Every finding on record at Aviata at Santa Barbara

Based on record review, review of facility's policy and procedure and staff interviews, the facility failed to provide immediate and appropriate basic life support to 1 (Resident #1) of 3 residents reviewed with full code status (Administer cardiopulmonary resuscitation in the event of cardiac or respiratory arrest).On [DATE] at approximately 2:07 a.m., the clinical staff consisting of one Registered Nurse (RN) and one Licensed Practical Nurse (LPN) administered Cardiopulmonary resuscitation (CPR) to Resident #1 when he was found without a pulse or respirations. The Licensed Nurses did not activate Emergency Medical Services (EMS) and discontinued CPR after approximately 20 minutes. The RN pronounced the resident's death without the required credentials. Clinical staff re-started CPR 4 hours later at the direction of the Director of Nursing and called EMS. Resident #1 was pronounced deceased by EMS.The facility failure to immediately activate EMS and administer CPR to Resident #1 until the arrival of EMS placed other residents with full code status at a likelihood of serious injury or death from not receiving appropriate lifesaving interventions in the event of cardiac and/or respiratory arrest. This failure resulted in the determination of Immediate Jeopardy (IJ).On [DATE], after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed, effective [DATE]. The scope and severity were reduced to D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.The findings included:Cross Reference F726Review of the facility's policy and procedure titled, Florida Cardiopulmonary Resuscitation (CPR) with a revision date of [DATE] revealed, Cardiopulmonary Resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. In the event of cardiac arrest, immediately call for assistance . Use the page system and call Code Blue to Room Number or location of the event three times. In the absence of a fully executed Florida Do Not Resuscitate order . the facility will immediately begin CPR. Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if the resident responds .Review of the clinical record for Resident #1 revealed an admission date of [DATE]. Diagnoses included Peripheral Vascular Disease (a slow-progressing circulation disorder involving the narrowing, blockage, or spasms of blood vessels), Chronic Obstructive Pulmonary Disorder (a condition that restricts airflow and makes breathing difficult), Vascular Dementia and Alzheimer's Disease.The physician's order dated [DATE] specified Full Code status.The care plan initiated on [DATE] noted that Resident #1had, Incapacity and Guardianship by Court Order honoring his wishes Full Code.On [DATE] at 2:07 a.m., RN Staff A wrote in a nursing progress note, CNA (Certified Nursing Assistant) called me. She found the resident unresponsive in his bed at 2:07 am. Assessment: Absence of pulse/Respiration. Pupils do not respond. DON (Director of Nursing), Guardian and Provider was [sic] notified.On [DATE] at 6:00 a.m., the DON wrote in a progress note, Received a message from assigned Nurse that resident has no pulse, no respiration, no blood pressure. It was reported that a CNA found the resident, assigned nurse-initiated CPR, EMS was notified, arrived at facility, continue CPR, unable to revive resident. EMS pronounced resident expired at 6:31 AM with Diagnosis: Sudden Cardiac arrest.Review of the EMS Patient Care Record dated [DATE] revealed EMS was activated on [DATE] at 6:18 a.m., arrived at the facility at 6:27 a.m., and pronounced Resident #1's death at 6:31 a.m. The EMS report noted that the patient's jaw was locked and non-moveable. The patient's extremities were stiff and unmovable. The narrative noted that on arrival, facility staff was doing active CPR. Resuscitation was not attempted-Considered Futile. The first impression was Rigor Mortis (postmortem stiffening of the muscles), Algor Mortis (postmortem cooling of the body), Apneic (cessation of breathing), Pulseless and Unresponsiveness. EMS documentation noted facility staff on scene stated the last time they saw the pt (patient) was 11pm last night. On [DATE] at 9:44 a.m., in an interview, the Administrator said that they investigated the incident and concluded that on [DATE] at 2:00 a.m., 911 was not called when Resident #1 was found unresponsive.Review of the facility provided investigation revealed:On [DATE], Certified Nursing Assistant (CNA) Staff C wrote in a witness statement that on [DATE] at 2:00 a.m., she found Resident #1 unresponsive and immediately notified RN Staff A. RN Staff A said that she already knew that the resident was going to die and instructed her to clean the resident. Another CNA helped her clean and cover Resident #1.On [DATE] RN Staff A documented in a witness statement that on [DATE] around 2:00 a.m., one of the caregivers told her that she thought Resident #1 was dead. She ran to the door, called LPN Staff B and said, Hey Code Blue. LPN Staff B brought the crash cart and they started CPR. RN Staff A said they administered CPR to Resident #1 for approximately 20 minutes. She told LPN Staff B that the resident had no vital signs (pulse, respiration, blood pressure) but he was warm and not responding at all. She thought Resident #1 was in hospice and that was the reason why she did not call 911. On [DATE] at approximately 5:50 a.m., the DON called and asked her if she had called 911. She then immediately called 911. They arrived at 6:00 a.m. and took control of the situation.On [DATE], LPN Staff B wrote in a witness statement that a Certified Nursing Assistant (CNA) notified RN Staff A that Resident #1 was unresponsive. RN Staff A checked her report sheet and called a code blue. He took the crash cart to the room, and they administered CPR to the resident. After about 20 minutes, RN Staff A called it off and said something about, He was gone or words to that effect. RN Staff A then started calling people.On [DATE], CNA Staff D wrote in a witness statement that she came in to work early on [DATE]. RN Staff A asked her to put the board under Resident #1 (Firm board to ensure effective chest compressions during CPR) and do compressions. She was doing compressions when EMS arrived. One minute later, EMS told her to stop the compressions. She left the room.On [DATE] at 10:39 a.m., in a telephone interview, CNA Staff D said that on [DATE] at around 6:00 a.m., RN Staff A asked her to place the board under Resident #1 and do chest compressions until EMS arrives. She had done 5 or 6 compressions when EMS arrived. She continued the chest compressions until EMS told her to stop.On [DATE] at 11:20 a.m., in a telephone interview, RN Staff A said that on [DATE] she was the nurse in charge for the night shift. At approximately 2:00 a.m., CNA Staff C told her that she thought Resident #1 had died. She yelled Code Blue and yelled for help. LPN Staff B brought the crash cart, and they administered CPR to the resident. After 3 to 5 rounds of CPR, she told LPN Staff B that Resident #1 was not there anymore. She said, I don't pronounce anyone dead, but he was without vital signs. She called the CNAs and they cleaned him up. RN Staff A verified she did not call 911 and discontinued CPR. RN Staff A said, This is not my normal resident. I thought he was hospice, so I did not call 911. She notified the DON, the Provider and Resident #1's family members. She said at approximately 5:50 a.m., the DON called the facility and asked if she had called 911. She told the DON that she had not called 911 since she was by herself with the CNA and LPN Staff B. RN Staff A said she told the DON that she was confused about who was on hospice and who was a full code. RN Staff A said, I don't pronounce them dead, but I knew he was dead, no vitals, no respirations. Nurses don't pronounce residents dead. We found him dead, we know he is dead because it is clinical. RN Staff A said the DON instructed her to call 911. She said she reinitiated CPR at 6:00 a.m. after calling 911. RN Staff A said, We tried to do something until EMS came because they have to see us doing CPR. They repronounced him dead after that. RN Staff A verified that she reinitiated CPR approximately 4 hours after Resident #1 had no pulse or respirations and CPR was stopped.On [DATE] at 1:22 p.m., in an interview, the DON said that on [DATE] at 2:42 a.m., RN Staff A sent her a text message letting her know that Resident #1 had expired. She called the facility at approximately 6:00 a.m., and instructed RN Staff A to call 911. She did not know why RN Staff A reinitiated CPR. She verified that the facility's investigation determined that RN Staff A and LPN Staff B did not follow the facility's established policy and procedure to call 911 and administer CPR to Resident #1 until the arrival of EMS.On [DATE] at 8:48 a.m., in a telephone interview, CNA Staff C said that on [DATE] at around 2:00 a.m., she found Resident #1 unresponsive and immediately notified RN Staff A. CNA Staff C said that RN Staff A came to the resident's room, took vital signs then instructed her to clean the resident.On [DATE] at 3:11 p.m., in a telephone interview, the Medical Director said that Resident #1 was a full code. They should have started CPR and called 911. He said that CPR should not be done 4 hours after a resident is pronounced On [DATE], the survey team verified through review of the CPR certification for all licensed nurses currently employed at the facility.Starting on [DATE], the Director of Nursing and/or nursing management educated licensed nurses on CPR policy and procedure and Florida DNRO (Do Not Resuscitate Order) policy. This included where to find the code status. Education also addressed what to do for scenario with full code hospice residents. Education was completed on initiating EMS services immediately when a resident is full code. Education included that CPR is to continue on a full code resident until EMS arrives and that the nurse cannot pronounce death on the full code resident and/or stop CPR until instructed by EMS. 32/32 licensed nurses have been educated.On [DATE], the survey team verified through review of the education provided and interview with 3 licensed nurses and 2 CNAs. On [DATE], 3 additional licensed nurses interviewed verified receipt and content of the education.Starting immediately on [DATE], Nursing Management conducted Emergency response code blue drills were conducted daily on all three shifts. Drills are ongoing daily on all three shifts with compliance noted. Drills included full code, DNR, and Full code hospice scenarios. Full code drills included emphasis on calling EMS immediately. 30/32 licensed nurses have participated. The remaining 2 licensed nurses are PRN (as needed) and have not worked since [DATE]. They will participate prior to their next working shift. 46/46 CNA's have participated.On [DATE], the survey team verified through review of the content of the daily emergency response code blue drills on all 3 shifts. On [DATE], 3 licensed nurses and 2 CNAs were interviewed and verified participation in code blue drills and verified content of the emergency response for full code residents. On [DATE], interview with 3 additional licensed nurses verified participation in code blue drills and emergency response when a resident is found in cardiac and/or respiratory arrest. Starting on [DATE], the Administrator and/or Nursing Management educated the licensed nurses and CNAs regarding the facility abuse and neglect policy, including resident rights. 32/32 licensed nurses have been educated. 46/46 CNAs have been educated.On [DATE], the survey team verified through review of the documentation of the education provided and interview with 3 licensed nurses and 2 CNAs.Starting on [DATE] licensed nurses received and completed a DNRO post-test. 30/32 licensed nurses have completed a DNRO post-test with 100% accuracy. The remaining 2 licensed nurses are prn and will complete the test prior to their next working shift.On [DATE], the survey team verified through record review that 30 licensed nurses completed the DNRO post-tests. On [DATE], interview with 3 licensed nurses verified that they received the training and completed the DNRO post-test. On [DATE] at 2:52 p.m., in an interview, the Administrator said that the 2 employees who have not completed their training will not be allowed to work until they complete the education.Starting on [DATE], the Director of Nursing and/or nursing management educated licensed nurses regarding change in condition. 30/32 licensed nurses have received the education. The remaining 2 licensed nurses are PRN will complete the test prior to their next working shift.On [DATE], the survey team verified through review of the education provided regarding change in condition and interview with 3 licensed nurses.Starting on [DATE] the Administrator placed laminated instructions on how to overhead page during a code for all four nursing station phones, the activity office phone, and the therapy gym phones.On [DATE] at 2:29 p.m., the survey team verified through observation that all 4 nurse's stations, the activity's office and the therapy gym's phone had laminated instructions on how to overhead page during a code.On [DATE] an ADHOC (unplanned) Quality Improvement Performance Committee meeting was held to review the recommendations made from the root cause analysis. The root cause analysis showed that the nurse believed the resident was hospice and did not start CPR or call EMS when the resident was found without respirations and pulse. The root cause of this was that she did not check the code status as outlined in the facility policy. All recommendations were approved by the committee. The following team members were in attendance: Medical Director (via telephone), Executive Director, Regional Director of Clinical Services (via telephone), Director of Nursing, Assistant Director of Nursing, Social Services, MDS (Minimum Data Set), Unit Manager, Business development Coordinator, Director of Patient Experience, Business Office Manager, Maintenance Director, Nutrition Director, Housekeeping Director, and Activities Director.On [DATE], the survey team verified through record review and interview with the Administrator that a Quality Improvement Performance Committee meeting was held on [DATE] and discussed the root cause of the incident and the recommendations were approved by the committee. The root cause documented was, staff knowledge on when CPR can be discontinued and when 911 is called. Nurse did not check code status. Policy not followed. The survey team verified participation of team members listed on the facility's removal plan.On [DATE], a follow-up Ad HOC Quality Improvement Performance Committee meeting was held to review plan progress. All recommendations were approved by the committee. The following team members were in attendance: Medical Director, Executive Director, Regional Director of Clinical Services (via telephone), Director of Nursing, Assistant Director of Nursing, Social Services, MDS (2), DON traveler, Unit Managers (2), Business development Coordinator, Director of Patient Experience, Business Office Manager, Maintenance Director, Nutrition Director, Housekeeping Director, and Activities Director.On [DATE], the survey team verified that on [DATE] the facility held a Quality Improvement Performance Committee meeting and reviewed the plan's progress. The survey team verified participation of team members listed on the facility's removal plan.On [DATE], the Regional Nurse Consultant completed a like resident audit. All expired residents and re-hospitalizations from [DATE] through [DATE] were reviewed to see if involved staff were the same as code event and if proper procedure was followed. Staff identified in incident were not involved in previous codes or re-hospitalizations. All codes were handled per policy.On [DATE], the survey team verified through record review and interview with the Administrator and DON that, on [DATE] the Regional Nurse Consultant completed an audit of all expired and re-hospitalized residents from [DATE] through [DATE] to ensure proper procedure was followed and all codes were handled per facility's policy. Staff identified in the incident involving Resident #1 were not involved in previous codes or re-hospitalization. Review of the clinical records for 2 residents listed on the audit revealed no concern. One resident coded at the facility and staff acted appropriately. One resident was appropriately transferred to the hospital and coded at the hospital.

Based on record review, review of facility policies and procedures, and staff interviews, the facility failed to ensure clinical staff had the competencies to respond appropriately to emergencies and ensure 1 (Resident #1) of 3 residents reviewed with full code status (Administer cardiopulmonary resuscitation in the event of cardiac or respiratory arrest) received timely life saving measures when found without pulse or respirations.Resident #1 had a full code status. On [DATE], Resident #1 was found in cardiac and respiratory arrest. Clinical staff administered cardiopulmonary resuscitation (CPR) for 20 minutes then pronounced the resident's death without authority to do so and without activating Emergency Medical Services (EMS). Clinical Staff re-started CPR and activated EMS 4 hours after CPR was stopped and the resident had no pulse and respirations.The facility failure to ensure nursing staff were trained and competent to respond appropriately to cardiac and respiratory arrests placed other residents with full code status at risk of significant delay in receiving lifesaving emergency treatment when found without pulse or respirations and resulted in the determination of Immediate Jeopardy.On [DATE], after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed, effective [DATE]. The scope and severity were reduced to D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.The findings included:Cross reference F678.Review of the Facility Assessment Tool updated [DATE] revealed, List all staff training and competencies needed by type of staff. Consider if it would be helpful to indicate which competencies are reviewed at the time the staff member is hired, and how often they are reviewed after that. Consider the following training topics . Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention . Consider the following competencies . Person-centered care .person-centered care planning . end-of-life care, and advance care planning . Review of the facility's policy and procedure titled, Florida Cardiopulmonary Resuscitation (CPR) with a revision date of [DATE] revealed, Cardiopulmonary resuscitation (CPR) will be provided to all residents who are identified to be in cardiac arrest unless such resident has a fully executed Florida Do Not Resuscitate (DNR) order. Procedure. In the event of cardiac arrest, immediately call for assistance . In the absence of a fully executed Florida Do Not Resuscitate order . the facility will immediately begin CPR. Center staff will continue performing CPR until Emergency Medical Technicians assume responsibility for CPR, or it may be discontinued if: The resident responds.Review of the facility provided incident investigations revealed that on [DATE] at approximately 2:07 a.m., clinical staff consisting of Registered Nurse (RN) Staff A and Licensed Practical Nurse (LPN) Staff B failed to respond appropriately when Resident #1 with a full code status was found without a pulse or respirations. The nurses did not activate EMS and discontinued CPR after 20 minutes. RN Staff A pronounced the resident's death without authority to do so. RN Staff A restarted CPR, four hours after she pronounced the resident's death, and activated Emergency Medical Services (EMS) per the Director of Nursing's instruction. EMS pronounced the resident's death on [DATE] at 6:31 a.m.Review of the Facility provided meeting minutes dated [DATE] revealed that the root cause of the incident was, Staff knowledge on when CPR can be discontinued and when 911 is called. Nurse did not check code status. On [DATE] at 10:39 a.m., in an interview, CNA Staff D said that on [DATE] at approximately 6:00 a.m., RN Staff A instructed her to put the board (Stiff board to ensure effective chest compressions) under Resident #1 and asked her to administer chest compressions to the resident. She did roughly 5 or 6 compressions before EMS arrived. She continued the chest compressions until EMS told her to stop.On [DATE] at 11:20 a.m., in a telephone interview, RN Staff A said that on [DATE] at 2:07 a.m., she did not activate EMS when Resident #1 with a full code status was found without a pulse or respirations. She asked LPN Staff B for help. They administered CPR for 20 minutes then stopped. RN Staff A said that nurses do not pronounce residents death and said, I knew he was dead, no vitals, no respirations. We found him dead, we know he is dead because it is clinical. She said that she was confused on who was hospice and who was a full code. She said, I thought he was hospice, so I did not call 911. RN Staff A said that on [DATE] at approximately 6:00 a.m., 4 hours after CPR was stopped, the Director of Nursing (DON) called the facility and instructed her to call EMS. RN Staff A said, We tried to do something until EMS came because they have to see us doing CPR. They [EMS] repronounced him [Resident #1] dead after that.On [DATE] at 11:38 a.m., in a telephone interview, LPN Staff B verified that on [DATE] at approximately 2:07 a.m., RN Staff A asked for his help when Resident #1 was found unresponsive. He said, I thought she had called 911. We did CPR for about 20 minutes, and she [RN Staff A] called the code. I did not call 911 because I was doing compressions. He said that RN Staff A told him, Oh, we are not going to bring him back, so she called the code (stopped CPR) and left. He said that RN Staff A was the charge nurse but he should have spoken up since he knew to continue CPR until the arrival of EMS. The Director of Nursing called the facility at approximately 6:00 a.m. and instructed RN Staff A to activate EMS. They called 911 and restarted CPR at that time. He said that RN Staff A did not say why they restarted CPR, no one said anything. It was strange.Review of RN Staff A's employee file revealed a date of hire of [DATE].RN Staff A's job description titled, Clinical Nurse I (RN), dated [DATE] revealed the job function included, Responsible for providing direct resident care in accordance with established plans . Duties and Responsibilities . Assist nursing personnel to act in compliance with corporate policies, procedures and regulatory requirements.Provide routine nursing services for residents as directed . Education & Certification . Must have CPR Certifications . Specific Requirements . Must possess the ability to make independent decisions when circumstances warrant such action . RN Staff A did not sign the job description to acknowledge that she had read the job description and agreed to perform the tasks outlined in the job description in a safe manner and in accordance with the facility's established policies and procedures.Review of RN Staff A's BLS (Basic Life Support)/CPR Certification revealed a completion date of [DATE]. The certification did not document a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards.On [DATE] at 12:33 p.m., in a telephone interview, a representative of the BLS/CPR provider company where RN Staff A completed her BLS/CPR certification said that the BLS/CPR certification was fully online, was not led by an instructor and had no live feedback.Review of the facility's Skills Competency Assessments for New Hires revealed, Evaluating and documenting competency of staff is required upon hire, annually and as otherwise indicated. Completed Skills Competency Assessment should be retained in employee personnel file .RN Staff A's personnel file did not include a Skills Competency Assessment.Review of LPN Staff B's Clinical Nurse I (LPN) job description signed and dated [DATE] with a date of hire of [DATE] revealed, Duties and Responsibilities . Act in compliance with the company, regulatory and professional standards and guidelines . Education & Certifications . Must have CPR Certifications . Specific Requirements . Must demonstrate knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served . Must possess the ability to make independent decisions when circumstances warrant such action . Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities.Review of LPN Staff B's BLS/CPR certification dated [DATE] revealed that it was valid for 2 years. Review of CNA Staff D's personnel file revealed a Certified Nursing Assistant /State Tested Nursing Assistant job description signed and dated [DATE] with a date of hire of [DATE]. The job description did not include BLS/CPR certification as an education requirement.CNA Staff D's personnel file included a BLS/CPR certification with an issue date of [DATE] and specified to renew by 09/2025.On [DATE] at 1:22 p.m., in an interview, the Assistant Director of Nursing (ADON) verified that LPN Staff B's BLS/CPR certification dated [DATE] was valid for 2 years, therefore was expired. The ADON also verified that CNA Staff D's BLS/CPR certification specified a renew date of 09/2025 and was expired. He said that per facility policy, CNAs were not allowed to do CPR, including chest compressions and that nurses were expected to renew their CPR certifications. The Human Resources department was responsible to review the nurses CPR certifications upon hire and annually and notify the nurses 90 days before their CPR certification expired.On [DATE] at 12:04 p.m., in an interview, the Assistant Director of Nursing (ADON) said since he started employment at the facility in [DATE], they have been conducting monthly Code Blue (cardiac/respiratory arrest) Drills. He said that RN Staff A went from working the night shift to working the day shift and went back to the night shift. RN Staff A then became the facility's weekend supervisor but had not participated in any Code Blue drill. Review of the facility provided monthly code blue drills for 11/2025, [DATE], [DATE], February 2026 and [DATE], failed to reveal documentation of RN Staff A's participation.On [DATE] at 10:28 a.m., in an interview, the Nursing Home Administrator said that RN Staff A received no orientation or skills competency evaluation since her hire date of [DATE] and was promoted to the weekend supervisor's position on [DATE].On [DATE] at 10:30 a.m., in an interview, the Human Resources Director, and the Director of Training verified that RN Staff A had no onboarding education, no orientation and no nursing competency evaluations on file.On [DATE] at 10:38 a.m., an interview was held with the DON and the ADON. The DON said that newly employed licensed nurses are expected to have 3 days of clinical orientation and complete skills competency evaluations. The licensed nurses must meet expectations. She said, No one should be working on the floor without completing orientation and skills competencies.The ADON said that the Administrator, DON and Human Resources were responsible to ensure staff completed orientation and skills competencies. He said that RN Staff A failed all the tests for the Clinical Manager's position and should not have been a Unit Manager. He said that RN Staff A, cut corners and got away with it. On [DATE] at 11:31 a.m., in an interview, the Administrator said that each department had a part in the onboarding process of new employees. She said that there was also a clinical orientation. She confirmed that there were no records that RN Staff A completed orientation or skills competencies before being promoted to the weekend supervisor's position.On [DATE], the immediate actions implemented by the facility and verified by the survey team included:On [DATE], the Regional Director of Clinical Services verbally educated the Administrator and Director of Nursing regarding the CPR policy and need to immediately contact EMS services in the event of a full code. The administrator and DON signed the education on [DATE]. On [DATE], the survey team verified documentation dated [DATE], that the Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and need to immediately contact EMS services in the event of a full code.Starting on [DATE], the Director of Nursing and/or nursing management educated licensed nurses on CPR policy and procedure. This included where to find the code status. Education also addressed what to do for scenario with full code hospice residents. Education was completed on initiating EMS services immediately when a resident is full code. Education included that CPR is to continue on a full code resident until EMS arrives and that the nurse cannot pronounce death on the full code resident and/or stop CPR until instructed by EMS. 32/32 licensed nurses have been educated.On [DATE], the survey team reviewed the content of the education and verified that 32 of 32 licensed nurses were educated. On [DATE], 3 licensed nurses and 2 CNAs verified receipt and content of the education related to CPR policy and procedure. On [DATE], 3 additional licensed nurses were interviewed. Each licensed nurse verified receipt of the education and verbalized content of the education related to the facility's CPR policy and procedure.On [DATE], an Ad HOC (unplanned) Quality Improvement Performance Committee meeting was held to review the recommendations made from the root cause analysis. The root cause analysis showed that the nurse believed the resident was hospice and did not start CPR or call EMS when the resident was found without respirations and pulse. The root cause of this was that she did not check the code status as outlined in the facility policy. All recommendations were approved by the committee. The following team members were in attendance: Medical Director (via telephone), Executive Director, Regional Director of Clinical Services (via telephone), Director of Nursing, Assistant Director of Nursing, Social Services, MDS (Minimum Data Set), Unit Manager, Business development Coordinator, Director of Patient Experience, Business Office Manager, Maintenance Director, Nutrition Director, Housekeeping Director, and Activities Director.On [DATE], the survey team verified through record review and interview with the Administrator and DON that on [DATE] a Quality Performance Meeting was conducted and the root cause of the incident discussed. The survey team verified participation of the Medical Director and department heads.On [DATE], a follow-up Ad HOC Quality Improvement Performance Committee meeting was held to review plan progress. All recommendations were approved by the committee. The following team members were in attendance: Medical Director, Executive Director, Regional Director of Clinical Services (via telephone), Director of Nursing, Assistant Director of Nursing, Social Services, MDS (2), DON traveler, Unit Managers (2), Business development Coordinator, Director of Patient Experience, Business Office Manager, Maintenance Director, Nutrition Director, Housekeeping Director, and Activities Director.On [DATE], the survey team verified through record review and interview with the Administrator, and DON that on [DATE] a follow up Quality Improvement Performance Committee meeting was held to review the plan's progress. The survey team verified participation of the Medical Director and department heads.

Based on record review, review of facility's policies and procedures, resident representative and staff interviews, the facility failed to allow the return to the facility post hospitalization for 1 (Resident #2) of 7 residents reviewed for discharge planning process.Resident #2 was discharged to a different nursing home approximately 73 miles from his family.The findings included:Review of the facility's policy and procedure titled, Transfer/Discharge Notification & Right to Appeal with a revision date of 04/28/25 revealed, Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements. The center must permit each resident to remain in the center, and not transfer or discharge the resident unless:The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the center;The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the center;The safety of individuals in the center is endangered due to clinical or behavioral status of the resident;The health of individuals in the center would otherwise be endangered. Emergency transfers to Acute Care: Residents who are sent emergently to an acute care setting, must be permitted to return to the center. If the Center initiates a discharge while the resident is in the hospital, the center must show evidence that the resident's status at the time of the return to the center meets the criteria listed above (A-D) .Review of the clinical record for Resident #2 revealed an admission date of 8/26/25. Diagnoses included Chronic viral Hepatitis C, Problem with Social Environment, Unspecified Anxiety Disorder, History of Traumatic Brain Injury, Mild cognitive Impairment of unknown origin, Mood Disorder due to known Psychological Condition with Mixed Features, and Adjustment Disorder with Mixed Anxiety and Depressed Mood.Review of the Minimum Data Set (MDS) Assessments revealed:The Quarterly MDS with an assessment reference date of 3/4/26 revealed Resident #2 scored 15 of 15 on the Brief Interview for Mental Status (screening to assess cognition, specifically memory and orientation), indicating intact cognition. The MDS noted that Resident #2 did not exhibit physical or verbal behavioral symptoms directed toward others.The Discharge MDS assessment with an observation end date of 3/20/26 revealed that on 3/20/26 Resident #2 had an unplanned discharge-return anticipated. The MDS noted that Resident #2 did not exhibit physical behavioral symptoms directed toward others or verbal behavioral symptoms directed toward others. Review of Resident #2's care plan revealed:The resident wished to stay Long Term Care (LTC) at the facility (Date initiated 9/1/25).Resident #2 was verbally aggressive towards staff (Date initiated 10/30/25). The goal was for the resident to demonstrate effective coping skills.Resident #2 had behaviors of yelling at other residents and telling them to Shut your mouth (Date initiated 2/24/26). The goal was for the resident to have fewer episodes of the behavior. Review of the progress notes revealed:On 3/20/26 the Psychiatric Provider documented that Resident #2 has been manic, psychotic, delusional and responding to internal stimuli. He has a history of psychosis, and he has been presenting with bizarre and tangential behavior. He has refused all medications or staff care and assistance that could help redirect him. He is being aggressive, impulsive refusing medications and is a danger to self. Resident #2 has failed all interventions by staff to keep him safe. He requires a higher level of care to ensure his safety and the safety of others. The Psychiatric Provider documented that Resident #2 required to be baker acted (involuntary, emergency examination). On 3/20/26 at 5:29 p.m., the Director of Nursing (DON) documented in a late entry, Resident had a burst of anger with uncontrolled behavior screaming, kicked the entrance door of his room and created a hole on the wall. He messed up his bed sheets as well, kicked the wall by his TV across from his bed TV, creating big hole, carrying on for approximately 1/2 hour, notified law enforcement . Psych Provider ordered to [NAME] Act. Law enforcement arrived followed by EMS (Emergency Medical Services). [NAME] Act order from (Psychiatric Provider) was presented to the law enforcement and EMS. When law enforcement arrived, resident had calm [sic] down but from clinical standpoint, the inappropriate behavior presented by the resident and witnessed by me and several staff and other alert residents was frightening and resident needs to be out of the facility for staff and other residents' safety. Resident's mother arrived and was fully aware of his inappropriate behavior. Resident left the facility via stretcher w/EMS (with) and law enforcement approximately 6 PM.On 3/22/26 at 3:52 p.m., the DON documented that Resident #2 was being admitted . She spoke with the case manager who will be available the next day to discuss discharge plan for the resident.The clinical record lacked documentation that a bed hold policy was offered to the resident or representative at the time of transfer to the hospital.Review of the hospital record revealed that Resident #2 was admitted on [DATE] and discharged on 3/23/26. The hospital course synopsis documented that Resident #2 was admitted under involuntary commitment for evaluation of mental health concerns following reported aggression at his memory care facility. On admission, Resident #2 was calm, cooperative, and oriented, with no evidence of acute distress or psychiatric complaint. He denied suicidal or homicidal ideation and was medically cleared in the Emergency Department. He was not accepted for psychiatric facility placement due to wheelchair dependence and chronic immobility.The psychiatric evaluation, including a telemedicine consult determined that Resident #2 did not meet criteria for involuntary inpatient or outpatient psychiatric placement. The [NAME] Act orders and associated safety protocols were discontinued. He was cleared for discharge from a psychiatric perspective with recommendations for intensive outpatient neurocognitive rehabilitation and provision of outpatient mental health resource information. Case management and social work were involved in discharge planning, as his prior skilled nursing facility refused to accept him back, and alternative placement options specializing in Traumatic Brain Injury were discussed with his emergency contact.On 4/14/26 at 11:00 a.m., in an interview, the DON verified that there was no documentation Resident #2 was offered a bed hold at the time of the transfer to the hospital. She said that Resident #2's emergency contact declined the bed hold. The DON said that when Resident #2 was ready to be discharged from the hospital, the facility refused to take him back. She thought that Resident #2 would be better off in a group home due to his age and volatile behavior.On 4/14/26 at 12:01 p.m., in a telephone interview, the emergency contact said since the facility refused to allow Resident #2 to come back, he was placed in a nursing home located approximately 73 miles and 2-hour drive from her house. She said that Resident #2 fell at the new facility once in the middle of the night and called her screaming for help. It caused her much distress since she could not get to him. The emergency contact said that Resident #2 was not available for an interview, but she would like for him to return to the facility. On 4/14/26 at 12:54 p.m., in an interview, the Admissions Director said that approximately 4 to 5 days after Resident #2 was transferred to the hospital under a [NAME] Act, the hospital notified them that he was ready to return to the facility. She said that her regional leader told her not to accept the resident and that he was not to be accepted to any of their sister facilities.On 4/14/26 at 12:57 p.m., in an interview, the Administrator said that a bed hold was not offered to Resident #2 and there was no documentation of the basis for discharge of the resident. She said the regional team decided to not allow Resident #2 to return to the facility, based on the information provided by facility staff.

Based on review of the clinical record, resident representative and staff interview the facility failed to have documentation of incontinent care to meet the needs of 1 (Resident #999) of 4 residents reviewed for toileting needs.The findings included:On 3/3/36 at 9:39 a.m., in a telephone interview, Resident #999's family representative said on 2/4/26 she came to visit the resident and found her in bed with the bedding soaked with urine and no incontinent brief or pad was in place. The representative said the resident had a very strong odor of urine.Review of the clinical record revealed Resident #999 had an admission date of 7/27/20 with most readmission on [DATE]. Diagnoses included chronic obstructive pulmonary disease, traumatic brain injury, anxiety and major depressive disorder.Review of the Quarterly Minimum Data Set (MDS) with an assessment reference date of1/16/26 documented Resident #999 was always incontinent of bowel and bladder. The MDS noted the resident's cognitive skills for daily decision making were intact.Review of the Certified Nursing Assistant (CNA) documentation of January 2026 failed to reveal documentation that incontinent care was provided on the day shift on 1/1/26,1/5/26, 1/7/26, 1/8/26, 1/12/26, 1/14/26, 1/26/26, 1/27/26 and 1/28/26.On the evening shift no documentation on 1/3/26, 1/30/26. N/A was documented on 1/3/26 and 1/13/26.On the night shift there was no documentation of care provided on 1/3/26, 1/4/26, 1/8/26, 1/12/26, 1/14/26, 1/15/26, 1/16/26, 1/18/26, 1/19/26, 1/20/26, 1/21/26, 1/22/26, 1/26/26, 1/28/26 and 1/31/26.Review of the CNA documentation for February 2026 revealed no documentation of incontinent care on the day shift on 2/2/26, 2/3/26, 2/4/26.The evening shift revealed no documentation of incontinent care for Resident #999 on 2/2/26, 2/3/26 and 2/4/26.On 3/3/36 at 11:26 a.m., in an interview CNA Staff F said, We toilet residents every 2 hours and when they ask us.On 3/3/26 at 3:30 p.m., in an interview, the Director of Nursing and the Regional Nurse Consultant verified that the lack of documentation that Resident #999 received the necessary care for incontinence.

Based on observations, interviews and record review, the facility failed to prevent verbal abuse from staff for 2 of 3 residents reviewed. (Patient #1 and Patient #2)The findings included: Review of the facility Abuse, Neglect, Exploitation & Misappropriation policy (last revised on 11/16/2022) says that residents should be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The policy further noted no employee may at any time commit an act of physical, psychological, or emotional abuse. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. The policy defines mental abuse as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. The policy defines verbal abuse as the use of oral, written, or gestured communication, or sounds, to residents within hearing distance regardless of age ability to comprehend or disability. The policy noted examples of mental and verbal abuse to include mocking, insulting, ridiculing and yelling or hovering over a resident, with the intent of intimidate. Record review for Resident #1 showed the resident was admitted on [DATE] with a diagnosis of Parkinsons Disease. Resident #1's most recent (10/20/25) Brief Interview for Mental Status (BIMS) was a score of 15 indicating intact cognition.Review of a Patient #1 psychiatric progress note (completed on 12/31/25) stated patient was seen today as staff request for psychiatric evaluation following a reportable incident. Patient reports feeling emotional discomfort following an interaction with a staff member on 12/25/25.During an interview on 1/13/26 at 11:16 a.m., Resident #1 said she was abused by a staff member around Christmas. She said CNA (Certified Nursing Assistant) Staff A came in to change her brief due to an episode of incontinence. She said she has Parkinsons Disease (a neurological disorder that affects movement) causing her to move very slowly and deliberately. Resident #1 said she told CNA Staff A to slow down prior to turning her. Resident #1 said CNA Staff A was yelling at me the whole time and not listening. Resident #1 said CNA Staff A was yelling at me with a tone and attitude of I have to get this done as fast as possible. Resident #1 said CNA Staff A grabbed the sheet and whipped me to the side. Resident #1 said she caught the windowsill which prevented her from hitting the floor. Resident #1 said CNA Staff A not listening to me and moving me rough like that made me feel inconsequential, like I don't matter to her.Review of the facility complaint/grievance reported on 12/25/25 from Resident #1 stated, CNA Staff A was verbally abusive by calling her 'heavy' and stating 'I don't get paid enough to do this. My back hurts'. Resident stated CNA 'bitched at me for not being able to get into my wheelchair'. Resident stated CNA rolled her over onto her right side 'so rough using the pad, I thought I was going to fall onto the floor'. Resident stated she overheard CNA yelling to night nurse about her.Review of a statement on 12/25/25 by LPN (Licensed Practical Nurse) Staff B said Resident #1 had turned on her call light, the CNA (Staff A) had just been in there and said out loud like what she wants now or something to that effect. LPN Staff B said CNA Staff A likes to talk loudly, so even though she was having a conversation with me and venting about the job, she was loud enough that Resident #1 could hear her through a shut door. In fact, Resident #1 actually called the nurses station and told me that if she has got time to talk, then she has time to change her.Review of a witness statement on 12/25/25 by Resident #2 (Resident #1's roommate) said the CNA was very loud and mean talking to Resident #1. She told Resident #1 she could break her back changing her.Record review for Resident #2 showed a most recent BIMS score of 13, dated 7/25/25, indicating intact cognition.During an interview on 1/13/26 at 12:01 p.m., Resident #2 said CNA Staff A treated Resident #1 very badly that night around Christmas. Resident #2 said, I have never seen anyone treat anybody the way she did. Resident #2 said CNA Staff A was yelling at Resident #1 while changing her brief. Resident #2 said, I was so nervous because of what was going on. Resident #2 said, it made me scared and I covered my face and hid under my blanket. Resident #2 said, I was scared of the woman and was scared of what she would do to me if I spoke up. I did not get involved due to this. I just hid.During an interview on 1/13/26 at 12:36 p.m., Resident #3 said CNA Staff A would come into my room in the middle of the night, slam on the lights and not explain anything. Resident #3 said you had to do it her way. Resident #3 said CNA Staff A used to yell at me all of the time. She would be nasty to my roommate as well. I feel bad for my roommate because he is very old and not with it sometimes. She would come in and yell at him. I always felt bad for him. She would always talk down to both of us as though she was entitled. Resident #3 said CNA Staff A was eventually not allowed in his room anymore. During an interview on 1/13/26 at 2:12 p.m., the Administrator said she came into the facility on Christmas due to an allegation of abuse. The Administrator said she collected statements, including statements from Resident #1 and Resident #2. The Administrator said both residents have a BIMS of 15 (indicating intact cognition). The Administrator said they did substantiate the allegation of abuse when the investigation was complete.

Based on observation, record review, resident and staff interviews, the facility failed to ensure staff provided incontinence care in accordance with accepted standards of care to meet the needs of 1 (Resident #800) of 3 residents reviewed.The findings included:On 10/15/25 at 9:24 a.m., Resident #800 was observed in bed in her room. In an interview Resident #800 said staff put two incontinent briefs and a towel on her because she was a heavy wetter. With the resident's permission, the incontinent briefs were observed. Resident #800 was wearing two incontinent briefs. A folded towel was placed inside the briefs. Resident #800 said it took 2 to 3 staff to provide incontinent care and change her briefs. She said the other day Certified Nursing Assistant (CNA) Staff A came in to change her. She tried to explain to the CNA how they did her care and that it took 2 to 3 staff to change her. The resident said that CNA Staff A did not explain what she was going to do and did not listen to her. She reported the incident.Review of the clinical record revealed Resident #800 had an admission date of 9/23/25. Diagnoses included severe morbid obesity, lymphedema (swelling caused by buildup of lymph fluid in body tissues), and chronic pain.Review of the admission Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 9/30/25 documented Resident #800 was dependent on staff for toileting, bathing and dressing. The MDS noted the resident scored 15 on the Brief Interview for Mental Status, indicating the resident's cognitive skills for daily decision making were intact.Review of the care plan for Resident #800 revealed:Resident #800 had non-blanchable redness to the buttocks, actual impairment to skin integrity of the medial thighs and groin secondary to fungus.Resident #800 was incontinent of bladder and bowel (Date initiated: 10/3/25). The goal was for the resident to remain free from skin breakdown due to incontinence and brief use.The interventions included: Clean the peri-area with each incontinence episode. Check for incontinence. Wash and dry perineum. Change clothing as needed after incontinence episode.Resident #800 had Alteration in usual functional performance in self-care related to lymphedema, Diabetes Mellitus, morbid obesity, Congestive Heart Failure, chronic pain and osteoarthritis.The interventions as of 10/3/25 noted:The resident used disposable briefs and was dependent on 3 staff assist for bed mobility (includes rolling from side to side and side to back).Resident #800 was dependent with 3 staff assist for Toilet Hygiene. Staff was to use disposable briefs, and clean peri-area with each incontinence episode. The care plan specified Resident performance: Bed mobility (includes rolling from side to side and side to back) - Dependent with 3 (three) staff assist.On 10/15/25 at 1:30 p.m., in an interview the Director of Nursing (DON) said the practice of putting 2 briefs on incontinent residents was not consistent with the facility's expectations. The DON said the facility's investigation verified that CNAs have been double briefing Resident #800 and other residents who were heavy wetter. She said after the incident, she addressed it in a staff meeting. She provided in-services dated 9/22/25, 9/23/25 and 9/26/25 on abuse, neglect and exploitation. 18 CNAs attended the in-services. The in-services provided did not address the practice of double briefing incontinent residents.Review of the facility provided incident investigation revealed that Resident #800 reported that on 10/5/25 CNA Staff A entered her room between 1:00 a.m. - 3:00 a.m. The resident tried to explain that it usually takes more than one person to help her with care, but the CNA did not listen. The facility's investigation documented Resident #800 was a heavy wetter. CNAs have been putting two disposable incontinent briefs and a wadded towel in front of her personal area.On 10/15/25 at 2:00 p.m., in an interview the Administrator said CNA Staff A did not provide quality of care as expected to Resident #800.

Based on observations, record review, review of facility's policies and procedures, residents and staff interviews the facility failed to have processes in place to prevent avoidable accidents for 6 (Residents #3, #103, #59, #74, #5, #95) of 6 residents by failure to accurately assess smoking risks, failure to identify unsafe storage and use of ignition devices where oxygen is in use and failure to adequately supervise residents who smoke tobacco products and electronic cigarettes. Residents #3 and #103 were roommates. Resident #3 was a smoker and Resident #103 received supplemental oxygen. On 8/27/25 Residents #3 and #103 were observed in their shared bedroom. Resident #3 was holding a cigarette and a lighter approximately 4 feet from Resident #103 who was receiving oxygen. On 8/27/25 a CNA was observed leaving cigarettes and lighters unlocked, unattended and easily accessible to 4 residents observed in the designated smoking area. Residents #59 and #74 were roommates and smokers. Resident #59 received supplemental oxygen via nasal cannula. On 8/27/25 Residents #74 and #59 were observed in their shared bedroom. Cigarette lighters were observed stored approximately 2 feet from Resident #59 while oxygen was in use. Both residents required constant supervision while smoking. Resident #5 used oxygen and vaped electronic cigarettes in her room. Staff did not intervene and allowed the resident to use and store the electronic cigarette in her room in close proximity of the oxygen source. The unsafe practice of allowing residents to use and/or store ignition sources such as lighters and electronic cigarettes in their rooms while oxygen is in use and the failure to ensure appropriate supervision of unsafe smokers created a likelihood of serious injury, impairment or death of residents from thermal burn and fire and resulted in the determination of Immediate Jeopardy.The findings included: Cross reference F726, F835, F926Review of the facility's policy titled, Smoking-Supervised (last revised 8/17/2017) revealed, The Center will provide a safe, designated smoking area for residents. Smoking is only allowed in designated area and oxygen is not permitted. The Center will have safety equipment available in designated smoking areas including: smoking blankets, smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. Residents who smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if additional adaptive or safety equipment is needed. Residents will be supervised during smoking including those residents utilizing electronic cigarettes. Staff will be assigned to supervise residents during designated smoking times. Smoking material will be retained and stored by the nursing staff for residents who have been granted smoking privileges. Residents who maintain smoking materials will be care planned as such. No ignition devices will be in the resident's possession at any time and is strictly prohibited. Electronic cigarettes are permitted, but only in facility designated smoking areas. The same rules that apply to regular tobacco cigarettes also apply to electronic smoking materials. Electronic cigarettes and materials, including the liquids, will be retained and stored by the nursing staff.Resident #3:On 8/27/25 at 9:10 a.m., Residents #3 and #103 were observed in their shared bedroom. Resident #103 was in bed receiving supplemental oxygen via nasal cannula. Resident #3 was in bed, approximately 4 feet from Resident #103. He was holding a cigarette in his left hand and a lighter in his right hand. On 8/27/25 at approximately 9:15 a.m., the observation of Resident #3 holding a lighter in close proximity of an oxygen source was shared with the Regional Nurse Consultant. She stated, Residents or family members can sneak stuff in. On 8/27/25 at 10:30 a.m., in an interview Resident #3 said he's been smoking and has kept a lighter in his room since his admission to the facility.On 8/27/25 at 10:32 a.m., in an interview Certified Nursing Assistant (CNA) Staff Z said Resident #3 has always been a smoking every day since his admission. CNA Staff Z said residents can keep cigarettes but not lighters in their room.On 8/27/25 at 10:33 a.m., in an interview CNA Staff Y said Resident #3 has been smoking every day since his admission. She said the resident was allowed to keep his cigarettes but no lighter.Review of the clinical record for Resident #3 revealed an admission date of 5/17/25. Diagnoses included unspecified dementia and acute respiratory failure with hypoxia (low oxygen level in the tissues).The admission evaluation dated 5/17/25 noted Resident #3 did not smoke, including electronic cigarettes.The care plan initiated on 5/19/25 did not include a focus for safe smoking.On 8/24/25 at 6:48 p.m., Registered Nurse (RN) Staff ZZ completed a smoking evaluation for Resident #3 which contained conflictive information. The evaluation noted the resident did not have the fine motor skills needed to securely hold a cigarette but the resident was determined to be a safe smoker. RN Staff ZZ entered none for Supervision needed while smoking.As of 8/24/25, the care plan was not updated to reflect Resident #3's smoking status, use and safe storage of lighters. Resident #103:Review of the clinical record for Resident #103 revealed a physician's order dated 12/1/23 for oxygen as needed 2 to 4 liters via nasal cannula. On 8/27/25 at 9:20 a.m., in an interview Resident #103 said he uses oxygen continuously.Resident #59:Review of the clinical record for Resident #59 revealed an admission date of 11/14/23. Diagnoses included Chronic Obstructive Pulmonary Disease, anxiety and bipolar disorder.The clinical record noted Resident #59 was a smoker.On 5/19/25, Licensed Practical Nurse (LPN) Staff S completed a smoking evaluation for Resident #59 which contained conflictive information. The evaluation noted Resident #59 was a safe smoker but needed constant supervision while smoking.The resident's ability to communicate why oxygen must always be shut off prior to lighting cigarette was not evaluated and left blank.Review of the physician's orders dated 8/25/25 revealed a new order for Oxygen as needed for shortness of breath or oxygen saturation below 90%.There was no documentation a new smoking evaluation was completed on 8/25/25 for Resident #59 when the physician issued an order for supplemental oxygen to determine if Resident #59 understood the importance of not smoking while receiving oxygen and the danger of storing lighters near an oxygen source.On 8/27/25 at 12:30 p.m., Resident #59 was observed in bed receiving oxygen via nasal cannula at 4 liters per minute.In an interview, Resident #59 verified he smoked cigarettes and stored his lighter and cigarettes in his nightstand. Observation of the resident's nightstand revealed a cigarette lighter stored in the top drawer, approximately 2 feet from the oxygen concentrator. photographic evidence obtained. Resident #74:Residents #74 and #59 were roommates.Review of the clinical record for Resident #74 revealed an admission date of 1/27/23. Diagnoses included Chronic Obstructive Pulmonary Disease, generalized muscle weakness and as of 6/19/24, nicotine dependence.Review of the smoking evaluations dated 4/23/25 and 7/24/25 revealed conflictive information. Both evaluations noted Resident #74 was a safe smoker and required constant supervision while smoking.On 8/27/25 at 12:45 p.m., in an interview Resident #74 verified he smoked cigarettes. He said he stored his cigarettes and lighter on windowsill of the bedroom he shared with Resident #59.Observation during the interview revealed a pack of cigarettes and a lighter on the windowsill of the bedroom. Resident #59 was not in the bedroom at the time of the observation. The oxygen concentrator was on and running.On 8/27/2025 at 10:27 a.m., an interview was held with LPN Staff N to discuss facility process to identify smokers and safe smoking practices. LPN Staff N said the facility identifies smokers on admission. A smoking assessment is completed to determine if the resident is a safe smoker. LPN Staff N said a safe smoker is someone who can take out cigarettes, light them and extinguish them on their own. When asked about storage of smoking material, LPN Staff N said, lighters and cigarettes are locked up even if the resident is a safe smoker. Residents should not have lighters or cigarettes in their room.On 8/27/25 at 10:54 a.m., in an interview CNA Staff X said residents should not have cigarettes or lighters in their rooms. Staff X said they lock cigarettes and lighters up. Resident #5:Review of the clinical record for Resident #5 revealed an admission date of 1/19/24. Diagnoses included Morbid Obesity, Bipolar Disorder and Major Depressive Disorder.The physician's orders dated 1/22/24 included oxygen at 3 liters per minute via nasal cannula at bedtime.The care plan related to smoking for Resident #5 was inconsistent:The care plan initiated on 10/12/23 with a target date of 10/28/25 noted Resident #5 was a former smoker and used oxygen at bedtime.The care plan initiated on 6/24/25 noted the resident was a smoker. The goal was for the resident not to smoke without supervision and the resident would not suffer injury from unsafe smoking practices.The care plan initiated on 6/24/25 noted the resident has behaviors and vapes (inhale and exhale vapors from an electronic cigarette) in her room. The goal was for the resident to have fewer episodes of vaping and the resident will have no evidence of behavioral concerns vaping. The interventions included to monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes.The care plan did not address the unsafe practice of vaping electronic cigarettes in the room while using oxygen.Review of the smoking evaluations revealed on 7/25/25 LPN Staff S documented Resident #5 was a safe smoker and the supervision required while smoking was constant.On 8/28/25 at 1:30 p.m., Resident #5 was observed in bed receiving oxygen via nasal cannula. In an interview Resident #5 said she doesn't get out of bed. She said she was a smoker but has been vaping electronic cigarettes in her room since she cannot get out of bed to go to the designated smoking area. She said she keeps her electronic cigarettes in her room.On 8/29/25 at 2:30 p.m., in an interview LPN Staff S verified she completed the smoking evaluations for Resident #5. She said she did not receive prior education on how to complete a smoking evaluation. She said, The smoking evaluation is self-explanatory. LPN Staff S said the residents are safe smokers because, they're having constant supervision. Resident #95:Record review for Resident #95 revealed a date of admission of 7/5/24. Diagnoses included hemiplegia (paralysis) /hemiparesis (weakness) of the right dominant side.Review of the smoking evaluation completed on 7/2/25 revealed Resident #95 was a safe smoker and did not need supervision while smoking.Review of Resident #95's care plan revealed on 8/26/25 a new intervention was added specifying the resident required a smoking apron while smoking.On 8/27/25 at 10:55 a.m., CNA Staff W was observed supervising residents #59 and #95 in the designated smoking area.Resident #95 was not wearing a protective smoking apron for safety as per his care plan initiated on 8/26/25. In an interview CNA Staff W said she gives the residents a cigarette and lights it for them. CNA Staff W said when the smoking time is over cigarettes and lighters are locked up in the designated box.On 8/27/25 at 10:58 a.m., Resident #59 interjected and said, I keep my lighter in my room. On 8/27/25 at 12:20 p.m., CNA Staff W was observed supervising residents in the courtyard.Resident #95 was in the designated smoking area holding an unlit cigarette.Resident #10 requested assistance to go to the bathroom. CNA Staff W left the smoking area with Resident #10. She left cigarettes and lighters unlocked, unsupervised, easily accessible to Resident #95 and 3 other residents observed in the designated smoking area.On 8/27/25 at 1:12 p.m., a tour of the designated smoking area was conducted with the Director of Nursing (DON). Resident #95 was observed smoking. Resident #95 was not wearing the protective smoking apron as specified in the care plan initiated on 8/26/25. The DON verified Resident #95 was not wearing the protective smoking apron and said the resident should be wearing the protective apron as care planned.On 8/27/25 at 2:49 p.m., an interview was conducted with the Administrator, DON, Regional [NAME] President, and the Maintenance Director to discuss identification of smokers, accurate smoking evaluations, adequate and appropriate supervision of smokers, development and revision of care plans to address smoking risks and individualized interventions to ensure the safety of smokers and other residents. The Administrator said he believes cigarettes and lighters should be locked up. He said they collect all the lighters.The Maintenance Director said smoking was a danger for residents who use oxygen. He said that oxygen was an accelerant which increased the risk of fire.The DON said smoking evaluations are done on admission and quarterly thereafter. The DON said as part of the evaluation, the licensed nurses completing the evaluation physically observe the resident smoking. She said a care plan is developed the next day at morning meeting. The DON said the CNA supervising the smokers has a list of residents who require protective aprons while smoking. He said Resident #95 was an example of a resident who needed a smoking apron due to left-sided weakness.When asked about supervision of residents during smoking sessions, the Administrator said the courtyard was always supervised and should never be left unattended even when residents are not smoking. He said he did not know who was responsible to educate the CNAs assigned to supervise the smokers.On 8/27/25 at 3:10 p.m., in an interview the Social Services Director said she purchases cigarettes but no lighters for residents when they give her the money. She said residents were not allowed to keep lighters in their rooms per facility policy. She tells the residents' family members the lighters are to be locked up. When asked how the facility monitors residents for compliance and enforces the smoking policy the Social Services Director said the managers have assigned residents' rooms and conduct angel rounds. She said during the rounds, managers look for lighters in residents' rooms. She said the Administrator kept the completed angel rounds forms.On 8/27/25 at 3:30 p.m., CNA Staff V was observed supervising the designated smoking area. In an interview, CNA Staff V said no one gave her training on smoking supervision.On 8/27/25 at 4:33 p.m., CNA Staff V was observed supervising the designated smoking area. In an interview CNA Staff V said she is supposed to light the residents' cigarettes but residents bring their lighters and light their own cigarettes. CNA Staff V said she tries to take the lighters from the residents but they don't listen. CNA Staff V said she has told the nursing staff and Social Services about the residents having their own lighters but they haven't done anything about it. She said she stopped reporting it to them because nothing was done.Review of the facility provided list of smokers (updated as of 8/25/25) revealed the facility currently had 14 current residents who smoke. Residents #5 and #3 were not on the list of smokers.On 8/28/25 at 11:55 a.m., an interview was held with the Administrator related to the prompt identification and evaluation of smokers. The Administrator said when residents are identified as smokers they should be put on the smoking list immediately. He verified the current list of smoker was incomplete. He said updating the smoking list is not happening. When asked about how the facility ensured complete and accurate smoking evaluations, the Administrator said a Registered Nurse determines if a resident is a safe smoker but did not know if the nurses received specific training on completing the smoking evaluations. He said safe smoker must be able to show they won't burn themselves or others. He said, We are not identifying safe smokers. We missed the boat.The Administrator said Resident #5 never leaves her room. She uses oxygen and vapes electronic cigarettes in her room. When asked about the process and expectation for angel rounds, he said angel rounds are expected to be done Monday through Friday. He said spot checks are done on weekends. The Administrator said the management staff conducting are supposed to look for lighters during angel rounds.The U.S. Food & Drug Administration noted in Tips to Help Avoid Vape Battery Fires or Explosions: . Although these incidents appear uncommon, vape fires and explosions are dangerous to the person using the vaping product and others around them. There may be added dangers, for example, if a vape battery catches fire or explodes near flammable gasses or liquids, such as oxygen.Tips to Help Avoid Vape Battery Fires or Explosions | FDA

Based on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to ensure licensed nurses had the appropriate training and competencies to complete accurate smoking risk evaluations and identify unsafe smoking practices. The smoking risk evaluations for 7 (Residents #59, #105, #3, #74, #64, #5, #95) of 7 residents reviewed contained conflicting, inaccurate information and did not accurately reflect the residents' abilities to smoke independently. Each smoking evaluation noted the resident was a safe smoker and needs constant supervision.4 (Residents #3, #5, #59, and #74) of 4 residents observed with oxygen in use in their rooms were allowed to store ignition devices in their rooms while oxygen was in use.On 8/27/25 a Certified Nursing Assistant (CNA) was observed leaving cigarettes and lighters unlocked, unattended and easily accessible to 4 residents observed in the designated smoking area.Staff assigned to monitor residents who require constant supervision during smoking had not received appropriate training and competencies.The facility failure to ensure licensed nurses were trained and competent to complete smoking evaluations resulted in improper safety risks evaluation, unsafe smoking practices, including storage of lighters where oxygen is used.This failure created a likelihood of serious harm, injury, impairment or death of residents from thermal burn and fire from unidentified unsafe smoking practices and resulted in the determination of Immediate Jeopardy (IJ). The findings included:Refer to F689, F726, F835Review of the Facility's policy titled, Smoking-Supervised (last revised 8/17/2017) revealed, The Center will provide a safe, designated smoking area for residents. Smoking is only allowed in designated area and oxygen is not permitted. The Center will have safety equipment available in designated smoking areas including: smoking blankets, smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. The policy further states Residents smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if additional adaptive or safety equipment is needed. Residents will be supervised during smoking including those resident utilizing electronic cigarettes. Staff will be assigned to supervise residents during designated smoking times. 1. On 8/27/25 at 9:10 a.m., during a tour of the facility, Residents #3 and #103 were observed in their shared bedroom.Resident #103 was in bed receiving oxygen via nasal cannula.Resident #3 was in bed approximately 4 feet from Resident #103's bed. Resident #3 was holding a lighter in his right hand and a cigarette in his left hand.On 8/27/25 at approximately 9:15 a.m., the observation of Resident #3 holding a lighter in close proximity of the oxygen source was shared with the Regional Nurse Consultant. She stated, Residents or family members can sneak stuff in.On 8/27/25 at 10:30 a.m., in an interview Resident #3 said he's been smoking and has had a lighter since his admission to the facility.On 8/27/25 at 10:33 a.m., in an interview Certified Nursing Assistant (CNA) Staff Y said Resident #3 has been smoking every day since his admission. She said the resident was allowed to keep his cigarettes but no lighter.Review of the clinical record for Resident #3 revealed an admission date of 5/17/25. Diagnoses included unspecified dementia, acute respiratory failure with hypoxia (low oxygen level in the tissues) and cerebral infarction.Review of the admission evaluation dated 5/17/25 revealed No was entered for Does the resident smoke (including electronic cigarettes).Review of the admission Minimum Data Set (MDS) assessment with a target date of 5/24/25 revealed Resident #3 scored 15 on the Brief Interview for Mental Status (BIMS), indicative of intact cognition. The MDS noted Resident #3 had functional limitation in range of motion of one upper extremity. No was entered in the MDS for current tobacco use.On 8/24/25 at 6:48 p.m., Registered Nurse (RN) Staff ZZ completed a smoking evaluation for Resident #3 which contained conflictive information. The evaluation noted the resident did not have the fine motor skills needed to securely hold a cigarette but the resident was determined to be a safe smoker. RN Staff ZZ entered none for supervision needed while smoking.2. Residents #59 and #74 were roommates.On 8/27/25 at 12:30 p.m., Resident #59 was observed in bed in his room receiving oxygen via nasal cannula at 4 liters per minute. In an interview Resident #59 said he was a smoker and kept his cigarettes and lighter in his nightstand.Observation of the resident's nightstand revealed a cigarette lighter stored in the top drawer, approximately 2 feet from the oxygen source. Photographic evidence obtained.Review of the clinical record for Resident #59 revealed an admission date of 11/14/23. Diagnoses included Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, anxiety disorder, and bipolar disorder.Review of the smoking evaluations revealed on 5/19/25, Licensed Practical Nurse (LPN) Staff S documented Resident #59 was a safe smoker and supervision needed while smoking was constant.No answer was entered on the smoking evaluation for Resident is able to communicate why oxygen must always be shut off prior to lighting cigarette .Review of the physician's orders revealed an order dated 8/25/25 for Oxygen as needed for shortness of breath or oxygen saturation below 90%.There was no documentation a new smoking evaluation was completed on 8/25/25 when the physician issued an order for supplemental oxygen for the resident to determine if Resident #59 understood the danger of smoking or storing lighters in his room while receiving oxygen.Review of the care plan for Resident #59 initiated on 11/20/24 and revised on 8/14/25 revealed the resident had impaired cognitive function/dementia or impaired thought processes related to impaired decision making. Resident #59 had current guardianship.3. On 8/27/25 at 12:45 p.m., a pack of cigarettes and a lighter were observed stored on the windowsill of Residents #74 and #59's shared bedroom. In an interview Resident #74 said he was a smoker and kept his cigarettes and lighter stored in the windowsill.4. On 8/28/25 at 1:30 p.m., Resident #5 was observed in bed receiving oxygen via nasal cannula. In an interview Resident #5 said she doesn't get out of bed. She said she was a smoker but has been vaping electronic cigarettes in her room since she cannot get out of bed to go to the designated smoking area. She said she keeps her electronic cigarette in her room.Review of the clinical record for Resident #5 revealed an admission date of 1/19/2024. Diagnoses included Morbid Obesity, Bipolar Disorder and Major Depressive Disorder.The physician's orders dated 1/22/24 included oxygen at 3 liters per minute via nasal cannula at bedtime.The care plan related to smoking for Resident #5 had conflictive information:The care plan initiated on 10/12/23 with a target date of 10/28/25 noted Resident #5 was a former smoker and used oxygen at bedtime.The care plan initiated on 6/24/25 noted the resident was a smoker. The goal was for the resident not to smoke without supervision and the resident would not suffer injury from unsafe smoking practices.The care plan initiated on 6/24/25 noted the resident has behaviors and vapes in her room. The goal was for the resident to have fewer episodes of vaping and the resident will have no evidence of behavioral concerns vaping. The interventions included to monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes.The care plan did not address the unsafe practice of vaping in the room while using oxygen.Review of the smoking evaluations revealed on 7/25/25 LPN Staff S documented Resident #5 was a safe smoker and the supervision required while smoking was constant.On 8/29/25 at 2:30 p.m., in an interview LPN Staff S verified she completed the smoking evaluations for Residents #5 and #59. She said she did not receive prior education on how to complete a smoking evaluation. She said, The smoking evaluation is self-explanatory. LPN Staff S said the residents are safe smokers because, they're having constant supervision.5. Record review for Resident #95 revealed a date of admission of 7/5/24. Diagnoses included hemiplegia (paralysis) /hemiparesis (weakness) of the right dominant side.Review of the smoking evaluations for Resident #95 revealed on 6/19/25 LPN Staff S answered No to Short term memory OK- Seems to recall after five (5) minutes. The summary of evaluation noted the resident was a safe smoker and needed constant supervision while smoking.The smoking evaluation dated 7/2/25 completed by LPN Staff T noted Resident #95 was alert and oriented and could consistently perform safe smoking techniques. LPN Staff T checked the box on the evaluation noting the resident was a safe smoker and did not require supervision while smoking.Review of the care plan initiated on 7/7/25 revealed Resident #95 had impaired cognitive function/dementia or impaired thought process related to impaired decision making.The care plan for smoking initiated on 7/7/25 noted the goal was for the resident to not smoke without supervision. The interventions as of 7/7/25 specified Resident #95 required supervision while smoking. On 8/26/25 the care plan was updated with the intervention to observe clothing and skin for signs of cigarette burns and The resident requires a smoking apron while smoking.On 7/15/25 the care plan was updated and noted Resident #95 was incontinent of bowel and bladder related to confusion.Complete review of the clinical record failed to reveal documentation a new smoking evaluation was completed on 7/7/25 to address the resident's impaired cognition, and ability to smoke independently.On 8/27/2025 at 11:07 a.m., Resident #95 was observed smoking a cigarette in the designated smoking area. The resident was not wearing a smoking apron while smoking as specified in the care plan.On 8/28/2025 at 2:12 p.m., in an interview LPN Staff T said he had not received any training on how to complete smoking evaluations. LPN Staff T verified he completed the smoking evaluation for Resident #95 on 7/2/25. He verified the smoking evaluation noted that the resident was a safe smoker and did not need supervision while smoking. Upon reviewing the resident's care plan LPN Staff T said he was not aware Resident #95 required a smoking apron during smoking sessions. He said if he had known, he would have noted the resident was an unsafe smoker and needed constant supervision while smoking.On 8/29/2025 at 2:50 p.m., CNA Staff R was observed supervising smokers in the designated smoking area. In an interview Staff R said Resident #95 was the only resident who required an apron because he drools. He said they did not have enough smoking aprons for the smokers who needed it but today they brought more aprons. CNA Staff R said they struggle to get a break when assigned to supervise the smoking area,. No one comes and checks on the staff assigned to supervise the courtyard and smoking area.6. Review of the clinical record for Resident #105 revealed an admission date of 8/24/23. Diagnoses included Type 2 Diabetes and bilateral above the knee amputations.The smoking evaluation dated 6/30/25 and completed by RN Staff YY noted revealed Resident #105 was a safe smoker did not need supervision while smoking. In the comment section RN Staff YY documented, Smoking is supervised.7. Review of the clinical record for Resident #64 revealed an admission date of 8/8/23. Diagnoses included Chronic Obstructive Pulmonary Disease, Bipolar Disorder and Major Depressive Disorder. The smoking evaluation completed on 6/2/25 by LPN Staff S was incomplete and contained conflictive information. No answer was documented for Decision-making skills are reasonable and consistent. The evaluation noted the resident was a safe smoker and constant supervision was needed while smoking.Review of the Brief Interview for Mental Status for Resident #64 dated 6/30/25 noted the resident had Moderate impairment.8. On 8/27/25 at 12:20 p.m., CNA Staff W was observed leaving the designated smoking area. The CNA left cigarettes and lighters unlocked, unattended and easily accessible to 4 residents observed in the designated smoking area.9. On 8/27/2025 at 2:49 p.m., in an interview the Director of Nursing (DON) said smoking evaluations are completed upon admission and quarterly. The DON said the care plan is updated at morning meeting the day after the smoking evaluation is completed.10. On 8/27/25 at 2:50 p.m., an interview was held with the Administrator to discuss the incomplete, inaccurate smoking evaluations, and the training and competency of the licensed nurses who complete the smoking evaluations. The Administrator said he did not know who was responsible to ensure the licensed nurses were trained and competent to complete accurate smoking evaluations. The observation of the CNA leaving the designated smoking area with cigarettes and lighters unlocked, unattended and easily accessible to 4 residents observed in the smoking area was shared with the Administrator. He said the CNAs assigned to the smoking area did not have a direct supervisor and he did not know who was responsible to educate the CNAs not to leave residents unattended, and not to leave smoking material unlocked in the smoking area. The Administrator said the courtyard should be supervised at all times, regardless of smoking times and the smoking area should never be left unsupervised.On 8/27/25 at 3:20 p.m., CNA Staff V was observed supervising smokers during a smoking session in the designated smoking area. In an interview, CNA Staff V said she had not received any training related to supervision of smokers during smoking sessions. On 8/27/25 at 4:33 p.m., in an interview the Regional Director of Clinical services said there was no specific training for CNAs who supervise smokers.On 8/28/2025 at 11:55 a.m., in an interview the Administrator said he did not know if there was a specific training on how to do a smoking evaluation. He said a safe smoker must be able to show they won't burn themselves or others. The Administrator said, We are not identifying unsafe smokers, we missed the boat. The observation of Resident #95 not wearing the smoking apron as per the interventions listed on the care plan was shared with the administrator. He said, If a resident is identified as someone who requires an apron, they are expected to wear the apron while smoking.

Based on observation, record review, residents and staff interviews, the facility administration failed to utilize its resources effectively to provide effective oversight and enforcement of safe smoking practices. The smoking evaluations for 5 (Residents #59, #3, #74, #64 and #5) of 6 residents reviewed contained conflicting and inaccurate smoking risks. The evaluations noted the residents were safe smokers and required constant supervision for smoking. The licensed nurses who completed the smoking evaluations had no documentation of training or competencies to ensure the smoking evaluations were complete and accurately reflected each resident's smoking risks.Residents #3, and #59 were smokers and used supplemental oxygen in their rooms. Resident #5 used oxygen and vaped electronic cigarettes in her room. The residents retained and stored ignition devices (lighters or electronic cigarettes) in their rooms while oxygen was in use. The management staff responsible to enforce safe smoking practices had not received training and did not consistently complete the observation of assigned residents' rooms and failed to identify the unsafe storage of lighters and electronic cigarettes in residents' rooms where oxygen was in use. Staff assigned to monitor residents who require constant supervision during smoking had not received appropriate training and competencies.These failures created a constant hazardous environment and a likelihood of serious harm, injury or death of residents from fire and thermal burns from the unsafe smoking practices and resulted in the determination of Immediate Jeopardy. The findings included: Refer to F689, F726 and F926. Review of the Executive Director (Administrator)'s job description signed on 3/27/25 revealed, The primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times . Job functions . You will also provide leadership to all facility staff in meeting the goal of providing quality resident care . Duties and Responsibilities . Ensure a safe, clean and comfortable environment for residents, visitors and staff .Review of the Director of Nursing's job description signed on 8/6/25 revealed, As the company Director of Nursing, you are entrusted with the responsibility of caring for our residents . The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our facility . to ensure that the highest degree of quality care is maintained at all times . Duties and Responsibilities . Establish, implement, and continually update competency/skills checklists for nursing staff .Review of the provided facility assessment revealed smoking was not addressed as it relates to resident safety and facility risk. Review of the provided facility's New Hire Orientation revealed the facility was a drug-free workplace, no smoking, no tobacco use.On 8/25/25, the facility provided a residents' list titled, Resident smoking list subject to change based on admit/discharge updated on 8/25/25. The list included 14 smokers. On 8/27/27 at 9:10 a.m., Resident #3 was observed in his room in bed, holding a cigarette and a lighter, approximately 4 feet from his roommate (Resident #103) receiving supplemental oxygen via nasal cannula. Resident #3's smoking evaluation completed on 8/24/25 noted the resident did not have the fine motor skills needed to securely hold a cigarette. The summary of the evaluation noted that the resident was a safe smoker and did not need supervision while smoking. The resident's care plan did not address smoking risks and safety interventions necessary while smoking. Resident #3 was not included in the facility provided list of smokers. On 8/27/25 at 12:30 p.m., Resident #59 was observed in his room receiving supplemental oxygen via nasal cannula. Resident #59 was included in the facility provided list of smokers. During observation and interview, a cigarette lighter was observed stored in the resident's nightstand, approximately 2 feet from the oxygen concentrator. Review of the resident's clinical record revealed a physician's order for supplemental oxygen dated 8/25/25. The clinical record did not include a smoking evaluation or assessment of the resident's comprehension of safety precautions and the dangers of smoking or storing ignition devices near oxygen. Resident #74 was included in the facility provided list of smokers and was Resident #59's roommate. The smoking evaluations completed on 4/23/25 and 7/24/25 contained conflictive information. The evaluations noted that the resident was a safe smoker and required constant supervision while smoking. The smoking evaluation completed on 7/24/25 did not include the resident's ability to communicate why oxygen must always be off prior to lighting cigarettes. On 8/27/25 at 12:45 p.m., cigarettes and a lighter were observed on the windowsill of Residents #74 and #59's shared bedroom. Resident #59's oxygen concentrator was on and running. In an interview Resident #74 said the lighter belonged to him and he kept it on the windowsill. On 8/28/25 at 1:30 p.m., Resident #5 was observed in her room in bed receiving supplemental oxygen. Resident #5 said she does not leave her room. She said she has been vaping and storing electronic cigarettes in her room. The resident's clinical record contained inconsistent and conflictive information related to smoking.The smoking evaluation completed on 7/25/25 noted Resident #5 was a safe smoker and also required constant supervision while smoking. Resident #5's current care plan noted she was a former smoker, a smoker, and had behaviors of vaping in her room. The care plan did not include interventions to stop the unsafe behavior of storing and vaping electronic cigarettes with oxygen in the room. Resident #64 was included in the facility provided list of smokers. The smoking evaluations completed on 3/4/25 and 6/2/25 noted that the resident was a safe smoker and needed constant supervision while smoking. On 8/27/25 at 12:20 p.m., Certified Nursing Assistant (CNA) Staff W was observed leaving cigarettes and lighters unlocked, unattended in the designated smoking area while she took a resident to the bathroom. The smoking materials were easily accessible to 4 Residents observed in the smoking area. On 8/27/25 at 2:50 p.m., an interview was held with the Administrator to discuss the incomplete, inaccurate smoking evaluations, and the training and competency of the licensed nurses who complete the smoking evaluations. The Administrator said he did not know who was responsible to ensure the licensed nurses were trained and competent to complete accurate smoking evaluations. The observation of the CNA leaving the designated smoking area with cigarettes and lighters unlocked, unattended and easily accessible to 4 residents observed in the smoking area was shared with the Administrator. He said the CNAs assigned to the smoking area did not have a direct supervisor and he did not know who was responsible to educate the CNAs not to leave residents unattended, and not to leave smoking material unlocked in the smoking area. The Administrator said the courtyard should be supervised at all times, regardless of smoking times and the smoking area should never be left unsupervised.On 8/27/25 at 4:33 p.m., in an interview the Regional Director of Clinical services said there was no specific training for CNAs who supervise smokers.On 8/28/25 at 11:55 a.m., an interview was held with the Administrator to discuss the unsafe smoking practices, and the facility oversight and leadership to maintain a safe environment for the residents. The Administrator said Managers conduct angel rounds Monday through Friday. Spot checks are done on the weekend. He said staff conducting the angel rounds were expected to intervene immediately if an issue is identified and notify him. The Administrator said managers had not received training specific on the angel rounds but they were expected to look for lighters in the residents' rooms.When asked for the completed angel rounds for the past two weeks, the Administrator said he had no documentation the management staff completed the angel rounds.When asked about operationalizing the smoking policy to ensure adequate supervision of residents who smoke tobacco or vape electronic cigarettes, the Administrator said a CNA is assigned to the smoking area each shift. They are told to never leave residents unsupervised.

Based on observations, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement and enforce the facility's supervised smoking policy to ensure accurate residents' smoking evaluations and prohibiting the use and storage of ignition devices around oxygen use in residents' rooms for 6 (Residents #3, #103, #59, #74, #5, and #95) of 6 residents reviewed for safe smoking.Residents #3 and #103 were roommates. Resident #3 was a smoker and Resident #103 received supplemental oxygen via nasal cannula.On 8/27/25 Residents #3 and #103 were observed in their shared bedroom. Resident #3 was holding a cigarette and lighter approximately 4 feet from Resident #103 who was in bed receiving supplemental oxygen.Residents #59 and #74 were roommates and smokers. Resident #59 received supplemental oxygen. Both residents required constant supervision while smoking. On 8/27/25 Resident #59 was receiving oxygen. A lighter was stored within 2 feet of the oxygen source and on the windowsill of the shared bedroom.Resident #5 received supplemental oxygen. The resident stored and vaped electronic cigarettes in her room without staff intervention or supervision. The facility failure to consistently implement and monitor for compliance with the smoking policy and allowing the presence and storage of ignition devices such as electronic cigarettes and lighters near oxygen sources in residents' rooms created a likelihood of serious harm, injury or death of residents from immediate fire which could result in serious thermal burn and resulted in the determination of Immediate Jeopardy.The findings included:Cross reference F689, F726 and F835Review of the facility's policy and procedure titled, Smoking-Supervised with a revision date of 8/17/2017 revealed, . Smoking is only allowed in designated areas and oxygen is not permitted . Residents smoke will be evaluated on admission/re-admission, quarterly and with a change of condition to determine if additional adaptive or safety equipment is needed. Residents will be supervised during smoking including those resident utilizing electronic cigarettes . Smoking materials will be retained and stored by the nursing staff for residents who have been granted smoking privileges . NO IGNITION DEVICES will be in the resident's possession at any time and is strictly prohibited. Electronic cigarettes are permitted, but only in facility designated smoking areas. The same rules that apply to regular tobacco cigarettes also apply to electronic smoking materials. Electronic cigarettes and materials, including the liquids, will be retained and stored by nursing staff .On 8/27/25 at 9:10 a.m., during a tour of the facility, Resident #103 was observed in his room in bed receiving supplemental oxygen via nasal cannula.Resident #3 was in bed within 4 feet of Resident #103. Resident #3 was holding a lighter and a cigarette. On 8/27/25 at approximately 9:15 a.m., the observation of Resident #3 holding a lighter in close proximity of an oxygen source was shared with the Regional Nurse Consultant. She stated, Residents or family members can sneak stuff in.Review of the clinical record for Resident #3 revealed the admission Minimum Data Set (MDS) assessment with a target date of 5/24/25 revealed Resident #3 scored 15 on the Brief Interview for Mental Status indicating intact cognition. The assessment noted Resident #3 had functional limitation in range of motion of one upper extremity. No was entered in the MDS for current tobacco use.On 8/24/25 Registered Nurse (RN) Staff ZZ completed a smoking evaluation for Resident #3. The evaluation noted the resident did not have the fine motor skills needed to securely hold a cigarette. RN Staff ZZ determined Resident #3 was a safe smoker and did not need supervision while smoking despite the inability to securely hold a cigarette. The clinical record did not include a care plan with individualized interventions for safe smoking.On 8/27/25 at 10:30 a.m., in an interview Resident #3 said he's been smoking and has kept a lighter in his room since his admission to the facility.On 8/27/25 at 10:32 a.m., in an interview Certified Nursing Assistant (CNA) Staff Z said Resident #3 has always been a smoking every day since his admission. CNA Staff Z said residents can keep cigarettes but not lighters in their room.On 8/27/25 at 10:33 a.m., in an interview CNA Staff Y said Resident #3 has been smoking every day since his admission. She said the resident was allowed to keep his cigarettes but no lighter.Resident #3 was not included in the facility provided Resident smoking list updated on 8/25/25. The Resident smoking list included Resident #59. On 8/27/25 at 12:30 p.m., Resident #59 was observed in bed in his room receiving oxygen at 4 liters via nasal cannula. In an interview Resident #59 verified he smoked cigarettes. Resident #59 said he stored his cigarettes and lighter in his nightstand. Resident #59 opened the first drawer of the nightstand where a cigarette lighter was observed, approximately 2 feet from the oxygen concentrator. Photographic evidence obtained.Review of the clinical record for Resident #59 revealed on 5/19/25 Licensed Practical Nurse (LPN) Staff S completed a smoking evaluation which contained conflictive information. The evaluation noted Resident #59 was a safe smoker but needed constant supervision while smoking. The resident's ability to communicate why oxygen must always be shut off prior to lighting cigarette was not evaluated and left blank. Review of the physician's orders revealed an order dated 8/25/25 for Oxygen as needed for shortness of breath or oxygen saturation below 90%. The clinical record lacked documentation a smoking evaluation was completed on 8/25/25 to address the use of oxygen and the resident's understanding and ability to verbalize why oxygen must always be shut off before lighting a cigarette. On 8/27/25 at 12:45 p.m., observation of Residents #59 and #74's shared bedroom revealed cigarettes and a lighter stored on the windowsill. Resident #59 was not in the room. The oxygen concentrator was on and running. In an interview during the observation, Resident #74 said he smoked cigarettes. He said the cigarettes and lighter on the windowsill belonged to him and that was where he stored them. On 8/28/25 at 1:30 p.m., Resident #5 was observed in bed receiving oxygen via nasal cannula. In an interview Resident #5 said she doesn't get out of bed. She said she was a smoker but has been vaping electronic cigarettes in her room since she cannot get out of bed to go to the designated smoking area. She said she has been using her electronic cigarette in her room for over a month but staff took it away from her last night. Resident #5 was not listed on the Resident smoking list. Review of the clinical record for Resident #5 revealed an admission date of 1/19/24. Diagnoses included Morbid Obesity, Bipolar Disorder and Major Depressive Disorder.The physician's orders dated 1/22/24 included oxygen at 3 liters per minute via nasal cannula at bedtime. The care plan related to smoking for Resident #5 was inconsistent:The care plan initiated on 10/12/23 with a target date of 10/28/25 noted Resident #5 was a former smoker and used oxygen at bedtime. The care plan initiated on 6/24/25 noted the resident was a smoker. The goal was for the resident not to smoke without supervision and the resident would not suffer injury from unsafe smoking practices. The care plan initiated on 6/24/25 noted the resident has behaviors and vapes in her room. The goal was for the resident to have fewer episodes of vaping and the resident will have no evidence of behavioral concerns vaping. The interventions included to monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. The care plan did not include interventions to stop the unsafe practice of vaping electronic cigarettes in the room while using oxygen. Review of the smoking evaluations revealed on 7/25/25 LPN Staff S documented Resident #5 was a safe smoker and the supervision required while smoking was constant.Resident #95 was included in the facility's Resident smoking list. Resident #95's name was listed under Apron Assistance.Review of the clinical record for Resident #95 revealed a date of admission of 7/5/24. Diagnoses included hemiplegia (paralysis)/hemiparesis (weakness) of the right dominant side. Review of the smoking evaluation completed by LPN Staff T on 7/2/25 revealed Resident #95 was a safe smoker and did not need supervision while smoking. On 8/27/25, review of Resident #95's care plan revealed on 8/26/25 a new intervention was added to the smoking care plan specifying the resident required a smoking apron while smoking. On 8/27/25 there was no documentation a new smoking evaluation was completed to address the smoking apron and evaluate the resident's ability to smoke independently and unsupervised. On 8/27/25 at 10:55 a.m., CNA Staff W was observed supervising the designated smoking area. Resident #95 was smoking and was not wearing the smoking apron per the safety intervention listed on the smoking care plan on 8/26/25.On 8/27/25 at 12:20 p.m., CNA Staff W was observed monitoring the designated smoking area. CNA Staff W left the smoking area with a resident. She left cigarettes and lighters unlocked, unsupervised and easily accessible to Resident #95 and 3 other residents observed in the designated smoking area. On 8/27/2025 at 1:12 p.m., the designated smoking area was observed with the Director of Nursing (DON). Resident #95 was smoking and was not wearing the protective apron as care planned. In an interview, the DON verified Resident #95 was not wearing the protective smoking apron as care planned. On 8/27/2025 at 3:10 p.m., in an interview the Social Services Director said per the facility' s policy, residents were not allowed to have lighters in their possession. The Social Services Director said the managers are assigned residents' rooms and conduct angel rounds. She said during the rounds, the managers look for lighters in the residents' rooms. She said the Administrator kept the completed angel rounds forms. On 8/27/25 at 4:33 p.m., CNA Staff V was observed supervising the designated smoking area. She said residents bring their own lighters and light their cigarettes. She tries to take the lighters from the residents but they don't listen. CNA Staff V said she told both the nursing staff and social services about the residents having and keeping their own lighters. She said they have not done anything about it so she stopped reporting it to them. On 8/28/25 at 11:55 a.m., in an interview the Administrator verified Resident #5 received oxygen and vaped electronic cigarettes in her room. He said Resident #5 was not able to go outside and vaped in her room. When asked about the facility process to enforce the smoking policy, the Administrator said the managers conduct angel rounds Monday through Friday. Spot checks are done on the weekend. He said staff conducting the angel rounds were expected to intervene immediately if an issue is identified and notify him. The Administrator said managers had not received training specific on the angel rounds but they were expected to look for lighters in the residents' rooms. Review of a blank form titled, Morning Room Round identified by the facility as the Angel Round form noted, No Meds, treatment supplies, or unsafe items in room was part of the checklist. Review of the Angel Round Room Assignments form revealed:The Maintenance Director was assigned to Residents #59 and #105. The facility's concierge was assigned to Resident #64.The Social Worker was assigned to Resident #95.The Activity Director was assigned to Resident #5.The Assistant Business Office Manager was assigned to Resident #3. When asked for the completed angel rounds for the past two weeks, the Administrator said he had no documentation the management staff completed the angel rounds.When asked about operationalizing the smoking policy to ensure adequate supervision of residents who smoke tobacco or vape electronic cigarettes, the Administrator said a CNA is assigned to the smoking area each shift. They are told to never leave residents unsupervised. The Administrator said the facility had no other policy addressing smoking other than the provided Smoking Supervised policy and procedure.

Based on record review and interview, the facility failed to have a written transfer agreement in effect with one or more hospitals approved for participation in Medicare/Medicaid programs. The findings included:On 8/29/25 a request was made to the facility to review the facility's transfer agreement with one or more hospitals approved for participation in the Medicare/Medicaid programs. On 8/29/25 at 12:15 p.m., in an interview the Regional [NAME] President of Operations said the facility did not have a transfer agreement with any hospital.On 8/29/25 at 1:30 p.m., in an interview the Administrator verified the facility did not have a transfer agreement with one or more hospitals approved for participation in the Medicare/Medicaid program.

Based on record review, review of facility's policy and procedure, residents and staff interviews, the facility failed to act promptly upon the grievance expressed by the resident council group during their monthly meetings. The findings included:Review of the facility's Complaint/Grievance policy and procedure N-1042 dated 11/30/14 and revised 10/24/22 revealed that the center would support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center would make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. An employee receiving a complaint/grievance from a resident, family and/or visitor would initiate a Complaint/Grievance Form. The original grievance form was then submitted to the Grievance Office/designee for further action. The Grievance Officer/designee would act on the grievance and begin follow-up of the concern or submit it to the appropriate department director for follow-up. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. The findings of the grievance should be recorded on the Complaint/Grievance Form. The results would be forwarded to the Executive Director for review and filing. The Grievance Official would log complaints/grievances in the Monthly Grievance Log. The individual voicing the grievance would receive follow-up communication with the resolution, a copy of the grievance resolution would be provided to the resident upon request. On 8/26/25 at approximately 11:30 a.m., a meeting was held with 15 residents who participate in Resident Council Meetings. The Resident Council President said they held monthly resident council meetings. The Activity Director or designee runs the meetings and documents the minutes on the Resident Council Minutes form. The group said the facility did not always follow up on the concerns/grievances expressed in the meetings and no resolution is discussed in the next meeting. The Resident Council President said the group told the Activity Director over the past several months the resident's call lights had not been answered timely, mostly during the night shift and the newer employees need better training on how to answer resident's call lights and other concerns (maintenance concerns and menu changes) they voiced during the meetings. The group said no one from the facility had spoken to them on how their concerns would be addressed and/or resolved even though staff wrote it on the next month's resident council meeting minutes. Review of the Resident Council Meeting minutes dated 6/25/25, noted in the New Business section, the Activity Director wrote: call lights, maintenance on (brand name) full body mechanical lifts and lifts, maintenance on hand and foot bike and menu changes. The Resident Council Meeting minutes dated 7/23/25 under Old Business the Activity Director wrote call lights - new people not trained, resident orientation and menu changes. In the New Business section, the Activity Director wrote call lights to be answered timely, audits and staff education to be completed, check (brand name) mechanical lift and hand bike weekly by the maintenance department, and weekly food audits by the Kitchen Manager. On 8/28/25 at 12:00 p.m., in an interview the Social Service Director (SSD) said the Activity Director normally conducts the monthly resident council meetings and documents the meeting on the Resident Council Minutes form. She said after the resident council meeting, the Activity Director tells her the concerns/grievances brought up during the resident council meeting. They document the grievances on the monthly grievance log. She then delegates the grievance to the appropriate departments. The grievances had to be addressed/resolved within 14 days per the facility's complaint/grievance policy. The resolution is explained in the next monthly resident council meeting. The SSD reviewed the resident council meeting minutes for 6/25/25 and 7/23/25. She confirmed the resident council voiced concerns/grievance related resident call lights not being answered timely, staff training related to call lights, maintenance of (brand name) mechanical lift and hand bike equipment, and menu changes. The SSD said she could not find documentation the grievances voiced by the resident council group in June and July 2025 were addressed and that the resolution was communicated to the resident council group.On 8/28/25 at 12:30 p.m., in an interview the Administrator verified the lack of documentation the grievances voiced by the resident council group in June and July 2025 had been addressed. He said the facility did not follow their grievance policy and procedure.

Based on observation, record review, and staff interviews the facility failed to provide appropriate care and services to prevent complications of enteral feeding tubes for 3 (Residents #52, #15 and #94) of 4 residents reviewed.The findings included: Review of the clinical record revealed Resident #52 was admitted to the facility on [DATE]. Diagnosis included but not limited to aphasia following cerebral infarction, neuropathy, and gastrostomy.Care Plan initiated 8/12/25, revision date 8/20/25 revealed Resident #52 is at risk for complications, infections, fluid balance, aspiration (accidental inhalation of food, liquid into the airways or lungs) related to Resident #52 requires tube feeding to meet hydration/nutrition needs secondary to cerebrovascular accident (stroke). Interventions include observe for signs and symptoms of infection, report promptly; provide local care to g-tube site as ordered and monitor for signs and symptoms of infection.Review of physician orders reveals Resident #52 does not have an order to cleanse g-tube site or to change dressing.On 8/27/25 at 10:27 a.m. during medication pass with Resident #52 observed Staff O, LPN insert ungloved pointer finger into plastic medication sleeve for each medication pulled before crushing. During medication pass observed Staff O, LPN insert gloved pointer finger into water that was being used to flush the g-tube. Observed dressing to g-tube site with moderate amount of brown and yellow drainage, extending approximately one inch from the insertion site . Staff O, LPN said she did not do the treatment yet. Staff O, LPN said she was planning on doing the treatment in the afternoon.On 8/28/25 at 8:50 a.m. observed Resident #52 with soiled dressing to g-tube site. Date on the dressing was 8/25/25. (photographic evidence obtained). Present was Staff CC, LPN. Staff CC, LPN said the dressing should be changed daily and as needed. Staff CC, LPN said an infection could happen by not changing the dressing daily and keeping the area clean. Staff CC, LPN said every nurse should check to see if the site needs to be cleaned and the dressing changed.On 8/29/25 at 9:40 a.m., in an interview with Staff AA, LPN said g-tube sites need to be cleaned and a dressing applied at least daily. Staff AA, LPN said if there is redness you have to notify the physician. Staff AA, LPN said that it was not good Resident #52 did not have an order to clean and apply dressing. Staff AA, LPN said an infection could occur if the area is not cleansed and if the dressing is soiled.On 8/29/25 at 9:51 a.m., in an interview with Staff BB, LPN said residents with a feeding tube should have an order to cleanse and change the dressing daily and as needed if soiled. Staff BB, LPN said she did not know why Resident #52 did not have an order. Staff BB, LPN said if a dressing is not changed an infection could happen. Staff BB, LPN said there could be damage to the stoma and compromised skin integrity. Staff BB, LPN said it was not acceptable for a dressing dated 8/25/25 to be on 8/28/25.On 8/29/25 at 10:28 a.m., in an interview with the DON said after reviewing the orders, Resident #52 did not have an order to clean or change dressing to g-tube site. The DON said Resident #52 should have an order because there is a potential for infection without cleansing and applying a new dressing. The DON said the infection control breaks during medication pass were against infection control practices and could lead to an infection.Review of the clinical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnosis included but are not limited to acute kidney failure, cerebral infarction, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) affecting right dominant side, and dysphagia (swallowing disorder).Care plan 4/25/25 revealed Resident #15 requires a g-tube feeding related to dysphagia. Interventions include provide local care to g-tube site as ordered and monitor for signs and symptoms of infection.Review of physician order 7/31/25 revealed enteral: stoma care every shift (2 times per day) left lower quadrant.Review of Treatment Administration Record revealed no documentation for 8/19/25 day shift.On 8/28/25 at 9:00 a.m., observed Resident #15 had no dressing to g-tube site. Staff CC, LPN said she did not know why Resident #15 did not have a dressing on. Staff CC, LPN said that no one had come to her to say the dressing was off.Review of the clinical record revealed Resident #94 was admitted to the facility on [DATE]. Diagnosis included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, and gastrostomy.Review of physician order 9/19/24 enteral: stoma care every shift (2 times per day).On 8/28/25 at 8:53 a.m. observed dressing to g-tube site dated 8/25/25. (photographic evidence obtained). Present was Staff CC, LPN. Staff CC, LPN said the dressing should be changed daily and as needed. Staff CC, LPN said an infection could happen by not changing the dressing daily and keeping the area clean. Staff CC, LPN said every nurse should check to see if the site needs to be cleaned and the dressing changed.Review of the Treatment Administration Record revealed no documentation for 8/19/25 day shift.Review of the Treatment Administration Record revealed enteral: stoma care every shift was signed for on 8/26/25 and 8/27/25 on both day and night shifts.On 8/29/25 at 10:12 a.m., in an interview with Staff S, LPN said it is not acceptable for a nurse to sign for something that was not done. Staff S, LPN said nurses have to follow physician orders and if you are signing, it must be done. Staff S, LPN said nurses are trained in feeding tubes and stoma care.On 8/29/25 at 10:28 a.m., in an interview with the DON said nurses should not sign for something they did not do. The DON said an infection could occur if the dressing is not changed and the area cleansed.

Based on record review and interview, the facility failed to ensure timely acquiring and administering of medications to meet the needs of 3 (Residents #48, #51, and #18) of 3 residents selected for medication administration observation.The findings included:1. On [DATE] at 8:16 a.m., during a medication administration observation for Resident #48, Licensed Practical Nurse (LPN) Staff M said Resident #48's Tenofovir Discoproxil Fumarate (hepatitis medication) was not available. She said the medication was ordered on [DATE] and had not arrived from the pharmacy yet. Review of Resident #48's Medication Administration Record for [DATE] revealed several days medications had not been documented as given including: [DATE]th and 25th which had blank boxes for Levothyroxine (thyroid medication), Naloxogol Oxalate (medication for constipation), Torsemide (diuretic medication). [DATE]th also had a blank box for Insulin Glargine (diabetic medication). No documentation was found explaining what the blank boxes meant or that the doctor had been notified anything regarding these medications on these days. 2. On [DATE] at 8:21 a.m., during observation of medication administration for Resident #18, LPN Staff N said Resident #18's Irbesartan (blood pressure medication) was not available. She said it was reordered today.Review of Resident #18's Medication Administration Record (MAR) for [DATE] revealed: On [DATE], [DATE], [DATE], and [DATE], 9 (other/see nurse's notes) was entered for OcuSoft eyelid cleansing external Pad (medication for eyelid inflammation).On [DATE] there was no documentation the ordered Miralax powder (laxative), Lorazepam (anxiety medication), Tramadol (opioid pain medication) were administered. Review of Resident #18's progress notes for [DATE] revealed a progress note on [DATE] that the Ibersartan had been ordered from pharmacy, but no documentation the doctor was notified about the missed dose. Progress notes were found for the Ocusoft indicting the medication was not available, however no documentation that the doctor was notified of the missed applications. No progress notes were found to explain the blank boxes on [DATE] for the Miralax, Lorazepam or Tramadol. 3. On [DATE] at 8:25 a.m., during a medication administration observation for Resident #51, LPN Staff N said Resident #15's Oxycontin Extended Release 15 mg every 12 hours (opioid pain medication) was not available. She said she would have to contact the pharmacy. Review of Resident #51's Medication Administration Record for [DATE] failed to reveal documentation the morning dose of Oxicontin was administered on [DATE], [DATE] and [DATE] or the evening dose was administered on [DATE]. Review of the progress notes revealed the medication was not available on those days and the doctor had been notified.On [DATE] at 4:49 p.m., in an interview the Director of Nursing (DON) said when a medication is unavailable the process should be to check the bottom drawer of the med cart for overflow and check the electronic medication dispensing system. The DON said if the medication is not found, staff should notify the doctor of the missed dose, write a progress note the doctor was notified and their response and write an order if the doctor gives one. He said nurses should be documenting on the MAR (Medication Administration Record) and not leaving blank spots. The DON said when it comes to re-ordering medications, if the prescription is still good, nursing staff should re-order before the medication runs out, usually when there is a 7-day supply left. He said if the prescription has expired, the doctor should be notified in the same time frame. The DON agreed when the boxes on the MAR are left blank there is no way to know whether the resident received the medication or not.

Based on record review, review of the facility's policy and procedure, and staff interview, the facility failed to ensure 2 (Residents #65, and #51) of 5 residents reviewed for immunization received education regarding the benefits and potential side effects and were offered pneumococcal immunization.The facility failed to ensure 1 (Resident #65) of 5 residents residing at the facility between October 1, 2024, and March 31, 2025, received education and was offered the influenza immunization.The findings included:Review of the Pneumococcal Vaccine Policy dated 2001, revised October 2019 revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. (1) Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated prior to admission. (2) Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission if not conducted prior to admission. (3) Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record. (5) Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the pneumococcal vaccination. (6) For residents who receive the vaccines, the date of the vaccination, lot number, expiration date, person administering, and the site of the vaccination will be documented in the resident's medical record.Review of the clinical record for Resident #65 revealed an admission date of 12/17/24.The clinical record for Resident #65 lacked documentation upon admission of screening, education, offering and current vaccination status for Pneumococcal Vaccine.Review of the clinical record for Resident #51 revealed an admission date of 8/27/24.The clinical record for Resident #51 lacked documentation upon admission of screening, education, offering and current vaccination status for Pneumococcal Vaccine.Review of the Influenza Vaccine Policy and Procedure for Residents with an effective date of 11/30/2014 and a revision date of 8/17/2020 revealed that residents will be offered the influenza vaccine annually (between October 1st and March 31st) unless otherwise directed by the Centers for Disease Control (CDC), to encourage and promote the benefits associated with vaccinations against influenza, in accordance with the local health department and CDC Guidelines. (1) Provide resident/resident representative education on potential side effects and risk benefits of the vaccine. Review the potential risk/side effects and benefits from the vaccine. (2) Obtain an informed consent form the patient/resident or legal representative if indicated indicating acceptance or declination. (5) File the informed consent in the medical record. (6) Document in the medical record including but not limited to: the resident or legal representative was provided education including potential side effects of the vaccine; the resident received the vaccine date, lot number, expiration date, manufacturer or, the resident did not receive the vaccine due to medical contraindication, has received the vaccine outside of the center, or refused.Record review showed Resident #65 was at the facility between October 1, 2024, and March 31, 2025.The clinical record for Resident #65 lacked documentation of screening, education, offering and current vaccination status for Influenza Vaccine.On 8/27/25 at 9:30 a.m., in an interview the Regional Director of Clinical Services said she reviewed the clinical record for Residents #65. She verified Residents #65 was at the facility between October 1, 2024, and March 31, 2025, had no contraindication to the vaccine and was not offered the influenza vaccine. The Regional Director of Clinical Services also verified that Residents #59, #64, #65 and #51's clinical record lacked documentation of pneumococcal vaccine status. She said there was no documentation Residents #59, #64, #65, and #51 received information about pneumococcal vaccination and were offered, requested or declined pneumococcal vaccination.

Based on record review and staff interview, the facility failed to ensure the Advanced Beneficiary Notice of Non-Coverage issued to 2 (Residents #15 and #57) of 3 residents was complete and accurately reflect the residents' decision to stop or continue skilled services and the financial liability. The findings included:Review of the Facility policy titled Advanced Beneficiary Notice - ABN with a revision date of 11/10/2015 revealed, An ABN will be utilized to notify resident of the possibility that Medicare will not pay for the item(s) or service(s) that are described on the form . The form will be reviewed with the resident or authorized representative .Procedure 1. d. The resident or authorized representative is to choose one of the three options, date and sign the form. The resident must comprehend the contents. If the resident is unable to comprehend the contents of the notice, it must be delivered to and signed by an authorized representative . On 8/27/25 the Social Services Director (SSD) provided the Advance Beneficiary Notices of non-coverage that had been issued to current Residents #15 and #57.Review of the Skilled Nursing Facility Advance Beneficiary Notice of non-Coverage (SNF ABN) forms revealed:On 7/23/25, Resident #15 signed the form that beginning on 7/28/25 the resident may have to pay out of pocket for Physical Therapy. The form did not include the estimate cost the resident would have to pay per day/item or service. The form contained instructions to check the box for one of the 3 options listed to choose whether the resident wanted to continue the care listed and assume financial responsibility or that they did not want to continue the care. The resident signed the form but no option was checked. On 8/14/25 Resident #57 signed the ABN notice that beginning on 8/22/25 Resident #57 may have to pay out of pocket for physical therapy care at a rate of $400.00 per day. Under the section titled Options: check only one box, which allows resident the option to choose whether they want to continue the care listed and assume financial responsibility or choose they do not want the care, all 3 options had been chosen indicating they wanted the care and they did not want the care. On 8/28/25 at 10:38 a.m., in an interview the SSD verified both forms had not been completed correctly. She said with the forms filled out in this manner, they could not say whether the resident wanted to continue care and potentially assume financial responsibility or that they did not want the care.

Based on record review, review of facility's policy and procedure and staff interview the facility failed to refer 1 (Resident #11) of 2 residents with signs of serious mental illness, intellectual disability or a related condition for a Level II Pre admission Screening and Resident Review as required. The findings included: Review of the facility's policy for Preadmission Screening and Resident Review (PASSR) with a revision date of 11/8/2021 indicated: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medial record. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the resident's records. Review of the clinical record for Resident #11 revealed an admission date of 7/20/15. Diagnoses included anxiety and unspecified head injury of head. Review of the Level I PASSR dated 7/20/15 revealed instructions that a Level II evaluation must be completed if any box in Section II.A is checked and there is a YES checked in Section III.1, III.2, or III.3.The form noted that Resident #11 had a diagnosis of anxiety (Section IIA). Yes was entered for Section III.2 (A). Fear of strangers was Underlined. Yes was entered for Section III.2 (B). Pacing was underlined. Yes was entered for Section III.2 ( C). Adaptation to changes. There was no documentation a level II PASSR was completed for Resident #11. Resident #11's clinical record contained a Level I PASSAR dated 2/18/24. The instructions specified that a level II PASSAR examination must be completed prior to admission if any box in section 1.A. or 1.B. is checked and there is a yes checked in section II.1 II.2 or II.3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. The form indicated Resident #11 was not a provisional admission. Section 1.A. was marked for anxiety disorder and depression disorder. Section 1.B. was marked for traumatic brain injury. Section II.1 was marked yes, Section II.2 A, B and C were marked yes and Section II.3 was marked yes for question B.The clinical record contained a letter dated 2/18/24 from a pre-admission screening company indicated Resident #11's Level I screening results indicated signs of serious mental illness and intellectual disability or a related condition were found. A Level II screening is needed.The clinical record lacked documentation of a Level II screening. On 8/27/25 at 1:20 p.m., in an interview the Regional Social Services Director (SSD) said Resident #11 did require a Level II screening. She said she could not find documentation that a Level II had been done. She said she could not explain why a Level II PASSAR screening was never done for Resident #11.

Based on observation, interview and record review the facility failed to provide an ongoing program of activities to meet the needs of 1 (Resident #113) of 3 reviewed for activities program.The findings included:Review of Individual Activities Policy and Procedure dated 11/1/21 revealed residents who are unwilling and/or unable to attend scheduled group activities are provided one-to-one individualized recreational and Community Life based on their needs, interests, and functional ability. (1) Review the preferred activities and activity times of the resident found on the following form: Activity Plan of Care, MDS (3) Include resident and family in development of recreational and Community Life interventions that meet their needs, interests, and functional ability. (4) Determine and schedule activities and times that support preferences. (5) Obtain the appropriate supplies for the 1:1 visits.Review of clinical record revealed Resident #113 was admitted to the facility on [DATE]. Diagnosis included but were not limited to mycosis (a disease caused by fungus), muscle weakness, cleft palate, dysphagia (difficulty swallowing).Minimum Data Set (MDS) admission Assessment 8/23/25 revealed Resident #113 scored a 00 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment.MDS admission Assessment 8/23/25 asked How important is it to you to do your favorite activities. Resident #113 response was very important.On 8/25/25 at 10:12 a.m., in an interview Resident #113's family member said the resident was special needs, developmentally delayed. She said Resident #113 was non-verbal and used gestures to communicate. She said Resident #113 likes to color and watch children's shows on television. Resident #113 family member said as long she is coloring or watching her shows on TV she is happy. Review of care plans revealed no Activity Care Plan.Care Plan revealed Resident #113 has impaired cognitive function/dementia or impaired thought process related to developmentally delayed initiated on 8/22/25. Interventions include asking yes/no questions in order to determine the resident's needs; cue, reorient and supervise as needed.Care Plan revealed Resident #113 has a communication problem related to no speech, responds to name, diagnosis of cleft palate initiated 8/25/25. Interventions include anticipate and meet needs; allow adequate time to respond; avoid isolation.On 8/26/25 at 9:15 a.m., 9:38 a.m.,10:15 a.m.,11:33 a.m.,11:45 a.m.,12:45 p.m. and 1:28 p.m. the resident was observed in window bed, curtain drawn, dressed in a hospital gown, the television was off, container of crayons on overbed table, no paper or coloring pages. On 8/28/25 at 11:19 a.m., in an interview with Staff Q, Activities Assistant, when asked about the program of activities for Resident #113 and the goals, she said she was not familiar with the resident. On 8/28/25 at 4:46 p.m. in an interview with Staff Q, Activities Assistant said she does not have access to a computer so she would not be able to see if an Activities Assessment was done for Resident #133. She said only the Activities Director has access to a computer, and she was not in. When asked about resident care plans, Staff Q said she does not have access to care plans.On 8/28/25 at 4:54 p.m. in an interview with Staff P, MDS said it doesn't look like the activities assessment was completed. He said it should have been done.

Based on record review, review of the facility's policies and procedures and staff interviews, the facility failed to have documentation of COVID-19 vaccination status, screening, education, and offering of the vaccine for 1 (Resident #65) of 5 residents reviewed for immunization status. The findings included:Review of Covid-19 Vaccine for Residents Policy and Procedure with an effective date of 8/03/21, and a revision date 11/17/2021 revealed documentation that residents or their representatives will be educated about and offered the Covid-19 vaccine.(1) Covid-19 vaccinations will be offered to residents (or their representative if they cannot make health care decision) per Centers for Disease Control (CDC) and/or Federal Drug Administration (FDA) guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or the individual refuses to receive the vaccine.(2) Residents/representatives will be educated on the Covid-19 vaccine they are offered, in a manner they understand, including information on the benefits and risks consistent with CDC and/or FDA information. (2c) Residents/representatives will be provided the opportunity to refuse the vaccine and/or change their decision about vaccination at any time. Documenting Covid-19 vaccine: (5) Review the consent with the resident/resident representative. (5b) File the consent form in the resident electronic health record. (6) Documentation includes but is not limited to (6a) Whether the resident consented or declined the vaccine. If declined, reason for declination.Review of the clinical record for Resident #65 revealed an admission date of 12/17/24. Diagnoses included coronary artery disease, malnutrition, arthritis and renal insufficiency.Review of the Comprehensive Minimum Data Set (MDS) Assessment with a target date of 7/10/25 revealed Resident #65 scored a 06 on the Brief Interview or Mental Status (BIMS), indicating severe cognitive impairment.Review of Immunization Record for Resident #65 revealed no documentation for the Covid-19 vaccine.On 8/27/25 at 9:30 a.m., in an interview the Regional Director of Clinical Services said she reviewed Resident #65's clinical record and verified the lack of documentation of immunization status or contraindication for COVID-19 for Resident #65 and lacked documentation the resident/responsible party received education regarding the benefits and potential risks associated with COVID-19 vaccine and was offered COVID-19 vaccination. The Regional Director of Clinical Services said, It should have been documented.

Based on record review and interview, the facility failed to ensure 3 (Residents #1, #2 and #3) of 3 residents reviewed received care and services in accordance with professional standards of practice by failing to ensure laboratory testing were done as ordered for Residents #1, #2, and #3. The facility failed to document family reported concerns and failed to notify the practitioner of several episodes of loose stools for Resident #1.The findings included:Resident #1:Review of the facility's policy and procedure titled, Laboratory, Diagnostic and X-Ray with a revision date of 02/02/2024 revealed, Procedure: Obtain a physician's order for laboratory work, diagnostic testing, and x-ray. Complete the required requisition form(s). Schedule laboratory work, diagnostic test and or x-ray as indicated.Review of the clinical record for Resident #1 revealed an admission date of 6/12/25.Review of the progress notes revealed on 7/5/25 the Advanced Practice Registered Nurse (APRN) documented Resident #1 was evaluated for persistent bilateral leg edema (swelling) and shortness of breath. Lungs with bilateral rhonchi and wheezing (abnormal breath sounds). The practitioner documented a CMP (Complete metabolic panel) and Pro-BNP (measures a specific protein) were ordered to monitor electrolytes and volume status. The plan of care was discussed with the nurse. The progress note documented next labs pending were comprehensive panel, CBC (complete blood count) and Pro-BNP.Review of the Treatment Administration Record (TAR) for July 2025 revealed on 7/7/25, the Licensed Nurse placed her initials, indicating Resident #1's blood was drawn for the CMP, CBC and Pro-BNP.On 7/8/25 the APRN documented in a progress note Resident #1 complained of dysuria (painful urination). A urinalysis revealed a urinary tract infection. The practitioner ordered an antibiotic. The progress note documented the nursing staff reported that the resident had a foul smelling vaginal discharge consistent with suspected bacterial vaginosis (vaginal infection). The resident was started on empiric antibiotic treatment. The APRN documented the laboratory tests were currently pending results to monitor kidney function and electrolytes. On 8/4/25 review of the clinical record for Resident #1 failed to reveal results for the CBC, BMP and Pro-BNP the licensed nurse signed as obtained on 7/7/25.On 8/4/25 at 2:50 p.m., in an interview the Director of Nursing (DON) and Regional Nurse verified the lack of results for the CBC, BMP and Pro-BNP the APRN ordered on 7/5/25. They said they were not aware the resident's blood was never drawn.Further review of the progress notes revealed on 6/14/25 the APRN documented Resident #1 complained of diarrhea and there was no documentation on the chart about diarrhea. The APRN documented he will order Imodium (antidiarrheal) and probiotics and if patient continues to have diarrhea collect sample for C diff (clostridium difficile, bacteria that causes inflammation of the colon) and put patient in isolation. Monitor for loose, watery stool, bloating, abdominal cramps, and nausea. Monitor for fever, severe pain, vomiting, blood or mucus in stool or weight loss. Monitor for symptoms of dehydration. Medications as ordered: Imodium 2 mg capsules.Review of the Documentation Survey Report for 6/2025 and 7/2025 revealed Resident #1 had large loose stools:On 6/14/25, 6/16/25, 6/18/25, 7/7/25, and 7/8/25 during the day shift (6:00 a.m., to 2:00 p.m.).On 6/28/25 during the evening shift (2:00 p.m., to 10:00 p.m.).On 6/13/25, 6/17/25, and 7/7/25, during the night shift (10:00 p.m., to 6:00 a.m.). There was no documentation in the clinical record the Practitioner was informed Resident #1 had large loose stools.On 8/4/25 at 1:22 p.m., in an interview LPN Staff A said he recalled talking with Resident #1's brother. He said Resident #1 had a lot of fluid in her legs and was on diuretics (medication to help urinate excess fluid). LPN Staff A said, according to the charting, the five days before she was sent to the hospital, Resident #1 had mixed stools, some formed and some loose. He went over the resident's medications with the brother. He said she did not recall anyone telling him they found Resident #1 in diarrhea. The resident's labs indicated she had a urinary tract infection. He talked with the family about getting checked out. Basically, he explained to them what was happening with the resident and what the facility was doing to treat it. He said the scheduled Morphine (pain medication) was causing the slurred speech and they stopped it.On 8/5/25 at 9:23 a.m., in a telephone interview, Resident #1's brother said at the beginning of July 2025 he was on the phone with his sister (Resident #1). She was mumbling, crying, trying to talk, she just couldn't talk. He said he was concerned and flew down to see her. He said several times when he visited, he found her soiled, a mess, diarrhea on the bed. She was having difficulty speaking clearly. He asked his cousin to come to the facility. On Monday 7/7/25, he and his cousin spoke with Licensed Practical Nurse (LPN) Staff A about their concerns related to Resident #1's mentation, medications, finding her in soiled diapers multiple times. They were concerned Resident #1would end up with a urinary tract infection and go septic. They requested to have Resident #1 sent to the hospital to be examined. LPN Staff A told them they were adjusting Resident #1's medications and there was nothing they could do at the hospital that they couldn't do at the facility. He said he returned home and within 24 hours, he received a call from the hospital informing him Resident #1 was sent to the emergency room on 7/8/25 and was admitted to the Intensive Care Unit with a diagnosis of septic shock and C-diff.On 8/5/25 at 9:47 a.m., in an interview LPN Staff A said when Resident #1's brother showed up he spoke with him about pharmacology and fluid. Staff A said he went through labs at the time. They spoke about the scheduled morphine. Resident #1 said she felt off and it was visually apparent. Her speech was off, her posture was affected. It was difficult for her to sit up, it seemed like she was drugged. LPN Staff A said they reached out to pain management and the morphine was discontinued.On 8/5/25 at 10:03 a.m., in a telephone interview the APRN said sometimes the ordered labs are not done. Sometimes the residents refuse. The APRN said if the labs had been drawn and resulted in critical levels, he would have sent Resident #1 to the hospital. The APRN said no one told him the resident was experiencing loose stools.On 8/5/25 at 3:23 p.m., in an interview the Assistant Director of Nursing (ADON), Registered Nurse (RN) Staff B said on 7/7/25 he spoke with Resident #1's brother and one other person. He said Resident #1 had confusion, bipolar and pain. He spoke with the family about bipolar disease and that Resident #1 could be cycling, making her more confused. He said the family did not complain to him about Resident #1 having loose or foul smelling stools or diarrhea. They did not say anything about concern of a urinary tract infection or sepsis. He talked to them about trying to assist Resident #1 to the bathroom with a Certified Nursing Assistant but Resident #1 couldn't do it because she was too weak. ADON, RN Staff B said he did not document the concerns the family brought to his attention.Record review of Resident #1's clinical record and grievance log revealed no documentation of the concerns expressed by Resident #1's family members on 7/7/25.On 8/6/25 at 11:07 a.m., in an interview the Administrator said they looked through Resident #1's clinical record and didn't find any lack of services. They did not catch that the lab was missed. The Administrator said, I would think there would be a nursing note to address the cause of the resident's confusion. There were some medication changes, but review of the chart showed no progress note of contacting the doctor or what the concerns were.Resident #2:Review of Resident #2's clinical record on 8/6/25 revealed a practitioner's order for blood work dated 7/24/25 for CBC, Comprehensive Panel and a Hemoglobin A1C. The lab collected blood work on 7/25/25, but not the Hemoglobin A1C. On 8/5/25 a new order was placed for the Hemoglobin A1C. Resident #3:On 8/6/25, review of Resident #3's clinical record revealed a practitioner's order for blood work dated 8/4/25. On 8/5/25, a progress note noted the labs were not drawn. The APRN was notified and the labs were reordered and rescheduled to be drawn on 8/6/25.On 8/6/25 at 11:41 p.m., in an interview the Regional Nurse said on 8/4/25 when they became aware of the missed blood work for Resident #1, they audited the clinical records for missed labs from 7/5/25 through 8/5/25. During the audits, they identified 13 other residents with missing labs, including Residents #2 and #3.

Based on record review, staff and resident representative interviews, the facility failed to protect residents' rights to be free from neglect. The facility failed to provide the necessary services to a resident to avoid physical harm, pain, mental anguish, or emotional distress, by failing to develop an appropriate care plan and closely supervise 1 (Resident #1) of 5 sampled residents with dysphagia (impaired swallowing) with known multiple incidents of choking during meals. Staff failed to address family's previous reports of Resident #1 stuffing food and choking during meals. On [DATE] Resident #1 was left unsupervised during meals. Resident #1 was found unresponsive. Staff performed CPR (Cardiopulmonary Resuscitation) and called EMS (Emergency Medical Services). EMS removed a golf size clump of food out of the resident's throat. Resident #1 was transferred to the hospital where she expired on [DATE]. The facility's failure to provide the necessary structures to prevent neglect and closely supervise residents with dysphagia with known incidents of choking during meals resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on [DATE]. The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 3:15 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The census was 114, with five current residents with dysphagia. The findings included: Cross reference F641, F684, F689 and F835. The facility policy, Abuse, Neglect, Exploitation & Misappropriation with a revision date of [DATE] noted, Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Failure to take precautionary measures to protect the health and safety of the residents. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Parkinson's disease (Long term degenerative disorder of the central nervous system). Review of the clinical record revealed a Speech Therapy (ST) evaluation dated [DATE] which noted Resident #1 was having more difficulty with mastication and swallowing, exhibiting coughing. The resident was now completely dependent on staff for feeding due to her Parkinson's. The Speech Language Pathologist noted she witnessed Resident #1 gagging on food and coughing after swallowing at times. The SLP documented a diagnosis of Oropharyngeal Dysphagia, (Swallowing issues in the mouth and/or the throat) phase. On [DATE] the ST documented in a discharge summary, Patient education on . compensatory strategies to improve oral management of the bolus (ball-like mixture of chewed food and saliva) and clear lingual residue. use of compensatory strategies and exercises for more effective and safe swallowing. Staff education on cueing and feeding strategies. The ST noted Resident #1 was controlling the bolus more effectively, the resident's Parkinson's disease was progressing, and she was no longer able to feed herself. Review of the Quarterly Minimum Data Set (MDS) v1.17.1 Assessment with an assessment reference date of [DATE] noted Resident #1 required set up and supervision (oversight, encouragement, cueing) for eating. The facility provided an Activity of Daily Living (ADL) MDS coding instruction sheet which noted set up meant opening food containers, cutting up food and providing one food at a time. Supervision meant observation during meals due to history of choking, orientation to food and fluid location on tray or plate, food to be given one item at a time. The physician's orders dated [DATE] noted Resident #1 received a regular texture diet with thin liquids, and two handled cups with lid for all meals. Resident #1's care plan initiated on [DATE] noted a diagnosis of Parkinson's disease. The interventions included to monitor, document, report to the physician as needed signs and symptoms of aspiration, or dysphagia, choking, coughing. Staff was to refer to Speech Therapy for any dysphagia problem. As of [DATE], the care plan indicated the resident was able to eat independently. The care plan was not updated to reflect the Speech Therapist's statement of [DATE] which noted Resident #1's Parkinson's disease had progressed, and she was no longer able to feed herself independently. On [DATE] the care plan was updated to provide meals in separate bowls as to not overwhelm the resident. As of [DATE] staff was to monitor, document, report PRN (as needed) any signs and symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned at meals. Review of the Certified Nursing Assistants (CNAs) Activities of daily living tracking forms for [DATE] noted the CNAs were to answer Y(Yes) or N(No) to the question: Has the resident been coughing during meals; has the resident held food in mouth or cheeks or had food in mouth after meals? The form was blank for 50 of the 90 meals offered in [DATE]. Six times the CNAs documented N/A meaning not applicable. On [DATE] for day and evening the CNA answered Y (Yes) twice during the shift to the question Has the resident been coughing during meals. There was no documentation the CNA reported the observation of Resident #1's coughing during meals on [DATE], despite the care plan's specific instructions. On [DATE] at approximately 3:30 p.m., the Director of Nursing (DON) said she did not know why the care plan said Resident #1 required supervision as needed. She said Resident #1 should have been observed during meals. Review of the progress notes revealed on [DATE] at 9:44 p.m., Registered Nurse (RN) Staff A documented, Resident had visitors in the morning up until 3:30 p.m. When she returned with her brother and daughter, the latest told me that while having lunch outside, Resident #1 choked with a piece of chicken nugget, she had to press her epigastric to make her expel the piece. Resident is currently ok, she is breathing without issues . On [DATE] at 2:31 p.m., Licensed Practical Nurse Staff B documented, Daughter [name] called to report when they brought patient out on Sunday that she choked on a chicken nugget. She states she kept shoving food into her mouth, noted no problems with her swallowing. States she had to do the Heimlich (abdominal thrusts to clear upper airway obstruction) . states patient has done this before . The clinical record lacked documentation the physician or speech therapist were notified of the resident's episodes of coughing and choking during meals for further evaluation as necessary. On [DATE] at 12:45 p.m., in a telephone interview Resident #1's daughter said in the last three to four months, Resident #1 had bad choking episodes while eating. She would tell the nursing staff each time it occurred. She said, you could only give her a couple of pieces of food on her tray at a time, like a toddler since she would stuff it into her mouth. She was a danger to herself, which is why she was at the facility. She said, I have reported it to the nurse, but I don't know if they ever did anything about it. Pretty much every time we visited there in the morning, she was by herself with her breakfast tray. They used to have someone to help feed and watch her when she first got there but that has stopped. On [DATE] at 1:20 p.m., RN staff A said Resident #1 was at risk for choking. He confirmed he wrote the note on [DATE] when the family reported the resident choked on a chicken nugget. He said he could not recall any other information. On [DATE] at 3:15 p.m., the Director of Rehab said she was not aware of the concerns of choking during meals Resident #1's family members reported to the staff. She said if she had known they would have done an evaluation. On [DATE] at approximately 3:30 p.m., the Director of Nursing (DON) said based on the notes dated [DATE] and [DATE] documenting the family reported Resident #1 choking on her food, she would expect a nursing assessment, communication with the physician and a referral for a Speech evaluation. After reviewing the clinical record, the DON said there was no documentation the physician was notified of the resident's choking during meals. She also verified there was no referral for a speech evaluation. On [DATE] at 2:17 p.m., Resident #1's brother who is the power of attorney said due her Parkinson's disease, Resident #1 had trouble with controlling her throat. She was supposed to always be supervised directly during eating or taken to a group dining room. But when he would come to visit her, she would be alone in her room with the food on her tray. He said there were several times that she had trouble getting her food down, he would remove the food from her mouth and remind her to eat slower. He said he told the staff each time she tried to put too much food in her mouth. Further review of the progress notes showed on [DATE] at 8:15 a.m., the Unit Manager documented Resident #1 was up in a wheelchair eating breakfast, took all her morning medications, yelling out at times. On [DATE] at 9:24 a.m., Registered Nurse Staff C documented, CNA informed nurse that resident was unresponsive. Nurse called Code Blue., resident a full code per chart 0925 CPR (cardiopulmonary resuscitation) started, crash cart in room, no v/s [vital signs] detected, 0930 911 called. Review of the EMS patient care record revealed they arrived onsite on [DATE] at 9:35 a.m. EMS noted what appeared to be signs of a foreign body airway obstruction. Patient had JVD (Jugular vein distention) and swelling in the throat. Patient also exhibited no chest rise and absent lung sounds during ventilations. EMS performed suction with no relief. EMS used a laryngoscope (tube with light to look at the voice box) and [NAME] forceps (angled forceps that can be used to remove foreign bodies) to open patient's airway. EMS was able to remove a golf ball size clump of oatmeal out of the patient's throat. EMS documentation noted Resident #1's cardiac arrest etiology (cause) was respiratory/asphyxia. Ventilation improved remarkably. Patient was transported to the local emergency room . Review of the local emergency room documentation dated [DATE] noted EMS found the resident unresponsive, pulseless, and apneic (not breathing) and took over CPR. EMS opened airway and noted airway obstruction; Large bolus (mass of chewed food) removed from airway by EMS and airway secured. The primary encounter diagnosis noted was airway obstruction due to foreign body. Resident #1 expired on [DATE] at the hospital. On [DATE] at approximately 3:30 p.m., the Director of Nursing said she did not know why the care plan said Resident #1 required supervision as needed. She said Resident #1 should have been observed during meals. On [DATE] at approximately 4:00 p.m., the Administrator said he thought Resident #1 expired due to cardiac arrest until [DATE] when the Department of Children and Families reported an allegation of neglect for the lack of supervision during meals for Resident #1.

Based on record review, staff, and resident representative interviews, the facility failed to have processes in place to ensure accurate assessment of swallowing ability for 2 (Resident #1 and #3) of 3 residents reviewed with a diagnosis of dysphagia (difficulty swallowing). Resident #1 had a diagnosis of Parkinson's disease and oropharyngeal dysphagia. Resident #1's power of attorney complained to several staff members of episodes of choking during meals. Resident #1's assessment did not accurately reflect Resident #1's episodes of coughing and choking during meals, resulting in an inadequate individualized care plan to ensure supervision and safe swallowing during consumption of food. On [DATE] Resident #1 did not receive the necessary supervision during meals. The resident was found unresponsive, staff performed CPR (Cardiopulmonary resuscitation) and called EMS (Emergency Medical Services). EMS removed a golf ball size clump of food out to the resident's throat. Resident #1 was transferred to the hospital and expired on [DATE]. The facility's failure to follow the necessary steps to accurately assess residents' ability to swallow safely resulted in the determination of Immediate Jeopardy which started on [DATE]. The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 3:15 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The census was 114, with five current residents with dysphagia. The findings included: Cross reference F600, F684, F689 and F835. The Resident Assessment Instrument (RAI) manual (Used to gather information on residents' strengths and needs which must be addressed in an individualized care plan) version 3.0, V1.17.1 notes section K is intended to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration. The RAI manual noted the ability to swallow safely can be affected by many disease processes and functional decline. Alterations in the ability to swallow can result in choking and aspiration. The RAI manual listed the following signs and symptoms of possible swallowing disorder: Loss of liquids/solids from mouth when eating or drinking. Holding food in mouth/cheeks or residual food in mouth after meals. Coughing or choking during meals or when swallowing medications, Complaints of difficulty or pain with swallowing. The steps for assessment listed in the RAI manual included: 1. Ask the resident if he or she has had any difficulty swallowing during the 7-day look-back period. 2. Observe the resident during meals or at other times when he or she is eating, drinking, or swallowing to determine whether any of the listed symptoms of possible swallowing disorder are exhibited. 3. Interview staff members on all shifts who work with the resident and ask if any of the four listed symptoms were evident during the 7-day look-back period. Care planning should include provisions for monitoring the resident during mealtimes and during functions/activities that include the consumption of food and liquids. Care plan should be developed to assist resident to maintain safe and effective swallow using compensatory techniques, alteration in diet consistency, and positioning during and following meals. 1. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Parkinson's disease (Long term degenerative disorder of the central nervous system). Review of the clinical record revealed a Speech Therapy (ST) evaluation dated [DATE] which noted Resident #1 was having more difficulty with mastication and swallowing, exhibiting coughing. The resident was now completely dependent on staff for feeding due to her Parkinson's. The Speech Language Pathologist noted she witnessed Resident #1 gagging on food and coughing after the swallow at times. The SLP documented a diagnosis of oropharyngeal dysphagia, (Impaired swallowing in the mouth and/or the throat) phase. On [DATE] the SLP documented in a discharge summary, Patient education on . compensatory strategies to improve oral management of the bolus and clear lingual residue. use of compensatory strategies and exercises for more effective and safe swallowing. Staff education on cueing and feeding strategies. The ST noted Resident #1 was controlling the bolus (ball-like mixture of food and saliva) more effectively, the resident's Parkinson's disease was progressing, and she was no longer able to feed herself . On [DATE] a Speech Therapist Evaluation showed documentation Resident #1 was declining in her ability to communicate effectively. The SLP documented Resident #1 had a severe impairment with expressive language skills, and a severe impairment with oral motor and speech production. The Discharge Summary completed on [DATE] showed the patient was uncooperative and unable to be tested clinically due to, perseverative crying and agitated behavior. At discharge The SLP recommended supervision and anticipation of patient needs for optimal safety and quality of life at this time. On [DATE] at 12:45 p.m., in a telephone interview Resident #1's daughter said in the last three to four months, Resident #1 had bad choking episodes while eating. She would tell the nursing staff each time it occurred. She said, you could only give her a couple of pieces of food on her tray at a time, like a toddler since she would stuff it into her mouth. She was a danger to herself, which is why she was at the facility. She said, I have reported it to the nurse, but I don't know if they ever did anything about it. Pretty much every time we visited there in the morning, she was by herself with her breakfast tray. They used to have someone to help feed and watch her when she first got there but that has stopped. On [DATE] at 2:17 p.m., Resident #1's brother who is the power of attorney said due her Parkinson's disease, Resident #1 had trouble with controlling her throat. She was supposed to always be supervised directly during eating or taken to a group dining room. But when he would come to visit her, she would be alone in her room with the food on her tray. He said there were several times that she had trouble getting her food down she he would take the food from her mouth and remind her to eat slower. He said he told the staff when it occurred that she tried to put too much food in her mouth. Review of the Quarterly Minimum Data Set (MDS) Assessment with an assessment reference date of [DATE] noted Resident #1 required set up and supervision (oversight, encouragement, cueing) for eating. The assessment noted Resident #1 did not display signs and symptoms of possible swallowing disorder as listed in the RAI manual, v1.17.1 The MDS noted the section related to the swallowing was completed by the Dietetic Technician , Registered (DTR) who signed the assessment verifying the information accurately reflected the resident assessment information and the information noted in the assessment was collected in accordance with applicable Medicare and Medicaid requirements. The clinical record lacked documentation of meal observation, or resident/representative interview as per the steps for assessment listed in the RAI manual. The Nutritional Review form completed by the DTR on [DATE] noted instructions to complete the review using information from the resident's medical record and resident/responsible party (as applicable). The form noted Resident #1 required assistance to feed herself. The DTR documented she was unable to obtain or update the resident's food preferences. There was no documentation Resident #1's family was contacted to participate in the nutritional review. On [DATE] at 2:00 p.m., in a telephone interview, the DTR verified she completed the swallowing section for the Quarterly MDS with an Assessment Reference Date of [DATE] indicating Resident #1 did not display signs or symptoms of possible swallowing disorder. She said she coded the assessment based on the answers the CNAs (Certified Nursing Assistants) documented about swallowing and looked for the information in Point Click Care (Electronic documentation software) to see how the resident was doing overall. She said she was not aware Resident #1 had choking episodes. She said she did not speak with Resident #1's family members before coding the MDS. She said the Registered Dietitian (who was no longer employed at the facility) was responsible to handle family communication. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident and dysphagia. Resident #3 received a pureed diet. The Speech Language Pathologist (SLP) evaluation dated [DATE] noted Resident #3 required Speech Language Pathology services due to recent history of aspiration, and oropharyngeal dysphagia. Resident #3 completed a modified barium swallow (an imaging test that uses barium and X-rays to create images of the upper gastrointestinal tract) at the hospital resulting in recommendations for restorative exercises and compensatory strategies to improve safety and efficiency of swallowing function. The Speech Therapist noted during the clinical feeding evaluation of [DATE] Resident #3 completed small bites of pureed solids without overt signs and symptoms of aspiration. The therapist documented the Resident was a known silent aspirator (food or liquid enters the airway and eventually the lungs without any outward signs of swallowing difficulty) and required cues to re-swallow. Penetration aspiration of 6 noted with straw sips of nectar thick. The assessment summary noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. The therapist documented the resident required supervision and assistance at mealtime due to swallowing safety 91 to 100% of the time. The Admission MDS v1.17.1. assessment with an assessment reference date of [DATE] noted Resident #3 required extensive physical assistance of one person for eating. The assessment also noted Resident #3 did not display any signs or symptoms of possible swallowing disorder, including coughing or choking during meals or swallowing medications, despite the Speech Therapist's evaluation dated [DATE] which noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. On [DATE] at 10:00 a.m., the current Registered Dietitian said she has been employed at the facility since [DATE]. She said the section related to swallowing is completed by the Registered Dietitian and correlates with the dietary assessment. She said she gathers all information by looking back one to six months. The care plan initiated on [DATE] noted the resident had a potential for altered nutrition related to therapeutic/mechanically altered diet and multiple diagnoses. The care plan did not include the precautionary measures noted in the SLP evaluation completed at the hospital to ensure safe swallowing and prevent aspiration. On [DATE] at 1:30 p.m., the SLP said Resident #3 needed to be sitting at a 90 degree angle when eating and needed one to one supervision during meals to cue for second swallow with each bite of food. She verified the care plan was not individualized to meet the needs of the resident and ensure safe swallowing. She said the facility developed a care plan to address the resident's dysphagia on [DATE]. Review of Resident #3's care plan developed on [DATE] showed Resident has a swallowing problem related to difficulty with thin liquids, nectar thick liquids. The interventions listed included to keep the head of the bed elevated at 45 degrees during meals, not the 90 degrees recommended by the SLP. The care plan did not include the necessary one to one supervision when consuming food and liquids to cue the resident to swallow twice with each bite of food. The care plan did not have an intervention Resident #3 was not to use straws when drinking due to the potential for choking.

Based on observation, record review, staff and resident representative interview, the facility failed to ensure ongoing clinical assessment, care planning and effective coordination to promptly identify and address significant decline in condition to meet the needs of 2 (Resident #1, and #3) of 3 sampled residents with a diagnosis of dysphagia (difficulty swallowing) requiring supervision. Resident #1 was a vulnerable resident with a diagnosis of Parkinson's disease. Resident #1 was diagnosed on [DATE] with oropharyngeal dysphagia (Swallowing issues in the mouth and/or the throat). The facility failed to have documentation of periodic accurate assessment to monitor for decline in ability to swallow safely. The facility failed to demonstrate effective coordination and address multiple complaints of coughing and choking with meals voiced by the family. On [DATE] Resident #1 was found unresponsive when left unsupervised during meal. Staff started CPR (Cardiopulmonary resuscitation) and called EMS (Emergency Medical Services). EMS removed a golf ball size clump of oatmeal in the resident's throat. Resident #1 was transferred to the hospital where she expired on [DATE]. The facility's failure to ensure ongoing accurate assessment, development of individualized care plan to meet of residents with dysphagia, and the failure to coordinate and address multiple complaints of coughing and choking during meals resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:15 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The census was 114, with 5 current residents with dysphagia. The findings included: Cross reference to F600, F641, F689 and F835 The facility's policy and procedure for Therapy Screenings with a review date of [DATE] notes, Screens are provided as permitted according to professional standards of practice and ethics, and within site of service, state, and federal regulatory guidelines. Screens are used for preliminary information gathering, and do not require a physician's order. Screens may be conducted: Upon admission or readmission, upon change in condition, upon request of the interprofessional team. upon a regularly scheduled frequency to support optimal function, health, and wellness. The Center for Medicare and Medicaid Services Resident Assessment Instrument (RAI) version 3.0 Manual, v1.17.1, noted, Federal requirements dictate, at a minimum, three Quarterly assessments be completed in each 12-month period. The RAI manual specifies the steps for assessment for swallowing include an observation of the resident during meals. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Parkinson's disease (Long term degenerative disorder of the central nervous system). Review of the clinical record revealed a Speech Therapy (ST) evaluation dated for dysphagia on [DATE] which noted Resident #1 was having more difficulty with mastication and swallowing, exhibiting coughing. The resident was now completely dependent on staff for feeding due to her Parkinson's. The Speech Language Pathologist noted she witnessed Resident #1 gagging on food and coughing after the swallow at times. The ST documented a diagnosis of Dysphagia, oropharyngeal (impaired swallowing issues in the mouth and/or the throat) phase. The Speech Therapy Discharge Summary dated [DATE] noted Resident #1 was within functional limit on dysphagia advanced diet and thin liquids. The therapist documented the prognosis to maintain the current level of functioning was excellent with consistent staff support. Review of the physician's orders revealed Resident #1 as of [DATE] was receiving a Regular Diet regular texture/thin liquids consistency, fortified foods all meals, 2 handled cup with lid for meals. There was no documentation in the clinical record Resident #1 received the dysphagia advanced diet recommended by the Speech Therapist on [DATE]. On [DATE] a Speech Therapist Evaluation showed Resident #1 was declining in her ability to communicate effectively. The Speech Therapist documented Resident #1 had a severe impairment with expressive language skills, and a severe impairment with oral motor and speech production. The Discharge Summary completed on [DATE] showed the patient was uncooperative and unable to be tested clinically due to, perseverative crying and agitated behavior. At discharge The Speech Language Pathologist recommended to continue supervision and anticipation of patient needs for optimal safety and quality of life at this time. There was no documentation the Speech Therapist assessed Resident #1's ability to swallow safely. Review of the Quarterly Minimum Data Set (MDS), v1.17.1, dated [DATE], and [DATE] showed no decrease in Resident #1's cognition. Her Brief Interview for Mental Score was 14 which showed no cognitive impairment. The MDS showed no swallowing difficulties were being assessed. A progress note dated [DATE] showed Resident #1 had a decline in weight of 10.3%. the Dietitian documented Weight stable the past week. Continue with current plan of care. RD [Registered Dietitian] will continue to monitor and follow up as needed. Resident #1's care plan initiated on [DATE] noted a diagnosis of Parkinson's disease. The interventions included to monitor, document, report to the physician as needed signs and symptoms of aspiration, or dysphagia, choking, coughing. Staff was to refer to Speech Therapy for any dysphagia problem. Review of the progress notes revealed on [DATE] at 9:44 p.m., Registered Nurse (RN) Staff A documented, Resident had visitors in the morning up until 3:30 p.m. When she returned with her brother and daughter, the latest told me that while having lunch outside, Resident #1 choked with a piece of chicken nugget, she had to press her epigastric to make her expel the piece. Resident is currently ok, she is breathing without issues . On [DATE] at 2:31 p.m., Licensed Practical Nurse Staff B documented, Daughter [name] called to report when they brought patient out on Sunday that she choked on a chicken nugget. She states she kept shoving food into her mouth, noted no problems with her swallowing. States she had to do the Heimlich (abdominal thrusts to clear upper airway obstruction) . states patient has done this before . On [DATE] at 12:45 p.m., in a telephone interview Resident #1's daughter said in the last three to four months, Resident #1 had bad choking episodes while eating. She would tell the nursing staff each time it occurred. She said, you could only give her a couple of pieces of food on her tray at a time, like a toddler since she would stuff it into her mouth. She was a danger to herself, which is why she was at the facility. She said, I have reported it to the nurse, but I don't know if they ever did anything about it. Pretty much every time we visited there in the morning, she was by herself with her breakfast tray. They used to have someone to help feed and watch her when she first got there but that has stopped. On [DATE] at 2:17 p.m., Resident #1's brother who is the power of attorney said due her Parkinson's disease, Resident #1 had trouble with controlling her throat. She was supposed to always be supervised directly during eating or taken to a group dining room. But when he would come to visit her, she would be alone in her room with the food on her tray. He said there were several times that she had trouble getting her food down she he would take the food from her mouth and remind her to eat slower. He said he told the staff when it occurred that she tried to put too much food in her mouth. The clinical record lacked documentation the facility addressed Resident #1 concerns of choking during meals voiced by the family. On [DATE] at 1:20 p.m., RN staff A said Resident #1 was at risk for choking. He confirmed he wrote the note on [DATE] when the family reported the resident choked on a chicken nugget. He said he could not recall any other information. On [DATE] at 2:00 p.m., during a telephone interview, the Dietetic Technician, Registered (DTR) described her process for completing quarterly nutritional assessments. She said there are questions that the CNAs (Certified Nursing Asssistants) answer about swallowing which she reviews and also uses the facility communication. she goes through the questions on the assessment, pulls information from PCC (Electronic documentation system) in terms of how the resident is doing overall. The DTR stated she did not discuss the resident's status with the family. She said the resident had not been able to communicate her needs during the time of the MDS assessments. the DTR did not say she observed the resident during meals to determine if the resident was experiencing swallowing difficulties. Review of the Certified Nursing Assistants (CNAs) Activities of daily living tracking forms for [DATE] noted the CNAs were to answer Y(Yes) or N(No) to the questions: Has the resident been coughing during meals; has the resident held food in mouth or cheeks or had food in mouth after meals. On [DATE] for day and evening the CNA answered Y twice during the shift to the question Has the resident been coughing during meals. There was no documentation the CNA reported the observation of Resident #1's coughing during meals, despite the care plan's specific instructions. There was no documentation for [DATE] the CNAs observed Resident #1 during meals for signs and symptoms of dysphagia. On [DATE] at 3:15 p.m., the Director of Rehab said she was not aware of the concerns of choking during meals Resident #1's family members reported to the staff. She said if she had known they would have done an evaluation. On [DATE] at approximately 3:30 p.m., the Director of Nursing (DON) said based on the notes dated [DATE] and [DATE] documenting the family reported Resident #1 choking on her food, she would expect a nursing assessment, communication with the physician and a referral for a Speech evaluation. After reviewing the clinical record, the DON said there was no documentation the physician was notified of the resident's choking during meals. She also verified there was no referral for a speech evaluation. She said it was the Unit Manager's responsibility to check the 24 hours report and discuss concerns during morning meetings with the interdisciplinary team. She said back in July when the family complained of Resident #1 choking during meals, she was on vacation and did not know why the concern was not addressed. On [DATE] at 3:15 p.m., the Director of Therapy said therapy does not do routine speech therapy evaluations. Therapy does quarterly and annual screenings which do not include observing the resident during meals. She said Therapy was not aware of the family complaining of the resident choking during her meals in [DATE], and did not screen Resident #1 for a decline in ability to swallow safely. She said if she would have known she would have evaluated the resident's swallowing ability. On [DATE] at approximately 3:30 p.m., the Director of Nursing said she did not know why the care plan said Resident #1 required supervision as needed. She said Resident #1 should have been observed during meals. On [DATE] at 10:30 a.m., the Registered Dietitian (RD) said it was the responsibility of the RD to complete Section K of the MDS every three months. The RD verified Section K of the MDS had four specific questions related to swallowing ability which needed to be answered during the assessment. She said she reviewed the record and spoke with staff and at times if they were available she would speak with the resident's family. the RD said it was not part of her assessment to observe the residents eat during the comprehensive assessment period. On [DATE] at 9:24 a.m., Registered Nurse Staff C documented, CNA informed nurse that resident was unresponsive. Nurse called code blue., resident a full code per chart 0925 CPR (cardiopulmonary resuscitation) started, crash cart in room, no v/s [vital signs] detected, 0930 911 called. Review of the EMS patient care record revealed they arrived onsite on [DATE] at 9:35 a.m. EMS noted what appeared to be signs of a foreign body airway obstruction. Patient had JVD (Jugular vein distention) and swelling in the throat. Patient also exhibited no chest rise and absent lung sounds during ventilations. EMS performed suction with no relief. EMS used a laryngoscope (tube with light to look at the voice box) and [NAME] forceps (angled forceps that can be used to remove foreign bodies) to open patient's airway. EMS was able to remove a golf ball size clump of oatmeal out of the patient's throat. EMS documentation noted Resident #1's cardiac arrest etiology (cause) was respiratory/asphyxia. Ventilation improved remarkably. Patient was transported to the local emergency room . Review of the local emergency room documentation dated [DATE] noted EMS found the resident unresponsive, pulseless, and apneic (not breathing) and took over CPR. EMS opened airway and noted airway obstruction; Large bolus (mass of chewed food) removed from airway by EMS and airway secured. The primary encounter diagnosis noted was airway obstruction due to foreign body. Resident #1 expired at the hospital on [DATE]. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident and dysphagia. Resident #3 received a pureed diet. The Speech Language Pathologist evaluation dated [DATE] noted Resident #3 required Speech Language Pathology services due to recent history of aspiration, and oropharyngeal dysphagia. Resident #3 completed a modified barium swallow at the hospital resulting in recommendations for restorative exercises and compensatory strategies to improve safety and efficiency of swallowing function. The Speech Therapist noted during the clinical feeding evaluation of [DATE] Resident #3 completed small bites of pureed solids without overt signs and symptoms of aspiration. The therapist documented the Resident was a known silent aspirator (food or liquid enters the airway and eventually the lungs) and required cues to re-swallow. Penetration aspiration of 6 noted with straw sips of nectar thick. The assessment summary noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. The therapist documented the resident required supervision and assistance at mealtime due to swallowing safety 91 to 100% of the time. The Admission Minimum Data Set (MDS) assessment with an assessment reference date of [DATE] noted Resident #3 required extensive physical assistance of one person for eating. The assessment also noted Resident #3 did not display any signs or symptoms of possible swallowing disorder, including coughing or choking during meals or swallowing medications, despite the Speech Therapist's evaluation dated [DATE] which noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. The care plan initiated on [DATE] noted the resident had a potential for altered nutrition related to therapeutic/mechanically altered diet and multiple diagnoses. The care plan did not include provision to cue the resident to re-swallow as per the Speech Therapy's swallowing assessment to ensure swallow safety. On [DATE] at 1:30 p.m., the Speech Therapist said Resident #3 needed to be sitting at a 90 degree angle when eating and needed one-to-one supervision during meals to cue for second swallow with each bite of food. She verified the care plan was not individualized to meet the needs of the resident and ensure safe swallowing. Review of Resident #3's care plan developed on [DATE] showed Resident #3 has a swallowing problem related to difficulty with thin liquids, nectar thick liquids. The interventions listed included to keep the head of the bed elevated at 45 degrees during meals, not the 90 degrees recommended by the Speech Therapist. The care plan did not include the necessary one-to-one supervision when consuming food and liquids to cue the resident to swallow twice with each bite of food. The care plan did not specify Resident #3 was not to use straws when drinking due to the potential for choking.

Based on observation, record review, residents' representatives and staff interviews, the facility failed to implement processes to ensure adequate supervision of residents with dysphagia (Impaired swallowing) and known episodes of choking during meals for 3 (Resident #1, #2 and #3) of 5 sampled residents with dysphagia. On [DATE] Resident #1 who had dysphagia did not receive the necessary supervision during meals. Resident #1 was found unresponsive. Staff performed CPR (Cardiopulmonary Resuscitation) and called Emergency Medical Services (EMS). EMS noted signs of foreign body airway obstruction and removed a golf ball size of oatmeal out of the resident's throat. Resident #1 was resuscitated and transferred to the hospital where she expired on [DATE]. The facility failure to ensure adequate supervision of residents with dysphagia to prevent choking which could lead to serious injury or death resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:15 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The census was 114, with five current residents with dysphagia. The findings included: Cross reference F600, F641, F684, and F835. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included Parkinson's disease (Long term degenerative disorder of the central nervous system). On [DATE] Resident #1's physician's orders included a Regular Diet regular texture/thin liquids consistency, fortified foods all meals, 2 handled cup with lid for meals. Review of the clinical record revealed a Speech Language Pathology (SLP) evaluation dated [DATE] which noted Resident #1 was having more difficulty with mastication and swallowing, exhibiting coughing. The resident was now completely dependent on staff for feeding due to her Parkinson's. The SLP noted she witnessed Resident #1 gagging on food and coughing after the swallow at times. The SLP documented a diagnosis of oropharyngeal dysphagia, (impaired swallowing in the mouth and/or the throat) phase. On [DATE] the ST documented in a discharge summary, Patient education on . compensatory strategies to improve oral management of the bolus and clear lingual residue . use of compensatory strategies and exercises for more effective and safe swallowing . Staff education on cueing and feeding strategies. The ST noted Resident #1 was controlling the bolus more effectively, the resident's Parkinson's disease was progressing, and she was no longer able to feed herself . The Speech Therapist diagnosis was documented as WFL [within functional limits] on Dysphagia Advanced diet [referring to the National Dysphagia Diet, Dysphagia-Advanced Level 3 (soft foods that require more chewing ability)] and thin liquids. On [DATE] a SLP Evaluation showed Resident #1 was declining in her ability to communicate effectively. The SLP documented Resident #1 had a severe impairment with expressive language skills, and a severe impairment with Oral Motor and speech production. The Discharge Summary completed on [DATE] showed the patient was uncooperative and unable to be tested clinically due to, perseverative crying and agitated behavior. At discharge The SLP recommended supervision and anticipation of patient needs for optimal safety and quality of life at this time. There was no documentation the SLP assessed Resident #1's ability to swallow safely. Review of the Quarterly Minimum Data Set v1.17.1, Assessment with an assessment reference date of [DATE] noted Resident #1 required set up and supervision (oversight, encouragement, cueing) for eating. The assessment showed no swallowing or choking issues were observed during the 7 day look back period. Resident #1's care plan initiated on [DATE] and revised on [DATE] (one day after the resident expired) noted a diagnosis of Parkinson's disease. The interventions included to monitor, document, report to the physician as needed signs and symptoms of aspiration, or dysphagia, choking, coughing. Staff was to refer to Speech Therapy for any dysphagia problem. As of [DATE] staff was to monitor, document, report PRN (as needed) any signs and symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned at meals. Review of the Certified Nursing Assistants (CNAs) Activities of daily living tracking forms for [DATE] noted the CNAs were to answer Y(Yes) or N(No) to the question: Has the resident been coughing during meals; has the resident held food in mouth or cheeks or had food in mouth after meals?. The form was blank for 50 of the 90 meals offered in [DATE]. Six times the CNAs documented N/A meaning not applicable. On [DATE] for day and evening the CNA answered Y twice during the shift to the question Has the resident been coughing during meals?. There was no documentation the CNA reported the observation of Resident #1's coughing during meals, despite the care plan's specific instructions. On [DATE] at 9:24 a.m., Registered Nurse Staff C documented, CNA informed nurse that resident was unresponsive. Nurse called Code Blue., resident a full code per chart 0925 CPR (cardiopulmonary resuscitation) started, crash cart in room, no v/s [vital signs] detected, 0930 911 called. Review of the EMS patient care record revealed they arrived onsite on [DATE] at 9:35 a.m. EMS noted what appeared to be signs of a foreign body airway obstruction. Patient had JVD (Jugular vein distention) and swelling in the throat. Patient also exhibited no chest rise and absent lung sounds during ventilations. EMS performed suction with no relief. EMS used a laryngoscope (tube with light to look at the voice box) and [NAME] forceps (angled forceps that can be used to remove foreign bodies) to open patient's airway. EMS was able to remove a golf ball size clump of oatmeal out of the patient's throat. EMS documentation noted Resident #1's cardiac arrest etiology (cause) was respiratory/asphyxia. Ventilation improved remarkably. Patient was transported to the local emergency room . Review of the local emergency room documentation dated [DATE] noted EMS found the resident unresponsive, pulseless, and apneic (not breathing) and took over CPR. EMS opened airway and noted airway obstruction; Large bolus (mass of chewed food) removed from airway by EMS and airway secured. The primary encounter diagnosis noted was airway obstruction due to foreign body. Resident #1 expired at the hospital on [DATE]. Review of the witness statement dated [DATE] showed the agency CNA assigned to care for Resident #1 documented on [DATE] she provided care to Resident #1 in her room, transferred her to a wheelchair and set her up with her breakfast at around 8:00 a.m. On [DATE] at around 9:22 a.m., she went to check on the resident and found her with her head tilted back and unresponsive. She quickly told the nurse who went to assess the resident. The nurse called a code blue. On [DATE] at approximately 3:30 p.m., the Director of Nursing said Resident #1 should have been observed during meals. On [DATE] at 2:17 p.m., Resident #1's brother who is the power of attorney said due her Parkinson's disease, Resident #1 had trouble with controlling her throat. She was supposed to always be supervised directly during eating or taken to a group dining room. But when he would come to visit her, she would be alone in her room with the food on her tray. He said there were several times that she had trouble getting her food down he would take the food from her mouth and remind her to eat slower. He said he told the staff when it occurred that she tried to put too much food in her mouth. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident and dysphagia. Resident #3 received a pureed diet. The Speech Language Pathologist evaluation dated [DATE] noted Resident #3 required Speech Language Pathology services due to recent history of aspiration, and oropharyngeal dysphagia. Resident #3 completed a modified barium swallow (an imaging test that uses barium and X-rays to create images of the upper gastrointestinal tract) at the hospital resulting in recommendations for restorative exercises and compensatory strategies to improve safety and efficiency of swallowing function. The SLP noted during the clinical feeding evaluation of [DATE] Resident #3 completed small bites of pureed solids without overt signs and symptoms of aspiration. The SLP documented the resident was a known silent aspirator (food or liquid enters the airway and eventually the lungs without any outward signs of swallowing difficulty) and required cues to re-swallow. Penetration aspiration of 6 noted with straw sips of nectar thick. The assessment summary noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. The SLP documented the resident required supervision and assistance at mealtime due to swallowing safety 91 to 100% of the time. The Admission Minimum Data Set (MDS) v1.17.1. assessment with an assessment reference date of [DATE] noted Resident #3 required extensive physical assistance of one person for eating. The assessment also noted Resident #3 did not display any signs or symptoms of possible swallowing disorder, including coughing or choking during meals or swallowing medications, despite the Speech Therapist's evaluation dated [DATE] which noted Resident #3 demonstrated coughing or choking during meals or when swallowing medications. The care plan initiated on [DATE] noted the resident had a potential for altered nutrition related to therapeutic/mechanically altered diet and multiple diagnoses. The care plan did not include provision to cue the resident to re-swallow as per the SLP's swallowing assessment to ensure swallow safety. Review of Resident #3's care plan developed on [DATE] showed Resident #3 has a swallowing problem related to difficulty with thin liquids, nectar thick liquids. The interventions listed included to keep the head of the bed elevated at 45 degrees during meals, not the 90 degrees recommended by the Speech Therapist. The care plan did not include the necessary one-to-one supervision when consuming food and liquids to cue the resident to swallow twice with each bite of food. The care plan did not have an intervention Resident #3 was not to use straws when drinking due to the potential for choking. On [DATE] at 1:30 p.m., the SLP said Resident #3 needed to be sitting at a 90 degree angle when eating and needed one-to-one supervision during meals to cue for second swallow with each bite of food. She verified the care plan was not individualized to meet the needs of the resident and ensure safe swallowing. 3. Resident #2 was initially admitted to the facility on [DATE] and diagnosed with dysphagia on [DATE]. Resident #2's diet order dated [DATE] read, Dysphagia Advanced Diet texture [referring to the National Dysphagia Diet, Dysphagia-Advanced Level 3 (soft foods that require more chewing ability)], Nectar Thickened Fluids Consistency. Resident #2's care plan initiated on [DATE] read, potential for ineffective airway clearance/aspiration . need for altered consistency diet and fluids with a history of Cerebral Vascular Accident. Interventions listed in Resident #2's care plan related to dysphagia included diet as ordered, observe during meals, Speech Therapy consult as ordered. On [DATE] at 12:50 p.m., observed a Styrofoam cup of thin water at Resident #2's bedside. Agency CNA, Staff B assigned to resident #2 verified the Styrofoam cup contained thin water. Staff B said no one reported to her Resident #2 was on thickened liquids. Staff B said there was no set process to pass on the information about meal supervision, assistance, and thickened liquid information. Staff B said the facility has a list of residents who need to go to the dining room for meals since the dining room is always supervised. On [DATE] at 11:55 a.m., Resident #2 was observed eating her lunch (rice, chicken, lima beans, cake, and ice cream) while lying in bed. The head of the bed was elevated approximately 40 degrees. The bed controller was observed at the foot of her bed and out of the resident's reach. Resident #2 was sliding down in the bed. There was no staff in the room assisting the resident. Resident #2 was not using utensils to eat. She was grabbing and bringing the food to her mouth with her right hand. On [DATE] 12:58 p.m., Agency CNA, Staff C said she thought she had placed the head of the resident's bed at 90 degrees when she set up her tray. Staff C said she was not aware Resident #2 needed continued observation and assistance during meals. On [DATE] at 1:30 p.m., the Speech Therapist said on [DATE] she received a referral to assess Resident #2 for dysphagia. She said she was a graduate Speech Therapist and was still learning. She said she did not know how to ensure her recommendations for interventions to prevent choking could be a part of the resident's care plan. The Speech Therapist said Resident #2 should only be allowed to eat when she is awake, alert, and sitting upright at 90 degrees. The Speech Therapist said she would recommend periodic observations by staff during her meals. On [DATE] at approximately 3:30 p.m., the DON said staff should be observing Resident #2 during meals. The DON said Resident #2 shouldn't have had thin water at the bedside on [DATE]. She said she was working with communication and documentation among all staff, but it was hard with so many agency staff being used by the facility.

Based on record review, resident and staff interview the facility administration failed to use its resources effectively to protect residents' rights to be free from neglect. The facility administration failed to ensure ongoing, accurate assessment, care planning, and adequate supervision of residents with dysphagia. Resident #1 who had dysphagia was not adequately assessed and did not have a care plan to meet her individualized needs for supervision during meals. On [DATE] Resident #1 did not receive the necessary supervision during meals. The resident was found unresponsive. Staff performed CPR (Cardiopulmonary resuscitation) and called Emergency Medical Services (EMS). EMS noted signs of foreign body airway obstruction and removed a golf ball size of oatmeal out of the resident's throat. Resident #1 was transferred to the hospital where she expired on [DATE]. The failure of the facility's administration to prevent neglect and ensure ongoing, accurate assessment and provide necessary supervision of residents with dysphagia resulted in a determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 3:15 p.m. and provided the IJ templates. The Immediate Jeopardy was ongoing. The findings included: Cross reference F600, F641, F684, and F689. Review of the Executive Director I (Administrator) job description showed the primary purpose of the Executive Director is to direct the day-to-day functions of the facility in accordance with current federal, state and local standards, guideline, and regulations that govern nursing facilities to ensure that the highest degree of quality care can be provided to our residents at all times . Job functions. Supervises Director of Clinical Services . Director of Rehabilitation Services . Duties and Responsibilities . Schedule regular meeting with direct report staff to provide supervision, ensure communication and to monitor facility operations. Maintain and guide the implementation of facility policies and procedures in compliance with corporate, state, federal, and other regulatory guidelines. Support and guide the facility's quality improvement process. Review of the Director of Clinical Services I (Director of Nursing) job description noted the purpose of the job position, . Entrusted with the responsibility of caring for our residents, families, co-workers, visitors, and all others . The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. Job Functions. As Director of Clinical Services I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for planning, organizing, and directing the functions for the nursing department . Duties and Responsibilities . Recruit and hire a sufficient number of qualified nursing staff to deliver efficient resident care in accordance with established staffing plan . Actively participate in the quality improvement process for the facility . Schedule, direct and document regular meetings with nursing staff to assure effective communication. The facility policy, Abuse, Neglect, Exploitation & Misappropriation with a revision date of [DATE] noted, Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Failure to take precautionary measures to protect the health and safety of the residents. 1. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Parkinson's disease (Long term degenerative disorder of the central nervous system). Review of the clinical record revealed a Speech Therapy (ST) evaluation dated [DATE] which noted Resident #1 was having more difficulty with mastication and swallowing, exhibiting coughing. The resident was now completely dependent on staff for feeding due to her Parkinson's. The Speech Therapist noted she witnessed Resident #1 gagging on food and coughing after the swallow at times. The ST documented a diagnosis of Dysphagia, oropharyngeal (Swallowing issues in the mouth and/or the throat) phase. Resident #1 received Speech Therapy and on [DATE] the Speech Therapist documented in a discharge summary, Patient education on . compensatory strategies to improve oral management of the bolus (mass of chewed food) and clear lingual residue. use of compensatory strategies and exercises for more effective and safe swallowing. Staff education on cueing and feeding strategies. The ST noted Resident #1 was controlling the bolus more effectively, the resident's Parkinson's disease was progressing, and she was no longer able to feed herself. Resident #1's care plan initiated on [DATE] and revised on [DATE] (one day after the resident expired) noted a diagnosis of Parkinson's disease. The interventions included to monitor, document, report to the physician as needed signs and symptoms of aspiration, or dysphagia, choking, coughing. Staff was to refer to Speech Therapy for any dysphagia problem. On [DATE] a Speech Therapist Evaluation showed Resident #1 was declining in her ability to communicate effectively. The Speech Therapist documented Resident #1 had a severe impairment with expressive language skills, and a severe impairment with oral motor and speech production. The Discharge Summary completed on [DATE] showed the patient was uncooperative and unable to be tested clinically due to, perseverative crying and agitated behavior. At discharge The Speech Therapist recommended supervision and anticipation of patient needs for optimal safety and quality of life at this time. There was no documentation the Speech Therapist assessed Resident #1's ability to swallow safely during the evaluation and treatment. The care plan as of [DATE] staff was to monitor, document, report PRN (as needed) any signs and symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned at meals. Review of the Certified Nursing Assistants (CNAs) Activities of daily living tracking forms for [DATE] noted the CNAs were to answer Y (Yes) or N (No) to the question: Has the resident been coughing during meals, has the resident held food in mouth or cheeks or had resident food in mouth after meals? The form was blank for 50 of the 90 meals offered in [DATE]. Six times the CNAs documented N/A meaning not applicable. On [DATE] for day and evening the CNA answered Y twice during the shift to the question Has the resident been coughing during meals. There was no documentation in the clinical record the CNA reported the episodes of coughing during meals as per the care plan instructions. CNA staff documented seven times during the month of ,d+[DATE] from [DATE] to [DATE] Resident #1 was dependent of staff for eating her meals. There was no documentation staff observed Resident #1 during meals from [DATE] to [DATE] for signs and symptoms of difficulty swallowing, aspiration, or dysphagia. On [DATE] at 9:24 a.m., Registered Nurse Staff C documented, CNA informed nurse that resident was unresponsive. Nurse called Code Blue., resident a full code per chart 0925 CPR started, crash cart in room, no v/s [vital signs] detected, 0930 911 called. Review of the EMS patient care record revealed they arrived onsite on [DATE] at 9:35 a.m. EMS noted what appeared to be signs of a foreign body airway obstruction. Patient had JVD (Jugular vein distention) and swelling in the throat. Patient also exhibited no chest rise and absent lung sounds during ventilations. EMS performed suction with no relief. EMS used a laryngoscope (tube with light to look at the voice box) and [NAME] forceps (angled forceps that can be used to remove foreign bodies) to open patient's airway. EMS was able to remove a golf ball size clump of oatmeal out of the patient's throat. EMS documentation noted Resident #1's cardiac arrest etiology (cause) was respiratory/asphyxia [a condition arising when the body is deprived of oxygen, causing unconsciousness or death]. Ventilation improved remarkably. Patient was transported to the local emergency room . Review of the local emergency room documentation dated [DATE] noted EMS found the resident unresponsive, pulseless, and apneic (not breathing) and took over CPR. EMS opened airway and noted airway obstruction; Large bolus removed from airway by EMS and airway secured. Review of the Emergency Department physician's documentation showed the primary encounter diagnosis documented was airway obstruction due to foreign body. Review of the facility's investigation dated [DATE] showed the agency CNA assigned to care for Resident #1 documented in a witness statement on [DATE] she provided care to Resident #1 in her room, transferred her to a wheelchair and set her up with her breakfast at around 8:00 a.m. On [DATE] at around 9:22 a.m., she went to check on the resident and found her with her head tilted back and unresponsive. She quickly told the nurse who went to assess the resident. The nurse called a code blue. The facility administration failed to conduct a thorough investigation of the incident. Review of the Nursing Home Federal Reporting submitted to the Florida Agency for Health Care Administration showed the facility did not substantiate the allegation of neglect for failure to provide the necessary supervision to Resident #1 on [DATE] when she was left unsupervised during meals. On [DATE] at approximately 3:30 p.m., the Director of Nursing said she did not know why the care plan said Resident #1 required supervision as needed. She said Resident #1 should have been observed during meals. On [DATE] at approximately 4:00 p.m., the Administrator said he thought Resident #1 expired due to cardiac arrest. He said on [DATE] he became aware of the allegation of neglect related to Resident #1 aspirating reported to him by adult protective services [Florida Department of Children and Families abuse investigator]. The Administrator provided a single sheet of paper signed and dated [DATE] by the Director of Nursing and Administrator listing the interventions implemented based on the incident involving Resident #1. The document read, Review in stand up meeting and it was decided by the team to restart the feeding program for resident at risk for dysphagia with emphasis on altered diet and fluids. PIP (Performance Improvement Project) was done in increase the number of residents attending dining room. Staff in serviced on documentation, checking Kardex (gives overview of each resident's needs), huddle to emphasis on eating with supervision. Plan of care for residents with like diagnosis checked and ongoing. Referral to be sent to speech on any change in condition pertaining to eating. Review of the Education In-service Attendance record dated [DATE], [DATE], [DATE] and [DATE] showed education on Check Kardex for assistance with eating and supervision was provided to nine of 20 Certified Nursing Assistants and four of 21 licensed nurses employed at the facility. There was no documentation the agency staff (Licensed Nurses and CNAs) were educated. There was no documented plan to ensure agency staff were educated prior to the start of their shift. The Administrator provided an ad hoc (unplanned) Quality Assurance and Performance Improvement meeting dated [DATE] to Increased in the number of residents attending the Main dining room for meals. The Administrator did not have documentation of a Performance Improvement Project with action steps and target date. The Administrator failed to provide documentation the facility administration discussed a process to ensure accurate evaluation , care planning, and the availability of staff to ensure residents with a diagnosis of dysphagia receive the necessary assistance and supervision during meals, or activities involving consumption of food and liquids. There was no audit to identify residents with dysphagia and ensure an accurate assessment and care plan was in place and implemented. 2. On [DATE] the facility provided a list of five residents with a diagnosis of dysphagia. Residents #2 and #3 were sampled for review. Resident #2 was initially admitted to the facility on [DATE] and diagnosed with dysphagia on [DATE]. Resident #2's diet order dated [DATE] read, Dysphagia Advanced Diet texture, Nectar Thickened Fluids Consistency. Resident #2's care plan initiated on [DATE] read, potential for ineffective airway clearance/aspiration . need for altered consistency diet and fluids with a history of Cerebral Vascular Accident. Interventions listed in Resident #2's care plan related to dysphagia included diet as ordered, observe during meals, Speech Therapy consult as ordered. On [DATE] at 12:50 p.m., observed a Styrofoam cup of thin water at Resident #2's bedside. Agency CNA, Staff B assigned to resident #2 verified the Styrofoam cup contained thin water. Staff B said no one reported to her Resident #2 was on thickened liquids. Staff B said there was no set process to pass on the information about meal supervision, assistance, and thickened liquid information. On [DATE] at 11:55 a.m., Resident #2 was observed eating her lunch (rice, chicken, lima beans, cake, and ice cream) while lying in bed. The head of the bed was elevated approximately 40 degrees. The bed controller was observed at the foot of her bed and out of the resident's reach. Resident #2 was sliding down in the bed. There was no staff in the room assisting the resident. Resident #2 was not using utensils to eat. She was grabbing and bringing the food to her mouth with her right hand. On [DATE] 12:58 p.m., Agency CNA, Staff C said she was not aware Resident #2 needed continued observation and assistance during meals. On [DATE] at 1:30 p.m., the Speech Language Pathologist (SLP) said on [DATE] she received a referral to assess Resident #2 for dysphagia. She said she was a graduate Speech Therapist and was still learning. She said she did not know how to ensure her recommendations for interventions to prevent choking could be a part of the resident's care plan. 3. Resident #3 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident and dysphagia. Resident #3 received a pureed diet. The SLP noted during the clinical feeding evaluation of [DATE] Resident #3 was a known silent aspirator (food or liquid enters the airway and eventually the lungs, without any outward signs of swallowing difficulty) and required cues to re-swallow. The SLP documented the resident required supervision and assistance at mealtime due to swallowing safety 91 to 100% of the time. The care plan initiated on [DATE] did not include provision to cue the resident to re-swallow as per the Speech Therapy's swallowing assessment to ensure swallow safety. On [DATE] at 1:30 p.m., the SLP said Resident #3 needed to be sitting at a 90 degree angle when eating and needed one-to-one supervision during meals to cue for second swallow with each bite of food. She verified the care plan was not individualized to meet the needs of the resident and ensure safe swallowing. 4. Review of the Facility assessment dated [DATE] showed documentation the facility will staff according to the minimum staffing hours required of one hour of licensed nursing hours per person per day and two hours of certified nursing assist hours per person per day. The Facility assessments noted the facility will meet the minimum daily required ratios for staffing daily. The facility assessment did not include an evaluation of the residents' acuity level to ensure appropriate competent staffing, and equipment to meet each resident's individual needs. Review of the CMS Resident Census and Condition of Residents dated [DATE] showed the facility's census was 114. 23 residents were totally dependent on staff for eating, and toileting, and 49 residents required the assistance of at least one staff member for eating, and toileting. On [DATE] at 10:45 a.m., the Director of Nursing (DON) said the facility did not address the residents acuity when staffing the facility. She said due to the daily admissions she asks for extra assistance at least twice a week. The DON stated she did not have any role in completing the Facility Assessment, and administration did not include her in calculating staffing needs.

Based on record review, resident and staff interviews the facility failed to provide the necessary services to maintain continence for 2 (Residents #260 and #261) of 2 residents sampled requiring toileting assistance. The failure to provide assistance with activities of daily living (ADL) caused the residents anxiety, apprehension, frustration, skin breakdown, and pain. (Also, see citation at F725.) The findings included: 1. On 12/9/19 at 1:15 p.m., Resident #260 said, I can't get to the bathroom because I fell prior to coming here and fractured my right hip and left arm. I need help to go to the toilet, but when I ask to be changed, they get nasty with me and tell me, 'I'll change you now but I'm not coming back again.' I have to sit in a wet brief, and I get frustrated. It is uncomfortable to sit in this wheelchair when you are wet. If I put the light on and it is during meal times, they tell me they can't help me because they can't stop until all the residents are served and assisted in the dining room and hallways. A review of Resident #260's medical record revealed the resident was admitted to the facility on [DATE] with a [MEDICAL CONDITION] femur (hip) and the left humerus (upper arm). The admission data collection tool dated 12/4/19 included documentation Resident #260 was occasionally incontinent and had skin condition on the buttocks. Record review on 12/12/19 revealed a physician's orders [REDACTED]. On 12/12/19 at 8:14 a.m., in an interview, the Unit Manager said Resident #260 is receiving a skin protectant to her buttocks for excoriation (loss of the surface layers of the skin possibly caused by exposure to urine, feces, or friction). The Unit Manager said Resident #260 required extensive assistance of one for toileting and incontinent care. 2. On 12/9/19 at 3:47 p.m., Resident #261 said, I ask to use the bedpan and they don't get it for me. They don't change me when I am wet; they make me wait, and they leave me here to suffer. When I am wet and sitting in it for a while [MEDICAL CONDITION] skin. When I tell you I have to go, I have to go, and I can't hold it for long so I wet myself, and then they don't want to change me. A review of medical record revealed Resident #261 was admitted on [DATE] and required extensive assistance of one for toileting. The care plan dated 12/6/19 indicated Resident #261 has the potential for pressure injury development related to limited mobility, ADL deficits, weakness, and diabetes. The interventions included to follow the facility policies/protocols for the prevention/ treatment of [REDACTED]. The facility policy Bowel and Bladder Evaluation, N-204 (revised 8/28/17) described on admission, residents are evaluated for continence. Residents who are determined to be incontinent without a documented irreversible cause are to be further evaluated for potential bowel and bladder management. 3. On 12/11/19 at 4:50 p.m., in an interview, the Unit Manager said a bowel and bladder assessment was completed for all new admissions for 3 days and then reviewed to determine what the resident's needs were for toileting. The Unit Manager said if a resident needed to be placed on the toileting program, she would initiate it once the assessment was completed. The Unit Manager confirmed the Bowel and Bladder assessment for Resident #260 and #261 were not completed on admission. The Unit Manager said Resident #260 and #261 were not on a scheduled toileting program. 4. On 12/11/19 at 5:57 p.m., the Director of Nursing (DON), said when a resident was admitted , the nurse was to complete the Potential for Bowel and Bladder form within 24 hours and score would determine if the resident would benefit from a toileting schedule or routine incontinent care. The DON confirmed the Bowel and Bladder assessment had not been completed for Resident #260 and #261 at the time of admission.

Based on observation, record review, resident, staff, and family interview staff interview, the facility failed to provide nursing care and services to meet the needs for 13 (Residents #161, #27, #162, #34, #308, #408, #159, #18, #69, #66, #103, #262, and #263) of 22 dependent residents interviewed and a confidential family interview. The facility also failed to provide adequate services for 2 (Residents #260 and #261) of 2 residents requiring assistance with activities of daily living. The failure to provide assistance with activities of daily living caused these residents anxiety, frustration, apprehension, and pain. The findings included: 1. On 12/9/19 at 10:06 a.m., Resident #161 said the nursing staff don't come quickly. He said, The time it takes depends. On 12/12/19 at 1:50 p.m., Resident #161 said the facility does not have enough staff to meet his needs. He said just to give an example, last night he needed his leg bag to be switched to the larger drainage bag to go to bed, it took them a very long time to switch the leg bag and he wanted to go to bed. 2. On 12/12/19 at 1:55 p.m., Resident #27 said he's been living at the facility for about a year. He said he can never find a CNA when he needs one. He said there used to be 3 CNAs on his hall but now there are none. He said the situation has gotten worse over the past year. He can ask for water and doesn't get it until God knows when. He said he's complained to all of them, but nothing has been done. He said, They don't want to be bothered. 3. On 12/12/19 at 1:57 p.m., Resident #162 said the night before, it took 1½ hours to get a treatment that was due at 6:00 p.m. The resident said it takes over an hour to get a glass of water or juice. 4. On 12/12/19 at 2:05 p.m., Resident #34 said she does not get the care that she needs. She said if she asks for water, the aide would say she'll be back and they never come back. She can ask to have her bed made and they never do it. She said she did not use the call button frequently, but when she asks for something, the aides would say I will be back and never come back. 5. On 12/9/19 at 9:37 a.m., Resident #308 stated she sometimes lays in bed in a dirty brief for at least an hour, waiting for staff to come change her when she puts her call light on. On 12/10/19 at 8:50 a.m., Resident #308 said she pulled her call light last night and had to wait a while. She said the night shift staff are not very helpful. The resident said she was in severe pain last night as she was laying on her back. She said her butt was hurting so she asked the aide for an extra pillow to put under her to relieve the pain but was told there are no extra pillows. The resident said she told the nurse it hurts so much she could scream, and the nurse told her to go ahead and scream. 6. On 12/9/19 at 1:47 p.m., Resident #408 said the facility was not staffed on Sunday (12/8/19) to provide coverage for smoking in the evening. The resident said a lot of times call lights are not answered promptly. The resident said nurses will respond to a call light and say I'll send in a CNA (certified nursing assistant), then turn the call light off; no aide comes. 7. On 12/9/19 at 4:32 p.m., Resident #159 was observed sitting in a wheelchair in his room. The resident said when he rings his bell it takes an hour or two for the staff to come. The resident said this happens primarily in the evenings and nights. 8. On 12/10/19 at 9:20 a.m., Resident #18 said the nurse aides are taken off the floor during meal time to be in the dining room. The resident said in the morning when he first gets up is the worst time for the call bell responsiveness. He said it took an hour the last time. 9. On 12/12/19 at 1:57 p.m., Resident #69 said she gets the help she needs but she is fairly independent but feels like it may not be enough staff for some other residents. Resident #69 said other residents require more care and sometimes there is not enough staff to help them, especially if they are agency staff. The resident said sometimes she has to wait long times when she puts on the call light. The resident said the longest wait has been 20 minutes. The resident said she worries that if she falls in her bathroom and pulls the call light no one will come to her assistance. 10. On 12/12/19 at 2:05 p.m., Resident #66 reiterated the concern from Resident Council interview that the residents have to wait a long time when they pull the call light, usually from 15 to 20 minutes and sometimes over an hour. The resident said this occurs on all shifts. The resident feels the facility needs more staff to assist with residents' needs. 11. On 12/12/19 at 3:08 p.m., Resident #103 said the facility said the facility is short staffed and it takes over 15 minutes for someone to answer his call light. 12. On 12/12/19 at 3:12 p.m., Resident #262 said they are trying to get people in here to work, but they weren't having any luck. I wait a long time to go back to bed when I ask. 13. On 12/12/19 at 3:17 p.m., Resident #263 said sometimes they are short on staff, and it takes a while for them to answer the call light. 14. On 12/12/19 at 1:45 p.m., an interview was conducted with a family member who wishes to remain anonymous. The family member said her spouse said the resident was recently admitted to the facility, and they do not have enough staff to meet her spouse's needs. It takes as long as 45 minutes to an hour to respond to her request for assistance for her husband. 15. During Resident Council meeting on 12/10/19 at 10:00 a.m., when asked if they get assistance for toileting and in a timely manner or if they have to wait long periods for help, the consensus was sometimes they have to wait long times when they pull the call light, usually 15-20 minutes. They said sometimes they have had to wait for over an hour, and it happens on all the shifts. 16. In an interview on 12/9/19 at 1:15 p.m., Resident #260 said if I ask to go back to bed, they tell me I will have to wait, and then they don't come back. The resident said, I can't get to the bathroom because I fell prior to coming here and fractured my right hip and left arm. I need help to go to the toilet but when I ask to be changed they get nasty with me and tell me, 'I'll change you now but I'm not coming back again.' I have to sit in a wet brief and I get frustrated. It is uncomfortable to sit in this wheelchair when you are wet. If I put the light on and it is during meal times, they tell me they can't help me because they can't stop until all the residents are served and assisted in the dining room and hallways. Resident #260's medical record showed the resident was admitted to the facility on [DATE] with a [MEDICAL CONDITION] femur and the left humerus. The admission data collection tool dated 12/4/19 contained documentation Resident #260 was occasionally incontinent and had skin condition on areas on the buttocks. 17. In an interview on 12/9/19 at 3:47 p.m., Resident #261 said, I ask to use the bedpan, and they don't get it for me. They don't change me when I am wet, they make me wait and they leave me here to suffer. When I am wet and sitting in it for a while [MEDICAL CONDITION] skin. Resident #261 said, When I tell you I have to go, I have to go and I can't hold it for long, so I wet myself and then they don't want to change me. A physician's orders [REDACTED]. On 12/12/19 at 8:14 a.m., the Unit Manager, she said Resident #260 was receiving a skin protectant to her buttocks for excoriation (loss of the surface layers of the skin caused by exposure to urine, feces or friction). The Unit Manager said Resident #260 required extensive assistance of one for toileting and incontinent care. 18. A review of the grievance log for (MONTH) and (MONTH) 2019 revealed 15 concerns related to nursing care, including: resident and family complaints about not receiving scheduled showers, nurse aides on all shifts refusing to respond to requests for assistance, not assisting residents to clean their mouths after meals, and not receiving fluids. 19. In an interview on 12/12/19 at 3:00 p.m., the Administrator said they are having difficulty scheduling CNAs. She said the worst scenario is when an agency CNA calls off. She said they are using non-certified resident assistants to change beds and transport residents. The Administrator confirmed that the CNA hours are below the State requirement and care of the residents is delayed.

Based on record review, observation, and interview, the facility failed to prevent neglect for 2 (Resident #53, #272) of 5 residents reviewed for accidents. An unidentified staff member deactivated a door alarm which was sounding after Resident #53, who was wearing a Wanderguard bracelet (a system used to trigger a sensor alarm by doors) exited the facility. Outside in her wheelchair, alone, and in the dark, Resident #53 fell and sustained injuries. The staff did not follow their door alarm policies and procedures. The facility also had inappropriately placed a Wanderguard device on the wheelchair of three residents (Resident #272, #145 and #63). Resident #272 had been assessed to be at risk for elopement. Resident # 272 left her wheelchair and ambulated to exit, left the facility and wandered into the parking lot undetected by staff. Staff were not checking the proper placement and function of the devices daily as per facility policy. This places all residents who are at risk for wandering into unsafe areas in immediate jeopardy of possible serious injury or death. The immediate jeopardy was removed 3/23/17 after policy and procedure review, audits and staff education were conducted and staff interviews confirmed they had received and were able to explain the proper use of the Wanderguard devices, resident neglect and the importance of resident supervision. As of 3/23/17, the scope and severity (S/S) was reduced from J to D for noncompliance at F223. The findings included: The facility's policy for abuse defined neglect as the failure to take precautionary measures to protect the health and safety of the resident. Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. Under the section of investigation: the abuse coordinator and/or Director of Clinical Services shall take statements from the victim, the suspects, and all possible witnesses including all other employees in the vicinity of the alleged abuse. The facility's policy defined elopement as when a resident, who is not alert and oriented, is found off Center premises, unaccompanied, without the knowledge of staff, or when a resident is identified as missing from the Center. The process included if utilizing a wander monitoring system device, check functionality every day The Wanderguard Departure Alert System User Manual, indicated under Warning; Do not place the signaling device on or next to metal, such as wheelchair frames as metal could interfere when the signal is sent to the door modules; and Caution; Wanderguard signaling devices are designed for wrist and ankle placement, and the Wanderguard system is designed to assist staff, not replace them. The responsibility for maintaining the security of wanderers remains with a conscientious alert staff. Under Silencing the alarm; once the alarm is activated, it will continue to sound until staff move the monitored resident out of range and reset the alarm. 1. Resident #53's clinical record indicated the resident had a [DIAGNOSES REDACTED]. The resident was noted to be confused, and utilized a wheelchair for mobility. An admission assessment was completed on 12/22/16 by Licensed Practical Nurse (LPN) Staff V which indicated the resident was at risk for elopement, unaware of safety limitations, and continues to try and stand despite redirection. LPN Staff V noted on the evening shift of 12/22/16, the resident was refusing to lie in bed, going room to room looking for her children, and at 9:00 p.m. was found on the floor with no injuries. LPN Staff V noted the resident attempted to leave the facility 4 times and a Wanderguard was attached to the resident's nightgown. On 12/23/16, the physician ordered a Wanderguard bracelet and seatbelt to wheelchair. The resident's care plan dated 12/23/16, under the problem of at risk for elopement related to exit seeking behaviors, listed the goal of the resident will not leave the facility unattended. Interventions included observe for exit seeking behaviors, re-direct from doors and exits as needed, increased one-to-one monitoring if indicated, and a personal wander protection device (Wanderguard bracelet). On 12/26/16 at 11:00 p.m. the nurse noted Resident #53 was confused, restless and sitting at the nurse's station in her wheelchair for her safety. A Minimum Data Set (MDS) admission assessment dated [DATE] indicated Resident #53 had scored a 9 on a Brief Interview for Mental Status (BIMS). A score of 9 to 12 points indicates moderate cognitive impairment. The MDS indicated the resident required the extensive assistance of a staff member for transfers and locomotion, was not steady in her balance, and had sustained 1 fall without injury since admission. On 1/15/17 in a nursing progress note, LPN Staff G noted at approximately 6:30 p.m., the resident was found outside of the facility at the southeast entrance of the building, lying buckled in her wheelchair with the left side of her face on the concrete. The resident was lying in a pool of blood with two front teeth missing. The resident sustained [REDACTED]. The resident's wounds were dressed and after contacting the resident's physician, an ambulance transported the resident to the emergency room for evaluation. LPN Staff G noted upon investigation, another resident's visitor had assisted the resident outside the building. In an interview on 3/22/17 at 11:41 a.m., LPN Staff G confirmed a visitor came up to him over a month ago and said there was a lady in a wheelchair face down outside. LPN Staff G said he went outside along with LPN Staff V and LPN Staff I and found Resident #53 on the ground with her wheelchair on top of her. LPN Staff G said they brought the resident inside and gave her first aid. LPN Staff G said staff have to use a code to disarm the alarm when it sounds. In an interview on 3/22/17 at 11:53 a.m., LPN Staff V said on 1/15/17 right after dinner, she was near the nurses' station when a young man she had never seen before, passed her in the hall and didn't say anything. LPN Staff V said he came by again, went outside (the southeast door) and came in again saying there is a lady outside and she has fallen. LPN Staff V said she and LPN Staff I, and LPN Staff G went outside to help her. She said it was dark outside and they found Resident #53 at the end of the sidewalk towards the front of the building facing the highway (approximately 150 feet from the southeast entrance and 240 feet from the highway). She said the resident was on the ground, partially off the curb, and in her wheelchair. LPN Staff V said they brought her back into the building and called the paramedics. Staff V said the resident did have a Wanderguard bracelet on and the alarm did sound when they brought her back in. LPN Staff V said only nursing staff know the code to deactivate the door alarm. On 1/16/17 at 2:30 a.m., LPN Staff H documented the resident returned from the hospital to the facility with lacerations to her face and upper lip area with sutures and lacerations to left hand and right knee with sutures. The record contained a physician's orders [REDACTED]. the sutures on the residents face in 5 days, to remove the sutures in the resident's right knee in 12-14 days. In an interview on 3/23/17 at 9:14 a.m., the Assistant Director of Nursing (ADON) said she interviewed the visitor who had opened the door and allowed Resident #53 to go outside. She said the visitor reported as he was walking into the facility, Resident #53 was in her wheelchair and asked if he could get the door for her. The visitor said an alarm did sound and continued to sound as he went down the hall to his family member's room. The visitor said after telling his family member what he had done, his family member told him to go check on the resident. He then went back outside and found the resident lying on her side in her wheelchair. The visitor reported he then went back inside and alerted staff. The ADON said she interviewed some staff, but could not determine when the alarm was turned off or by whom. The ADON said the investigation resulted in placing a sign on the door for visitors not to let any resident out. On 3/22/17 at 10:29 a.m., in an interview, LPN Staff J said she had observed Resident #53 exit seeking and identified the southeast door as the one the resident attempts exit from. On 3/23/17 at 10:50 a.m., the Director of Nursing (DON) said staff interviews confirmed the Wanderguard system was operational and nursing staff were the only ones who have the code to deactivate the alarm. The alarm does not stop sounding until a code is entered by staff. 2. Resident #272's clinical record indicated the resident was admitted [DATE] with a [DIAGNOSES REDACTED]. An admission assessment was completed on 2/27/17 by Registered Nurse (RN) Staff M. The assessment was incomplete, and did not indicate if the resident was at risk for elopement. An admission care plan dated 2/27/17 identified the resident likes to wander around facility, has to be redirected In an interview on 3/24/17 at 10:45 a.m., RN Staff M said from the time Resident #272 arrived at the facility, she would say I have to go get my son, he's my baby. She would wander the hallway in her wheelchair, but she could ambulate independently. RN Staff M said the resident would hang out by the door saying she wanted to go get her son. RN Staff M said that was before the resident got really agitated, but she was always wandering. RN Staff M said the resident was confused and was even more confused at night. A psychiatric progress note dated 3/2/17 indicated psychiatry was asked to assess the resident for paranoia and possible visual hallucinations. The resident believes the ceiling tiles are falling on her. Unable to explain where she is and will not participate in short-term memory exam. In an interview on 3/24/17 at 2:03 p.m., CNA Staff N said when Resident #272 was first admitted she wandered a lot and would head toward the doors and try to get out. Staff N said the resident became increasingly agitated when they moved her roommate (on 3/1/17) and she would try to look for her. On 3/22/17, the Wanderguard checklist was reviewed for March 2017. The checklist indicated Wanderguard devices were to be checked daily to ensure proper placement, function, and to verify expiration date. There were 20 residents on the list, including Resident #272. The checklist indicated CNA Staff N checked the resident's Wanderguard device on 3/2, 3/3, 3/6, 3/7, 3/8 3/9, 3/10, 3/13 and 3/14. There was no documentation found of the Wanderguard system being checked on the weekends. In an interview on 3/24/17 at 2:03 p.m., CNA Staff N said she has been the one responsible to test the Wanderguard devices to see if they are working for about 5 years. She said she does this Monday through Friday; she looks for the device on the resident's wrist or ankle, but sometimes it may be on their wheelchair. CNA Staff N confirmed a Wanderguard device was on the wheelchairs of Resident #145 and Resident #63 and was instructed to put them there. CNA Staff N confirmed there was no documentation of any of the Wanderguard devices being checked on the weekends when she was not on duty. In an interview on 3/24/17 at 10:55 a.m., CNA Staff Q said Resident #272 was able to walk around but also used a wheelchair. Staff Q said the resident would be involved in activities during the day but would get upset towards the evening. Staff Q said the resident's Wanderguard may have been on her wheelchair as she did see something taped to the wheelchair. On 3/22/17 at 4:31 p.m., in an interview, CNA Staff K said a couple weeks ago she was up front at the reception desk right before dinner when a lady walked in the front door wearing a nightgown, no shoes, and with an adult brief rolled up in her hand. CNA Staff K said Resident #272 was unattended when she came in the front door and did not have a Wanderguard on her wrist. Staff K said the Wanderguard was on the resident's wheelchair which was still in the activity room by the southeast door near the nurses' station. Staff K said no one knows how long the resident was outside the facility. On 3/22/17 at 11:41 a.m., in an interview, LPN Staff G said about three weeks ago Resident #272 eloped and was brought back into the facility by the DON. Staff G said we don't know how she got out of the building and did not think she was wearing a Wanderguard bracelet. In an interview on 3/23/17 at 11:10 a.m., the DON said she was not aware of any wandering behavior by Resident #272. The DON said she was notified on 3/5/17 Resident #272 was in the lobby. The DON said she instructed LPN Staff G, to put a Wanderguard bracelet on the resident right away. The DON said no one saw the resident leave the building and confirmed there was no incident report completed. The DON said she did not have any documentation of an investigation into the events leading up to the resident going outside, and confirmed there was no nursing note about the event. The DON acknowledged the parking lot was not a safe place for the resident to wander but did not consider the event an elopement. The DON confirmed the lack of documentation of the resident's behaviors to include wandering, aggression, and exit seeking in the resident records. On 3/6/17 the Advanced Registered Nurse Practitioner documented the resident wandered outside yesterday, luckily ended up coming back and entering the front of the building. A Wanderguard is now in place. On 3/5/17 at 12:30 p.m., physician orders [REDACTED]. There was no further documentation of the resident being outside, if she was evaluated for injury if she was distressed by the incident, or the hourly checks being conducted as ordered. An MDS admission assessment dated [DATE] indicated the resident had scored a 9 on a Brief Interview for Mental Status and had exhibited a wandering behavior. The MDS was not coded to indicate the residents wandering behavior placed her at significant risk of getting into a potentially dangerous place (e.g. outside). On 3/24/17 at 1:36 p.m., in an interview, LPN Staff H said he has observed Wanderguard on the resident wheelchairs. 3. On 3/23/17 at 2:41 p.m., observation of Wanderguard devices on the wheelchairs of Resident #145 and Resident #63. CNA Staff P confirmed the Wanderguard device was on the wheelchairs and not the resident at the time of the observation. The DON confirmed she observed the inappropriate placement of the Wanderguard device on the wheelchair for Resident #145 and Resident #63. The Wanderguard checklist form instructs staff to checked Wanderguard devices to ensure proper placement, function, and to verify expiration date.

Based on record review, observation, and staff interview, the facility failed to prevent accidents by not providing appropriate interventions and adequate supervision for 3 (#53, #272, and #205) of 5 residents reviewed for accidents. An unidentified staff member deactivated a door alarm which was sounding after Resident #53, who was wearing a Wanderguard bracelet exited the facility. By staff not investigating the reason for the alarm sounding, Resident #53 was outside in her wheelchair, fell , and sustained injuries. The facility inappropriately placed a Wanderguard device on the wheelchair of Resident #272 determined to be at risk for elopement. The resident left her wheelchair, ambulated out of the facility and wandered into the parking lot undetected by staff, later re-entering the front of the facility. By not properly applying the Wanderguard device to the resident, she left the building for an undetermined amount of time and wandered to an unknown location before coming in the front door. The facility failed to ensure the function of the devices daily per facility policy. The facility failed to provide appropriate interventions to prevent falls for Resident #205, by not keeping a clutter-free environment and following the plan of care for fall prevention. This places all residents who are at risk for falls, elopement, and wandering into unsafe areas in immediate jeopardy of possible serious injury or death. The immediate jeopardy was removed 3/23/17 after policy and procedure review, audits and staff education were conducted and staff interviews confirmed they had received and were able to explain the proper use of the Wanderguard devices, the importance of resident supervision. As of 3/23/17, the scope and severity (S/S) was reduced from J to D for noncompliance at F323. The findings included: The facility's policy defined elopement as when a resident, who is not alert and oriented, is found off Center premises, unaccompanied, without the knowledge of staff, or when a resident is identified as missing from the Center. The process included checking the functionality every day if utilizing a wander monitoring system device. The Wanderguard departure alert system user manual, indicated under Warning; Do not place the signaling device on or next to metal, such as wheelchair frames as metal could interfere when the signal is sent to the door modules; and Caution; Wanderguard signaling devices are designed for wrist and ankle placement, and the Wanderguard system is designed to assist staff, not replace them. The responsibility for maintaining the security of wanderers remains with a conscientious alert staff. Under Silencing the alarm; once the alarm is activated, it will continue to sound until staff move the monitored resident out of range and reset the alarm. 1. Resident #53's clinical record indicated the resident had a [DIAGNOSES REDACTED]. The resident was noted to be confused, and utilized a wheelchair for mobility. An admission assessment was completed on 12/22/16 by Licensed Practical Nurse (LPN) Staff V. The assessment indicated the resident was at risk for elopement, unaware of safety limitations and continues to try and stand despite redirection. Staff V noted on the evening shift of 12/22/16, the resident was refusing to lay in bed, going room to room looking for her children and at 9:00 p.m. was found on the floor with no injuries. Staff V noted the resident attempted to leave the facility 4 times and a Wanderguard (a system used to trigger a sensor alarm by doors) was attached to the resident's nightgown. The physician's orders [REDACTED]. On 12/26/16 at 11:00 p.m. the nurse noted Resident #53 was confused, restless and sitting at the nurse's station in her wheelchair for her safety. A Minimum Data Set (MDS) admission assessment dated [DATE] indicated the resident had scored a 9 on a Brief Interview for Mental Status (BIMs). A score of 9 to 12 points indicates moderate cognitive impairment. The MDS indicated the resident required the extensive assistance of a staff member for transfers and locomotion; was not steady in her balance; and had sustained 1 fall without injury since admission. The resident's careplan dated 12/23/16, under the problem of at risk for elopement related to exit seeking behaviors, listed the goal of the resident will not leave the facility unattended. Interventions included observe for exit seeking behaviors; re-direct from doors and exits as needed; increased one to one monitoring if indicated; and for a personal wander protection device (Wanderguard bracelet). On 1/15/17 in a nursing progress note, LPN Staff G noted at approximately 6:30 p.m., the resident was found outside of the facility at the southeast entrance of the building, lying buckled in her wheelchair with the left side of her face on the concrete. The resident was lying in a pool of blood with two front teeth missing. The resident sustained [REDACTED]. The resident's wounds were dressed and after contacting the resident's physician, an ambulance transported the resident to the ER for evaluation. On 1/16/17 at 2:30 a.m., LPN Staff H noted the resident returned to the facility from the hospital with lacerations to her face and upper lip area with sutures, and lacerations to left hand and right knee with sutures. The record contained a physician's orders [REDACTED]. On 3/22/17 at 10:29 a.m., in an interview, LPN Staff J said she had observed Resident #53 exit seeking and identified the southeast door as the one the resident attempts to go out of. Staff J said the resident wears a Wanderguard bracelet which will cause the door to lock and set off an alarm if the resident goes near the door at the southeast and front entrances. Staff J said if the door was opened an alarm would still sound when the resident goes through the door. On 3/22/17 at 11:41 a.m., in an interview, LPN Staff G said a visitor told him there was a lady in a wheelchair face down outside. Staff G said he went outside along with LPN Staff V and LPN Staff I and found Resident #53 on the ground with her wheelchair on top of her. Staff G said they brought the resident inside and gave her first aid. He said did not hear the alarm did not sound at the southeast exit door but he thought the resident had a Wanderguard bracelet on. Staff G said nursing staff would have to use a code to disarm the alarm when it sounds. On 3/22/17 at 11:53 a.m., in an interview, LPN Staff V said on 1/15/17 right after dinner, she was near the nurses station when a young man she had never seen before passed her in the hall. Staff V said he came by again, went outside (the southeast door) and came in again saying there is a lady outside and she has fallen. Staff V said she, LPN Staff I, and LPN Staff G went outside to help her. She said it was dark outside and they found Resident #53 at the end of the sidewalk towards the front of the building facing the highway (approximately 150 feet from the southeast entrance and 240 feet from the highway). She said the resident was on the ground, partially off the curb, and in her wheelchair. Staff V said they brought her back into the building and called the paramedics. Staff V said she did not hear the alarm sounding when she was walking up the hall to the nurses station and does not know how long the resident was outside. Staff V said the resident did have a Wanderguard bracelet on and the alarm did sound when they brought her back in. Staff V said only nursing staff know the code to deactivate the door alarm. On 3/22/17 at 4:31 p.m., in an interview, Certified Nursing Assistant (CNA) Staff K said she was on duty the evening Resident #53 went outside and fell . Staff K said she did not hear any alarm sound. Staff K said every time she has seen a Wanderguard near the door, the alarm goes off. She said the resident is confused and has fallen several times. On 3/22/17 at 5:45 p.m., in an interview, the Administrator who is also the risk manager, said Resident #53 was assisted out of the facility by a visitor. She said the alarm was functioning properly and staff deactivated the alarm as they saw the visitor with the resident. She said the resident fell but was outside for less than 5 minutes. The Administrator said a sign was posted to alert visitors not to open the door for any resident to go outside and a notice was placed in the new admission packets with information about not letting residents out of the building. The Administrator said education was provided to staff on the new procedure. On 3/23/17 at 9:14 a.m., in an interview, the Assistant Director of Nursing (ADON) said she interviewed the visitor who had opened the door and allowed Resident #53 to go outside. She said the visitor reported as he was walking into the facility, Resident #53 was in her wheelchair and asked if he could get the door for her. The visitor said an alarm did sound and continued to sound as he went down the hall to his family members room. The visitor said after telling his family member what he had done, his family member told him to go check on the resident. He then went back outside and found the resident lying on her side in her wheelchair. The visitor said he went back inside and alerted staff. The ADON said she called the visitor back to confirm the alarm had sounded when he let the resident out the door. The ADON said she was unsure of when the alarm was turned off or by whom. The ADON said the investigation resulted in placing a sign on the door for visitors not to let any resident out. On 3/23/17 at 10:50 a.m., reviewed with the Director of Nursing (DON), staff interviews confirmed the Wanderguard was operational and nursing staff were the only ones to have the code to deactivate the alarm. The alarm does not stop sounding until a code is entered by staff. No staff member has been identified as being responsible for deactivating the alarm and then not checking to see if any resident had gone outside. The DON confirmed the system was operational and she had not conducted an investigation into who had deactivated the alarm and allowed the confused resident to remain outside in the dark, unsupervised. 2. Resident #272's clinical record indicated the resident was admitted with a [DIAGNOSES REDACTED]. A recent Baker Act (transfer of persons in a psychiatric emergency) dated 2/20/17, indicated the family had reported the resident was increasingly confused and agitated with visual hallucinations as well as expressed paranoid ideation that people are trying to break in and harm her. An admission assessment was completed on 2/27/17 by Registered Nurse (RN) Staff M. The assessment indicated the resident had no cognitive impairment and good decision making skills. The assessment was incomplete, and did not indicate if the resident was or was not at risk for elopement. An admission careplan dated 2/27/17 identified the resident Likes to wander around facility, Has to be redirected. Under behavioral symptoms: has history of being agitated and gets upset easily. A psychiatric progress note dated 3/2/17 indicated psychiatry was asked to assess the resident for paranoia and possible visual hallucinations. The resident believes the ceiling tiles are falling on her. Unable to explain where she is and will not participate in short term memory exam. A physician's orders [REDACTED]. On 3/6/17 the Advanced Registered Nurse Practitioner documented the resident wandered outside yesterday, luckily ended up coming back and entering the front of the building. Wanderguard now placed. There was no further documentation of the resident being outside, if she was assessed for injury, distressed by the incident, or the hourly checks being conducted as ordered. An MDS assessment dated [DATE] indicated the resident had scored a 9 (indicating moderate cognitive impairment) on a Brief Interview for Mental Status and had exhibited a wandering behavior. The MDS was not coded to indicate the resident's wandering placed her at significant risk of getting into a potentially dangerous place (e.g. outside). On 3/22/17, the Wanderguard checklist was reviewed for March 2017. The check list indicated the Wanderguard devices were to be checked daily to ensure proper placement, function and to verify expiration date. There were 20 residents on the list, including Resident #272. The checklist had documentation the resident had a Wanderguard device being checked weekdays by CNA Staff N, on 3/2, 3/3, 3/6, 3/7,3/8 3/9, 3/10, 3/13 and 3/14. No documentation of checks for Wanderguard function conducted on weekends On 3/22/17 at 11:41 a.m., in an interview, LPN Staff G said about three weeks ago Resident #272 eloped and was brought in by the DON. Staff G said we don't know how she got out of the building and did not think she was wearing a Wanderguard bracelet. On 3/22/17 at 4:31 p.m., in an interview, CNA Staff K said a couple weeks ago she was up front at the reception desk right before dinner when a resident walked in the front door wearing a nightgown, no shoes, and with a adult brief rolled up in her hand. Staff K said Resident #272 was unattended when she came in the door and did not have a Wanderguard on her wrist. Staff K said the Wanderguard was on the residents wheelchair which was still in the activity room by the southeast door near the nurses station. She said the resident must have gotten up from her wheelchair, walked out the southeast door and came in the front door. Staff K said the DON came to look at the resident and set up hourly location checks for the next 24 hours. Staff K said no one knows how long the resident was outside the facility. On 3/23/17 at 11:10 a.m., in an interview, the DON said she first observed Resident #272 sitting in the front hallway barefoot. The DON said she took the resident back to the unit and told a CNA to put socks and shoes on the resident. The DON said approximately 10 minutes later she was notified by receptionist Staff O, a resident came in the front door by the lobby. The DON said she instructed LPN Staff G to put a Wanderguard bracket on the resident right away. The DON said to her knowledge no one saw the resident leave the building and confirmed there was no incident report completed. The DON said she did not have any documentation of an investigation into the events leading up to the resident going outside, to include staff interviews, and confirmed there was no nursing note about the event. The DON said she was not aware of any wandering behavior by the resident prior to this date. The DON did acknowledge the parking lot was not a safe place for the resident to wander. On 3/24/17 at 9:08 a.m., in an interview, MDS Staff U said Resident #272 wandered day and night from the time of admission. Staff U confirmed she had done the initial careplan identifying wandering behavior and it was completed within the first 24 hours of admission. Staff U said if someone acts like they are going to exit the facility, staff do put a Wanderguard device on them. Staff U confirmed the admission MDS completed on 3/6/17 for Resident #272 did not indicate she had wandered into a potentially dangerous place as in outside the facility. Staff U said she never heard of any incident where the resident got outside, she attends morning meetings but does not recall any discussion of this occurring. On 3/24/17 at 10:45 a.m., in an interview, RN Staff M said from the time Resident #272 got here she would say I have to go get my son, he's my baby. She would wander the hallway in her wheelchair but she could walk. Staff M said the residents room was near the end of the hallway and she would hang out by the door saying she wanted to go get her son. Staff M said the resident was confused and was even worse at night. Staff M believed the resident did have a Wanderguard device on her wrist. On 3/24/17 at 10:55 a.m., in an interview, CNA Staff Q said Resident #272 was able to walk around but also used a wheelchair. Staff Q said the resident was involved in activities during the day but would get upset towards the evening. Staff Q said the residents Wanderguard may have been on her wheelchair as she did see something taped to the wheelchair. On 3/24/17 at 1:36 p.m., in an interview, LPN Staff H said he has seen Wandergaurds on resident wheelchairs. Staff H said he did not remember a time when the resident was successful at getting out the door but he did know the first or second night she was there he was told she tried to get out. On 3/24/17 at 3:25 p.m., the DON and Corporate Nurse said Resident #272 had been identified as an elopement risk by staff and did have a Wanderguard taped to her wheelchair on 3/2/17. There is no documentation of the resident leaving the facility, if the resident was assessed for injury, if one hour checks were being done as ordered, or if any interventions were put in place on 3/2/17 other than the device being scanned for function. They acknowledged the inappropriate placement of the device on the resident's wheelchair as not in accordance with manufacturers instructions as it may interfere with the signal. They could not produce documentation the function of the devices was being checked daily in accordance with facility policy. They agreed there is lack of documentation of the resident's behaviors to include wandering, aggression, and exit seeking from in the residents's record. On 3/23/17 at 2:41 p.m., Wanderguard devices were observed on the wheelchairs of Resident #145 and Resident #63. CNA Staff P confirmed the wanderguard device was on the wheelchairs and not the resident at the time of the observation. On 3/24/17 at 2:03 p.m., in an interview, CNA Staff N said she has been the one responsible to test the Wanderguard devices to see if they are working for about 5 years. She said she does this Monday through Friday. Staff N said she looks for the device on the resident's wrist or ankle, but sometimes it may be on their wheelchair. Staff N confirmed a Wanderguard device was on the wheelchairs of Resident #145 and Resident #63, and was instructed to put them there by LPN Staff B. Staff N confirmed there was no documentation of any of the Wanderguard devices being checked on the weekends when she was not on duty. On 3/24/17 at 3:25 p.m., the DON said she had also observed the inappropriate placement of the Wanderguard device for Resident #145 and Resident #63. 1. On 3/20/17 at 12:03 p.m., during an interview the Unit Manager-South Staff E identified Resident #205 as having a fall in the past 30 days. Observation of Resident #205 on 3/20/17 at 2:40 p.m., shows she has bruises on her face. On 3/23/17 at 12:30 p.m. during an interview Resident #205 stated she fell and landed on her face. A review of Resident #205's medical record was conducted on 3/23/17. The nursing notes, throughout the record, show safety measures are applied for Resident #205. She is independent with ambulation using her wheelchair. A review of Resident #205's care plan shows she was care planned for safety due to falls. Some of the approaches to minimize the risk for injury are: maintain a clear pathway, sensory alarm to wheelchair, toileting program and maintain safe environment. On 3/23/17 at 1:45 p.m., observation of Resident #205's bedroom with Staff revealed a floor mat was on the floor next to her bed. At the time of this observation Staff E stated the floor mat should be off the floor when the resident is not in bed. A walker was placed leaning against the wall in between the bed and against her closet door. This walkway leads to her nightstand table. Resident #205 would not be able to get to her nightstand table without moving this walker. The walker also prevents her from opening her closet door. An interview was conducted with Staff E at the time of this observation. Staff E confirmed Resident #205 is independent with her ambulation using her wheelchair and she does not use her walker anymore. This environment does not have a clear path to her nightstand table, closet door or next to her bed and is not a safe environment. Resident #205, while sitting in her wheelchair, shows she does not have a sensory alarm attached to her. Staff E confirmed the alarm is not attached to her. On 3/23/17 at 2:55 p.m., during an interview the certified nursing assistant Staff F said the floor mats are to be on the floor at all times. She does not pick them up when Resident #205 is out of bed. She is not aware the environment is to be cleared for Resident #205's safety. She said a sensory alarm is supposed to be attached to her wheelchair. Staff F observed Resident #205 and confirmed the alarm is not attached to her wheelchair. Staff F also said she is not aware of a toileting program for Resident #205. A review of the Nurse Tech Information Kardex form shows Resident #205 is to be toileted every two hours and uses a wheelchair for ambulation. On 3/23/17 at 3:05 p.m. during an interview, Staff E said when a resident is on a two hour toileting program, they have a form Bowel & Bladder Elimination Pattern Evaluation. The staff are to fill this form out every two hours when the staff take the resident to the bathroom. Resident #205 has this form located in the Certified Nursing Assistant documentation book. This form is blank for Resident #205. Staff E observed this form and confirmed it was blank. On 3/23/17 from 1:45 p.m., through 4:00 p.m., observed Resident #205 sitting in her wheelchair without a sensory alarm.

Based on record review, observation, and interview, the facility was not managed in a manner to effectively prevent neglect for 2 (#53, #272) of 5 residents reviewed for accidents. The facility did not conduct a full investigation into the incident of Resident #53 being allowed by a visitor to exit the facility; not attempting to interview all staff in the vicinity as per facility policy; and not attempting to identify the staff member who deactivated the Wanderguard door alarm which was sounding after the resident went through the door. By staff not determining the reason for the alarm sounding, Resident #53 was outside in her wheelchair alone and in the dark. The resident fell in her wheelchair, and sustained injuries. The facility also inappropriately placed a Wanderguard device on the wheelchair of Resident #272 who was ambulatory and determined to be at risk for elopement. The resident left her wheelchair, exited the facility and wandered into the parking lot undetected by staff. The resident later re-entered the front of the facility. By not properly applying the Wanderguard device to the resident she left the building for an undetermined amount of time and wandered to unknown location before coming in the front door. The Administrative staff did not investigate the second incident or recognize both events occurred on a Sunday around a meal time so that staffing patterns could be evaluated. The Administrative staff were unaware and failed to identify the Wanderguard devices were not always being placed on the resident's wrist or ankle. As a result the practice continued even after the incident with Resident #272. Administrative staff were unaware Resident #272 was identified as an elopement risk or had a Wanderguard device placed. The Administrative staff did not follow up to determine there was no documentation by nursing of the incident, or if the one hour checks had been done as ordered. Due to the lack of investigation, assessment, and analysis of the events surrounding these two incidents, this places all residents at risk for elopement and wandering into unsafe areas in immediate jeopardy of possible serious injury or death. The immediate jeopardy was removed 3/23/17 after policy and procedure review, audits and staff education were conducted and staff interviews confirmed they had received and were able to explain the proper use of the Wanderguard devices, resident neglect and the importance of resident supervision. As of 3/23/17, the scope and severity (S/S) was reduced from J to D for noncompliance at F490. The findings included: 1. The facility's policy for abuse defined neglect as the failure to take precautionary measures to protect the health and safety of the resident. Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. The administrative staff failed to ensure residents who were at risk for wandering and leaving the building were properly supervised to prevent accidents or to take other measures to to protect the health and safety of the residents. 2. Under the section of investigation; the abuse coordinator and/or Director of Clinical Services shall take statements from the victim, the suspects, and all possible witnesses including all other employees in the vicinity of the alleged abuse. The administrative staff failed to ensure an investigation of the events of 1/15/17 was conducted to prevent a similar incident of a resident exiting the building without staff being aware dure to the lack of supervision. 3. The facility's policy defined elopement as when a resident, who is not alert and oriented, is found off Center premises, unaccompanied, without the knowledge of staff, or when a resident is identified as missing from the Center. The process included if utilizing a wander monitoring system device, check functionality every day. The administrative staff failed to ensure a safe and secure enviroment is provided for all residents. 4. The Wanderguard departure alert system user manual, indicated under Warning; Do not place the signaling device on or next to metal, such as wheelchair frames as metal could interfere when the signal is sent to the door modules; and Caution; Wanderguard signaling devices are designed for wrist and ankle placement, and the wanderguard system is designed to assist staff, not replace them. The responsibility for maintaining the security of wanderers remains with a conscientious alert staff. Under Silencing the alarm; once the alarm is activated, it will continue to sound until staff move the monitored resident out of range and reset the alarm. The administrative staff failed to follow the user manual to ensure the Wandergaurd devices were appropriately placed to ensure proper functions to assist with resident supervision and safety. The immediate jeopardy was removed 3/23/17 after policy and procedure review, audits and staff education were conducted and staff interviews confirmed they had received and were able to explain the proper use of the Wanderguard devices, resident neglect and the importance of resident supervision. As of 3/23/17, the scope and severity (S/S) was reduced from J to D for noncompliance at F490.

Based on record review, observation, and interview, the facility failed to have an effective Quality Assessment and Assurance(QAA) program to evaluate processes when incidents occur and require investigation for potential quality of care concerns. The QAA program did not ensure care practices were consistently applied, or ensure policy and procedures were followed. The QAA program did not fully assess, investigate, and identify incidents of neglect for 4 (#53, #272, #145 and #63) of 5 residents reviewed for accidents. The immediate jeopardy was removed 3/23/17 after policy and procedure review, audits and staff education were conducted and staff interviews confirmed they had received and were able to explain the proper use of the Wanderguard devices, resident neglect and the importance of resident supervision. As of 3/23/17, the scope and severity (S/S) was reduced from J to D for noncompliance at F223. The findings included: The QAA committee failed to identify areas of concern to ensure the safety of residents. 1. The facility did not conduct a full investigation into the incident of Resident #53 being allowed by a visitor to exit the facility; not attempting to interview all staff in the vicinity as per facility policy; and not attempting to identify the staff member who deactivated the Wanderguard door alarm which was sounding after the resident went through the door. By staff not determining the reason for the alarm sounding, Resident #53 was outside in her wheelchair alone and in the dark. The resident fell in her wheelchair, and sustained injuries. 2. The facility also inappropriately placed a Wanderguard device on the wheelchair of Resident #272 who was ambulatory and determined to be at risk for elopement. The resident left her wheelchair, exited the facility and wandered into the parking lot undetected by staff. The resident later re-entered the front of the facility. By not properly applying the Wanderguard device to the resident she left the building for an undetermined amount of time and wandered to unknown location before coming in the front door. 3. The QAA committee did not recognize both events occurred on a Sunday around a meal time so that staffing patterns could be evaluated. 4. The QAA committee were unaware and failed to identify the Wanderguard devices were not always being placed on the resident's wrist or ankle per the user manual which put residensts at risk 5. The QAA committee failed to recogonize system failures due to the lack of investigation, assessment, and analysis of the events. This places all residents at risk for wandering into unsafe areas in immediate jeopardy of possible serious injury or death.

Based on observation, record review, and resident, family, and staff interviews, the facility failed to prevent a pressure wound for 1 (Resident #56) of 1 resident reviewed. Although assessed at high risk for developing pressure wound, the facility failed to prevent the development of a pressure ulcer. The National Pressure Ulcer Advisory Panel on 4/13/16 updated the definition of Pressure Injuries to state, A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. The findings include: Record review revealed Resident #56 was admitted on [DATE] with multiple medical [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] indicated upon admission there was an abrasion to the left knee, a skin tear to the left thigh, a wound to the left calf, a scab to the left upper thigh, a bruise to the forehead, an ecchymotic (reddened) area to the left arm and right arm, and an abrasion to the left cheek. The Braden Scale assessments (to determine how susceptible a person might be to developing pressure wounds) on 1/20/17, 1/27/17, 2/3/17, and 2/10/17 indicated her score was 18, at high risk for developing a pressure ulcer. A score of 18 is the highest risk factor on the Braden Scale. Review of the skin assessment of 1/31/17 a reddened open area was noted to Resident #56's coccyx. Physician orders [REDACTED]. A dietary consult was completed and Pro-Stat (a liquid supplement) daily was ordered for additional protein intake. Record review revealed the wound was assessed by a Registered Nurse (RN) on 2/7/17, 2/15/17, 2/21/17, 2/28/17, 3/7/17, 3/13/17 and 3/21/17. All of these assessments documented the wound was a stage 2 pressure ulcer with slough (devitalized tissue) at the wound bed. During an interview on 3/21/17 at 12:43 p.m., Resident #56 said the air mattress on her bed was applied because she has a pressure ulcer. She said did not have a bedsore (pressure ulcer) when she was admitted to the nursing home. Resident #56's husband said the air mattress was applied after she got a bedsore. On 3/23/17 at 3:01 p.m., Unit Manager Staff C acknowledged even though the resident had a Braden Score of 18 on 1/20/17, an air mattress was not ordered and placed on the bed until 2/1/17. She said, It just didn't get done. On 3/22/17 at 10:21 a.m. observed wound care performed by Licensed Practical Nurse Staff D. There was an open wound to the resident's coccyx. The wound had slough to the wound bed, there was no drainage or odor. There was a pressure relieving mattress to bed and a pressure relieving pad to wheelchair.

Based on observation, clinical record review and staff interview, the facility failed to implement adequate supervision and interventions to prevent fall and injury for 2 (Resident #191 and #35) of 29 sampled residents. The findings include: 1. Observation of Resident #191 on 3/8/11 at 8:24 a.m. revealed a large bruise to the right forehead, large black and red area around the right eye and mild redness under the left eye. The resident was not able to explain how she sustained this significant bruising. Review of the clinical record on 3/9/11 revealed Resident #191 was admitted to the facility on [DATE] from an acute care hospital. The history and physical contained documentation she sustained several falls at home, the last one resulting in a fracture of the left distal radius. Upon admission to the facility, the resident was assessed to be at risk for falls and an interim care plan was developed. The interventions listed included the use of a sensor alarm to the bed. The clinical record also contained a care plan for poor safety awareness. Interventions included, but were not limited to, monitoring for changes in the resident's condition that may warrant increased supervision and assistance. The resident received both physical and occupational therapy and was discharged from physical therapy on 12/15/10. The Physical Therapy discharge summary, dated 12/16/10, revealed documentation the resident required SBA/CGA (stand-by assistance/contact-guard assistance) for all treatments and mobility with rolling walker for safety. The resident was transferred to restorative care for maintenance of functional level. Further review of the record revealed on 12/8/10 the use of the sensor alarm to the bed was discontinued. Review of the quarterly MDS (Minimum Data Set), dated 2/18/11, with an assessment reference on 2/11/11, indicated in section G (functional status) the resident had both short term and long term memory problem and required supervision for transfer, limited assistance of 1 person for walking in room, corridor and on the unit. Review of the Licensed Nurses' notes revealed documentation, dated 12/8/10, the resident was "ambulating around without assist." The nurse's note, dated 12/14/10, documented the resident's gait was "unsteady with walker," the resident had "periods of leaning to the left," and was "ambulating in her room without assistance." On 2/21/11 at 10:45 a.m. the nurse's note contained documentation the resident was found on the floor by staff. The resident stated, "I just sat on floor." The care plan for poor safety awareness was updated on 2/23/11 indicating the resident attempts to assist others even though she is unsteady on her feet. The care plan for fall was revised on 2/22/11 and a box checked indicating interventions were updated. The care plan, however, did not list any new interventions than those noted upon admission. Record review of a therapist note, dated 2/23/11, revealed "the resident was at prior level of functioning and required supervision secondary to inability for safety awareness." The clinical review form, dated 2/8/11, reveal documentation the resident "had safety concerns due to impaired cognition and is able to be mobile with or without an assistive device." Further review of the nurse's notes revealed the resident sustained [REDACTED]. She fell to the floor hitting her right elbow and right forehead. At the family's request, the resident was sent to an acute care hospital for evaluation and returned to the facility at 2:15 p.m. On 3/2/11 at 11:00 p.m. the Licensed Nurse documented the resident remained with a hematoma to the right forehead and right elbow abrasion. The facility updated the care plan on 3/2/11 adding the use of a sensor alarm to the bed. Observation on 3/10/11 at 10:00 a.m. revealed the resident in bed, fully dressed. She was not able to answer questions appropriately. A sensor alarm was noted on the bed. The resident was able to stand with cueing from the Certified Nursing Assistant. The alarm did not go off to alert staff of the unassisted transfer. During an interview on 3/10/11 at 10:13 a.m., the CNA (Certified Nursing Assistant) who cares for the patient regularly stated she came on duty at 6:00 a.m. that morning and helped the resident to get dressed. When she checked the sensor alarm, as part of her daily routine, she noticed it wasn't working and informed the restorative CNA. During an interview on 3/10/11 at 10:23 a.m., the Restorative CNA stated she was not informed the resident's alarm was not functioning, and it is the facility's procedure to check the alarm on a weekly basis. She provided documentation she last checked it on 3/7/11 and it was working properly. During an interview on 3/10/11 at 10:28 a.m., a member of the central supply staff stated she had just replaced the alarm on the resident's bed, but the control box was an old one and was not "triggering all the time." A review of the fall investigation was conducted with the Unit Manager on 3/10/11 at 10:40 a.m. She stated, "The resident is impulsive and tries to help other people. It was her attempt to get out of bed and help her roommate that caused her fall on 2/21/11." The Unit Manager was asked what interventions were put into place after the first fall to closely monitor the resident and ensure she received the supervision and limited assistance of 1 person needed as per the MDS assessment. The Unit Manager stated she should have thought about putting an alarm on the bed on 2/21/11 to prevent further falls. She also said the facility did not have any written policies and procedures to ensure the residents' alarms were functioning properly, but she does a weekly check. During an interview on 3/10/11 at 3:28 p.m., the director of rehab stated Resident #191 has no safety awareness - "she's not reaching back for her chair and she forgets her walker and holds onto furniture. She doesn't use the call light. She's 'not there,' she tends to trip." The director of rehab stated, Resident #191 is not going to get any better because she has no retention, "you can tell her something and 5 minutes later she will do the exact same thing you tell her not to do." The failure to develop and implement adequate interventions for this resident who was determined to be at risk for falls, resulted in a fall, injury and transfer to an acute care facility. The failure to immediately replace the defective alarm placed Resident # 191 at risk for further fall and significant injuries. 2. On 03/07/2011 the main dining room lunch meal was observed. Resident #35 requested to be returned to her room after lunch. While backing her wheelchair away from the table a staff member hit the resident's left leg on the table leg. The resident yelled out, "My leg, you hurt my leg." The LPN (Licensed Practical Nurse) observing the dining room went to the resident, examined the left leg (which was in a splint due to a previous fall) and removed the resident from the dining room. During an interview at 12:30 p.m., the LPN stated "I guess we could move the other tables and make more room for this resident due to the leg splint/immobilizer." On 03/10/2011 at 3:45 p.m. during an interview, the nurse manager stated, "the resident receives her meals in her room since the incident due to pain levels and requested meals there until pain is under control." The nurse also said the resident would be asked to return to the dining room at the end of this week. On 03/11/2011 an interview with the risk manager designee revealed this was documented as an incident. The facility failed to move the resident in a safe manner in the dining room, resulting in staff hitting the resident's leg, causing her pain.

Based on observation, clinical record review and staff interview, the facility failed to provide care and services to prevent worsening of pressure ulcers for 1 (Resident #1) of 3 clinical records reviewed for pressure ulcers. The findings include: 1. Resident # 1 was re-admitted to the facility on [DATE] after a stay at an acute care hospital. Review of the clinical record on 09/07/10 revealed an admission skin sweep dated 090/3/10. The form contained documentation the resident had 3 different pressure ulcers, including a Stage II ulcer of the right buttock. The licensed nurse documented the pressure ulcer of the right buttock measured 3.5 centimeters. She did not document the width or the depth of the Stage II pressure ulcer. Review of the Treatment Administration Record and the nurses notes for 09/10 failed to reveal documentation the Stage II pressure ulcer of the right buttock received any treatment from 09/03/10 until 09/10/10, seven days after the pressure ulcer was first identified. Review of the physician's orders [REDACTED]. Peri-guard is a barrier cream. The clinical record also contained an order dated 09/08/10 for a consultation at a local hospital wound care center for the resident's left heel and right foot ulcer. There was no documentation in the clinical record at the time of the survey the facility obtained the necessary appointment for the resident. The subsequent skin grids were reviewed. On 09/15/10 the pressure ulcer to the right buttock measured 3 centimeters by 2.5 centimeters by less than 0.1 centimeter. On 09/23/10 the pressure ulcer was larger and measured 3 centimeters by 3 centimeters by less than 0.1 centimeter. On 09/30/10 the licensed nurse documented another increase in size of the pressure ulcer of the right buttock. The ulcer now measured 3 centimeters by 3.5 centimeters by less than 0.1 centimeter. This indicated the ulcer was 1 centimeter wider than the previous two weeks. The clinical record did not contain documentation the physician was notified of the worsening of the ulcer. On 10/07/10 at 11:40 a.m. the wound care was observed for all 3 pressure ulcers. The licensed nurse measured the ulcer to the resident's right buttock. It measured 6 centimeters by 5 centimeters by less than 0.1 centimeter, indicating further deterioration of the ulcer. The licensed nurse washed her hands and donned a pair of clean gloves. She retrieved a pair of scissors from her pocket. She did not sanitize the scissors and used them cut the soiled dressing from the resident's left foot. The dressing was noted to have a small amount of bloody drainage. The nurse placed the scissors back into her pocket. She used the same scissors to cut open the dressing from the right foot. She did not sanitize the scissors before or after use. The licensed nurse placed the scissors once again into her pocket and went on to change the dressing to the resident's right buttock. She washed her hands and donned a clean pair of gloves. With the gloves on, the licensed nurse raised the head of the bed, turned the resident to the right side and moved the Foley catheter to the other side of the bed. She opened the resident's incontinent brief, removed the soiled dressing from the resident's right buttock. She cleaned the wound with normal saline without washing her hands or changing the dirty gloves. On 10/07/10 at 2:31 p.m. an interview was held with the wound care nurse regarding the worsening of the pressure ulcer and the lack of infection control during the wound care. The wound care nurse explained the Unit Manager did not inform her of the pressure ulcer until 09/15/10, thus the delay in treatment. The nurse stated she was sure the physician was aware of the worsening of the pressure ulcer. She added the physician did not change the treatment as the ulcer was getting bigger. The licensed nurse also confirmed the breech of infection control observed during the wound care. Telephone interview on 10/07/10 at 3:07 p.m. with the physician revealed he was not aware of the deterioration of the pressure ulcer. A second interview was held on 10/08/10 at 2:48 p.m. with the physician. He confirmed the pressure ulcer to the resident's right buttock was significantly worse. The physician stated if he had been notified of the progressive worsening of the resident's right buttock ulcer, he would have definitely changed the treatment to avoid further deterioration of the wound. The physician stated he had just issued an order for [REDACTED]. The delay in treatment and the failure to report a significant change in condition of the resident's right buttock ulcer to the physician resulted in the avoidable deterioration of the resident's pressure ulcer to the right buttock.