior to starting their shift by DON or a nurse manager who as previously been in serviced on the topic. Daily staffing sheets will be audited prior to each scheduled shift starting on [DATE] by staffing coordinator or nurse manager daily for one week or until determined effective to ensure all staff who have worked are in service prior to their shift. The new CNA hires will be in-serviced on pain management during orientation process. Start Date: [DATE] End Date: ongoing Who is Responsible: DON or Nurse Managers Who will Monitor: Administrator/Designee How will the system be monitored to ensure compliance? The DON or nurse manager will review daily all pain assessments in the residents' eMAR and assess all residents with injuries to ensure all assessments are completed and document by the licensed nurse appropriately in addressing patients' acute injuries and pain for 2 weeks starting [DATE]. Any discrepancies identified will be addressed immediately and further education by the DON or nurse manager. Start Date: [DATE] End Date: until metrics met Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Starting [DATE] the DON or nurse manager will interview 10 residents daily for 2 weeks to ensure the licensed charge nurses are assessing and addressing pain and acute injuries effectively. Post the daily monitoring the DON/nurse manager will review pain assessments of 10 residents and acute injuries twice weekly for 4 weeks to ensure acute injuries are effectively treated for pain. Any discrepancies identified will be addressed immediately by the nurse manager and further education provided by the DON or designee when necessary. Administrator will review the pain assessment auditing and rounding on patients on a weekly basis to ensure nurse managers are following the plan of correction for six weeks or until it is determined the metric is met starting [DATE] Start Date: [DATE] End Date: until metrics met Who is Responsible: DON and Nurse Managers Who will Monitor: Administrator/Designee Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Survey team monitored the Plan of Removal from [DATE] - [DATE] as followed: During interviews on [DATE] from 5:51 PM - 6:21 PM, three RN's, two LVN's, one MA, and one CNA stated they had been in-serviced on resident falls, assessments, and pain management. They were able to identify different indicators of pain - groaning, wincing, grimacing, clenching fists. All stated if when providing care, the resident voices pain or shows indicators of pain, care should be stopped immediately, and a nurse should be notified. During interview on [DATE] from 1:15 PM - 3:00 PM, two LVN's and on RN stated they had received education regarding assessing for pain and effective pain management, education regarding communication with hospice agencies/staff and addressing acute injuries, and non-verbal indicators of pain. During an interview on [DATE] at 1:45 PM, the DON stated she had finished the in-services for all staff for the completion of the POR. She stated staff that were unable to be reached would be in-serviced before working the floor. She stated there were currently no resident with acute injuries or unmanaged pain. Review of an in-service conducted to all staff by the DON, dated [DATE], reflected education was provided on ADL Care and Pain: When providing ADL care, if resident complains of pain or shows signs/symptoms of pain, notify nurse immediately. If nurse does not administer medication, notify DON/ADON. If resident is in pain, you must stop ADL care until pain is addressed. Review of an in-service conducted to all staff by the DON, dated [DATE], reflected education was provided on Acute Injury Incidents and Pain: - Assessing residents effectively for pain and injuries using numerical/painAD sale with head-to-toe assessment pot injuries - Assess immediately after fall and medicate based on pain level - Assess effectiveness of pain management within ,d+[DATE] minutes post pain medications The ADM and DON were notified [DATE] at 4:30 PM that the IJ had been lowered. While the IJ was lowered on [DATE] at 4:30 PM, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated identified due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure residents admitted without pressure ulcers do not develop pressure ulcers and once developed, provide care to prevent decline for one of eight residents with pressure ulcers (Resident #63). 1. The facility failed to ensure Resident #63's unstageable pressure ulcer to his heel was assessed and treated daily to ensure Resident #63's pressure ulcer did not decline. 2. The facility failed to update the care plan to indicate a change in the status of the pressure ulcer. 3. The facility failed to ensure that once the pressure ulcer declined, that the Physician treatment orders were followed and failed to notify the Physician of x-ray results indicating osteomyelitis. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of actual harm at a scope of isolated due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers, Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Findings include: Review of Resident #63's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of ataxia (impaired balance or coordination) following unspecified cerebrovascular disease (group of conditions that affect blood flow and blood vessels in brain), transient cerebral ischemic attack (brief stroke-like attack), idiopathic normal pressure hydrocephalus (potentially reversible neurodegenerative disease characterized by dementia, gait and urinary disturbance), anxiety disorder, primary hypertension (high blood pressure), polyneuropathy (malfunction of many peripheral nerves throughout the body), contracture left hip and knee (condition of shortening and hardening of muscles, tendons or other tissue, leading to deformity and rigidity of joints). Review of Resident #63's Care Plan dated [DATE] reflected he had a pressure injury Stage 2 (some of outer surface of skin, (epidermis) or deeper layer (dermis) is damaged leading to skin loss) to the left heel with potential for further pressure injury development related to deceased mobility. Goal: pressure injury will show signs of healing and remain free from infection through review date. Target date: [DATE]. Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Obtain and monitor lab/Diagnostic work as ordered. Report results to MD and follow up as indicated. (The care plan did not reflect the current stage or treatment of Resident #63's left heel pressure ulcer.) Review of Resident #63's Quarterly MDS dated [DATE] reflected he had a BIMS of 7 indicating severe cognitive impairment, Prognosis: no to does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months. Reflected no unhealed pressure ulcers or injuries. Review of a Facility Wide Pressure Ulcer Assessment list dated [DATE] and completed by LVN Treatment Nurse reflected Resident #63 first documentation on the list with a stage 3 pressure ulcer ( full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue) to his left heel measuring 6 cm length X 4 cm wide and 0.2 cm deep, and indicated it was facility acquired on [DATE]. Treatment was alginate and chemical debridement. Review of a Facility Wide Pressure Ulcer Aassessment completed by LVN Treatment Nurse on [DATE] reflected Resident #63's wound measurements had not changed, the treatment remained the same and reflected multivitamins and protein supplement had been added to his treatment. Review of a Surgical Progress Note dated [DATE] by the Wound Care Dr. for Resident #63 reflected the reason for the visit was consultation and evaluation of a wound found on the left heel. Patient conversive, alert and oriented X 2 (person, place). Location: left heel pressure injury/ulcer wound stage 3 - pressure injury, Preoperative indications: Breakdown of muscle, breakdown of tissue, necrotic tissue, poor healing, and slough. Signs of infection: none. A muscle tissue debridement was performed using surgical incision of devitalized subcutaneous (fat) muscle, fascia (connective tissue) and tendon tissue. The preop wound area was 4 cm X 4 cm X 0.2 cm with post-op wound area measuring the same. There was no odor noted to the wound and the drainage was moderate and serosanguineous. (yellow with small amounts of blood) The wound progress was noted as decreased in size. Assessment and plan: The patient has a wound at the left heel. The wound debrided today is at the left heel. For this wound, there was confirmation of tissue breakdown which will entail ongoing surveillance and may require future debridement. Reason for continued debridement: the patient continues to need ongoing weekly debridement since he shows signifiers that can hamper wound healing which consist recurring slough, difficulty offloading ulcer, and resistance to prescribed protective devices. This patient has a chronic wound which may or may not heal and may worsen because of chronic comorbidities (more than one disease or condition in body), restricted mobility, and wound edge epiboly (rolled or curled under closed wound edges). Follow up at an interval of one week. Goals: overall goals for the wound are wound stabilization, prevention of wound decline and prevention of further wound decline. Review of a Pressure Ulcer Assessment completed by LVN Treatment Nurse on [DATE] reflected the wound for Resident #63's left heel was 4 cm length X 4 cm wide X 0.2 cm deep. On [DATE] Resident #63's wound had slightly increased in size to 4.0 cm length X 5.0 cm wide X 0.8 cm deep. Review of a Progress Note by the NP service date [DATE] for Resident #63 reflected Patient is seen sitting up in WC in common area, he appears fatigued and reports his left foot has been bothering him. He is noted to have a Stage 3 pressure ulcer on his left heel, foul odor noted. Review of Physician Orders for Resident #63 dated [DATE] and signed by LVN A reflected x-ray left heel. Review of a Radiology Report for Resident #63 dated Saturday [DATE] at 3:52 PM reflected Findings suspicious for calcaneal (heel) osteomyelitis (bone infection), recommend MRI. Review of the [DATE] TAR for Resident #63 reflected that treatment was not documented as completed on the weekend of [DATE]-[DATE]. Review of Progress Notes for Resident #63 on the weekend of [DATE]-[DATE] reflected there were no wound care progress notes documented. Review of Physician Orders for Resident #63 dated [DATE] reflected Location of wound: stage 3 pressure ulcer left heel. Treatment order, every day shift for wound healing Cleanse with dakins ,d+[DATE] strength, pat dry gently, wipe skin prep to peri wound, apply thin layer of santyl to wound bed, apply calcium alginate to wound bed , cover with foam dressing. Review of the Hospital Records for Resident #63 reflected he presented to theER on [DATE] at 8:15 AM with a fever, was hypoxic (an absence of enough oxygen in the tissues to sustain bodily functions) with an O2 sat of 80%, had chronic pressure wounds to his right hip and left heel. He had an open, necrotic wound on his left heel draining black, foul-smelling liquid at the base of his calcaneus (heel). Probable acute osteomyelitis (bone infection) of the plantar aspect (thick tissue at bottom of foot) of the calcaneus with adjacent gas gangrene (bacterial infection releasing toxins that cause tissue death) He was admitted to the hospital for sepsis. (blood infection). Interview on [DATE] at 8:30 AM LVN Treatment Nurse stated Resident #63's left heel wound was getting worse on Friday [DATE], had dark eschar and was starting to smell necrotic. The NP saw Resident #63 on Friday [DATE] and changed the wound care to Dakins solution ( broad-spectrum antibacterial cleanser) and Santyl (removes damaged tissue from the wound) and LVN Treatment Nurse stated he was going to start that treatment on Monday. LVN Treatment Nurse further stated, the wound care Dr. was involved with Resident #63's wound care every Monday, but the Wound Care Dr. was out due to illness for two weeks and last saw the Rresident #63 on [DATE]. LVN Treatment Nurse stated, We used to have a wound care nurse on the weekends but haven't for the past two months. Interview [DATE] at 8:45 AM DON stated there was no proof the wound care for Resident #63 was completed on the weekend of [DATE]-[DATE] as it was not documented on the TAR. DON further stated they used to have an RN weekend supervisor who completed the wound care but now the charge nurses were doing wound care. Interview on [DATE] at 9:00 AM LVN Treatment Nurse stated the potential risk of not doing wound care is it could get infected, but he was unsure if that would lead to osteomyelitis. (Infection of the bone). Interview [DATE] at 10:16 AM LVN A stated she performed the wound care over the weekend of [DATE]-[DATE] for Resident #63 but could not recall the condition of the wound except for a little yellow slough in the middle. LVN A did not remember any odor from the wound. LVN A stated she had repositioned him in his wheelchair several times and fed him in the dining room but denied noticing any change in his condition. Interview on [DATE] at 10:51 AM NP stated the nurses told her Resident #63 didn't look right on Friday ([DATE]) and described him as sluggish. NP stated she ordered labs CBC, BMP, ESR, CRP, an x-ray of the foot and a wound culture. NP stated she assumed they would collect the lab that day and further stated if they had collected the lab, she would have received the lab results on Saturday and would have started a broad-spectrum antibiotic. NP said the wound care nurse said he was going to wait to collect the wound culture on Monday and she was unsure why he would wait. NP received the lab results on Monday and the WBCs were up, (indicating infection) but by the time the facility called, Resdient #63 had been sent to the hospital. Interview on [DATE] at 1:38 PM with LVN A who stated an x-ray technician came and performed the left heel x-ray for Resident #63 (on Saturday, [DATE]). LVN A stated she didn't see the x-ray results and Those (results) go directly to management. LVN A denied noticing any changes in Resident #63's behavior and did not smell any unusual odors. Interview on [DATE] at 11:18 AM ADON stated she had been ADON since July and did not know anything about Resident #63's condition on Friday the 13th, 2023 when the NP came to her unit and gave her a verbal order for labs. (blood work). ADON stated she asked the NP if she wanted them STAT (now) or the next lab draw, and she stated the next lab draw was fine. ADON stated she was not sure the NP was aware the next draw was to be on Monday or not and that the DON oversaw the wound care system. Interview on [DATE] at 9:20 AM with Resident #63 in his hospital room who stated, I've been hurting every minute from his heel wound. Resident #63 was unable to answer any other questions. Interview on [DATE] at 9:25 AM with Resident #63's family member who stated they couldn't do surgery because they were afraid to put him under anesthesia, that he wouldn't make it. The family member stated, Hospice is coming. I never asked what size the wound was on his foot. I thought it was healed. Someone from the facility called and told me they had checked the wound on Friday (13th, 2023), and it was fine and that he had developed a fever over the weekend. She stated He's septic and has pneumonia. I was never informed how bad the wound was getting. Interview on [DATE] at 11:18 AM ADON LVN stated, Wound care is coordinated by the DON and wound care nurse and the charge nurses perform wound care on the weekends. ADON LVN further stated The facility used to have an RN weekend supervisor who completed wound care on the weekends but now the LVN Treatment Nurse leaves the keys to the treatment cart with the charge nurses on Fridays. Interview on [DATE] at 12:30 PM the Wound Care Dr. stated The last time I saw (Resident #63) was on [DATE]nd (2023) when I debrided his left heel. It was 20% slough. We were having luck with Medi-honey. I changed the orders to silver gel and calcium alginate. On [DATE] it measured 6 cm X 4 cm, then on [DATE] it was 4 cm X 4 cm. There's no way the wound could go from necrotic with foul odor on Friday ([DATE]th, 2023) to no odor and slight yellow drainage and yellow slough on the weekend then back again. I think we failed him on the weekend. Interview on [DATE] at 1:22 PM LVN M stated the last time she saw Resident #63 prior to the morning of [DATE]th (2023) was on Thursday [DATE]th (2023). LVN M stated Resident #63 was getting up in his WC, was talking and responding and he was at his normal baseline. LVN M stated Monday morning ([DATE]) the CNA working on Resident #63's hall came to her and told her the resident was not doing well. LVN M stated she went to assess him, and he was clammy to touch, was not responding, had a low-grade temperature of 99.7 and his heart rate was 138. LVN M stated she felt at that time he was full blown septic (the body's extreme reaction to an infection) and knew Resident #63 had a wound on his heel with a very strong necrotic (dead tissue) odor. LVN M stated Resident #63's oxygen saturation rate was ,d+[DATE]%. LVN M further stated she called the MD to have Resident #63 sent to the hospital and stated the night nurse, LVN N, did not give her any report that Resident #63 was not doing well. Interview attempt was made by Surveyor who placed a phone call to LVN N on [DATE] at 1:25 PM and left a message for a return call. Surveyor placed a call on [DATE] at 1:41 PM to CNA O (who had worked the night shift of [DATE]-[DATE] with LVN N) and she responded she was busy and would call back. As of [DATE] no return calls had been received. Interview on [DATE] at 1:30 PM CNA B stated she had worked the ,d+[DATE] shift on [DATE]-[DATE] and cared for Resident #63. CNA B stated when she turned him over, he screamed in pain. CNA B stated she smelled his foot and the odor smelled like death. CNA B stated she told LVN A he was in pain because every time she moved him, he yelled. CNA B stated she got Resident #63 up in his wheelchair and could tell he was not his normal self as he was moving a lot in pain and fidgeting. Interview on [DATE] at 1:50 PM ADMIN stated his expectation for wound care is that it be done and to follow the Dr's orders. Interview on [DATE] at 2:07 PM DON stated her expectations for wound care are that it should be done and documented. The potential risk if not completed is deterioration of the wound and that could cause a change of condition and infection. She further stated she pulled the x-ray report on Monday morning ([DATE]) for Resident #63 indicating osteomyelitis and that LVN A had access to that report over the weekend. DON stated, I don't know why (LVN A) didn't pull the x-ray report. The NP knew the next lab draw wouldn't be until Monday. Interview on [DATE] at 2:18 PM DON stated regarding Resident #63's Care Plan it should have been updated as his wound progressed and the Care Plan stating Resident #63 had a Stage 2 pressure ulcer was not appropriate and could affect his care. DON stated his wound measurements and staging indicating Resident #63's wound had slough and necrotic tissue and staging at Stage 3 was not appropriate since the wound bed was not fully visible, but they were staging it that way because the wound doctor did. DON stated nurse aides can update the management staff on resident conditions in the POC (point of care, wall mounted kiosk) and none of the aides did that regarding Resident #63. Interview on [DATE] at 8:08 AM ER RN at a local hospital stated when Resident #63 arrived at theER on [DATE] he had altered mental status and was not at his baseline per the NH. He could gesture yes or no. He was non-verbal. He did react to painful stimuli. The first thing I noticed was a putrid odor. I removed his sock and dressing, and he had a nasty heel ulcer that desperately needed attention. His sock was soaked through with sero-sanguineous (yellow body fluid with blood) and purulent (thick, foul smelling) wound drainage. I don't recall a date on the old dressing. He had the beginning of pressure ulcers on his right hip in three spots. He had a nasty cough, sepsis, and pneumonia. That odor ranked in the top three worst in my twelve years of nursing. It was so bad that when the daughter came in, she asked for air freshener. Interview on [DATE] at 2:00 PM ER Dr. stated Resident #63 came into the ER with a foul-smelling wound on his left foot. ER Dr. said the wound was necrotic with osteomyelitis and had black fluid draining from the wound. ER Dr. did not see the date of the dressing that was on the wound, but it did not appear to be a fresh dressing or one that had been changed recently as it was soaked through and dirty. ER Dr. said the wound did not appear to have been cared for or treated recently and it was likely it had not been since Friday. ER Dr. stated he would find it hard to believe that the heel had wound treatment the day before his admission. ER Dr. stated it was tough to say if earlier transfer to the hospital would have changed the outcome to the wound but it would have given Resident #63 a better chance of saving his foot (as an amputation of the foot was recommended) and a better chance for a positive outcome. ER Dr. stated Resident #63 also had diagnoses of pneumonia and a UTI. Review of a Facility Policy titled Change in Residents Condition or Status dated 2001 and revised in [DATE] reflected Our facility shall promptly notify the resident, his or her attending Physician and representative of changes in the residents medical/mental condition and or status. The nurse will notify the resident's Attending Physician or physician on call when there has been a significant change int the residents physical/emotional/mental condition, need to alter the resident's medical treatment significantly. A significant change of condition is a major decline in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Impacts more than one area of the resident's health status. Requires interdisciplinary review and/or revision to the care plan. The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:20 PM and the IJ template was provided. The Administrator stated he understood the meaning of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on [DATE] at 5:00 PM and included the following: Impact Statement: On [DATE], a health survey was initiated at Accel at College Station at 1500 Medical Ave., College Station, TX 77845. On [DATE], the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute an Immediate Jeopardy to the resident's health due to the failure to prevent wound, development and worsening of a wound, which caused the resident to be admitted to the hospital with sepsis related to acute osteomyelitis of the wound. What corrective actions have been implemented for the identified residents? The resident with the deficient practice was discharged to the hospital on [DATE]. How were other residents at risk to be affected by this deficient practice identified? All residents (95) residing in the facility on [DATE] are at risk for the same deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? The Clinical Service Director completed an in-service on [DATE] with the DON (Director of Nursing) and Administrator on how to properly complete and review skin treatments, lab orders, and diagnostic test orders are completed and followed as per physician's orders during the daily clinical meeting held Monday - Friday. Start Date: [DATE] End Date: [DATE] Who is Responsible: DON, and Nurse Managers Who will Monitor: Administrator/Designee The DON completed an in-service with Nurse Managers on [DATE] to review and ensure that skin treatments, lab, and diagnostic orders are completed and followed as per the physician's orders during the clinical meeting. Facility Nursing Managers will complete these tasks during the weekends by following the assigned Manager on Duty Schedule. The facility's nurse managers will complete these tasks on weekends until a weekend manager is hired to monitor wound treatment is provided, documentation of wound care, and abnormal diagnostic test and labs are reported to the DON and Physician. Start Date: [DATE] End Date: [DATE] Who is Responsible: Nurse Managers Who will Monitor: DON and Administrator The DON completed a 1 to 1 with the Wound Care nurse on [DATE] covering wound care treatments, assessing skin, receiving and implementing wound care orders, reporting any wound changes to the DON and Physician, reporting abnormal labs and diagnostic test results to the DON and Physician, and documenting wound care. Start Date: [DATE] End Date: [DATE] Who is Responsible: Wound Care Nurse Who will Monitor: DON The DON completed an in-service on [DATE] with nurse managers on; wound treatments, wound prevention, assessing skin, receiving and implementing wound care orders, reporting any wound changes to the DON and Physician, reporting abnormal labs and diagnostic test results to the DON and Physician, and documenting wound care. Start Date: [DATE] End Date: [DATE] Who is Responsible: Nurse Managers Who will Monitor: DON The DON initiated in-service on [DATE] with licensed nursing staff on the wound care treatments, assessing skin, receiving, and implementing wound care orders, reporting any wound changes, following, and reporting abnormal lab and diagnostic test results, and documenting wound care. The facility will continue to be in service until 100% of the nursing staff have received in-servicing. PRN and agency staff will be in service prior to their next scheduled shift and provide care to the residents. Start Date: [DATE] End Date: [DATE] Who is responsible: DON Who will Monitor: Administrator The DON initiated in-services on [DATE] with licensed nurses, CNAs, and MAs, on pressure injury prevention including reporting any skin changes to the licensed nurse. The facility will continue to be in service until 100% of the nursing staff have completed the training. PRN and agency staff will be in-serviced prior to the start of their next scheduled shift and prior to providing care to residents. Start Date: [DATE] End Date: [DATE] Who is Responsible: DON/Nursing Managers Who will Monitor: Administrator Starting on [DATE] all newly hired licensed nurses will be in-serviced by DON/Nurse Managers during the orientation process prior to providing care to residents on wound care, skin assessments, receiving, and implementing wound care orders, reporting any wound changes, following, and reporting labs and diagnostic test results, when to notify the DON and physician of changes and documenting wound care. Start Date: [DATE] End Date: Ongoing Who is Responsible: DON/Nurse Managers Who will Monitor: Administrator Starting on [DATE] all newly hired nursing staff including certified nurse aides, medications aides, and licensed nurses will be in-serviced by DON/Nurse Managers during the orientation process on pressure injury prevention to include but not limited to turning and repositioning, incontinent care, offloading, nutrition, reporting skin discolorations or any skin changes. Start Date: [DATE] End Date: Ongoing Who is Responsible: DON/Nurse Managers Who will Monitor: Administrator How will the system be monitored to ensure compliance? DON or designee will audit the wound system and labs/diagnostics weekly to ensure residents with wounds have necessary treatment and services initiated and followed, and any wound with decline will be evaluated for signs and symptoms of infection. Any decline in wounds will be reported immediately to the physician for evaluation and a treatment plan. The DON and Administrator will make bi-weekly random rounds starting on [DATE] to ensure residents at risk for skin injuries are proactively turned and repositioned, toileted, and nutritional needs addressed to prevent wounds. This will continue for the next two months or until further recommendations by the QAPI process. Weekly skin assessments will be completed on residents residing in the facility. The DON or designee will conduct a weekly skin meeting to review current wounds in the facility to monitor for healing or worsening wounds and the physician will be notified of any concerns for further orders. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on [DATE] with the Medical Director. The Medical Director reviewed and agreed with this plan. Monitoring for Plan of Removal was completed from [DATE] - [DATE] as follows: In an interview on [DATE] 09:30 AM DON stated they have initiated a change on the weekend for the week supervisor to do treatments for all wounds. She stated the treatment nurse was on call this weekend for treatments and is doing them today. She stated the charge nurses would no longer be responsible for wound care on the weekends. In an interview on [DATE] at 10:12 AM LVN charge nurse on 500 & 600 hall stated she had been in-serviced on wound management and the new protocol that the weekend supervisor would be doing wound care on the weekend. Observation on [DATE] at 10:15 AM revealed the TREATMENT NURSE was performing a treatment on Resident #66 with no concerns noted during the treatment. Review of IJ in-service training on [DATE] reflected a one on one with CSD RN and the DON which reflected training in wound care and assessment. Wounds were to be reviewed by the DON in clinical meetings to ensure orders were implemented and followed. Any decline in wounds would be further assessed and evaluated and to ensure all preventive measures were implemented and followed. In an in interview on [DATE] at 10:30 AM the DON stated her training reflected she was knowledgeable about the new process and verbalized understanding of the importance of monitoring the wound care nurse assessment but also monitoring the documentation from the wound care physician to ensure the wound care nurse and the physicians assessments were accurate. Orders were to be carried out and changes in condition were to be monitored and reported. Review of IJ in-service training on [DATE] for the TREATMENT NURSE reflected he was in-serviced by the DON regarding completion of wound care and notifying the MD of wound declines and if the wound care MD was not available, the Primary MD must assess the wounds weekly and the assessment of the wounds must be completed weekly. Any changes in wound would be reported to the DON promptly. In an interview with the TREATMENT NURSE on [DATE] at 11:58 AM he verbalized understanding of the above. Review of IJ in-service training dated [DATE] regarding stop and watch related to CNAs reporting all changes in condition including wound odor must be competed and preventative measures must be checked and in place for residents. Interviews on [DATE] with CNA Q, CNA R, CNA S, CNA T, and CNA U stated they received training on the stop and watch program and verbalized understanding of when changes should be reported. Observation [DATE] at 12:07 PM revealed the DON trained CNA V on the stop and watch procedures in the EMR and regarding reporting changes in condition and sending alerts to her. The DON trained CNA V notifying nursing of resident changes she covered preventative measures and ensuring they are in place. CNA V verbalized understanding. Observation and interview on [DATE] at 12:20 PM revealed Resident #42 in bed and he stated he received his wound care treatment to his right heel. His his heel boot was in place. Resident #42 stated he had no pain. Observation and interview on [DATE] at 12:30 PM revealed Resident #89 in room in bed on an air mattress. RP at bedside stated she had received her wound care treatment and was getting ready for lunch with resident and RP had no concerns. Observation and interview on [DATE] at 12:35 PM revealed Resident #79 in room in bed on air mattress. Observation of his coccyx wound revealed dressing D&I dated [DATE]. Review of QA&A Committee Minutes dated [DATE] revealed QA&A committee members held an ad hoc QAPI meeting regarding the IJ for 686 and the plan of removal. The meeting included the ADMIN, MEDICAL DIRECTOR, the DON, the CSD RN, and the regional director of operations. Review of 1 on 1 In-Service Record dated [DATE] revealed the DON, the ADMIN and TREATMENT NURSE were inserviced by the CSD RN regarding weekly skin integrity reviews to be completed by TREATMENT NURSE by a schedule per hallway. Any new skin issues will be immediately reported to the MD/DON for new orders to be placed. If there was another skin integrity review that a nurse had placed that was not accurate the findings should be reported to the DON promptly. Review of On Call Schedule 2023 revealed on call nurses designated each weekend for the remainder of 2023 and will complete wound care on the weekends. In an interview on [DATE] at 2:10 PM , LVN E stated she received training regarding the on call nurse will complete wound care on the weekends. She stated if a resident had a new skin issue or decline in a wound she would contact the doctor immediately and notify the DON. She stated aides were to notify the charge nurses immediately if a resident had a change in a wound or a new skin issue. In an interview on [DATE] at 2:30 PM, LVN G stated she received training on new skin issues or decline of a wound and would notify the MD or the DON. She stated the weekend on call nurse would be completing the wound treatments and charge nurses would no longer be responsible for wound care on the weekends. In an interview on [DATE] at 2:45 PM, the ADMIN stated he received training on the wound care protocol and what nursing staff should do if a resident experienced a change in condition or decline of a wound. He stated the wounds would be monitored by the DON and they would review in clinical meetings weekly. On [DATE] at 11:00 AM, the ADMIN was notified that the Immediate Jeopardy (IJ) was removed. However, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy with a scope of isolated, due to the facility need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (Resident #1) reviewed for pain. The facility failed to administer Resident #1's pain medications of [MEDICATION(S)] and [MEDICATION(S)], ordered for pain by the physician. This failure caused the resident to experience extreme pain and difficulty sleeping on 06/16/2022. Findings include: Record review of Resident #1's face sheet, dated 07/01/2022, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's minimum data set (MDS) assessment, dated 06/30/2022, reflected a brief interview for mental status (BIMS) score of 15, which indicated the resident was cognitively intact. Functional abilities for self-care included the resident needed supervision for eating and oral hygiene. The resident needed partial/moderate assistance for toileting hygiene and showers. Pain assessment interview revealed Resident #1 had experienced pain or hurting frequently over the last five days. Resident #1's pain intensity was rated on a numerical scale as 7 out of 10. Record review of Resident #1's care plan, dated 06/17/2022, reflected a nursing plan of care which included assistance with administering medication, all medical needs, and fulfilling Doctor's orders. Record review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/16/2022, medication was not given to the resident at 9:00 PM and on 06/17/2022 at 3:00 AM. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/16/2022, medication was not offered to the resident despite resident being in extreme pain as it was not checked and initialed on the medication administration record. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/16/2022 at 9:00 PM Acetaminophen was given by Medication Aide C to Resident #1. No pain levels documented on 06/16/2022. Record review of Resident #1's pain assessment dated [DATE] revealed the presence of pain or hurting during the last five days, frequently experienced pain or hurting over the last five days, over the last five days pain made it hard for resident to sleep at night, pain had limited residents' ability for his day-to-day activity. Resident gave a numerical listing of pain at level of seven out of ten. An interview on 07/01/2022 at 11:00 AM with Resident #1 revealed he arrived at the facility from the hospital on 06/16/2022 around 3:30 PM. Resident #1 stated the doctor had prescribed him with pain medication when he left the hospital. He stated the staff at the hospital gave him medication before his transfer to the facility. He stated around 4:30 PM he pressed his call light and it took an hour for an aide to respond to the call light and another 30 minutes for a nurse to respond. He stated he was told by the aide and the nurse the facility didn't have any pain medication for him and there was nothing they could do. He did not remember the names or descriptions of aide or nurse. Resident #1 stated the staff had no empathy as the staff were rude and didn't seem to care about his pain. Resident #1 stated he was told by the aide this isn't a hospital after he asked to speak with the Administrator. He stated at this point he was in excruciating pain. Resident #1 was told by the aide there is nothing for you, tomorrow morning they will order something for you. He stated around 7:00-8:00 PM nursing staff brought him two Tylenol and said, you can either take this or leave it and walked out. Resident #1 stated he did not know any names or descriptions of nursing staff as he was in excruciating pain. He stated his wife tried calling the nursing line, the office, and the afterhours number in order to get ahold of someone to help but was not able to reach anyone. Resident #1 stated at this point he wanted to call EMS to have him transferred back to the hospital. He stated in the middle of the night, the aide came in and told him there is medication for you to take, but the nurse is on her break and took the medication cart key with her, we figured out the problem, your medication is on the other nurses' cart. Resident #1 stated he finally got the prescribed medication at some point the next morning (06/17/2022) but was unsure of the time as he was in so much pain. Stated the next morning the ADMIN came in and apologized for the resident's experience saying, we need to do a better job training the staff. An interview on 07/01/2022 at 2:30 PM with the DON revealed the facility should have ensured the residents prescribed medications were at the pharmacy. If the pharmacy did not have any orders for the resident, the facility staff should have called the Doctor on call. If the Doctor on-call was not available, the facility staff should have called the emergency nursing on-call for guidance. The DON stated it was not acceptable to leave a resident in pain. After looking at the resident records, the DON stated the facility nursing staff missed the residents pain medication at 9:00 PM on 06/16/2022 and at 3:00 AM on 06/17/2022. She stated Nurse B, who was on duty that night, was terminated from the facility for leaving during a shift and the aide who assisted, CNA B, the resident was no longer working at the facility either. She stated the facility had an E-Kit and stated she was not sure why the nurse on-duty didn't utilize this kit if Resident #1 was in pain. She stated that she was unsure why the resident did not receive his medication and that the nurse in charge of resident's hallway should have ensured he received his medication to manage his pain. An interview on 07/01/2022 at 12:10 PM with Nurse A revealed residents should have a pain assessment if they stated they were in pain. She stated if medications were not on hand, the nursing staff should contact the Doctor. Nursing staff could have medications sent over immediately from the pharmacy and it was unacceptable to have residents in pain. She stated pain management was a critical piece of resident care. An interview on 07/01/2022 at 12:20 PM with CNA D revealed she had been trained to never leave a resident in pain. She stated if a resident complained of pain, she was trained to immediately notify the charge nurse. She stated the facility could always call the doctor or nurse on call. There was no documentation of calls to Resident #1's doctor in records. An interview on 07/01/2022 at 2:00 PM with CNA B revealed she no longer worked at the facility and did not recall the resident. CNA B stated so many people asked for pain medications, I can't remember. CNA B stated there were so many admissions the nurses got frustrated and dropped the ball with ensuring residents had needed medications. CNA B stated there were times when the rehabilitation unit had no charge nurse and no way to pass medications to residents. She stated she asked a charge nurse from a different hallway to come over, but they refused. She stated no-one answered when the on-call emergency numbers were called. She stated she had not notified administration regarding the issue. She had no answer to why she did not notify anyone. An interview on 07/01/2022 at 3:00 PM with Nurse E revealed she did remember Resident #1 and he did not ask for pain medications until 2 or 3 in the morning of 06/17/2022. She stated she talked to Resident #1 and explained the facility did not have any medications for him but told him the facility would have to get in touch with the pharmacy. She stated that medication were not on hand because of the late admission for many of residents. She stated she did not remember when or if Resident #1 received pain medications. She stated the facility had an ongoing issue with late admission times and not having narcotics for residents who need them. Nurse B stated she did not remember the resident was in pain when she left her shift for the day. An interview on 07/01/2022 at 4:00 PM with the ADMIN revealed he was not aware of the incident on 06/16/2022 with Resident #1. He stated he was made aware that Resident #1 did not receive his pain medication on 06/16/2022 on 06/17/2022 and addressed the incident with the resident. He stated he ensured the resident was comfortable and needed medications. He stated there were policies in place to ensure all staff knew the protocols of resident pain management and all staff had been in-serviced regarding pain management. He stated leaving a resident in pain without a resolution was not acceptable as it could causes negative outcomes for residents. Record review of the facility's administering medications policy, dated December 2012, revealed medications must be administered in accordance with the orders, including any prescribed time, unless otherwise specified. Medications must be administered within one hour of their prescribed time, unless otherwise specified.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision to prevent accidents for one of five residents reviewed for accidents (Resident #5). The facility provided cups and hot coffee that was above a safe serving temperature to the dining room when the dining room was accessible to residents and was not continually supervised. Resident #5 [MEDICAL CONDITION] his mouth and throat from the hot coffee on the morning of 07/30/2019. These failures led to Resident #5's hospitalization in a Houston hospital burn unit with [MEDICAL CONDITION] the mouth and throat, with the outcome of having lost the ability to eat and drink by mouth. This failure resulted in an Immediate Jeopardy situation on 08/05/2019. While the IJ was removed on 08/07/2019, the facility remained out of compliance at a severity level of actual harm due to staff needing more time to monitor the plan of removal for effectiveness. The hot coffee temperatures could have affected any resident in the facility that drank coffee. Findings included; Review of Resident #5's Face Sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Admission MDS dated [DATE] reflected; he lived in room [ROOM NUMBER], he had no difficulty with understanding others or being understood. His vision was adequate and his BIMS score was two which indicated severe cognitive impairment. The MDS reflected Resident #5's ADL self-performance was limited assistance of one person except for showers when he required physical assistance in part of the bathing activity. The MDS further reflected he normally used a walker, or a wheelchair. He was occasionally incontinent, and the discharge plan was for the resident to return to his community. Review of Resident #5's Care Plan reflected it was initiated on 07/29/2019 and had focus/problems on impaired cognition, wishes to discharge home with his wife, and his ADL plan reflected he required limited staff participation to toilet, transfer, and dress. The ADL Care Plan for eating dated 07/29/2019 reflected, The resident requires (x 1, tray set up and supervision) staff participation to eat. In an interview on 08/06/2019 at 7:54 AM when asked why he was in the hospital, Resident #5 stated, Hot coffee, she gave it to me. Then he spoke of the nursing home and the nurse he says gave him the hot coffee. Surveyor checked him for his orientation; It is 2019. I am in Memorial hospital in Houston (correct). I am waiting on breakfast which I am never going to get. No, I do not have feeding tube now. I have a bag going through my IV (for nutrition). The electric machine does it for you. Observation of hall 500 revealed it had a dining area to the left and a parlor to the right. You could see the coffee service from the hall, and from the parlor. There were two insulated coffee service containers on the top shelf of a table with coffee cups for self-service on shelves two and three. The coffee service was in the dining area throughout the survey except for short times when it was taken to the kitchen to be refilled. In an interview on 08/06/2019 at 12:40 PM the Administrator stated it was the Kitchen Supervisor's responsibility to ensure the coffee came out at a safe temperature. Coffee is to be brought out when staff start coming in dining room. In an interview on 08/05/2019 at 3:15 PM the Staffing Coordinator stated the coffee is made in the morning and comes to the dining rooms. It remains in the urns throughout the day and slowly cools during the day. She stated the residents have the coffee as long as there is some in the urn. In an interview on 08/07/2019 at 9:25 AM the Staffing Coordinator stated the coffee comes to the satellite dining area at about 5:30 AM every morning. The coffee is available on a serving cart with cups on the lower shelves. In an interview on 08/07/2019 at 12:25 PM CNA F stated, No one has ever said the coffee service had to be continually monitored. In an interview on 08/07/2019 at 12:29 PM LVN C stated, No one has ever said the coffee service had to be continually monitored. In an interview on 08/07/2019 at 12:32 PM CNA [NAME] stated, Breakfast comes out at about 6:45 AM and the coffee service comes out before then. She stated she starts resident care as soon as she gets to work but they try to keep an eye on the coffee service and resident who may try to get their own coffee. Review of the nursing home facility document Service Line Checklists reflected: Food serving temperatures taken and recorded on the below log prior to meal service Breakfast Lunch Dinner. Item names and temperatures for all hot and cold foods should be taken prior to service and recorded in the boxes below. -07/26/2019 - Hot Beverage Breakfast Coffee Temp (F) 175 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 180 -07/27/2019 - Hot Beverage Breakfast Coffee Temp (F) blank Lunch Coffee Temp (F) blank Dinner Coffee Temp (F) blank -07/28/2019 - Hot Beverage Breakfast Coffee Temp (F) 175 Lunch Coffee Temp (F) 170 Dinner Coffee Temp (F) 168 -07/29/2019 - Hot Beverage Breakfast Coffee Temp (F) 180 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) blank -07/30/2019 - Hot Beverage Breakfast Coffee Temp (F) 186 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 180 -07/31/2019 - Hot Beverage Breakfast Coffee Temp (F) 180 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 170 -08/01/2019 - Hot Beverage Breakfast Coffee Temp (F) 145 Lunch Coffee Temp (F) 170 Dinner No Coffee Temp (F) -08/02/2019 - Hot Beverage Breakfast Coffee Temp (F) 130 Lunch Coffee Temp (F) 160 Dinner No Coffee Temp (F) -08/03/2019 - Hot Beverage Breakfast Coffee Temp (F) 140 Lunch Coffee Temp (F) 145 Dinner Coffee Temp (F) 145 -08/04/2019 - Hot Beverage Breakfast Coffee Temp (F) 150 Lunch Coffee Temp (F) 160 Dinner Coffee Temp (F) 150 -08/05/2019 - Hot Beverage Breakfast Coffee Temp (F) 165 Lunch Coffee Temp (F) 164 Dinner Coffee Temp (F) 164 During an interview with Resident #5's wife on 8/3/2019 at 1:32 PM Resident #5's wife stated that she had left the facility at between 5:45 and 6:12 am on 7/30/2019 because her husband was extremely agitated. Resident #5's wife stated that when she returned to the facility the afternoon of 7/30/2019 about 1:40 PM she found that Resident #5 had a severely swollen upper lip that looked like a burn. She said that Resident #5 told her it was from hot coffee. Resident #5's wife stated that LVN D said that Resident #5 had been biting his lip all day until it swelled up, and they had put salve on it. Resident #5's wife stated Resident #5 told her that he had been spitting because he was spitting out the hot coffee. The facility sent him to the ER (Hospital #1) where she was told that the resident's lip was burned 1st and 2nd degree by the ER nurse. She stated that she took Resident #5 home and then took Resident #5 to his Resident Family MD for [MEDICAL CONDITION] 7/31/2019 then to the ER (Hospital #2). She said that when she took Resident #5 to the Hospital #2, the physicians diagnosed Resident #5 with serious scalds to his mouth and esophagus and he was emergently transferred to a burn unit in a Houston Hospital. Resident #5's wife said that Resident #5 repeatedly said it was a coffee burn. In an interview on 08/05/2019 at 9:15 AM Resident #5 stated he just did not feel like talking to the surveyor. Review of Resident #5's Responsible Party's/wife's Concern Form dated 07/30/2019 provided to surveyor by the facility on 08/05/2019 reflected; (Resident #5) had a rough night last night (7-29-19) and didn't sleep any. He told me to leave on morning of 7/30/19, at 5:30 - 5:45 AM. I returned at 1:30 PM and found that he had a swelled upper lip. The nurse said he had bitten his lip. There isn't a bite mark on his lip. He told me that the nurse gave him hot coffee to take his meds with and it burned his mouth and tongue . Review of Resident #5's Progress Notes reflected the staff did not document any behaviors, lip biting or spitting in the Progress notes until: -07/30/2019 at 7:00 AM LVN D documented Pharmacy called for obtaining [MEDICATION NAME], they have not received prescription. Pharmacist will contact MD for script. Resident behaviors continue, resident transferred to dining room for breakfast. -07/30/2019 at 7:20 AM LVN D documented Resident spitting, biting upper lip, refusing to eat and unbuttoning clothes in dining, resident removed from dining room. -07/30/2019 at 7:30 AM LVN D documented Wife notified of order for [MEDICATION NAME]. She verbalized permission to give her husband [MEDICATION NAME]. -07/30/2019 at 7:45 AM the DON documented This nurse wheeled resident to courtyard to sit with him one on one. Resident kept biting top lip and was redirected many times. -07/30/2019 at 9:25 AM LVN D documented [MEDICATION NAME] 1 mg give by mouth every 12 hours as needed for behaviors related to Altered mental Status Resident agitated and spitting continuously. -07/30/2019 at 11:53 AM LVN D documented . PRN administration was ineffective. Resident continues with behaviors. -07/30/2019 at 5:34 PM RN B documented Resident presents with increased productive cough with yellow sputum, wheezes noted in all fields bilaterally, minor respiratory distress 88-90 % on room air respiratory rate 20- 24. -07/30/2019 at 8:34 PM RN B documented Service here to transport resident to emergency department secondary to increased shortness of breath and productive cough. -7/31/2019 at 3:58 PM RN A documented weekly interdisciplinary meeting: making good progress was going to discuss discharge planning to day but client began to have behaviors, was 1:1, then developed cough and shortness of breath and was sent to ER, has not returned as of this writing. Review of the Emergency Department Triage Notes dated 07/30/2019 at 7:54 PM at Hospital #1 reflected; the Triage Registered Nurse wrote - Resident presents to the emergency Department with shortness of breath. Patient stated he drank very hot coffee with a clearly burnt upper lip. Patient is 87% on room air. Patient alert and oriented currently. Review of the Hospital #1's emergency department Provider Note dated 07/30/2019 at 10:13 PM reflected Resident #5's Chief Complaint was shortness of breath. Resident #5 presents to the Emergency Department via transport from Nursing Home for evaluation of shortness of breath which occurred prior to arrival. The patient is complaining of congestion, a productive cough, and a burned upper lip secondary to drank very hot coffee. Date and time of completed History and Physical Information: 07/30/2019 at 8:01 PM. Review of Resident #5's labs from Hospital #1 reflected he had a Critical High [NAME] Blood Cell count of 35.7 blood sample collected on 07/30/2019 at 7:58 PM (the day of the allegation of the burn) with the reference of normal being 4.8 to 10.8. Review of Resident #5's Hospital #1 Chest Computerized Axial [NAME]ography Assessment (CAT scan) performed on 07/30/2019 at 9:57 PM reflected: Opacified lower lobe bronchi, likely retained or less likely aspirated secretions. (Indications he was aspirating or what he was supposed to swallow was getting in his lungs also.) Review of Resident #5's Hospital #1's notes reflected Resident #5 was discharged to his home on 07/30/2019 at 10:30 PM. In an interview on 08/07/2019 at 4:37 PM the Houston Hospital MD stated: Treating him (Resident #5) for potential aspiration pneumonia based on elevated white blood cell count, consolidation on x-rays and a little hypoxic all suggestive of pneumonia. He now has a feeding tube. Due to his advanced age he may not recover. The EGD report has a burn pattern. He stated there was nothing to indicate a poisoning occurred and he believed hot coffee was the burn agent due to there was esophagitis and redness throughout. He [MEDICAL CONDITION] white blood cell counts to elevate and if Resident #5 was burned at 6:30 AM on 07/30/2019 his [NAME] Blood Cells would be elevated by 7:30 PM. The doctor stated he could not say definitely the burn caused the elevated white blood cells by 07/30/2019 PM but it was probable. In an interview on 08/06/2019 at 5:02 PM Resident #5's Primary Family Physician stated he saw Resident #5 in the clinic on 07/31/2019 after he had spent the night at home. He stated Resident #5 had burned his mouth on hot coffee, the burn was severe and to the entire mouth and throat. He further stated the time was appropriate for the burn event to have occurred early in the AM on 07/30/2019. Review of the Houston Hospital Emergency Department Provider Documentation dated 07/31/2019 at 9:01 PM reflected Resident #5 presented to the Emergency Department with second degree [MEDICAL CONDITION] mouth and posterior pharynx after drinking hot coffee yesterday. Review of the Houston Hospital History and Physical report dated 08/01/2019 at 3:23 AM reflected; Chief Complaint: Transferred from Hospital #2 with complaints [MEDICAL CONDITION] upper lip and mouth from hot coffee. Minor blisters to lip. [AGE] year old male with past medical history of [REDACTED]. Per history patient was at nursing home and had hot coffee which caused a burn to his oral mucosa. He was seen at outside hospital emergency roiagnom on Tuesday evening (Hospital #1 on 7/30/2019) and was later discharged . Later, he also saw his Primary Care Physician yesterday morning who prescribed oral steroids as well as antibiotic. His symptoms were worsening, difficulty eating and drinking as well as increased secretions from mouth. So, he went to outside emergency department (Hospital #2) and was referred here for ear, nose, and throat evaluation. At home he was placed on oxygen yesterday. [NAME] Blood Cells 21.9 at 07/31/19 10:52 PM. Assessment/Plan 1. Acute Hypoxemic [MEDICAL CONDITION] secondary to oral, laryngeal burn injury as well as [MEDICAL CONDITION]. 2. Burn of Oral mucosa. 3. [MEDICAL CONDITION]/[MEDICAL CONDITION]. 4. Oral Thrush 5. Dementia 8. Leukocytosis likely related to oral burns, starting on intravenous antibiotics. Review of the Houston Hospital Consultation note dated 08/01/2019 reflected; Patient transferred from local Hospital #2 after ingestion of hot coffee early this week at a nursing home with oral and laryngeal burn injury. Ingestion occurred approximately 7:30 AM on 7/30/2019. Reportedly was given two hot cups of coffee by a care giver at the facility. Later that day he was first noticed by wife to have blistering of his lips and tongue. He was having raspy voice and pain with swallowing which has been worsening. Has trouble swallowing his secretions and has not been able to eat or drink anything. Problems were worsening so he presented to ED earlier and was transferred here. Lips, tongue and palate with burn injury, sloughing mucosa. Uvula and oropharynx with [DIAGNOSES REDACTED]. Alert, mood and effect normal. Laryngoscopy and oral exam show burn injury ([MEDICAL CONDITION]/[DIAGNOSES REDACTED]) to lips, tongue, palate, epiglottis and arytenoids. Copious pooling secretions with possible aspiration. Recommend admission to hospitalist and nothing by mouth until Speech Therapy Evaluation. Recommend [MEDICATION NAME] evaluation for concern for [MEDICAL CONDITION] injury. Signed 08/01/2019 at 8:00 PM. Review of the Houston Hospital Rehabilitation Services document dated 08/01/2019 at 11:55 AM reflected a bedside speech evaluation which recommended Resident #5 no longer be given any food or fluids by mouth due to his deficits of wet vocal quality, coughing, and regurgitation/expectoration following all trials. Review of the Houston Hospital Radiology Report done 08/05/2019 at 10:21 AM (four days later) reflected Resident #5 was tested for his ability to maneuver and successfully swallow thin liquids, nectar thick liquids and pudding thick consistency. The results were that he had deep penetration with all consistencies (he could not control the substance in his mouth until he swallowed, it went down his throat without his control) and had significant residue remaining after swallowing the nectar and pudding consistencies (his swallow did not clear his throat). In an interview on 08/05/2019 at 11:30 AM the DON stated LVN D was the charge nurse who called her in early to come help with Resident #5 at 7:25 AM. The DON explained Resident #5 was extremely agitated and demonstrated multiple behaviors on the morning of 07/30/2019. She stated he was in the halls ambulating independently by the coffee service. In an interview on 08/05/2019 at 3:00 PM the Kitchen Supervisor stated, The coffee pot brews coffee at 205 degrees. He stated the procedure is for the staff to remove the lid and let it cool for 15 to 20 minutes or however long it takes for the coffee to cool to 165 to 180 degrees. He stated then the staff may send it out to the kitchenettes/dining room. He stated he only puts coffee out in the morning and it is the last thing he does when he leaves in the evening. He stated there would not be new coffee put out until 7:00 PM just before he left for the day. In an interview on 08/05/2019 at 4:10 PM the Kitchen Supervisor stated the temperatures on the flow sheet are accurate because he is the one that temped the coffee before it was put in the dining room on 07/30/2019. He stated he would not be serving the coffee for the evening until he left usually at 7:00 to 7:30 PM. When asked why there was a temperature recorded on the log for breakfast, lunch and dinner he stated he would put four pots out for breakfast to each dining room and one pot for each dining room would be put out for lunch then he said one pot would be put out to each dining room at about 7:00 PM. In an interview on 08/05/2019 at 4:41 PM the Administrator stated, I talked to the Kitchen Supervisor about the coffee temperature Saturday. We talked about state was here and the allegation was that a Resident was burned with coffee and that the nurse poured coffee down his throat. He told me he was taking temperatures and it could be anywhere from 160 to 185 degrees. In an interview on 08/05/2019 at 4:48 PM the Administrator stated, I talked to him about it yesterday (Sunday) when I got in town. In an interview on 08/05/2019 at 4:50 PM the Kitchen Supervisor stated, No one has talked to me about whether the coffee was at a safe temperature. My other facility is who taught me what a safe temperature was when we had a resident who dropped coffee on their lap and got burned. That is when I found out about proper temperatures. Today there is nothing different that is happening except that I am teaching them (kitchen staff) this is why we take the temperatures. In an interview on 08/05/2019 at 4:50 PM the Administrator stated, We have not had any other residents burned. She stated the facility did not have a policy for how the coffee should be served. In an interview on 08/05/2019 at 4:52 PM the Kitchen Supervisor stated he did not have a policy for coffee temperatures and it was the facility's practice to put the coffee in the dining room when it had cooled off to 180 degrees or below. On 08/05/2019 at 5:40 PM the Administrator and DON were notified the facility had an IJ situation for the above failures in accidents and hazards. In a telephone interview on 08/05/19 at 5:45 PM the contracted Food Service Supervisor (FSS) stated there was no policy for what temperature the facility was to serve coffee at. She stated coffee will not brew at much less than 200 degrees Fahrenheit. She further stated the facility was to cool the coffee for ten minutes after it was brewed to ensure it came down to a palatable temperature. The contracted FSS stated oatmeal will burn a resident at 150 degrees, cream soup at 160 degrees causes a really bad burn and food is placed on the steam table at 165 degrees. The contracted FSS stated if the coffee temperature was lowered it would cause a lot of residents to complain and if coffee service was placed out of reach of residents that would also make them very unhappy. In an interview on 08/06/2019 at 11:10 AM the Corporate RN stated, The temperature of the coffee that leaves the kitchen is a variable. She stated it was not the facility's policy or procedure to temp the coffee just prior to it being served to see what the serving temperature was. In an interview on 08/06/2019 at 11:17 AM the Regional Vice President stated he had clarified with the Kitchen Supervisor that the numbers on the temperature log forms were not serving temperatures, but they were prior to service temperatures. He stated there was not a policy on the temperature of the coffee coming out of the kitchen to the dining room. Interview on 08/06/2019 at 11:24 AM revealed the Regional vice President, Corporate RN and the Administrator requested the surveyor to watch the coffee brew. In an interview on 08/06/2019 at 11:30 AM the Contracted FSS stated, We temp the coffee before it is released from the kitchen and it goes to the kitchenettes (dining room). Yes, there is room for error because we do not have a set temperature for the coffee to leave the kitchen. The Administrator stated, The coffee sits for 10 to 15 minutes before the temperature is taken. Observation/interview on 08/06/2019 at 11:35 AM reflected the coffee was finished brewing straight into the insulated serving container and the temperature was 178 degrees F per the Kitchen Supervisor (measured in surveyor's presence). Surveyor asked the Kitchen Supervisor why the brew temperature was lower than what he recorded on his temp log so many times. He stated maybe it was because this was the second batch that was brewed. In an interview on 08/06/2019 at 12:14 PM RN B stated he was the nurse who sent Resident #5 to the hospital on the evening of 07/30/2019 when he had A swollen upper lip, crackles in his lungs, green sputum and a low oxygen saturation of 89% on room air. His tongue was white. The whiteness of the tongue was my concern when I looked in his mouth. LVN D had told me she thought he had mentioned he may have been burned with coffee. On a previous weekend I observed him getting another resident a cup of coffee and he kept putting one drink in the bottom of the cup. The other resident was getting angry. I kept telling him I would get the coffee. He tried to get coffee four or five times but only put one sip in each time. As far as the day I sent him out (07/30/2019), he was spitting all shift, he refused supper, he drank maybe two ounces of water total for the shift. The coffee service comes out at a different time every day. In an interview on 08/06/2019 at 3:17 PM the Medical Director who was also Resident #5's MD stated he recalled a QA meeting several months ago that some coffee was spilled. The facility was addressing it in the QA meeting. There was an issue about resident not pouring it or having their own containers. They had changed their procedures about serving it. Maybe there was a resident hurt or that there was a spill at that time. I definitely remember discussing hot liquids. I definitely remember patients shouldn't be getting it themselves. I do not feel like it was neglect. When asked was it neglect that the facility last temped the coffee at 180 degrees and then placed it on a serving cart at three-foot height in the dining room he stated; No, I guess that was not the best choice. I was not told last Tuesday (07/30/2019) we had a complaint that a resident was burned. A QA meeting would have been prudent to be done a week ago. If they knew that this was going to be an issue it should have been addressed in Q[NAME] In an interview on 08/07/2019 at 9:20 AM the Kitchen Supervisor stated it took 1.5 hours to cool the coffee to 155 degrees F after brewing. He stated he had come in early and timed it. He requested for surveyor to go to the kitchen at 9:30 AM for him to brew the coffee for lunch which was scheduled to be served at 11:00 AM. Review of the Policy Food Preparation and Service dated (MONTH) 2014 reflected; 20. Prior to the point of service, the temperature of coffee or hot beverage will be checked to ensure temperature is 155 degrees Fahrenheit or below. If above 155 degrees, ice will be added to the coffee until at or below 155 degrees. The following Plan of Removal was submitted by the Administrator on 08/07/2019 at 10:00 AM. Resident #5 involved in alleged deficient practice was sent to hospital for respiratory distress and did not return to facility. Facility notified Medical Director, (who was the resident's primary physician) was notified on 08/03/2019 of physical abuse allegation on staff member LVN D. Medical Director then was notified on 08/05/2019 of alleged coffee burn on Resident #5. Nursing staff completed full assessment of all residents residing in the facility on 08/05/2019. No signs or symptoms of burns/redness present. How are other residents at risk to be affected by this deficient practice identified? Nursing staff completed full assessment of all residents residing in the facility on 08/05/2019. All resident that are drinking coffee were identified at risk to be affected by the alleged deficient practice, none found to be affected. Facility audited water temperature logs for several months with no evidence of noncompliant practice. Maintenance Director audited on 08/05/2019 the water temperature from faucets with temperature data meeting safe temperature. Facility audited the grievances for any concerns on coffee/hot beverages on 08/05/2019. No grievances present with the alleged practice. Facility audited the resident council minutes for any concerns/issues of the alleged deficient practice on 08/05/2019. No concerns/issues present. Satisfactory surveys on coffee/hot beverages completed with residents on each hall on 08/05/2019. Facility reviewed incidents from (MONTH) to present; no burn incidents present. Resident council president interviewed on 8/6/19 and no complaints of coffee being too hot was made. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? Administrator completed 1:1 in-service with Dietary Manager on 8/5/19 on the protocol of hot beverages/coffee to ensure coffee is not served or accessible to residents at temperatures greater than 140 degrees Fahrenheit. Dietary staff in-service on the protocol of coffee/hot beverages on 8/5/19. In-service completed with dietary staff on 8/5/19 and 8/6/19 on checking coffee/hot beverage temperatures before leaving the kitchen to be served to resident to ensure temperature is 140 degrees or lower. In-service completed on five out of total of 11 dietary staff on taking temperatures before serving or releasing coffee thermos from main kitchen on 8/6/19. The other two dietary staff will be in-serviced before their next scheduled shift. Facility implemented temperature log for coffee/hot beverages to monitor the temperature with all three meals or anytime coffee/hot beverages served. In-service completed on six of the total eight dietary staff on taking temperatures before serving or releasing coffee thermos from main kitchen on 8/6/19. The other two dietary staff will be in-serviced before their next scheduled shift. 34 out of 87 nursing staff in-serviced on coffee/hot beverages protocol and reheating food/liquids protocol on 8/6/19. The rest of nursing staff will in in-serviced before their next scheduled shift. Nursing staff in-serviced to report to Administrator or designed any incidents involving hot beverages immediately. How will the system be monitored to ensure compliance? Facility will continue to in-service all new hires during orientation on hot beverages protocol. Facility will review any incidents and grievances [MEDICAL CONDITION] the Daily Interdisciplinary Team meeting. Administrator/Designee will watch return demonstration of coffee/hot beverages protocol three times a week for four weeks then one time a week for four weeks. The Administrator/Designee will review the Dietary manager Temperature Logs three times weekly for four weeks then one time a week for four weeks, or until compliance is achieved. Any discrepancies noted will be immediately reported to the Quality Assurance and performance Improvement committee for evaluation and correction. The Administrator/Designee will review the grievance log three times weekly for four weeks then one time a week for four weeks, or until compliance is achieved. Any discrepancies noted will be immediately reported to the Quality Assurance and performance Improvement committee for evaluation and correction. All finding to be reviewed in QAPI meetings with PIP review for effectiveness. New interventions to be implemented immediately when and if necessary. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 8/6/19 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The POR was accepted by the Program manager on 08/07/2019 at 10:24 AM. Monitoring for the plan of removal began on 08/07/2019 at 11:51 AM. Staff were interviewed for understanding regarding safe coffee service temperatures and reheating of hot liquids by staff. The staff voiced a good understanding of the training. 100% of the kitchen staff were in-serviced in person or by telephone. The nursing staff continued to in-service and required additional time to complete the training. The Administrator stated no staff were to be allowed to work their shift without first being trained in the new safety procedure for hot liquids. On 08/07/2019 at 1:00 PM the IJ was lifted. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interview and record review the facility failed to ensure each resident received drinks provided at a safe and appetizing temperature for one of five residents reviewed for safe temperatures (Resident #5). The facility provided cups and hot coffee that was above a safe serving temperature to the dining room when the dining room was accessible to residents and was not continually supervised. Resident #5 [MEDICAL CONDITION] his mouth and throat from the hot coffee on the morning of 07/30/2019. On 07/30/2019 the facility received the written grievance that he was burned by hot coffee and the facility did not assess and evaluate the coffee service for safe/unsafe temperatures and access by residents. These failures led to Resident #5's hospitalization in a Houston hospital #2 burn unit with [MEDICAL CONDITION] the mouth and throat, with the outcome of having lost the ability to eat and drink by mouth. This failure resulted in an Immediate Jeopardy situation on 08/05/2019. While the IJ was removed on 08/07/2019, the facility remained out of compliance at a severity level of actual harm due to staff needing more time to monitor the plan of removal for effectiveness. The hot coffee temperatures could have affected any resident in the facility that drank coffee from the insulated serving urns. Findings included; Review of Resident #5's Face Sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Admission MDS dated [DATE] reflected; he lived in room [ROOM NUMBER], he had no difficulty with understanding others or being understood. His vision was adequate and his BIMS score was two which indicated severe cognitive impairment. The MDS reflected Resident #5's ADL self-performance was limited assistance of one person except for showers when he required physical assistance in part of the bathing activity. The MDS further reflected he normally used a walker, or a wheelchair. He was occasionally incontinent, and the discharge plan was for the resident to return to his community. Review of Resident #5's Care Plan reflected it was initiated on 07/29/2019 and had focus/problems on impaired cognition, wishes to discharge home with his wife, and his ADL plan reflected he required limited staff participation to toilet, transfer, and dress. The ADL Care Plan for eating dated 07/29/2019 reflected, The resident requires (x 1, tray set up and supervision) staff participation to eat. In an interview on 08/06/2019 at 7:54 AM when asked why he was in the hospital, Resident #5 stated, Hot coffee, she gave it to me. Then he spoke of the nursing home and the nurse he says gave him the hot coffee. Surveyor checked him for his orientation; It is 2019. I am in Memorial hospital in Houston (correct). I am waiting on breakfast which I am never going to get. No, I do not have feeding tube now. I have a bag going through my IV (for nutrition). The electric machine does it for you. Observation of hall 500 revealed it had a dining area to the left and a parlor to the right. You could see the coffee service from the hall, and from the parlor. There were two insulated coffee service containers on the top shelf of a table with coffee cups for self-service on shelves two and three. The coffee service was in the dining area throughout the survey except for short times when it was taken to the kitchen to be refilled. In an interview on 08/06/2019 at 12:40 PM the Administrator stated it was the Kitchen Supervisor's responsibility to ensure the coffee came out at a safe temperature. Coffee is to be brought out when staff start coming in dining room. In an interview on 08/05/2019 at 3:15 PM the Staffing Coordinator stated the coffee is made in the morning and comes to the dining rooms. It remains in the urns throughout the day and slowly cools during the day. She stated the residents have the coffee as long as there is some in the urn. In an interview on 08/07/2019 at 9:25 AM the Staffing Coordinator stated the coffee comes to the satellite dining area at about 5:30 AM every morning. The coffee is available on a serving cart with cups on the lower shelves. In an interview on 08/07/2019 at 12:25 PM CNA F stated, No one has ever said the coffee service had to be continually monitored. In an interview on 08/07/2019 at 12:29 PM LVN C stated, No one has ever said the coffee service had to be continually monitored. In an interview on 08/07/2019 at 12:32 PM CNA [NAME] stated, Breakfast comes out at about 6:45 AM and the coffee service comes out before then. She stated she starts resident care as soon as she gets to work but they try to keep an eye on the coffee service and resident who may try to get their own coffee. Review of the nursing home facility document Service Line Checklists reflected: Food serving temperatures taken and recorded on the below log prior to meal service Breakfast Lunch Dinner. Item names and temperatures for all hot and cold foods should be taken prior to service and recorded in the boxes below. -07/26/2019 - Hot Beverage Breakfast Coffee Temp (F) 175 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 180 -07/27/2019 - Hot Beverage Breakfast Coffee Temp (F) blank Lunch Coffee Temp (F) blank Dinner Coffee Temp (F) blank -07/28/2019 - Hot Beverage Breakfast Coffee Temp (F) 175 Lunch Coffee Temp (F) 170 Dinner Coffee Temp (F) 168 -07/29/2019 - Hot Beverage Breakfast Coffee Temp (F) 180 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) blank -07/30/2019 - Hot Beverage Breakfast Coffee Temp (F) 186 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 180 -07/31/2019 - Hot Beverage Breakfast Coffee Temp (F) 180 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 170 -08/01/2019 - Hot Beverage Breakfast Coffee Temp (F) 145 Lunch Coffee Temp (F) 170 Dinner No Coffee Temp (F) -08/02/2019 - Hot Beverage Breakfast Coffee Temp (F) 130 Lunch Coffee Temp (F) 160 Dinner No Coffee Temp (F) -08/03/2019 - Hot Beverage Breakfast Coffee Temp (F) 140 Lunch Coffee Temp (F) 145 Dinner Coffee Temp (F) 145 -08/04/2019 - Hot Beverage Breakfast Coffee Temp (F) 150 Lunch Coffee Temp (F) 160 Dinner Coffee Temp (F) 150 -08/05/2019 - Hot Beverage Breakfast Coffee Temp (F) 165 Lunch Coffee Temp (F) 164 Dinner Coffee Temp (F) 164 During an interview with Resident #5's wife on 8/3/2019 at 1:32 PM Resident #5's wife stated that she had left the facility at between 5:45 and 6:12 am on 7/30/2019 because her husband was extremely agitated. Resident #5's wife stated that when she returned to the facility the afternoon of 7/30/2019 about 1:40 PM she found that Resident #5 had a severely swollen upper lip that looked like a burn. She said that Resident #5 told her it was from hot coffee. Resident #5's wife stated that LVN D said that Resident #5 had been biting his lip all day until it swelled up, and they had put salve on it. Resident #5's wife stated Resident #5 told her that he had been spitting because he was spitting out the hot coffee. The facility sent him to the ER (Hospital #1) where she was told that the resident's lip was burned 1st and 2nd degree by the ER nurse. She stated that she took Resident #5 home and then took Resident #5 to his Resident Family MD for [MEDICAL CONDITION] 7/31/2019 then to the ER (Hospital #2). She said that when she took Resident #5 to the Hospital #2, the physicians diagnosed Resident #5 with serious scalds to his mouth and esophagus and he was emergently transferred to a burn unit in a Houston Hospital. Resident #5's wife said that Resident #5 repeatedly said it was a coffee burn. In an interview on 08/05/2019 at 9:15 AM Resident #5 stated he just did not feel like talking to the surveyor. Review of Resident #5's Responsible Party's/wife's Concern Form dated 07/30/2019 provided to surveyor by the facility on 08/05/2019 reflected; (Resident #5) had a rough night last night (7-29-19) and didn't sleep any. He told me to leave on morning of 7/30/19, at 5:30 - 5:45 AM. I returned at 1:30 PM and found that he had a swelled upper lip. The nurse said he had bitten his lip. There isn't a bite mark on his lip. He told me that the nurse gave him hot coffee to take his meds with and it burned his mouth and tongue . Review of Resident #5's Progress Notes reflected the staff did not document any behaviors, lip biting or spitting in the Progress notes until: -07/30/2019 at 7:00 AM LVN D documented Pharmacy called for obtaining [MEDICATION NAME], they have not received prescription. Pharmacist will contact MD for script. Resident behaviors continue, resident transferred to dining room for breakfast. -07/30/2019 at 7:20 AM LVN D documented Resident spitting, biting upper lip, refusing to eat and unbuttoning clothes in dining, resident removed from dining room. -07/30/2019 at 7:30 AM LVN D documented Wife notified of order for [MEDICATION NAME]. She verbalized permission to give her husband [MEDICATION NAME]. -07/30/2019 at 7:45 AM the DON documented This nurse wheeled resident to courtyard to sit with him one on one. Resident kept biting top lip and was redirected many times. -07/30/2019 at 9:25 AM LVN D documented [MEDICATION NAME] 1 mg give by mouth every 12 hours as needed for behaviors related to Altered mental Status Resident agitated and spitting continuously. -07/30/2019 at 11:53 AM LVN D documented . PRN administration was ineffective. Resident continues with behaviors. -07/30/2019 at 5:34 PM RN B documented Resident presents with increased productive cough with yellow sputum, wheezes noted in all fields bilaterally, minor respiratory distress 88-90 % on room air respiratory rate 20- 24. -07/30/2019 at 8:34 PM RN B documented Service here to transport resident to emergency department secondary to increased shortness of breath and productive cough. -7/31/2019 at 3:58 PM RN A documented weekly interdisciplinary meeting: making good progress was going to discuss discharge planning to day but client began to have behaviors, was 1:1, then developed cough and shortness of breath and was sent to ER, has not returned as of this writing. Review of the Emergency Department Triage Notes dated 07/30/2019 at 7:54 PM at Hospital #1 reflected; the Triage Registered Nurse wrote - Resident presents to the emergency Department with shortness of breath. Patient stated he drank very hot coffee with a clearly burnt upper lip. Patient is 87% on room air. Patient alert and oriented currently. Review of the Hospital #1's emergency department Provider Note dated 07/30/2019 at 10:13 PM reflected Resident #5's Chief Complaint was shortness of breath. Resident #5 presents to the Emergency Department via transport from Nursing Home for evaluation of shortness of breath which occurred prior to arrival. The patient is complaining of congestion, a productive cough, and a burned upper lip secondary to drank very hot coffee. Date and time of completed History and Physical Information: 07/30/2019 at 8:01 PM. Review of Resident #5's labs from Hospital #1 reflected he had a Critical High [NAME] Blood Cell count of 35.7 blood sample collected on 07/30/2019 at 7:58 PM (the day of the allegation of the burn) with the reference of normal being 4.8 to 10.8. Review of Resident #5's Hospital #1 Chest Computerized Axial [NAME]ography Assessment (CAT scan) performed on 07/30/2019 at 9:57 PM reflected: Opacified lower lobe bronchi, likely retained or less likely aspirated secretions. (Indications he was aspirating or what he was supposed to swallow was getting in his lungs also.) Review of Resident #5's Hospital #1's notes reflected Resident #5 was discharged to his home on 07/30/2019 at 10:30 PM. In an interview on 08/07/2019 at 4:37 PM the Houston Hospital MD stated: Treating him (Resident #5) for potential aspiration pneumonia based on elevated white blood cell count, consolidation on x-rays and a little hypoxic all suggestive of pneumonia. He now has a feeding tube. Due to his advanced age he may not recover. The EGD report has a burn pattern. He stated there was nothing to indicate a poisoning occurred and he believed hot coffee was the burn agent due to there was esophagitis and redness throughout. He [MEDICAL CONDITION] white blood cell counts to elevate and if Resident #5 was burned at 6:30 AM on 07/30/2019 his [NAME] Blood Cells would be elevated by 7:30 PM. The doctor stated he could not say definitely the burn caused the elevated white blood cells by 07/30/2019 PM but it was probable. In an interview on 08/06/2019 at 5:02 PM Resident #5's Primary Family Physician stated he saw Resident #5 in the clinic on 07/31/2019 after he had spent the night at home. He stated Resident #5 had burned his mouth on hot coffee, the burn was severe and to the entire mouth and throat. He further stated the time was appropriate for the burn event to have occurred early in the AM on 07/30/2019. Review of the Houston Hospital Emergency Department Provider Documentation dated 07/31/2019 at 9:01 PM reflected Resident #5 presented to the Emergency Department with second degree [MEDICAL CONDITION] mouth and posterior pharynx after drinking hot coffee yesterday. Review of the Houston Hospital History and Physical report dated 08/01/2019 at 3:23 AM reflected; Chief Complaint: Transferred from Hospital #2 with complaints [MEDICAL CONDITION] upper lip and mouth from hot coffee. Minor blisters to lip. [AGE] year old male with past medical history of [REDACTED]. Per history patient was at nursing home and had hot coffee which caused a burn to his oral mucosa. He was seen at outside hospital emergency roiagnom on Tuesday evening (Hospital #1 on 7/30/2019) and was later discharged . Later, he also saw his Primary Care Physician yesterday morning who prescribed oral steroids as well as antibiotic. His symptoms were worsening, difficulty eating and drinking as well as increased secretions from mouth. So, he went to outside emergency department (Hospital #2) and was referred here for ear, nose, and throat evaluation. At home he was placed on oxygen yesterday. [NAME] Blood Cells 21.9 at 07/31/19 10:52 PM. Assessment/Plan 1. Acute Hypoxemic [MEDICAL CONDITION] secondary to oral, laryngeal burn injury as well as [MEDICAL CONDITION]. 2. Burn of Oral mucosa. 3. [MEDICAL CONDITION]/[MEDICAL CONDITION]. 4. Oral Thrush 5. Dementia 8. Leukocytosis likely related to oral burns, starting on intravenous antibiotics. Review of the Houston Hospital Consultation note dated 08/01/2019 reflected; Patient transferred from local Hospital #2 after ingestion of hot coffee early this week at a nursing home with oral and laryngeal burn injury. Ingestion occurred approximately 7:30 AM on 7/30/2019. Reportedly was given two hot cups of coffee by a care giver at the facility. Later that day he was first noticed by wife to have blistering of his lips and tongue. He was having raspy voice and pain with swallowing which has been worsening. Has trouble swallowing his secretions and has not been able to eat or drink anything. Problems were worsening so he presented to ED earlier and was transferred here. Lips, tongue and palate with burn injury, sloughing mucosa. Uvula and oropharynx with [DIAGNOSES REDACTED]. Alert, mood and effect normal. Laryngoscopy and oral exam show burn injury ([MEDICAL CONDITION]/[DIAGNOSES REDACTED]) to lips, tongue, palate, epiglottis and arytenoids. Copious pooling secretions with possible aspiration. Recommend admission to hospitalist and nothing by mouth until Speech Therapy Evaluation. Recommend [MEDICATION NAME] evaluation for concern for [MEDICAL CONDITION] injury. Signed 08/01/2019 at 8:00 PM. Review of the Houston Hospital Rehabilitation Services document dated 08/01/2019 at 11:55 AM reflected a bedside speech evaluation which recommended Resident #5 no longer be given any food or fluids by mouth due to his deficits of wet vocal quality, coughing, and regurgitation/expectoration following all trials. Review of the Houston Hospital Radiology Report done 08/05/2019 at 10:21 AM (four days later) reflected Resident #5 was tested for his ability to maneuver and successfully swallow thin liquids, nectar thick liquids and pudding thick consistency. The results were that he had deep penetration with all consistencies (he could not control the substance in his mouth until he swallowed, it went down his throat without his control) and had significant residue remaining after swallowing the nectar and pudding consistencies (his swallow did not clear his throat). In an interview on 08/05/2019 at 11:30 AM the DON stated LVN D was the charge nurse who called her in early to come help with Resident #5 at 7:25 AM. The DON explained Resident #5 was extremely agitated and demonstrated multiple behaviors on the morning of 07/30/2019. She stated he was in the halls ambulating independently by the coffee service. In an interview on 08/05/2019 at 3:00 PM the Kitchen Supervisor stated, The coffee pot brews coffee at 205 degrees. He stated the procedure is for the staff to remove the lid and let it cool for 15 to 20 minutes or however long it takes for the coffee to cool to 165 to 180 degrees. He stated then the staff may send it out to the kitchenettes/dining room. He stated he only puts coffee out in the morning and it is the last thing he does when he leaves in the evening. He stated there would not be new coffee put out until 7:00 PM just before he left for the day. In an interview on 08/05/2019 at 4:10 PM the Kitchen Supervisor stated the temperatures on the flow sheet are accurate because he is the one that temped the coffee before it was put in the dining room on 07/30/2019. He stated he would not be serving the coffee for the evening until he left usually at 7:00 to 7:30 PM. When asked why there was a temperature recorded on the log for breakfast, lunch and dinner he stated he would put four pots out for breakfast to each dining room and one pot for each dining room would be put out for lunch then he said one pot would be put out to each dining room at about 7:00 PM. In an interview on 08/05/2019 at 4:41 PM the Administrator stated, I talked to the Kitchen Supervisor about the coffee temperature Saturday. We talked about state was here and the allegation was that a Resident was burned with coffee and that the nurse poured coffee down his throat. He told me he was taking temperatures and it could be anywhere from 160 to 185 degrees. In an interview on 08/05/2019 at 4:48 PM the Administrator stated, I talked to him about it yesterday (Sunday) when I got in town. In an interview on 08/05/2019 at 4:50 PM the Kitchen Supervisor stated, No one has talked to me about whether the coffee was at a safe temperature. My other facility is who taught me what a safe temperature was when we had a resident who dropped coffee on their lap and got burned. That is when I found out about proper temperatures. Today there is nothing different that is happening except that I am teaching them (kitchen staff) this is why we take the temperatures. In an interview on 08/05/2019 at 4:50 PM the Administrator stated, We have not had any other residents burned. She stated the facility did not have a policy for how the coffee should be served. In an interview on 08/05/2019 at 4:52 PM the Kitchen Supervisor stated he did not have a policy for coffee temperatures and it was the facility's practice to put the coffee in the dining room when it had cooled off to 180 degrees or below. On 08/05/2019 at 5:40 PM the Administrator and DON were notified the facility had an IJ situation for the above failures in accidents and hazards. In a telephone interview on 08/05/19 at 5:45 PM the contracted Food Service Supervisor (FSS) stated there was no policy for what temperature the facility was to serve coffee at. She stated coffee will not brew at much less than 200 degrees Fahrenheit. She further stated the facility was to cool the coffee for ten minutes after it was brewed to ensure it came down to a palatable temperature. The contracted FSS stated oatmeal will burn a resident at 150 degrees, cream soup at 160 degrees causes a really bad burn and food is placed on the steam table at 165 degrees. The contracted FSS stated if the coffee temperature was lowered it would cause a lot of residents to complain and if coffee service was placed out of reach of residents that would also make them very unhappy. In an interview on 08/06/2019 at 11:10 AM the Corporate RN stated, The temperature of the coffee that leaves the kitchen is a variable. She stated it was not the facility's policy or procedure to temp the coffee just prior to it being served to see what the serving temperature was. In an interview on 08/06/2019 at 11:17 AM the Regional Vice President stated he had clarified with the Kitchen Supervisor that the numbers on the temperature log forms were not serving temperatures, but they were prior to service temperatures. He stated there was not a policy on the temperature of the coffee coming out of the kitchen to the dining room. Interview on 08/06/2019 at 11:24 AM revealed the Regional vice President, Corporate RN and the Administrator requested the surveyor to watch the coffee brew. In an interview on 08/06/2019 at 11:30 AM the Contracted FSS stated, We temp the coffee before it is released from the kitchen and it goes to the kitchenettes (dining room). Yes, there is room for error because we do not have a set temperature for the coffee to leave the kitchen. The Administrator stated, The coffee sits for 10 to 15 minutes before the temperature is taken. Observation/interview on 08/06/2019 at 11:35 AM reflected the coffee was finished brewing straight into the insulated serving container and the temperature was 178 degrees F per the Kitchen Supervisor (measured in surveyor's presence). Surveyor asked the Kitchen Supervisor why the brew temperature was lower than what he recorded on his temp log so many times. He stated maybe it was because this was the second batch that was brewed. In an interview on 08/06/2019 at 12:14 PM RN B stated he was the nurse who sent Resident #5 to the hospital on the evening of 07/30/2019 when he had A swollen upper lip, crackles in his lungs, green sputum and a low oxygen saturation of 89% on room air. His tongue was white. The whiteness of the tongue was my concern when I looked in his mouth. LVN D had told me she thought he had mentioned he may have been burned with coffee. On a previous weekend I observed him getting another resident a cup of coffee and he kept putting one drink in the bottom of the cup. The other resident was getting angry. I kept telling him I would get the coffee. He tried to get coffee four or five times but only put one sip in each time. As far as the day I sent him out (07/30/2019), he was spitting all shift, he refused supper, he drank maybe two ounces of water total for the shift. The coffee service comes out at a different time every day. In an interview on 08/06/2019 at 3:17 PM the Medical Director who was also Resident #5's MD stated he recalled a QA meeting several months ago that some coffee was spilled. The facility was addressing it in the QA meeting. There was an issue about resident not pouring it or having their own containers. They had changed their procedures about serving it. Maybe there was a resident hurt or that there was a spill at that time. I definitely remember discussing hot liquids. I definitely remember patients shouldn't be getting it themselves. I do not feel like it was neglect. When asked was it neglect that the facility last temped the coffee at 180 degrees and then placed it on a serving cart at three-foot height in the dining room he stated; No, I guess that was not the best choice. I was not told last Tuesday (07/30/2019) we had a complaint that a resident was burned. A QA meeting would have been prudent to be done a week ago. If they knew that this was going to be an issue it should have been addressed in Q[NAME] In an interview on 08/07/2019 at 9:20 AM the Kitchen Supervisor stated it took 1.5 hours to cool the coffee to 155 degrees F after brewing. He stated he had come in early and timed it. He requested for surveyor to go to the kitchen at 9:30 AM for him to brew the coffee for lunch which was scheduled to be served at 11:00 AM. Review of the Policy Food Preparation and Service dated (MONTH) 2014 reflected; 20. Prior to the point of service, the temperature of coffee or hot beverage will be checked to ensure temperature is 155 degrees Fahrenheit or below. If above 155 degrees, ice will be added to the coffee until at or below 155 degrees. The following Plan of Removal was submitted by the Administrator on 08/07/2019 at 10:00 AM. Resident #5 involved in alleged deficient practice was sent to hospital for respiratory distress and did not return to facility. Facility notified Medical Director, (who was the resident's primary physician) was notified on 08/03/2019 of physical abuse allegation on staff member LVN D. Medical Director then was notified on 08/05/2019 of alleged coffee burn on Resident #5. Nursing staff completed full assessment of all residents residing in the facility on 08/05/2019. No signs or symptoms of burns/redness present. How are other residents at risk to be affected by this deficient practice identified? Nursing staff completed full assessment of all residents residing in the facility on 08/05/2019. All resident that are drinking coffee were identified at risk to be affected by the alleged deficient practice, none found to be affected. Facility audited water temperature logs for several months with no evidence of noncompliant practice. Maintenance Director audited on 08/05/2019 the water temperature from faucets with temperature data meeting safe temperature. Facility audited the grievances for any concerns on coffee/hot beverages on 08/05/2019. No grievances present with the alleged practice. Facility audited the resident council minutes for any concerns/issues of the alleged deficient practice on 08/05/2019. No concerns/issues present. Satisfactory surveys on coffee/hot beverages completed with residents on each hall on 08/05/2019. Facility reviewed incidents from (MONTH) to present; no burn incidents present. Resident council president interviewed on 8/6/19 and no complaints of coffee being too hot was made. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? Administrator completed 1:1 in-service with Dietary Manager on 8/5/19 on the protocol of hot beverages/coffee to ensure coffee is not served or accessible to residents at temperatures greater than 140 degrees Fahrenheit. Dietary staff in-service on the protocol of coffee/hot beverages on 8/5/19. In-service completed with dietary staff on 8/5/19 and 8/6/19 on checking coffee/hot beverage temperatures before leaving the kitchen to be served to resident to ensure temperature is 140 degrees or lower. In-service completed on five out of total of 11 dietary staff on taking temperatures before serving or releasing coffee thermos from main kitchen on 8/6/19. The other two dietary staff will be in-serviced before their next scheduled shift. Facility implemented temperature log for coffee/hot beverages to monitor the temperature with all three meals or anytime coffee/hot beverages served. In-service completed on six of the total eight dietary staff on taking temperatures before serving or releasing coffee thermos from main kitchen on 8/6/19. The other two dietary staff will be in-serviced before their next scheduled shift. 34 out of 87 nursing staff in-serviced on coffee/hot beverages protocol and reheating food/liquids protocol on 8/6/19. The rest of nursing staff will in in-serviced before their next scheduled shift. Nursing staff in-serviced to report to Administrator or designed any incidents involving hot beverages immediately. How will the system be monitored to ensure compliance? Facility will continue to in-service all new hires during orientation on hot beverages protocol. Facility will review any incidents and grievances [MEDICAL CONDITION] the Daily Interdisciplinary Team meeting. Administrator/Designee will watch return demonstration of coffee/hot beverages protocol three times a week for four weeks then one time a week for four weeks. The Administrator/Designee will review the Dietary manager Temperature Logs three times weekly for four weeks then one time a week for four weeks, or until compliance is achieved. Any discrepancies noted will be immediately reported to the Quality Assurance and performance Improvement committee for evaluation and correction. The Administrator/Designee will review the grievance log three times weekly for four weeks then one time a week for four weeks, or until compliance is achieved. Any discrepancies noted will be immediately reported to the Quality Assurance and performance Improvement committee for evaluation and correction. All finding to be reviewed in QAPI meetings with PIP review for effectiveness. New interventions to be implemented immediately when and if necessary. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 8/6/19 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The POR was accepted by the Program manager on 08/07/2019 at 10:24 AM. Monitoring for the plan of removal began on 08/07/2019 at 11:51 AM. Staff were interviewed for understanding regarding safe coffee service temperatures and reheating of hot liquids by staff. The staff voiced a good understanding of the training. 100% of the kitchen staff were in-serviced in person or by telephone. The nursing staff continued to in-service and required additional time to complete the training. The Administrator stated no staff were to be allowed to work their shift without first being trained in the new safety procedure for hot liquids. On 08/07/2019 at 1:00 PM the IJ was lifted. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of isolated due to the facility requiring time to train all staff and monitor their plan of removal.

Based on observation, interview, and record review, the facility failed to ensure in response to an allegation of abuse or neglect there was a thorough investigation, ensure further potential abuse was prevented during the investigation and ensure the investigative results were reported to the state agency for one of five residents reviewed for neglect/abuse (Resident #5). The facility failed to investigate the serious injury of Resident #5 by the administration of hot coffee which [MEDICAL CONDITION] the resident's face, mouth, and esophagus and resulted in the resident requiring emergent transfer to a specialized burn care unit. The facility was notified by the wife of Resident #5 of the specific allegation of abuse by LVN D in writing on the 7/30/2019 and did not thoroughly investigate the injury or the allegation of abuse until surveyor intervention on 08/03/2019. Additionally, the facility failed to protect the residents from the alleged staff member/perpetrator and allowed LVN D to continue working with the residents after the allegation until surveyor intervention on 08/03/2019. This failure placed all residents at risk to potentially suffer abuse with risk of physical and psychosocial harm. This failure resulted in an Immediate Jeopardy situation on 08/05/2019. While the IJ was removed on 08/07/2019, the facility remained out of compliance at a severity level of actual harm due to staff needing more time to monitor the plan of removal for accidents and hazards effectiveness. A second IJ notification was identified at the facility on 08/15/2019. While the IJ was removed on 08/15/2019, the facility remained out of compliance at a severity level of actual harm due to staff needing more time to monitor the plan of removal for thorough investigation process effectiveness. Findings included: Review of Resident #5's Face Sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Admission MDS dated [DATE] reflected; he lived in room [ROOM NUMBER], he had no difficulty with understanding others or being understood. His vision was adequate and his BIMS score was two which indicated severe cognitive impairment. The MDS reflected Resident #5's ADL self-performance was limited assistance of one person except for showers when he required physical assistance in part of the bathing activity. The MDS further reflected he normally used a walker, or a wheelchair. He was occasionally incontinent, and the discharge plan was for the resident to return to his community. Review of Resident #5's Care Plan reflected it was initiated on 07/29/2019 and had focus/problems on impaired cognition, wishes to discharge home with his wife, and his ADL plan reflected he required limited staff participation to toilet, transfer, and dress. The ADL Care Plan for eating dated 07/29/2019 reflected, The resident requires (x 1, tray set up and supervision) staff participation to eat. Review of Resident #5's Responsible Party's/wife's Concern Form dated 07/30/2019 provided to surveyor by the facility on 08/05/2019 reflected; (Resident #5) had a rough night last night (7-29-19) and didn't sleep any. He told me to leave on morning of 7/30/19, at 5:30 - 5:45 AM. I returned at 1:30 PM and found that he had a swelled upper lip. The nurse said he had bitten his lip. There isn't a bite mark on his lip. He told me that the nurse gave him hot coffee to take his meds with and it burned his mouth and tongue. When he didn't drink it, he said she poured it in his mouth. He has a blister on his top lip, and it is swelled. After this they have informed me that they are moving him to another facility. I have pictures of his mouth, and his cap where he spit out the pill when he was taking it with his coffee. (LVN D), the nurse told me he spit in his hat. The page two Response to Concern signed by the DON reflected; This nurse went right away to room [ROOM NUMBER] after receiving this concern. Upon entering the room, the responsible party was standing at the wall and texting while the resident was sitting in his char. Did you apologize for the concern? Yes. I explained to the wife that I was the one that gave him four 0.25 mg [MEDICATION NAME] with his nurse present with a cup that was white with blue flowers of water from the med cart. I asked the nurse, (LVN D), if she had given him coffee with pills and she said no. I had explained to wife that we were moving him to a memory care unit because of him taking off his clothes multiple times and running down the hallway. Later that day checked back with resident and wife and no concerns. Signed DON. Went back in room with Weekend Supervisor to do an assessment. Resident noted to have wheezes with (oxygen) saturation of 88%. Wife stated Resident had a [MEDICAL CONDITION] in the past and was on breathing treatments at times. During an interview with Resident #5's wife on 8/3/2019 at 1:32 PM Resident #5's wife stated that she had left the facility at between 5:45 and 6:12 am on 7/30/2019 because her husband was extremely agitated. She stated that LVN D was there, and that she noted that LVN D seemed frustrated with Resident #5. Resident #5's wife stated that she had been informed on 07/30/2019 that the facility was going to discharge Resident #5 due to behavior issues. Resident #5's wife stated that when she returned to the facility the afternoon of 7/30/2019 about 1:40 PM she found that Resident #5 had a severely swollen upper lip that looked like a burn. She said that Resident #5 told her that LVN D (he described LVN D to the wife) had forced him to drink hot coffee. He said that LVN D had held his chin and said, you're going to drink this and poured coffee into his mouth. Resident #5's wife stated that LVN D said that Resident #5 had been biting his lip all day until it swelled up, and they had put salve on it. Resident #5's wife stated Resident #5 told her that he had been spitting because he was spitting out the hot coffee. Resident #5's wife said that she was told that the resident was going to be sent to a different nursing home due to his behavior. She stated that later the male nurse went into the room to check on Resident #5 with LVN D and they shut the door, and then told her Resident #5 might have aspiration pneumonia. They called the doctor who sent him to the ER (Hospital #1) where she was told that the resident's lip was burned 1st and 2nd degree by the ER nurse. She stated that she took Resident #5 home and then took Resident #5 to his Resident Family MD for [MEDICAL CONDITION] 7/31/2019, but that Resident #5 was unable to go to the specialist he recommended, and she instead took him to the ER (Hospital #2) the Resident Family MD had recommended. She said that when she took Resident #5 to the Hospital #2, the physicians diagnosed Resident #5 with serious scalds to his mouth and esophagus and he was emergently transferred to a burn unit in a Houston Hospital. Resident #5's wife said that Resident #5 repeatedly said that LVN D pushed coffee and poured coffee in his mouth. Resident #5's wife stated that she was at Resident #5's bedside in the burn unit where he had been transferred. She stated that he was not able to eat, and the physicians were giving him fluids and medications intravenously. Resident #5's wife stated that she had filed a written complaint on a facility grievance form on 7/30/2019 and insisted that the man at the front desk sign the form confirming that he had received the complaint, and she requested and obtained a copy of the form at that time. Resident #5's wife sent this investigator a photograph of the copy of the form that she had submitted to the facility on [DATE]. She also sent photographs of Resident #5's injuries. Observation/interview on 8/3/2019 at 11:58 am revealed LVN D was on duty in the facility distributing medications to residents. LVN D stated that she was on duty as a unit Charge Nurse. Records review of facility staffing on 08/03/2019 revealed that LVN D worked multiple shifts after the allegation she abused Resident #5 was reported to the facility on [DATE]. Review of the facility self-report document reflected: Date reported to HHSC 8/3/2019, Time 6:49 PM (following surveyor intervention four days after the written allegation was received by the facility). Incident date: 07/30/2019 time 1:30 PM. Investigation Summary: HHSC came for a complaint survey on Resident #5 with an allegation of Abuse. On 07/30/2019 resident wife filled out a concern form that her husband had a swollen upper lip. Resident told her that the nurse gave him hot coffee to swallow his medications with and it burned his mouth and tongue. He also told his wife when he didn't drink it the nurse LVN D poured it in his mouth. Wife stated he had a blister on his lip and it was swollen. The summary did not reflect when the Administrator was made aware of the allegation, or if the alleged perpetrator was suspended, that the coffee temperatures were checked, or if the facility followed up on Resident #5's [DIAGNOSES REDACTED]. The document did not reflect the law enforcement agency was notified. The document reflected: Investigation Findings: Unfounded. It was signed on 08/04/2019 by the Administrator. In an interview on 08/05/2019 at 9:30 AM Resident #5's Responsible Party/wife stated she left the nursing home before daylight on 07/30/2019 about the time for shift change. She stated the nurse got on to him, You get in that bed and do what your told and stop aggravating your wife.' I did not like her tone. She called me later and told me he needed [MEDICATION NAME] (LVN D). Review of Resident #5's Progress Notes reflected the staff did not document any behaviors, lip biting or spitting in the Progress notes until: -07/30/2019 at 7:00 AM LVN D documented Pharmacy called for obtaining [MEDICATION NAME], they have not received prescription. Pharmacist will contact MD for script. Resident behaviors continue, resident transferred to dining room for breakfast. -07/30/2019 at 7:20 AM LVN D documented Resident spitting, biting upper lip, refusing to eat and unbuttoning clothes in dining, resident removed from dining room. -07/30/2019 at 7:30 AM LVN D documented Wife notified of order for [MEDICATION NAME]. She verbalized permission to give her husband [MEDICATION NAME]. -07/30/2019 at 7:45 AM the DON documented This nurse wheeled resident to courtyard to sit with him one on one. Resident kept biting top lip and was redirected many times. -07/30/2019 at 9:25 AM LVN D documented [MEDICATION NAME] 1 mg give by mouth every 12 hours as needed for behaviors related to Altered mental Status Resident agitated and spitting continuously. -07/30/2019 at 11:53 AM LVN D documented . PRN administration was ineffective. Resident continues with behaviors. -07/30/2019 at 5:34 PM RN B documented Resident presents with increased productive cough with yellow sputum, wheezes noted in all fields bilaterally, minor respiratory distress 88-90 % on room air respiratory rate 20- 24. -07/30/2019 at 8:34 PM RN B documented Service here to transport resident to emergency department secondary to increased shortness of breath and productive cough. -7/31/2019 at 3:58 PM RN A documented weekly interdisciplinary meeting: making good progress was going to discuss discharge planning to day but client began to have behaviors, was 1:1, then developed cough and shortness of breath and was sent to ER, has not returned as of this writing. Review of the Emergency Department Triage Notes dated 07/30/2019 at 7:54 PM at Hospital #1 reflected; the Triage Registered Nurse wrote - Resident presents to the emergency Department with shortness of breath. Patient stated he drank very hot coffee with a clearly burnt upper lip. Patient is 87% on room air. Patient alert and oriented currently. Review of the Hospital #1's emergency department Provider Note dated 07/30/2019 at 10:13 PM reflected Resident #5's Chief Complaint was shortness of breath. Resident #5 presents to the Emergency Department via transport from Nursing Home for evaluation of shortness of breath which occurred prior to arrival. According to transport service they were called to facility after Resident's oxygen saturation dropped to 87% on room air. The patient is complaining of congestion, a productive cough, and a burned upper lip secondary to drank very hot coffee. The patient has a medical history of [REDACTED]. Head eyes nose throat: Positive for congestion. Negative for ear pain and sore throat. He appears ill (chronically). No distress. Mouth/Throat: No oropharyngeal exudate. His behavior is normal. Review of Systems Respiratory: Positive for cough (productive) and shortness of breath. Review of Resident #5's labs from Hospital #1 reflected he had a Critical High [NAME] Blood Cell count of 35.7 blood sample collected on 07/30/2019 at 7:58 PM with the reference of normal being 4.8 to 10.8. Review of Resident #5's Hospital #1 Chest Computerized Axial [NAME]ography Assessment (CAT scan) performed on 07/30/2019 at 9:57 PM reflected: Opacified lower lobe bronchi, likely retained or less likely aspirated secretions. (Indications he was aspirating or what he was supposed to swallow was getting in his lungs also.) Review of Resident #5's Hospital #1's notes reflected Resident #5 was discharged to his home on 07/30/2019 at 10:30 PM. In an interview on 08/06/2019 at 7:24 AM Resident #5's responsible party stated she took Resident #5 to his personal Primary Family Physician on 07/31/2019 due to Resident #5 was in intense pain and it was scaring her. She stated she just didn't want to go to another hospital (Hospital #2), so she asked the Primary Family Physician for a specialist appointment. The Responsible Party stated when they got to the specialist on 07/31/2019 her husband stated he could not go in and sit in the specialist's office, so she took him to the Hospital #2 that her Primary Family Physician had wanted her to immediately go to when she left his office. She stated Hospital #2 saw her husband on 07/31/2019 in the emergency room and transferred him to the Houston Hospital from the emergency room . In an interview on 08/07/2019 at 4:37 PM the Houston Hospital MD stated: Treating him (Resident #5) for potential aspiration pneumonia based on elevated white blood cell count, consolidation on x-rays and a little hypoxic all suggestive of pneumonia. He now has a feeding tube. Due to his advanced age he may not recover. The EGD report has a burn pattern. He stated there was nothing to indicate a poisoning occurred and he believed hot coffee was the burn agent due to there was esophagitis and redness throughout. He [MEDICAL CONDITION] white blood cell count to elevate and if Resident #5 was burned at 6:30 AM on 07/30/2019 his [NAME] Blood Cells would be elevated by 7:30 PM. The doctor stated he could not say definitely the burn caused the elevated white blood cells by 07/30/2019 PM but it was probable. In an interview on 08/06/2019 at 5:02 PM Resident #5's Primary Family Physician stated he saw Resident #5 in the clinic on 07/31/2019 after he had spent the night at home. He stated Resident #5 had burned his mouth on hot coffee, the burn was severe and to the entire mouth and throat. He further stated the time was appropriate for the burn event to have occurred early in the AM on 07/30/2019. In an interview on 08/06/2019 at 7:54 AM Resident #5 stated, Hot coffee, she gave it to me, 'Here take a drink of this coffee.' It burned bad. I was screaming with my mouth open and she turned it up again and poured more in while my mouth was open. She was white, thin and worked at the nursing home, blonde and kind of short hair right above or touching the top of her shoulder. I don't know if anyone saw it. I was sitting down, not in my room but looking out the window in the little room by the dining room. She was mad at me. She grabbed me by the shoulder and I turned around and told her to never do that again. That was the same day. I told her never touch me again or I would check out. She sat beside me and she had two cups of coffee. I said, 'No thank you' and she throwed it down my throat. When I screamed she threw the second one in and scalded me. She has ruined my life and I am going to sue them. I was in pain. My wife got there the next morning. I was sitting on the couch that looked outside to the courtyard. Surveyor checked him for his orientation; It is 2019. I am in Memorial hospital in Houston. I am waiting on breakfast which I am never going to get. No, I do not have feeding tube now. I have a bag going through my IV (for nutrition). The electric machine does it for you. Review of the Houston Hospital Emergency Department Provider Documentation dated 07/31/2019 at 9:01 PM reflected Resident #5 presented to the Emergency Department with second degree [MEDICAL CONDITION] mouth and posterior pharynx after drinking hot coffee yesterday. Review of the Houston Hospital History and Physical report dated 08/01/2019 at 3:23 AM reflected; Chief Complaint: Transferred from Hospital #2 with complaints [MEDICAL CONDITION] upper lip and mouth from hot coffee. Minor blisters to lip. [AGE] year old male with past medical history of [REDACTED]. Per history patient was at nursing home and had hot coffee which caused a burn to his oral mucosa. He was seen at outside hospital emergency roiagnom on Tuesday evening (Hospital #1 on 7/30/2019) and was later discharged . Later, he also saw his Primary Care Physician yesterday morning who prescribed oral steroids as well as antibiotic. His symptoms were worsening, difficulty eating and drinking as well as increased secretions from mouth. So, he went to outside emergency department (Hospital #2) and was referred here for ear, nose, and throat evaluation. At home he was placed on oxygen yesterday. [NAME] Blood Cells 21.9 at 07/31/19 10:52 PM. Assessment/Plan 1. Acute Hypoxemic [MEDICAL CONDITION] secondary to oral, laryngeal burn injury as well as [MEDICAL CONDITION]. 2. Burn of Oral mucosa. 3. [MEDICAL CONDITION]/[MEDICAL CONDITION]. 4. Oral Thrush 5. Dementia 8. Leukocytosis likely related to oral burns, starting on intravenous antibiotics. Review of the Houston Hospital Consultation note dated 08/01/2019 reflected; Patient transferred from local Hospital #2 after ingestion of hot coffee early this week at a nursing home with oral and laryngeal burn injury. Ingestion occurred approximately 7:30 AM on 7/30/2019. Reportedly was given two hot cups of coffee by a care giver at the facility. Later that day he was first noticed by wife to have blistering of his lips and tongue. He was having raspy voice and pain with swallowing which has been worsening. Has trouble swallowing his secretions and has not been able to eat or drink anything. Problems were worsening so he presented to ED earlier and was transferred here. Lips, tongue and palate with burn injury, sloughing mucosa. Uvula and oropharynx with [DIAGNOSES REDACTED]. Alert, mood and effect normal. Laryngoscopy and oral exam show burn injury ([MEDICAL CONDITION]/[DIAGNOSES REDACTED]) to lips, tongue, palate, epiglottis and arytenoids. Copious pooling secretions with possible aspiration. Recommend admission to hospitalist and nothing by mouth until Speech Therapy Evaluation. Recommend [MEDICATION NAME] evaluation for concern for [MEDICAL CONDITION] injury. Signed 08/01/2019 at 8:00 PM. Review of the Houston Hospital Rehabilitation Services document dated 08/01/2019 at 11:55 AM reflected a bedside speech evaluation which recommended Resident #5 no longer be given any food or fluids by mouth due to his deficits of wet vocal quality, coughing, and regurgitation/expectoration following all trials. Review of the Houston Hospital Radiology Report done 08/05/2019 at 10:21 AM (four days later) reflected Resident #5 was tested for his ability to maneuver and successfully swallow thin liquids, nectar thick liquids and pudding thick consistency. The results were that he had deep penetration with all consistencies (he could not control the substance in his mouth until he swallowed, it went down his throat without his control) and had significant residue remaining after swallowing the nectar and pudding consistencies (his swallow did not clear his throat). Observation of hall 500 revealed it had a dining area to the left and a parlor to the right. You could see the coffee service from the hall, and from the parlor. There were two insulated coffee service containers on the top shelf of a table with coffee cups for self-service on shelves two and three. The coffee service was in the dining area throughout the survey except for short times when it was taken to the kitchen to be refilled. Review of the nursing home facility document Service Line Checklists reflected: Food serving temperatures taken and recorded on the below log prior to meal service Breakfast Lunch Dinner. Item names and temperatures for all hot and cold foods should be taken prior to service and recorded in the boxes below. -07/26/2019 - Hot Beverage Breakfast Coffee Temp (F) 175 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 180 -07/27/2019 - Hot Beverage Breakfast Coffee Temp (F) blank Lunch Coffee Temp (F) blank Dinner Coffee Temp (F) blank -07/28/2019 - Hot Beverage Breakfast Coffee Temp (F) 175 Lunch Coffee Temp (F) 170 Dinner Coffee Temp (F) 168 -07/29/2019 - Hot Beverage Breakfast Coffee Temp (F) 180 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) blank -07/30/2019 - Hot Beverage Breakfast Coffee Temp (F) 186 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 180 -07/31/2019 - Hot Beverage Breakfast Coffee Temp (F) 180 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 170 -08/01/2019 - Hot Beverage Breakfast Coffee Temp (F) 145 Lunch Coffee Temp (F) 170 Dinner No Coffee Temp (F) -08/02/2019 - Hot Beverage Breakfast Coffee Temp (F) 130 Lunch Coffee Temp (F) 160 Dinner No Coffee Temp (F) -08/03/2019 - Hot Beverage Breakfast Coffee Temp (F) 140 Lunch Coffee Temp (F) 145 Dinner Coffee Temp (F) 145 -08/04/2019 - Hot Beverage Breakfast Coffee Temp (F) 150 Lunch Coffee Temp (F) 160 Dinner Coffee Temp (F) 150 -08/05/2019 - Hot Beverage Breakfast Coffee Temp (F) 165 Lunch Coffee Temp (F) 164 Dinner Coffee Temp (F) 164 In an interview on 08/05/2019 at 11:25 AM the Administrator stated, Last week Resident #5's wife submitted a concern. She left at 5:45 AM and she was crying because he had been mean to her all night. While she was trying to leave he was chasing her out. She returned at 1:30 PM and stated (in her concern form) the resident had a swollen upper lip. The Administrator stated when she was told about the allegation she was also told the DON witnessed LVN D give Resident #5 medicine and his allegation was not true. In an interview on 08/05/2019 at 11:30 AM the DON stated LVN D was the charge nurse who called her in early to come help with him at 7:25 AM. They told me he was streaking down the hall when they tried to dress him about 10 to 14 times. He would strip his clothes off in the lounge area by the nurse station and in his room. He is fully ambulatory with a walker, but he doesn't always have it with him. I had them put him in a wheelchair, so I could take him out side to sit with him. He was yelling, he was angry, and he kept biting his lip. He never told me he had any hot coffee. I got four 0.25 mg [MEDICATION NAME] pills out of the dispensary and I have them one at a time with water in a paper cup. I brought him in the building about 8:30 to 8:45 AM and went to the morning meeting. The wife/responsible party left early the morning of 07/30/2019 which was not her normal. After she came back and filled out the concern form it was given to me. I immediately read it and went to her and explained it wasn't true as I helped the nurse give him the medicine and we gave the pills with water. I told the Administrator. That evening RN B came and got me because he was wheezing, and he was still spitting up stuff. His oxygen saturation was 89 to 90% on room air and that was when we called the doctor and sent him out. I tried to look in his mouth and he kept his lip pursed and would only show the top of his tongue, about a fourth of it. It was white. RN B told me he could see more of the tongue earlier and the tongue was white. Resident was to go by ambulance due to his change of condition. He was sent out at 8:34 PM. He had been coughing up stuff all day. He spit out his food at breakfast. He was doing that outside with me before he received any medications. He was spitting in the flower pot before he got medications. We sent him out per ambulance. She stated she was suspended for the investigation after the surveyor came to the facility on [DATE]. In an interview on 08/06/2019 at 11:47 AM the Admissions Coordinator stated she was aware Resident #5 was in the Houston hospital before the surveyor came to the facility on [DATE]. In an interview on 08/06/2019 at 12:44 PM the SW stated she was aware Resident #5 was in the Houston hospital before surveyor came to the facility on [DATE]. In an interview on 08/06/2019 at 12:12 PM the Administrator was asked why the facility did not conduct an investigation regarding Resident #5 being burned at the facility by hot coffee and allegation of abuse at the hands of LVN D made by Resident #5 and she stated, It was witnessed, and I knew it didn't happen. He was not in his right mind. The DON was a reliable witness. In an interview on 08/05/2019 at 3:00 PM the Kitchen Supervisor stated, The coffee pot brews coffee at 205 degrees. He stated the procedure is for the staff to remove the lid and let it cool for 15 to 20 minutes or however long it takes for the coffee to cool to 165 to 180 degrees. He stated then the staff may send it out to the kitchenettes/dining room. He further stated no one has asked him about coffee temperatures and he has not spoken to anyone about the coffee temperatures until today. In an interview on 08/05/2019 at 3:15 PM the Staffing Coordinator stated the coffee is made in the morning and comes to the dining rooms. It remains in the urns throughout the day and slowly cools during the day. She stated the residents have the coffee as long as there is some in the urn. In an interview on 08/05/2019 at 4:10 PM the Kitchen Supervisor stated the temperatures on the flow sheet are accurate because he is the one that temped the coffee before it was put in the kitchenettes on 07/30/2019. He stated he would not be serving the coffee for the evening until he left usually at 7:00 to 7:30 PM. When asked why there was a temperature recorded on the log for breakfast, lunch and dinner he stated he would put four pots out for breakfast to each dining room and one pot for each dining room would be put out for lunch then he said one pot would be put out to each dining room at about 7:00 PM. In an interview on 08/05/2019 at 4:41 PM when the Administrator was asked if she had investigated the allegation of abuse and the allegation that the coffee is so hot [MEDICAL CONDITION] residents the Administrator stated, I talked to the Kitchen Supervisor about the coffee temperature Saturday. We talked about state was here and the allegation was that a Resident was burned with coffee and that the nurse poured coffee down his throat. He told me he was taking temperatures and it could be anywhere from 160 to 185 degrees. After that statement, the Administrator stated she talked to the Kitchen Supervisor on Sunday after she returned from her trip. In an interview on 08/05/2019 at 4:50 PM the Kitchen Supervisor stated, No one has talked to me about whether the coffee was at a safe temperature. My other facility is who taught me what a safe temperature was when we had a resident who dropped coffee on their lap and got burned. That is when I found out about proper temperatures. Today there is nothing different that is happening except that I am teaching them (kitchen staff) this is why we take the temperatures. The Kitchen Supervisor stated the allegation of his coffee being so hot it burned the residents was never brought up to him. He further stated he felt his coffee temperatures were not a problem when they were last temped at greater than 180 degrees when they left the kitchen. In an interview on 08/05/2019 at 4:50 PM the Administrator stated, We have not had any other residents burned. She stated the facility did not have a policy for how the coffee should be served. The Administrator expressed that the residents liked their coffee hot and that lowering the temperature was going to cause many complaints. In an interview on 08/05/2019 at 4:52 PM the Kitchen Supervisor stated he did not have a policy for coffee temperatures and it was the facility's practice to put the coffee in the dining room when it had cooled off to 180 degrees F or below. On 08/05/2019 at 5:40 PM the Administrator and DON were notified the facility had an IJ situation for the above failures in accidents and hazards. In a telephone interview on 08/05/19 at 5:45 PM the contracted Food Service Supervisor (FSS) stated there was no policy for what temperature the facility was to serve coffee at. She stated coffee will not brew at much less than 200 degrees Fahrenheit. She further stated the facility was to cool the coffee for ten minutes after it was brewed to ensure it came down to a palatable temperature. The contracted FSS stated oatmeal will burn a resident at 150 degrees, cream soup at 160 degrees causes a really bad burn and food is placed on the steam table at 165 degrees. The contracted FSS stated if the coffee temperature was lowered it would cause a lot of residents to complain and if coffee service was placed out of reach of residents that would also make them very unhappy. In an interview on 08/06/2019 at 11:10 AM the Corporate RN stated, The temperature of the coffee that leaves the kitchen is a variable. She stated it was not the facility's policy or procedure to temp the coffee just prior to it being served to see what the serving temperature was. In an interview on 08/06/2019 at 11:17 AM the Regional Vice President stated he had clarified with the Kitchen Supervisor that the numbers on the temperature log forms are not serving temperatures, but they are prior to service temperatures. He stated there was not a policy on the temperature of the coffee coming out of the kitchen to the dining room. In an interview on 08/06/2019 at 11:30 AM the Contracted FSS stated, We temp the coffee before it is released from the kitchen and it goes to the kitchenettes (dining room). Yes, there is room for error because we do not have a set temperature for the coffee to leave the kitchen. The Administrator stated, The coffee sits for 10 to 15 minutes before the temperature is taken. Observation/interview on 08/06/2019 at 11:35 AM reflected the coffee was finished brewing straight into the serving container and the temperature was 178 degrees F per the Kitchen Supervisor (measured in surveyor's presence). Surveyor asked the Kitchen Supervisor why the brew temperature was lower than what he recorded on his temp log so many times. He stated maybe it was because this was the second batch that was brewed. In an interview on 08/06/2019 at 12:12 PM the Administrator was asked if she investigated the coffee temperatures or the allegation of abuse and she stated, I was here on Tuesday 07/30/2019. I didn't leave here until Wednesday. The DON was there, and it was witnessed, and I knew it didn't happen. I had a reliable witness. He (Resident #5) was not in his right mind. In an interview on 08/06/2019 at 12:14 PM RN B stated he was the nurse who sent Resident #5 to the hospital on the evening of 07/30/2019 when he had A swollen upper lip, crackles in his lungs, green sputum and a low oxyge

Based on observation, interview and record review the facility failed to ensure the resident was free from abuse or neglect for one of five residents reviewed for neglect (Resident #5). The facility neglected to ensure Resident #5's safety when they provided hot coffee that was above a safe serving temperature to the dining room when the dining room was accessible to residents and was not continually supervised. Resident #5 [MEDICAL CONDITION] his mouth and throat from the hot coffee on the morning of 07/30/2019. On 07/30/2019 the facility received the written grievance of abuse in that Resident #5 was burned by hot coffee administered by LVN D and the facility neglected to fully investigate the abuse allegation and assess and evaluate the coffee service for safe/unsafe temperatures and access by residents until surveyor intervention on 08/05/2019. These failures led to Resident #5's hospitalization in a hospital burn unit with [MEDICAL CONDITION] the mouth and throat, with the outcome of having lost the ability to eat and drink by mouth. In addition, the hot coffee temperatures could have affected any resident in the facility that drank coffee. This failure resulted in an Immediate Jeopardy situation on 08/05/2019. While the IJ was removed on 08/07/2019, the facility remained out of compliance at a severity level of actual harm due to staff needing more time to monitor the plan of removal for effectiveness. A second IJ notification for Failure to Investigate an Allegation of Abuse was identified at the facility on 08/15/2019. While the IJ was removed on 08/15/2019, the facility remained out of compliance at a severity level of actual harm due to staff needing more time to monitor the plan of removal for effectiveness. Findings included; Review of Resident #5's Face Sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Admission MDS dated [DATE] reflected; he lived in room [ROOM NUMBER], he had no difficulty with understanding others or being understood. His vision was adequate and his BIMS score was two which indicated severe cognitive impairment. The MDS reflected Resident #5's ADL self-performance was limited assistance of one person except for showers when he required physical assistance in part of the bathing activity. The MDS further reflected he normally used a walker, or a wheelchair. He was occasionally incontinent, and the discharge plan was for the resident to return to his community. Review of Resident #5's Care Plan reflected it was initiated on 07/29/2019 and had focus/problems on impaired cognition, wishes to discharge home with his wife, and his ADL plan reflected he required limited staff participation to toilet, transfer, and dress. The ADL Care Plan for eating dated 07/29/2019 reflected, The resident requires (x 1, tray set up and supervision) staff participation to eat. Review of Resident #5's Responsible Party's/wife's Concern Form dated 07/30/2019 provided to surveyor by the facility on 08/05/2019 reflected; (Resident #5) had a rough night last night (7-29-19) and didn't sleep any. He told me to leave on morning of 7/30/19, at 5:30 - 5:45 AM. I returned at 1:30 PM and found that he had a swelled upper lip. The nurse said he had bitten his lip. There isn't a bite mark on his lip. He told me that the nurse gave him hot coffee to take his meds with and it burned his mouth and tongue. When he didn't drink it, he said she poured it in his mouth. He has a blister on his top lip, and it is swelled. After this they have informed me that they are moving him to another facility. I have pictures of his mouth, and his cap where he spit out the pill when he was taking it with his coffee. (LVN D), the nurse told me he spit in his hat. The page two Response to Concern signed by the DON reflected; This nurse went right away to room [ROOM NUMBER] after receiving this concern. Upon entering the room, the responsible party was standing at the wall and texting while the resident was sitting in his char. Did you apologize for the concern? Yes. I explained to the wife that I was the one that gave him four 0.25 mg [MEDICATION NAME] with his nurse present with a cup that was white with blue flowers of water from the med cart. I asked the nurse, (LVN D), if she had given him coffee with pills and she said no. I had explained to wife that we were moving him to a memory care unit because of him taking off his clothes multiple times and running down the hallway. Later that day checked back with resident and wife and no concerns. Signed DON. Went back in room with Weekend Supervisor to do an assessment. Resident noted to have wheezes with (oxygen) saturation of 88%. Wife stated Resident had a [MEDICAL CONDITION] in the past and was on breathing treatments at times. During an interview with Resident #5's wife on 8/3/2019 at 1:32 PM Resident #5's wife stated that she had left the facility at between 5:45 and 6:12 am on 7/30/2019 because her husband was extremely agitated. She stated that LVN D was there, and that she noted that LVN D seemed frustrated with Resident #5. Resident #5's wife stated that she had been informed on 07/30/2019 that the facility was going to discharge Resident #5 due to behavior issues. Resident #5's wife stated that when she returned to the facility the afternoon of 7/30/2019 about 1:40 PM she found that Resident #5 had a severely swollen upper lip that looked like a burn. She said that Resident #5 told her that LVN D (he described LVN D to the wife) had forced him to drink hot coffee. He said that LVN D had held his chin and said, you're going to drink this and poured coffee into his mouth. Resident #5's wife stated that LVN D said that Resident #5 had been biting his lip all day until it swelled up, and they had put salve on it. Resident #5's wife stated Resident #5 told her that he had been spitting because he was spitting out the hot coffee. Resident #5's wife said that she was told that the resident was going to be sent to a different nursing home due to his behavior. She stated that later the male nurse went into the room to check on Resident #5 with LVN D and they shut the door, and then told her Resident #5 might have aspiration pneumonia. They called the doctor who sent him to the ER (Hospital #1) where she was told that the resident's lip was burned 1st and 2nd degree by the ER nurse. She stated that she took Resident #5 home and then took Resident #5 to his Resident Family MD for [MEDICAL CONDITION] 7/31/2019, but that Resident #5 was unable to go to the specialist he recommended, and she instead took him to the ER (Hospital #2) the Resident Family MD had recommended. She said that when she took Resident #5 to the Hospital #2, the physicians diagnosed Resident #5 with serious scalds to his mouth and esophagus and he was emergently transferred to a burn unit in a Houston Hospital. Resident #5's wife said that Resident #5 repeatedly said that LVN D pushed coffee and poured coffee in his mouth. Resident #5's wife stated that she was at Resident #5's bedside in the burn unit where he had been transferred. She stated that he was not able to eat, and the physicians were giving him fluids and medications intravenously. Resident #5's wife stated that she had filed a written complaint on a facility grievance form on 7/30/2019 and insisted that the man at the front desk sign the form confirming that he had received the complaint, and she requested and obtained a copy of the form at that time. Resident #5's wife sent this investigator a photograph of the copy of the form that she had submitted to the facility on [DATE]. She also sent photographs of Resident #5's injuries. Observation/interview on 8/3/2019 at 11:58 am revealed LVN D was on duty in the facility distributing medications to residents. LVN D stated that she was on duty as a unit Charge Nurse. Records review of facility staffing on 08/03/2019 revealed that LVN D worked multiple shifts after the allegation she abused Resident #5 was reported to the facility on [DATE]. Review of the facility self-report document reflected: Date reported to HHSC 8/3/2019, Time 6:49 PM (following surveyor intervention four days after the written allegation was received by the facility). Incident date: 07/30/2019 time 1:30 PM. Investigation Summary: HHSC came for a complaint survey on Resident #5 with an allegation of Abuse. On 07/30/2019 resident wife filled out a concern form that her husband had a swollen upper lip. Resident told her that the nurse gave him hot coffee to swallow his medications with and it burned his mouth and tongue. He also told his wife when he didn't drink it the nurse LVN D poured it in his mouth. Wife stated he had a blister on his lip and it was swollen. The summary did not reflect when the Administrator was made aware of the allegation, or if the alleged perpetrator was suspended, that the coffee temperatures were checked, or if the facility followed up on Resident #5's [DIAGNOSES REDACTED]. The document did not reflect the law enforcement agency was notified. The document reflected: Investigation Findings: Unfounded. It was signed on 08/04/2019 by the Administrator. In an interview on 08/05/2019 at 9:30 AM Resident #5's Responsible Party/wife stated she left the nursing home before daylight on 07/30/2019 about the time for shift change. She stated the nurse got on to him, You get in that bed and do what your told and stop aggravating your wife.' I did not like her tone. She called me later and told me he needed [MEDICATION NAME] (LVN D). In an interview on 08/07/2019 at 9:20 AM the Kitchen Supervisor stated it took 1.5 hours to cool the coffee to 155 degrees F after brewing. He stated he had came in early and timed it. He requested for surveyor to go to the kitchen at 9:30 AM for him to brew the coffee for lunch which was scheduled to be served at 11:00 AM. In an interview on 08/07/2019 at 9:25 AM the Staffing Coordinator stated the coffee comes to the satellite dining area at about 5:30 AM every morning. The coffee is available on a serving cart with cups on the lower shelves. In an interview on 08/07/2019 at 12:25 PM CNA F stated, No one has ever said the coffee service had to be continually monitored. In an interview on 08/07/2019 at 12:29 PM LVN C stated, No one has ever said the coffee service had to be continually monitored. In an interview on 08/07/2019 at 12:32 PM CNA [NAME] stated, Breakfast comes out at about 6:45 AM and the coffee service comes out before then. She stated she starts resident care as soon as she gets to work but they try to keep an eye on the coffee service and resident who may try to get their own coffee. Review of Resident #5's Progress Notes reflected the staff did not document any behaviors, lip biting or spitting in the Progress notes until: -07/30/2019 at 7:00 AM LVN D documented Pharmacy called for obtaining [MEDICATION NAME], they have not received prescription. Pharmacist will contact MD for script. Resident behaviors continue, resident transferred to dining room for breakfast. -07/30/2019 at 7:20 AM LVN D documented Resident spitting, biting upper lip, refusing to eat and unbuttoning clothes in dining, resident removed from dining room. -07/30/2019 at 7:30 AM LVN D documented Wife notified of order for [MEDICATION NAME]. She verbalized permission to give her husband [MEDICATION NAME]. -07/30/2019 at 7:45 AM the DON documented This nurse wheeled resident to courtyard to sit with him one on one. Resident kept biting top lip and was redirected many times. -07/30/2019 at 9:25 AM LVN D documented [MEDICATION NAME] 1 mg give by mouth every 12 hours as needed for behaviors related to Altered mental Status Resident agitated and spitting continuously. -07/30/2019 at 11:53 AM LVN D documented . PRN administration was ineffective. Resident continues with behaviors. -07/30/2019 at 5:34 PM RN B documented Resident presents with increased productive cough with yellow sputum, wheezes noted in all fields bilaterally, minor respiratory distress 88-90 % on room air respiratory rate 20- 24. -07/30/2019 at 8:34 PM RN B documented Service here to transport resident to emergency department secondary to increased shortness of breath and productive cough. -7/31/2019 at 3:58 PM RN A documented weekly interdisciplinary meeting: making good progress was going to discuss discharge planning to day but client began to have behaviors, was 1:1, then developed cough and shortness of breath and was sent to ER, has not returned as of this writing. Review of the Emergency Department Triage Notes dated 07/30/2019 at 7:54 PM at Hospital #1 reflected; the Triage Registered Nurse wrote - Resident presents to the emergency Department with shortness of breath. Patient stated he drank very hot coffee with a clearly burnt upper lip. Patient is 87% on room air. Patient alert and oriented currently. Review of the Hospital #1's emergency department Provider Note dated 07/30/2019 at 10:13 PM reflected Resident #5's Chief Complaint was shortness of breath. Resident #5 presents to the Emergency Department via transport from Nursing Home for evaluation of shortness of breath which occurred prior to arrival. According to transport service they were called to facility after Resident's oxygen saturation dropped to 87% on room air. The patient is complaining of congestion, a productive cough, and a burned upper lip secondary to drank very hot coffee. The patient has a medical history of [REDACTED]. Head eyes nose throat: Positive for congestion. Negative for ear pain and sore throat. He appears ill (chronically). No distress. Mouth/Throat: No oropharyngeal exudate. His behavior is normal. Review of Systems Respiratory: Positive for cough (productive) and shortness of breath. Review of Resident #5's labs from Hospital #1 reflected he had a Critical High [NAME] Blood Cell count of 35.7 blood sample collected on 07/30/2019 at 7:58 PM with the reference of normal being 4.8 to 10.8. Review of Resident #5's Hospital #1 Chest Computerized Axial [NAME]ography Assessment (CAT scan) performed on 07/30/2019 at 9:57 PM reflected: Opacified lower lobe bronchi, likely retained or less likely aspirated secretions. (Indications he was aspirating or what he was supposed to swallow was getting in his lungs also.) Review of Resident #5's Hospital #1's notes reflected Resident #5 was discharged to his home on 07/30/2019 at 10:30 PM. In an interview on 08/06/2019 at 7:24 AM Resident #5's responsible party stated she took Resident #5 to his personal Primary Family Physician on 07/31/2019 due to Resident #5 was in intense pain and it was scaring her. She stated she just didn't want to go to another hospital (Hospital #2), so she asked the Primary Family Physician for a specialist appointment. The Responsible Party stated when they got to the specialist on 07/31/2019 her husband stated he could not go in and sit in the specialist's office, so she took him to the Hospital #2 that her Primary Family Physician had wanted her to immediately go to when she left his office. She stated Hospital #2 saw her husband on 07/31/2019 in the emergency room and transferred him to the Houston Hospital from the emergency room . In an interview on 08/07/2019 at 4:37 PM the Houston Hospital MD stated: Treating him (Resident #5) for potential aspiration pneumonia based on elevated white blood cell count, consolidation on x-rays and a little hypoxic all suggestive of pneumonia. He now has a feeding tube. Due to his advanced age he may not recover. The EGD report has a burn pattern. He stated there was nothing to indicate a poisoning occurred and he believed hot coffee was the burn agent due to there was esophagitis and redness throughout. He [MEDICAL CONDITION] white blood cell count to elevate and if Resident #5 was burned at 6:30 AM on 07/30/2019 his [NAME] Blood Cells would be elevated by 7:30 PM. The doctor stated he could not say definitely the burn caused the elevated white blood cells by 07/30/2019 PM but it was probable. In an interview on 08/06/2019 at 5:02 PM Resident #5's Primary Family Physician stated he saw Resident #5 in the clinic on 07/31/2019 after he had spent the night at home. He stated Resident #5 had burned his mouth on hot coffee, the burn was severe and to the entire mouth and throat. He further stated the time was appropriate for the burn event to have occurred early in the AM on 07/30/2019. In an interview on 08/06/2019 at 7:54 AM Resident #5 stated, Hot coffee, she gave it to me, 'Here take a drink of this coffee.' It burned bad. I was screaming with my mouth open and she turned it up again and poured more in while my mouth was open. She was white, thin and worked at the nursing home, blonde and kind of short hair right above or touching the top of her shoulder. I don't know if anyone saw it. I was sitting down, not in my room but looking out the window in the little room by the dining room. She was mad at me. She grabbed me by the shoulder and I turned around and told her to never do that again. That was the same day. I told her never touch me again or I would check out. She sat beside me and she had two cups of coffee. I said, 'No thank you' and she throwed it down my throat. When I screamed she threw the second one in and scalded me. She has ruined my life and I am going to sue them. I was in pain. My wife got there the next morning. I was sitting on the couch that looked outside to the courtyard. Surveyor checked him for his orientation; It is 2019. I am in Memorial hospital in Houston. I am waiting on breakfast which I am never going to get. No, I do not have feeding tube now. I have a bag going through my IV (for nutrition). The electric machine does it for you. Review of the Houston Hospital Emergency Department Provider Documentation dated 07/31/2019 at 9:01 PM reflected Resident #5 presented to the Emergency Department with second degree [MEDICAL CONDITION] mouth and posterior pharynx after drinking hot coffee yesterday. Review of the Houston Hospital History and Physical report dated 08/01/2019 at 3:23 AM reflected; Chief Complaint: Transferred from Hospital #2 with complaints [MEDICAL CONDITION] upper lip and mouth from hot coffee. Minor blisters to lip. [AGE] year old male with past medical history of [REDACTED]. Per history patient was at nursing home and had hot coffee which caused a burn to his oral mucosa. He was seen at outside hospital emergency roiagnom on Tuesday evening (Hospital #1 on 7/30/2019) and was later discharged . Later, he also saw his Primary Care Physician yesterday morning who prescribed oral steroids as well as antibiotic. His symptoms were worsening, difficulty eating and drinking as well as increased secretions from mouth. So, he went to outside emergency department (Hospital #2) and was referred here for ear, nose, and throat evaluation. At home he was placed on oxygen yesterday. [NAME] Blood Cells 21.9 at 07/31/19 10:52 PM. Assessment/Plan 1. Acute Hypoxemic [MEDICAL CONDITION] secondary to oral, laryngeal burn injury as well as [MEDICAL CONDITION]. 2. Burn of Oral mucosa. 3. [MEDICAL CONDITION]/[MEDICAL CONDITION]. 4. Oral Thrush 5. Dementia 8. Leukocytosis likely related to oral burns, starting on intravenous antibiotics. Review of the Houston Hospital Consultation note dated 08/01/2019 reflected; Patient transferred from local Hospital #2 after ingestion of hot coffee early this week at a nursing home with oral and laryngeal burn injury. Ingestion occurred approximately 7:30 AM on 7/30/2019. Reportedly was given two hot cups of coffee by a care giver at the facility. Later that day he was first noticed by wife to have blistering of his lips and tongue. He was having raspy voice and pain with swallowing which has been worsening. Has trouble swallowing his secretions and has not been able to eat or drink anything. Problems were worsening so he presented to ED earlier and was transferred here. Lips, tongue and palate with burn injury, sloughing mucosa. Uvula and oropharynx with [DIAGNOSES REDACTED]. Alert, mood and effect normal. Laryngoscopy and oral exam show burn injury ([MEDICAL CONDITION]/[DIAGNOSES REDACTED]) to lips, tongue, palate, epiglottis and arytenoids. Copious pooling secretions with possible aspiration. Recommend admission to hospitalist and nothing by mouth until Speech Therapy Evaluation. Recommend [MEDICATION NAME] evaluation for concern for [MEDICAL CONDITION] injury. Signed 08/01/2019 at 8:00 PM. Review of the Houston Hospital Rehabilitation Services document dated 08/01/2019 at 11:55 AM reflected a bedside speech evaluation which recommended Resident #5 no longer be given any food or fluids by mouth due to his deficits of wet vocal quality, coughing, and regurgitation/expectoration following all trials. Review of the Houston Hospital Radiology Report done 08/05/2019 at 10:21 AM (four days later) reflected Resident #5 was tested for his ability to maneuver and successfully swallow thin liquids, nectar thick liquids and pudding thick consistency. The results were that he had deep penetration with all consistencies (he could not control the substance in his mouth until he swallowed, it went down his throat without his control) and had significant residue remaining after swallowing the nectar and pudding consistencies (his swallow did not clear his throat). Observation of hall 500 revealed it had a dining area to the left and a parlor to the right. You could see the coffee service from the hall, and from the parlor. There were two insulated coffee service containers on the top shelf of a table with coffee cups for self-service on shelves two and three. The coffee service was in the dining area throughout the survey except for short times when it was taken to the kitchen to be refilled. Review of the nursing home facility document Service Line Checklists reflected: Food serving temperatures taken and recorded on the below log prior to meal service Breakfast Lunch Dinner. Item names and temperatures for all hot and cold foods should be taken prior to service and recorded in the boxes below. -07/26/2019 - Hot Beverage Breakfast Coffee Temp (F) 175 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 180 -07/27/2019 - Hot Beverage Breakfast Coffee Temp (F) blank Lunch Coffee Temp (F) blank Dinner Coffee Temp (F) blank -07/28/2019 - Hot Beverage Breakfast Coffee Temp (F) 175 Lunch Coffee Temp (F) 170 Dinner Coffee Temp (F) 168 -07/29/2019 - Hot Beverage Breakfast Coffee Temp (F) 180 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) blank -07/30/2019 - Hot Beverage Breakfast Coffee Temp (F) 186 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 180 -07/31/2019 - Hot Beverage Breakfast Coffee Temp (F) 180 Lunch Coffee Temp (F) 175 Dinner Coffee Temp (F) 170 -08/01/2019 - Hot Beverage Breakfast Coffee Temp (F) 145 Lunch Coffee Temp (F) 170 Dinner No Coffee Temp (F) -08/02/2019 - Hot Beverage Breakfast Coffee Temp (F) 130 Lunch Coffee Temp (F) 160 Dinner No Coffee Temp (F) -08/03/2019 - Hot Beverage Breakfast Coffee Temp (F) 140 Lunch Coffee Temp (F) 145 Dinner Coffee Temp (F) 145 -08/04/2019 - Hot Beverage Breakfast Coffee Temp (F) 150 Lunch Coffee Temp (F) 160 Dinner Coffee Temp (F) 150 -08/05/2019 - Hot Beverage Breakfast Coffee Temp (F) 165 Lunch Coffee Temp (F) 164 Dinner Coffee Temp (F) 164 In an interview on 08/05/2019 at 11:25 AM the Administrator stated, Last week Resident #5's wife submitted a concern. She left at 5:45 AM and she was crying because he had been mean to her all night. While she was trying to leave he was chasing her out. She returned at 1:30 PM and stated (in her concern form) the resident had a swollen upper lip. The Administrator stated when she was told about the allegation she was also told the DON witnessed LVN D give Resident #5 medicine and his allegation was not true. In an interview on 08/05/2019 at 11:30 AM the DON stated LVN D was the charge nurse who called her in early to come help with him at 7:25 AM. They told me he was streaking down the hall when they tried to dress him about 10 to 14 times. He would strip his clothes off in the lounge area by the nurse station and in his room. He is fully ambulatory with a walker, but he doesn't always have it with him. I had them put him in a wheelchair, so I could take him out side to sit with him. He was yelling, he was angry, and he kept biting his lip. He never told me he had any hot coffee. I got four 0.25 mg [MEDICATION NAME] pills out of the dispensary and I have them one at a time with water in a paper cup. I brought him in the building about 8:30 to 8:45 AM and went to the morning meeting. The wife/responsible party left early the morning of 07/30/2019 which was not her normal. After she came back and filled out the concern form it was given to me. I immediately read it and went to her and explained it wasn't true as I helped the nurse give him the medicine and we gave the pills with water. I told the Administrator. That evening RN B came and got me because he was wheezing, and he was still spitting up stuff. His oxygen saturation was 89 to 90% on room air and that was when we called the doctor and sent him out. I tried to look in his mouth and he kept his lip pursed and would only show the top of his tongue, about a fourth of it. It was white. RN B told me he could see more of the tongue earlier and the tongue was white. Resident was to go by ambulance due to his change of condition. He was sent out at 8:34 PM. He had been coughing up stuff all day. He spit out his food at breakfast. He was doing that outside with me before he received any medications. He was spitting in the flower pot before he got medications. We sent him out per ambulance. She stated she was suspended for the investigation after the surveyor came to the facility on [DATE]. In an interview on 08/06/2019 at 11:47 AM the Admissions Coordinator stated she was aware Resident #5 was in the Houston hospital before the surveyor came to the facility on [DATE]. In an interview on 08/06/2019 at 12:44 PM the SW stated she was aware Resident #5 was in the Houston hospital before surveyor came to the facility on [DATE]. In an interview on 08/06/2019 at 12:12 PM the Administrator was asked why the facility did not conduct an investigation regarding Resident #5 being burned at the facility by hot coffee and allegation of abuse at the hands of LVN D made by Resident #5 and she stated, It was witnessed, and I knew it didn't happen. He was not in his right mind. The DON was a reliable witness. In an interview on 08/05/2019 at 3:00 PM the Kitchen Supervisor stated, The coffee pot brews coffee at 205 degrees. He stated the procedure is for the staff to remove the lid and let it cool for 15 to 20 minutes or however long it takes for the coffee to cool to 165 to 180 degrees. He stated then the staff may send it out to the kitchenettes/dining room. He further stated no one has asked him about coffee temperatures and he has not spoken to anyone about the coffee temperatures until today. In an interview on 08/05/2019 at 3:15 PM the Staffing Coordinator stated the coffee is made in the morning and comes to the dining rooms. It remains in the urns throughout the day and slowly cools during the day. She stated the residents have the coffee as long as there is some in the urn. In an interview on 08/05/2019 at 4:10 PM the Kitchen Supervisor stated the temperatures on the flow sheet are accurate because he is the one that temped the coffee before it was put in the kitchenettes on 07/30/2019. He stated he would not be serving the coffee for the evening until he left usually at 7:00 to 7:30 PM. When asked why there was a temperature recorded on the log for breakfast, lunch and dinner he stated he would put four pots out for breakfast to each dining room and one pot for each dining room would be put out for lunch then he said one pot would be put out to each dining room at about 7:00 PM. In an interview on 08/05/2019 at 4:41 PM when the Administrator was asked if she had investigated the allegation of abuse and the allegation that the coffee is so hot [MEDICAL CONDITION] residents the Administrator stated, I talked to the Kitchen Supervisor about the coffee temperature Saturday. We talked about state was here and the allegation was that a Resident was burned with coffee and that the nurse poured coffee down his throat. He told me he was taking temperatures and it could be anywhere from 160 to 185 degrees. After that statement, the Administrator stated she talked to the Kitchen Supervisor on Sunday after she returned from her trip. In an interview on 08/05/2019 at 4:50 PM the Kitchen Supervisor stated, No one has talked to me about whether the coffee was at a safe temperature. My other facility is who taught me what a safe temperature was when we had a resident who dropped coffee on their lap and got burned. That is when I found out about proper temperatures. Today there is nothing different that is happening except that I am teaching them (kitchen staff) this is why we take the temperatures. The Kitchen Supervisor stated the allegation of his coffee being so hot it burned the residents was never brought up to him. He further stated he felt his coffee temperatures were not a problem when they were last temped at greater than 180 degrees when they left the kitchen. In an interview on 08/05/2019 at 4:50 PM the Administrator stated, We have not had any other residents burned. She stated the facility did not have a policy for how the coffee should be served. The Administrator expressed that the residents liked their coffee hot and that lowering the temperature was going to cause many complaints. In an interview on 08/05/2019 at 4:52 PM the Kitchen Supervisor stated he did not have a policy for coffee temperatures and it was the facility's practice to put the coffee in the dining room when it had cooled off to 180 degrees F or below. On 08/05/2019 at 5:40 PM the Administrator and DON were notified the facility had an IJ situation for the above failures in accidents and hazards. In a telephone interview on 08/05/19 at 5:45 PM the contracted Food Service Supervisor (FSS) stated there was no policy for what temperature the facility was to serve coffee at. She stated coffee will not brew at much less than 200 degrees Fahrenheit. She further stated the facility was to cool the coffee for ten minutes after it was brewed to ensure it came down to a palatable temperature. The contracted FSS stated oatmeal will burn a resident at 150 degrees, cream soup at 160 degrees causes a really bad burn and food is placed on the steam table at 165 degrees. The contracted FSS stated if the coffee temperature was lowered it would cause a lot of residents to complain and if coffee service was placed out of reach of residents that would also make them very unhappy. In an interview on 08/06/2019 at 11:10 AM the Corporate RN stated, The temperature of the coffee that leaves the kitchen is a variable. She stated it was not the facility's policy or procedure to temp the coffee just prior to it being served to see what the serving temperature was. In an interview on 08/06/2019 at 11:17 AM the Regional Vice President stated he had clarified with the Kitchen Supervisor that the numbers on the temperature log forms are not serving temperatures, but they are prior to service temperatures. He stated there was not a policy on the temperature of the coffee coming out of the kitchen to the dining room. In an interview on 08/06/2019 at 11:30 AM the Contracted FSS stated, We temp the coffee before it is released from the kitchen and it goes to the kitchenettes (dining room). Yes, there is room for error because we do not have a set temperature for the coffee to leave the kitchen. The Administrator stated, The coffee sits fo