Every finding on record at Avir at Borger

Based on observations, interviews, and record reviews the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #14) of 12 residents reviewed for pain management.The facility failed to ensure Resident #14 did not have mouth pain from at least March of 2025 to August of 2025.This failure could place residents at risk of living for extended periods of time with unaddressed pain. Findings included:Record review of Resident #14's admission record dated 08/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, aggressive periodontitis localized moderate (severe, rapid periodontal disease affecting few teeth characterized by significant bone and attachment loss that progresses quickly, requires early and comprehensive treatment involving mechanical debridement, potentially systemic antibiotics, and periodontal surgery to halt destruction and prevent tooth loss), myelodysplastic syndrome (group of blood disorders characterized by abnormal production of blood cells in the bone marrow), and dental caries (cavities). The diagnosis date for aggressive periodontitis was 12/10/24. The diagnosis date for the myelodysplastic syndrome was 07/25/19. The diagnosis date for the dental caries was 02/28/22.Record review of Resident #14's annual MDS assessment completed on 08/25/25 revealed a BIMS score of 15 which indicated intact cognition. Section J Health Conditions revealed Resident had mild pain and received pain medication. The pain was coded as rarely interfering with sleep, therapy, and day to day activities. Section L Oral/Dental Status revealed Resident #14 was not coded as having Mouth or facial pain, discomfort or difficulty chewing.Record review of Resident #14's care plan completed 08/20/25 revealed no mention of mouth or dental pain/issues. The care plan stated Resident #14 had complaints of acute pain but did not specify where the pain was located.Record review of Resident #14's EHR under the MISC tab revealed the following:a letter dated 01/22/25 which indicated her dental assistance case had been reviewed and she was found to qualify for assistance.a dental visit report dated 02/25/25 revealed Resident #14 had two teeth extracted and had others that needed to be extracted. She was put on a round of amoxicillin 500 mg 3 times a day for 5 days.an encounter note from an oral and maxillofacial surgeon's office dated 07/07/25 revealed Resident #14 was evaluated for osteonecrosis of her jaw due to cancer treatment drugs she used to take. She was a noted to have exposed bone in her right maxilla and mandible. She was noted to have been seen by oral surgeon and referred for further evaluation due to the extensive nature of her disease. Resident #14 was noted to have pain and an occasional foul taste in her right jaw upper and lower. The encounter note stated, Patient has a 2 cm exposed bone in her right maxilla as well as her right mandible which is necrotic. The oral and maxillofacial surgeon noted he would obtain x-rays from her dentist and call with a date for surgery which is usually excision of for quality bone with primary closure.Record review of Resident #14's progress notes revealed the following notes and corresponding dates: 03/20/25 a note from NP with an order for an oral numbing gel PRN which was to be kept at Resident #14's bedside. 03/23/25 a note which stated Resident #14 complained multiple times of tooth pain. [Resident #14] asked if I knew anything regarding her dentist appointment, I informed her I did not. She had a document with her from 01/22/25 regarding her tooth. I advised [Resident #14] had no information about any dental appointment for her but I would pass on her question to DON [first name of DON]. 06/26/25 Resident c/o pain radiating from right Nursing side of jaw to front of jaw. [NP] in facility and assessed resident. new orders to d/c chlorhexadine mouth wash d/t not for long term use. Clindamycin 300mg 1 capsule q8 hours x3 days and acidophilus capsule 1 capsule BID x3 days. 08/19/25 resident continues to c/o oral pain 8/1 O (8 out of 10) after PRN APAP administered as ordered, with significant halitosis noted, [NP] notified new order CBC BMP one time resident informed 08/26/25 at 02:57 AM Res complaining of oral pain of 4 APAP given to res.During an observation and interview on 08/25/25 at 07:40 AM Resident #14 stated she had bone and blood cancer. As she spoke her breath was foul and noticeable from 3 feet away. Resident #14 stated she was in pain all the time due to a pocket with pus and all that in her mouth. She stated she had x-rays in a nearby town and was told by that doctor that the only doctor who could handle her needed surgery was a doctor out of state. She stated the out of state doctor told her he would set a date for surgery, but it had not happened yet.During an observation and interview on 08/27/25 at 07:55 AM Resident #14 stated she regularly told staff about the pain she had in her mouth.During an interview on 08/27/25 at 08:54 AM CC stated Resident #14's mouth pain, has been an issue for a while. She stated an inaccurate care plan could potentially affect their (residents') care and treatment.During an interview on 08/27/25 at 10:46 AM CCM stated she did not know much about Resident #14's mouth pain. She stated, I know she had been having some.During an interview on 08/27/25 at 11:06 AM LVN F stated Resident #14's mouth pain has been for a very long time. This poor woman has been dragged through the ropes. We are just waiting on the surgeon to get it together.During an interview on 08/27/25 at 11:14 AM ADM stated she knew Resident #14 had mouth pain.During an interview on 08/27/25 at 01:04 PM DON stated she knew about Resident #14's mouth pain. She stated the pain had been going on for a minute. DON stated the facility took Resident #14 to a dentist and were told to take her to an oral surgeon who sent them to an out of state oral surgeon who took forever and a day to get her in and is now taking forever and a day to get her in for surgery.Record review of facility policy titled, Pain Management and dated 7-2025 revealed the following: . The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain). Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. 3. The interdisciplinary team and the resident and/or the resident's representative will collaborate to arrive at pertinent, realistic and measurable goals for treatment. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics: a. Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain. c. Consider administering medication around the clock instead of PRN (pro re nata/on demand) or combining longer acting medications with PRN medications for breakthrough pain. e. Use lower doses of medication initially and titrate slowly upward until comfort is achieved. f. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences . If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety.The facility failed to ensure stored food was properly labelled and dated.The facility failed to ensure dented cans were placed in the specified area to be returned.The facility failed to discard leftover food by use by date on the label.The facility failed to ensure the floor, walls, trashcan, and bathroom of the kitchen were clean and sanitized.The facility failed to ensure food was stored at least 6 inches off the floor.These failures could place residents at risk of food borne illness.Findings included:An observation on 08/25/25 at 05:35 AM revealed a meal trolley outside the door to the kitchen. It was full of dirty dishes and trays with two dirty trays and their dirty dishes sitting on top of the trolley.An observation on 08/25/25 at 05:36 AM revealed the sink next to the dishwasher was full of dirty dishes, pots, and pans and the three compartment sink on the other side of the dishwasher was full of dirty dishes, pots, and pans.An observation on 08/25/25 at 05:37 AM revealed three round, 5-gallon, opaque plastic, lidded containers stacked on top of one another on the floor of the kitchen next to the stand mixer. The bottom container was 1/4 full of yellow substance and labeled Cornmeal 07/17/25 use by 08/17/25. The middle container was 1/2 full of white substance and labeled Sugar 07/17/25 use by 08/17/25. The top container was 1/6 full of white powdery substance and had no label or date.An observation on 08/25/25 at 05:39 AM revealed the kitchen floor around the step-to-open trashcan was littered with white crumbs which were stuck to the floor but could be scraped off using the toe of this surveyor's shoe. The trash can did not have a liner and the inside of the trashcan is smeared. The bottom of the trash can contained crumbs, two individual ketchup packets, and one individual butter packet.An observation on 08/25/25 at 05:40 AM revealed the kitchen floor next to the stove, steam table, and prep table was littered with crumbs and black/brown streaks and smears that were sticky to the bottom of this surveyor's shoes.An observation on 08/25/25 at 05:42 AM of the counter next to the microwave revealed the following:two bags of circular fruit flavored breakfast cereal open to aira bag of cheese sauce mix open to air with no datea banana peeled 1/3 of the way down and open to airAn observation on 08/25/25 at 05:43 AM of the shelving under the microwave counter and the steam table revealed clean steam pans and a scattering of white crumbs.An observation on 08/25/25 at 05:46 AM of the walls next to and behind the oven revealed brown/orange substance splattered from about 6 feet high to the bottom of the walls.An observation on 08/25/25 at 05:48 AM of the prep table reveals a brown/grey smear approximately the size of a dessert plate that is sticky and greasy to touch on the end of the table closest to the serving door.An observation on 08/25/25 at 05:48 AM of the refrigerator and freezer temperature logs revealed the last entry was 08/20/25.An observation on 08/25/25 at 05:51 of the large freezer revealed the following: 1 zip topped plastic bag contained what appeared to be pancakes no label or date 1 zip topped plastic bag contained breaded meat patties no label or date 2 large plastic bags of what appeared to be fried shrimp no label or date 1 plastic bag labeled cookies open to airAn observation on 08/25/25 at 05:55 AM of the walk-in refrigerator revealed the following: 2 individual butter spread containers on the floor 1 unopened, clear plastic bag labeled coleslaw and dated 07/22/25 1 zip topped plastic bag labeled cucumber onion dated 08/21/25 use by 08/24/25 1 large opaque circular tub 1/3 full of what appears to be chopped carrots in liquid no label or date 1 plastic circular opaque tub 1/3 full labeled cream of chicken and dated 08/19/25 use by 08/22/25 1 rectangular, metal, lidded steam table pan 1/2 full of what appears to be oatmeal no label or date 1 zip topped plastic bag labeled Roast dated 08/20/25 use by 08/23/25 1 buffet ham in original packaging dated 07/29/25 1 package of what appears to be round luncheon meat with no label or date. 1 package of sliced ham no date 1 box of bacon open to airAn observation on 08/25/25 at 06:07 AM revealed a round, lidded, plastic tub of chocolate frosting with 1/6th used sitting on the counter next to the coffee maker. Manufacturer's label stated, Refrigerate leftovers for up to 2 weeks.An observation on 08/25/25 at 06:08 AM of the pantry revealed the following: 1 can of apples dented on the side and top seam of the can1 large bag of parboiled rice open to air1 undated box of small macaroni noodles open to air1 zip topped plastic bag with open cheese sauce package inside with no open date1 zip topped plastic bag with open bag of potato chips inside with no open date4 macaroni noodles and lots of crumbs and dirt on the floor behind the pantry door.An observation on 08/25/25 at 06:23 AM of the kitchen bathroom revealed the following: 1 wet spot under the sink the size of a sheet of letter paper, with dirty end of plunger resting in the wet spot toilet bowl was speckled with brown spots yellow stains on underside of toilet seat in a splatter pattern sink drain is broken and lying crookedly in the bottom of the sink sink was stained grey/brown along the top right side floor of bathroom was sticky and stained with brown/black smears walls of bathroom were dirty with grey/brown/black smudges light switch was stained greyish brown and sticky spiderwebs on the shelf above the toilet and on the ceiling An observation on 08/25/25 at 08:43 AM revealed cornmeal, sugar, and third unlabeled tubs still stacked on the floor of the kitchen next to the stand mixer. An observation on 08/25/2025 at 08:43 AM of prep table revealed it still has same smear of grey/brown sticky, greasy substance on the end closest to the DR. An observation on 08/25/2025 at 08:43 AM of kitchen floor revealed it was still littered with crumbs and black/brown sticky smears. An observation on 08/25/2025 at 08:45 AM of the walk-in refrigerator revealed a pitcher of opaque plastic with red lid 1/3 full of white substance no label or date. An observation on 08/25/2025 at 08:47 AM of locked freezer revealed the following:4 cylindrical packages of what appears to be ground meat with no label or date2 turkey breasts with no datebox of bite-sized pieces of what appears to be meat with no label or date open to air.During an observation on 08/26/2025 at 07:32 AM DA B used her right index finger to stir apple juice into ground sausage patty as she prepared puree meal.During an observation on 08/26/2025 at 07:56 AM DA B finished using the blender for one pureed item and used water from the tap to rinse out the blender before reusing it for the next pureed item.During an observation on 08/26/2025 at 08:10 AM DA A used her gloved hand to pick up a half slice of toast and place it on a plate for a resident after touching trays, utensils, and the doorhandle to the walk-in refrigerator.During an interview on 08/25/2025 at 09:09 AM DA C stated he had worked for facility for 2 months. He stated all kitchen staff were responsible for cleaning pantry, kitchen floors, and kitchen bathroom. He stated there was a cleaning log and they communicate with one another to see who does what each shift. DA C stated the bathroom was cleaned at least 3 times a week. He stated all kitchen staff were responsible for labeling and dating food in pantry, freezer, and fridge. DA C stated they were flying by the seat of their pants while DM was out on medical leave. He stated he was not trained on labelling and dating food. DA C stated he managed a kitchen previously and all he needed to know was where the stickers to label and date were kept. During an interview on 08/25/2025 at 09:16 AM DA A stated she had worked for the facility for 3 years. She stated all kitchen staff were responsible for cleaning pantry and kitchen floors. DA A stated they did both things daily. She stated the kitchen bathroom was cleaned by kitchen staff at least 3 times a week. DA A stated she noticed the water under the sink in the kitchen bathroom yesterday. She stated it was often necessary to leave dirty dishes in the tray trolley and dirty dishes, pots, and pans in the sinks overnight due to needing to clock out at 06:00 PM after dinner was served at 05:30 PM. DA A stated whoever puts food in the fridge needs to label it with the day made and the use by date. She stated she was trained on labelling and dating food.During an interview on 08/26/25 at 03:22 PM RD stated residents could be negatively impacted if food was not labeled and dated properly. She stated, A lot of different things could go wrong with that if it is expired or out of date, you wouldn't know.During an interview on 08/27/25 at 10:27 AM DA A stated she had been trained on labeling and dating food at least 6 times in 3 years. She stated if food was not properly labeled and dated it could make residents sick. DA A stated she was trained on sorting canned goods for dented cans when the food truck arrives. She stated residents could be negatively impacted by eating food from dented cans. DA A stated she had been trained on cleaning the floors of the kitchen 10 times. She stated she was never trained on cleaning the kitchen bathroom. Of cleaning the kitchen bathroom, DA A stated, We just do it when we have the chance, and our hours have been cut; we cannot keep up with everything. She stated dirty floors, walls, and kitchen bathroom could make residents sick.During interview on 08/27/25 at 10:37 AM DA B stated she was trained her first three days on labeling and dating food. She stated she was taught to label food with the open date and the use by date. DA B stated leftover food was to be used in 3 days or discarded. She stated all food was to be labeled as it came into the kitchen from the food truck with the date of arrival. DA B stated food that was improperly labeled could affect health of residents. She stated she was not trained to sort canned goods and place dented cans on the specially marked shelf in the pantry. DA B stated regarding cleanliness of the kitchen, I am going crazy here. I want to clean everything. I want to scrape it all with bleach. I just bleached the floors when I just got here. She stated a dirty kitchen could allow bacteria into the food and make residents sick.Record review of posted cleaning duties form hanging in the kitchen revealed 3 of 168 possible items were initialed/dated on 08/22/25. The three initial/dated items revealed counters, fridge, freezers, and storeroom were cleaned.Record review of an in-service training titled F812 Kitchen Sanitation, Cook/Aide Responsibilities, Cleaning Schedules, RD Inspection, Food Storage, Infection Control, Dish Room provided to DA A and DA C by ADM and HR on 07/16/25 revealed the following: . Employees should never use bare hand contact with any foods, ready to eat or otherwise. The appropriate use of items such as gloves, tongs, deli paper, and spatulas is essential in minimizing the risk of foodborne illness. According to the Food Code, gloves are necessary when directly touching ready-to-eat food. Keep food and food products off the floor . Label, date, and monitor refrigerated food, including, leftovers, so it is used by its use-by date . Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands . Clean and sanitize work surfaces, including . food contact equipment (e.g. blenders .) between uses. Food preparation or service area problems/risks to avoid include: . Handling food with bare hands or improperly handling equipment and utensils; . Aide's Daily Responsibility .10 Sweep and mop area. 17. Complete cleaning assigned tasks. 18. Wipe down walls. 19. Wash Trashcans weekly. 22. Sweep and mop the storeroom daily. Proper Food Labeling and Dating All leftover foods or foods removed from their original containers require proper labeling when stored *Item Identification *Date of Preparation *Date foods are to be used or discarded When to Date At time food is being removed from its original container and placed in another container At time leftover foods are removed from either hot or cold handling and placed in a container . Dry Storage Guidelines All items stored at least 6 inches above the floor . Proper Storage of Leftovers Non-perishable * Reseal, label and date all products * Sealed in airtight manner * Use products with in 'use by' dates stated on original package . *Clearly label food item . Discard expired food promptly . Kitchen Sanitation and Cleaning Schedules All surfaces, including floors, walls, storage shelves, prep tables, trash cans, and all food contact surfaces must be routinely cleaned and sanitized. All equipment must be thoroughly washed and sanitized between uses . Food Storage and Sanitation * Foods are stored at least 6 inches off the floor . * Food removed from its original packaging must be labeled with name of food. *Do not use bare hands to touch read to eat food contact surfaces. Document temperature on appropriate temperature log for all refrigerators and freezers daily. * All opened containers or leftover food is to be tightly wrapped or covered in clean containers. It should be labeled, dated with the opened or use by date. * Dented or otherwise damaged cans will not be used. Once identified, dented cans should be stored in a separate area of the storeroom to be returned to vendor or discarded. Cleaning Schedules * Cleaning schedules are posted at the beginning of each day, week or month in the kitchen depending on the type of schedule. * It is the responsibility of the team member to follow the cleaning schedule and to complete as indicated. Sign the cleaning schedule once task is complete.Record review of facility menus for pureed pork breakfast sausage patty, pureed oatmeal, and pureed scrambled eggs dated 08/26/25 revealed the following: . Wash hands before beginning preparation and sanitize surfaces and equipment.Record review of facility policy titled Hand Washing and dated 10/01/18 revealed the following: . The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition and Foodservice employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness. Hands should be washed after the following occurrences: . k. Touching un-sanitized equipment, work surfaces .Record review of facility policy titled General Kitchen Sanitation and dated 10/01/18 revealed the following: . All Nutrition and Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. 1. Clean and sanitize all food preparation areas, food contact surfaces . 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. 6. Clean non-food contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles . 11. Check restrooms regularly throughout the shift .Record review of facility policy titled Food Preparation and Handling and dated 6/1/19 revealed the following: . To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes . General Guidelines a. Use clean, sanitized surfaces, equipment . c. Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly.Record review of facility policy titled Food Storage and dated 10/01/19 revealed the following: . To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes . Dry storage rooms d. All containers must be labeled and dated.h. Store all items at least 6 inches above the floor . Refrigerators . d. Date, label, and tightly seal all refrigerated foods . e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. h. Temperatures (of refrigerators) should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the refrigerator. Freezers . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.Record review of facility policy titled Handwashing Guidelines for Dietary Employees and dated 07/25/25 revealed the following: . Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Frequency of Handwashing . n. 3. After engaging in any activity that may contaminate the hands.

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #2, Resident #8, and Resident #14) of 12 residents reviewed for accuracy of assessment.1. The facility failed to accurately code Resident #2's oxygen therapy status.2. The facility failed to accurately code Resident #8's tobacco use status.3. The facility failed to accurately code Resident #14's dental status.These failures could place residents at risk of not receiving necessary care and/or consideration.Findings Included:1. Record review of Resident #2's admission record dated 08/25/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, generalized anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), shortness of breath, and acute chronic congestive heart failure (a type of progressive heart disease where both aspects of the heart's pumping mechanism are significantly impaired over a prolonged period resulting in shortness of breath, swelling, fatigue, wheezing, and confusion or forgetfulness).Record review of Resident #2's annual MDS with an ARD of 08/07/25 and completed 08/22/25 revealed a BIMS of 9 which indicated moderately impaired cognition. Resident #2 was not coded as receiving oxygen therapy.Record review of Resident #2's care plan completed on 08/20/25 revealed the following problem: Resident requires PRN oxygen therapy R/T heart failure. This problem area was initiated on 12/28/20. One of the approaches was, Administer oxygen at 2L via Nasal Cannula. Observe oxygen precautions. This approach was initiated on 12/28/20.Record review of Resident #2's active orders dated 08/27/25 revealed the following order with start date of 08/27/25: Nasal Cannula (Continuous): O2 @ 2 L/Min Every Shift Shift 1, Shift 2.Record review of Resident #2's oxygen saturation notes from 07/25/25, 07/31/25, 08/01/25, 08/02/25, 08/05/25 and 08/07/25 revealed she was receiving O2 via NC at 2 lpm.During an observation and attempted interview on 08/25/2025 at 6:28 AM Resident #2 was in bed sleeping wearing O2 via a N/C. Resident #2 was asleep and did not wake to knocking or introduction. During an observation on 08/27/2025 at 7:32 AM Resident #2 was in bed sleeping wearing O2 via a N/C. Resident #2 was asleep and did not wake to knocking or introduction.During an interview on 08/27/2025 at 10:32 AM CCM reviewed Resident #2 annual MDS assessment completed 8/07/25 and reported that Resident #2 was not marked for oxygen use. CCM reported that Resident #2 was not documented on her MAR for oxygen use and that is why she did not mark Resident #2 on her MDS for oxygen therapy. CCM reviewed Resident #2 O2 assessments per request by this surveyor and noted the resident was documented for oxygen therapy for the 7-day look back period for the 8/07/25 annual MDS and stated, I didn't see this. Resident #2 should have been marked for oxygen therapy. I do not know why it was not documented on her MAR's. CCM reported not addressing the residents' needs on an MDS such as respiratory therapy would affect the residents care plan and could affect the resident care and would also affect the facility's reimbursement for care provided which could eventually affect resident care indirectly. CCM reported that the facility used the RAI manual to complete all MDS assessments.2. Record review of Resident #8's admission record dated 08/26/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), flaccid hemiplegia (a type of paralysis characterized by muscles that are weak, limp, and floppy due to a lack of nerve signals) affecting left non-dominant side, and nicotine dependence. The admission record indicated Resident #8 was diagnosed as nicotine dependent on 04/07/23.Record review of Resident #8's quarterly MDS completed 08/25/25 revealed a BIMS of 9 which indicated moderately impaired cognition.Record review of Resident #8's annual MDS completed 02/07/25 revealed he was coded as not using tobacco.Record review of Resident #8's care plan completed on 08/20/25 revealed the following: I want to smoke. I am a safe smoker. This problem area was initiated on 05/26/25. The care plan made no mention of chewing tobacco.Record review of Resident #8's Smoking Risk form completed 04/28/23 revealed he was a safe smoker. The form revealed no mention of chewing tobacco.Record review of Resident #8's Smoking Evaluation completed 05/26/25 revealed he required supervision while smoking. The evaluation made no mention of chewing tobacco.Record review of the smoking list provided to surveyors on 05/25/25 by ADM revealed Resident #8 was not listed as a smoker.During an observation and interview on 08/27/25 Resident #8 was seated in his bed. He stated he smoked and chewed snuff (tobacco) quite a bit. He stated he started both habits after he was admitted to the facility but was not sure when. He stated he had not stopped smoking or chewing tobacco since he started.During an interview on 08/27/25 at 08:54 AM CN stated Resident #8 smoked once every week or two when he arrived at the facility. She stated she was not sure if he smoked any longer.During an interview on 08/27/25 at 10:46 AM CCM stated she was responsible for completing MDS assessments and she was not sure how long Resident #8 had been smoking or why his annual MDS did not code him as using tobacco.During an interview on 08/27/25 at 11:06 AM LVN F stated she had worked for the facility off and on and had been back working for the facility for a year. She stated Resident #8 had been smoking since before she met him. She stated, He prefers dip, but he hardly ever, ever has any to use.During an interview on 08/27/25 at 11:14 AM ADM stated Resident #8 very rarely asks to smoke. She stated she thought he was initially assessed as a smoker when he was admitted to the facility.During an interview on 08/27/25 at 01:04 PM DON stated she did not know how long Resident #8 had used tobacco.3. Record review of Resident #14's admission record dated 08/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, aggressive periodontitis localized moderate (severe, rapid periodontal disease affecting few teeth characterized by significant bone and attachment loss that progresses quickly, requires early and comprehensive treatment involving mechanical debridement, potentially systemic antibiotics, and periodontal surgery to halt destruction and prevent tooth loss), myelodysplastic syndrome (group of blood disorders characterized by abnormal production of blood cells in the bone marrow), and dental caries (cavities). The diagnosis date for aggressive periodontitis was 12/10/24. The diagnosis date for the myelodysplastic syndrome was 07/25/19. The diagnosis date for the dental caries was 02/28/22.Record review of Resident #14's annual MDS assessment completed on 08/25/25 revealed a BIMS of 15 which indicated intact cognition. Section J Health Conditions revealed Resident had mild pain and received pain medication. The pain was coded as rarely interfering with sleep, therapy, and day to day activities. Section L Oral/Dental Status revealed Resident #14 was not coded as having Mouth or facial pain, discomfort or difficulty chewing.Record review of Resident #14's care plan completed 08/20/25 revealed no mention of mouth or dental pain/issues. The care plan stated Resident #14 had complaints of acute pain but did not specify where the pain was located.Record review of Resident #14's EHR under the MISC tab revealed the following:a letter dated 01/22/25 which indicated her dental assistance case had been reviewed and she was found to qualify for assistance.a dental visit report dated 02/25/25 revealed Resident #14 had two teeth extracted and had others that needed to be extracted. She was put on a round of amoxicillin 500 mg 3 times a day for 5 days.an encounter note from an oral and maxillofacial surgeon's office dated 07/07/25 revealed Resident #14 was evaluated for osteonecrosis of her jaw due to cancer treatment drugs she used to take. She was a noted to have exposed bone in her right maxilla and mandible. She was noted to have been seen by oral surgeon and referred for further evaluation due to the extensive nature of her disease. Resident #14 was noted to have pain and an occasional foul taste in her right jaw upper and lower. The encounter note stated, Patient has a 2 cm exposed bone in her right maxilla as well as her right mandible which is necrotic. The oral and maxillofacial surgeon noted he would obtain x-rays from her dentist and call with a date for surgery which is usually excision of for quality bone with primary closure.Record review of Resident #14's progress notes revealed the following notes and corresponding dates: 03/20/25 a note from NP with an order for an oral numbing gel PRN which was to be kept at Resident #14's bedside. 03/23/25 a note which stated Resident #14 complained multiple times of tooth pain. [Resident #14] asked if I knew anything regarding her dentist appointment, I informed her I did not. She had a document with her from 01/22/25 regarding her tooth. I advised [Resident #14] had no information about any dental appointment for her but I would pass on her question to DON [first name of DON]. 04/03/25 at 03:40 PM Made multiple attempts to contact the [name of foundation], which approved [Resident #14] for financial aid. The Dental provider they referred [Resident #14] to has reportedly not been working with the foundation for quite some time. The facility has obtained approval to pay for the dental consult at [name of local dentist], which is pending. 04/03/25 at 04:19 PM [Resident #14] has an appointment at 1 pm on April 8, 2025 at [name of local dentist]. 04/08/25 DON consulted on call facility provider for abt for dental abscess reported by dental provider this shift, new order received clindamycin 300mg PO TID x5 days as well as acidophilus BID x5 days resident aware initial dose given from stat safe at this time. office formulated plan of treatment to be entered into residents chart, new order received for chlorhexidine 0.12% mouth rinse take one capful and swish for 1 minute and expectorate. do not eat or drink for 30 min after swishing. 04/09/25 at 09:36 AM This nurse contacted [sic] [name of local oral and maxillofacial surgeon] per referral from [name of local dentist]. She stated they do not accept patients in this age group. 04/09/25 at 09:52 AM This nurse contacted oral surgeons in [names of larger cities near facility] area and none take adult medicaid [sic] at this time. 04/09/25 at 09:53 AM This nurse contacted superior Medicaid who stated that oral surgeons are not covered under her dental plan. 04/09/25 at 10:00 AM Spoke with [name of NP] regarding update on oral surgeon referral. She stated to speak to [MD] for suggestions for next steps. [MD] will be in facility today and will provide update. 04/09/25 at 02:47 PM This nurse left message with [name of doctor at oncology office]. This explained that dentist was wanted pocket that was in gums to be biopsied and that insurance did not cover oral surgeon and was inquiring to see if Oncologist would be comfortable performing biopsy and treating. awaiting a call back at this time. 04/09/25 05:07 PM Received a call back from [oncologist's] office and stated they can not perform biopsys [sic] of that nature. more information regarding dental situation. This nurse provided all requested information and nurse stated she would speak to the physician and give call back. 04/25/25 12:24 PM Received visit note from [local dentist] regarding patients visit. Follow up with [local dentist] as needed and refer to Dr. [oral and maxillofacial surgeon's name] in [city out of state]. 04/25/25 03:07 PM Message left with [out of state oral and maxillofacial surgeon's] office concerning referral. awaiting a call back at this time. 06/11/25 This social worker placed a call to [oral and maxillofacial surgeon's] office regarding a dental referral to him for a dental referral and a staff member from his office states that the office does not have a dental referral for resident. Social worker will let DON, that [oral and maxillofacial surgeon's] office does not have a dental referral on resident. regards to oral surgery for resident and the phone rang numerous times, but no one answered the phone from his office and there was no prompt to leave a message for the office. Social worker will try to call the office back after lunch and check for the referral to [oral and maxillofacial surgeon's name] for resident's dental needs. 06/18/25 This social worker called the office of [oral and maxillofacial surgeon] in [city out of state], and talked with a staff member regarding surgery on resident's mouth for an abscessed toot by [oral and maxillofacial surgeon]. The staff member told this social worker that [oral and maxillofacial surgeon] will be in the office at 3:30 pm and the staff member will talk with him to check if [oral and maxillofacial surgeon] can help resident with the surgery and if he is not able to assist resident then the staff member stated that he may know a dentist that can assist resident with oral surgery. The staff member states that she will call this social worker back after talking with [oral and maxillofacial surgeon] regarding possible assistance for surgery on resident. assistance on enrolling resident on a dental insurance plan and the representative stated that straight Medicare does not cover dental services and that resident would have to get on Medicare Advantage plan to receive any dental benefits or resident will have to enroll in a private dental insurance plan. The agent then gave the number to the phone number to Area On Aging to talk with a staff member over there regarding some assistance to enroll resident on a private dental insurance plan. This social worker then called the number for Area On Aging phone number and i was then transferred to the phone for a staff member named [name of staff member]. There was no answer at the phone for [name of staff member] and this social worker has left a message for [name of staff member] to call this social worker back on 6-16-25 to assist with dental insurance for resident. 06/25/25 This social worker did fax a doctor referral over to [oral and maxillofacial surgeon] for him to see resident for a dental intervention. in regards to if [oral and maxillofacial surgeon] can see resident for the oral surgery and the staff member did state that [oral and maxillofacial surgeon] can see resident if their office receives a referral from another provider. This social worker then called [local dentist] and asked for their office to send a referral to [oral and maxillofacial surgeon's] office so resident can be seen by [oral and maxillofacial surgeon]. The staff member from [local dentist] states that they can send the referral to [oral and maxillofacial surgeon's] office. This social worker then informed resident that [local dentist] will send a referral to [oral and maxillofacial surgeon's] office for him to see resident. 06/26/25 Resident c/o pain radiating from right Nursing side of jaw to front of jaw. [NP] in facility and assessed resident. new orders to d/c chlorhexadine mouth wash d/t not for long term use. Clindamycin 300mg 1 capsule q8 hours x3 days and acidophilus capsule 1 capsule BID x3 days. 06/30/25 This social worker has made a call to [oral and maxillofacial surgeon's] office to check if a referral has gotten to his office for resident to see [oral and maxillofacial surgeon] for oral surgery. A staff member from [oral and maxillofacial surgeon's] office has checked and states that the office has received the referral from our nursing home and has scheduled a consult for resident to see [oral and maxillofacial surgeon] on 7-7-2025 at 3:15 pm. This social worker has informed resident that she has an appointment on 7-7-2025 to see [oral and maxillofacial surgeon] for oral surgery. Resident voiced understanding. 07/02/25 This social worker called [oral and maxillofacial surgeon's] office and had the billing office run resident's insurance to check if the insurance will pay for the consultation with [oral and maxillofacial surgeon] when resident goes to his office on 7-7-25 for the consult. The staff member in [oral and maxillofacial surgeon's] office states that the insurance will pay for the consultation with [oral and maxillofacial surgeon]. 07/14/25 Social worker checked with resident to see if she saw [oral and maxillofacial surgeon] last Monday on 07-07-25 in [out of state city], for her consult with him in regards to oral surgery and resident states that she did see [oral and maxillofacial surgeon] in {out of state city], and she states that he thinks the problem in her mouth could be the cause of cancer and he is going to talk with the doctor that is following resident and then will schedule oral surgery on resident's mouth, according to resident. 08/06/25 This nurse spoke with [oral and maxillofacial surgeon's] office. Requested visit note again and stated they would fax over. Fax number provided. This nurse inquired about follow up and nurse at [oral and maxillofacial surgeon's] office stated that they are planning on surgery but nothing scheduled at this time. They are obtaining images from previous oral surgeon. 08/19/25 resident continues to c/o oral pain 8/1 O (8 out of 10) after PRN APAP administered as ordered, with significant halitosis noted, [NP] notified new order CBC BMP one time resident informed 08/22/25 Called [oral and maxillofacial surgeon's] office to inquire about scheduling procedure date for the resident. Spoke with a nurse who informed me that [oral and maxillofacial surgeon] was currently in the operating room and unavailable at the moment. Nurse stated she would send him a text message with the inquiry and follow up with me before the end of the day. Provided the nurse with the resident's full name and date of birth , as well as this nurse's personal cell phone number for a return call. Awaiting response. 08/26/25 at 02:57 AM Res complaining of oral pain of 4 APAP given to res. 08/26/25 at 02:29 PM Followed up with oral surgeon's office regarding patient's upcoming procedure. Spoke with nurse for [oral and maxillofacial surgeon], who stated there is currently no update on the procedure date. She reported that she has messaged the physician again and expects a response after he completes surgery, estimated to be around 1600 (4 PM) today. Nurse provided a call-back number, and we are currently awaiting a return phone call from [oral and maxillofacial surgeon] or his office with further information.During an observation and interview on 08/25/25 at 07:40 AM Resident #14 stated she had bone and blood cancer. As she spoke her breath was foul and noticeable from 3 feet away. Resident #14 stated she was in pain all the time due to a pocket with pus and all that in her mouth. She stated she had x-rays in a nearby town and was told by that doctor that the only doctor who could handle her needed surgery was a doctor out of state. She stated the out of state doctor told her he would set a date for surgery, but it had not happened yet.During an observation and interview on 08/27/25 at 07:55 AM Resident #14 stated she regularly told staff about the pain she had in her mouth.During an interview on 08/27/25 at 08:54 AM CC stated Resident #14's mouth pain, has been an issue for a while.During an interview on 08/27/25 at 10:46 AM CCM stated she did not know much about Resident #14's mouth pain. She stated, I know she had been having some. She stated she was not sure why it was not coded on Resident #14's most recent MDS assessment.During an interview on 08/27/25 at 11:06 AM LVN F stated Resident #14's mouth pain has been for a very long time. This poor woman has been dragged through the ropes. We are just waiting on the surgeon to get it together.During an interview on 08/27/25 at 11:14 AM ADM stated she knew Resident #14 had mouth pain.During an interview on 08/27/25 at 01:04 PM DON stated she knew about Resident #14's mouth pain. She stated the pain had been going on for a minute. DON stated the facility took Resident #14 to a dentist and were told to take her to an oral surgeon who sent them to an out of state oral surgeon who took forever and a day to get her in and is now taking forever and a day to get her in for surgery.During an interview on 08/27/25 at 08:54 AM CC stated CCM was responsible for completing MDS assessments and an inaccurate MDS assessment could negatively affect the care and treatment of a resident.During an interview on 08/27/25 at 10:46 AM CCM stated an inaccurate MDS assessment could affect the way things are care planned.During an interview on 08/27/25 at 11:14 AM ADM stated CCM was responsible for completing MDS assessments and an inaccurate care plan could negatively impact the care the resident received. She stated, The MDS tells the full picture of care that should be provided for the resident and helps build the care plan for CNAs. We want it accurate and up to date.During an interview on 08/27/25 at 01:04 PM DON stated CCM was responsible for completing MDS assessments. She stated an inaccurate MDS assessment could cause residents to receive inaccurate care.Record review of facility policy titled Resident Smoking Policy and dated 2024 revealed the following: . 6. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: . J: Health Conditions . Current Tobacco Use . 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period.L: Oral/Dental Status . 1. Ask the resident about the presence of chewing problems or mouth or facial pain/discomfort. Check L0200F, mouth or facial pain or discomfort with chewing: if the resident reports any pain in the mouth or face, or discomfort chewing.O: Special Treatments, Procedures, and Programs . Check all of the following treatments, procedures, and programs that were performed during the last 14 days . Respiratory Treatments C. Oxygen therapy .

Based on observations, interviews, and record reviews the facility failed to provide or obtain from an outside resource, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services for 1 (Resident #14) of 12 residents reviewed for dental issues.The facility failed to obtain oral surgery for Resident #14 timely.This failure could place residents at risk of exacerbated dental issues and/or pain.Findings Included:Record review of Resident #14's admission record dated 08/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, aggressive periodontitis localized moderate (severe, rapid periodontal disease affecting few teeth characterized by significant bone and attachment loss that progresses quickly, requires early and comprehensive treatment involving mechanical debridement, potentially systemic antibiotics, and periodontal surgery to halt destruction and prevent tooth loss), myelodysplastic syndrome (group of blood disorders characterized by abnormal production of blood cells in the bone marrow), and dental caries (cavities). The diagnosis date for aggressive periodontitis was 12/10/24. The diagnosis date for the myelodysplastic syndrome was 07/25/19. The diagnosis date for the dental caries was 02/28/22.Record review of Resident #14's annual MDS assessment completed on 08/25/25 revealed a BIMS of 15 which indicated intact cognition. Section J Health Conditions revealed Resident had mild pain and received pain medication. The pain was coded as rarely interfering with sleep, therapy, and day to day activities. Section L Oral/Dental Status revealed Resident #14 was not coded as having Mouth or facial pain, discomfort or difficulty chewing.Record review of Resident #14's care plan completed 08/20/25 revealed no mention of mouth or dental pain/issues. The care plan stated Resident #14 had complaints of acute pain but did not specify where the pain was located.Record review of Resident #14's EHR under the MISC tab revealed the following:a letter dated 01/22/25 which indicated her dental assistance case had been reviewed and she was found to qualify for assistance.a dental visit report dated 02/25/25 revealed Resident #14 had two teeth extracted and had others that needed to be extracted. She was put on a round of amoxicillin 500 mg 3 times a day for 5 days.an encounter note from an oral and maxillofacial surgeon's office dated 07/07/25 revealed Resident #14 was evaluated for osteonecrosis of her jaw due to cancer treatment drugs she used to take. She was a noted to have exposed bone in her right maxilla and mandible. She was noted to have been seen by oral surgeon and referred for further evaluation due to the extensive nature of her disease. Resident #14 was noted to have pain and an occasional foul taste in her right jaw upper and lower. The encounter note stated, Patient has a 2 cm exposed bone in her right maxilla as well as her right mandible which is necrotic. The oral and maxillofacial surgeon noted he would obtain x-rays from her dentist and call with a date for surgery which is usually excision of for quality bone with primary closure.Record review of Resident #14's progress notes revealed the following notes and corresponding dates: 03/20/25 a note from NP with an order for an oral numbing gel PRN which was to be kept at Resident #14's bedside. 03/23/25 a note which stated Resident #14 complained multiple times of tooth pain. [Resident #14] asked if I knew anything regarding her dentist appointment, I informed her I did not. She had a document with her from 01/22/25 regarding her tooth. I advised [Resident #14] had no information about any dental appointment for her but I would pass on her question to DON [first name of DON]. 04/03/25 at 03:40 PM Made multiple attempts to contact the [name of foundation], which approved [Resident #14] for financial aid. The Dental provider they referred [Resident #14] to has reportedly not been working with the foundation for quite some time. The facility has obtained approval to pay for the dental consult at [name of local dentist], which is pending. 04/03/25 at 04:19 PM [Resident #14] has an appointment at 1 pm on April 8, 2025 at [name of local dentist]. 04/08/25 DON consulted on call facility provider for abt for dental abscess reported by dental provider this shift, new order received clindamycin 300mg PO TID x5 days as well as acidophilus BID x5 days resident aware initial dose given from stat safe at this time. office formulated plan of treatment to be entered into residents chart, new order received for chlorhexidine 0.12% mouth rinse take one capful and swish for 1 minute and expectorate. do not eat or drink for 30 min after swishing. 04/09/25 at 09:36 AM This nurse contacted [sic] [name of local oral and maxillofacial surgeon] per referral from [name of local dentist]. She stated they do not accept patients in this age group. 04/09/25 at 09:52 AM This nurse contacted oral surgeons in [names of larger cities near facility] area and none take adult medicaid [sic] at this time. 04/09/25 at 09:53 AM This nurse contacted superior Medicaid who stated that oral surgeons are not covered under her dental plan. 04/09/25 at 10:00 AM Spoke with [name of NP] regarding update on oral surgeon referral. She stated to speak to [MD] for suggestions for next steps. [MD] will be in facility today and will provide update. 04/09/25 at 02:47 PM This nurse left message with [name of doctor at oncology office]. This explained that dentist was wanted pocket that was in gums to be biopsied and that insurance did not cover oral surgeon and was inquiring to see if Oncologist would be comfortable performing biopsy and treating. awaiting a call back at this time. 04/09/25 05:07 PM Received a call back from [oncologist's] office and stated they can not perform biopsys [sic] of that nature. more information regarding dental situation. This nurse provided all requested information and nurse stated she would speak to the physician and give call back. 04/25/25 12:24 PM Received visit note from [local dentist] regarding patients visit. Follow up with [local dentist] as needed and refer to Dr. [oral and maxillofacial surgeon's name] in [city out of state]. 04/25/25 03:07 PM Message left with [out of state oral and maxillofacial surgeon's] office concerning referral. awaiting a call back at this time. 06/11/25 This social worker placed a call to [oral and maxillofacial surgeon's] office regarding a dental referral to him for a dental referral and a staff member from his office states that the office does not have a dental referral for resident. Social worker will let DON, that [oral and maxillofacial surgeon's] office does not have a dental referral on resident. regards to oral surgery for resident and the phone rang numerous times, but no one answered the phone from his office and there was no prompt to leave a message for the office. Social worker will try to call the office back after lunch and check for the referral to [oral and maxillofacial surgeon's name] for resident's dental needs. 06/18/25 This social worker called the office of [oral and maxillofacial surgeon] in [city out of state], and talked with a staff member regarding surgery on resident's mouth for an abscessed toot by [oral and maxillofacial surgeon]. The staff member told this social worker that [oral and maxillofacial surgeon] will be in the office at 3:30 pm and the staff member will talk with him to check if [oral and maxillofacial surgeon] can help resident with the surgery and if he is not able to assist resident then the staff member stated that he may know a dentist that can assist resident with oral surgery. The staff member states that she will call this social worker back after talking with [oral and maxillofacial surgeon] regarding possible assistance for surgery on resident. assistance on enrolling resident on a dental insurance plan and the representative stated that straight Medicare does not cover dental services and that resident would have to get on Medicare Advantage plan to receive any dental benefits or resident will have to enroll in a private dental insurance plan. The agent then gave the number to the phone number to Area On Aging to talk with a staff member over there regarding some assistance to enroll resident on a private dental insurance plan. This social worker then called the number for Area On Aging phone number and i was then transferred to the phone for a staff member named [name of staff member]. There was no answer at the phone for [name of staff member] and this social worker has left a message for [name of staff member] to call this social worker back on 6-16-25 to assist with dental insurance for resident. 06/25/25 This social worker did fax a doctor referral over to [oral and maxillofacial surgeon] for him to see resident for a dental intervention. in regards to if [oral and maxillofacial surgeon] can see resident for the oral surgery and the staff member did state that [oral and maxillofacial surgeon] can see resident if their office receives a referral from another provider. This social worker then called [local dentist] and asked for their office to send a referral to [oral and maxillofacial surgeon's] office so resident can be seen by [oral and maxillofacial surgeon]. The staff member from [local dentist] states that they can send the referral to [oral and maxillofacial surgeon's] office. This social worker then informed resident that [local dentist] will send a referral to [oral and maxillofacial surgeon's] office for him to see resident. 06/26/25 Resident c/o pain radiating from right Nursing side of jaw to front of jaw. [NP] in facility and assessed resident. new orders to d/c chlorhexadine mouth wash d/t not for long term use. Clindamycin 300mg 1 capsule q8 hours x3 days and acidophilus capsule 1 capsule BID x3 days. 06/30/25 This social worker has made a call to [oral and maxillofacial surgeon's] office to check if a referral has gotten to his office for resident to see [oral and maxillofacial surgeon] for oral surgery. A staff member from [oral and maxillofacial surgeon's] office has checked and states that the office has received the referral from our nursing home and has scheduled a consult for resident to see [oral and maxillofacial surgeon] on 7-7-2025 at 3:15 pm. This social worker has informed resident that she has an appointment on 7-7-2025 to see [oral and maxillofacial surgeon] for oral surgery. Resident voiced understanding. 07/02/25 This social worker called [oral and maxillofacial surgeon's] office and had the billing office run resident's insurance to check if the insurance will pay for the consultation with [oral and maxillofacial surgeon] when resident goes to his office on 7-7-25 for the consult. The staff member in [oral and maxillofacial surgeon's] office states that the insurance will pay for the consultation with [oral and maxillofacial surgeon]. 07/14/25 Social worker checked with resident to see if she saw [oral and maxillofacial surgeon] last Monday on 07-07-25 in [out of state city], for her consult with him in regards to oral surgery and resident states that she did see [oral and maxillofacial surgeon] in {out of state city], and she states that he thinks the problem in her mouth could be the cause of cancer and he is going to talk with the doctor that is following resident and then will schedule oral surgery on resident's mouth, according to resident. 08/06/25 This nurse spoke with [oral and maxillofacial surgeon's] office. Requested visit note again and stated they would fax over. Fax number provided. This nurse inquired about follow up and nurse at [oral and maxillofacial surgeon's] office stated that they are planning on surgery but nothing scheduled at this time. They are obtaining images from previous oral surgeon. 08/19/25 resident continues to c/o oral pain 8/1 O (8 out of 10) after PRN APAP administered as ordered, with significant halitosis noted, [NP] notified new order CBC BMP one time resident informed 08/22/25 Called [oral and maxillofacial surgeon's] office to inquire about scheduling procedure date for the resident. Spoke with a nurse who informed me that [oral and maxillofacial surgeon] was currently in the operating room and unavailable at the moment. Nurse stated she would send him a text message with the inquiry and follow up with me before the end of the day. Provided the nurse with the resident's full name and date of birth , as well as this nurse's personal cell phone number for a return call. Awaiting response. 08/26/25 at 02:57 AM Res complaining of oral pain of 4 APAP given to res. 08/26/25 at 02:29 PM Followed up with oral surgeon's office regarding patient's upcoming procedure. Spoke with nurse for [oral and maxillofacial surgeon], who stated there is currently no update on the procedure date. She reported that she has messaged the physician again and expects a response after he completes surgery, estimated to be around 1600 (4 PM) today. Nurse provided a call-back number, and we are currently awaiting a return phone call from [oral and maxillofacial surgeon] or his office with further information.During an observation and interview on 08/25/25 at 07:40 AM Resident #14 stated she had bone and blood cancer. As she spoke her breath was foul and noticeable from 3 feet away. Resident #14 stated she was in pain all the time due to a pocket with pus and all that in her mouth. She stated she had x-rays in a nearby town and was told by that doctor that the only doctor who could handle her needed surgery was a doctor out of state. She stated the out of state doctor told her he would set a date for surgery, but it had not happened yet.During an observation and interview on 08/27/25 at 07:55 AM Resident #14 stated she regularly told staff about the pain she had in her mouth.During an interview on 08/27/25 at 08:54 AM CC stated Resident #14's mouth pain, has been an issue for a while.During an interview on 08/27/25 at 10:46 AM CCM stated she did not know much about Resident #14's mouth pain. She stated, I know she had been having some. She stated she was not sure why it was not coded on Resident #14's most recent MDS assessment.During an interview on 08/27/25 at 11:06 AM LVN F stated Resident #14's mouth pain has been for a very long time. This poor woman has been dragged through the ropes. We are just waiting on the surgeon to get it together.During an interview on 08/27/25 at 11:14 AM ADM stated she knew Resident #14 had mouth pain.During an interview on 08/27/25 at 01:04 PM DON stated she knew about Resident #14's mouth pain. She stated the pain had been going on for a minute. DON stated the facility took Resident #14 to a dentist and were told to take her to an oral surgeon who sent them to an out of state oral surgeon who took forever and a day to get her in and is now taking forever and a day to get her in for surgery.Record review of facility policy titled Dental Services and dated 7-2025 revealed the following: . It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. 'Emergency dental services' includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. 1. The dental needs of each resident are identified through the physical assessment and MDS assessment processes, and are addressed in each resident's plan of care. Oral/dental status shall be documented according to assessment findings. Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care. Referrals to . or dental provider shall be made as appropriate. 9. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.Record review of an undated facility policy titled Dental Services Referral and Approval Policy revealed only information related to contracted dental services occurring in the facility and nothing related to dental surgery.

Based on observation, interview, and record review the facility failed to ensure each resident received food prepared in a form designed to meet individual needs for 1 (Resident #13) of 12 residents reviewed for dietary needs.The facility failed to prepare Resident #13's pureed diet appropriately.This failure could place residents at risk of aspiration, choking, and/or weight loss.Findings Included:Record Review of Resident #13's admission record dated 08/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia severe (a group of thinking and social symptoms that interferes with daily functioning), unspecified protein-calorie malnutrition (state of inadequate intake of food), dysphagia oropharyngeal phase (swallowing disorder that makes it difficult or unsafe to move food from the mouth to the esophagus), and other dietary vitamin B12 deficiency anemia (a form of anemia that occurs when the body lacks sufficient vitamin B12 due to an inadequate intake of natural sources, such as meat and dairy, or fortified foods).Record review of Resident #13's quarterly MDS completed 08/22/25 revealed no BIMS score as Resident #13 was rarely to never understood. The staff assessment revealed her cognition was severely impaired. Section GG Functional Abilities revealed Resident #13 was dependent across all ADLs except for eating where she required substantial/maximal assistance. Section K Swallowing/Nutritional Status revealed she received a mechanically altered diet while a resident.Record review of Resident #13's care plan completed 08/20/25 revealed the following: Nutrition: . physician/NP diet orders, functional assistance level with eating, swallowing precautions as needed will be maintained until further nutritional evaluation is completed. Resident #13 was noted to have impaired functional abilities r/t severe dementia. One of the approaches to address this problem area was Eating: usual performance: dependent Staff assistance: X 1 Assistive device, if applicable: food separated into bowls. Resident #13 was noted to have a regular puree diet order. The goal for this problem area was I will be offered an appetizing meal . help me avoid choking on food that I cannot eat over the next 90 days. This goal was edited on 08/11/25. One of the approaches regarding this goal was My texture is puree.Record review of Resident #13's active orders as of 08/27/25 revealed the following order:Order start date of 06/05/25 Diet: regular diet Texture: PUREE . Special Instructions: Serve food in bowlsDuring an observation on 08/25/25 at 8:07 AM Resident #13 was seated in the dining room being fed by a CNA from bowls on the table in front of her.During an observation and interview on 08/26/25 at 07:26 AM DA B was taking temps of breakfast foods on the steam table. The breakfast was scrambled eggs, oatmeal, sausage patties, and toast. There were two bowls in a steam pan. One bowl contained a brown, dry, crumbly substance and the other contained a yellow substance that appeared to be the texture of cottage cheese. DA B stated the bowls were the puree diet and she had not added the gravy to the bowls yet.During an observation on 08/26/25 at 07:28 AM DA B asked DA A what liquid to add to the puree. DA A told DA B to add apple juice to the pureed sausage and eggs.During an observation on 08/26/25 at 07:32 AM DA B opened a small plastic, single serve container of apple juice and poured half of it into the bowl of ground eggs and half (approximately 1/4 cup) of it into the bowl of ground sausage. She then heated each bowl in the microwave.During an observation on 08/26/25 at 07:37 AM this surveyor tasted the pureed eggs and found them to be sweet from the addition of the applesauce. The flavor was not appetizing, and the texture was watery with small lumps of egg. This surveyor then tasted the pureed sausage patty. The sausage tasted better than the eggs but was still on the sweet side. The sausage texture was watery with grainy lumps and larger lumps. There was no pureed bread.During an observation on 08/26/25 at 07:49 AM The bowls of pureed food for Resident #13 were placed by DA A on the wrong tray and delivered to the wrong resident.During an observation on 08/26/25 at 07:53 AM DA B began to remake the puree. She placed a serving of eggs in the blender with approximately 1/4 cup of apple juice. DA B ran the blender for about 30 seconds and poured the egg mixture into a bowl.During an observation on 08/26/25 at 07:56 AM DA B rinsed the blender and added a sausage patty and approximately 1/4 cup of apple juice. She ran the blender for about 30 seconds and poured the sausage mixture into a bowl.During an observation on 08/26/25 at 07:58 AM DA B scooped oatmeal from the pan on the stove, added it to a bowl and placed the bowl of oatmeal, pureed eggs, and pureed sausage on a tray to be delivered to Resident #13.During an interview on 08/26/25 at 11:33 AM RD stated pureed food needed to be the consistency of thick pudding or mashed potatoes. She stated correctly pureed food should not fall through and fork and should fall off a spoon in one lump. She stated grainy or watery texture was not correct. RD stated regular oatmeal was not suitable for a pureed diet as it had lumps. She stated the liquid used to puree eggs should be milk or gravy. She stated the liquid used to puree sausage should be broth or gravy. RD stated apple juice was not an appropriate liquid to puree eggs or sausage. She stated water was never an appropriate liquid.During an interview on 08/26/25 at 03:22 AM RD stated if a pureed diet was not the correct texture it could be a choking hazard.During an interview on 08/27/25 at 07:26 AM CNA D stated she fed Resident #13 her breakfast yesterday and Resident #13 ate one hundred percent of her breakfast. CNA D stated Resident #13 did not seem to have any trouble swallowing her breakfast.During an observation on 08/27/25 at 07:42 AM Resident #13 was seated at a table in the DR. CNA D was stirring a sugar packet into the bowls of what appeared to be eggs and sausage in front of Resident #13. The pureed eggs appear to be watery and grainy. The pureed sausage appears to be watery and grainy. The liquid seems to have separated from the eggs and from the sausage. Resident #13 had a bowl of regular oatmeal as well and it appears to be lumpy. Resident #13 did not have pureed bread, though the other residents observed eating in the dining room did have toast with their eggs, sausage, and oatmeal.During an interview on 08/27/25 at 08:54 AM CC stated if a resident with a dietary order of pureed received food that was watery, grainy, or lumpy it could lead to aspiration.During an interview on 08/27/25 at 10:27 AM DA A stated she had worked for the facility as a DA for 3 years. She stated her dining manager was out on medical leave. DA A stated ADM had been in charge of the kitchen operation during his absence. She stated the facility had only 2 residents with pureed diets and one of them was currently in the hospital. She stated she was trained by her first boss on making pureed meals. She stated she was trained to use milk or water as the liquid added to pureed food. DA A stated she was trained more recently to use apple juice or water as the liquid added to pureed food. She stated if a pureed food was not the correct consistency a resident could choke. DA A stated pureed food was supposed to be the consistency of pudding. She stated she trained DA B to use water and apple juice when making pureed food.During an interview on 08/27/25 at 10:37 AM DA B stated she has been working for the facility for 3 weeks. She stated she was not trained to make pureed meals by this facility. DA B stated at her previous job she was trained to use water and a breakfast gravy as the liquid to puree breakfast food and a brown gravy as the liquid to puree lunch or dinner items. She stated pureed food was supposed to be smooth, no chunks. DA B stated pureed food that was not the correct consistency was a choking hazard and might lead to aspiration.During an interview on 08/27/25 at 10:46 AM CCM stated if a resident with a dietary order of pureed received food that was watery, grainy, or lumpy they could choke or get pneumonia, or it could cause an obstruction and/or death.During an interview on 08/27/25 at 11:06 AM LVN F stated a resident with a pureed diet order who received watery, grainy food would not have any issues unless they were ordered to have thickened liquids. She stated if a resident with a pureed diet order was given food with lumps it could cause choking or aspiration.During an interview on 08/27/25 at 11:14 AM ADM stated a resident with a pureed diet order who received food that was not the correct consistency could aspirate. She stated pureed food should be good and smooth like a baby food like texture. ADM stated she did not know why dietary staff did not make pureed bread for Resident #13 as they have bags of puree bread mix and puree pancake mix in the pantry.During an interview on 08/27/25 at 01:04 PM DON stated if a resident with a pureed diet order received watery, grainy, or lumpy food they could choke or aspirate.Record review of an in-service training titled F812 Kitchen Sanitation, Cook/Aide Responsibilities, Cleaning Schedules, RD Inspection, Food Storage, Infection Control, Dish Room provided to DA A and DA C by ADM and HR on 07/16/25 revealed the following: . Meal Service . Follow the recipe. Using incorrect ingredient measurements or changing/omitting ingredients can affect the overall quality or nutritive value of the food .Record review of an in-service provided to DA A and DA B by ADM on 08/27/25 revealed the following: . Employees will have knowledge and understanding on how to blend and prepare items for pureed ordered diets to include portions, consistency, acceptable liquids, and required temperatures. Pureed diet-is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be a smooth and moist consistency (mashed potato, pudding) and able to hold its shape. Pureed recipes are found in the recipe book. The recipe includes the type of liquid and additional ingredients to be used. It is important to pay attention to the type and amount of liquid. This helps ensure the puree food is the correct consistency and provides the appropriate nutrition. Examples of liquids: Milk, broth, gravy, apple juice. Water is typically not used because it will dilute flavors and nutrients in the food. Scrambled eggs do need to be pureed. Puree items on low until a paste consistency and then add the reciped [sic] fluid gradually until a smooth pudding consistency is achieved. If a pureed item is too thick, thickeners can be used . Pureed foods need to be served on a dinner plate for dignity and on in bowls or divided plate. Pureed foods should not be running together on the plate. If this is the case, then it is not the correct consistency. Taste the pureed food. Is it smooth? Does it taste like the regular food item?Record review of facility recipe for pureed pork breakfast sausage patty dated 08/26/25 revealed the following: . Ingredients 1 Sausage Pork Bkft (breakfast) Patty . 1 Tbsp Milk or appropriate liquid . Pureed foods should be soft and smooth without any lumps or visible particles. Liquids should not separate from the solids. Recipe liquid and thickener amounts, if needed, are an estimate only. NOTE: Cooking liquid, broth, gravy or other suitable liquid may be substituted for liquid in recipe with pureeing this food for PU4. Pureed Usually eaten with a spoon (a fork is possible) * Cannot be drunk from a cup because it does not flow easily * Cannot be sucked through a straw * Does not require chewing * Can be piped, layered or molded because it retains its shape . Shows some very slow movement under gravity but cannot be poured * Falls off spoon in a single spoonful when tilted and continues to hold its shape on a plate * No lumps * . Liquid must not separate from solid .Record review of facility recipe titled PU4 Milk or Appropriate Liquid (Milk or Other Appropriate Liquid) and dated 08/26/25 revealed the following: . Entrees - Broth or other appropriate sauce/gravy from menu .Record review of facility recipe for pureed scrambled eggs dated 08/26/25 revealed the following: . Ingredients 1 Tbsp Milk or Appropriate Liquid 1/4 Cup Egg Scrambled . NOTE: Cooking liquid, broth, gravy or other suitable liquid may be substituted for liquid in recipe with pureeing this food for PU4. NOTE: As this food item contains a high percentage of fluid, additional fluid may not be needed. Drain well before pureeing, and once the items in pureed, add additional liquid only if necessary. Thickener may also be needed to achieve the proper consistency for PU4.Record review of facility recipe for pureed oatmeal dated 08/26/25 revealed the following: . Ingredients 1/2 cup Cereal Oatmeal f/Quick Oats 1 Tbsp Milk or Appropriate Liquid . Drain any excess liquid from food. Place prepared recipe portion into a blender or food processor. Blend until smooth. Additional liquid and/or thickener may be needed to ensure puree is smooth, moist and appropriate for PU4.Record review of facility policy titled Puree Food Preparation and dated 08/01/25 revealed the following: . It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. 'Puree' means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding. 1. The facility should provide each resident food that is prepared by methods that conserve nutritive value, flavor, and appearance. 2. Puree foods should be prepared to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes. 3. If the food item requires chewing, it should be excluded from the puree diet and prepared in a way that preserved vitamins and a minimum loss of nutrients. 5. Follow the recipe to prepare puree foods. 7. Examples of items to use to puree foods: . Meats: broth or gravy .

Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #10) of 12 residents reviewed for advanced directives. Resident #10 had a DNR in her record that was missing the date when the physician signed the form. The facility's failure could place residents a risk for not receiving healthcare as per their or their legal representatives wishes.Findings included: Record review of Resident #10's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), malnutrition (lack of proper nutrition), muscle wasting (the loss of muscle mass and strength due to disease, injury, or lack of use), anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and hypertension (a condition in which the force of the blood against the artery walls is too high). During an record review of Resident #10's last MDS was an annual assessment completed [DATE] listing her with a BIMS of 15 indicating she was cognitively intact, and she had a functionality of requiring partial/moderate assistance with most of her activities of daily living. Record review of During a record review of Resident #10's care plan with admission date of [DATE] revealed the following: Problem start date: [DATE].Category: Code Status.I am a DNR. I do not wish to be resuscitated.Edited: [DATE]. Record review of the clinical record for Resident #10 revealed an Order Summary printed [DATE] with the following order: -Code Status: Do Not Resuscitate (DNR). Start Date: [DATE] Record review of the clinical record for Resident #10 revealed a DNR dated [DATE] (signed by Resident #10) with the following:Section - Physician's Statement: The physician signed the form, provided his printed name, and his license number. There was no date of when the physician signed the form. During an interview on [DATE] at 01:24 PM RN E reported the current DNR process for the facility was to check the daily printed list that gives each resident's code status, check the computer, and they can check the residents color coded door. RN E checked his printed sheet and verified that Resident #10 was currently a DNR, then checked the computer and verified again that Resident #10 was a DNR. RN E confirmed if Resident #10 was found without a heartbeat or breathing he would not start CPR. RN E reported that he would also review the DNR in the resident's chart just to be sure. RN E reviewed Resident #10 DNR in her electronic record and noted that the Physician did not date the DNR. When asked if Resident #10's DNR was valid RN E stated, to be honest, I don't know. During an interview on [DATE] at 7:40 AM the DON reported that a resident with a DNR that was not completed correctly would be an issue in that it could be a legal problem that would involve the resident and the family and if a resident died and the nurse could not fallow the residents DNR wishes then that nurse would have to start CPR. The DON reported this would have a negative effect on the resident and the family. During an interview on [DATE] at 8:47 AM the CN reported a DNR that was not completed accurately would definitely be an issue and could possibly result in the improper or not coding of a resident which would affect them negatively. The CN reported that she and the DON were responsible for ensuring that the DNR's are accurately completed and they just missed this one. Record review of the facility provided policy titled Code Status Guidelines undated, revealed no information for completing a DNR accurately. Record review of the facility provided policy titled Advance Directives Available in Texas revised [DATE], revealed no information for completing a DNR accurately. Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, undated revealed the following:- The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professional.

Based on observation, interview, and record review, the facility failed to provide a safe and clean environment for 1 (Resident #9) of 12 residents reviewed for environment. -Resident #9 had a dining tray left in his room for 18 hours. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.Findings include:Record review of Resident #9's face sheet revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include bipolar disorder (a disorder associated with episode of mood swings ranging from depressive lows to manic highs), cognitive communication deficit (difficulty with thinking and how someone uses language), mild intellectual disabilities (a condition that affects a person's intellectual functioning and adaptive skills), mood disorder (any of a group of conditions of mental and behavioral disorder where the main underlying characteristic was a disturbance in a person mood), and vitamin D deficiency (a condition that occurs when the body does not have enough vitamin D which may resulting in bone pain, weakness, cramps, fatigue, and increased risk of falls). Record review of Resident #9's last MDS was a quarterly assessment completed 6/24/25 listing him with a BIMS of 15 indicating he was cognitively intact, and he had a functionality of being independent with most of his activities of daily living. Record review of Resident #9's care plan with admission date of 10/15/24 revealed the following: Problem start date: 8/20/25.Unintended weight gain related to increase access to food/snacks. Problem start date: 10/15/24.Nutritional StatusApproach:Monitor meal % Record review of the clinical record for Resident #9 revealed an Order Summary printed 08/26/25 with the following order: Diet: Regular Diet. Start Dated 6/02/25 During an observation on 08/25/2025 at 7:50 AM Resident #9 was not in his room. Noted on Resident #9's bedside table was his lunch tray from 08/24/25 (Sun-Lunch was printed on the meal ticket left on the lunch tray) with approximately 50% of the food eaten. Noted Resident #9's lunch ticket and a cup placed on top of the plate with food exposed. During an observation and interview on 08/27/2025 at 7:30 AM Resident #9 was observed in his room laying on top of his bed dressed well for the day. Resident #9 did not have a food tray present but was able to verify a tray had been left in his room Monday morning (8/25/25) from the lunch meal delivered on Sunday 08/24/25. Resident #9 stated the staff sometime will leave his tray in his room overnight. When asked if this was an issue Resident #9 shrugged his shoulder and did not respond. During an interview on 08/25/2025 at 7:57 AM this surveyor asked the CN to enter Resident #9's room where she verified Resident #9's meal tray was in his room on his bedside table. The CN verified the meal tray was Resident #9's lunch tray from the previous day and it should not have been left out for Resident #9 to eat because if could be an infection control issue and it could make him sick if he ate any of it. The CN also reported if a confused resident wandered in the room, it could make them sick too. The CN reported floor staff were responsible for delivering hall trays to resident rooms. During an interview on 08/26/2025 at 1:23 PM RN E reported a food tray delivered to a resident's room should be picked up in a timely manner which in his opinion should be within one to two hours. RN E reported a tray left over one to two hours could grow something and place a resident at risk of getting sick if they were to eat it. When asked if a tray left in a resident's room for 18 hours would be considered too long RN E stated, that is much too long. RN E reported the resident in the room could eat something off the tray or a confused resident could enter the room and eat something off the tray and become ill. During an interview on 08/27/2025 at 7:38 AM the DON reported leaving a tray in a resident's room for a period of time was an issue especially if the resident ate it or a confused resident entered the room and ate it. The DON reported the facility had a couple of confused wanderers could possible do that. The DON reported leaving a tray out in a room could result in a food born illness. Record review of the facility provided policy titled, Food Safety Requirements date revised 7/23/25, revealed the following: Policy:. Food will be stored, prepared, distributed, and served in accordance with professional standard for food service safety. Definitions:Food service safety - refers to handling, preparing, and storing food in ways that prevent foodborne illness.Foodborne illness - refers to an illness cause by the ingestion of contaminated for or beverages.Record review further revealed there were no instructions for when a residents meal tray was to be retrieved once the meal was completed. Record review of the facility provided in-service titled Hall Tray started 8/25/25 revealed the following training provided to 18 staff members: Topic: Hall TraysTimely pickup of hall trays after meals is an important aspect of providing quality care in the healthcare or long-term care setting

Based on interview and record review the facility failed to complete a significant change assessment within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for 1 (Resident #7) of 12 residents reviewed for timing of assessments.The facility failed to complete Resident #7's significant change MDS within 14 days of his admission to hospice care on 03/01/25.This failure could place residents at risk of not receiving necessary care/coordination of care.Findings Included:Record review of Resident #7's admission record dated 08/26/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), chronic viral hepatitis C (viral infection the body is no longer able to fight off that causes liver swelling and can lead to serious liver damage), chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), and cirrhosis of the liver (impaired liver function caused by the formation of scar tissue). Resident #7's admission record noted his primary payer as Hospice and listed the name of the hospice company providing his services.Record review of Resident #7's quarterly MDS completed on 06/17/25 revealed he was receiving hospice care While a Resident.Record review of Resident #7's significant change MDS, documenting his change to hospice care, revealed a completion date of 03/21/25.Record review of Resident #7's care plan completed 06/04/25 revealed he was receiving terminal care from hospice. This problem area was initiated on 03/01/25 and the approaches for this area were initiated on 03/03/25.Record review of Resident #7's active physician's orders dated 08/27/25 revealed he was admitted to hospice care on 03/01/25 for COPD.During an interview on 08/27/25 at 08:54 AM CN stated CCM was responsible for completing MDS assessments. She stated a resident's care could be negatively impacted if a significant change MDS was not completed timely.During an interview on 08/27/25 at 10:46 AM CCM stated she was responsible for completing MDS assessments timely. She stated a resident's care could be negatively impacted if a significant change MDS was not completed within the 14 days allotted because the care plan for the resident was based on the MDS assessment. CCM stated she was not sure why Resident #7's significant change MDS was not completed within the 14-day time frame.During an interview on 08/27/25 at 11:14 AM ADM stated CCM and the interdisciplinary team were responsible for MDS assessments. She stated a resident's care could be negatively impacted if a significant change MDS was not completed timely.During an interview on 08/27/25 at 01:04 PM DON stated CCM was responsible for completing MDS assessments. She stated a resident might not get the correct care if their MDS was not completed timely.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed a chart on page 38 with the following: Assessment Type.Significant Change.MDS Completion Date.no later than 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). Significant Change in Status Assessment . Must be completed (item Z0500B) within 14 days after the determination that the criteria are met for a Significant Change in Status assessment.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #14) of 12 residents reviewed for comprehensive care plans.1. The facility failed to include Resident #14's mouth pain and need for oral surgery in her care plan.This failure could lead to residents not receiving needed care and/or receiving improper care/treatment.Findings Included:Record review of Resident #14's admission record dated 08/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, aggressive periodontitis localized moderate (severe, rapid periodontal disease affecting few teeth characterized by significant bone and attachment loss that progresses quickly, requires early and comprehensive treatment involving mechanical debridement, potentially systemic antibiotics, and periodontal surgery to halt destruction and prevent tooth loss), myelodysplastic syndrome (group of blood disorders characterized by abnormal production of blood cells in the bone marrow), and dental caries (cavities). The diagnosis date for aggressive periodontitis was 12/10/24. The diagnosis date for the myelodysplastic syndrome was 07/25/19. The diagnosis date for the dental caries was 02/28/22.Record review of Resident #14's annual MDS assessment completed on 08/25/25 revealed a BIMS of 15 which indicated intact cognition. Section J Health Conditions revealed Resident had mild pain and received pain medication. The pain was coded as rarely interfering with sleep, therapy, and day to day activities. Section L Oral/Dental Status revealed Resident #14 was not coded as having Mouth or facial pain, discomfort or difficulty chewing.Record review of Resident #14's care plan completed 08/20/25 revealed no mention of mouth or dental pain/issues. The care plan stated Resident #14 had complaints of acute pain but did not specify where the pain was located.Record review of Resident #14's EHR under the MISC tab revealed the following:a letter dated 01/22/25 which indicated her dental assistance case had been reviewed and she was found to qualify for assistance.a dental visit report dated 02/25/25 revealed Resident #14 had two teeth extracted and had others that needed to be extracted. She was put on a round of amoxicillin 500 mg 3 times a day for 5 days.an encounter note from an oral and maxillofacial surgeon's office dated 07/07/25 revealed Resident #14 was evaluated for osteonecrosis of her jaw due to cancer treatment drugs she used to take. She was a noted to have exposed bone in her right maxilla and mandible. She was noted to have been seen by oral surgeon and referred for further evaluation due to the extensive nature of her disease. Resident #14 was noted to have pain and an occasional foul taste in her right jaw upper and lower. The encounter note stated, Patient has a 2 cm exposed bone in her right maxilla as well as her right mandible which is necrotic. The oral and maxillofacial surgeon noted he would obtain x-rays from her dentist and call with a date for surgery which is usually excision of for quality bone with primary closure.Record review of Resident #14's progress notes revealed the following notes and corresponding dates: 03/20/25 a note from NP with an order for Orajel PRN which was to be kept at Resident #14's bedside. 03/23/25 a note which stated Resident #14 complained multiple times of tooth pain. [Resident #14] asked if I knew anything regarding her dentist appointment, I informed her I did not. She had a document with her from 01/22/25 regarding her tooth. I advised [Resident #14] had no information about any dental appointment for her but I would pass on her question to DON [first name of DON]. 04/03/25 at 03:40 PM Made multiple attempts to contact the [name of foundation], which approved [Resident #14] for financial aid. The Dental provider they referred [Resident #14] to has reportedly not been working with the foundation for quite some time. The facility has obtained approval to pay for the dental consult at [name of local dentist], which is pending. 04/03/25 at 04:19 PM [Resident #14] has an appointment at 1 pm on April 8, 2025 at [name of local dentist]. 04/08/25 DON consulted on call facility provider for abt for dental abscess reported by dental provider this shift, new order received clindamycin 300mg PO TID x5 days as well as acidophilus BID x5 days resident aware initial dose given from stat safe at this time. office formulated plan of treatment to be entered into residents chart, new order received for chlorhexidine 0.12% mouth rinse take one capful and swish for 1 minute and expectorate. do not eat or drink for 30 min after swishing. 04/09/25 at 09:36 AM This nurse contacted [sic] [name of local oral and maxillofacial surgeon] per referral from [name of local dentist]. She stated they do not accept patients in this age group. 04/09/25 at 09:52 AM This nurse contacted oral surgeons in [names of larger cities near facility] area and none take adult medicaid [sic] at this time. 06/26/25 Resident c/o pain radiating from right Nursing side of jaw to front of jaw. [NP] in facility and assessed resident. new orders to d/c chlorhexadine mouth wash d/t not for long term use. Clindamycin 300mg 1 capsule q8 hours x3 days and acidophilus capsule 1 capsule BID x3 days. 08/26/25 at 02:57 AM Res complaining of oral pain of 4 APAP given to res. 08/26/25 at 02:29 PM Followed up with oral surgeon's office regarding patient's upcoming procedure. Spoke with nurse for [oral and maxillofacial surgeon], who stated there is currently no update on the procedure date. She reported that she has messaged the physician again and expects a response after he completes surgery, estimated to be around 1600 (4 PM) today. Nurse provided a call-back number, and we are currently awaiting a return phone call from [oral and maxillofacial surgeon] or his office with further information.During an observation and interview on 08/25/25 at 07:40 AM Resident #14 stated she had bone and blood cancer. As she spoke her breath was foul and noticeable from 3 feet away. Resident #14 stated she was in pain all the time due to a pocket with pus and all that in her mouth. She stated she had x-rays in a nearby town and was told by that doctor that the only doctor who could handle her needed surgery was a doctor out of state. She stated the out of state doctor told her he would set a date for surgery, but it had not happened yet.During an observation and interview on 08/27/25 at 07:55 AM Resident #14 stated she regularly told staff about the pain she had in her mouth.During an interview on 08/27/25 at 08:54 AM CC stated Resident #14's mouth pain, has been an issue for a while. She stated an inaccurate care plan could potentially affect their (residents') care and treatment. She stated CCM and DON were responsible for care plans.During an interview on 08/27/25 at 10:46 AM CCM stated she did not know much about Resident #14's mouth pain. She stated, I know she had been having some. She stated she was ultimately responsible for care plans. She stated an inaccurate care plan could negatively impact the care provided to the resident.During an interview on 08/27/25 at 11:06 AM LVN F stated Resident #14's mouth pain has been for a very long time. This poor woman has been dragged through the ropes. We are just waiting on the surgeon to get it together. She stated DON was responsible for care plans. She stated an inaccurate care plan could negatively impact a resident's care and treatment depending on what was inaccurate.During an interview on 08/27/25 at 11:14 AM ADM stated she knew Resident #14 had mouth pain. She stated DON and CCM were responsible for care plans. She stated an inaccurate care plan can have adverse outcomes if staff don't know specifically what the issues are and the correct interventions are regarding resident care and treatment.During an interview on 08/27/25 at 01:04 PM DON stated she knew about Resident #14's mouth pain. She stated the pain had been going on for a minute. DON stated the facility took Resident #14 to a dentist and were told to take her to an oral surgeon who sent them to an out of state oral surgeon who took forever and a day to get her in and is now taking forever and a day to get her in for surgery. She stated she and CCM were responsible for care plans. She stated an inaccurate care plan could place residents at risk of not receiving the care they need or how they need it.Record review of facility policy titled Comprehensive Care Plans and dated 7/2025 revealed the following: .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal . preferences . The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. f. Resident specific interventions that reflect the resident's needs and preferences .

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 2 (Resident #2 and #15) of 12 residents reviewed for respiratory care. -Resident #2 did not have orders for her oxygen therapy. -Resident #15 was not receiving oxygen at the correct dose. These failures could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings include: Resident #2Record review of Resident #2's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include history of COVID-19, shortness of breath, diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), dementia (a group of thinking and social symptoms that interferes with daily functioning), myocardial infarction (heart attack), peripheral vascular disease (a circulatory condition in which narrowed blood vessels recue blood flow to the limbs), and rheumatoid arthritis (autoimmune inflammation of the joints). Record review of Resident #2's clinical record revealed her last MDS was an annual completed 8/07/2025 listing her with a BIMS score of 9 indicating she was moderately cognitively impaired, and she had a functionality of being dependent on staff for most of her activities of daily living. Section O-Special Treatments, Procedures, and Programs-Respiratory Programs: Oxygen Therapy-Resident #2 was marked as not having oxygen While a Resident. Record review of Resident #2's Orders printed 8/27/25 revealed the following order:- O2 @ 2 L/Min. Start Date: 08/27/2025 Record review of Resident #2's Medication Administration Record printed 8/26/25 for 7/01/25 to 7/31/25 and 8/01/25 to 8/26/25 revealed no orders for oxygen administration or dosage and no documentation of oxygen administration. Record review of Resident #2's clinical record revealed a care plan with the admission date of 7/20/19, which revealed the following: Problem Start Date: 12/28/2020.Resident requires PRN Oxygen therapy R/T heart failure. During an observation on 08/25/2025 at 6:28 AM Resident #2 was in bed sleeping wearing O2 via a N/C. During an observation on 08/27/2025 at 7:32 AM Resident #2 was in bed sleeping wearing O2 via a N/C. Resident #2 did not wake to knocking or introduction. During an interview on 08/27/2025 at 7:34 AM the DON reviewed Resident #2 clinical records and stated, I can't find an order for her oxygen. I know there used to be one and I know she was on it, but I can't find one in her chart now. The DON reported if a resident was on a medication such as oxygen, then they need an order for the medication and if the resident did not have an order, it could affect the resident's treatment. During an interview on 08/27/2025 at 8:54 AM the CN reported oxygen was a medication, and any medication administered to a resident required a physician order. The CN reported administering a medication without an order can be a legal issue and can affect a resident's condition and their treatment. During an interview on 08/27/2025 at 10:12 AM the CN reported the oxygen order for Resident #2 was inadvertently discontinued due to it was a duplicate. The CN provided a General Order Summary revealing oxygen for Resident #2 was ordered on 9/10/2019 and dc'd on 11/15/2022. The CN stated, I don't know why it has been missed since then. During an interview on 08/27/2025 at 10:32 AM the CCM reviewed Resident #2 annual MDS assessment completed 8/07/25 and reported Resident #2 was not marked for oxygen use on her 7/25 and 8/25 MAR. The CCM reported because Resident #2 was not documented on her MAR for oxygen use, she did not mark Resident #2 on her on the MDS for oxygen therapy. Resident #15 Record review of Resident #15's admission record dated 08/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, COPD (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Record review of Resident #15's clinical record revealed her last MDS was an annual completed 8/21/25 listing her with a BIMS score of 07 indicating she was severely cognitively impaired, and she had a functionality of requiring substantial/maximal assistance with most of her activities of daily living. Section O-Special Treatments, Procedures, and Programs-Respiratory Programs: Oxygen Therapy-Resident #15 was marked as having oxygen While a Resident. Record review of Resident #15's active orders printed 8/27/25 revealed the following order with a start date of 12/27/24: O2 at 2 LPM via NC @ HS. Record review of Resident #15's care plan with admission date of 7/23/25 revealed the following: Problem Start Date: 7/23/25Resident requires oxygen therapy at times due to diagnoses of COPD. During an observation on 08/25/25 at 07:57 AM Resident #15 was lying in bed receiving O2 via NC at 3 lpm. During an observation and interview on 08/25/25 at 08:02 AM Resident #15 was sitting on the side of her bed eating breakfast and receiving O2 via NC at 3 lpm. She stated she was not sure how long she had been using O2. During an observation on 08/26/25 at 09:22 AM Resident #15 was lying in bed receiving O2 via NC at 3 lpm. During an observation on 08/26/25 at 03:32 PM Resident #15 was lying in bed receiving O2 via NC at 3 lpm. During an observation on 08/27/25 at 07:44 AM Resident #15 was lying in bed receiving O2 via NC at 2.75 lpm. During an interview on 08/27/25 at 08:54 AM the CN stated nurses were responsible for setting flow rates on O2 concentrators. The CN stated nurses knew what level to set the O2 flow rate by referring to physician's orders for that resident. The CN stated if a resident had a DX of COPD and received O2 at higher concentrations than ordered it could be a real issue. The CN stated the resident could go hypoxic or have a low blood oxygen saturation. During an interview on 08/27/25 at 10:46 AM the CCM stated nursing staff were responsible to set flow rates on O2 concentrators. The CCM stated, There should be an order to determine what flow rate to use. The CCM stated a resident could be negatively affected by receiving O2 at a different flow rate than ordered. During an interview on 08/27/25 at 10:57 AM CNA D stated nurses were responsible for setting flow rates on O2 concentrators. During an interview on 08/27/25 at 11:06 AM LVN F stated nurses were responsible for setting flow rates on O2 concentrators. LVN F stated the physician's order determined what flow rate to set. LVN F stated if a resident had COPD and received O2 at higher levels than ordered it could negatively affect their respiratory drive and they could stop breathing altogether. LVN F stated she did not know why Resident #15 was receiving O2 at higher rates than ordered. During an interview on 08/27/25 at 11:14 AM the ADM stated nurses were responsible for setting O2 flow rates and they referred to physician's orders to determine the rate. The ADM stated residents could be negatively impacted if they received O2 at different rates than ordered. During an interview on 08/27/25 at 01:04 PM the DON stated nurses were responsible for setting O2 flow rates and they were to set them according to the physician's order. The DON stated if a resident received O2 at higher rates than ordered it can suppress their respiratory drive. Record review of the facility provided policy titled, Oxygen Concentrator date implemented 7/25, revealed the following: Policy Explanation and Compliance Guidelines:2. Oxygen is administered under the orders of the attending physician.4. Use of a concentrator:a. The nurse shall verify physician's order for the rate of flow and route of administration of oxygen.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #29) of 12 residents reviewed for resident rights. Resident #29 was observed with her catheter bag not in a privacy bag. This failure could place resident at risk for feeling uncomfortable, disrespected, and embarrassed leading to isolation. Findings include:Record review of Resident #29's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include major depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and neuromuscular dysfunction of the bladder (the nerves and muscles of the bladder do not work well resulting in the bladder not filling or emptying well). Record review of Resident #29's was a new admission and did not require a MDS assessment to be completed at this time according to the RAI manual. Record review of the care plan with admission date of 8/22/25 for Resident #29 revealed the following: Problem start date: 8/25/25Category: Indwelling Catheter. During an observation on 08/25/2025 at 06:33 AM Resident #29 was in her bed with the light on, her curtain pulled up against the wall, and the door open. Resident #29 could be observed with a shirt on and a sheet covering her midsection. Resident #29's lower thighs and legs were exposed. This surveyor observed Resident #29 attempting to move her catheter bag on the frame of her bed. The catheter bag was not in a privacy bag. The catheter bag was noted to be approximately half full of urine. During an observation from the hallway on 08/25/2025 at 9:08 AM Resident #29 continued to be in her bed with the light on, her curtain pulled up against the wall, and her door open with her catheter bag hanging from the bedframe with no privacy bag. This surveyor observed two residents pass Resident #29 room that could have observed the exposed catheter bag. During an interview on 08/26/2025 at 1:18 PM RN E (the nurse providing resident care this shift) reported all resident catheter bags should be stored in a privacy bag to prevent them from being viewed by visitors and other residents. RN E stated if the catheter bag was stored where it could be viewed it could result in humiliation and degradation for the resident with the catheter and could be gross or disgusting for anyone who viewed the exposed urine bag. During an interview on 08/27/2025 at 7:36 AM the DON reported a urinary catheter bag should be stored off the floor, attached to a bed below the resident's bladder, and in a privacy bag. The DON stated if a resident catheter bag was not stored in a privacy bag it would be a dignity issues. The DON stated, I would not want to walk around and let someone see my urine and I am sure others would not want to see it either. During an interview on 08/27/2025 at 8:45 AM the CN reported a catheter bag should be stored in a privacy bag, off the floor, secured, and below the bladder. The CN reported if the catheter bag was not stored in a privacy bag, then it was a dignity issue for the resident. The CN reported leaving the catheter bag exposed could result in a resident feeling bad about themselves. Record review of facility provided policy titled, Resident Rights Under Texas Law revised 2/22/22, revealed the following: You have the right:6. to privacy. Record review of facility provided policy titled, Promoting/Maintaining Resident Dignity date implemented 7-25, revealed the following: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity.Compliance Guidelines:12. Maintain resident privacy. Record review of facility provided policy titled, Catheter Care date implemented 7-24, revealed the following: Policy: It is the policy of this facility to ensure that resident with indwelling catheter receive appropriate catheter care and maintain their dignity and privacy.Policy Explanations:2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #5) of 3 residents observed for infection control practices. The DON did not wear a gown when performing wound care for Resident #5. This failure could place residents at risk of cross-contamination and infections.Findings include: Record review of Resident #5's clinical record revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include stage 4 pressure ulcer of the sacral region (a sever, full-thickness skin and tissue injury that extends into the muscle, tendo, and ligament, or bone at the base of the spine, below the lumbar vertebrae and above the coccyx (tailbone) and dysphagia (difficulty or discomfort in swallowing). Record review of Resident #5's clinical record revealed his last MDS was a quarterly completed 7/25/25 listing him with a BIMS of 15 indicating he was cognitively intact, he had a functionality of requiring supervision for most of his activities of daily living, and he had an unhealed stage 4 pressure ulcer. Record review of Resident #5's care plan with admission date of 11/06/24 revealed the following: Problem Start Date: 06/05/2025Category: GeneralI require enhanced barrier precautions due to the following:I am at increased risk of a MDRO acquisition due to having a wound. Approach Start Date: 06/05/2025PPE will be available (including gowns/gloves/face shield or goggles) will be available right outside my room, in the shower room. Problem Start Date: 06/05/2025Category: GeneralI require enhanced barrier precautions due to the following: pressure ulcer and colostomy. Approach Start Date: 06/05/2025Staff will wear PPE during high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing, device care or use. Problem Start Date: 05/29/2025I have a colostomy R/T chronic wound infection to buttocks. Record Review of Resident #5's Orders printed 8/26/25 revealed the following order: -Enhanced Barrier Precautions - I have a pressure ulcer and colostomy. Start Date: 6/05/25. During an observation on 08/26/2025 at 09:42 AM the DON performed Resident #5's wound care to his Stage 4 Pressure Ulcer on his coccyx. The DON did not put on a gown at any time during the care. During an interview on 08/26/2025 at 9:56 AM the DON verified she did not put on a gown during the wound care for Resident #5's pressure ulcer on his coccyx. The DON reported this did violate EBP precautions because he had a wound and he had a colostomy. The DON reported not following EBP would result in violating infection control. During an interview on 08/26/2025 at 1:20 PM RN E reported any resident on EBP was on that process to maintain infection control. Anyone with a catheter, wound, or something similar to that should be on EBP which means they should have a station placed outside their room with gowns, gloves, and googles if needed. RN E reported EBP was done to prevent the spread of infection. During an interview on 08/27/2025 at 8:52 AM the CN reported EBP should be utilized with any resident that has a catheter, wound, ostomy, PICC line, of something like that. The CN reported she expects staff to wear the appropriate PPE with any of these procedures. The CN reported if staff do not follow EBP then they violate infection control and can spread infections. Record review of the facility provided policy titled, Enhanced Barrier Precautions date implemented 6/25, revealed the following: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 3. Implementation of Enhance Barrier Precautions:b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.4. High-contact care activities include:h. Wound care: any skin opening requiring a dressing.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety.The facility failed to ensure stored food was properly labelled and dated.The facility failed to ensure dented cans were placed in the specified area to be returned.The facility failed to discard leftover food by use by date on the label.The facility failed to ensure the floor, walls, trashcan, and bathroom of the kitchen were clean and sanitized.The facility failed to ensure food was stored at least 6 inches off the floor.These failures could place residents at risk of food borne illness.Findings included:An observation on 08/25/25 at 05:35 AM revealed a meal trolley outside the door to the kitchen. It was full of dirty dishes and trays with two dirty trays and their dirty dishes sitting on top of the trolley.An observation on 08/25/25 at 05:36 AM revealed the sink next to the dishwasher was full of dirty dishes, pots, and pans and the three compartment sink on the other side of the dishwasher was full of dirty dishes, pots, and pans.An observation on 08/25/25 at 05:37 AM revealed three round, 5-gallon, opaque plastic, lidded containers stacked on top of one another on the floor of the kitchen next to the stand mixer. The bottom container was 1/4 full of yellow substance and labeled Cornmeal 07/17/25 use by 08/17/25. The middle container was 1/2 full of white substance and labeled Sugar 07/17/25 use by 08/17/25. The top container was 1/6 full of white powdery substance and had no label or date.An observation on 08/25/25 at 05:39 AM revealed the kitchen floor around the step-to-open trashcan was littered with white crumbs which were stuck to the floor but could be scraped off using the toe of this surveyor's shoe. The trash can did not have a liner and the inside of the trashcan is smeared. The bottom of the trash can contained crumbs, two individual ketchup packets, and one individual butter packet.An observation on 08/25/25 at 05:40 AM revealed the kitchen floor next to the stove, steam table, and prep table was littered with crumbs and black/brown streaks and smears that were sticky to the bottom of this surveyor's shoes.An observation on 08/25/25 at 05:42 AM of the counter next to the microwave revealed the following:two bags of circular fruit flavored breakfast cereal open to aira bag of cheese sauce mix open to air with no datea banana peeled 1/3 of the way down and open to airAn observation on 08/25/25 at 05:43 AM of the shelving under the microwave counter and the steam table revealed clean steam pans and a scattering of white crumbs.An observation on 08/25/25 at 05:46 AM of the walls next to and behind the oven revealed brown/orange substance splattered from about 6 feet high to the bottom of the walls.An observation on 08/25/25 at 05:48 AM of the prep table reveals a brown/grey smear approximately the size of a dessert plate that is sticky and greasy to touch on the end of the table closest to the serving door.An observation on 08/25/25 at 05:48 AM of the refrigerator and freezer temperature logs revealed the last entry was 08/20/25.An observation on 08/25/25 at 05:51 of the large freezer revealed the following: 1 zip topped plastic bag contained what appeared to be pancakes no label or date 1 zip topped plastic bag contained breaded meat patties no label or date 2 large plastic bags of what appeared to be fried shrimp no label or date 1 plastic bag labeled cookies open to airAn observation on 08/25/25 at 05:55 AM of the walk-in refrigerator revealed the following: 2 individual butter spread containers on the floor 1 unopened, clear plastic bag labeled coleslaw and dated 07/22/25 1 zip topped plastic bag labeled cucumber onion dated 08/21/25 use by 08/24/25 1 large opaque circular tub 1/3 full of what appears to be chopped carrots in liquid no label or date 1 plastic circular opaque tub 1/3 full labeled cream of chicken and dated 08/19/25 use by 08/22/25 1 rectangular, metal, lidded steam table pan 1/2 full of what appears to be oatmeal no label or date 1 zip topped plastic bag labeled Roast dated 08/20/25 use by 08/23/25 1 buffet ham in original packaging dated 07/29/25 1 package of what appears to be round luncheon meat with no label or date. 1 package of sliced ham no date 1 box of bacon open to airAn observation on 08/25/25 at 06:07 AM revealed a round, lidded, plastic tub of chocolate frosting with 1/6th used sitting on the counter next to the coffee maker. Manufacturer's label stated, Refrigerate leftovers for up to 2 weeks.An observation on 08/25/25 at 06:08 AM of the pantry revealed the following: 1 can of apples dented on the side and top seam of the can1 large bag of parboiled rice open to air1 undated box of small macaroni noodles open to air1 zip topped plastic bag with open cheese sauce package inside with no open date1 zip topped plastic bag with open bag of potato chips inside with no open date4 macaroni noodles and lots of crumbs and dirt on the floor behind the pantry door.An observation on 08/25/25 at 06:23 AM of the kitchen bathroom revealed the following: 1 wet spot under the sink the size of a sheet of letter paper, with dirty end of plunger resting in the wet spot toilet bowl was speckled with brown spots yellow stains on underside of toilet seat in a splatter pattern sink drain is broken and lying crookedly in the bottom of the sink sink was stained grey/brown along the top right side floor of bathroom was sticky and stained with brown/black smears walls of bathroom were dirty with grey/brown/black smudges light switch was stained greyish brown and sticky spiderwebs on the shelf above the toilet and on the ceiling An observation on 08/25/25 at 08:43 AM revealed cornmeal, sugar, and third unlabeled tubs still stacked on the floor of the kitchen next to the stand mixer. An observation on 08/25/2025 at 08:43 AM of prep table revealed it still has same smear of grey/brown sticky, greasy substance on the end closest to the DR. An observation on 08/25/2025 at 08:43 AM of kitchen floor revealed it was still littered with crumbs and black/brown sticky smears. An observation on 08/25/2025 at 08:45 AM of the walk-in refrigerator revealed a pitcher of opaque plastic with red lid 1/3 full of white substance no label or date. An observation on 08/25/2025 at 08:47 AM of locked freezer revealed the following:4 cylindrical packages of what appears to be ground meat with no label or date2 turkey breasts with no datebox of bite-sized pieces of what appears to be meat with no label or date open to air.During an observation on 08/26/2025 at 07:32 AM DA B used her right index finger to stir apple juice into ground sausage patty as she prepared puree meal.During an observation on 08/26/2025 at 07:56 AM DA B finished using the blender for one pureed item and used water from the tap to rinse out the blender before reusing it for the next pureed item.During an observation on 08/26/2025 at 08:10 AM DA A used her gloved hand to pick up a half slice of toast and place it on a plate for a resident after touching trays, utensils, and the doorhandle to the walk-in refrigerator.During an interview on 08/25/2025 at 09:09 AM DA C stated he had worked for facility for 2 months. He stated all kitchen staff were responsible for cleaning pantry, kitchen floors, and kitchen bathroom. He stated there was a cleaning log and they communicate with one another to see who does what each shift. DA C stated the bathroom was cleaned at least 3 times a week. He stated all kitchen staff were responsible for labeling and dating food in pantry, freezer, and fridge. DA C stated they were flying by the seat of their pants while DM was out on medical leave. He stated he was not trained on labelling and dating food. DA C stated he managed a kitchen previously and all he needed to know was where the stickers to label and date were kept. During an interview on 08/25/2025 at 09:16 AM DA A stated she had worked for the facility for 3 years. She stated all kitchen staff were responsible for cleaning pantry and kitchen floors. DA A stated they did both things daily. She stated the kitchen bathroom was cleaned by kitchen staff at least 3 times a week. DA A stated she noticed the water under the sink in the kitchen bathroom yesterday. She stated it was often necessary to leave dirty dishes in the tray trolley and dirty dishes, pots, and pans in the sinks overnight due to needing to clock out at 06:00 PM after dinner was served at 05:30 PM. DA A stated whoever puts food in the fridge needs to label it with the day made and the use by date. She stated she was trained on labelling and dating food.During an interview on 08/26/25 at 03:22 PM RD stated residents could be negatively impacted if food was not labeled and dated properly. She stated, A lot of different things could go wrong with that if it is expired or out of date, you wouldn't know.During an interview on 08/27/25 at 10:27 AM DA A stated she had been trained on labeling and dating food at least 6 times in 3 years. She stated if food was not properly labeled and dated it could make residents sick. DA A stated she was trained on sorting canned goods for dented cans when the food truck arrives. She stated residents could be negatively impacted by eating food from dented cans. DA A stated she had been trained on cleaning the floors of the kitchen 10 times. She stated she was never trained on cleaning the kitchen bathroom. Of cleaning the kitchen bathroom, DA A stated, We just do it when we have the chance, and our hours have been cut; we cannot keep up with everything. She stated dirty floors, walls, and kitchen bathroom could make residents sick.During interview on 08/27/25 at 10:37 AM DA B stated she was trained her first three days on labeling and dating food. She stated she was taught to label food with the open date and the use by date. DA B stated leftover food was to be used in 3 days or discarded. She stated all food was to be labeled as it came into the kitchen from the food truck with the date of arrival. DA B stated food that was improperly labeled could affect health of residents. She stated she was not trained to sort canned goods and place dented cans on the specially marked shelf in the pantry. DA B stated regarding cleanliness of the kitchen, I am going crazy here. I want to clean everything. I want to scrape it all with bleach. I just bleached the floors when I just got here. She stated a dirty kitchen could allow bacteria into the food and make residents sick.Record review of posted cleaning duties form hanging in the kitchen revealed 3 of 168 possible items were initialed/dated on 08/22/25. The three initial/dated items revealed counters, fridge, freezers, and storeroom were cleaned.Record review of an in-service training titled F812 Kitchen Sanitation, Cook/Aide Responsibilities, Cleaning Schedules, RD Inspection, Food Storage, Infection Control, Dish Room provided to DA A and DA C by ADM and HR on 07/16/25 revealed the following: . Employees should never use bare hand contact with any foods, ready to eat or otherwise. The appropriate use of items such as gloves, tongs, deli paper, and spatulas is essential in minimizing the risk of foodborne illness. According to the Food Code, gloves are necessary when directly touching ready-to-eat food. Keep food and food products off the floor . Label, date, and monitor refrigerated food, including, leftovers, so it is used by its use-by date . Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands . Clean and sanitize work surfaces, including . food contact equipment (e.g. blenders .) between uses. Food preparation or service area problems/risks to avoid include: . Handling food with bare hands or improperly handling equipment and utensils; . Aide's Daily Responsibility .10 Sweep and mop area. 17. Complete cleaning assigned tasks. 18. Wipe down walls. 19. Wash Trashcans weekly. 22. Sweep and mop the storeroom daily. Proper Food Labeling and Dating All leftover foods or foods removed from their original containers require proper labeling when stored *Item Identification *Date of Preparation *Date foods are to be used or discarded When to Date At time food is being removed from its original container and placed in another container At time leftover foods are removed from either hot or cold handling and placed in a container . Dry Storage Guidelines All items stored at least 6 inches above the floor . Proper Storage of Leftovers Non-perishable * Reseal, label and date all products * Sealed in airtight manner * Use products with in ‘use by' dates stated on original package . *Clearly label food item . Discard expired food promptly . Kitchen Sanitation and Cleaning Schedules All surfaces, including floors, walls, storage shelves, prep tables, trash cans, and all food contact surfaces must be routinely cleaned and sanitized. All equipment must be thoroughly washed and sanitized between uses . Food Storage and Sanitation * Foods are stored at least 6 inches off the floor . * Food removed from its original packaging must be labeled with name of food. *Do not use bare hands to touch read to eat food contact surfaces. Document temperature on appropriate temperature log for all refrigerators and freezers daily. * All opened containers or leftover food is to be tightly wrapped or covered in clean containers. It should be labeled, dated with the opened or use by date. * Dented or otherwise damaged cans will not be used. Once identified, dented cans should be stored in a separate area of the storeroom to be returned to vendor or discarded. Cleaning Schedules * Cleaning schedules are posted at the beginning of each day, week or month in the kitchen depending on the type of schedule. * It is the responsibility of the team member to follow the cleaning schedule and to complete as indicated. Sign the cleaning schedule once task is complete.Record review of facility menus for pureed pork breakfast sausage patty, pureed oatmeal, and pureed scrambled eggs dated 08/26/25 revealed the following: . Wash hands before beginning preparation and sanitize surfaces and equipment.Record review of facility policy titled Hand Washing and dated 10/01/18 revealed the following: . The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition and Foodservice employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness. Hands should be washed after the following occurrences: . k. Touching un-sanitized equipment, work surfaces .Record review of facility policy titled General Kitchen Sanitation and dated 10/01/18 revealed the following: . All Nutrition and Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. 1. Clean and sanitize all food preparation areas, food contact surfaces . 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. 6. Clean non-food contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles . 11. Check restrooms regularly throughout the shift .Record review of facility policy titled Food Preparation and Handling and dated 6/1/19 revealed the following: . To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes . General Guidelines a. Use clean, sanitized surfaces, equipment . c. Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly.Record review of facility policy titled Food Storage and dated 10/01/19 revealed the following: . To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes . Dry storage rooms d. All containers must be labeled and dated.h. Store all items at least 6 inches above the floor . Refrigerators . d. Date, label, and tightly seal all refrigerated foods . e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. h. Temperatures (of refrigerators) should be checked each morning and again on the PM shift. Record the temperatures on a log that is kept near the refrigerator. Freezers . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.Record review of facility policy titled Handwashing Guidelines for Dietary Employees and dated 07/25/25 revealed the following: . Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Frequency of Handwashing . n. 3. After engaging in any activity that may contaminate the hands.

Based on observation, interview, and record review the facility failed to ensure each resident received food prepared in a form designed to meet individual needs for 1 (Resident #13) of 12 residents reviewed for dietary needs.The facility failed to prepare Resident #13's pureed diet appropriately.This failure could place residents at risk of aspiration, choking, and/or weight loss.Findings Included:Record Review of Resident #13's admission record dated 08/26/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia severe (a group of thinking and social symptoms that interferes with daily functioning), unspecified protein-calorie malnutrition (state of inadequate intake of food), dysphagia oropharyngeal phase (swallowing disorder that makes it difficult or unsafe to move food from the mouth to the esophagus), and other dietary vitamin B12 deficiency anemia (a form of anemia that occurs when the body lacks sufficient vitamin B12 due to an inadequate intake of natural sources, such as meat and dairy, or fortified foods).Record review of Resident #13's quarterly MDS completed 08/22/25 revealed no BIMS score as Resident #13 was rarely to never understood. The staff assessment revealed her cognition was severely impaired. Section GG Functional Abilities revealed Resident #13 was dependent across all ADLs except for eating where she required substantial/maximal assistance. Section K Swallowing/Nutritional Status revealed she received a mechanically altered diet while a resident.Record review of Resident #13's care plan completed 08/20/25 revealed the following: Nutrition: . physician/NP diet orders, functional assistance level with eating, swallowing precautions as needed will be maintained until further nutritional evaluation is completed. Resident #13 was noted to have impaired functional abilities r/t severe dementia. One of the approaches to address this problem area was Eating: usual performance: dependent Staff assistance: X 1 Assistive device, if applicable: food separated into bowls. Resident #13 was noted to have a regular puree diet order. The goal for this problem area was I will be offered an appetizing meal . help me avoid choking on food that I cannot eat over the next 90 days. This goal was edited on 08/11/25. One of the approaches regarding this goal was My texture is puree.Record review of Resident #13's active orders as of 08/27/25 revealed the following order:Order start date of 06/05/25 Diet: regular diet Texture: PUREE . Special Instructions: Serve food in bowlsDuring an observation on 08/25/25 at 8:07 AM Resident #13 was seated in the dining room being fed by a CNA from bowls on the table in front of her.During an observation and interview on 08/26/25 at 07:26 AM DA B was taking temps of breakfast foods on the steam table. The breakfast was scrambled eggs, oatmeal, sausage patties, and toast. There were two bowls in a steam pan. One bowl contained a brown, dry, crumbly substance and the other contained a yellow substance that appeared to be the texture of cottage cheese. DA B stated the bowls were the puree diet and she had not added the gravy to the bowls yet.During an observation on 08/26/25 at 07:28 AM DA B asked DA A what liquid to add to the puree. DA A told DA B to add apple juice to the pureed sausage and eggs.During an observation on 08/26/25 at 07:32 AM DA B opened a small plastic, single serve container of apple juice and poured half of it into the bowl of ground eggs and half (approximately 1/4 cup) of it into the bowl of ground sausage. She then heated each bowl in the microwave.During an observation on 08/26/25 at 07:37 AM this surveyor tasted the pureed eggs and found them to be sweet from the addition of the applesauce. The flavor was not appetizing, and the texture was watery with small lumps of egg. This surveyor then tasted the pureed sausage patty. The sausage tasted better than the eggs but was still on the sweet side. The sausage texture was watery with grainy lumps and larger lumps. There was no pureed bread.During an observation on 08/26/25 at 07:49 AM The bowls of pureed food for Resident #13 were placed by DA A on the wrong tray and delivered to the wrong resident.During an observation on 08/26/25 at 07:53 AM DA B began to remake the puree. She placed a serving of eggs in the blender with approximately 1/4 cup of apple juice. DA B ran the blender for about 30 seconds and poured the egg mixture into a bowl.During an observation on 08/26/25 at 07:56 AM DA B rinsed the blender and added a sausage patty and approximately 1/4 cup of apple juice. She ran the blender for about 30 seconds and poured the sausage mixture into a bowl.During an observation on 08/26/25 at 07:58 AM DA B scooped oatmeal from the pan on the stove, added it to a bowl and placed the bowl of oatmeal, pureed eggs, and pureed sausage on a tray to be delivered to Resident #13.During an interview on 08/26/25 at 11:33 AM RD stated pureed food needed to be the consistency of thick pudding or mashed potatoes. She stated correctly pureed food should not fall through and fork and should fall off a spoon in one lump. She stated grainy or watery texture was not correct. RD stated regular oatmeal was not suitable for a pureed diet as it had lumps. She stated the liquid used to puree eggs should be milk or gravy. She stated the liquid used to puree sausage should be broth or gravy. RD stated apple juice was not an appropriate liquid to puree eggs or sausage. She stated water was never an appropriate liquid.During an interview on 08/26/25 at 03:22 AM RD stated if a pureed diet was not the correct texture it could be a choking hazard.During an interview on 08/27/25 at 07:26 AM CNA D stated she fed Resident #13 her breakfast yesterday and Resident #13 ate one hundred percent of her breakfast. CNA D stated Resident #13 did not seem to have any trouble swallowing her breakfast.During an observation on 08/27/25 at 07:42 AM Resident #13 was seated at a table in the DR. CNA D was stirring a sugar packet into the bowls of what appeared to be eggs and sausage in front of Resident #13. The pureed eggs appear to be watery and grainy. The pureed sausage appears to be watery and grainy. The liquid seems to have separated from the eggs and from the sausage. Resident #13 had a bowl of regular oatmeal as well and it appears to be lumpy. Resident #13 did not have pureed bread, though the other residents observed eating in the dining room did have toast with their eggs, sausage, and oatmeal.During an interview on 08/27/25 at 08:54 AM CC stated if a resident with a dietary order of pureed received food that was watery, grainy, or lumpy it could lead to aspiration.During an interview on 08/27/25 at 10:27 AM DA A stated she had worked for the facility as a DA for 3 years. She stated her dining manager was out on medical leave. DA A stated ADM had been in charge of the kitchen operation during his absence. She stated the facility had only 2 residents with pureed diets and one of them was currently in the hospital. She stated she was trained by her first boss on making pureed meals. She stated she was trained to use milk or water as the liquid added to pureed food. DA A stated she was trained more recently to use apple juice or water as the liquid added to pureed food. She stated if a pureed food was not the correct consistency a resident could choke. DA A stated pureed food was supposed to be the consistency of pudding. She stated she trained DA B to use water and apple juice when making pureed food.During an interview on 08/27/25 at 10:37 AM DA B stated she has been working for the facility for 3 weeks. She stated she was not trained to make pureed meals by this facility. DA B stated at her previous job she was trained to use water and a breakfast gravy as the liquid to puree breakfast food and a brown gravy as the liquid to puree lunch or dinner items. She stated pureed food was supposed to be smooth, no chunks. DA B stated pureed food that was not the correct consistency was a choking hazard and might lead to aspiration.During an interview on 08/27/25 at 10:46 AM CCM stated if a resident with a dietary order of pureed received food that was watery, grainy, or lumpy they could choke or get pneumonia, or it could cause an obstruction and/or death.During an interview on 08/27/25 at 11:06 AM LVN F stated a resident with a pureed diet order who received watery, grainy food would not have any issues unless they were ordered to have thickened liquids. She stated if a resident with a pureed diet order was given food with lumps it could cause choking or aspiration.During an interview on 08/27/25 at 11:14 AM ADM stated a resident with a pureed diet order who received food that was not the correct consistency could aspirate. She stated pureed food should be good and smooth like a baby food like texture. ADM stated she did not know why dietary staff did not make pureed bread for Resident #13 as they have bags of puree bread mix and puree pancake mix in the pantry.During an interview on 08/27/25 at 01:04 PM DON stated if a resident with a pureed diet order received watery, grainy, or lumpy food they could choke or aspirate.Record review of an in-service training titled F812 Kitchen Sanitation, Cook/Aide Responsibilities, Cleaning Schedules, RD Inspection, Food Storage, Infection Control, Dish Room provided to DA A and DA C by ADM and HR on 07/16/25 revealed the following: . Meal Service . Follow the recipe. Using incorrect ingredient measurements or changing/omitting ingredients can affect the overall quality or nutritive value of the food .Record review of an in-service provided to DA A and DA B by ADM on 08/27/25 revealed the following: . Employees will have knowledge and understanding on how to blend and prepare items for pureed ordered diets to include portions, consistency, acceptable liquids, and required temperatures. Pureed diet-is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be a smooth and moist consistency (mashed potato, pudding) and able to hold its shape. Pureed recipes are found in the recipe book. The recipe includes the type of liquid and additional ingredients to be used. It is important to pay attention to the type and amount of liquid. This helps ensure the puree food is the correct consistency and provides the appropriate nutrition. Examples of liquids: Milk, broth, gravy, apple juice. Water is typically not used because it will dilute flavors and nutrients in the food. Scrambled eggs do need to be pureed. Puree items on low until a paste consistency and then add the reciped [sic] fluid gradually until a smooth pudding consistency is achieved. If a pureed item is too thick, thickeners can be used . Pureed foods need to be served on a dinner plate for dignity and on in bowls or divided plate. Pureed foods should not be running together on the plate. If this is the case, then it is not the correct consistency. Taste the pureed food. Is it smooth? Does it taste like the regular food item?Record review of facility recipe for pureed pork breakfast sausage patty dated 08/26/25 revealed the following: . Ingredients 1 Sausage Pork Bkft (breakfast) Patty . 1 Tbsp Milk or appropriate liquid . Pureed foods should be soft and smooth without any lumps or visible particles. Liquids should not separate from the solids. Recipe liquid and thickener amounts, if needed, are an estimate only. NOTE: Cooking liquid, broth, gravy or other suitable liquid may be substituted for liquid in recipe with pureeing this food for PU4. Pureed Usually eaten with a spoon (a fork is possible) * Cannot be drunk from a cup because it does not flow easily * Cannot be sucked through a straw * Does not require chewing * Can be piped, layered or molded because it retains its shape . Shows some very slow movement under gravity but cannot be poured * Falls off spoon in a single spoonful when tilted and continues to hold its shape on a plate * No lumps * . Liquid must not separate from solid .Record review of facility recipe titled PU4 Milk or Appropriate Liquid (Milk or Other Appropriate Liquid) and dated 08/26/25 revealed the following: . Entrees - Broth or other appropriate sauce/gravy from menu .Record review of facility recipe for pureed scrambled eggs dated 08/26/25 revealed the following: . Ingredients 1 Tbsp Milk or Appropriate Liquid 1/4 Cup Egg Scrambled . NOTE: Cooking liquid, broth, gravy or other suitable liquid may be substituted for liquid in recipe with pureeing this food for PU4. NOTE: As this food item contains a high percentage of fluid, additional fluid may not be needed. Drain well before pureeing, and once the items in pureed, add additional liquid only if necessary. Thickener may also be needed to achieve the proper consistency for PU4.Record review of facility recipe for pureed oatmeal dated 08/26/25 revealed the following: . Ingredients 1/2 cup Cereal Oatmeal f/Quick Oats 1 Tbsp Milk or Appropriate Liquid . Drain any excess liquid from food. Place prepared recipe portion into a blender or food processor. Blend until smooth. Additional liquid and/or thickener may be needed to ensure puree is smooth, moist and appropriate for PU4.Record review of facility policy titled Puree Food Preparation and dated 08/01/25 revealed the following: . It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. ‘Puree' means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding. 1. The facility should provide each resident food that is prepared by methods that conserve nutritive value, flavor, and appearance. 2. Puree foods should be prepared to prevent lumps or chunks. The goal is a smooth, soft, homogenous consistency similar to soft mashed potatoes. 3. If the food item requires chewing, it should be excluded from the puree diet and prepared in a way that preserved vitamins and a minimum loss of nutrients. 5. Follow the recipe to prepare puree foods. 7. Examples of items to use to puree foods: . Meats: broth or gravy .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #5) of 3 residents observed for infection control practices. The DON did not wear a gown when performing wound care for Resident #5. This failure could place residents at risk of cross-contamination and infections.Findings include: Record review of Resident #5's clinical record revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include stage 4 pressure ulcer of the sacral region (a sever, full-thickness skin and tissue injury that extends into the muscle, tendo, and ligament, or bone at the base of the spine, below the lumbar vertebrae and above the coccyx (tailbone) and dysphagia (difficulty or discomfort in swallowing). Record review of Resident #5's clinical record revealed his last MDS was a quarterly completed 7/25/25 listing him with a BIMS of 15 indicating he was cognitively intact, he had a functionality of requiring supervision for most of his activities of daily living, and he had an unhealed stage 4 pressure ulcer. Record review of Resident #5's care plan with admission date of 11/06/24 revealed the following: Problem Start Date: 06/05/2025Category: GeneralI require enhanced barrier precautions due to the following:I am at increased risk of a MDRO acquisition due to having a wound. Approach Start Date: 06/05/2025PPE will be available (including gowns/gloves/face shield or goggles) will be available right outside my room, in the shower room. Problem Start Date: 06/05/2025Category: GeneralI require enhanced barrier precautions due to the following: pressure ulcer and colostomy. Approach Start Date: 06/05/2025Staff will wear PPE during high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing, device care or use. Problem Start Date: 05/29/2025I have a colostomy R/T chronic wound infection to buttocks. Record Review of Resident #5's Orders printed 8/26/25 revealed the following order: -Enhanced Barrier Precautions - I have a pressure ulcer and colostomy. Start Date: 6/05/25. During an observation on 08/26/2025 at 09:42 AM the DON performed Resident #5's wound care to his Stage 4 Pressure Ulcer on his coccyx. The DON did not put on a gown at any time during the care. During an interview on 08/26/2025 at 9:56 AM the DON verified she did not put on a gown during the wound care for Resident #5's pressure ulcer on his coccyx. The DON reported this did violate EBP precautions because he had a wound and he had a colostomy. The DON reported not following EBP would result in violating infection control. During an interview on 08/26/2025 at 1:20 PM RN E reported any resident on EBP was on that process to maintain infection control. Anyone with a catheter, wound, or something similar to that should be on EBP which means they should have a station placed outside their room with gowns, gloves, and googles if needed. RN E reported EBP was done to prevent the spread of infection. During an interview on 08/27/2025 at 8:52 AM the CN reported EBP should be utilized with any resident that has a catheter, wound, ostomy, PICC line, of something like that. The CN reported she expects staff to wear the appropriate PPE with any of these procedures. The CN reported if staff do not follow EBP then they violate infection control and can spread infections. Record review of the facility provided policy titled, Enhanced Barrier Precautions date implemented 6/25, revealed the following: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 3. Implementation of Enhance Barrier Precautions:b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.4. High-contact care activities include:h. Wound care: any skin opening requiring a dressing.

Based on observations, interviews, and record reviews the facility failed to ensure that the resident's environment remained as free of accident hazards as possible, and that the resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accident hazards. CNA A failed to use a transfer belt while attempting to transfer Resident #1 from the bed to the wheelchair. This failure could place residents at risk of unsafe transfers, resulting in falls, injuries, and a decreased quality of life. Findings included: Record review of Resident #1's clinical records revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a diagnoses which included Unspecified Systolic (congestive) Heart Failure ( a condition of the heart where the heart is weak and the left ventricle cannot contract normally when the heart beats), Urinary Tract Infection, site not specified, Other Abnormalities of Gait and Mobility, Unspecified Dementia, moderate, with Anxiety, Muscle weakness (generalized), Cognitive Communication Deficit (communication difficulty cause by cognitive impairment), Cellulitis of Right Lower limb (Infection of the skin), Pain in unspecified shoulder, Dementia in other diseases classified elsewhere, Unspecified severity, with Other Behavioral Disturbance, Altered mental status, unspecified, Heart failure, unspecified, and Acute Respiratory Failure with Hypoxia (impairment of gas exchange between the lungs and the blood, causing shortness of breath, anxiety and confusion). Resident #1 had a BIMS score of 02, which indicated severe cognitive impairment. Her Morse Fall Scale dated 12/13/2024 revealed a history of falling related to a secondary diagnosis, the use of a walker for ambulation, a weak gate, and an overestimation of her physical limitations. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Resident #1's bed mobility and transfers were extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist. Record review of Resident #1's Care Plan dated 01/02/2025 revealed Resident #1's Problem of ADL Functional Status/Rehabilitation Potential, a Goal of Resident will achieve maximum functional mobility and an Approach of Bed mobility amount of assist: extensive x 1 assist and Transferring amount of assist: extensive x 1 assist. Resident #1's Care Conference Notes indicated Resident #1 needed substantial assistance to both sit up and stand, as her condition was declining, and she received Hospice services. In a phone interview 01/28/2025 at 2:27PM Resident #1's POA revealed she had video surveillance from a [NAME] which had been place in Resident #1's room, prior to her death in the facility on 01/11/2025. The POA stated the video clearly showed an improper transfer being done by CNA A, where she first lifts Resident #1 from a supine (laying on the back) position to a sitting position by lifting her from the back of her neck to aid Resident #1 in sitting up. The POA stated CNA A then helped Resident #1 to a sitting position on the edge of the bed and began to lift Resident #1 by pulling on the resident's outstretched arms, trying to bring Resident #1 to a standing position. The video was reviewed by the state surveyor and the POA's observations proved to be correct. The POA stated Resident #1 was not hurt in any way during the attempted transfer, but the manner in which the transfer was attempted, was concerning. An interview with the Administrator, the DON and the Corporate Nurse on 01/29/2025 at 12:55PM revealed a competency checklist was used by the ADON and DON to evaluate CNA competency in transfers from bed to wheelchair and were to be done using a transfer belt. The administrator stated Resident #1 did not like the transfer belt but was told its use was for her safety. She stated she did not know why CNA A had not used a transfer belt, as was revealed in the supplied video from the resident's POA. Phone interviews with CNA A were attempted on 01/29/2025 at 11:12AM and 1:22PM but were unsuccessful. She was unable to be reached and there was no voicemail set up to request a return call. Record review of the CNA Transfers Competency Checklist read as follows: Before assisting to stand, resident is assisted to a sitting position with feet flat on the floor. Before assisting to stand, apply transfer belt securely at the waist over clothing/gown. Before assisting to stand, provide instructions to enable resident to assist in the transfer including a prearranged signal to alert when to begin standing. Stand facing the resident, positioning self to ensure safety of resident during transfer. Count to three (or say prearranged signal) to alert resident to begin standing. On signal, gradually assist resident to stand by grasping transfer belt on both sides with an upward grasp (resident's hands are in an upward position) and maintain stability by standing knee-to-knee or toe-to- toe with the resident. Record review of CNA A's checklist reflected it was signed by the ADON as competent on 12/26/2024. The ADON was not available for interview.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Resident #19 and #89) of 2 residents reviewed for catheter care in that: Resident #19 was observed several times with his catheter bag not in a privacy bag. Resident #89 was observed several times with his catheter bag not in a privacy bag. This failure could cause residents to feel uncomfortable and disrespected leading to feeling of isolation and deterioration in general health conditions. Findings include: Resident #19 Record review of Resident #19's face sheet revealed he was a [AGE] year-old male resident admitted to the facility originally on 3-1-2023 and readmitted on [DATE] with diagnoses to include cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), Schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), intermittent explosive disorder (repeated sudden outbursts of anger), anxiety (a group of mental illnesses that cause constant fear and worry), long term use of antibiotics, aphasia (loss of the ability to understand or express speech caused by brain damage), acute kidney failure (longstanding disease of the kidneys leading to kidney failure), neuromuscular dysfunction of the bladder (the nerves and muscles of the bladder do not work well resulting in the bladder not filling or emptying well), and cognitive communication deficit (Impaired thought processes). Record review of Resident #19's last MDS revealed a quarterly assessment completed on 6-25-2024 with a BIMS that was not completed because he is rarely/never understood, and he had a functional status of requiring setup or clean up assistance to substantial/maximal assistance with his activities of daily living. Resident #19 is marked as having an indwelling catheter. Record review of the care plan with admitted [DATE] for Resident #19 revealed the following: Problem: Behavioral Symptoms -I become fixated on my catheter. I continue to remove the dignity bag and place the bag in the seat of my wheelchair, which increases my risk of UTI. Approach: -Place dignity bag over catheter bag when resident removes. Problem: Indwelling Catheter -I have a urinary catheter . Approach: - Provide catheter care and change catheter per policy. During an observation on 07-22-2024 at 09:27 AM Resident #19 was in his room listening to music. Resident #19 was dressed well and in a specialized wheelchair. Resident #19 was alert but answered each questioned with Ya. No other response given other than a thumbs up when this surveyor was leaving the room. Resident #19 appeared in good condition with his catheter hanging from the far side of his wheelchair out of view. During an observation and interview on 07-22-2024 at 09:39 AM Resident #19 was in the hallway in his wheelchair with his catheter bag hanging from the right side of his wheelchair with no privacy bag. A small amount of amber urine could be observed in the catheter bag. When questioned if he wanted the catheter bag in a privacy bag Resident #19 stated Ya. During an observation on 07-22-2024 at 09:50 Resident #19 was at the nurse's station with his catheter bag hanging from his wheelchair with no privacy bag. Noted was a small amount of urine present in the catheter bag. This surveyor noted two residents present and 1 staff member present at the nurse's station. During an observation on 07-22-2024 at 12:00 PM Resident #19 was in the dining room sitting at a table with 3 other residents. This surveyor noted that Resident #19's catheter bag could be observed with no privacy bag hanging from his wheelchair. This surveyor noted a small amount of amber urine in the catheter bag. A total of 17 residents were present in the dining room. During an observation on 07-23-2024 08:09 AM Resident #19 was in the dining room finishing the AM meal with 9 other residents present. Resident #19's catheter bag was hanging from his wheelchair without a privacy bag. A small amount of amber urine was observed in the catheter bag. Resident #89 Record review of Resident #89's face sheet revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include heart failure (a chronic condition in which the heart dose not pump blood as well as it should), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urinary dysfunction), obstructive and reflux uropathy, and diabetes. (a chronic condition that affects the way the body processes blood sugar (glucose). Record review of Resident #89's clinical record revealed he had not been in the facility long enough for a MDS to be completed. Record review of the care plan with admitted [DATE] for Resident #89 revealed a baseline/general care plan that was not specific for his catheter care. During an observation and interview on 07-22-2024 at 09:54 AM Resident #89 was observed in his room in his bed with a catheter bag hanging from the side of his bed with no privacy bag. Resident #89 reported no concerns or issues with the catheter or catheter bag and that staff were good about emptying the catheter bag. During an observation on 07-22-2024 12:00 PM, 17 residents were present in the dining room when the first tray was delivered. Resident #19 and Resident #89 were at a table in the middle of the dining room with two other residents present at that table. Residents #19 and #89 had catheter bags present that were not in privacy bags. Small amounts of amber urine could be noticed in each resident's catheter bag. During an observation on 07-22-2024 at 12:46 AM Resident #89 was moved from the dining room in his wheelchair by a CNA to the day area of the facility with his catheter bag hanging from his wheelchair that did not have a privacy bag. [NAME] urine could be observed in the catheter bag. During an interview on 07-23-2024 at 03:29 PM, CNA A and CNA B had just completed incontinent care for Resident #89. Both CNA A and CNA B verified that any resident who has a catheter should have their catheter bag in a privacy bag. CNA A stated, especially when out of their room or in the dining room since that it is a dignity issue and can be an embarrassment for the resident. Both CNA A and CNA B reported that other residents who observed the exposed catheter bags could be affected negatively. CNA A and CNA B reported they were not sure what negative outcomes would be from not placing the catheter in a privacy bag, but they knew it would not be good. CNA A stated that she worked on the hallway that Resident #19 was on during the day shift on 7-22-2024 and stated, I tried to put his catheter in a privacy bag once yesterday, but he just removed it. CNA A verified a second time that she only attempted one time to put Resident #19's catheter bag in a privacy bag. During an interview on 07-24-2024 at 09:29 AM the CRN reported that catheter bags are supposed to be in privacy bags especially when residents are out of their rooms so other residents or visitors do not have to observe the resident's urine. The CRN reported that it could negatively affect the resident with the catheter or residents who observe the catheter by causing embarrassment for the resident with the catheter and affecting residents observing by causing affects like losing their appetites and not being able to eat. Record review of facility provided policy titled, Dignity revised February 2021 revealed the following: Policy Statement: Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist resident; examples are: a. helping the resident to keep urinary catheter bags covered. 48209

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of for 4 of 9 anonymous residents observed for 3 of 3 days and reviewed for quality of life. The facility failed to ensure activities provided met residents' needs or desires. These failures could place residents at risk of boredom and a decline in their quality of life. Findings included: During an observation and interview on 07/22/24 at 10:15 AM, an anonymous resident stated she did not get an activity calendar each month and stated she wished there were more games in the facility. Observation of her room revealed there was no activity calendar. During an anonymous interview on 07/23/24 at 10:00 AM, 4 of 9 residents stated there were few activities provided by the facility, and the activities that were provided were boring. The residents stated they were bored a lot and they only get bingo 2 times a week, on the big screen tv. The residents stated the activities were provided on the tv. Observation on 07/23/24 at 10:45 AM revealed bulletin board in dining room of July calendar of activities. On 07/23/24 at 11:00 AM the activity listed was Tuesday Tea on the lawn. Observation on 07/23/24 at 11:04 AM revealed there were 3 residents on the front patio drinking iced tea with 2 staff members. Observation on 07/23/24 at 2:01 PM revealed residents were in the dining room waiting for bingo to start. Bingo was on an application on the big screen television. Observation of Med Rec/Transport staff struggling to work the bingo application on the big screen tv. During an interview on 07/23/24 at 3:31 PM, the Med Records/Transport staff member stated she was running bingo today because the AA did not come into work, so she was told to fill in by the AD. She stated she did not know what she was doing since it was not her job. She stated she just came from trying to round up residents for the Glam Grandmas, which was an activity that was on the calendar for 3:00 PM, which allowed residents to put on makeup, but no one wanted to participate. She stated she had worked here for 3 months, and the AD was supposed to do activities when the Activity Assistant was not here, but the AD stated she did not have time. During a telephone interview on 07/23/24 at 04:22 PM with family member of an anonymous resident. She stated that it was pitiful that the facility does not engage her family member who has dementia and was completely dependent on staff. During an interview and observation on 07/24/24 at 08:15 AM, anonymous resident stated she had lived in the facility about a month and has been confined to her bed because of an illness. She stated she had never been able to go to activities, and no one had offered her any activities in her room, but she would love to do word puzzles if she could. At 8:20 AM there was no activity calendar observed in anonymous resident's room. During an interview on 07/24/24 at 8:20 AM, anonymous resident stated he does not participate in any activities in the facility because they do not offer anything he was interested in and that he was bored all the time. In an interview on 07/24/24 at 9:27 AM, CNA C revealed the AA was responsible for doing activities. CNA C stated residents will ask her what activities are going on in the facility for the day. During an interview on 07/24/24 at 9:35 AM, the AD stated she and the AA are responsible for making stimulating activities for residents. She stated they are having one on ones at 1:00 PM today in residents' rooms with those who are unable to participate in activities. The AD stated activities should be care planned and that it was the SW's responsibility to put activities into care plans from quarterly assessments. She stated the AA would not be in today until 1:00 PM and the SW was not in today. The AD stated a possible negative outcome for not having stimulating activities would be the resident could become depressed or upset. During an interview on 07/24/24 at 9:51 AM, the ADM stated it was the AD and AA's responsibility for providing stimulating activities to residents and she stated she felt there were enough activities for residents. She stated activities should be care planned and the SW and AD were responsible for that. She stated a negative outcome for not having stimulating activities could be depression. Interview and observation on 07/24/24 at 10:21 AM, the AD handed surveyor a folder containing Activities Assessments. The AD stated these were the activity assessments for each resident. Observation of folder did not contain quarterly activity assessments for all residents. During an interview on 07/24/24 at 10:26 AM, the ADM stated she did not know why the activity assessments were not in the care plans and to ask the AD about it. During an interview on 07/24/24 01:08 PM, the AA stated it was her and the AD's responsibility to make the activity calendar each month. She stated she was doing the one on one's activity right now where she goes around to different rooms to see if anyone needs anything. She stated every resident gets a calendar for their room every month. She stated activities should be care planned so that everyone knows what stimuli the resident needs. Observation on 07/24/24 at 01:15 PM of AA coming out of employee break room and going outside to smoking area during facility planned activity of one on ones' from 1:00-2:00 PM. Record review on 07/24/24 of clinical records for 4 anonymous resident's care plans. No documentation of activities in care plans were noted. Record review of facility policy titled Comprehensive Care Plans and dated 01/26/24 revealed the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. . f. Other appropriate staff or professional in disciplines are determined by the resident's needs or as requested by the resident Examples include, but are not limited to: .ii. Activities director/Staff - responsible for Activity Care Plan . Record review of facility policy titled Resident Rights and dated February 2021 revealed nothing about activities.

The facility failed to ensure stored food was properly labeled and dated. This failure could put place Residents at risk for foodborne illness. Findings Included: Observation of pantry #1 on 7/22/24 at 9:17 am revealed 1 bag of ground cinnamon with no date. Observation of pantry #1 on 7/22/24 at 9:18 am revealed 1 large container of food thickener with a date of 10/25/22. Observation of pantry #1 on 7/22/24 at 11:08 am revealed 1 box of chili mix with no date. Observation of pantry #1 on 7/22/24 at 11:08 am revealed 2 bags of turkey gravy with no date. Observation of kitchen counter on 7/22/24 at 9:30 am revealed 3 containers of cereal with no label or date. Observation of refrigerator #2 on 7/22/24 at 9:23 am revealed 1 bag of sliced watermelon with no label or date. During an interview on 7/23/24 at 9:40 am, the DM stated all kitchen staff are responsible for safe food storage per their policy. The DM stated all items must be labeled and dated. The DM stated the negative outcome for not practicing food storage would be contamination. During an interview on 7/23/24 at 9:54 pm the [NAME] stated kitchen staff are to follow facility policy for proper food storage. The [NAME] stated a negative outcome for residents would be contamination and food poisoning. Record review of the facility's food service policy, dated 2018, addressed proper dating and labeling of food items and how to store dry goods appropriately. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. Date, label and tightly seal all refrigerated foods using clean nonabsorbent covered containers that are approved for food storage.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in accordance with State and Federal laws in locked compartments for 1 (600 hall cart) of 1 medication carts reviewed for medication storage. The facility failed to lock the medication cart on hall 600. This failure could place residents at risk for obtaining medications not prescribed to them and experiencing adverse reactions. Findings included: During an observation on 06/25/24 at 9:54 AM the medication cart in hall 600 was unlocked. All three drawers were easily opened and full of what looked like topical medications. A resident was awake and seated in his wheelchair in his room in line of sight of the medication cart. No staff members were in sight. During an interview and observation on 06/25/24 at 9:55 AM CNA A opened the top drawer of the 600 hall cart and stated if a medication cart was left unlocked someone could take medications, either residents or staff, and it would be bad for that to happen. During an observation on 06/25/24 at 10:02 AM of 2 nurses, Wound care nurse and RN B, coming back to the medication cart on hall 600 which had been left unlocked and abandoned for almost 10 minutes. During an interview and observation on 06/25/24 at 10:03 AM the Wound Care nurse stated she was a nurse practitioner who worked at the facility as their wound care nurse. The Wound Care nurse opened unlocked drawer of the 600 hall cart. The Wound Care nurse stated the cart was unlocked but it only held medications that were for topical wounds only. She stated the cart was normally locked and a possible negative outcome would be a resident could get into the supplies and take them. During an interview on 06/25/24 at 10:05 AM RN B Charge Nurse stated that the medication cart is normally locked. He stated that if a medication cart is not locked that someone could get into the cart and get things that are not theirs and a poor outcome could be a result. Record review of facility policy titled Storage of Medications and dated November 2020 revealed the following: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. .1. Drugs and biologicals used in the facility are stored in locked compartments . .6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on interviews, observations, and record reviews, the facility failed to ensure that the residents are free from accidents and hazards for 1 (Resident #1) of 5 residents reviewed for mechanical lift transfers. LVN A failed to prevent accidents and hazards with Resident #1 from injury and harm by not following mechanical lift standards of a two person assist resulting in severe injuries of a 10+ centimeter laceration on the head revealing skull, a laceration on the hand, and a fractured C1 vertebrae. This failure could affect residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, subdural hematomas, and death. An Immediate Jeopardy (IJ) was identified on 11/07/2023 at 2:43 PM. While the immediate jeopardy was lifted on 11/08/2023 at 2:55 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and scope of isolated, due to the facility's need to evaluate the effectiveness of their corrective systems. Findings Included: Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included but are not limited to unspecified dementia, dysuria, muscle weakness (generalized), other reduced mobility, cognitive communication deficit, need for assistance with personal care, and difficulty in walking. Record review of Resident #1's MDS, dated [DATE], revealed a BIMS score of 04 that indicated severe cognitive impairment. Resident #1 did not display behaviors. Resident #1 was scored as followed for functional status: Bed mobility and transfer (extensive assistance with 2+ person assist) and Locomotion on/off unit, dressing, and personal hygiene (extensive assistance with 1 person assist). Record review of Resident #1's care plan, revised 11/07/23, revealed history of falls with fracture to C1 vertebrae, required the use of a Hoyer lift for transfers with an approach of 2 staff to assist resident with the use of the lift, incontinent of bowel and bladder, and required assistance with all activities of daily living. Record review of written statement by LVN A, dated 11/04/23, confirmed LVN A was aware that two people are required to assist with lift. LVN A indicated Resident #1 was residing in the lift when CNA F went across the hall to answer a call light. LVN A stated all clips were intact, and lift was placed at an angle not too far from the bed. The resident was lifted to an acceptable level and was lowered to bed. LVN A stated the lift came forward and the resident fell forward to the floor. LVNA stated the resident must have hit the edge of the lift as the sling was still intact. LVN A yelled for CNA F, CNA F entered, and CNA I called 911. LVN A indicated pressure was applied to Resident #1's head, Resident #1 was on back. LVN A stated when ambulance arrived, EMS took over. Arms and legs were checked and no complaints, only to head. LVN A indicated resident was positioned where pressure could be applied, and level of consciousness could be checked. Record review of written statement by CNA F, dated 11/4/23 revealed that CNA F stated she left Resident #1's room to go to another room and left LVN A with resident, Resident #1 was residing in wheelchair. CNA F stated she verbalized to LVN A she would be right back. CNA F indicated when she finished assisting the other resident, she had exited that room, and saw the light to Resident #1's room was on. CNA F stated she opened the door to a lot of blood. LVN A verbally stated to CNA F that resident came out of sling. CNA F went into hall, said a nurse was needed, bring the cart, and call 911. One nurse heard CNA F and nurse came down with the cart. The ambulance came quickly. She stated staff was looking for something to apply pressure to the resident's injury and a sheet was grabbed off the bed. CNA F indicated resident was awake and asked about pain. CNA F noticed resident had a right-hand skin tear, tear on right side of head above the temple, and skin tear on the head. CNA F identified blood on the wheels, and they were cleaned off with wipes due to the amount. CNA F ran up the hall and obtained a packet to give to EMS. She stated she gave EMS the packet and later went back to change the trash and clean the room. CNA F stated this was a really bad accident. CNA F stated there are to be two people when using the lift. There was no verbal indication if CNA F was aware that LVN A would attempt the transfer independently or confirmed if she heard LVN A yelling for help. Record review of the FRDT notes, dated 11/4/23, revealed the facility staff indicated the patient fell out of a lift swing while being transferred to bed. Record stated the patient fell face first on her head causing the head wound, they denied the patient hitting anything else. Further review revealed the Resident #1 had a large laceration on left side of her head with head bleeding controlled, end of nose swollen and red. Wound on head was dressed with 4x4 and curlex wrap, right hand skin tear dressed. Medical necessity indicated to admit to hospital, bed confined, hemorrhage, history of falls, possible fracture, reduced mobility, stretcher. Record review of HSPT B face sheet, dated 11/4/23, revealed Resident #1's admitting diagnosis was a C1 cervical fracture. History and Physical under final report indicated review of imaging demonstrated cervical spine fracture involving C1. Assessment/Plan reveled diagnoses of dementia, fall, laceration of scalp, C1 cervical fracture, VTE prophylaxis. Record review of HSPT B neurosurgery report an assessment/plan dated, 11/04/2023, indicated Resident #1 had a C1 fracture and was mechanically neurologically stable. Report indicated Resident #1 can continue to be in Miami J collar and can follow-up in 4 to 6 weeks with a CT CAT scan of the cervical spine in clinic. Record review of HSPT A, dated 11/7/23, revealed Resident #1 was admitted to HSPT A on 11/4/23 at 14:52 PM. Diagnoses list reveals description as an Avulsion of Scalp Initial Encounter (rare injury where the scalp and hair are torn away from the body). Record indicated that mode of arrival was by ambulance and was unaccompanied. Resident was noted as being alert and CT scan ordered for Resident #1 and CT scan proved wound to be a 10 plus cm diameter scalp avulsion with skull exposed. Skin assessment read, the location was the scalp, side of the face and hand(s). The laceration was 10 centimeters in length. No foreign body was identified. There was no distal capillary refill deficit, distal pulse deficit, distal sensory deficit or distal motor deficit. Page 5 revealed under disposition management that patient care management was not discussed .with any outside entities. The patient was considered for hospitalization or escalation of level of care. Needed higher level of care no surgery here. Page 8 stated, under INJURY title; The patient presented with an injury that was report from [NAME] EMS. In an observation on 11/07/23 at 10:48 AM, Resident #1 was observed lying in bed in lowest position with fall mat on floor. Resident #1 was sleeping heavily, covered with blankets, and a green cervical collar around neck. In an observation on 11/07/23 at 2:07 PM, Resident #1 was lying in bed with cervical collar in place, bed in lowest position and fall mat in place. Observed bruising to right side of face in different stages, laceration containing two staples above left eye, laceration on left side beginning at temple area and moving up to the middle of the forehead and back donning multiple staples. In an interview on 11/06/2023 at 5:37 PM, the CMPT indicated that they were not able to get information about the resident. CMPT made a call to the facility and unknown staff answered and stated they were unable to tell how far Resident #1 fell but they fell forward out of the mechanical lift. Resident #1 had a head laceration that measured approximately the length of a pen, semi-circular like half of a grapefruit, and was able to be lifted, revealing skull. CMPT stated due to the extent of the injuries, Resident #1 needed a higher level of care and was transferred to HSPTL B. CMPT stated the injuries of the head laceration and the fractured C1 vertebrae are not compatible to the injuries Resident #1 sustained during the fall. In an interview on 11/7/23 at 10:28 AM, LVN B indicated CLNS contacted LVN B by telephone. after the incident. regarding two person assists with mechanical lift and it was emphasized. Stated a negative outcome is somebody could die or not get proper care. In an interview on 11/7/23 at 10:48 AM, CNA C stated she has been employed at the facility since October 2023. CNA C stated she received training on mechanical lifts during orientation. CNA C stated she had not witnessed one person transfers with mechanical lifts. She stated a negative outcome could be bad things. It could have been a lot worse. In an interview on 11/7/23 at 11:45 AM, CNA C stated a negative outcome of two people not assisting with the mechanical lift could be the person could fall and get hurt. In an interview on 11/7/2023 at 11:19 AM, CNA D stated that she received an in-service and training from CLNS and to make sure two people operated the lift. CNA D stated that a negative outcome could be resident and staff can get hurt. In an interview on 11/7/23 at 11:46 AM, CNA D indicated a negative outcome of two people not assisting with the mechanical lift could be an injury, aide can get in trouble, and the facility could get in trouble. In an interview on 11/7/23 at 11:33 AM, RN E indicated CLNS contacted to provide phone training on using lift. CLNS emphasized that there always needs to be two people. In an interview on 11/7/23 at 11:48 AM, CLNS indicated that she was called by the ADM. The ADM conveyed that LVN A transferred a resident alone and knew it needed to be reported higher. CLNS stated CNA F reported she was in room with LVN A to do transfer, a call light went off across the hall, and CNA F told LVN A to wait until finished with need for room with call light. CNA F reported that after exiting, the call light was on and upon entering room, Resident #1 was on the floor with blood. CLNS indicated was made aware of an incident at 2:35 PM on 11/4/23 and was on a call with both ADM and LVN A (time not obtained). CLNS stated she left for facility immediately. CLNS indicated no in-service was completed for a fall as it was not viewed as a fall. CLNS indicated did do an abuse, neglect, and exploitation in-service. CLNS stated phone attestations were obtained regarding lift to be done with two people in the room to check straps. CLNS indicated that both CLNS and ADM inspected the mechanical lift and slings and concluded there was no malfunction. CLNS stated a negative outcome could be death, subdural hematoma, fracture, and lacerations. In an interview on 11/7/23 at 12:01 PM, ADM indicated learned of incident on 11/04/2023 at 2:23 PM. ADM called and talked to CLNS and HRC regarding incident. ADM stated that LVN A contacted ADM. ADM stated that CNA F and LVN A were both in the room as there was supposed to be two people. ADM stated that CNA F indicated she went across the hall to answer a call light. When CNA F exited room across the hall, CNA F reported to ADM that the call light was on and rang the bell. ADM reported that CNA F stated walked into room and saw blood everywhere. LVN F reported to ADM that help was yelled down the hall for help and to call 911. ADM indicated took pictures of sling and mechanical lift used with Resident #1 during the incident. ADM indicated that LVN A was suspended. ADM stated she felt the accident could have been avoided. ADM stated a negative outcome could be significant injury. ADM also indicated that LVN A had provided a written statement of the incident. In an interview on 11/7/23 at 1:58 PM, ADM stated that LVN A was hired as a nurse. In an interview on 11/7/23 at 2:02 PM, CLNS indicated that staff was not trained on specific equipment. CLNS stated she was unsure if AGNY trained for specific equipment. CLNS provided training packet for agency nurses located at the nurse's station and stated she would attempt to get AGNY training for LVN A. In an interview on 11/7/23 at 2:09 PM, CLNS stated ADM had not received training for LVN A from AGNY. Record of review of Agency Orientation Guidelines for agency nurses, obtained 11/7/23, undated, does not have guidelines or orientation regarding mechanical lifts. Record review of Employee Corrective Action Form, dated 11/4/23, revealed LVN A was to be suspended pending investigation. An interview on 11/9/23 at 8:51 AM, LVN A recalled the incident. LVN A stated CNA F was in room but left. LVN A cannot recall why she left. LVN A stated putting all 6 straps on lift but does not remember how it was placed on Resident #1. LVN A does not remember if the last two straps, located at the bottom of the sling, were crossed between resident legs or not. LVN A stated when turning Resident #1 to bed was when Resident #1 fell out of the sling. LVN A stated the mechanical lift was moved and called for CNA F. CNA F arrived shortly after as she was with resident next door. CNA F yelled for CNA I to call 911 and they (EMS) got to the facility quickly. LVN A stated that two people are to operate the lift. LVN A stated she has not done a lift transfer since she was a CNA and stated the ADM said if it was a lift, two people are to be present. On 11/7/23 at 2:43 PM, the ADM was notified that an Immediate Jeopardy had been identified, IJ templates were provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted on 11/7/23 at 5:22 PM and indicated: It is alleged that the facility failed to ensure that the residents are free from accidents and hazards due to LVN A failing to use a two person assist on a mechanical lift resulting in severe injuries to a resident. Need for Immediate Action: The IJ documentation provided to the facility on [DATE] states: The facility failed to ensure that the residents are free from accidents and hazards. In a stand-alone incident, one LVN attempted to transfer a resident with a mechanical lift independently on 11/04/2023 at approximately 2:30 PM. As a result, the resident fell out of the sling and obtained severe injuries. These injuries lead to emergency services transporting the patient to local hospital and then to a higher level of care due to the severity of the laceration. The resident had injuries of a head laceration measuring 10+ centimeters requiring staples, a laceration to the hand, and a fractured C1 vertebrae. In a written statement and interview by LVN A confirms that lifts require a two person assist. Facility Plan of Removal states: Resident was assessed and sent to the hospital for further evaluation. Charge nurse (agency) who allegedly made an improper hoyer lift transfer has been suspended pending the investigation. All care plans for resident reviewed to ensure correct transfer information is available for staff that may transfer a resident. Staff, including facility and agency that may transfer a resident have been educated in all aspects for safe transfers related to hoyer transfers (at minimum 2x person assist). Education will include minimum number of staff required for a hoyer transfer and will be provided prior to next shift. Staff, facility and agency, that may transfer a resident have been educated where to find information, what transfer a resident is, and how many staff member will need to assist the resident with their transfer. All staff will be trained prior to next shift. Hoyer and hoyer slings were inspected by the administrator and Regional Nurse Manager to ensure they were in good/working condition. Regional Nurse Manager will observe a minimum of 5 transfers a week for 4 weeks to ensure appropriate and safe transfer. An Ad hoc QAPI was performed with Medical Director regarding the facilities plan of action as a result of the self-identified deficient practice. Monitoring of the Plan of Removal Included: An interview on 11/8/23 at 1:14 PM, AGST J stated LVN A had been suspended and disabled from the platform. Interviews on 11/8/23 from 12:51 PM to 3:17 pm, 12 direct care staff (7 CNA's, 1 RN, and 4 LVNS) and 1 agency staff (1 CNA) members stated they had received training on proper use of a mechanical lift, abuse/neglect, and records either via in-service at the facility or via phone. In an interview on 11/8/23 at 2:43 PM, interview with MD revealed he was notified of injury on 11/4/23. MD stated the Ad hoc QAPI meeting occurred and was able to sign paper and fax it back. MD stated CLNS and ADM were planning on remediation and training. MD indicated knew Resident #1 was transferred to HSPTL B and feels Resident #1 received adequate care as MD knew of hospitalist on case. MD stated he was O.K. with plan of action with ADM and CLNS. An interview on 11/9/23 at 1:46 PM with LVN K revealed training was provided the night of 11/4/2023 when arrived for PM shift and an in-service was signed. LVN K stated that she came in the night of the incident, 11/04/2023, and was provided an in-service on mechanical lifts and abuse and neglect. Record review of Resident #1 hospital records, dated 11/4/23, from HSPT A and HSPT B revealed Resident #1 visited the emergency room in one entity and was transported and admitted to second entity. Written statements provided by LVN A and CNA F relayed assessing the resident prior to emergency services arriving by ensuring consciousness and applying pressure to wound on scalp. Record review of Employee Corrective Action form, dated 11/4/23, revealed LVN A suspension with signature of ADM and LVN A. Record review of invoice provided by AGNY, dated 11/7/23, revealed LVN A worked 2 shifts with last one being on 11/4/23 from 6:00 AM to 5:45 PM Record review of mechanical lifts and abuse prevention program in-service, dated 11/4/23, revealed 14 direct care staff signatures. Record review of accessing resident ADL needs via Resident profile on MatrixCare Point of Care, dated 11/5/23, revealed 12 direct care staff signatures. Record review of Competency Assessment: Lifting Machine, Using A Mechanical, dated 11/5/23-11/7/23, revealed a competency review of general guidelines, steps in the procedure, whether the competency was demonstrated correctly or not and if instruction was needed for competency area. The assessment was completed for 17 direct care staff (8 CNA's, 5 LVN's, 1 TCNA, 3 RN's). Record review of statement by ADM, dated 11/4/23, revealed ADM assessed and checked lift and transfer sling utilized during incident and found the items to be in good, working condition. Record review of Ad hoc QAPI meeting minutes, dated 11/4/23, revealed MD, ADM, and CLNS signatures dated 11/4/23. Record review on 11/8/2023 of resident's care plans that utilized mechanical lifts, were reviewed for use of mechanical lift requiring two+ person assist. An Immediate Jeopardy (IJ) was identified on 11/7/23 at 2:43 PM. While the IJ was lifted on 11/8/23 at 2:55 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 of 5 residents (Resident # 1) reviewed for medications. The facility failed to ensure Resident #1's hospital discharge medication orders were followed for insulin from his admitted [DATE] until he was found unresponsive and sent to the hospital on [DATE]. Resident #1 was not administered his scheduled insulin at night for 3 nights nor did he receive his insulin per sliding scale three times a day, missing 8 total doses. Resident #1 expired on [DATE]. An Immediate Jeopardy was identified on [DATE] at 4:30 PM as having occurred from [DATE] - [DATE]. However, the facility remained out of compliance at a severity level of actual harm not IJ with a scope of isolated because the facility had not had time to monitor their plan of removal for effectiveness. This failure placed current and future diabetic residents at risk for elevated blood sugars, coma, and death. Findings included: Closed record review of Resident #1's Face Sheet dated [DATE] indicated a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's Face Sheet also revealed he was discharged to the hospital on [DATE]. Record review of Resident #1's admission MDSs dated [DATE] and [DATE] indicated they were still in process and were incomplete. Record review of Resident #1's care plan dated [DATE] indicated the following: Problem: Diabetes Goal: No Complications Approach: Labs as ordered, Observe for S/S of hypo/[CONDITION(S)] (low blood sugar/high blood sugar) Closed record review of the Discharge Instructions for Resident #1 from the hospital dated [DATE] provided by the DON indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Home Medications Continue these medications Insulin [MEDICATION(S)] ([MEDICATION(S)]) 100 Unit/1 Ml Cartridge, Dose: Unknown Dose, SUB-Q, TID Per Sliding Scale New Prescriptions Insulin [MEDICATION(S)], Hum.Rec.Anlog ([MEDICATION(S)]) 100 Unit/1 Ml Vial, Dose: 20 Unit, SUB-Q, HS for 30 days Stop taking these medications Insulin [MEDICATION(S)], Hum.Rec.Anlog ([MEDICATION(S)]) 100 Unit/1 Ml Vial, Dose: 9 Unit, SUB-Q, HS Record review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Type 2 diabetes mellitus was listed as a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's Progress Note dated [DATE] at 3:53 PM written by the on-call physician documented the following: Chief Complaint : Altered Mental Status Patient is a 79yearold male with respiratory failure is currently on oxygen. Patient has had decreased responsiveness since this afternoon, difficult to arouse and is hypotensive (low blood pressure). Transfer to Emergency Department Record review of Resident #1's Visit Summary from the hospital's emergency room he was sent to on [DATE] revealed the following: admitted : [DATE] at 5:10 PM Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Serum Glucose at 5:28 PM on [DATE] was greater than 625, reference range ,d+[DATE] During an interview with LVN B on [DATE] at 11:21 AM she said the first day she worked with Resident #1 was on [DATE], the day he was sent to the hospital. She took her lunch break and when she came back, she said LVN A told her Resident #1 was unresponsive and that she already took his vitals. LVN B went ahead and took his vitals again herself. She said he was not responding, and his oxygen was low, around ,d+[DATE]. She said she got it up to only ,d+[DATE] at 4 liters of oxygen. She was doing a sternal rub to him but that didn't arouse him. She said the on-call physician was called and said to send Resident #1 to the emergency room . LVN B said there were no blood sugar checks done; there were no orders for insulin or blood sugar checks. LVN B said LVN A worked with him for his first few days at the facility and would have more information about him. During an interview with LVN A on [DATE] at 11:26 AM she said Resident #1 was admitted Thursday, [DATE] and she admitted him. She said she got report from the nurse at the hospital and was told his primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was told they treated him at the hospital for [CONDITION(S)] and that they got it under control. She said they didn't need to do finger sticks to check his blood sugar because he had a device in his arm for checking his blood glucose levels. She was told by the nurse at the hospital to get with his doctor and decide if they wanted to use this device or not. She never did . She called the NP and went over his list of meds from the hospital. She said his insulin was listed as new/continue but also on the discontinue list. She took that as to discontinue his insulin and she said that was what she relayed to the NP. She said she failed to look at the whole dosage and just looked at the medicine listed. She didn't see that it said to start 20 units and down at the bottom of the list it said discontinue 9 units. He was previously on 9 units and was ordered to take 20 units. She said she made a mistake when she looked at the orders wrong. She said because she told the NP the insulin was discontinued, the NP said they would see how he does and didn't order to do the finger sticks to check his blood sugar. The NP did order to get his Hemoglobin A1C labs, however this was never done. When he became unresponsive on [DATE] while his nurse was out for lunch, LVN A took his vitals and she administered oxygen to him. When his nurse came back from lunch, she told her what was going on and left him to the care of his nurse. LVN A said she was sure it was all respiratory issues since was oxygen level was low. During a confidential interview on [DATE] at 11:45 AM, Individual stated Resident #1 was still in the hospital and his kidneys were failing. He wasn't expected to survive. Individual said before Resident #1 was admitted to the nursing facility his blood sugar was checked at least 4 times a day and was administered insulin shots 4 times a day. Individual said he got a scheduled amount and then a sliding scale dose on top of that. Individual said Resident #1 had diabetes for [AGE] years and was insulin dependent. During an interview with the DON on [DATE] at 2:15 PM she said that no lab work was done for Resident #1, including his hemoglobin A1C that was ordered on [DATE] when he was admitted . She said their scheduled lab days were Monday - Thursday. He would have had his lab done on [DATE] but he went to the hospital on [DATE]. During a simultaneous interview with LVN A, both where asked who wrote a note on Resident #1's Discharge Instructions from the hospital that read, Is DM but no FS rt now. At first LVN A denied writing the note but after closer inspection and the DON saying it looked like her handwriting, LVN A said she wrote the handwritten note. When asked what was said and what it meant, she said, Is diabetic but no finger sticks right now. DON said she usually double checks the orders of the newly admitted residents, but she didn't work again until Monday, [DATE]. She said normally, if she doesn't review the orders, then the ADON would review them. She said the ADON didn't review them either because she was working the night shift as a floor nurse. When asked what could happen to a person with diabetes if they were supposed to have insulin every day but don't get it for 3 days, both said a person with diabetes could go into a diabetic coma. When asked if this situation could have been prevented, DON said it could have been prevented and should have been found within 24 hours if someone had reviewed Resident #1's admission paperwork and orders. During an interview with NP on [DATE] at 2:55 pm, she said she expects the nurses to give her the correct information from the hospital's discharge orders. She said she remembered ordering Resident #1's hemoglobin A1C and that lab work should have been done the next day, not wait until Monday on their routine lab days. She said she went off of what the nurse said and that she never saw Resident #1, nor did she have any paperwork on him. During an interview with DON on [DATE] at 3:40 pm, she said they didn't do any finger stick blood sugar checks on Resident #1 because LVN A said the hospital wasn't doing them, so they didn't do them at the nursing facility either. She said Resident #1 had a device in his arm that checked his blood sugars, and it was read from an unknown agency. They didn't know where that information was sent, and they didn't have access to that information. DON said they should have been finding out what his glucose levels were. Record review of the facility's Admission Assessment and Follow Up: Role of the Nurse policy and procedure, revised February 2022 revealed the following: 11. Reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to the established procedures. 12. Contact the Attending Physician or after hours Telehealth provider to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the facility's Nursing Care of the Older Adult with Diabetes Mellitus policy and procedure revised [DATE] revealed the following: Symptoms Associated with Diabetes 1. [CONDITION(S)]. Uncontrolled diabetes from lack of insulin or inadequate insulin results in [CONDITION(S)] (blood sugar above target levels). 2. Diabetic ketoacidosis (DKA) (diabetic coma). Ketoacidosis occurs when [CONDITION(S)] is untreated and the cells begin to metabolize fat for energy. The byproduct of fat metabolism is ketones, which build up quickly in the blood. Diabetic ketoacidosis is a life-threatening emergency that needs immediate medical attention. Medication Management 5. Closely monitor the diabetes management of cognitively impaired residents. Documentation 1. For residents with confirmed diabetes, the nurse shall assess and document/report the following during the initial assessment: c. Dose and time of the most recent anti-hyperglycemic given; d. All other current medications; i. Resident's blood sugar history over 48 hours; j. Usual patterns (fluctuations, trends) of blood sugar over recent months; An Immediate Jeopardy (IJ) was identified on [DATE] at 4:30 PM. The ADM and DON were informed. A Plan of Removal was requested. The facility's plan of removal of Immediate Jeopardy was accepted on [DATE] at 8:30 AM and included the following: *DON provided education to each nurse working: Nurses must administer insulin and other medications as ordered by the physician in accordance with the healthcare center policy. Failure to verify and administer insulin may result in the decline of residents, elevated blood sugars, coma, and death. Failure to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Care of the Older Adult with Diabetes Mellitus education was given. Admission Assessment and Follow Up: Role of the Nurse education was given. This included addressing medication reconciliation, history, and discharge summaries as well as verification of medication and review of pertinent findings with the physician. *Regional Nurse Manager provided education to the DON and ADM to include: Review of all new resident orders for existing resident and for every new admission during the Daily Clinical Meeting Monday - Friday. This review will include any clarification concerning medications. The Admission Checklist Tool will be utilized to ensure completion of reviews. *ADM conducted off-cycle QAPI meeting to review failure by the nurse to give the resident insulin as ordered by the physician which resulted in the resident decline and need for immediate actions to prevent future negative outcomes for residents with diabetes which includes risk for elevated blood sugars, coma, and death. Review of the plan for immediate and ongoing staff education, monitoring of new orders for current residents, and reconciliation, verification, and implementation of new admit orders was approved by the Medical Director and the committee. *A 100% audit of all diabetic resident orders was completed by the DON. On [DATE] at 8:38 AM the Investigator confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Review of training records reflected on [DATE] , nurses received in-services titled Admission Assessment, Verify orders with on-call provider, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interviews with the 2 LVNs working on [DATE] at 8:38 AM and 9:04 AM indicated staff had been in-serviced on admissions and the role of the nurse. They said when they get a new admit and the resident was diabetic or even has a history of hyper or [CONDITION(S)], they will initiate finger sticks on them. There are now standing orders for that. The NP was on the phone during the in-service and the Regional Nurse was too. They said there was another lab they can get lab work done at over the weekends and not wait until Monday anymore. They said the in-service lasted over 2 hours and most of the nurses came in for it. During an interview with DON on [DATE] at 8:55 AM she said they implemented a new procedure where the following shift will review any new orders or admissions from the previous shift. They will also be verified by the ADON or DON. During an interview on [DATE] at 8:58 AM, ADM was asked How do you think this incident (Immediate Jeopardy) in area of Quality of Care and Significant Medication Errors came about? She stated the nurse should have called the hospital back to get clarification with the nurse giving report. She said from now on they will have additional eyes looking at the paperwork with the admission checklist, there will be more double checking the orders. During a follow up interview on [DATE] at 9:07 AM, ADM said they didn't make any new policies, they went over existing policies that were already in place, they just weren't being followed. She said they stayed here late last night to get all of the in-services done. The facility remained out of compliance at a severity level of actual harm that is not IJ with a scope of isolated because the facility had not had time to monitor their plan of removal for effectiveness. During a confidential interview on [DATE] at 10:12 AM, Individual said Resident #1 passed away on the night of [DATE].

Based on interviews and record review, the facility failed to ensure the resident environment remains as free from accidents hazards as is possible, and each resident received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for transfers. LVN A failed to hold the smoke room door open when Resident #1 had two fingers on his left hand squashed between a door jam and the door resulting in a trip to the emergency room and receiving 19 stitches and multiple fractures. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, suffocation, subdural hematomas, and death. Findings included: Record review of Resident #1's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE], with the following diagnoses: age-related cognitive decline, cerebral infarction ([CONDITION(S)]), hypertension (high blood pressure), muscle weakness, low back pain, central retinal vein occlusion to both eyes (blockage of the small veins that carry blood away from the retina which can lead to sudden and permanent vision loss), Preglaucoma to both eyes (pressure inside your eye is higher than normal), unsteadiness on feet, reduced mobility, need for assistance with personal care, abnormalities of gait and mobility, chronic pain, difficulty in walking, visuospatial deficit (loss of the sense of whereness) and spatial neglect (a behavioral syndrome occurring after [CONDITION(S)]) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it. A lack of adequate blood supply to the brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). Record review of Resident #1's quarterly MDS resident assessment, dated 12/17/21, reflected the resident scored 12 of 15 on a mini-mental exam for cognitive awareness which indicated he was interviewable. Record review of Resident #1's nurses notes, documented by LVN A on 3/7/22, revealed the following: dated 3/07/2022 at 12:06 a.m. - at 11:30 p.m. smoke break, while this nurse was taking patient to smoke, let the door close, not noticing that the patient was still outside, patient got left fingers pinched in pivot point of smoke room door, patient noted to have excessive bleeding from laceration and loose skin on pinky and ring finger where the door had compressed his fingers, notified ADON, DON, and patient went to ER via 911. During an interview on 3/17/22 at 9:05 a.m., the Administrator stated Resident #1 had fractures to his 4th and 5th finger on his left hand when the smoke door accidentally caught his fingers in the door jam. During an interview on 3/17/22 at 9:25 a.m., the DON stated Resident #1 had an appointment today with a local hand surgeon. The DON stated Resident #1, who was blind, had his left hand pinched in the smoke room door and had to have 19 stiches between both fingers and had fractures to both tips of the 4th and 5th fingers. During an interview on 3/17/22 at 9:50 a.m., Resident #1 stated he was going to the smoke room and LVN A was holding the metal door open with her leg, releasing it before he got into the room. Resident #1 stated he had his hand in the door jamb to pull himself into the smoke room and the nurse let go of the door before he got inside. Resident #1 stated he got the stiches out of his fingers last week but the finger tips were hurting a lot and not looking very good. An observation on 3/17/22 at 10:00 a.m., of Resident #1's finger tips on his 4th and 5th finger of his left hand revealed both finger tips were a purple and black, swollen with the nail bed raised. During an interview on 3/17/22 at 11:30 a.m., Resident #1's family member stated Resident #1 had multiple stiches and fractures to two of his fingers During a telephone interview on 3/17/22 at 1:10 p.m., LVN A stated on the day of the incident with Resident #1, she was holding the smoking room door open with her leg and she thought Resident #1 was already in the room so she let the door go and heard Resident #1 scream. LVN A stated she quickly opened the door and found Resident #1 holding his left hand which was bleeding a lot. LVN A stated it was just horrible with blood everywhere. LVN A stated she hurried and got Resident #1 assessed and called 911 so he could get treatment.

Based on interview and record review the facility failed to ensure residents the right to formulate advance directives for 2 of 6 residents (Residents #2 & #5) reviewed for advance directives in that: 1. Resident #2's code status alert was inaccurately reflected in the medical record, including the comprehensive care plan. Resident #2 had an order for [REDACTED]. 2. Resident #5's code status was not correctly reflected in the comprehensive care plan. Resident #5 was a DNR, but the Care Plan indicated that the resident was a Full Code. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy, and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This deficient practice could affect the 22 residents in the facility that elected a Do Not Resuscitate status by not having their end of life wishes followed. This facility failure also has the potential for those 13 residents with a Full Code Status to not be provided resuscitation, which could result in death; or for those residents who wished to be a DNR to be subjected to the undue physical trauma of the resuscitation procedures. The findings were: 1. Review of Resident #2's medical record on [DATE] at 12:00 pm revealed an admission face sheet with an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's medical chart documented a physician order [REDACTED]. The red code status alert sheet in the front of the medical record indicated that the resident was a DNR. There was no original dated and signed DNR (Do Not Resuscitate) order found in the record. The care plan with a start date of [DATE] stated, " ...Should I expire I do not want CPR (Cardio [MEDICAL CONDITION] Resuscitation)." This care plan was updated on the following dates: [DATE], [DATE], and [DATE]. During the entrance conference with the ADM on [DATE], the ADM stated the code status for each resident was indicated on the red/green alert sheet in the front of the record and also on a sheet on the cart, and that that the staff were made aware of the code status of each resident by looking at the red/green alert sheet in the front of the medical record. During an interview with the DON on [DATE] at 3:20 pm, the DON stated that the Resident #2 had just changed code status and that the DON would check the order in the computer. At 3:47 pm on [DATE], the DON brought the written orders dated [DATE] - Do Not Resuscitate and [DATE] - Full Code per resident request. The DON stated that she had changed the code alert page in the resident medical record to indicate the current Full Code status, and would place the written orders in the plastic sleeve behind this page. In an interview with the DON and the MDS nurse on [DATE] at 4:37 pm it was reported that the resident returned to the facility from a hospitalization (in July, 2013) with the current Full code status and had been a DNR prior to this return to the facility. They were not aware of a reason for this change. When asked where the code status of residents is located , the MDS nurse said there is a list in the Nursing 24 hour Book and also a list on the resuscitation cart in addition to the alert in the medical record. The MDS nurse stated that he would look at the red/green sheet in the front of the medical record for the code status of a resident and would also confirm this by looking for the physician written order. Neither the DON nor the MDS nurse were sure of what the facility policy said relating to where to look for a resident code status. Interview with Resident #2 on [DATE] at 4:50 pm revealed that when the resident went to the hospital about one and one/half months ago, that the resident wanted to be a full code. The resident further stated, "Before that I thought it would be better, but I have since decided that I am young enough to survive and have a good chance to survive if something happens." 2. Review of Resident #5's medical record documented an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #5's medical chart shows a monthly physician order [REDACTED]. The red alert sheet for DNR was in the front of the medical record. The Care Plan for this resident dated [DATE] stated, "I want to live as long as possible so I do wish to have CPR started if I stop breathing". This care plan was updated on [DATE], [DATE] and [DATE]. There was an additional care plan located in Resident #5's record with the start dated of [DATE] that stated, "Status of Advance Directives - Out of Hospital DNR" and this care plan was updated on [DATE]. 3. Observation of the facilities clinical records on [DATE] at 11:50 am shows a red DNR sheet or a green full code sheet in a plastic sleeve as the first page of the record. 4. During an interview with LVN B on [DATE] at 4:45 pm, the LVN stated that the procedure to confirm code status is to look at the red DNR or green full code sheet in front of the chart and to confirm by looking at the order. LVN B continued to say that the MAR's (Medication Administration Record) also have code status on them but it is not always correct. 5. During an interview on [DATE] at 4:49 pm, LVN D stated that there is a list of resident code status in the 24 hour Nurse Book at the nurses' station which is updated monthly. LVN D would look at the red or green sheet in the front of the chart and also look for a physician order. LVN D continued by saying, " It's time consuming looking through all the physician orders [REDACTED]. Review of the facility's policy titled, "Senior Living Properties Code Status System" revised on [DATE] revealed the resident's end of life decisions are reflected via an alert system for the direct care staff members. The policy states that the red alerts located in the front of the clinical record reflect the resident's desire to forgo CPR and a green alerts indicate the resident's desire to have CPR and every attempt to provide all heroic measures must be recognized. The policy states that a copy of the resident's end of life decision should be reflected on a telephone order placed in the front of the active clinical record. The facility administrator was notified on [DATE] at 5:40 pm that an IJ situation had been identified due to the above failures. The Facility Plan of Removal was provided on [DATE] at 9:00 am. The Plan of Removal was accepted at 11:17 am on [DATE]. The facility took the following actions to remove the IJ: 1. 100% audit of all charts completed to ensure that a physician order [REDACTED]. 2. Order for code status election has been entered into Matrix software program as designated by resident/responsible party. 3. Red/green sheet has been placed in chart plastic sleeve. 4. OOHDNR form has been placed in chart in plastic sleeve holder containing Red sheet if resident's responsible party elects DNR status. 5. In-service licensed nurses on code status system. 6. Quarterly audit of code status has been completed and will be conducted quarterly by the social worker beginning in January, 2014. 7. A physician order [REDACTED]. The order will be entered into the Matrix software program. The chart will be checked to determine that a red or green sheet has been placed in the plastic sleeve in front of the chart within two to four hours of admission. The DON will audit the chart the day after the admission to ensure that the correct colored sheet is present (that matches the physician order). The day after admission, the chart will be brought to stand-up for review. The chart will also be reviewed at the first Standards of Care meeting following the admission. 8. Should a resident decide to change his/her status, the physician will be contacted and an order obtained. 9. If the resident elects DNR status, the social worker will visit with the resident to complete the OOHDNR. 10. An out of cycle QA&A (Quality Assurance and Assessment) Committee meeting was held on [DATE] at 8:15 pm. The action plan was submitted to the committee and approved. 11. Results of the quarterly code status audit will be presented to the QA&A committee at each quarterly meeting. The results of the audit just completed will be presented at the QA&A meeting scheduled for Nov. 20, 2013 at 1:30 pm. Record review of the in-service indicated on the Plan of Removal shows that all fourteen of the licensed nursing staff were in-serviced as well as the facilities social worker by 9:00 am on [DATE]. Chart audit completed on [DATE] at 12:39 pm of the 22 DNR resident's medical records revealed that the records were complete with the correct red or green alert sheet. Records of the facilities completed chart audit for code status were provided with the initial plan of removal. Review of the medical record for Resident #3 who was admitted on [DATE] revealed that the Full Code status was completely and accurately documented in the resident medical record. Interviews with facility staff nurses (RN A, LVN C, LVN D, and LVN E) that occurred from 12:30 pm to 15:07 pm on [DATE] revealed that the staff had been in-serviced on code status procedures and that all staff interviewed would look to the alert status sheet for code status for the residents. The staff members interviewed all stated that they would also confirm code status by looking at the written order. On [DATE] at 4:15 pm the Administrator and CRN were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy, and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place Review of a document provided by the facility on [DATE] revealed there were 22 residents in the facility with a DNR advance directive and 13 that had full code status. The CMS Form 672 dated [DATE] states a resident census of 35 residents.

Based on observation, interview and record review the facility failed to implemet Comprehensive Care Plans that described the services ordered for 2 of the 6 residents (Resident's #2 & #5) reviewed for Advance Directives. 1. Resident #2's code status alert was inaccurately reflected in the medical record, including the comprehensive care plan. Resident #2 had an order for [REDACTED]. 2. Resident #5's code status was not correctly reflected in the comprehensive care plan. Resident #5 was a DNR, but the Care Plan indicated that the resident was a Full Code. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy, and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This deficient practice could affect the 22 residents in the facility that elected a Do Not Resuscitate status by not having their end of life wishes followed. This facility failure alos has the potential for those residents with a Full Code Status to not be provided resuscitation, which dcould result in death; or or those residents who wished to be a DNR to be subjected to the undue physical trauma of the resuscitation procedures. This facility failure has the potential to affect all 35 residents in the facility to not have their medical, nursing, mental, and psychosocial needs met. This failure could lead to increased medical conditions and the development of complications. ______________________ Non- immediate Jeopardy ______________________ 3. Based on observation and record review the facility failed to ensure Comprehensive Care Plan accuracy for Resident #6. The facility failure to accurately reflect the type of Urinary Catheter for Resident #6 on the Comprehensive Care Plan could lead to improper urinary catheter care and ineffective patient education. These failures could lead to the introduction of infection and other possible complications associated with catheter care. There were 3 residents with urinary catheters in the facility as identified by the Form 672. The findings were: 1. Review of Resident #2's medical record on [DATE] at 12:00 pm revealed an admission face sheet with an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's medical chart documented a physician order [REDACTED]. The red code status alert sheet in the front of the medical record indicated that the resident was a DNR. There was no original dated and signed DNR (Do Not Resuscitate) order found in the record. The care plan with a start date of [DATE] stated, " ...Should I expire I do not want CPR (Cardio [MEDICAL CONDITION] Resuscitation)." This care plan was updated on the following dates: [DATE], [DATE], and [DATE] During an interview with the DON on [DATE] at 3:20 pm, the DON stated that the Resident #2 had just changed code status and that the DON would check the order in the computer. At 3:47 pm on [DATE], the DON brought the written orders dated [DATE] - Do Not Resuscitate and [DATE] - Full Code per resident request. The DON stated that she had changed the code alert page in the resident medical record to indicate the current Full Code status, and would place the written orders in the plastic sleeve behind this page. In an interview with the DON and the MDS nurse on [DATE] at 4:37 pm it was reported that the resident returned to the facility from a hospitalization (in July, 2013) with the current Full code status and had been a DNR prior to this return to the facility. They were not aware of a reason for this change. When asked where the code status of residents is located, the MDS nurse said there is a list in the Nursing 24 hour Book and also a list on the resuscitation cart in addition to the alert in the medical record. The MDS nurse stated that he would look at the red/green sheet in the front of the medical record for the code status of a resident and would also confirm this by looking for the physician written order. Neither the DON nor the MDS nurse were sure of what the facility policy said relating to where to look for a resident code status Interview with Resident #2 on [DATE] at 4:50 pm revealed that when the resident went to the hospital about one and one/half months ago, that the resident wanted to be a full code. The resident further stated, "Before that I thought it would be better, but I have since decided that I am young enough to survive and have a good chance to survive if something happens." 2. Review of Resident #5's medical record documented an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #5's medical chart shows a monthly physician order [REDACTED]. The Care Plan for this resident dated [DATE] stated, "I want to live as long as possible so I do wish to have CPR started if I stop breathing". This care plan was updated on [DATE], [DATE] and [DATE]. There was an additional care plan located in Resident #5's record with the start dated of [DATE] that stated, "Status of Advance Directives - Out of Hospital DNR" and this care plan was updated on [DATE]. 3. Observation of the facilities clinical records on [DATE] at 11:50 am shows a red DNR sheet or a green full code sheet in a plastic sleeve as the first page of the record. 4. Review of the facility's policy titled, "Care Plan, Resident" revealed the following: III. The exact date of the long-term goal and each problem should be clearly documented. XII. B. The licensed nurses must review the resident care plan each time an order is received from a physician to determine if an entry is needed. The facility administrator was notified on [DATE] at 5:40 pm that an IJ situation had been identified due to the above failures. The Facility Plan of Removal was provided on [DATE] at 9:00 am. The plan of removal was accepted at 11:17 am on [DATE]. The facility took the following actions to remove the IJ: 1. 100% audit of all charts completed to ensure that a physician order [REDACTED]. 2. Order for code status election has been entered into Matrix software program as designated by resident/responsible party. 3. Red/green sheet has been placed in chart plastic sleeve. 4. OOHDNR form has been placed in chart in plastic sleeve holder containing Red sheet if resident's responsible party elects DNR status. 5. In-service licensed nurses on code status system. 6. Quarterly audit of code status has been completed and will be conducted quarterly by the social worker beginning in January, 2014. 7. A physician order [REDACTED]. The order will be entered into the Matrix software program. The chart will be checked to determine that a red or green sheet has been placed in the plastic sleeve in front of the chart within two to four hours of admission. The DON will audit the chart the day after the admission to ensure that the correct colored sheet is present (that matches the physician order). The day after admission, the chart will be brought to stand-up for review. The chart will also be reviewed at the first Standards of Care meeting following the admission. 8. Should a resident decide to change his/her status, the physician will be contacted and an order obtained. 9. If the resident elects DNR status, the social worker will visit with the resident to complete the OOHDNR. 10. An out of cycle QA&A (Quality Assurance and Assessment) Committee meeting was held on [DATE] at 8:15 pm. The action plan was submitted to the committee and approved. 11. Results of the quarterly code status audit will be presented to the QA&A committee at each quarterly meeting. The results of the audit just completed will be presented at the QA&A meeting scheduled for Nov. 20, 2013 at 1:30 pm. Record review of the in-service indicated on the Plan of Removal showed that all fourteen of the licensed nursing staff were in-serviced as well as the facilities social worker by 9:00 am on [DATE]. Chart audit completed on [DATE] at 12:39 pm of the 22 DNR resident's medical records revealed that the records were complete with the correct red or green alert sheet. Records of the facilities completed chart audit for code status were provided with the initial plan of removal. Review of the medical record for Resident #3 who was admitted on [DATE] revealed that the Full Code status was completely and accurately documented in the resident medical record. Interviews with facility staff nurses (RN A, LVN C, LVN D, and LVN E) that occurred from 12:30 pm to 15:07 pm on [DATE] revealed that the staff had been in-serviced on code status procedures, and that all staff interviewed would look to the alert status sheet for code status for the residents. The staff members interviewed all stated that they would also confirm code status by looking at the written order. On [DATE] at 4:15 pm the Administrator and CRN were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy, and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. ______________________ Non- immediate Jeopardy ______________________ 5. Review of Resident #6's medical record revealed an admission date of [DATE] with the following Diagnoses: [REDACTED]. Observation of peri-care on [DATE] at 9:03 am, presented a resident with a suprapubic catheter. Record review of the care plans for Resident #6 shows a care plan for foley catheter care that was initiated on [DATE]. The care plan states interventions for teaching the resident how to care for the foley catheter, as well as approaches for the nursing staff to provide care for a foley catheter. This care plan was last updated on [DATE]. The CMS Form 672 dated [DATE] states a resident census of 35 residents, and indicated 3 residents in the facility with urinary catheters.

Based on observation, interview and record review the administrator failed to administrate the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility Administrator and DON failed to implement the facility policy for Advance Directives so that lifesaving procedures were provided, if ordered for 2 of 6 residents reviewed for Advance Directives. 1. Resident #2's code status alert was inaccurately reflected in the medical record, including the comprehensive care plan. Resident #2 had an order for [REDACTED]. 2. Resident #5's code status was not correctly reflected in the comprehensive care plan. Resident #5 was a DNR, but the Care Plan indicated that the resident was a Full Code. These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy, and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This deficient practice could affect the 22 residents in the facility that elected a Do Not Resuscitate status by not having their end of life wishes followed. This facility failure also has the potential for those residents 13 with a Full Code Status to not be provided resuscitation, which could result in death; or for those residents who wished to be a DNR to be subjected to the undue physical trauma of the resuscitation procedures. The findings were: 1. Review of Resident #2's medical record on [DATE] at 12:00 pm documented an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's medical chart documented a physician order [REDACTED]. The red code status alert sheet in the front of the medical record indicated that the resident was a DNR. There was no original dated and signed DNR (Do Not Resuscitate) order found in the record. The care plan with a start date of [DATE] stated, " ...Should I expire I do not want CPR (Cardio [MEDICAL CONDITION] Resuscitation)." This care plan was updated on the following dates: [DATE], [DATE], and [DATE]. During the entrance conference with the ADM on [DATE], the ADM stated the code status for each resident was indicated on the red/green alert sheet in the front of the record and also on a sheet on the cart; and that that the staff were made aware of the code status of each resident by looking at the red/green alert sheet in the front of the medical record. During an interview with the DON on [DATE] at 3:20 pm, the DON stated that the Resident #2 had just changed code status and that the DON would check the order in the computer. At 3:47 pm on [DATE], the DON brought the written orders dated [DATE] - Do Not Resuscitate and [DATE] - Full Code per resident request. The DON stated that she had changed the code alert page in the resident medical record to indicate the current Full Code status, and would place the written orders in the plastic sleeve behind this page. In an interview with the DON and the MDS nurse on [DATE] at 4:37 pm it was reported that the resident returned to the facility from a hospitalization (in July, 2013) with the current Full code status and had been a DNR prior to this return to the facility. They were not aware of a reason for this change. When asked where the code status of residents is located , the MDS nurse said there is a list in the Nursing 24 hour Book and also a list on the resuscitation cart in addition to the alert in the medical record. The MDS nurse stated that he would look at the red/green sheet in the front of the medical record for the code status of a resident and would also confirm this by looking for the physician written order. Neither the DON nor the MDS nurse were sure of what the facility policy said relating to where to look for a resident code status. Interview with Resident #2 on [DATE] at 4:50 pm revealed that when the resident went to the hospital about one and one/half months ago, that the resident wanted to be a full code. The resident further stated, "Before that I thought it would be better, but I have since decided that I am young enough to survive and have a good chance to survive if something happens." 2. Review of Resident #5's medical record documented an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #5's medical chart shows a monthly physician order [REDACTED]. The Care Plan for this resident dated [DATE] stated, "I want to live as long as possible so I do wish to have CPR started if I stop breathing". This care plan was updated on [DATE], [DATE] and [DATE]. There was an additional care plan located in Resident #5's record with the start dated of [DATE] that stated, "Status of Advance Directives - Out of Hospital DNR" and this care plan was updated on [DATE]. 3. Observation of the facilities clinical records on [DATE] at 11:50 am shows a red DNR sheet or a green full code sheet in a plastic sleeve as the first page of the record. 4. Review of the facility's policy titled, "Senior Living Properties Code Status System" revised on [DATE] revealed the resident's end of life decisions are reflected via an alert system for the direct care staff members. The policy states that the red alerts located in the front of the clinical record reflect the resident's desire to forgo CPR and a green alerts indicate the resident's desire to have CPR and every attempt to provide all heroic measures must be recognized. The policy states that a copy of the resident's end of life decision should be reflected on a telephone order placed in the front of the active clinical record. 5. Review of the facility's policy titled, "Care Plan, Resident" revealed the following: III. The exact date of the long-term goal and each problem should be clearly documented. XII. B. The licensed nurses must review the resident care plan each time an order is received from a physician to determine if an entry is needed. The facility administrator was notified on [DATE] at 5:40 pm that an IJ situation had been identified due to the above failures. The Facility Plan of Removal was provided on [DATE] at 9:00 am. The plan of removal was revised 5 times and the final Plan of Removal was accepted 11:17 am on [DATE]. The facility took the following actions to remove the IJ: 1. 100% audit of all charts completed to ensure that a physician order [REDACTED]. 2. Order for code status election has been entered into Matrix software program as designated by resident/responsible party. 3. Red/green sheet has been placed in chart plastic sleeve. 4. OOHDNR form has been placed in chart in plastic sleeve holder containing Red sheet if resident's responsible party elects DNR status. 5. In-service licensed nurses on code status system. 6. Quarterly audit of code status has been completed and will be conducted quarterly by the social worker beginning in January, 2014. 7. A physician order [REDACTED]. The order will be entered into the Matrix software program. The chart will be checked to determine that a red or green sheet has been placed in the plastic sleeve in front of the chart within two to four hours of admission. The DON will audit the chart the day after the admission to ensure that the correct colored sheet is present (that matches the physician order). The day after admission, the chart will be brought to stand-up for review. The chart will also be reviewed at the first Standards of Care meeting following the admission. 8. Should a resident decide to change his/her status, the physician will be contacted and an order obtained. 9. If the resident elects DNR status, the social worker will visit with the resident to complete the OOHDNR. 10. An out of cycle QA&A (Quality Assurance and Assessment) Committee meeting was held on [DATE] at 8:15 pm. The action plan was submitted to the committee and approved. 11. Results of the quarterly code status audit will be presented to the QA&A committee at each quarterly meeting. The results of the audit just completed will be presented at the QA&A meeting scheduled for Nov. 20, 2013 at 1:30 pm. Record review of the in-service indicated on the Plan of Removal shows that all fourteen of the licensed nursing staff were in-serviced as well as the facilities social worker by 9:00 am on [DATE]. Chart audit completed on [DATE] at 12:39 pm of the 22 DNR resident's medical records revealed that the records were complete with the correct red or green alert sheet. Records of the facilities completed chart audit for code status were provided with the initial plan of removal. Review of the medical record for Resident #3 who was admitted on [DATE] revealed that the Full Code status was completely and accurately documented in the resident medical record. Interviews with facility staff nurses (RN A, LVN C, LVN D, and LVN E) that occurred from 12:30 pm to 15:07 pm on [DATE] revealed that the staff had been in- serviced on code status procedures, and that all interviewed staff would look to the alert status sheet for code status for the residents. The staff members interviewed all stated that they would also confirm code status by looking at the written order. On [DATE] at 4:15 pm the Administrator and CRN were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy, and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place Review of a document provided by the facility on [DATE] revealed there were 22 residents in the facility with a DNR advance directive and 13 residents with full code status. The CMS Form 672 dated [DATE] states a resident census of 35 residents.

Based on observation, interview and record review the facility failed to ensure clinical records were complete and accurate for 3 of the 6 residents (Resident's #2, #5, and #6) reviewed for clinical record completeness, accuracy, accessibility, and organization. 1. Resident #2's code status alert was inaccurately reflected in the medical record, including the comprehensive care plan. Resident #2 had an order for [REDACTED]. 2. Resident #5's code status was not correctly reflected in the comprehensive care plan. Resident #5 was a DNR, but the Care Plan indicated that the resident was a Full Code These failures resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. While the immediacy of the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy, and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This deficient practice could affect the 22 residents in the facility that elected a Do Not Resuscitate status by not having their end of life wishes followed. This facility failure also has the potential for those13 residents with a Full Code Status to not be provided resuscitation, which could result in death; or for those residents who wished to be a DNR to be subjected to undue physical trauma of the resuscitation procedures. ______________________ Non- immediate Jeopardy ______________________ 3. Based on observation and record review the facility failed to ensure Comprehensive Care Plan accuracy for Resident #6. The facility failure to accurately reflect the type of Urinary Catheter for Resident #6 on the Comprehensive Care Plan could lead to improper urinary catheter care and ineffective patient education. These failures could lead to the introduction of infection and other possible complications associated with catheter care. There were 3 residents with urinary catheters in the facility as identified by the Form 672. 4. Audit of the 22 resident medical records with an indicated DNR status revealed two resident records (#11 and #12) were found with written DNR orders that did not include a physician signature. This deficient practice could affect the 22 residents in the facility that elected a Do Not Resuscitate status by not having their end of life wishes followed. This facility failure also has the potential to delay the initiation of CPR for residents electing a full code or starting to code a DNR while the staff are searching for a signed physician order [REDACTED]. The findings were: 1. Review of Resident #2's medical record on [DATE] at 12:00 pm revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's medical chart documented a physician order [REDACTED]. The red code status alert sheet in the front of the medical record indicated that the resident was a DNR. There was no original dated and signed DNR (Do Not Resuscitate) order found in the record. The care plan with a start date of [DATE] stated, " ...Should I expire I do not want CPR (Cardio [MEDICAL CONDITION] Resuscitation)." This care plan was updated on the following dates: [DATE], [DATE], and [DATE]. During the entrance conference with the ADM on [DATE], the ADM stated the code status for each resident was indicated on the red/green alert sheet in the front of the record and also on a sheet on the cart; and that that the staff were made aware of the code status of each resident by looking at the red/green alert sheet in the front of the medical record. During an interview with the DON on [DATE] at 3:20 pm, the DON stated that the Resident #2 had just changed code status and that the DON would check the order in the computer. At 3:47 pm on [DATE], the DON brought the written orders dated [DATE] - Do Not Resuscitate and [DATE] - Full Code per resident request. The DON stated that she had changed the code alert page in the resident medical record to indicate the current Full Code status, and would place the written orders in the plastic sleeve behind this page. In an interview with the DON and the MDS nurse on [DATE] at 4:37 pm it was reported that the resident returned to the facility from a hospitalization (in July, 2013) with the current Full code status and had been a DNR prior to this return to the facility. They were not aware of a reason for this change. When asked where the code status of residents is located, the MDS nurse said there is a list in the Nursing 24 hour Book and also a list on the resuscitation cart in addition to the alert in the medical record. The MDS nurse stated that he would look at the red/green sheet in the front of the medical record for the code status of a resident and would also confirm this by looking for the physician written order. Neither the DON nor the MDS nurse were sure of what the facility policy said relating to where to look for a resident code status. Interview with Resident #2 on [DATE] at 4:50 pm revealed that when the resident went to the hospital about one and one/half months ago, that the resident wanted to be a full code. The resident further stated, "Before that I thought it would be better, but I have since decided that I am young enough to survive and have a good chance to survive if something happens." 2. Review of Resident #5's medical record revealed an admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #5's medical chart revealed a monthly physician order [REDACTED]. The Care Plan for this resident dated [DATE] stated, "I want to live as long as possible so I do wish to have CPR started if I stop breathing". This care plan was updated on [DATE], [DATE] and [DATE]. There was an additional care plan located in Resident #5's record with the start dated of [DATE] that stated, "Status of Advance Directives - Out of Hospital DNR" and this care plan was updated on [DATE]. 3. Observation of the facilities clinical records on [DATE] at 11:50 am shows a red DNR sheet or a green full code sheet in a plastic sleeve as the first page of the record The facility administrator was notified on [DATE] at 5:40 pm that an IJ situation had been identified due to the above failures. The Facility Plan of Removal was provided on [DATE] at 9:00 am. The plan of removal was accepted 11:17 am on [DATE]. The facility took the following actions to remove the IJ: 1. 100% audit of all charts completed to ensure that a physician order [REDACTED]. 2. Order for code status election has been entered into Matrix software program as designated by resident/responsible party. 3. Red/green sheet has been placed in chart plastic sleeve. 4. OOHDNR form has been placed in chart in plastic sleeve holder containing Red sheet if resident's responsible party elects DNR status. 5. In-service licensed nurses on code status system. 6. Quarterly audit of code status has been completed and will be conducted quarterly by the social worker beginning in January, 2014. 7. A physician order [REDACTED]. The order will be entered into the Matrix software program. The chart will be checked to determine that a red or green sheet has been placed in the plastic sleeve in front of the chart within two to four hours of admission. The DON will audit the chart the day after the admission to ensure that the correct colored sheet is present (that matches the physician order). The day after admission, the chart will be brought to stand-up for review. The chart will also be reviewed at the first Standards of Care meeting following the admission. 8. Should a resident decide to change his/her status, the physician will be contacted and an order obtained. 9. If the resident elects DNR status, the social worker will visit with the resident to complete the OOHDNR. 10. An out of cycle QA&A (Quality Assurance and Assessment) Committee meeting was held on [DATE] at 8:15 pm. The action plan was submitted to the committee and approved. 11. Results of the quarterly code status audit will be presented to the QA&A committee at each quarterly meeting. The results of the audit just completed will be presented at the QA&A meeting scheduled for Nov. 20, 2013 at 1:30 pm. Record review of the in-service indicated on the Plan of Removal showed that all fourteen of the licensed nursing staff were in-serviced as well as the facilities social worker by 9:00 am on [DATE]. Chart audit completed on [DATE] at 12:39 pm of the 22 DNR resident's medical records revealed that the records were complete with the correct red or green alert sheet. Records of the facilities completed chart audit for code status were provided with the initial plan of removal. Review of the medical record for Resident #3 who was admitted on [DATE] revealed that the Full Code status was completely and accurately documented in the resident medical record. Interviews with facility staff nurses (RN A, LVN C, LVN D, and LVN E) that occurred from 12:30 pm to 15:07 pm on [DATE] revealed that the staff had been in- serviced on code status procedures, and that all staff interviewed would look to the alert status sheet for code status for the residents. The staff members interviewed all stated that they would also confirm code status by looking at the written order. On [DATE] at 4:15 pm the Administrator and CRN were notified that the immediacy of the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy, and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. ______________________ Non- immediate Jeopardy ______________________ 4. Review of Resident #6's medical record revealed an admission date of [DATE] with the following Diagnoses: [REDACTED]. Observation of peri-care on [DATE] at 9:03 am, presented a resident with a suprapubic catheter. Record review of the care plans for Resident #6 shows a care plan for foley catheter care that was initiated on [DATE]. The care plan states interventions for teaching the resident how to care for his foley catheter, as well as approaches for the nursing staff to provide care for a foley catheter. This care plan was last updated on [DATE]. 5. During audit of the 22 resident medical records with an indicated DNR status on [DATE] at 12:39 pm, two resident records (#11 and #12) were found with written DNR orders that did not include a physician signature. Both of these were written by the ADON on [DATE]. The CMS Form 672 dated [DATE] states a resident census of 35 residents with 3 residents with urinary catheters. Review of a document provided by the facility on [DATE] revealed there were 22 residents in the facility with a DNR Advance DIrective and 13 residents with a full code status.

Based on interview and record review, the facility failed to consult with the physician for 1 of 11 residents (Resident #1) reviewed for a change in condition. The facility failed to notify the physician of newly developed wounds on Resident #1, caused by [DIAGNOSES REDACTED], secondary to end stage [MEDICAL CONDITION]. Resident #1 continued to develop worsening wounds and the facility failed to notify the physician for treatment plan changes. Resident #1was transported from the facility to the [MEDICAL TREATMENT] Center where she was assessed, sent to the emergency room , and admitted to the critical care unit with a [DIAGNOSES REDACTED]. After Administrative review, the surveyors re-entered the facility on 10/14/13 to gather more information and a Past Immediate Jeopardy (IJ) was identified that existed from 9-3-13 to 9-16-13 for Resident #1. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Past IJ. This deficient practice affected one resident with [DIAGNOSES REDACTED] due to the facility failing to notify physician of Resident #1's change in condition resulting in Resident #1's not getting the necessary medical treatment and services to prevent infection. Findings include: Record review of the Resident #1's chart revealed a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. ([DIAGNOSES REDACTED] is a condition of vascular calcification of the skin and cutaneous necrosis. The mortality rate is high, with more than 50 percent of patients dying within one year of diagnosis. The exact pathogenesis of [DIAGNOSES REDACTED] is unclear. Lower extremities are most commonly involved. Treatment options include wound care, surgical debridement, sodium [MEDICATION NAME], bisphosphonates, hyperbaric oxygen). The Journal of Clinical and Aesthetic Dermatology. Record review of skin assessment sheets dated 9-3-13, revealed Resident #1 had 2 wounds to right hip, 1 wound to lower abdominal area extending across the left side of the abdomen to the right side of the abdomen, 1 wound to right shin, 1 wound to left shin, 1 wound to mid coccyx, 1 wound to mid back, 1 wound to right buttock, 1 wound to left hip, 2 wounds to abdominal folds on the right and left, and 1 wound to upper left shoulder. These wound and skin assessments were only conducted weekly even though [DIAGNOSES REDACTED] wounds can appear suddenly. Record review of Resident #1's care plan did not address these numerous wounds. Record review of nurse's notes dated 9-3-13 through 9-15-13 documented Resident #1 was complaining daily of pain in the hip area. There was no notation of observation of the hip area on nurses notes dated 9-4-13 through 9-15-13. Record review of the skin assessment sheet of assessment of the left hip wound on 9-8-13 showed a measurement of 2 cm in length and 1 centimeter in width. On 9-15-13, a measurement of the left hip wound showed it increasing in size to a measurement of 3 cm in length and 2 cm in width, there was no documentation of a call to physician found in the nurses' notes. Record review of the skin assessment sheet of right hip showed a wound increasing in size from 6 cm in length and 3 cm in width on 9-3-13, to 8 cm in length and 4 centimeters in width on 9-15-13. No documentation of a call to the physician was noted in the nurses' notes. Record review of Resident #1's admission MDS dated [DATE] revealed the resident required extensive assistance with two people in relation to bed mobility, total dependence with transfer with two people in attendance. Record review of the MAR for the month of September, 2013 showed admission orders [REDACTED]. Chlorine is the active ingredient in Dakin's solution (WebMD). The MAR indicated [REDACTED]. Record review of hospital records documented Resident #1 was admitted to the emergency room from the [MEDICAL TREATMENT] Center on 9-16-13 with the [DIAGNOSES REDACTED]. Wound culture obtained at the hospital [MEDICAL CONDITION] colonized in the wounds. Final discharge [DIAGNOSES REDACTED]. Interview on 9-25-13 at 11:30 a.m., with the [MEDICAL TREATMENT] Center MD revealed Resident #1 was seen at the [MEDICAL TREATMENT] Center on 9-16-13. The [MEDICAL TREATMENT] Center MD stated that Resident #1 has a condition called [DIAGNOSES REDACTED] that causes multiple [MEDICAL CONDITION] on the body and the resident will continue to get new [MEDICAL CONDITION]. The condition is painful and is usually caused by end stage [MEDICAL CONDITION]. The [MEDICAL TREATMENT] Center MD stated the back and abdominal wounds were not the concern, the left hip and flank wounds were terribly infected, pus was oozing out of these wounds and the wounds were not covered. The [MEDICAL TREATMENT] Center MD felt like these wounds had not been addressed. The [MEDICAL TREATMENT] Center MD stated the facility should have taken note of these areas and noticed Resident #1 needed a higher level of care. The [MEDICAL TREATMENT] Center MD stated they called an ambulance and Resident #1 was taken to the emergency room . Interview with the DON on 9-25-13 at 1:15 p.m., revealed Resident #1 was admitted on [DATE] with a large wound on the abdomen, right hip and buttocks. The DON stated they were treating the wounds with Dakin's solution daily and leaving them open to air. The DON stated, "I did not know the resident had any draining wounds. I did not see a wound on Resident #1's left hip." The DON continued, "I look at residents weekly for skin assessments. No nurse came to me with a concern or a change of condition for Resident #1." The DON acknowledged there was an odor, but said wounds always smelled. Interview with LVN B on 9-25-13 at 1:22 p.m., revealed LVN B had instructions to leave the belly wound alone. LVN B stated Resident #1 had yeast under abdominal folds, and wounds on the right hip had brown slough. LVN B acknowledged not being able to remember when she last looked at Resident #1's wounds. LVN B stated the wounds were getting larger and had more of an odor. LVN B stated she didn't call the doctor for a change of condition because they were told not to do anything. An interview with the PA on 9/26/13 at 10:37 am, concerning Resident #1, revealed the PA could not remember this resident or if the facility staff had ever tried to contact him concerning Resident #1's change in condition of wounds or medication orders. Record review of the facility's undated policy and procedure titled, "Nursing Guidelines: Change of Condition Notification" documents the following in part: "Notification of changes shall include: 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; 3. A need to alter treatment significantly." It was determined these failures placed Resident #1 in a Past IJ situation from 9-3-13 to 9-16-13. The Administrator was notified of the Past IJ on 10-14-13 at 3:15 p.m. The facility demonstrated the following measures to correct the noncompliance: Resident #1 no longer resides in the facility. The facility recognized all residents in the facility could be affected. The facility held a Quality Assurance meeting on 9-20-13 to discuss pain management, protocols, and wound care. The DON is completing weekly skin rounds on residents in the facility. The DON will audit skin treatments weekly for 8 weeks for effectiveness. The physician will be contacted for any changes in wounds that do not heal. A directed inservice will be held on 10-17-13, which will include training on wound care, pain management, and providing pain medications. Review of the facility's CMS Form 672, obtained 9/26/13, confirmed the census was 37.

Based on interview and record review, the facility failed to follow their policy and procedure to prevent neglect for 1 of 11 residents (Resident #1). 1. The facility failed to provide a physician's orders [REDACTED]. Resident #1 experienced severe pain related to wounds on her body from 9/3/10 - 9/16/13. 2. The facility failed to assess, recognize, and notify physician regarding the development and worsening of wounds. Resident #1 was transported from the facility to the [MEDICAL TREATMENT] Center where she was assessed, sent to the emergency room , and admitted to the critical care unit with a [DIAGNOSES REDACTED]. After Administrative review, the surveyors re-entered the facility on 10/14/13 to gather more information and a Past Immediate Jeopardy (IJ) was identified that existed from 9-3-13 to 9-16-13 for Resident #1. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Past IJ. This deficient practice could place 7 of 37 residents identified with wounds in the facility at risk for neglect, by not recognizing a change in condition and promptly notifying the physician. Findings include: Record review of the Resident #1's chart on 9-25-13, revealed Resident #1 is [AGE] years of age, and was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. ([DIAGNOSES REDACTED] is a condition of vascular calcification of the skin and cutaneous necrosis. The mortality rate is high, with more than 50 percent of patients dying within one year of diagnosis. The exact pathogenesis of [DIAGNOSES REDACTED] is unclear. Lower extremities are most commonly involved. Treatment options include wound care, surgical debridement, sodium [MEDICATION NAME], bisphosphonates, hyperbaric oxygen). The Journal of Clinical and Aesthetic Dermatology. Record review of Resident #1's admission orders [REDACTED]. Record review of Resident #1's pain evaluation dated 9-3-13, revealed Resident #1's pain level on that date was 9-10 on a scale of 1-10. The location of the pain was documented to be in the hips and was chronic and frequent. Record review of the nursing facility's daily skilled nursing notes, dated 9/3/13, revealed the following: Resident #1 had been on a scheduled pain medication regimen. Resident #1 complained of pain in the hips and was bed bound due to severe weakness and pain. Record review of Physician Telephone Orders, dated 9-4-13, reflected: a decrease in [MEDICATION NAME] from 50 mcg to 25 mcg topically every 72 hours. Record Review of Resident #1's MAR for September 2013 revealed the order for the [MEDICATION NAME] Patch had been changed from to 50 mcg to 25 mcg on 9-6-13, but there was no entry for the [MEDICATION NAME] Patch being given at all between 9-3-13 and 9-10-13. Record review of the nursing facility's daily skilled nursing notes, dated 9/6/13, the PA was called by facility staff requesting increase in pain medication. The PA replied, "Absolutely not!! Please do not call to ask for increased pain medications. Once she (Resident #1) begins eating and moving around some, then he may increase the dose, but not until then." Record review of the nursing facility's daily skilled nursing notes, dated 9/8/13, revealed no [MEDICATION NAME] available for Resident #1. DON was called and informed. Order and date of birth of Resident #1 was faxed to Physician with the DON to follow up on 9/9/13 in the morning. There is no documentation in Resident 1's chart of follow-up by the DON on 9-9-13. Record review of Resident #1's admission MDS dated [DATE] revealed that extensive assistance was required with two people in relation to bed mobility, total dependence with transfer with two people in attendance, should be assessed for pain, is on a scheduled pain regimen, has had pain the last five days, has constant pain, and describes pain as severe. 1. Resident #1's Physician Telephone Orders, dated 9/10/13, reflected: increase [MEDICATION NAME] Patch to 50 mcg every 72 hours for pain. Review of the MAR indicated [REDACTED]. Resident #1 went 7 days without receiving the physician-ordered [MEDICATION NAME] Patch. Record review of the nursing facility's daily skilled nursing notes, dated September 4,5,6,7,9,10 revealed the following: Under the section "Pain Management and Interventions" At any time in the last 5 days, has the resident been on a scheduled pain medication regimen? The box next to "No" was checked on all dates listed above. The comment section reflected Resident #1 complained of bilateral pain to the hips on all dates listed above. The nursing notes 9/10/13 documented Resident #1 was in a "pain crisis". Interview with the DON on 9-25-13 at 1:15 p.m., revealed Resident #1 was admitted on [DATE] with a large wound on the abdomen, right hip and buttocks. The DON stated they were treating the wounds with Dakin's solution daily and leaving them open to air. The DON stated, "I did not know the resident had any draining wounds. I did not see a wound on Resident #1's left hip." The DON continued, "I look at residents weekly for skin assessments. No nurse came to me with a concern or a change of condition for Resident #1." The DON acknowledged there was an odor, but said wounds always smelled. Interview with LVN B on 9-25-13 at 1:22 p.m., revealed LVN B had instructions to leave the belly wound alone. LVN B stated Resident #1 had yeast under abdominal folds, and wounds on the right hip had brown slough. LVN B acknowledged not being able to remember when she last looked at Resident #1's wounds. LVN B stated the wounds were getting larger and had more of an odor. LVN B stated she didn't call the doctor for a change of condition because they were told not to do anything. Interview with the PA on 9/26/13 at 10:37 am, concerning Resident #1, revealed the PA could not remember this resident or if the facility staff had ever tried to contact him concerning Resident #1's medication or wound orders. Interview with the DON on 9/26/13 at 10:50 am, concerning Resident #1 being admitted to the facility on [DATE] with orders for a [MEDICATION NAME] Patch 50 mcg every 72 hours, revealed the [MEDICATION NAME] Patch was not obtained by the facility until 9/10/13 because the PA would not sign the triplicate. The DON stated the facility staff could not do anything if the PA would not sign the triplicate. Interview with the ADM on 9/26/13 at 11:30 am, concerning Resident #1's [MEDICATION NAME] Patch not being given from 9/3/13 - 9/10/13, revealed the [MEDICATION NAME] Patch was not available because facility staff could not get the triplicate signed. The ADM stated staff had tried calling the Physician to get the triplicate signed. When the ADM was informed there was no documentation showing that staff had tried to call the Physician to get the [MEDICATION NAME] Patch for Resident #1 that was ordered, the ADM stated she was sure they called. 2. Record review of skin assessment sheets dated 9-3-13, revealed Resident #1 had 2 wounds to right hip, 1 wound to lower abdominal area, 1 wound to right shin, 1 wound to left shin, 1 wound to mid coccyx, 1 wound to mid back, 1 wound to right buttock, 1 wound to left hip, 2 wounds to abdominal folds on the right and left, and 1 wound to upper left shoulder. There was no documentation of any draining wounds. These wound and skin assessments were only conducted weekly. Record review of Resident #1's care plan dated 9-13-13 did not address these numerous [MEDICAL CONDITION]. Record review of nurse's notes dated 9-3-13 through 9-15-13 documented Resident #1 was complaining daily of pain in the hip area. There was no notation of observation of the hip area on nurses' notes dated 9-4-13 through 9-15-13. Record review of skin assessment sheet of right hip showed a wound increasing in size from 6 cm in length and 3 cm in width on 9-3-13, to 8 cm in length and 4 centimeters in width on 9-15-13. There was no documentation of any draining wounds or any change of condition reported to the physician in the nurses' notes. Record Review of skin assessment sheet of the left hip wound on 9-8-13 showed a measurement of 2 cm in length and 1 centimeter in width. On 9-15-13, a measurement of the left hip wound showed it increasing in size to a measurement of 3 cm in length and 2 cm in width. There was no documentation of any draining wounds or any change of condition reported to the physician in the nurses' notes. Review of the MAR indicated [REDACTED]. Chlorine is the active ingredient in Dakin's solution. The MAR indicated [REDACTED]. There were no other orders for treatment of [REDACTED]. During an interview on 9-23-13 with the SW at the [MEDICAL TREATMENT] Center, she stated she had contact with Resident #1 on 9-16-13 at the [MEDICAL TREATMENT] Center. The SW stated Resident #1 was sitting in the hallway in a wheelchair, with her head down and moaning. The SW asked Resident #1 what was wrong. Resident #1 stated her hips and stomach hurt. Resident #1 was taken into a room; the MD examined the resident and discovered multiple wounds on the both hips, and a very large wound on the abdomen. The SW stated the waistband of Resident #1's pants was causing pressure and pain on these uncovered sores. The SW stated that an ambulance was called and Resident #1 was taken to the emergency room . The SW stated these wounds should have been covered or have had some type of dressing on them. The SW stated the facility had not addressed these wounds. Interview on 9-25-13 at 11:30 a.m., with the [MEDICAL TREATMENT] Center MD, the [MEDICAL TREATMENT] Center MD stated Resident #1 was seen at the [MEDICAL TREATMENT] center on 9-16-13. The [MEDICAL TREATMENT] Center MD stated that Resident #1 has a condition called [DIAGNOSES REDACTED] that causes multiple [MEDICAL CONDITION] on the body and the resident will continue to get new [MEDICAL CONDITION]. The condition is painful and is usually caused by end stage [MEDICAL CONDITION]. The [MEDICAL TREATMENT] Center MD stated the back and abdominal wounds were not the concern, the left hip and flank wounds were terribly infected, pus was oozing out of these wounds and the wounds were not covered. The [MEDICAL TREATMENT] Center MD felt like these wounds had not been addressed. The [MEDICAL TREATMENT] Center MD stated the facility should have taken note of these areas and noticed Resident #1 needed a higher level of care. The [MEDICAL TREATMENT] Center MD stated they called an ambulance and Resident #1 was taken to the emergency room . Interview with a family member of Resident #1, on 9-25-13 at 11:50 a.m., revealed concern that staff did not take care of Resident #1's wounds. Resident #1 was to have daily wound care and the staff did not do this. The family member stated Resident #1 would ask the staff to clean the wounds and they would ignore these requests. The family member had gone to the facility to see Resident #1 before [MEDICAL TREATMENT] on 9-16-13 and Resident #1 was sick and "acting out of it." The family member had expressed concerns to the administrator about the poor care Resident #1 received at the facility. Record review of the facility's Abuse and Neglect Policy and Procedure with the most current review/revision dated 11-11-11 documented, in part: Policy Statement "Our facility implements an effective system for the prevention of abuse and neglect."...... "The facility initiates a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect." Interpretation & Implementation "1. Identify, assess, care-plan, and monitor residents........that require heavy nursing care or are totally dependent on staff." Report & Respond "3. To assist our facility's staff members in recognizing incidents of abuse, the following definitions of abuse are provided: g. Neglect is defined as failure to provide goods and service necessary to avoid physical harm, mental anguish, or mental illness." It was determined these failures placed Resident #1 in a Past IJ situation from 9-3-13 to 9-16-13. The Administrator was notified of the Past IJ on 10-14-13 at 3:15 p.m. The facility demonstrated the following measures to correct the noncompliance: Resident #1 no longer resides in the facility. The facility recognized all residents in the facility could be affected. The facility held a Quaility Assurance meeting on 9-20-13 to discuss pain management, protocols, and wound care. The DON is completing weekly skin rounds on residents in the facility. The DON will audit skin treatments weekly for 8 weeks for effectiveness. The physician will be contacted for any changes in wounds that do not heal. A directed inservice will be held on 10-17-13, which will include training on wound care, pain management, and providing pain medications. Record Review of 9 active resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with 2 residents on a pain management program revealed they are satisfied and have no complaints. Review of the facility's CMS Form 672, obtained 9/26/13, confirmed the census was 37.

Based on interview and record review, the facility failed to follow their policy and procedure to prevent neglect for 1 of 11 residents (Resident #1). 1. The facility failed to provide a physician's orders [REDACTED]. Resident #1 experienced severe pain related to wounds on her body from 9/3/10 - 9/16/13. 2. The facility failed to assess, recognize, and notify physician regarding the development and worsening of wounds. Resident #1 was transported from the facility to the [MEDICAL TREATMENT] Center where she was assessed, sent to the emergency room , and admitted to the critical care unit with a [DIAGNOSES REDACTED]. After Administrative review, the surveyors re-entered the facility on 10/14/13 to gather more information and a Past Immediate Jeopardy (IJ) was identified that existed from 9-3-13 to 9-16-13 for Resident #1. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Past IJ. This deficient practice could place 7 of 37 residents identified with wounds in the facility at risk for neglect, by not recognizing a change in condition and promptly notifying the physician. Findings include: Record review of the Resident #1's chart on 9-25-13, revealed Resident #1 is [AGE] years of age, and was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. ([DIAGNOSES REDACTED] is a condition of vascular calcification of the skin and cutaneous necrosis. The mortality rate is high, with more than 50 percent of patients dying within one year of diagnosis. The exact pathogenesis of [DIAGNOSES REDACTED] is unclear. Lower extremities are most commonly involved. Treatment options include wound care, surgical debridement, sodium [MEDICATION NAME], bisphosphonates, hyperbaric oxygen). The Journal of Clinical and Aesthetic Dermatology. Record review of the facility's Abuse and Neglect Policy and Procedure with the most current review/revision dated 11-11-11 documented, in part: Policy Statement "Our facility implements an effective system for the prevention of abuse and neglect."...... "The facility initiates a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect." Interpretation & Implementation "1. Identify, assess, care-plan, and monitor residents........that require heavy nursing care or are totally dependent on staff." Report & Respond "3. To assist our facility's staff members in recognizing incidents of abuse, the following definitions of abuse are provided: g. Neglect is defined as failure to provide goods and service necessary to avoid physical harm, mental anguish, or mental illness." Record review of Resident #1's admission orders [REDACTED]. Record review of Resident #1's pain evaluation dated 9-3-13, revealed Resident #1's pain level on that date was 9-10 on a scale of 1-10. The location of the pain was documented to be in the hips and was chronic and frequent. Record review of the nursing facility's daily skilled nursing notes, dated 9/3/13, revealed the following: Resident #1 had been on a scheduled pain medication regimen. Resident #1 complained of pain in the hips and was bed bound due to severe weakness and pain. Record review of Physician Telephone Orders, dated 9-4-13, reflected: a decrease in [MEDICATION NAME] from 50 mcg to 25 mcg topically every 72 hours. Record Review of Resident #1's MAR for September 2013 revealed the order for the [MEDICATION NAME] Patch had been changed from to 50 mcg to 25 mcg on 9-6-13, but there was no entry for the [MEDICATION NAME] Patch being given at all between 9-3-13 and 9-10-13. Record review of the nursing facility's daily skilled nursing notes, dated 9/6/13, the PA was called by facility staff requesting increase in pain medication. The PA replied, "Absolutely not!! Please do not call to ask for increased pain medications. Once she (Resident #1) begins eating and moving around some, then he may increase the dose, but not until then." Record review of the nursing facility's daily skilled nursing notes, dated 9/8/13, revealed no [MEDICATION NAME] available for Resident #1. DON was called and informed. Order and date of birth of Resident #1 was faxed to Physician with the DON to follow up on 9/9/13 in the morning. There is no documentation in Resident 1's chart of follow-up by the DON on 9-9-13. Record review of Resident #1's admission MDS dated [DATE] revealed that extensive assistance was required with two people in relation to bed mobility, total dependence with transfer with two people in attendance, should be assessed for pain, is on a scheduled pain regimen, has had pain the last five days, has constant pain, and describes pain as severe. 1. Resident #1's Physician Telephone Orders, dated 9/10/13, reflected: increase [MEDICATION NAME] Patch to 50 mcg every 72 hours for pain. Review of the MAR indicated [REDACTED]. Resident #1 went 7 days without receiving the physician-ordered [MEDICATION NAME] Patch. Record review of the nursing facility's daily skilled nursing notes, dated September 4,5,6,7,9,10 revealed the following: Under the section "Pain Management and Interventions" At any time in the last 5 days, has the resident been on a scheduled pain medication regimen? The box next to "No" was checked on all dates listed above. The comment section reflected Resident #1 complained of bilateral pain to the hips on all dates listed above. The nursing notes 9/10/13 documented Resident #1 was in a "pain crisis". Interview with the DON on 9-25-13 at 1:15 p.m., revealed Resident #1 was admitted on [DATE] with a large wound on the abdomen, right hip and buttocks. The DON stated they were treating the wounds with Dakin's solution daily and leaving them open to air. The DON stated, "I did not know the resident had any draining wounds. I did not see a wound on Resident #1's left hip." The DON continued, "I look at residents weekly for skin assessments. No nurse came to me with a concern or a change of condition for Resident #1." The DON acknowledged there was an odor, but said wounds always smelled. Interview with LVN B on 9-25-13 at 1:22 p.m., revealed LVN B had instructions to leave the belly wound alone. LVN B stated Resident #1 had yeast under abdominal folds, and wounds on the right hip had brown slough. LVN B acknowledged not being able to remember when she last looked at Resident #1's wounds. LVN B stated the wounds were getting larger and had more of an odor. LVN B stated she didn't call the doctor for a change of condition because they were told not to do anything. Interview with the PA on 9/26/13 at 10:37 am, concerning Resident #1, revealed the PA could not remember this resident or if the facility staff had ever tried to contact him concerning Resident #1's medication or wound orders. Interview with the DON on 9/26/13 at 10:50 am, concerning Resident #1 being admitted to the facility on [DATE] with orders for a [MEDICATION NAME] Patch 50 mcg every 72 hours, revealed the [MEDICATION NAME] Patch was not obtained by the facility until 9/10/13 because the PA would not sign the triplicate. The DON stated the facility staff could not do anything if the PA would not sign the triplicate. Interview with the ADM on 9/26/13 at 11:30 am, concerning Resident #1's [MEDICATION NAME] Patch not being given from 9/3/13 - 9/10/13, revealed the [MEDICATION NAME] Patch was not available because facility staff could not get the triplicate signed. The ADM stated staff had tried calling the Physician to get the triplicate signed. When the ADM was informed there was no documentation showing that staff had tried to call the Physician to get the [MEDICATION NAME] Patch for Resident #1 that was ordered, the ADM stated she was sure they called. 2. Record review of skin assessment sheets dated 9-3-13, revealed Resident #1 had 2 wounds to right hip, 1 wound to lower abdominal area, 1 wound to right shin, 1 wound to left shin, 1 wound to mid coccyx, 1 wound to mid back, 1 wound to right buttock, 1 wound to left hip, 2 wounds to abdominal folds on the right and left, and 1 wound to upper left shoulder. There was no documentation of any draining wounds. These wound and skin assessments were only conducted weekly. Record review of Resident #1's care plan dated 9-13-13 did not address these numerous [MEDICAL CONDITION]. Record review of nurse's notes dated 9-3-13 through 9-15-13 documented Resident #1 was complaining daily of pain in the hip area. There was no notation of observation of the hip area on nurses' notes dated 9-4-13 through 9-15-13. Record review of skin assessment sheet of right hip showed a wound increasing in size from 6 cm in length and 3 cm in width on 9-3-13, to 8 cm in length and 4 centimeters in width on 9-15-13. There was no documentation of any draining wounds or any change of condition reported to the physician in the nurses' notes. Record Review of skin assessment sheet of the left hip wound on 9-8-13 showed a measurement of 2 cm in length and 1 centimeter in width. On 9-15-13, a measurement of the left hip wound showed it increasing in size to a measurement of 3 cm in length and 2 cm in width. There was no documentation of any draining wounds or any change of condition reported to the physician in the nurses' notes. Review of the MAR indicated [REDACTED]. Chlorine is the active ingredient in Dakin's solution. The MAR indicated [REDACTED]. There were no other orders for treatment of [REDACTED]. During an interview on 9-23-13 with the SW at the [MEDICAL TREATMENT] Center, she stated she had contact with Resident #1 on 9-16-13 at the [MEDICAL TREATMENT] Center. The SW stated Resident #1 was sitting in the hallway in a wheelchair, with her head down and moaning. The SW asked Resident #1 what was wrong. Resident #1 stated her hips and stomach hurt. Resident #1 was taken into a room; the MD examined the resident and discovered multiple wounds on the both hips, and a very large wound on the abdomen. The SW stated the waistband of Resident #1's pants was causing pressure and pain on these uncovered sores. The SW stated that an ambulance was called and Resident #1 was taken to the emergency room . The SW stated these wounds should have been covered or have had some type of dressing on them. The SW stated the facility had not addressed these wounds. Interview on 9-25-13 at 11:30 a.m., with the [MEDICAL TREATMENT] Center MD, the [MEDICAL TREATMENT] Center MD stated Resident #1 was seen at the [MEDICAL TREATMENT] center on 9-16-13. The [MEDICAL TREATMENT] Center MD stated that Resident #1 has a condition called [DIAGNOSES REDACTED] that causes multiple [MEDICAL CONDITION] on the body and the resident will continue to get new [MEDICAL CONDITION]. The condition is painful and is usually caused by end stage [MEDICAL CONDITION]. The [MEDICAL TREATMENT] Center MD stated the back and abdominal wounds were not the concern, the left hip and flank wounds were terribly infected, pus was oozing out of these wounds and the wounds were not covered. The [MEDICAL TREATMENT] Center MD felt like these wounds had not been addressed. The [MEDICAL TREATMENT] Center MD stated the facility should have taken note of these areas and noticed Resident #1 needed a higher level of care. The [MEDICAL TREATMENT] Center MD stated they called an ambulance and Resident #1 was taken to the emergency room . Interview with a family member of Resident #1, on 9-25-13 at 11:50 a.m., revealed concern that staff did not take care of Resident #1's wounds. Resident #1 was to have daily wound care and the staff did not do this. The family member stated Resident #1 would ask the staff to clean the wounds and they would ignore these requests. The family member had gone to the facility to see Resident #1 before [MEDICAL TREATMENT] on 9-16-13 and Resident #1 was sick and "acting out of it." The family member had expressed concerns to the administrator about the poor care Resident #1 received at the facility. It was determined these failures placed Resident #1 in a Past IJ situation from 9-3-13 to 9-16-13. The Administrator was notified of the Past IJ on 10-14-13 at 3:15 p.m. The facility demonstrated the following measures to correct the noncompliance: Resident #1 no longer resides in the facility. The facility recognized all residents in the facility could be affected. The facility held a Quaility Assurance meeting on 9-20-13 to discuss pain management, protocols, and wound care. The DON is completing weekly skin rounds on residents in the facility. The DON will audit skin treatments weekly for 8 weeks for effectiveness. The physician will be contacted for any changes in wounds that do not heal. A directed inservice will be held on 10-17-13, which will include training on wound care, pain management, and providing pain medications. Record Review of 9 active resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with 2 residents on a pain management program revealed they are satisfied and have no complaints. Review of the facility's CMS Form 672, obtained 9/26/13, confirmed the census was 37.

Based on interview and record review the facility failed to provide the necessary care and services to ensure 1 of 11 Residents, Resident #1 attained the highest practicable, physical, mental and psychosocial well-being by: 1. The facility failed to provide a physician's orders [REDACTED]. Resident #1 experienced severe pain related to wounds on her body from 9/3/10 - 9/16/13. 2. The facility failed to assess, recognize, and notify physician regarding the development and worsening of wounds. Resident #1 was transported from the facility to the [MEDICAL TREATMENT] Center where she was assessed, sent to the emergency room , and admitted to the critical care unit with a [DIAGNOSES REDACTED]. After Administrative review, the surveyors re-entered the facility on 10/14/13 to gather more information and a Past Immediate Jeopardy (IJ) was identified that existed from 9-3-13 to 9-16-13 for Resident #1. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Past IJ. This deficient practice could place 7 of 37 residents identified with wounds in the facility at risk for neglect, by not recognizing a change in condition and promptly notifying the physician. Findings include: Record review of the Resident #1's chart on 9-25-13, revealed Resident #1 is [AGE] years of age, and was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. ([DIAGNOSES REDACTED] is a condition of vascular calcification of the skin and cutaneous necrosis. The mortality rate is high, with more than 50 percent of patients dying within one year of diagnosis. The exact pathogenesis of [DIAGNOSES REDACTED] is unclear. Lower extremities are most commonly involved. Treatment options include wound care, surgical debridement, sodium [MEDICATION NAME], bisphosphonates, hyperbaric oxygen). The Journal of Clinical and Aesthetic Dermatology. Record review of Resident #1's admission orders [REDACTED]. Record review of Resident #1's pain evaluation dated 9-3-13, revealed Resident #1's pain level on that date was 9-10 on a scale of 1-10. The location of the pain was documented to be in the hips and was chronic and frequent. Record review of the nursing facility's daily skilled nursing notes, dated 9/3/13, revealed the following: Resident #1 had been on a scheduled pain medication regimen. Resident #1 complained of pain in the hips and was bed bound due to severe weakness and pain. Record review of Physician Telephone Orders, dated 9-4-13, reflected: a decrease in [MEDICATION NAME] from 50 mcg to 25 mcg topically every 72 hours. Record Review of Resident #1's MAR for September 2013 revealed the order for the [MEDICATION NAME] Patch had been changed from to 50 mcg to 25 mcg on 9-6-13, but there was no entry for the [MEDICATION NAME] Patch being given at all between 9-3-13 and 9-10-13. Record review of the nursing facility's daily skilled nursing notes, dated 9/6/13, the PA was called by facility staff requesting increase in pain medication. The PA replied, "Absolutely not!! Please do not call to ask for increased pain medications. Once she (Resident #1) begins eating and moving around some, then he may increase the dose, but not until then." Record review of the nursing facility's daily skilled nursing notes, dated 9/8/13, revealed no [MEDICATION NAME] available for Resident #1. DON was called and informed. Order and date of birth of Resident #1 was faxed to Physician with the DON to follow up on 9/9/13 in the morning. There is no documentation in Resident 1's chart of follow-up by the DON on 9-9-13. Record review of Resident #1's admission MDS dated [DATE] revealed that extensive assistance was required with two people in relation to bed mobility, total dependence with transfer with two people in attendance, should be assessed for pain, is on a scheduled pain regimen, has had pain the last five days, has constant pain, and describes pain as severe. 1. Resident #1's Physician Telephone Orders, dated 9/10/13, reflected: increase [MEDICATION NAME] Patch to 50 mcg every 72 hours for pain. Review of the MAR indicated [REDACTED]. Resident #1 went 7 days without receiving the physician-ordered [MEDICATION NAME] Patch. Record review of the nursing facility's daily skilled nursing notes, dated September 4,5,6,7,9,10 revealed the following: Under the section "Pain Management and Interventions" At any time in the last 5 days, has the resident been on a scheduled pain medication regimen? The box next to "No" was checked on all dates listed above. The comment section reflected Resident #1 complained of bilateral pain to the hips on all dates listed above. The nursing notes 9/10/13 documented Resident #1 was in a "pain crisis". Interview with the DON on 9-25-13 at 1:15 p.m., revealed Resident #1 was admitted on [DATE] with a large wound on the abdomen, right hip and buttocks. The DON stated they were treating the wounds with Dakin's solution daily and leaving them open to air. The DON stated, "I did not know the resident had any draining wounds. I did not see a wound on Resident #1's left hip." The DON continued, "I look at residents weekly for skin assessments. No nurse came to me with a concern or a change of condition for Resident #1." The DON acknowledged there was an odor, but said wounds always smelled. Interview with LVN B on 9-25-13 at 1:22 p.m., revealed LVN B had instructions to leave the belly wound alone. LVN B stated Resident #1 had yeast under abdominal folds, and wounds on the right hip had brown slough. LVN B acknowledged not being able to remember when she last looked at Resident #1's wounds. LVN B stated the wounds were getting larger and had more of an odor. LVN B stated she didn't call the doctor for a change of condition because they were told not to do anything. Interview with the PA on 9/26/13 at 10:37 am, concerning Resident #1, revealed the PA could not remember this resident or if the facility staff had ever tried to contact him concerning Resident #1's medication or wound orders. Interview with the DON on 9/26/13 at 10:50 am, concerning Resident #1 being admitted to the facility on [DATE] with orders for a [MEDICATION NAME] Patch 50 mcg every 72 hours, revealed the [MEDICATION NAME] Patch was not obtained by the facility until 9/10/13 because the PA would not sign the triplicate. The DON stated the facility staff could not do anything if the PA would not sign the triplicate. Interview with the ADM on 9/26/13 at 11:30 am, concerning Resident #1's [MEDICATION NAME] Patch not being given from 9/3/13 - 9/10/13, revealed the [MEDICATION NAME] Patch was not available because facility staff could not get the triplicate signed. The ADM stated staff had tried calling the Physician to get the triplicate signed. When the ADM was informed there was no documentation showing that staff had tried to call the Physician to get the [MEDICATION NAME] Patch for Resident #1 that was ordered, the ADM stated she was sure they called. 2. Record review of skin assessment sheets dated 9-3-13, revealed Resident #1 had 2 wounds to right hip, 1 wound to lower abdominal area, 1 wound to right shin, 1 wound to left shin, 1 wound to mid coccyx, 1 wound to mid back, 1 wound to right buttock, 1 wound to left hip, 2 wounds to abdominal folds on the right and left, and 1 wound to upper left shoulder. There was no documentation of any draining wounds. These wound and skin assessments were only conducted weekly. Record review of Resident #1's care plan dated 9-13-13 did not address these numerous [MEDICAL CONDITION]. Record review of nurse's notes dated 9-3-13 through 9-15-13 documented Resident #1 was complaining daily of pain in the hip area. There was no notation of observation of the hip area on nurses' notes dated 9-4-13 through 9-15-13. Record review of skin assessment sheet of right hip showed a wound increasing in size from 6 cm in length and 3 cm in width on 9-3-13, to 8 cm in length and 4 centimeters in width on 9-15-13. There was no documentation of any draining wounds or any change of condition reported to the physician in the nurses' notes. Record Review of skin assessment sheet of the left hip wound on 9-8-13 showed a measurement of 2 cm in length and 1 centimeter in width. On 9-15-13, a measurement of the left hip wound showed it increasing in size to a measurement of 3 cm in length and 2 cm in width. There was no documentation of any draining wounds or any change of condition reported to the physician in the nurses' notes. Review of the MAR indicated [REDACTED]. Chlorine is the active ingredient in Dakin's solution. The MAR indicated [REDACTED]. There were no other orders for treatment of [REDACTED]. During an interview on 9-23-13 with the SW at the [MEDICAL TREATMENT] Center, she stated she had contact with Resident #1 on 9-16-13 at the [MEDICAL TREATMENT] Center. The SW stated Resident #1 was sitting in the hallway in a wheelchair, with her head down and moaning. The SW asked Resident #1 what was wrong. Resident #1 stated her hips and stomach hurt. Resident #1 was taken into a room; the MD examined the resident and discovered multiple wounds on the both hips, and a very large wound on the abdomen. The SW stated the waistband of Resident #1's pants was causing pressure and pain on these uncovered sores. The SW stated that an ambulance was called and Resident #1 was taken to the emergency room . The SW stated these wounds should have been covered or have had some type of dressing on them. The SW stated the facility had not addressed these wounds. Interview on 9-25-13 at 11:30 a.m., with the [MEDICAL TREATMENT] Center MD, the [MEDICAL TREATMENT] Center MD stated Resident #1 was seen at the [MEDICAL TREATMENT] center on 9-16-13. The [MEDICAL TREATMENT] Center MD stated that Resident #1 has a condition called [DIAGNOSES REDACTED] that causes multiple [MEDICAL CONDITION] on the body and the resident will continue to get new [MEDICAL CONDITION]. The condition is painful and is usually caused by end stage [MEDICAL CONDITION]. The [MEDICAL TREATMENT] Center MD stated the back and abdominal wounds were not the concern, the left hip and flank wounds were terribly infected, pus was oozing out of these wounds and the wounds were not covered. The [MEDICAL TREATMENT] Center MD felt like these wounds had not been addressed. The [MEDICAL TREATMENT] Center MD stated the facility should have taken note of these areas and noticed Resident #1 needed a higher level of care. The [MEDICAL TREATMENT] Center MD stated they called an ambulance and Resident #1 was taken to the emergency room . Interview with a family member of Resident #1, on 9-25-13 at 11:50 a.m., revealed concern that staff did not take care of Resident #1's wounds. Resident #1 was to have daily wound care and the staff did not do this. The family member stated Resident #1 would ask the staff to clean the wounds and they would ignore these requests. The family member had gone to the facility to see Resident #1 before [MEDICAL TREATMENT] on 9-16-13 and Resident #1 was sick and "acting out of it." The family member had expressed concerns to the administrator about the poor care Resident #1 received at the facility. It was determined these failures placed Resident #1 in a Past IJ situation from 9-3-13 to 9-16-13. The Administrator was notified of the Past IJ on 10-14-13 at 3:15 p.m. The facility demonstrated the following measures to correct the noncompliance: Resident #1 no longer resides in the facility. The facility recognized all residents in the facility could be affected. The facility held a Quaility Assurance meeting on 9-20-13 to discuss pain management, protocols, and wound care. The DON is completing weekly skin rounds on residents in the facility. The DON will audit skin treatments weekly for 8 weeks for effectiveness. The physician will be contacted for any changes in wounds that do not heal. A directed inservice will be held on 10-17-13, which will include training on wound care, pain management, and providing pain medications. Record Review of 9 active resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview with 2 residents on a pain management program revealed they are satisfied and have no complaints. Review of the facility's CMS Form 672, obtained 9/26/13, confirmed the census was 37.

Based on interview and record review, it was determined the facility failed to ensure 1 of 11 residents, Resident #1, reviewed was free of significant medication errors. Resident #1 did not receive the physician-ordered [MEDICATION NAME] Patch (used for pain relief) from 09/03/13 to 09/10/13. This failure adversely affected Resident #1 causing Resident #1 to be in significant pain for 7 days in a row. Resident #1 was transported from the facility to the [MEDICAL TREATMENT] Center where she was assessed, sent to the emergency room , and admitted to the critical care unit with a [DIAGNOSES REDACTED]. After Administrative review, the surveyors re-entered the facility on 10/14/13 to gather more information and a Past Immediate Jeopardy (IJ) was identified that existed from 9-3-13 to 9-16-13 for Resident #1. The facility remained out of compliance at a pattern of actual harm due to the need to institute corrective measures for the failures that caused the Past IJ. This failure to ensure medication was administered as ordered by the physician could affect all 37 residents who reside at the nursing facility and place the residents at risk for the potential of exacerbation of their [DIAGNOSES REDACTED]. Findings included: Record review of the Resident #1's chart revealed Resident #1 is [AGE] years of age, and was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. ([DIAGNOSES REDACTED] is a condition of vascular calcification of the skin and cutaneous necrosis. The mortality rate is high, with more than 50 percent of patients dying within one year of diagnosis. The exact pathogenesis of [DIAGNOSES REDACTED] is unclear. Lower extremities are most commonly involved. Treatment options include wound care, surgical debridement, sodium [MEDICATION NAME], bisphosphonates, hyperbaric oxygen). The Journal of Clinical and Aesthetic Dermatology. Record review of Resident #1's admission orders [REDACTED]. Record review of Resident #1's pain evaluation dated 9-3-13, revealed Resident #1's pain level on that date was 9-10 on a scale of 1-10. The location of the pain was documented to be in the hips and was chronic and frequent. Record review of the nursing facility's daily skilled nursing notes, dated 9/3/13, revealed the following: Resident #1 had been on a scheduled pain medication regimine. Resident #1 complained of pain in the hips and was bed bound due to severe weakness and pain. Record review of Physician Telephone Orders, dated 9-4-13, reflected: a decrease in [MEDICATION NAME] from 50mcg to 25mcg topically every 72 hours. Record Review of Resident #1's MAR for September 2013 revealed the order for the [MEDICATION NAME] Patch had been changed from to 50mcg to 25 mcg on 9-6-13, but there was no entry for the [MEDICATION NAME] Patch being given at all between 9-3-13 and 9-10-13. Record review of the nursing facility's daily skilled nursing notes, dated September 4,5,6,7,9,10 revealed the following: Under the section "Pain Management and Interventions" At any time in the last 5 days, has the resident been on a scheduled pain medication regimen? The box next to "No" was checked on all dates listed above. The comment section reflected Resident #1 complained of bilateral pain to the hips on all dates listed above. Record review of the nursing facility's daily skilled nursing notes, dated 9/6/13, the PA was called by facility staff requesting increase in pain medication. The PA replied, "Absolutely not!! Please do not call to ask for increased pain medications. Once she (Resident #1) begins eating and moving around some, then he may increase the dose, but not until then." Record review of the nursing facility's daily skilled nursing notes, dated 9/8/13, revealed no [MEDICATION NAME] available for Resident #1. DON was called and informed. Order and date of birth of Resident #1 was faxed to Physician with the DON to follow up on 9/9/13 in the morning. There is no documentation in Resident 1's chart of follow-up by the DON on 9-9-13. Resident #1's Physician Telephone Orders, dated 9/10/13, reflected: increase [MEDICATION NAME] Patch to 50 mcg every 72 hours. Review of the MAR indicated [REDACTED]. Resident #1 went 7 days without receiving the physician-ordered [MEDICATION NAME] Patch. Record review of Resident #1's admission MDS dated [DATE] revealed that extensive assistance was required with two people in relation to bed mobility, total dependence with transfer with two people in attendance, be assessed for pain, was on a scheduled pain regimen, has had pain the last five days, has constant pain, and described pain as severe. An interview with the PA on 9/26/13 at 10:37 am, concerning Resident #1, revealed the PA could not remember this resident or if the facility staff had ever tried to contact him concerning Resident #1's medication orders. Interview with the DON on 9/26/13 at 10:50 am, concerning Resident #1 being admitted to the facility on [DATE] with orders for a [MEDICATION NAME] Patch 50 mcg every 72 hours, revealed the [MEDICATION NAME] Patch was not obtained by the facility until 9/10/13 because the PA would not sign the triplicate. The DON stated the facility staff could not do anything if the PA would not sign the triplicate. Interview with the ADM on 9/26/13 at 11:30 am, concerning Resident #1's [MEDICATION NAME] Patch not being given from 9/3/13 - 9/10/13, revealed the [MEDICATION NAME] Patch was not available because facility staff could not get the triplicate signed. The ADM stated staff had tried calling the Physician to get the triplicate signed. When the ADM was informed there was no documentation showing that staff had tried to call the Physician to get the [MEDICATION NAME] Patch for Resident #1 that was ordered, the ADM stated she was sure they called. It was determined these failures placed Resident #1 in a Past IJ situation from 9-3-13 to 9-16-13. The Administrator was notified of the Past IJ on 10-14-13 at 3:15 p.m. The facility demonstrated the following measures to correct the noncompliance: Resident #1 no longer resides at the facility. The facility recognizes all residents could be affected by this deficient practice. The facility had a nursing consultant initiated inservice on 9-19-13 on obtaining triplicate prescriptions in a timely manner. The DON had an inservice for nursing staff on obtaining triplicate prescriptions. The DON will monitior physician orders [REDACTED]. A directed inservice will be held on 10-17-13 which will include providing pain medications, The DON audited pain evaluations on residents to determine if assessments were completed. The DON will continue to monitor pain assessments on a random basis, 2 times weekly for the next 8 weeks. The DON/Designee will report results of pain assessment monitoring to the Quality Assessment and Assurance committee for 60 days. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interviews with 2 residents on a pain management program revealed they were very satisfied and have no complaints with their current pain management program. Review of the facility's CMS Form 672, obtained 9/26/13, confirmed the census was 37.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to help Resident #2 attain or maintain their highest practicable physical, mental, and psychosocial well-being when they failed to provide pain management for 1 of 13 sampled residents (Residents #2), This failure was evidenced by: Resident #2 was observed to have a [MEDICATION NAME] placed incorrectly on 11/27/12 at 4:15 p.m., at that time she complained that her chest and her ear were hurting. Resident #2 was observed crying and moaning on 11/28/12 at 8:30 a.m. the MAR indicated [REDACTED]. The facility's failure to provide pharmacy services as ordered placed Residents #2, as well as 10 other residents, who were on a pain management program, at risk of not having their pain managed effectively. The evidence is as follows: 1. Resident #2 Review of Resident #2's clinical record documented the following: - She was a [AGE] year old female who admitted to the facility on [DATE], with the following Diagnosis: [REDACTED]. - The care plan dated 11/1/12, documented she had a compression fracture to Lumbar 1 confirmed by MRI and has severe pain at times. An updated entry on 11/15/12 documented that pain was controlled at this time with [MEDICATION NAME] and [MEDICATION NAME] and that a pain management physican was using injections to control the pain. - The MDS resident assessment, dated 10/16/12, documented the following: she could repeat three of three words, and could recall three words. It documented she was oriented to the correct month and day of the week but unable to recall the correct year. It documented that she received scheduled pain medication and as needed pain medication and almost constantly experienced pain or hurting. It documented her pain level was a 9 out a numeric rating score of 1-10. It documented the intensity as severe. Entries in Progress notes: - 11/8/12 - When CNA offers bath, resident screams in pain and refuses. - 11/15/12 - Resident moans and groans every time she is touched. - 11/13/12 resident complained of pain and documented an order was received for [MEDICATION NAME] 50 mg 1 tab orally every 4 hours as needed for moderate pain and 2 tabs as needed for severe pain. - 11/21/12 that Resident #2 was having LLL( left lower lobe) pain. A chest x-ray was performed which suggested a [DIAGNOSES REDACTED]. - 11/23/12 at 10:45, an entry was made in the nurses notes continues on PRN breathing treatments, states "I finally coughed up a big ball of mucous last night. That left side isn't as sore now". - 11/28/12 - Resident tearful and crying out in pain. - The November 2012 physician recapitulation order documented [MEDICATION NAME] one 50 mcg patch topically every 72 hours for pain. An order was written on 11/13/12 for [MEDICATION NAME] 50 mg 1 orally every 4 hours as needed for moderate pain, [MEDICATION NAME] 50 mg 2 tabs orally every 4 hours as needed for severe pain. The MAR indicated [REDACTED]. - A Cat scan was ordered on [DATE] with results being obtained on 11/28/12 which reported a mass in the chest area. A Hospice referral was made on 11/28/12 at 8:20 a.m. after the physican received the report. 2. During an interview with Resident #2, at 4:00 p.m., she said she has a lot of back and chest pain. She said she had a pain patch but continued to have pain all the time. She said she needs assistance with all activities of daily living. She said there are problems controlling her pain, which is mostly in the chest area. She said she also is having trouble swallowing and that she is ready to die. 3. During an observation on 11/27/12 at 4:15 p.m. in Resident #2's room, with LVN A, she showed the surveyor the [MEDICATION NAME] that was placed on the right inner arm, under the axillary area. LVN A said she had given Resident #2 some pain medication earlier today. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. LVN A said she did not know why it said on hold. There was no order for the medication to be held. 4. During an observation on 11/28/12 at 8:30 a.m. in Resident #2's room, she was crying and moaning and stated she needed some pain medicine and that her chest hurt. 5. During an interview with the Corporate Nurse on 11/27/12 at 4:35 p.m., she said the inner arm is not a good place for the patch because of problems with absorption. 6. During an interview with the Corporate Nurse on 11/28/12 at 9:00 a.m., she said she had in-serviced the nursing staff on the proper placement of [MEDICATION NAME]es. She said she had removed the [MEDICATION NAME] from Resident #2's arm and it was replaced to the chest area. 7. During an interview with the Hospice Nurse on 11/29/12 at 11:00 a.m., she said the pain regimen that was ordered since Resident #2 was admitted to hospice is working. She said she would talk to the physician about ordering medications PRN because the staff won't usually give the medication as needed. 8. A facility submitted policy titled Medication Administration, [MEDICATION NAME] Delivery Systems (Patches) dated 10/07, documented to check the last site of application and to select a new appropriate site, rotating in accordance with manufacturer's recommendation. 9. According to the Lippincott Nursing 2012 Drug Handbook, it indicates that the best place to place a [MEDICATION NAME] would be on the chest or back. 10. The CMS form 672 completed and signed by the MDS Coord. listed 11 residents on a pain management program out of 52 residents in the facility.

Based on record reviews and interviews, it was determined the facility failed to ensure 1 of 12 sampled residents, who was assessed and care planned to have a cognitive deficit and to be at risk of injuries due to in ability to ambulate without assistance, received timely care and services. Cognitively impaired Resident #1 had a bruised, swollen ring finger. Five days later, the physician was consulted. An x-ray revealed Resident #1 had a fractured ring finger. Furthermore, Resident #1 had a previous incident of a bruised, swollen wrist. Over 24 hours transpired before the physician was consulted. An x-ray revealed a fractured wrist. Failure to ensure nurses immediately consulted Resident #1's physician resulted in delayed evaluation and treatment. As a result, Resident #1 experienced unnecessary pain. Failure to immediately consult a resident's attending physician placed the two residents who had had fractures at risk of not receiving timely care and services. The evidence is as follows: 1. Review of Resident #1's clinical record revealed the following: - The face sheet documented she admitted to the facility on [DATE] and that her current age was 93. - The February 2011 physician's recapitulation order documented her [DIAGNOSES REDACTED]. - The admission Minimum Data Set Resident assessment, dated 2/02/11, documented Resident #1 had a short and long-term memory deficit, severe cognitive impairment, required extensive assistance with bed mobility, transfers and ambulation, used a wheelchair for mobility and had a history of [REDACTED]. - LVN "C's" nurse's note, dated 2/08/11 at 5:40 p.m., documented Resident #1 fell in the dining room while attempting to walk and landed on her buttocks. It documented she sustained no injuries. - LVN "D's" nurse's note the following day, dated 2/09/11 at 4:00 p.m., documented Resident #1's left ring finger was swollen. It documented the family was notified of the swelling and asked to call a jeweler to remove the ring. It documented a jeweler promptly arrived and removed the ring. It then documented the [MEDICAL CONDITION] continued and the finger had bruising. There was no documented evidence the physician was consulted. - The record provided no additional information regarding the bruised, swollen finger until two days later. A nurse's note, dated 2/11/10 at 12:30 a.m., LVN "D" documented Resident #1's finger continued to remain bruised and had decreased swelling, although it had 1+ [MEDICAL CONDITION] (swelling). There was no documented evidence the physician was consulted. - The nurses' notes, dated 2/11/11 at 9:30 a.m. and 8:00 p.m., and 2/12/11 at 8:15 a.m. and 8:00 p.m., provided additional evidence Resident #1's left finger continued to remain swollen. The notes on 2/11/11 and 2/12/11 were written by LVN "A" and LVN "E", respectively. - LVN "A's" nurses' notes, dated 2/13/11 (Sunday), documented at 7:30 a.m., Resident #1 continued to have bruising to her palm and ring finger. LVN "A" noted at 9:50 a.m., Resident #1 fell in in the lobby landing on her left hand and buttock. The notes documented she was assessed and had no new injuries. The notes added that her left ring finger had swelling to the inner knuckle and Resident #1 was rubbing her finger. The notes then documented that at 10:20 a.m., a facsimile (fax) was sent to the physician regarding the swollen ring finger, but there was no documented evidence the physician was immediately contacted (i.e., by telephone) to consult with him regarding the swollen finger. LVN "A" then documented at 10:30 a.m., Resident #1's left hand was elevated above her heart and the left ring finger was tender when bent at the knuckle. - A nurse's note, dated 2/14/11 (Monday) at 10:50 a.m. (24 hours later), documented they received an order to send Resident #1 to the local hospital for an x-ray. It further noted she continued to have [MEDICAL CONDITION] to her left ring finger. - An x-ray report, dated 2/14/11, documented Resident #1 had a 4th proximal phalangeal fracture (fractured finger). - A nurse's note, dated 2/15/11, documented the physician gave an order for [REDACTED]. 2. During an interview with LVN "A" on 3/2/11 at 2:30 p.m., she said Resident #1 fell on [DATE] and was not wearing her splint for the left wrist at the time of the incident. She said she did not work the next two days, but when she returned, Resident #1's left ring finger was swollen and they had a jeweler cut a ring off her finger. She confirmed she failed to consult with the physician regarding the identified swelling of Resident #1's left ring finger and the need to have a jeweler cut a ring off her finger. 3. During an interview with LVN "B" on 3/3/11 at 4:00 p.m., she said she did not work as Resident #1's charge nurse, but had been present when the jeweler cut a ring off her left ring finger. She said the finger was swollen from the ring to the end of the finger. She said the finger was visibly larger than her other fingers. 4. During an interview with the ADON on 3/2/11 at 3:10 p.m., she said she was aware a jeweler had to cut a ring off Resident #1's finger, but she did not know why the finger was swollen. 5. During an interview with Resident #1's family on 3/02/11 at 4:44 p.m., they said prior to the jeweler cutting a ring off Resident #1's finger, she had never had issues with being able to wear her ring due to having no prior issues with her left ring finger swelling. 6. During an interview with Resident #1's attending physician on 3/02/11 at 4:06 p.m., he said he first became aware of the bruising and swelling of Resident #1's left ring finger after she fell on [DATE]. He said he was unaware the swelling and bruising had been present since the day after a fall on 2/8/11. He further said he had been unaware that on 2/9/11, a jeweler had to cut a ring off her left ring finger due to the swelling. He said staff should have immediately notified him of the swelling and bruising, and the need to cut the ring off her finger. He said had he been aware of this condition change, he would have given an order for [REDACTED]. 7. Further review of Resident #1's clinical record revealed that in January 2011, she fractured her left wrist. The record documented the following: - The nurses' notes documented that on 1/04/11 (a Tuesday), Resident #1 fell and was transferred to a local hospital, but she returned that same day with no new orders. The nurses' notes for 1/04/11 provided no evidence Resident #1 had a swollen, bruised left wrist and forearm. The following day, LVN "A's" nurse's notes, dated 1/5/11 at 7:00 a.m., documented Resident #1 was found with a purple-red bruise from her left wrist from her mid forearm to her hand. There was no documented evidence the physician was immediately consulted, although, 24 hours later on 1/06/11 at 7:00 a.m., LVN "A" documented Resident #1 had 3+ [MEDICAL CONDITIONS] to her left wrist and hand with dark purple bruising measuring 9 cm x 2 1/2 cm. LVN "A" documented the area was red and warm to touch and the resident said, "Ouch," when it was touched. LVN "A" documented that two hours later (not immediately) she left a message for the physician and the physician responded at 9:10 a.m. with an order to obtain an x-ray of her wrist. - An x-ray report, dated 1/06/11, documented the findings were a "questionable" hairline fracture and evidence of osteopenia (reduction in bone volume). A subsequent x-ray, dated 1/21/11, documented the conclusion was ". . . suggestive of nondisplaced scaphoid wrist fracture". (Scaphoid is one of the bones in the wrist.) An x-ray report, dated 2/14/11, documented there was no change in the appearance of the scaphoid wrist fracture. 8. During an interview with the DON on 3/2/11 at 3:00 p.m., she said she was a corporate registered nurse and the interim DON. She said the prior DON had not worked since approximately the end of December 2010 and the facility had no other registered nurses. She said she became the interim DON the middle of February 2011. She said she thought Resident #1 admitted with the wrist fracture. She said she knew about Resident #1's subsequent fractured ring finger. She said she thought Resident #1's finger was swollen due to the ring being too tight and that the fracture occurred when the jeweler cut the ring off her finger. She said she was unaware the nurses failed to immediately consult the physician regarding Resident #1's swollen, bruised left ring finger. She said nurses were to call the physician when a resident had an injury or change of condition. When asked to provide evidence of additional training for nurses regarding timely consultation with resident's attending physician, she was unable to provide any evidence of additional training. 9. The facility's Resident Roster, dated 3/1/2011, documented two residents with fractures.

Based on record reviews and interviews, it was determined 4 nurses failed to immediately notify 1 of 12 sampled residents' attending physician when they noted a change in Resident #1's condition requiring a need for possible evaluation and treatment. Cognitively impaired Resident #1 had a bruised, swollen ring finger. Five days later, the physician was consulted. An x-ray revealed Resident #1 had a fractured ring finger. Furthermore, Resident #1 had a previous incident of a bruised, swollen wrist. Over 24 hours transpired before the physician was consulted. An x-ray revealed a fractured wrist. Failure to immediately consult Resident #1's physician resulted in delayed evaluation and treatment. As a result, Resident #1 experienced unnecessary pain. Failure to immediately consult a resident's attending physician placed the two residents who had had fractures at risk of not receiving timely care and services. The evidence is as follows: 1. Review of Resident #1's clinical record revealed the following: - The face sheet documented she admitted to the facility on [DATE] and that her current age was 93. - The February 2011 physician's recapitulation order documented her [DIAGNOSES REDACTED]. - The admission Minimum Data Set Resident assessment, dated 2/02/11, documented Resident #1 had a short and long-term memory deficit, severe cognitive impairment, required extensive assistance with bed mobility, transfers and ambulation, used a wheelchair for mobility and had a history of [REDACTED]. - LVN "C's" nurse's note, dated 2/08/11 at 5:40 p.m., documented Resident #1 fell in the dining room while attempting to walk and landed on her buttocks. It documented she sustained no injuries. - LVN "D's" nurse's note the following day, dated 2/09/11 at 4:00 p.m., documented Resident #1's left ring finger was swollen. It documented the family was notified of the swelling and asked to call a jeweler to remove the ring. It documented a jeweler promptly arrived and removed the ring. It then documented the [MEDICAL CONDITION] continued and the finger had bruising. There was no documented evidence the physician was consulted. - The record provided no additional information regarding the bruised, swollen finger until two days later. A nurse's note, dated 2/11/10 at 12:30 a.m., LVN "D" documented Resident #1's finger continued to remain bruised and had decreased swelling, although it had 1+ [MEDICAL CONDITION] (swelling). There was no documented evidence the physician was consulted. - The nurses' notes, dated 2/11/11 at 9:30 a.m. and 8:00 p.m., and 2/12/11 at 8:15 a.m. and 8:00 p.m., provided additional evidence Resident #1's left finger continued to remain swollen. The notes on 2/11/11 and 2/12/11 were written by LVN "A" and LVN "E", respectively. - LVN "A's" nurses' notes, dated 2/13/11 (Sunday), documented at 7:30 a.m., Resident #1 continued to have bruising to her palm and ring finger. LVN "A" noted at 9:50 a.m., Resident #1 fell in in the lobby landing on her left hand and buttock. The notes documented she was assessed and had no new injuries. The notes added that her left ring finger had swelling to the inner knuckle and Resident #1 was rubbing her finger. The notes then documented that at 10:20 a.m., a facsimile (fax) was sent to the physician regarding the swollen ring finger, but there was no documented evidence the physician was immediately contacted (i.e., by telephone) to consult with him regarding the swollen finger. LVN "A" then documented at 10:30 a.m., Resident #1's left hand was elevated above her heart and the left ring finger was tender when bent at the knuckle. - A nurse's note, dated 2/14/11 (Monday) at 10:50 a.m. (24 hours later), documented they received an order to send Resident #1 to the local hospital for an x-ray. It further noted she continued to have [MEDICAL CONDITION] to her left ring finger. - An x-ray report, dated 2/14/11, documented Resident #1 had a 4th proximal phalangeal fracture (fractured finger). - A nurse's note, dated 2/15/11, documented the physician gave an order for [REDACTED]. 2. During an interview with LVN "A" on 3/2/11 at 2:30 p.m., she said Resident #1 fell on [DATE] and was not wearing her splint for the left wrist at the time of the incident. She said she did not work the next two days, but when she returned, Resident #1's left ring finger was swollen and they had a jeweler cut a ring off her finger. She confirmed she failed to consult with the physician regarding the identified swelling of Resident #1's left ring finger and the need to have a jeweler cut a ring off her finger. 3. During an interview with Resident #1's attending physician on 3/02/11 at 4:06 p.m., he said he first became aware of the bruising and swelling of Resident #1's left ring finger after she fell on [DATE]. He said he was unaware the swelling and bruising had been present since the day after a fall on 2/8/11. He further said he had been unaware that on 2/9/11, a jeweler had to cut a ring off her left ring finger due to the swelling. He said staff should have immediately notified him of the swelling and bruising, and the need to cut the ring off her finger. He said had he been aware of this condition change, he would have given an order for [REDACTED]. 5. Further review of Resident #1's clinical record revealed that in January 2011, she fractured her left wrist. The record documented the following: - The nurses' notes documented that on 1/04/11 (a Tuesday), Resident #1 fell and was transferred to a local hospital, but she returned that same day with no new orders. The nurses' notes for 1/04/11 provided no evidence Resident #1 had a swollen, bruised left wrist and forearm. The following day, LVN "A's" nurse's notes, dated 1/5/11 at 7:00 a.m., documented Resident #1 was found with a purple-red bruise from her left wrist from her mid forearm to her hand. There was no documented evidence the physician was immediately consulted, although, 24 hours later on 1/06/11 at 7:00 a.m., LVN "A" documented Resident #1 had 3+ [MEDICAL CONDITIONS] to her left wrist and hand with dark purple bruising measuring 9 cm x 2 1/2 cm. LVN "A" documented the area was red and warm to touch and the resident said, "Ouch," when it was touched. LVN "A" documented that two hours later (not immediately) she left a message for the physician and the physician responded at 9:10 a.m. with an order to obtain an x-ray of her wrist. - An x-ray report, dated 1/06/11, documented the findings were a "questionable" hairline fracture and evidence of osteopenia (reduction in bone volume). A subsequent x-ray, dated 1/21/11, documented the conclusion was ". . . suggestive of nondisplaced scaphoid wrist fracture". (Scaphoid is one of the bones in the wrist.) An x-ray report, dated 2/14/11, documented there was no change in the appearance of the scaphoid wrist fracture. 6. During an interview with the DON on 3/2/11 at 3:00 p.m., she said she was a corporate registered nurse and the interim DON. She said the prior DON had not worked since approximately the end of December 2010 and the facility had no other registered nurses. She said she became the interim DON the middle of February 2011. She said she thought Resident #1 admitted with the wrist fracture. She said she knew about Resident #1's subsequent fractured ring finger. She said she thought Resident #1's finger was swollen due to the ring being too tight and that the fracture occurred when the jeweler cut the ring off her finger. She said she was unaware the nurses failed to immediately consult the physician regarding Resident #1's swollen, bruised left ring finger. She said nurses were to call the physician when a resident had an injury or change of condition. When asked to provide evidence of additional training for nurses regarding timely consultation with resident's attending physician, she was unable to provide any evidence of additional training. 7. The facility's Resident Roster, dated 3/1/2011, documented two residents with fractures.

Based on record reviews and interviews, it was determined the facility failed to prohibit incidents of neglect when for 1 of 12 sampled residents 4 nurses failed to ensure Resident #1 received timely evaluation and treatment. Cognitively impaired Resident #1 had a bruised, swollen ring finger. Five days later, the physician was consulted. An x-ray revealed Resident #1 had a fractured ring finger. Furthermore, Resident #1 had a previous incident of a bruised, swollen wrist. Over 24 hours transpired before the physician was consulted. An x-ray revealed a fractured wrist. Failure to immediately consult Resident #1's physician resulted in delayed evaluation and treatment. As a result, Resident #1 experienced unnecessary pain. This facility failure to prohibit incidents of resident neglect related to failure to immediately consult with a resident's attending physician placed the two residents who had had fractures at risk of not receiving timely care and services. all residents at risk of not receiving timely care and services. The evidence is as follows: 1. Review of Resident #1's clinical record revealed the following: - The face sheet documented she admitted to the facility on [DATE] and that her current age was 93. - The February 2011 physician's recapitulation order documented her [DIAGNOSES REDACTED]. - The admission Minimum Data Set Resident assessment, dated 2/02/11, documented Resident #1 had a short and long-term memory deficit, severe cognitive impairment, required extensive assistance with bed mobility, transfers and ambulation, used a wheelchair for mobility and had a history of [REDACTED]. - LVN "C's" nurse's note, dated 2/08/11 at 5:40 p.m., documented Resident #1 fell in the dining room while attempting to walk and landed on her buttocks. It documented she sustained no injuries. - LVN "D's" nurse's note the following day, dated 2/09/11 at 4:00 p.m., documented Resident #1's left ring finger was swollen. It documented the family was notified of the swelling and asked to call a jeweler to remove the ring. It documented a jeweler promptly arrived and removed the ring. It then documented the [MEDICAL CONDITION] continued and the finger had bruising. There was no documented evidence the physician was consulted. - The record provided no additional information regarding the bruised, swollen finger until two days later. A nurse's note, dated 2/11/10 at 12:30 a.m., LVN "D" documented Resident #1's finger continued to remain bruised and had decreased swelling, although it had 1+ [MEDICAL CONDITION] (swelling). There was no documented evidence the physician was consulted. - The nurses' notes, dated 2/11/11 at 9:30 a.m. and 8:00 p.m., and 2/12/11 at 8:15 a.m. and 8:00 p.m., provided additional evidence Resident #1's left finger continued to remain swollen. The notes on 2/11/11 and 2/12/11 were written by LVN "A" and LVN "E", respectively. - LVN "A's" nurses' notes, dated 2/13/11 (Sunday), documented at 7:30 a.m., Resident #1 continued to have bruising to her palm and ring finger. LVN "A" noted at 9:50 a.m., Resident #1 fell in in the lobby landing on her left hand and buttock. The notes documented she was assessed and had no new injuries. The notes added that her left ring finger had swelling to the inner knuckle and Resident #1 was rubbing her finger. The notes then documented that at 10:20 a.m., a facsimile (fax) was sent to the physician regarding the swollen ring finger, but there was no documented evidence the physician was immediately contacted (i.e., by telephone) to consult with him regarding the swollen finger. LVN "A" then documented at 10:30 a.m., Resident #1's left hand was elevated above her heart and the left ring finger was tender when bent at the knuckle. - A nurse's note, dated 2/14/11 (Monday) at 10:50 a.m. (24 hours later), documented they received an order to send Resident #1 to the local hospital for an x-ray. It further noted she continued to have [MEDICAL CONDITION] to her left ring finger. - An x-ray report, dated 2/14/11, documented Resident #1 had a 4th proximal phalangeal fracture (fractured finger). - A nurse's note, dated 2/15/11, documented the physician gave an order for [REDACTED]. 2. During an interview with LVN "A" on 3/2/11 at 2:30 p.m., she said Resident #1 fell on [DATE] and was not wearing her splint for the left wrist at the time of the incident. She said she did not work the next two days, but when she returned, Resident #1's left ring finger was swollen and they had a jeweler cut a ring off her finger. She confirmed she failed to consult with the physician regarding the identified swelling of Resident #1's left ring finger and the need to have a jeweler cut a ring off her finger. 3. During an interview with LVN "B" on 3/3/11 at 4:00 p.m., she said she did not work as Resident #1's charge nurse, but had been present when the jeweler cut a ring off her left ring finger. She said the finger was swollen from the ring to the end of the finger. She said the finger was visibly larger than her other fingers. 4. During an interview with the ADON on 3/2/11 at 3:10 p.m., she said she was aware a jeweler had to cut a ring off Resident #1's finger, but she did not know why the finger was swollen. 5. During an interview with Resident #1's family on 3/02/11 at 4:44 p.m., they said prior to the jeweler cutting a ring off Resident #1's finger, she had never had issues with being able to wear her ring due to having no prior issues with her left ring finger swelling. 6. During an interview with Resident #1's attending physician on 3/02/11 at 4:06 p.m., he said he first became aware of the bruising and swelling of Resident #1's left ring finger after she fell on [DATE]. He said he was unaware the swelling and bruising had been present since the day after a fall on 2/8/11. He further said he had been unaware that on 2/9/11, a jeweler had to cut a ring off her left ring finger due to the swelling. He said staff should have immediately notified him of the swelling and bruising, and the need to cut the ring off her finger. He said had he been aware of this condition change, he would have given an order for [REDACTED]. 7. Further review of Resident #1's clinical record revealed that in January 2011, she fractured her left wrist. The record documented the following: - The nurses' notes documented that on 1/04/11 (a Tuesday), Resident #1 fell and was transferred to a local hospital, but she returned that same day with no new orders. The nurses' notes for 1/04/11 provided no evidence Resident #1 had a swollen, bruised left wrist and forearm. The following day, LVN "A's" nurse's notes, dated 1/5/11 at 7:00 a.m., documented Resident #1 was found with a purple-red bruise from her left wrist from her mid forearm to her hand. There was no documented evidence the physician was immediately consulted, although, 24 hours later on 1/06/11 at 7:00 a.m., LVN "A" documented Resident #1 had 3+ [MEDICAL CONDITIONS] to her left wrist and hand with dark purple bruising measuring 9 cm x 2 1/2 cm. LVN "A" documented the area was red and warm to touch and the resident said, "Ouch," when it was touched. LVN "A" documented that two hours later (not immediately) she left a message for the physician and the physician responded at 9:10 a.m. with an order to obtain an x-ray of her wrist. - An x-ray report, dated 1/06/11, documented the findings were a "questionable" hairline fracture and evidence of osteopenia (reduction in bone volume). A subsequent x-ray, dated 1/21/11, documented the conclusion was ". . . suggestive of nondisplaced scaphoid wrist fracture". (Scaphoid is one of the bones in the wrist.) An x-ray report, dated 2/14/11, documented there was no change in the appearance of the scaphoid wrist fracture. 8. During an interview with the DON on 3/2/11 at 3:00 p.m., she said she was a corporate registered nurse and the interim DON. She said the prior DON had not worked since approximately the end of December 2010 and the facility had no other registered nurses. She said she became the interim DON the middle of February 2011. She said she thought Resident #1 admitted with the wrist fracture. She said she knew about Resident #1's subsequent fractured ring finger. She said she thought Resident #1's finger was swollen due to the ring being too tight and that the fracture occurred when the jeweler cut the ring off her finger. She said she was unaware the nurses failed to immediately consult the physician regarding Resident #1's swollen, bruised left ring finger. She said nurses were to call the physician when a resident had an injury or change of condition. When asked to provide evidence of additional training for nurses regarding timely consultation with resident's attending physician, she was unable to provide any evidence of additional training. 9. Review of the facility's policies revealed the following: a. The policy titled "Change in a Resident's Condition or Status," revised December 2006 documented "Our facility shall promptly notify . . . his or her attending physician . . of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care . . . )" It further noted the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a) an accident or incident involving the resident; b) a discovery of injuries of an unknown source; d) a significant change in the resident's physical/emotional/mental condition. b. The policy titled "Abuse and Neglect Policy and Procedure" (no date) documented "Our facility implements an effective system for the prevention of abuse and neglect." It defined neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness." 10. The facility's Resident Roster, dated 3/1/2011, documented two residents with fractures.

Based on record reviews and interviews, it was determined the facility failed to implement their written neglect prevention policies and procedures when they failed to ensure 1 of 12 sampled residents timely evaluation and treatment. Cognitively impaired Resident #1 had a bruised, swollen ring finger. Five days later, the physician was consulted. An x-ray revealed Resident #1 had a fractured ring finger. Furthermore, Resident #1 had a previous incident of a bruised, swollen wrist. Over 24 hours transpired before the physician was consulted. An x-ray revealed a fractured wrist. Failure to ensure nurses immediately consulted Resident #1's physician resulted in delayed evaluation and treatment. As a result, Resident #1 experienced unnecessary pain. This facility failure to prohibit incidents of resident neglect related to failure to immediately consult with a resident's attending physician placed the two residents who had had fractures at risk of not receiving timely care and services. all residents at risk of not receiving timely care and services. The evidence is as follows: 1. Review of the facility's policies revealed the following: a. The policy titled "Change in a Resident's Condition or Status," revised December 2006 documented "Our facility shall promptly notify . . . his or her attending physician . . of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care . . . )" It further noted the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a) an accident or incident involving the resident; b) a discovery of injuries of an unknown source; d) a significant change in the resident's physical/emotional/mental condition. b. The policy titled "Abuse and Neglect Policy and Procedure" (no date) documented "Our facility implements an effective system for the prevention of abuse and neglect." It defined neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness." 2. Review of Resident #1's clinical record revealed the following: - The face sheet documented she admitted to the facility on [DATE] and that her current age was 93. - The February 2011 physician's recapitulation order documented her [DIAGNOSES REDACTED]. - The admission Minimum Data Set Resident assessment, dated 2/02/11, documented Resident #1 had a short and long-term memory deficit, severe cognitive impairment, required extensive assistance with bed mobility, transfers and ambulation, used a wheelchair for mobility and had a history of [REDACTED]. - LVN "C's" nurse's note, dated 2/08/11 at 5:40 p.m., documented Resident #1 fell in the dining room while attempting to walk and landed on her buttocks. It documented she sustained no injuries. - LVN "D's" nurse's note the following day, dated 2/09/11 at 4:00 p.m., documented Resident #1's left ring finger was swollen. It documented the family was notified of the swelling and asked to call a jeweler to remove the ring. It documented a jeweler promptly arrived and removed the ring. It then documented the [MEDICAL CONDITION] continued and the finger had bruising. There was no documented evidence the physician was consulted. - The record provided no additional information regarding the bruised, swollen finger until two days later. A nurse's note, dated 2/11/10 at 12:30 a.m., LVN "D" documented Resident #1's finger continued to remain bruised and had decreased swelling, although it had 1+ [MEDICAL CONDITION] (swelling). There was no documented evidence the physician was consulted. - The nurses' notes, dated 2/11/11 at 9:30 a.m. and 8:00 p.m., and 2/12/11 at 8:15 a.m. and 8:00 p.m., provided additional evidence Resident #1's left finger continued to remain swollen. The notes on 2/11/11 and 2/12/11 were written by LVN "A" and LVN "E", respectively. - LVN "A's" nurses' notes, dated 2/13/11 (Sunday), documented at 7:30 a.m., Resident #1 continued to have bruising to her palm and ring finger. LVN "A" noted at 9:50 a.m., Resident #1 fell in in the lobby landing on her left hand and buttock. The notes documented she was assessed and had no new injuries. The notes added that her left ring finger had swelling to the inner knuckle and Resident #1 was rubbing her finger. The notes then documented that at 10:20 a.m., a facsimile (fax) was sent to the physician regarding the swollen ring finger, but there was no documented evidence the physician was immediately contacted (i.e., by telephone) to consult with him regarding the swollen finger. LVN "A" then documented at 10:30 a.m., Resident #1's left hand was elevated above her heart and the left ring finger was tender when bent at the knuckle. - A nurse's note, dated 2/14/11 (Monday) at 10:50 a.m. (24 hours later), documented they received an order to send Resident #1 to the local hospital for an x-ray. It further noted she continued to have [MEDICAL CONDITION] to her left ring finger. - An x-ray report, dated 2/14/11, documented Resident #1 had a 4th proximal phalangeal fracture (fractured finger). - A nurse's note, dated 2/15/11, documented the physician gave an order for [REDACTED]. 3. During an interview with LVN "A" on 3/2/11 at 2:30 p.m., she said Resident #1 fell on [DATE] and was not wearing her splint for the left wrist at the time of the incident. She said she did not work the next two days, but when she returned, Resident #1's left ring finger was swollen and they had a jeweler cut a ring off her finger. She confirmed she failed to consult with the physician regarding the identified swelling of Resident #1's left ring finger and the need to have a jeweler cut a ring off her finger. 4. During an interview with LVN "B" on 3/3/11 at 4:00 p.m., she said she did not work as Resident #1's charge nurse, but had been present when the jeweler cut a ring off her left ring finger. She said the finger was swollen from the ring to the end of the finger. She said the finger was visibly larger than her other fingers. 5. During an interview with the ADON on 3/2/11 at 3:10 p.m., she said she was aware a jeweler had to cut a ring off Resident #1's finger, but she did not know why the finger was swollen. 6. During an interview with Resident #1's family on 3/02/11 at 4:44 p.m., they said prior to the jeweler cutting a ring off Resident #1's finger, she had never had issues with being able to wear her ring due to having no prior issues with her left ring finger swelling. 7. During an interview with Resident #1's attending physician on 3/02/11 at 4:06 p.m., he said he first became aware of the bruising and swelling of Resident #1's left ring finger after she fell on [DATE]. He said he was unaware the swelling and bruising had been present since the day after a fall on 2/8/11. He further said he had been unaware that on 2/9/11, a jeweler had to cut a ring off her left ring finger due to the swelling. He said staff should have immediately notified him of the swelling and bruising, and the need to cut the ring off her finger. He said had he been aware of this condition change, he would have given an order for [REDACTED]. 8. Further review of Resident #1's clinical record revealed that in January 2011, she fractured her left wrist. The record documented the following: - The nurses' notes documented that on 1/04/11 (a Tuesday), Resident #1 fell and was transferred to a local hospital, but she returned that same day with no new orders. The nurses' notes for 1/04/11 provided no evidence Resident #1 had a swollen, bruised left wrist and forearm. The following day, LVN "A's" nurse's notes, dated 1/5/11 at 7:00 a.m., documented Resident #1 was found with a purple-red bruise from her left wrist from her mid forearm to her hand. There was no documented evidence the physician was immediately consulted, although, 24 hours later on 1/06/11 at 7:00 a.m., LVN "A" documented Resident #1 had 3+ [MEDICAL CONDITIONS] to her left wrist and hand with dark purple bruising measuring 9 cm x 2 1/2 cm. LVN "A" documented the area was red and warm to touch and the resident said, "Ouch," when it was touched. LVN "A" documented that two hours later (not immediately) she left a message for the physician and the physician responded at 9:10 a.m. with an order to obtain an x-ray of her wrist. - An x-ray report, dated 1/06/11, documented the findings were a "questionable" hairline fracture and evidence of osteopenia (reduction in bone volume). A subsequent x-ray, dated 1/21/11, documented the conclusion was ". . . suggestive of nondisplaced scaphoid wrist fracture". (Scaphoid is one of the bones in the wrist.) An x-ray report, dated 2/14/11, documented there was no change in the appearance of the scaphoid wrist fracture. 9. During an interview with the DON on 3/2/11 at 3:00 p.m., she said she was a corporate registered nurse and the interim DON. She said the prior DON had not worked since approximately the end of December 2010 and the facility had no other registered nurses. She said she became the interim DON the middle of February 2011. She said she thought Resident #1 admitted with the wrist fracture. She said she knew about Resident #1's subsequent fractured ring finger. She said she thought Resident #1's finger was swollen due to the ring being too tight and that the fracture occurred when the jeweler cut the ring off her finger. She said she was unaware the nurses failed to immediately consult the physician regarding Resident #1's swollen, bruised left ring finger. She said nurses were to call the physician when a resident had an injury or change of condition. When asked to provide evidence of additional training for nurses regarding timely consultation with resident's attending physician, she was unable to provide any evidence of additional training. 10. The facility's Resident Roster, dated 3/1/2011, documented two residents with fractures.